Barriers and supports to implementation of MDI/spacer use in nine Canadian pediatric emergency departments: a qualitative study

Scott, Shannon D; Osmond, Martin H; O'Leary, Kathy A; Graham, Ian D; Grimshaw, Jeremy; Klassen, Terry

A comparative case study design [8] was used within the EDs of nine Canadian pediatric tertiary-care teaching hospitals. Case studies are appropriate when the boundaries between the phenomenon of interest and the context in which it occurs are not clear [8] . For this study, the phe-nomenon of interest was the adoption of MDI/spacers for the treatment of asthma, and while data collection occurred at the level of the individual practitioners, the unit of analysis was the individual PEDs. All of the hospitals belong to Pediatric Emergency Research Canada (PERC), a collaborative, nationwide pediatric emergency medicine research network. The EDs were classified into one of three categories based on stage of MDI/spacer implementation: 'early adopters,' 'adopting,' and those 'yet to adopt' [9] . Level of adoption was based on results from Osmond et al.'s study [6] in which members of ten Canadian PEDs were surveyed regarding MDI/spacer use, and was verified by a key informant. In the study by Osmond et al., sites were categorized based on how individual emergency physicians at each site responded to a specific scenario given to them as part of the survey. For the purposes of the present study, 'early adopters' were those sites in which MDI/spacer had already been incorporated into routine practice for the treatment of mild to moderate asthma. 'Adopting' sites were those that were actively involved in switching from nebulised to MDI/ spacer treatment, and 'yet to adopt' sites were those sites that exclusively used nebulised treatments and had not started a process to adopt MDI/spacers. We purposively sampled [10] from among the ten eligible PEDs so that there was equal representation from each of the three categories (the single site that was not chosen from the study by Osmond et al . had yet to adopt MDI/spacer use). Eligible participants included all PED physicians, ED registered nurses (RNs), respiratory therapists (RT) (in those EDs where RTs administered asthma treatment), as well as the medical and nursing directors in each of the departments.