Preoperative Anemia and Iron Deficiency Screening, Evaluation and Management: Barrier Identification and Implementation Strategy Mapping

Figures & data

Figure 1 Data analysis process overview.

Table 1 Summarised Results of Identified Barrier by CFIR Domain and Construct

CFIR Domain	CFIR Construct	Barrier	Exemplar Quote
Outer setting	External policy and incentives	The structure of the Australian health care system is split into public and private healthcare sectors.	“A perverse incentive in the private setting exists around how we fund certain things. Prescribing a blood transfusion triggers a payment to the doctor (despite evidence suggesting we should be working towards reducing the number of blood transfusions).”
	Patient needs and resources	Patients explained that they were often not given information about anaemia or screening before surgery. Patients are reluctant to come back for testing.	Patients stated their source of information came from “Mrs Google”. Ward nurses shared that often patients “ … just take advice from the doctors.” Surgeons stated “ … getting patients to come back on multiple occasions to the hospital when they are anaemic can be difficult at the best of times.”
Inner setting	Structural characteristics	Different care models impede care standardisation. “Silos” in health care facilities.	The “public model would see a lot more clinicians involved in maintaining a standard of care.” Pre-admission staff stated, “… there is a definite difference in process. Most private consultants use their own private physician who decides what that patient requires and I’m not aware of the level of workup … however, our level of workup here in the public appears to be more robust.” Blood bank stated, “ … because we are shut away, they don’t see A) how hard we work or B) that we are very patient focused.”
	Networks and communications	Limited interprofessional relationships. Opportunities for communication. Knowing who can help with improvements.	Haematology stated, “… potentially it can be a little bit of an awkward discussion if you’re challenging someone’s management. So, especially if it’s, as you said, a very senior and experienced person who has been doing something somewhere for a long time. You’d have to have personality to be able to deal with those interactions.” Clinical governance stated, “… I think there’s a gap there in having the opportunity to attend meetings where audit results might be getting discussed, and then having the opportunity to, I guess, have some input and try and give examples of what the results are trying to say. I don’t think we’re given that opportunity.” Pre-admission stated, “… there’s too many layers. So I have to go through about five people to get to the person I need: One person does the marketing, one does the clinical forms, one does the nonclinical forms, one does the patient information … none of them speak to each other and it’s awful.”
	Implementation climate - Relative priority	Not considered a high priority by some in the organisation as it is not perceived as being appealing or interesting by clinical and executive staff.	Pre-admission stated, “… I think they’re disengaged with making further improvements because there are further improvements that can be made … but It’s (PAIDSEM-P) a pretty dry subject for people and not many people are passionate about it. So, it’s very low on the list of priorities.”
	Readiness for implementation- Available resources	The public model has more resources for preoperative workup, in contrast to the private sector, where this is minimal due to funding arrangements.	The surgeon stated, “… the facility for fixing someone’s anaemia preoperatively is a more difficult path to go down because in the public sphere they get sent to the pre-admission clinic, the preoperative team look after it, and they manage the preoperative anaemia. In the private sphere, there isn’t a centralised service such as that. So, you’d have to book a haematologist, or go back to a GP to determine what would be appropriate blood transfusion, or blood correction of anaemia.”
	Readiness for implementation - access to knowledge and information	Patients or staff do not know where to access information, cannot access it flexibly, have too much to sift through or receive it in such a distilled form that it loses meaning.	Clinical governance stated, “I think one big gap is the accessibility of our documents, particularly for medical staff. So, having them easily available on the internet, or an app by the phone, just some way that they can get access to our documents to review different things. (would be helpful)” Executive staff commented, “There’s a lower level of awareness amongst the private specialists. Whilst regular communications go out to them, they’re usually in an abbreviated format and with the amount of policy updates and production, they don’t see as much detail as an employed doctor would see. So, one of the big areas that’s challenging is the private sector.”
Individual characteristics	Knowledge and beliefs about the intervention Self-efficacy	Variation in practice is evident across the organisation as outlined in previous audits, and was acknowledged throughout the interview process	The anaesthetist commented, “… patients don’t necessarily get the blood tests, and if they get blood test, it’s analysing the blood tests appropriately. Which, for example, I’m picking the example of ferritin as a number. Someone’s got a haemoglobin of 108 and the ferritin is 31 and they come in for a major surgery. The ferritin is just one above the reference range, which satisfies the GP and the surgeon. They could all be happy with that, but as far as I’m concerned, it significantly increases the risk of a blood transfusion in the perioperative period.” Medical staff stated, “People’s beliefs are probably the biggest barriers we have”. He explained that “I think it’s purported to be strong science but so was the evidence behind previous iterations of the guidelines. And obviously if they’re different, they both can’t be right, but they’re both alleging they’re right.“
	Self-efficacy	Discomfort with the idea of speaking up for best practice.	One Nurse stated, “We probably don’t speak up enough. We definitely don’t inquire as to is this necessary, it’s really not something that is done very well. We don’t necessarily have the … you know, the haemoglobin’s ninety-eight and completely asymptomatic and maybe they don’t need that bag of blood today.”
Process	Executing	The absence of a policy that supports best practice.	The anaesthetist commented, “If any policy says you shouldn’t have given IV Iron under anaesthesia it creates a barrier, because even if you’re doing what’s in the best interest of patients, if they were one of the rare people and had adverse reactions, you would feel unsupported because you’re going directly against the guideline.”

Table 2 Actor, Action, Barriers and Recommended Strategies

Actor	Action	Barriers CFIR	Recommended Implementation Strategies (ERIC)
Patient	Comply with requests to have blood tests promptly	Access to knowledge and information	Conduct educational meetings. Develop educational materials. Distribute educational materials
		Patient needs and resources	Obtain and use patients/consumers family feedback. Involve patients/consumers/family members. Conduct a local needs assessment.
Anaesthetist	-Initiate preventative treatment through referral to GP or hospital IV Iron infusion clinic - Provide IV Iron instead of blood if appropriate	Knowledge and beliefs about the intervention	Conduct educational meetings
		Executing	Nil strong recommendations
Surgeon/ Surgical Residents/ Perioperative medicine teams	Initiate test requests and follow up	Access to knowledge and information	Conduct educational meetings. Develop educational materials. Distribute educational materials.
		Available resources	Access new funding
		Knowledge and beliefs about the intervention	Conduct educational meetings
		Patient needs and resources	Obtain and use patients/consumers family feedback. Involve patients/consumers/family members. Conduct a local needs assessment
Ward Physicians/ Clinical haematologists	- Use restrictive transfusion thresholds - Use Iron supplementation instead of blood, where appropriate	Knowledge and beliefs about the intervention	Conduct educational meetings
Pathology/ Blood bank	- Perform tests in a timely manner - Streamline processes to enable add on screening - Communicate with clinicians to support sound clinical decision making	Available resources	Access new funding
		Executing	Nil strong recommendations
		Structural characteristics	Nil strong recommendations
Lab haematologist	- Encourage practise in line with PBM guidelines - Communicate with clinicians to support sound clinical decision making	Networks and communications	Promote network weaving. Organise clinician implementation team meetings
		Knowledge and beliefs about the intervention	Conduct educational meetings
		Structural characteristics	Nil strong recommendations
Preadmission/ Private practice nurses	- Check results and help facilitate treatment or referral - Educate patients about anaemia and the importance of addressing - Champion the change and liaise with the treating team	Networks and communications	Promote network weaving. Organise clinician implementation team meetings
		Relative priority	Nil strong recommendations
		Structural characteristics	Nil strong recommendations
Ward nurses	- Encourage restrictive approach - Liaise with physicians when blood may not be needed - Educate patients about blood management	Knowledge and beliefs about the intervention	Conduct educational meetings
		Patient needs and resources	Obtain and use patients/consumers family feedback. Involve patients/consumers/family members
		Self-efficacy	Nil strong recommendations
Executive staff	- Endorse policy and procedure - Allocate sufficient resources - Encourage engagement between physicians and clinical governance	Access to knowledge and information	Conduct educational meetings. Develop educational materials. Distribute educational materials
		External policy and incentives	Nil strong recommendations
		Structural Characteristics	Nil strong recommendations
Clinical governance/ quality	- Develop process, policy and procedure - Facilitate consensus discussions - Consult with educators to ensure accurate content delivery - Monitor and report progress to relevant stakeholders - Gain engagement from senior leadership	Networks and communications	Promote network weaving. Organise clinician implementation team meetings
		Access to knowledge and information	Conduct educational meetings Develop educational materials Distribute educational materials
		Available resources	Access new funding
		Knowledge and beliefs about the intervention	Conduct educational meetings

Note: Bolded CFIR barriers indicate a strongly recommended ERIC strategy exists.