Reasons for Poor Adherence
Major contributors to poor adherence to guidelines are many fold and include failure to recognize sepsis, lack of familiarity or lack of awareness of the sepsis guideline, lack of agreement with the specific guideline, or lack of agreement with guidelines in general, as well as lack of motivation. In addition there are many external barriers to guideline implementation. For instance, the characteristics of the guidelines may render them impractical to implement - in some cases they are too detailed and try to address all eventualities, whereas in others they may suggest resources, such as laboratory tests, methods of monitoring and treatment options, that are not available locally. Environmental factors, such as lack of time, lack of resources, lack of reimbursement and organizational constraints, may also preclude adoption of guidelines. For instance, in areas where there are critical staff shortages, it is unreasonable to place further burdens, such as frequent monitoring and documentation, which are the standard of care in areas with substantially more resources. In many areas of the world, white blood cell counts to determine systemic inflammatory response syndrome (SIRS) criteria, laboratory capabilities for blood culture and pulse oximetry or supplemental oxygen are not readily available.
Poor guideline adoption may also be due to the fact that incentives may not be aligned to the behavior. There are also concerns which lead to skepticism that guidelines may be subject to biases (used as a financial and marketing tool). Doubts about the evidence on which a guideline is based stems from skepticism of the composition of the panels of experts that mold these judgments. While guideline users could sometimes adjust for these biases, in some cases the values and goals and conflicts are not explicit to allow for any adjustments. Moreover, some have argued that there are too many sepsis guidelines and some are out of date and present conflicting information. A major concern in the United States is the fact that these guidelines may be turned into performance measures to critique the quality of physician care and even dictate hospital accreditation.
In our local experience, clinicians were skeptical when a sepsis guideline was introduced because they felt that screening for sepsis in the emergency department was not necessary because their triage system was robust enough to detect sepsis. Others felt their pediatric early warning systems served the same purpose on the wards, and still others felt that introduction of the sepsis guideline implied that they were managing sepsis incorrectly beforehand. These reasons for skepticism are not unique to any single institution or any particular guideline and imply that crafting a resource-appropriate guideline is an important process but without attention to cultural issues, implementation and adoption are likely to be less than optimal (Figure 3). Another area that has hindered adoption and sustainability is the failure to measure meaningful outcomes and share the information widely with team members.
(Enlarge Image)
Figure 3.
Clinical practice guidelines. Preparation, implementation, evaluation and revision are all important for successful adoption.