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Barriers and Facilitators of Intensivists’ Adherence to Hyperinsulinemia-Euglycemia Therapy in the Treatment of Calcium Channel Blocker Poisoning

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Abstract

Introduction

Adherence to poison center (PC) recommendations for the management of calcium channel blocker (CCB) poisoning is inconsistent. This study aimed to identify behaviors that determine adherence to hyperinsulinemia-euglycemia therapy (HIET) for CCB poisoning.

Methods

Semistructured interviews were conducted involving a convenience sample of 18 intensivists. Interview responses were analyzed using the theoretical domains framework (TDF) to identify relevant domains influencing physician adherence to HIET. Two independent reviewers performed qualitative content analysis of the interview transcripts to identify beliefs influencing decisions to initiate HIET. Initially, beliefs were classified and frequencies reported as being likely to facilitate, likely to decrease, or unlikely to affect adherence. Subsequently, beliefs were linked to a domain within the TDF. Based on the potential impact on physician behavior and frequency of reported behavior, we selected the most relevant domains likely to influence physician adherence to HIET for CCB poisoning.

Results

Positive beliefs were identified in the following domains: “behavioral regulation” (e.g., algorithm for adjustment of perfusions), “belief about capabilities” (e.g., confidence about being able to manage HIET), “belief about consequences” (e.g., fear of clinical deterioration), and “reinforcement” (e.g., clinical instability). Negative beliefs were identified in the following domains as “nature of behavior” (e.g., preference for vasopressors over HIET) and “environmental context and resources” (e.g., accessing dextrose 50% and increased nurse workload).

Conclusion

This qualitative study identified potential behavioral targets for future implementation strategies to address to improve adherence to HIET.

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Acknowledgements

We thank all participants who participated in this study. We thank the Canadian Critical Care Society for sharing access to their electronic mailing list of members.

Sources of Funding

None.

Author information

Authors and Affiliations

  1. Department of Anesthesiology and Critical Care, Université Laval, Québec, Québec, Canada

    Eric Brassard, Patrick Archambault & Maude St-Onge

  2. Centre de Recherche du Centre intégré en santé et services sociaux de Chaudière-Appalaches, Lévis, Québec, Canada

    Patrick Archambault

  3. Department of Family Medicine and Emergency Medicine, Université Laval, Québec, Québec, Canada

    Patrick Archambault, Guillaume Lacombe & Maude St-Onge

  4. Centre antipoison du Québec, CIUSSS Capitale Nationale, Québec, Canada

    Maude St-Onge

  5. CHU de Québec Research Center, Population Health and Optimal Health Practices, Université Laval, Québec, Québec, Canada

    Maude St-Onge

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  1. Eric Brassard
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  4. Maude St-Onge
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Corresponding author

Correspondence to Maude St-Onge.

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Additional information

Previously presented at the American College of Medical Toxicology (ACMT) Annual Scientific Meeting (ASM), March 2017, San Juan, Puerto Rico.

Appendix 1

Appendix 1

Interview questions for intensivists

This is a semistructured interview with the purpose of identifying barriers and facilitators to adherence to PCC treatment recommendations for patients with a calcium channel blocker intoxication. By answering these questions, we consider that you consent to the recording of your answers and their use for research purposes. All information will be kept confidential and no nominal information will be kept.

Use of HIET

What place do you perceive your PCC protocol suggests for the use of HIET?

How does the strength of the evidence behind HIET influence your decision to use it?

Do you tend to use more vasopressors or to initiate a HIET?

What reasons would limit you to initiate a HIET?

Does the knowledge behind the mechanism of action and the reasons why it is recommended have an influence on your decision to initiate HIET?

How confident are you about proceeding to a HIET and the potential technical difficulties?

How is it easy or complicated for you to proceed to a HIET?

How does the credibility you give to your PCC influence your decision to initiate HIET if suggested by the PCC?

What is the impact on your perception of your professional identity and autonomy when PCC suggests to initiate HIET?

What problems have you encountered while doing it?

What could help you to do a HIET?

What is your level of optimism or pessimism about the effects of a HIET?

What do you think could happen if you do not use a HIET (for example if you only use pressors)?

How does the risk–benefit of a HIET influence your decision to initiate it?

What incentives are there for you to initiate a HIET?

What is your level of motivation to initiate a HIET when you have a CCB-poisoned patient?

What other goals could interfere with the HIET? What is your priority?

Is there any conflict between these treatment recommendations and other guidelines that you need to follow? How does it influence your decision to initiate a HIET?

Is HIET something you usually do?

How is it intuitive for you to consider a HIET when you have a patient with CCB poisoning?

What reasons could make you decide not to do a HIET when it is recommended by the PCC?

How do other tasks requesting your attention limit you to initiate a HIET with a patient with significant CCB poisoning?

How does CCP recommendations to initiate a HIET influence your decision-making process?

How do resources limitations influence your decision to initiate a HIET (staff, financial, time, or other)?

Are the resources necessary to do a HIET accessible when needed?

Have you seen colleagues use a HIET? Does it influences your decision to use it?

Do you perceive opposition by other professionals or colleagues when you want to initiate a HIET? How does it influence your decision to initiate it?

Does using a HIET ever brought you interpersonal conflicts?

Are treatment recommendations from the PCC a practice standard, an option, an opinion, a norm?

What emotional response do you have while initiating HIET (apprehension, anxiety, worry?)

How does this emotional response affect your decision to initiate or not a HIET?

What preliminary steps appear essential to you before you initiate a HIET (personal or structural etc.)

Are there processes or strategies that you think would facilitate the application of a HIET?

Do you receive any feedback or follow-up on your CCB-poisoned patients when PCC recommends to initiate a HIET?

How much does your ease with therapeutic options that were used before the arrival of HIE influence your decision to initiate a HIE?

What effect does your past practice have on your decision to initiate a HIE when it is recommended by PCC?

Do you think physicians consider or will consider HIE as a standard treatment? If not will it become a standard? Will it be long?

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Brassard, E., Archambault, P., Lacombe, G. et al. Barriers and Facilitators of Intensivists’ Adherence to Hyperinsulinemia-Euglycemia Therapy in the Treatment of Calcium Channel Blocker Poisoning. J. Med. Toxicol. 14, 283–294 (2018). https://doi.org/10.1007/s13181-018-0676-2

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