Enablers and barriers for implementation of the outpatient intravenous diuretic treatment across NHS Greater Glasgow and Clyde
Authors: Nowak K , Forsyth P , Green S , Clark P , Sorensen P 
Published: November 2023

Abstract

Introduction
The burden of heart failure is underestimated, and it has a long average inpatient stay. Many healthcare institutions have trialled the outpatient administration of intravenous diuretics, which demonstrated a reduction in hospitalisation, however the reasons for not implementing this service model more widely remain unknown.

Aim
The aim was to explore the qualitative views on the enablers and barriers for implementation of an outpatient intravenous diuretic service across NHS Greater Glasgow & Clyde.

Methods
This study was qualitative in design and participants were recruited by convenience sampling from three professional groups: doctors, nurses and pharmacists. Inclusion criteria stipulated at least 10 years of professional practice and current experience within cardiology. We aimed to recruit 12 participants as this is the minimal number needed to deliver saturation of ideas.1
Data was gathered through semi-structured, individual interviews, which were conducted via videoconferencing platform, Microsoft Teams. The interviews were recorded and transcribed. Inductive thematic analysis was undertaken using Braun and Clarke’s six phases, via the NVivo software.2
Approval from the University of Strathclyde Ethics Committee was received.

Results
Analysis of transcripts generated 6 main themes: system performance (staffing levels, training, inpatient stay and budgetary control, utilisation of healthcare); person factors (experience and satisfaction, physical factors, collaboration, attitude and person-centred care); treatment – procedure (practicalities, governance, referral, treatment effectiveness); environment and technology (hospital environment, designated area, transport); external factors (impact of the pandemic, support from management, vision and innovation); alternative location.
Barriers and enablers were interdependent, and some themes featured both, depending on the context.
The overall perspective of the service was positive due the impact on system performance and reduction of inpatient stay as well as improved wellbeing of patients related to favourable person factors. Themes, which represented barriers were limited staffing levels and unavailability of a designated area.

Discussion/Conclusion
Although certain themes identified through this research were expected, they reemphasise the common underpinning interactions within dynamic healthcare systems. Described themes may form an improvement framework, which could be transferrable to other therapeutic areas and aid patient care beyond cardiology.
The proposed outpatient diuretic service has potential for development and may bridge a gap between current and future treatment strategies, which supports priorities related to transforming patient care during post-Covid recovery. Barriers and enablers are interdependent and unlikely to be resolved by a single intervention. It was recognized that a whole system approach with the focus on disease prevention as well as wider collaboration are required to broaden the range of available options. It may be achieved by creating more effective partnerships between healthcare settings.
The study highlighted the importance of promoting innovation, as the results may narrow the evidence gap in the formation of future care pathways. Data emerging from research may empower healthcare providers to apply innovation to deliver person-centred care in accordance with national priorities.
Limitations included small study sample, however the sampling strategy allowed diversity of opinions. Analysis continued until last interview to form the framework, which was not limited by pre-existing models.

References
1. Ritchie J, Lewis J, Elam G, Tennant R, Rahim N. Chapter 5: Designing and Selecting Samples. In: Ritchie J, Lewis J, McNaughton Nicolls C, Ormston R, editors. Qualitative Research Practice: A Guide for Social Science Students and Researchers. London (UK): SAGE Publications; 2013. p 111-119.
2. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006; 3: 77-101