Exploring Factors Contributing to Chronic Obstructive Pulmonary Disease (COPD) Guideline Non-Adherence and Potential Solutions in the Emergency Department: Interdisciplinary Staff Perspective

Figures & data

Table 1 Interview Questions Designed to Create Discussion and Share Experiences

Interview Questions	Purpose of Question and Supporting Literature
1. Share your experience of managing a COPD patient in ED using COPD-X national guidelines in your day-to-day practice 2. In your experience what aspects of COPD-X guideline are used more frequently than the others depending on your discipline	Role clarification, decreased awareness and lack of familiarity are some reasons for suboptimal COPD treatment^Citation16,Citation23
3. In your experience, what aspects of COPD-X plan are poorly adhered to by doctors, nurses and interdisciplinary team	Lack of integrated care affects health related quality of life (Hrqol) of COPD patients^Citation24,Citation25
4. Share an experience that highlights barriers whilst providing holistic care for AECOPD patients as per COPD-X plan	Publication of guidelines has not achieved optimal COPD treatment, hence exploring barriers to adherence needs emphasis in future research^Citation16,Citation26
5. Share an example of probable solutions to the barriers that are experienced in using the COPD X plan guideline or caring for presentations in the emergency department with an episode of COPD exacerbation	Explore probable solutions such as having guidelines and cues accessible at point of care may improve concordance^Citation16,Citation26

Abbreviations: COPD, chronic obstructive pulmonary disease; AECOPD, acute exacerbation of chronic obstructive pulmonary disease.

Figure 1 Data analysis graphic representation. Notes: Research design stages utilising reflexive thematic analysis (data from Braune & Clarke³⁷) merged with theoretical domains framework (TDF) and Capability, Opportunity, Motivation- behaviour change wheel (COM-B, BCW) (data from Michie et al³⁸).

Table 2 Identified Barriers Mapped to COM-B Model and Recommended Implementation Strategies from BCW and Participants for TDF Domain 1: Knowledge

Guideline Uptake Barrier	Frequency Score/8	Participant Quotation (Barriers)	COM-B Components	Recommended Intervention (BCW)	Participants Recommended Implementation Strategies
Lack of awareness of guidelines Lack of awareness of respiratory management for ED Lack of education or in services sessions	6	P1. Physio.1: -“I am Vaguely aware of the guidelines being a musculoskeletal physiotherapy expert. COPD Awareness Week might be something that you can do like Falls Prevention Month, which is like a whole month of awareness events” P2. Physio.2:-“there is literally no respiratory focus in our competency in ED, so we are just taking whatever knowledge that we’ve got from our degrees and from our previous work” P3. Nurse.1:-“Probably for nurses, it’s just not having the ongoing education is a barrier, like who to refer to, how to refer to them, having someone based in the Department would be helpful because that would break down the barrier of not being able to find them” P6. Doctor.1:-“Doctors through their medical training would have looked closely at the COPD Guidelines, so I can speak for that. I’m not sure about nursing staff and other allied health staff” P7. Pharmacist: - “ If we had knowledge and access of available Community services, we could provide the patient with that sort of information” P8. Doctor.2: -“Hospital intranet has access to a multitude of different Guidelines. Frankly I don’t see any of us using any of that. We tend to use the Australian Therapeutic Guidelines for right course of therapy”	Capability Psychological Physical	Training Modelling Enablement	In services training (P1, P4) Education on guidelines (P2, P3,P4) Provision of resources and readily access in clinical practice(P7)

Abbreviations: COM-B, capability, opportunity, motivation-behaviour model; TDF, theoretical domains framework; ED, emergency department; COPD, chronic obstructive pulmonary disease; BCW, behaviour change wheel.

Table 3 Identified Barriers Mapped to COM-B Model and Recommended Implementation Strategies from BCW and Participants for TDF Domain 2: Skills

Guideline Uptake Barrier	Frequency Score/8	Participant Quotation (Barriers)	COM-B Components	Recommended Intervention (BCW)	Participants Recommended Implementation Strategies
Current job skills or roles are not respiratory management oriented Lacking skills and experience to provide patient education	4	P1. Physio.1:-“I’m here as a Musculo-skeletal expert, from time to time we might answer some questions from doctors about respiratory physiotherapy management, but we’re not involved in directly managing the patients in the emergency department” P2. Physio.2:- “Experience managing COPD patients in the ED is very little. We don’t directly treat COPD patients in the Emergency Department” P4. Nurse.2:-“Usually the nurses do patient education and we’re currently using spacers at the moment for teaching inhaler technique. We are never given any training around this in the department. We don’t have any specific COPD management In-services or education especially in winter which precipitates their symptoms” P8. Doctor.2: - “I don’t see Respiratory Specialty Nursing or Allied health, specifically being utilised in the Emergency Department”	Capability Physical	Training modelling	Education/In-services (P4) Resources for self-directed study(P2) ED champions to lead educational sessions (P8)

Abbreviations: COM-B, capability, opportunity, motivation-behaviour model; TDF, theoretical domains framework; ED, emergency department; COPD, chronic obstructive pulmonary disease; BCW, behaviour change wheel.

Table 4 Identified Barriers Mapped to COM-B Model and Recommended Implementation Strategies from BCW and Participants for TDF Domain 3: Beliefs and Capabilities

Guideline Uptake Barrier	Frequency Score/8	Participant Quotation (Barriers)	COM-B Components	Recommended Intervention (BCW)	Participants Recommended Implementation Strategies
Confidence in COPD management Nature and pace of emergency departments makes it impossible to provide care more than acute emergent needs of the patient Time constraints impact capabilities to provide care	5	P1. Physio.1: -“We certainly have community services available which we could refer before discharge from Ed, Respiratory care is within their scope of practice for those community-based physios, I’m not sure about that. I’ll need to find out” P1. Physio.1:-“As we have a specific National emergency access target (NEAT) to meet and the Emergency Department is probably not the ideal place or the expertise to optimise their care” P8. Doctor.2:-“We discharge the patient back to Primary Care, we frankly don’t know what is happening to the patient in terms of Physiotherapy and pulmonary rehabilitation and we could potentially help direct some care. But I think in terms of developing processes, I see that that in itself is a little bit of a barrier to care” P8. Doctor.2: -“we are pressured for time due to NEAT targets (4 hours in Ed), providing the full gamut or array of multi-disciplinary care within ED is difficult. Priority would be to ensure that they are not in acute respiratory failure and then hand over to the Respiratory Medical Team/primary care for their further cares” P8. Doctor.2: -“The utilisation of opportunistic vaccination in the Emergency Department is a good public health initiative, but it is completely impractical in the context of an Emergency Department. We may be able to do that, but one fails to see that there is time that is consumed in these actions and the question is who is missing out on Emergency Care” P5.Social worker:- “ often it takes longer than four hours to provide social work input so if I am not able to get someone reviewed by four hours, I think “Ok, I’ve gone over the four hours so send it straight out to the Community” P6.Doctor.1:-“Volume of patients that we have is a major barrier as you’re rapidly trying to get through a huge amount of different patients at the same time as trying not to miss serious things, but then trying to assess people and discharge people who don’t need admission” P7. Pharmacist:- Smoking cessation will get asked as part of the medical review but it will probably be something like “well, you know, if you cut down, your symptoms will be better” but that’s probably the extent of it (P7)	Motivation Reflective	Environmental restructuring Education	Provide information or accessible resources in workplace on how to make community referrals (P1) Electronic referrals provides time efficient care in the Emergency department (P7,P8) Easily accessible packages for smoking cessation assistance during admission (P7) Research and implement less time consuming processes for facilitating referral and management in the Emergency Department (P1, P8) Direct community referrals by ED admin (P8)

Abbreviations: COM-B, capability, opportunity, motivation-behaviour model; TDF, theoretical domains framework; ED, emergency department; COPD, chronic obstructive pulmonary disease; BCW, behaviour change wheel; NEAT, national emergency access target.

Table 5 Identified Barriers Mapped to COM-B Model and Recommended Implementation Strategies from BCW and Participants for TDF Domain 4: Memory Attention and Decision Process

Guideline Uptake Barrier	Frequency Score/8	Participant Quotation (Barriers)	COM-B Components	Recommended Intervention (BCW)	Participants Recommended Implementation Strategies
Difficulty recalling all treatment and management modality from COPD guidelines	3	P3.Nurse.1:-“Respiratory clinical nurse consultants (CNC) won’t always come through Emergency and if it’s someone who’s going home, they’re probably seen as not that critical and I’m not sure how often they would be able to come or be willing to come down to Emergency. Having a deck phone, we could ring to actually talk to a respiratory expert, someone would be a big help, and if we knew that the resource was there, we would use it” P3. Nurse.1: - “We have multitude of different guidelines, which itself can be confusing” P7. Pharmacist: -“Twenty other people wait outside that can’t stay for someone to make a phone call for them unfortunately so direct, non-time consuming digital referrals will help” P8. Doctor.1:-“Dealing with multiple disciplines and speciality cases my primary complaint at the moment would be that we used to have ‘UptoDate’ database access for international guidelines in electronic form for quick reference. We no longer have it. It is unreasonable to expect ED staff to provide discipline-based discharge”	Capability Psychological physical	Modelling Environmental re-structuring Education Enablement	Availability of respiratory nurse specialist for advice and review in ED patients (P3) Electronic resources access to international and national guidelines (P8) Adding prompts and cues to clinical area (p3) COPD discharge template (P8)

Abbreviations: COM-B, capability, opportunity, motivation-behaviour model; TDF, theoretical domains framework; ED, emergency department; COPD, chronic obstructive pulmonary disease; BCW, behaviour change wheel.

Table 6 Identified Barriers Mapped to COM-B Model and Recommended Implementation Strategies from BCW and Participants for TDF Domain 5: Behavioural Regulation

Guideline Uptake Barrier	Frequency Score/8	Participant Quotation (Barriers)	COM-B Components	Recommended Intervention (BCW)	Participants Recommended Implementation Strategies
Failure to abide COPD guidelines or related quality initiative available in ED	7	P1. Physio.1: - “Pulmonary rehabilitation I’m not aware of that practice in ED, mostly done by respiratory physios in the respiratory ward” P2. Physio.2: -“We have a pulmonary rehab service that we can refer to from ED and then we have other general rehab services like we have Day Therapy that we could use but currently not so much” P2. Physio.2: -“Community/Respiratory ward physio referrals from Ed can be done, maybe have a phone discussion with the ward physio to do the community referral. Not a huge time commitment” P2. Physio.2: “There have been a couple of patients, who have potentially been frail, discharged home and then have re-presented with another fall or not coping at home and then have had MDT input or an admission and MDT input to optimise them at home. Yeah, that’s certainly happened multiple times” P3. Nurse.1: - “Lack of addressing anxiety is a reason for failed discharges. They’re not coping at home. That’s probably the biggest one” P5. Social worker: - “Medical teams don’t ask that question about anxiety may cause some readmissions” P6. Doctor.1:-“we do not do community or pulmonary rehabilitation referrals and all of those kinds of things is a barrier, because I think that is one of the things that does slip through the cracks” P6. Doctor.1: -“ED is certainly capable of giving pulmonary rehabilitation referrals but I haven’t myself or seen anybody do that. We would more expect patients who go to the Respiratory Ward can get it there” P7.Pharmacist:-“It would benefit if our doctors write into the discharge letter to the GP, ‘please ask for a Home Medicine Review’ If we make the call as a Pharmacist that we want their inhaler technique checked at home or their medicines checked” P8. Doctor.2: -“We do not provide the opportunistic vaccination to patients whilst they are in ED partially because it is public health responsibility and by utilising staff time we lose time to provide acute emergent care for other patients” P7. Pharmacist: -“Inhaler compliance thing really, that is the problem most of the time for readmissions. You know, there’s the smoke in the air that brings them in and then there’s flu season that brings them in but a lot of the time the only thing that can actually be fixed is probably like, lifestyle and inhaler compliance”	Capability Psychological physical	Modelling Enablement	Respiratory management champions in ED to model, educate and lead (P8) Easier referrals using electronic systems and telecommunications technology (p6) Direct community referrals to GP for patients discharged from ED (P7,P1,P8,P6) COPD discharge templates for ED (P8) Vaccination and inhaler technique education referrals to primary care or resources in ED linked through respiratory department (P6, P7, P8) Patients coping mechanisms, anxiety and triggers to be screened and referred to appropriate services (P3, P5)

Abbreviations: COM-B, capability, opportunity, motivation-behaviour model; TDF, theoretical domains framework; ED, emergency department; COPD, chronic obstructive pulmonary disease; BCW, behaviour change wheel; GP, general practitioner; MDT, multidisciplinary team.

Table 7 Identified Barriers Mapped to COM-B Model and Recommended Implementation Strategies from BCW and Participants for TDF Domain 6: Environmental Context and Resources

Guideline Uptake Barrier	Frequency score/8	Participant Quotation (Barriers)	COM-B Components	Recommended Intervention (BCW)	Participants Recommended Implementation Strategies
Lack of human resources affect adherence to guideline Lack of monetary funding affects guideline adherence lack of equipment is a barrier to guideline adherence Lack of interdisciplinary communication means	8	P1.physio.1:-“Physiotherapy Department as a whole in the hospital employ more physios during the winter peak because we have more presentations of respiratory infections in the COPD population we have no respiratory physios in ED, current workload is just not sustainable” P1.physio.1:-“occupational therapists that work in the Respiratory Wards are also the ones that come to the pulmonary rehabilitation sessions teach the patients on pacing, activity modification, relaxation and I guess also functional things using appropriate furniture or tools. Patients discharged from ED; can they be seen in clinics is another question for multidisciplinary input” P1. Physio.1: - “For special patient populations in the ED a resource area champion could be useful and I use the example of geriatric emergency medicine” P2. physio.2:-“There is next to no occupational therapist (OT) input in Emergency apart from the Allied Health Practitioner in older person’s assessment and Liaison services. I guess funding, space, skill set is a barrier” P3. Nurse.1:- “Smoking cessation, probably not in Emergency as you would say you shouldn’t still be smoking”, but that’s it. That’s the end of the discussion not offering any support. we do not actually give them any Community referrals” We just do not do that well in Ed when we have the opportunity” P3. Nurse.1:- “if we had Clinicians who were Allied Health Practitioners for COPD management/respiratory ‘stuff’ we would be quick to refer to them” P4. Nurse.2: - “Incase family is there and the patient is actively dying from this illness, social worker is involved. we don’t get OT’s involved down here or communicate with palliative care” P5. Social worker: - “They don’t provide Psychology support in ED from a mental health perspective” P6. Doctor.1: -“Doctors potentially ask for inhaler technique education if that’s been flagged as an issue. Patients say they take puffers but we can’t figure out what ones they are and Pharmacy might call the GP and do some more digging around and ask what kind of medications they do take. Time becomes a barrier in ED” P7. Pharmacist: -“Due to workload and the bed situation, we can’t kind of have people in just for a vaccination. Upskilling our doctors and nurses on COPD management will compete with so many other priorities. Resourcing with respiratory staff will help” P7. Pharmacist: -“if there was a way to refer to Respiratory Outpatients Clinics straight from EDIS (ED referral system), which would probably be useful if you thought someone needed follow up but not today. We have our electronic Emergency Department referral system (EDIS) where staff would click on ‘refer to Respiratory Registrar’ when they do it, that doesn’t go anywhere. That’s just for our record that we called them, so it wouldn’t be phone call which is a barrier” P7. Pharmacist: -“We don’t have enough Pharmacists or registrars or consultants to see every respiratory patient in ED. Respiratory nurses should come and see every patient. Automatic referrals might come in handy her too”	Opportunity Physical	Environmental restructuring Persuasion Incentivisation	Enabling interdisciplinary communication (P2) Prompts and clue for care and referrals (P6, P7) Funding resources (P7,P1) Staffing resources including department resource champions (P3, P1,P7) Providing appropriate equipment (P2, P5,P1) Automatic referrals and direct community referrals (pulmonary rehab) (P7) Restructuring processes of care (Respiratory clinic referral, respiratory nurse review in ED) (P1,P7) Electronic concise COPD guidelines for ED (P8, P3)
		P7. Pharmacist: -“Twenty other people wait outside that can’t stay for someone to make a phone call for them unfortunately so direct, non-time consuming digital referrals will help” P8. Doctor.2: -“Equipment aspects of barrier we do not provide this cohort of patient a Spirometry or any Pulmonary function testing, it may not be appropriate in acute exacerbations anyway” P8. Doctor.2: -“Sometimes the patient has left without the discharge letter for some reason, in which case our Admin officers then fax the letter, diligently, to the patient’s GP, some Guidelines could be sent this way too”

Abbreviations: COM-B, capability, opportunity, motivation-behaviour model; TDF, theoretical domains framework; ED, emergency department; COPD, chronic obstructive pulmonary disease; BCW, behaviour change wheel; GP, general practitioner.

Table 8 Identified Barriers Mapped to COM-B Model and Recommended Evidenced Based Implementation Strategies from BCT and Participants for TDF Domain 7: Social Professional Role Identity

Guideline Uptake Barrier	Frequency Score/8	Participant Quotation (Barriers)	COM-B Components	Recommended Intervention (BCW)	Participants Recommended Implementation Strategies
Professional boundaries and roles are affecting guideline adherence	5	P1. Physio.1:- “We don’t routinely get referred to respiratory patients as my role in Ed is not that often as a general physiotherapist. I’m here as a Musculo-skeletal expert” P1.Physio.1:- “I have received a call from one of our doctors saying “can we do a six-minute walk test in the ED to see if this patient de-saturates on room air” and I said to them,“I haven’t worked in COPD care for a long time but we used to do that, but we don’t do that anymore. We do arterial blood gas (ABG) instead” P2. Physio.2: - “I don’t get any respiratory referrals for COPD patients in ED being a musculoskeletal expert” P3. Nurse.1: -“We have Physios for Fast Track area and we have the OT in OPALS but they are for older people, like their catchment is 70 years and older. There’s social worker which is obviously for everyone but there’s no-one else really in the Emergency Department for patients discharged from ED” P5. Social worker: - “Doctors and nurses during their assessment should be asking something in relation to emotional status. So they are asking about home – “do you live on your own, do you live with somebody, do you have any community supports” and then “emotionally how are you managing your COPD diagnosis” P7. Pharmacist: - “Respiratory CNC won’t always come through to ED”	Opportunity Social	Environmental restructuring Education Persuasion	ED champions to promote and monitor referral pathways (P1) Encourage doctors and nurses to ask emotional status during history collection (P5)

Abbreviations: COM-B, capability, opportunity, motivation-behaviour model; TDF, theoretical domains framework; ED, emergency department; COPD, chronic obstructive pulmonary disease; BCW, behaviour change wheel; GP, general practitioner; MDT, multidisciplinary team; OPALS, older person assessment and liaison service; CNC, clinical nurse consultant.

Table 9 Identified Barriers Mapped to COM-B Model and Recommended Implementation Strategies from BCW and Participants for TDF Domain 8: Emotion

Guideline Uptake Barrier	Frequency Score/8	Participant Quotation (Barriers)	COM-B Components	Recommended Intervention (BCW)	Participants Recommended Implementation Strategies
Perception and views of treating staff	3	P1. Physio.1:-“Different professions are involved in the Emergency Department in terms of setting and treating patients with respiratory problems or respiratory side of Physiotherapy is probably not part of my scope and agenda as musculoskeletal physio” P8. Doctor.2: - “It is unreasonable to expect ED staff to provide discipline based discharge” P4. Nurse.2: -“We usually approach our doctors for specific case knowledge of COPD. We don’t refer to our Guidelines. I think it is probably changing, but nurses probably think we’ll just do what the doctor told us to do rather than suggesting stuff ourselves” P8. Doctor.2;- “The context in which the patient is cared for, in other words in an Emergency Department, in itself has got some limitations as to how we are going to go about diagnosing, treating and following up or helping to follow up these patients. it is the immediate problem that we are going to be attending to and we are not going to be providing the service of follow up care because that’s in the hands of the General Practitioner or the other sub-Specialty such as Respiratory Medicine, So I think that in itself, sort of inherently limits the scope of care that we provide. Number one is I would say, we can do change management better. there is very little thought put into the time it will take a Practitioner to actually deploy the service and if it does take time, what is the opportunity cost of that time and I do not ever see this being debated’	Motivation Reflective Automatic	Coercion Education	Reassure staff with education (P1) Automatic easier referrals through current software such as EDIS (P7) Prompts and clues including discharge templates for all COPD patients (P8)

Abbreviations: COM-B, capability, opportunity, motivation-behaviour model; TDF, theoretical domains framework; ED, emergency department; COPD, chronic obstructive pulmonary disease; BCW, behaviour change wheel.

Table 10 Identified Barriers Mapped to COM-B Model and Recommended Implementation Strategies from BCW and Participants for Domains 9,10, 11,12,13 (Beliefs About Consequences, Reinforcement, Optimism, Intention, Social Influences)

Guideline Uptake Barrier	Frequency Score/8	Participant Quotation (Barriers)	COM-B Components	Recommended Intervention (BCW)	Implementation Strategies from Participants
Domain.9 (Belief about consequences) Adverse health outcomes due to COPD guidelines adherence in ED	2	P7. Pharmacist: -“We get referrals where we can’t necessarily see everyone, so we’ve got to decide who the highest risk is and who we’re going to see. You can’t take up an Emergency bed to wait for a Pharmacist to arrive” P1. Physio.1:- “I would suspect if they will follow up with their GP within 24 to 48 hours to make sure that they are not deteriorating and I suspect that they are routinely followed up within the Respiratory team as well in the Outpatients Clinic in	Motivation Reflective	Education Environmental restructuring	Refer or arrange community pharmacist review (P7) Direct referrals to respiratory outpatient clinic for interdisciplinary input (smoking cessation, pulmonary rehabilitation, inhaler technique education) (P1, P7)
Domain.10 (Reinforcement) Reinforcing Clinician and interdisciplinary staff knowledge utilization and resource provision will improve guideline adherence	3	P1. Physio.1: -“COPD primary core practice nurse coming in and doing In-services and education training, easily accessible information, tool kits that are available on the Intranet”. P2. Physio.2:-“Providing information on who to refer to, how to refer to them, having someone based in the Department would be awesome, because that would break down the barrier of not being able to find them or they work ‘these’ hours and you don’t know where they are” P3. Nurse.1: - “Inhaler technique, we don’t give education to carers and family members who might be helping them at home, using their inhalers so that’s a huge barrier” P1. Physio.1- “consultants within ED or staff who are here more on the longer term could be involved in projects about COPD so that they are championing the cause”	Motivation Automatic	Education coercion	Education/in-service by ED and Thoracic respiratory department to increase utilisation (P1) Automatic referrals and documentation of the same during clinical care (P2) Pharmacy department to initiate inhaler technique educational sessions for staff (P3, P7) Automatic referrals to community for allied health input (P1, P7,P8)
Domain.11 (Optimism) Clinician and interdisciplinary staff attitude about COPD guideline adherence	3	P1. Physio.1: -“It might be possible with education awareness and perhaps – I know that there is a respiratory resource nurse or, someone like that who can be aware of the COPD patients coming to the hospital, coming through the ED and sort of making sure that these patients are getting those guidelines met” P4. Nurse.2: - -“There is a potential if patient getting discharged from ED to continue that multi-disciplinary care, exploring with the current network or service model. We’ve got an inpatient medical team with the multi-disciplinary support and how can that be expanded into the ED or community like hospital to home programme” P2. Physio.2:-“Community health staff provide antibiotics, nursing care and physiotherapy inputted into their care. So that will probably be the sort of expansion of the service that I can foresee happening. Would this also reduce inpatient admissions which would be more beneficial”	Motivation Reflective	Education Persuasion Enablement	Provide resources/guideline easily accessible for reference (P1) Improvise present systems and process based on staff opinion and less time consumption to complete (P4) Utilise Community health providers for referrals (P2)
Domain. 12 (Intention) Motivation and initiative to change and better care	2	P8. Doctor.2: - “As part of their discharge letter, there is an opportunity provide guidance to the Primary Care Physician about what should be done next” P6. Doctor.1: - “Communicating with the ward and saying “look we’re admitting this person or they need admission, but during this admission perhaps, we could focus on why they keep coming back frequently or what we can do that’s extra to what we’re doing?”	Motivation Reflective	Environmental restructuring Education	COPD discharge templates (P8) Direct referrals to ward or outpatient allied health for pulmonary rehabilitation (P1)
Domain. 13 (Social influences) Communication and suggestion of care might help	2	P3. Nurse.1:”Respiratory CNC won’t always come through Emergency and if it’s someone who’s going home, they’re probably seen as not that critical and I’m not sure how often they would be able to come or be willing to come down to Emergency” P6. Doctor.1:-“On our system we can flag frequent presenters so if it was used to streamline or communicate to the Respiratory Team then perhaps that could bring in some kind of intervention” P8. Doctor.2:- “Almost invariably, the last sentence to the GP is “can you please re-refer this patient to the Respiratory Outpatients for follow up”. This may or may not be done for the patient as it is not often followed up (p8)	Opportunity Social	Restriction Environmental restructuring Persuasion	Improve interdisciplinary communication using digital technology (P6) Reassuring staff with less time consuming referrals may lead to improve adherence (P7, P3, P8)

Abbreviations: COM-B, capability, opportunity, motivation-behaviour model; TDF, theoretical domains framework; ED, emergency department; COPD, chronic obstructive pulmonary disease; BCW, behaviour change wheel; GP, general practitioner; CNC, clinical nurse consultant.

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