The purpose of this research was to explore and describe barriers to the implementation of adjunctive NPWT for incorporation into acute paediatric burn care. This investigation identified eight barriers to the implementation of adjunctive NPWT into acute paediatric burn care covering five CFIR domains. In addition, this study has co-designed tailored strategies to address identified barriers to adjunctive NPWT implementation including the following: development of a NPWT implementation toolkit (INPREP toolkit) tailored to participating site’s local hospital guidelines and standards of care for the acute management of paediatric burn injuries; development and distribution of a suite of educational material and resources (i.e., NPWT education and troubleshooting guide for caregivers, and a NPWT clinician handout document containing a QR code linking to a detailed instructional video demonstrating adjunctive NPWT application using two different NPWT devices); established and conducted regular educational meetings; and identified and prepared NPWT champions at participating sites. These strategies will also address ambiguities regarding supporting evidence and the relative advantage of adjunctive NPWT for acute burn injuries.
Resource availability, or lack thereof, was identified as a significant barrier to the implementation of adjunctive NPWT into acute burn care at participating hospitals. This was one of the most commonly reported barriers in online questionnaire data across participating sites, and is consistent with previous reported studies as a significant barrier to implementation in healthcare settings (48, 49). Limited resources include access to operating theatres, staff time constraints (within EDs, Wards, and Burns Outpatient Departments), number of hospital beds, and number of NPWT devices available. Additional funding has been obtained to help address this barrier, however the power to influence some of these resource limitations are outside the scope of this investigation. Whilst initial staff time and expenses might increase with the implementation of adjunctive NPWT for acute paediatric burns, the potential reduction in time to re-epithelialisation and subsequent reduction in total number of dressings changes required for children, as well as reducing referrals to scar managements and skin grafting requirements, might reduce overall hospital costs and staff time constraints down the line.
Lack of, or limited access to, knowledge and information regarding NPWT use was also a common reported barrier. This CFIR construct is often described as a significant barrier in implementation science research – however this barrier is seldom reported in studies assessing NPWT use in burn wound care (20). Matched and tailored implementation strategies to address this barrier include the provision of in-person, in-service education and training sessions to improve clinical competence and understanding of the benefits of acute adjunctive NPWT for burn injuries. Education and training sessions will encompass practical exercises in NPWT application, how to achieve a seal in different anatomical regions, troubleshooting for different NPWT devices, and summaries of NPWT evidence.
Patient needs and resources was another implementation barrier to emerge from the data. Clinicians anticipate that NPWT will cause issues with mobilisation and walking when applied to foot burns, cause additional pain and discomfort for patients, require additional analgesia and sedation for patients, and place high levels of treatment burden on patients and their families. This is consistent with broader literature. In a recent randomised trial investigating adjunctive NPWT for acute paediatric burns – children treated with NPWT healed 22% faster compared to children who received standard care, but significant associated treatment burden related to NPWT use was identified (20). Parents and caregivers of burn patients (aged < 8 years) treated with adjunctive NPWT reported movement and at-home management of the device to be more difficult in comparison to the standard care group. Ten families (out of n = 47 in the intervention arm) in the aforementioned randomised trial requested premature removal and discontinuation of adjunctive NPWT due to issues with alarms (e.g., loss of pressure, air leaks in dressing, device charging abnormalities), difficulties attending school with the device, and the physical burden of carrying the NPWT pump (20).
Following the conclusion of this aforementioned trial, an informal telephone interview was conducted with approximately 60% of parents and caregivers of children in the adjunctive NPWT arm (including families who requested premature NPWT removal). When parents and caregivers were informed of the results of the investigation, and the 22% reduction in time to re-epithelialisation for children treated with adjunctive NPWT, all parents and caregivers reported that they would recommend this treatment to other families (50). Whilst data indicates increased treatment burden with NPWT for children and their families, there is inconclusive evidence to suggest that acute adjunctive NPWT application and removal causes additional pain and discomfort for paediatric burn patients (20, 50). In the aforementioned trial examining adjunctive NPWT for acute paediatric burns, NPWT application and removal was not found to be more painful than standard silver dressing changes, in accordance with burns clinicians, parents and caregivers, and patients (20). Despite this, healthcare professionals often report fear of increased pain in children during NPWT procedures (51).
In addition to developing implementation resources for clinicians, we created NPWT resources for patients, parents, and caregivers using data from interviews with families of burn patients who received NPWT within the last 12-months. Parents and caregivers reported wanting more information about adjunctive NPWT, how it works, the proposed benefits, and clear guidelines on when to return to hospital. Parents and caregivers also indicated that the information sheet provided to them following hospital discharge was for a NPWT device that was different to the device their child received (as hospital and health services can often have multiple NPWT devices from different manufactures). Furthermore, parents and caregivers indicated a preference to have both electronic and paper versions of the NPWT handout and troubleshooting guide. We developed a NPWT handout and troubleshooting guide incorporating all components requested from parents and caregivers. This resource included detailed information on NPWT in plain English, fall prevention tips, images of NPWT devices, what different alarms and alerts look like (with images) and how to resolve them, in-hours and after-hours hospital contact details, and information on when to present to the hospital.
Lack of hospital policies and guidelines, indicating an absence of government policies and/or local hospital and health service guidelines for the use and management of adjunctive NPWT for acute burn care, was reported as a barrier to NPWT implementation. At present, all participating hospitals involved in this research use NPWT – but not all sites use adjunctive NPWT in acute burn care. There are also conflicting guidelines for NPWT between participating sites and the maximum application timeframe for NPWT varies. Some hospitals have strict treatment duration timeframes – mandating NPWT removal after 72 hours (and reapplication of NPWT if required) whereas other sites permit continuous NPWT application for up to one week. To address these identified barriers, guidelines should encompass the appropriate use and management of NPWT for acute burn care, defining the optimal application timeframe for NPWT and establishing a consensus on its duration, ensuring consistent and evidence-based NPWT practices.
The level of complexity and intricacy to apply adjunctive NPWT to paediatric burn patients was also reported as an implementation barrier. Clinicians perceive adjunctive NPWT application to be complex and difficult. Moreover, NPWT application is believed to be more time consuming when compared to current standard care. This is also consistent with broader literature. Burns clinicians, comprising surgeons and senior burns nurses, reported acute adjunctive NPWT to be more difficult to manage in paediatric patients in comparison to standard care alone (i.e., silver impregnated dressings) (20). In addition, burns clinicians reported adjunctive NPWT application and removal to be more time consuming compared to standard care (20). Individual stage of change, indicating that clinicians are not enthusiastic about using NPWT or might prefer to use a different intervention, as well as knowledge and beliefs about NPWT were identified as significant barriers to the implementation of adjunctive NPWT for acute burn care in the current investigation. This CFIR construct ties in well with the previous reported construct (complexity). It is not surprising that clinicians are not enthusiastic about implementing a treatment they perceived to be more complex, intricate, and time consuming to use.
Strengths and Limitations
Strengths of this research include the involvement of relevant clinical stakeholders and end users. Identified barriers and resulting co-designed implementation strategies are evidence-based and acceptable to participating healthcare professionals across four Australian States. To promote trustworthiness, initial barrier data derived from electronic questionnaires were triangulated with participants in the subsequent semi-structured interviews. The co-designed strategies, however, require further testing to examine feasibility, acceptability, and appropriateness for adjunctive NPWT implementation into acute paediatric burn care. This will be examined in future studies.
Findings from this investigation must also be interpreted with consideration of several limitation. Limitations include the use qualitative mixed methods and self-report nature of the data. Verbatim semi-structured interview data were analysed using framework-guided rapid analysis methods over traditional in-depth thematic analysis. Rapid data analysis can be less rigorous and less trustworthy when compared to thematic data analysis (44). Moreover, qualitative methods such as these are susceptible to influence from researchers’ own expectations, assumptions, and views. However, to address this limitation, data coding was grounded in a theoretical framework (i.e., the CFIR), which contained predetermined and predefined barriers that helped minimise coding inaccuracies. In addition, healthcare professionals who participated in electronic questionnaires and semi-structured interviews volunteered to do so. This might have elicited a self-selection bias from clinicians who hold strong positive or negative feelings about adjunctive NPWT implementation into acute paediatric burn care. Moreover, this research did not include healthcare professionals from mixed hospitals that treat adult and paediatric patients, or rural and remote settings, and thus results might not be generalisable nationwide. It is recommended that future studies investigate adjunctive NPWT implementation into acute burn care in mixed adult and paediatric hospitals, as well as in rural, regional, and remote Australian healthcare contexts. Lastly, the electronic REDCap questionnaire used was purposed-built for the investigation. This questionnaire has not been validated or undergoing reliability testing, and therefore might not measure the intended concepts or produce consistent and reliable results across different settings, populations, or timepoints.