Barriers and Co-Designed Strategies for the Implementation of Negative Pressure Wound Therapy in Acute Paediatric Burn Care in Australia: A Mixed Method Study

Barriers and Co-Designed Strategies for the Implementation of Negative Pressure Wound Therapy in Acute Paediatric Burn Care in Australia: A Mixed Method Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Barriers and Co-Designed Strategies for the Implementation of Negative Pressure Wound Therapy in Acute Paediatric Burn Care in Australia: A Mixed Method Study Maleea D Holbert, Jed Duff, Fiona Wood, Andrew Holland, Warwick Teague, and 13 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3577058/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Paediatric burn injuries pose a major clinical problem worldwide and result in significant morbidity. Early adjunctive application of negative pressure wound therapy (NPWT) significantly improves time to healing by re-epithelialisation in children with burns. This treatment strategy has not been consistently adopted as part of acute paediatric burn care. Methods This investigation used a sequential mixed methods design to identify and explore barriers to the implementation of adjunctive NPWT in acute paediatric burn care. An online questionnaire was developed and disseminated to healthcare professionals within four major paediatric hospitals in Australia, each with a dedicated burns service. Specific barrier data were coded according to the Consolidated Framework for Implementation Research (CFIR). Semi-structured interviews were then conducted with senior clinicians across the four participating hospitals to tailor implementation strategies to local contexts. A stakeholder consensus meeting was then conducted to consolidate implementation strategies and local processes. Results A total of 63 healthcare professionals participated in the online questionnaire, and semi-structured interviews were conducted with nine senior burn clinicians. Two interviews were also conducted with parents and caregivers of paediatric burn patients who had received adjunctive NPWT as part of their acute burn treatment within the last 12-months. This investigation identified eight implementation barriers across all five CFIR domains then co-designed targeted strategies to address these identified barriers. Barriers included lack of available resources, limited access to knowledge and information, individual stage of change (which describes clinicians’ readiness or enthusiasm to change practice), patient needs and resources, limited knowledge and beliefs about the intervention, lack of external policies and incentives, intervention complexity, and poor planning of the intervention implementation. Conclusion There are multiple and inter-related contextual characteristics that influence the uptake of adjunctive NPWT into acute paediatric burn settings in Australia. Results from this investigation will be used within a multi-state stepped-wedge cluster randomised controlled trial. In order to implement adjunctive NPWT into clinical practice for the acute treatment of paediatric burn injuries, additional resources, education, training, and updates to policies and guidelines are required. It is anticipated that adjunctive NPWT, in conjunction with tailored implementation strategies, will enhance adoption and sustainability. Trial Registration This trial was prospectively registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR) on the 1st of February 2022 – registration number ACTRN12622000166774. Critical Care & Emergency Medicine Burns Negative Pressure Wound Therapy Implementation Health Service Child Health Figures Figure 1 Figure 2 Contributions to the Literature This research is the first to investigate barriers to the implementation of early adjunctive negative pressure wound therapy (NPWT) for acute burn injuries within a paediatric hospital setting. The Consolidated Framework for Implementation Research and the Expert Recommendations for Implementing Change were used to determine and explore barriers to NPWT implementation and develop matched strategies to overcome identified barriers. To implement adjunctive NPWT into clinical practice for the acute treatment of paediatric burn injuries, additional resources, education, training, and updates to hospital policies and guidelines are required. Background Burns rank among the top five most common causes of non-fatal childhood injuries worldwide ( 1 , 2 ). In Australia, thousands of children present to Emergency Departments (EDs) each year with burn injuries that require acute management and definitive wound care ( 3 ). Accidental scald and contact injuries are the most frequent causes of paediatric burns, often resulting from hot liquid and food spills and contact with hot surfaces ( 3 ). A considerable proportion of childhood burn injuries are small to medium in size: the Burns Registry of Australian and New Zealand (BRANZ) reports nearly 90% of paediatric burn injuries were less than 10% total body surface area (TBSA) ( 3 ). Burns less than 5% TBSA were recorded in 62% of paediatric cases ( 3 ). While the majority of paediatric burns seen in Australia are relatively small, these injuries demand carefully planned treatment to reduce the risk of infection and improve time to re-epithelialisation ( 4 ). Infection and scarring remain common problems for paediatric patients, even in those with smaller burns, despite advances in knowledge and treatment including evidence based first aid ( 5 ), early debridement ( 6 ), burn pain ( 7 ), and silver-impregnated dressings ( 8 , 9 ). Previous studies have shown the strongest predictor of scarring in paediatric burn patients is time to healing, defined as 95% burn wound re-epithelialisation ( 10 ). Burn wounds taking longer than 14–17 days to re-epithelialise are at significantly increased risk of hypertrophic scarring ( 11 ), this affects between 16% and 35% of children who sustain burns [( 10 ) and ( 6 ) respectively]. Therefore, a critical goal of burn care is to achieve more rapid re-epithelialisation to reduce the impact of scarring. Negative pressure wound therapy (NPWT) is a wound dressing system that provides sub-atmospheric pressure within a closed dressing. It is associated with improved patient outcomes in a wide range of complex chronic and acute wounds ( 12 – 14 ). Proposed mechanisms and benefits of NPWT include the induction of macrodeformation (i.e., wound contraction), microdeformation (i.e., tissue and dressing interactions on a microscopic level), stimulation of angiogenesis around the wound bed, promotion of granulation tissue, improved microvascular perfusion, oedema control, wound exudate control, and reduced risk of infection via decreasing bacterial loads ( 15 – 17 ). There is strong evidence from experimental ( 18 ), randomised controlled trials (RCTs) ( 19 , 20 ), and prospective cohort studies ( 21 – 25 ) to support the benefits of adjunctive NPWT in acute burn care. Compared to standard silver-impregnated dressings alone, early adjunctive NPWT (i.e., applied over standard silver dressings) results in significant improvements in time to re-epithelialisation in children with burns, and decreases dressing change requirements and referrals for scar management ( 20 ). Early adjunctive treatment in this context refers to NPWT application within the first 48-hours post-burn. Adjunctive NPWT applied within the first 48 hours of the initial burn aims to reduce burn wound progression and the development of deeper injuries, as vascular comprise can worsen for up to 48 hours post-burn ( 14 ). Adjunctive NPWT can also offer a cost-effective solution for the acute treatment of paediatric burns. One recent investigation evaluated the healthcare costs of adjunctive NPWT in small-area paediatric burns, and found the mean total cost was $ 765 AUD less per person for those treated with adjunctive NPWT compared to standard silver dressings alone [ $ 904 AUD (95% CI 671–1235) compared to $ 1,669 AUD (95% CI 659–3269)] ( 26 ). NPWT has been used for decades as a non-invasive treatment to bolster skin grafts in burn and non-burn patients to reduce shearing forces and promote graft take ( 27 – 31 ). Whilst some specialist burn services make selected or ad hoc use of adjunctive NPWT in children during the acute burn phase (i.e., within 48-hours post-burn or after initial wound debridement), a wider and more systematic application informed by evidence-based guidelines is lacking. Any intervention which reliably improves time to re-epithelialisation in paediatric burn patients warrants further consideration for implementation into recommended best practice. Within healthcare research, considerable time lags from the identification of evidence-based treatments to their widespread implementation into clinical practice are well recognised ( 32 , 33 ). This investigation aimed to identify barriers to the application and use of adjunctive NPWT for the acute management of paediatric burn injuries in a hospital setting and co-design implementation strategies to address identified barriers. Co-design in healthcare research is a collaborative and iterative process aiming to bring together relevant stakeholders to address implementation issues, develop targeted solutions, and improve patient outcomes. Our co-design process targeted experienced burn surgeons, burn nurses and nurse practitioners, burn allied health staff, ED doctors, ED nurses, and ED nurse practitioners with a focus on identification of NPWT implementation barriers within their local hospital and health service. In this paper, we discuss themes and strategies relating to barriers to the implementation of adjunctive NPWT into acute burn care at four paediatric hospitals with dedicated burns centres. A im and Objectives This investigation aimed to determine barriers to the implementation of adjunctive NPWT for the acute management of paediatric burn injuries and co-design targeted implementation strategies. To achieve this aim, the following research objectives were completed: Determine barriers to acute adjunctive NPWT implementation via a purpose-built electronic questionnaire and semi-structured interviews with relevant clinical stakeholders. Co-design tailored strategies to overcome the identified barriers in acute adjunctive NPWT implementation. These strategies will serve as the foundation for an NPWT implementation toolkit specifically designed for the acute care of paediatric burn patients. The co-designed implementation strategies will inform the “Implementation of Negative PressuRe for acutE Paediatric burns” (INPREP) toolkit. The INPREP toolkit will subsequently undergo testing in a type III hybrid implementation-effectiveness study, utilizing a stepped-wedge cluster randomised controlled trial (SW-RCT) ( 34 – 37 ) design with results to be reported separately. Methods Study Design A sequential mixed methods qualitative approach was used to address the study aims comprising: i) electronic questionnaires, ii) semi-structured interviews, and iii) a stakeholder consensus meeting. Procedures for each are outlined below. Study Setting Participating sites were distributed across four tertiary children’s hospitals, each the nominated statewide burns referral centre for their respective Australian states (New South Wales, Queensland, Victoria, and Western Australia). Participants Participants recruited for this investigation comprised of healthcare professionals involved in the acute treatment and management of paediatric burn injuries across four participating paediatric hospitals. Participants included medical consultants, junior medical officers, registered nurses, clinical nurse consultants, nurse practitioners, and allied health staff from burns and ED departments across the four participating sites. As aforementioned, parents and caregivers of paediatric burn patients who had received adjunctive NPWT within the last 12-months were also invited to participate in a semi-structured interview. Procedures Electronic Questionnaires A purpose-built electronic questionnaire was developed and managed using REDCap (Research Electronic Data Capture, Vanderbilt, USA, hosted at Griffith University). REDCap is a secure, web-based software platform designed to support data capture for research studies ( 38 , 39 ). The questionnaire was disseminated to healthcare professionals involved in the acute treatment of burn injuries at the four participating hospitals (full questionnaire provided in Supplementary File 1). The questionnaire focused on engagement with clinical stakeholders in the identification, specification, and prioritisation of NPWT implementation barriers. The questionnaire contained three paediatric burn clinical case scenarios, and asked participants to record perceived barriers to the application and use of early adjunctive NPWT for that specific patient (via a free text-response box in the online questionnaire). The three clinical case scenarios were developed by a multidisciplinary team of burns experts and piloted on 12 healthcare professionals and burns researchers. The scenarios aimed to capture a variety of clinical and contextual variables, which cover the scope of projected future adjunctive use of NPWT in acute paediatric burn care. Using a free text response box, participants were also prompted to list barriers perceived to impact their ability to deliver optimal, evidence-based acute paediatric burn care at their local hospital and health service. Electronic Questionnaire Data Analysis Deductive coding based on the Consolidated Framework for Implementation Research (CFIR) was used to evaluate free text data on barriers to NPWT implementation gathered from the electronic REDCap questionnaires ( 40 ). The CFIR is a determinant framework and uses five domains (inner setting, outer setting, intervention characteristics, characteristics of individuals, and planning) to understand barriers to implementation in complex systems ( 41 ). The CFIR was used to develop a comprehensive understanding of the complex contextual characteristics of acute burn care (EDs/burn centres) across multiple Australian states and contexts so that early adjunctive NPWT implementation strategies can be better targeted. Identified CFIR barriers from questionnaire data were used to generate matched implementation strategies using the Expert Recommendations for Implementing Change (ERIC) matching tool ( 42 ). Semi-Structured Interviews Semi-structured interviews were then conducted with senior clinicians at each participating hospital, using interview questions derived from the electronic questionnaire data; The CFIR Interview Tool Guide ( 43 ) was used to generate interview questions based on identified CFIR domains and constructs from questionnaire data. Interview questions were open-ended and designed to generate detailed responses from clinicians. Semi-structured interviews aimed to determine clinicians’ level of agreement and consensus with adjunctive NPWT implementation barriers identified in the initial questionnaire, and to further develop the matched implementation strategies tailored to local needs. In addition, these interviews examined for consensus or divergence of clinician opinion on other key clinical aspects of adjunctive NPWT use in acute paediatric burn care (clinician interview guide is provided in Supplementary File 2). Site principal investigators identified senior clinicians within their local hospitals. Potential participants were emailed information about the research and invited to partake in a semi-structured interview (hosted online via Microsoft Teams or in-person). Interviews were recorded and transcribed verbatim. To gain relevant consumer feedback and involvement, two semi-structured telephone interviews were conducted with parents and caregivers of paediatric burn patients who had received adjunctive NPWT as part of their acute burn treatment within the last 12-months. Interviews were conducted with one parent-caregiver of a child treated as an inpatient receiving adjunctive NPWT, and one parent-caregiver of a paediatric patient treated as an outpatient receiving adjunctive NPWT (parent-caregiver interview guide is provided in Supplementary File 3). Semi Structured Interview Data Analysis Semi-structured interview data were analysed using framework-guided rapid analysis methods ( 44 , 45 ). Verbatim transcripts were summarised using a structured template based on the five CFIR domains and matched ERIC strategies, and then consolidated into matrices with actionable and tailored recommendations for adjunctive NPWT implementation into acute burn care based on hospital sites. This allowed for group comparisons of consolidated data across the four sites to determine core components and themes, and components that need to be tailored to local contexts. Consensus Meeting Following the dissemination of electronic questionnaires and semi-structured interviews with burn and ED clinicians across the four participating sites, a consensus meeting was held to present questionnaire and interview data back to the consensus group – to ensure relevant stakeholders at participating hospitals were satisfied with the tailored implementation strategies. The consensus meeting was conducted using informal consensus development panel methods ( 46 ). An online meeting was held via Microsoft Teams in April 2023. The stakeholder consensus group comprised of experts in burn care, chief investigators, and site principal investigators from New South Wales, Queensland, Victoria, and Western Australia. On meeting commencement, stakeholders were reintroduced to the aims of the consensus meeting (i.e., gaining final consensus tailored implementation strategies). Questionnaire and interview data were presented and whole group discussions occurred until final consensus was reached. Following the consensus meeting, detailed minutes of the discussions were documented and disseminated out to the consensus group participants. Figure 1 . Generation of initial barrier data perceived to impact the implementation of adjunctive NPWT into acute paediatric burn care across participating sites, generation of matched implementation strategies (non-tailored), tailoring of implementation strategies, and consolidation and consensus of strategies and processes to form the evidence-based intervention and INPREP toolkit. Results Results presented below are an integration of findings from electronic questionnaires, semi-structured interviews, and stakeholder consensus meeting data. CFIR Domains and Constructs – Barriers to NPWT Implementation The following barriers regarding the implementation of NPWT for acute paediatric burn injuries were generated from N = 63 healthcare professionals who responded to the electronic REDCap questionnaire; n = 18 from New South Wales, n = 20 from Queensland, n = 16 from Victoria, and n = 9 from Western Australia. Participant’s professional streams are presented below in Table 1. Eight barriers (CFIR constructs) covering five CFIR domains were identified: 1. INNER SETTING Lack of Available Resources Resources (e.g., operating theatre access, bed availability, staff availability, time constraints, and number of available NPWT devices) are insufficient to support implementation of adjunctive NPWT into acute paediatric burn care. “Sometimes in peak burn seasons (e.g. school holidays), we run out of NPWT pumps, which prevents us from being able to apply NPWT…” (Participant 23) “Time, staff, non-specialty staff, high ED turnover with an already significant learning need, storage of supply, emergent nature of department requiring nurses to be pulled at a moment’s notice” (Participant 34) “…if operating theatre not available, attempting a NPWT dressing in a burn of this size on a child of this age is going to be very difficult in an ED setting without a GA so may be more prudent to opt for non-NPWT options.” (Participant 55) Lacking Access to Knowledge and Information Stakeholders lack adequate access to digestible information and knowledge about adjunctive NPWT and how to best incorporate adjunctive NPWT into acute burn care at their hospital and health service (e.g., lack of clinical guidelines surrounding early adjunctive NPWT use, lack of NPWT troubleshooting resources for clinicians and families; lack of trained and experienced staff). “Not all [Participating Hospital Site] ED Nursing staff are proficient in the application of NPWT dressings. Currently ED would rely on Burns Nursing staff for support and education” (Participant 18) “No idea what NPWT is” (Participant 42) “I've never heard of NPWT” (Participant 44) 2. CHARACTERISTICS OF INDIVIDUALS Individual Stage of Change Stakeholders acknowledged a lack of skills or enthusiasm about using NPWT in a sustained way (e.g., clinicians view it as extra work). “Nursing concerns over additional time and resources to both apply and monitor NPWT as well as patient discomfort” (Participant 10) “A VAC dressing is time consuming for an ED Department – takes regular skill from the user to apply” (Participant 35) “…Concerned burden of increased workload of new dressings and associated staffing and sedation will fall onto the emergency department” (Participant 30) Knowledge & Beliefs about the Intervention Clinical stakeholders have negative attitudes toward early adjunctive NPWT, place low value on implementing adjunctive NPWT into acute paediatric burn care, and/or are not familiar with current evidence supporting early adjunctive NPWT (e.g., clinicians are unsure or sceptical about the benefits of adjunctive NPWT compared to standard care and other adjunctive treatments). “Logistical barriers – dressing takes longer to place, more difficult for parents to manage at home. Clinician preference – I am interested in being involved in trials for NPWT and partial thickness burns but I am not aware of enough evidence to change my standard practice, particularly for burns away from limbs” (Participant 57) “There is evidence for improved outcomes with the application of Biobrane within 24-hours of mid-dermal burns” (Participant 16) “Want to know that significant improvement in wound healing timeframes to make a difference and justify use and change in practice…” (Participant 19) “Unclear evidence for better outcome in this age group” (Participant 50) 3. OUTER SETTING Patient Needs and Resources Patient needs, including barriers and enables to meet those needs, are not accurately known (e.g., clinicians suspect NPWT will cause issues with mobilisation and walking when applied to foot burns, cause pain and discomfort for paediatric patients, and place an additional burden on parents and caregivers). “…Parents already have a lot of things going on with an active toddler they are less likely to want to use it…” (Participant 3) “…Does standard Acticoat dressing provide similar healing results and timeframes, less costly, and easier for patient and family to manage?” (Participant 19) “Patient reluctance to carry the machine, restriction on schooling, and whether parents are able to take time off to care for [the] patient” (Participant 32) “Age – would unlikely tolerate the pump device. Parents – they would find keeping the kid away from the pump difficult” (Participant 49) Lack of External Policy & Incentives External policies, regulations, mandates, recommendations, or guidelines do not exist to implement the innovation into acute burn care (e.g., lack of hospital policies surrounding use of adjunctive NPWT for acute paediatric burn management, clinician do not view early adjunctive NPWT as standard treatment for acute burn injuries). “Lack of current policy for NPWT, lack of training, lack of availability” (Participant 12) “…decision makers need to update their approaches to burn wound management to prioritise early(ier) debridement AND primary application of NPWT – new dressing skills need to be learned by a broader population of staff – health service has to increase financial outlay at the front end of patient care with the prospect (but not guarantee) of a later saving” (Participant 55) 4. INTERVENTION CHARACTERISTICS Complexity Clinical stakeholders hold the belief that NPWT is complex, based on their perception of duration, scope, disruptiveness, intricacy, and the number of steps involved in its implementation. For instance, clinicians commonly perceive adjunctive NPWT as challenging and time consuming to apply, anticipating an increased need for analgesia and sedation for patients that receive early adjunctive NPWT in comparison to standard care. “Intricacy of application, benefit versus standard dressing, obtaining and maintaining a seal, requirement for analgesia and sedation” (Participant 19) “Application is already difficult on tiny toes and feet. I honestly cannot even imagine how negative pressure would work in this way. NPWT would be better suited to a flat surface burn in my experience. Also, you can't even get a sats probe on a 2-year-old without them having a tantrum so I don't think a machine connected to their feet would stay on for very long” (Participant 27) “…Unless staff in ED get regular support from these services we cannot take on a more complicated dressing technique such as NPWT” (Participant 35) 5. PROCESS Planning: A structured scheme or sequence of tasks necessary to implement adjunctive NPWT into acute burn care has yet to be developed. This is exemplified by the absence of adjunctive NPWT application within the ED processes of certain participating hospitals. “NPWT not historically an ED treatment. No exposure to education in this space. No idea of how to access NPWT resources or experienced staff” (Participant 42) Implementation Strategies – Matched ERIC Strategies and Tailored Strategies The following implementation strategies presented below in Fig. 2 were selected from the CFIR-ERIC Barrier Buster V0.53 tool ( 47 ) to address identified barriers and challenges to adjunctive NPWT implementation into acute burn care. This tool generates and selects implementation strategies using identified CFIR constructs. Semi-structured interviews were conducted with nine clinicians across New South Wales, Queensland, Victoria, and Western Australia, which were then used to tailor the generated CFIR-ERIC matched implementation strategies to local contexts. Interviews aimed to extrapolate details of identified barriers to define the INPREP toolkit and matched implementation strategies for each participating site. Table 2 below presents the initial matched implementation strategies (generic and non-tailored) and the tailored implementation strategies, which incorporated data and feedback from semi-structured clinician interviews. Figure 2. CFIR domains and implementation barriers (constructs) that emerged from online questionnaire data, the associated matched ERIC strategies, and their influence on implementation into clinical practice. Figure 2 has been adapted from Damschroder et al. Figure: Major Domains of the CFIR ( 40 ). Table 2. Initial CFIR-ERIC matched implementation strategies were refined and tailored to local needs and contexts during semi-structured interviews with clinicians, and then consolidated in a consensus group meeting with clinical investigators. Discussion 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. Conclusion The time lag in evidence-to-practice implementation is a well-recognised issue in clinical and healthcare research. This investigation is one of the first to define barriers and co-design tailored strategies and treatment plans for the implementation of adjunctive NPWT for acute paediatric burns. Furthermore, findings from this research can help inform and guide other acute burn related implementation studies in the future, the implementation of other technologies, devices, or treatment pathways for paediatric patients in a healthcare setting. This investigation identified several barriers to adjunctive NPWT implementation in the acute management of paediatric burn injuries and co-designed targeted implementation strategies to address these barriers. The mixed methods co-design approach used in this investigation enabled detailed contextualisation and identification of factors affecting implementation and adoption of early adjunctive NPWT across four Australian states. This ensured that implementation strategies were relevant, comprehensive, and tailored to the specific contexts of each participating hospital. The implementation strategies developed as part of this investigation will be adopted as part of a type III hybrid implementation-effectiveness SW-RCT. Findings and implementation strategies from this research can help inform and guide the implementation of adjunctive NPWT in other acute care settings, leading to improved patient outcomes and quality of care for children who have acquired a burn injury. List of Abbreviations ANZCTR: Australian and New Zealand Clinical Trials Registry AUD: Australian Dollars BRANZ: Burns Registry of Australian and New Zealand CFIR: Consolidated Framework for Implementation Research CHQHHS: Children’s Health Queensland Hospital and Health Service CI: Confidence Intervals ED: Emergency Departments ERIC: Expert Recommendations for Implementing Change GCP: Good Clinical Practice HREC: Human Research Ethic Committee NHMRC: National Health and Medical Research Council NPWT: Negative Pressure Wound Therapy RCT: Randomised Controlled Trial REDCap: Research Electronic Data Capture TBSA: Total Body Surface Area USA: United States of America VSM: Victorian Specific Module WASM: Western Australian Specific Module Declarations Ethics approval and consent to participate Human Research Ethics Committee (HREC) approval has been obtained for this investigation (HREC/21/QCHQ/81002) from Children’s Health Queensland Hospital and Health Service HREC. This research was also approved by the Griffith University Human Research Ethics Committee (GU Ref No: 2022/157). Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This project has been awarded funding from the National Health and Medical Research Council (NHMRC) Partnership Projects PRC2 Funding ID: 2006970. Authors’ contributions BRG is the lead coordinating principal investigator – she designed the trial and obtained research funding. JD is the lead implementation scientist. DV is the lead biostatistician. LC is the lead scientist. SM is the lead health economist. ADY is the lead child psychologist. FW, AJAH, WT, NP, KS, DC, YS, LM, CF, PC, and RMK are investigators who contributed to the development and design of the trial at each of the participating paediatric hospitals. MDH wrote the draft manuscript, conducted semi-structured interviews, and analysed the data. All authors have read and approved the final manuscript. Acknowledgements We acknowledge and thank the following partners for their assistance in developing this research; The Children’s Hospital at Westmead, Perth Children’s Hospital, Queensland Children’s Hospital, and The Royal Children’s Hospital Melbourne. We would also like to acknowledge and give thanks to Dr Laura Damschroder for providing permission to adapt and reproduce her Major Domains of the CFIR Figure (40) . References World Health Organisation. Global Burden of Disease Geneva. 2008. [Accessed September 2023] Peck MD. Epidemiology of burns throughout the world. Part I: Distribution and risk factors. Burns. 2011;37(7):1087-100. Burns Registry of Australia and New Zealand (2022). Annual Report 2020/21. Department of Epidemiology and Preventive Medicine, Monash University. Melbourne, Australia. [Accessed September 2023] Greenhalgh DG. Management of Burns. N Engl J Med. 2019;380(24):2349-59. Griffin BR, Frear CC, Babl F, Oakley E, Kimble RM. Cool Running Water First Aid Decreases Skin Grafting Requirements in Pediatric Burns: A Cohort Study of Two Thousand Four Hundred Ninety-five Children. Ann Emerg Med. 2019;75(1):75-85. Griffin B, Bairagi A, Jones L, Dettrick Z, Holbert M, Kimble R. Early non-excisional debridement of paediatric burns under general anaesthesia reduces time to re-epithelialisation and risk of skin graft. Sci Rep. 2021;11(1). Holbert MD, Kimble RM, Jones LV, Ahmed SH, Griffin BR. Risk factors associated with higher pain levels among pediatric burn patients: A retrospective cohort study. Reg Anesth Pain Med. 2021;46(3):222. Wang Y, Beekman J, Hew J, Jackson S, Issler-Fisher AC, Parungao R, Lajevardi SS, Li Z, Maitz PKM. Burn injury: Challenges and advances in burn wound healing, infection, pain and scarring. Adv Drug Deliv Rev. 2018;123:3-17. Nunez Lopez O, Cambiaso-Daniel J, Branski LK, Norbury WB, Herndon DN. Predicting and managing sepsis in burn patients: Current perspectives. Ther Clin Risk Manag. 2017;13:1107-17. Chipp E, Charles L, Thomas C, Whiting K, Moiemen N, Wilson Y. A prospective study of time to healing and hypertrophic scarring in paediatric burns: Every day counts. Burns Trauma. 2017;5(1):1-6. Cubison TCS, Pape SA, Parkhouse N. Evidence for the link between healing time and the development of hypertrophic scars (HTS) in paediatric burns due to scald injury. Burns. 2006;32(8):992-999. Kantak NA, Mistry R, Varon DE, Halvorson EG. Negative pressure wound therapy for burns. Clin Plast Surg. 2017;44(3):671-677. Anghel EL, Kim PJ. Negative-pressure wound therapy: A comprehensive review of the evidence. Plast Reconstr Surg. 2016;138(3 Suppl):129S-137S. Krug E, Berg L, Lee C, Hudson D, Birke-Sorensen H, Depoorter M, Dunn R, Jeffery S, Duteille F, Bruhin A, et al. Evidence-based recommendations for the use of negative pressure wound therapy in traumatic wounds and reconstructive surgery: Steps towards an international consensus. Injury. 2011;42(Supplement 1):S1-S12. Lalezari S, Lee CJ, Borovikova AA, Banyard DA, Paydar KZ, Wirth GA, Widgerow AD. Deconstructing negative pressure wound therapy. Int Wound J. 2017;14(4):649-657. Borgquist O, Gustafsson L, Ingemansson R, Malmsjö M. Micro- and macromechanical effects on the wound bed of negative pressure wound therapy using gauze and foam. Ann Plast Surg. 2010;64(6):789-793. Daigle P, Despatis MA, Grenier G. How mechanical deformations contribute to the effectiveness of negative-pressure wound therapy. Wound Repair Regen. 2013;21(4):498-502. Morykwas MJ, David LR, Scneider AM, Whang C, Jennings DA, Canty C, Parker D, White WL, Argenta LC. Use of subatmospheric pressure to prevent progression of partial- thickness burns in a swine model. J Burn Care Rehabil. 1999;20(1 Pt I):15-21. Zheng XP, Chen J, Chen TS, Jiang YN, Shen T, Xiao SC, Hu XY. Preliminary effect observation on the application of micro-negative pressure in children with small-area deep partial-thickness burn. Chin J Burns. 2019;35(10):720-5. Frear CC, Cuttle L, McPhail SM, Chatfield MD, Kimble RM, Griffin BR. Randomized clinical trial of negative pressure wound therapy as an adjunctive treatment for small‐area thermal burns in children. Brit J Surg. 2020;107(13):1741-50. Kamolz LP, Andel H, Haslik W, Winter W, Meissl G, Frey M. Use of subatmospheric pressure therapy to prevent burn wound progression in human: First experiences. Burns. 2004;30(3):253-258. Schrank C, Mayr M, Overesch M, Molnar J, Henkel VDG, Mühlbauer W, Ninkovic M. Results of vacuum therapy (V.A.C.) of superficial and deep dermal burns. Zentralbl Chir. 2004;129(Sup01):S59-S61. doi:10.1055/s-2004-822605 Chen J, Zhou JJ, Su GL, Shi JW, Su SJ. Evaluation of the clinical curative effect of applying vacuum sealing drainage therapy in treating deep partial-thickness burn wound at the initial stage. Chin J Burns. 2010;26(3):170-174. Haslik W, Kamolz LP, Andel H, Meissl G, Frey M. The use of subatmospheric pressure to prevent burn wound progression: first experiences in burn wound treatment. Zentralbl Chir. 2004;129(Sup01):S62-S63. Molnar JA, Heimbach DM, Tredget EE, Hickerson WL, Still JM, Luterman A. Prospective randomized controlled multicenter trial applying subatmospheric pressure to acute hand burns: An interim report. 2 nd World Union of Wound Healing Societies’ Meeting, Paris, 2004. Frear CC, Griffin BR, Cuttle L, Kimble RM, McPhail SM. Cost-effectiveness of adjunctive negative pressure wound therapy in paediatric burn care: evidence from the SONATA in C randomised controlled trial. Sci Rep. 2021;11(1):16650. Jiang ZY, Yu XT, Liao XC, Liu MZ, Fu ZH, Min DH, Guo GH. Negative-pressure wound therapy in skin grafts: A systematic review and meta-analysis of randomized controlled trials. Burns. 2021;47(4):747-755. Blackburn JH, Boemi L, Hall WW, Jeffords K, Hauck RM, Banducci DR, Graham WP. Negative-pressure dressings as a bolster for skin grafts. Ann Plast Surg. 1998;40(5):453-457. Fischer S, Wall J, Pomahac B, Riviello R, Halvorson EG. Extra-large negative pressure wound therapy dressings for burns - Initial experience with technique, fluid management, and outcomes. Burns. 2016;42(2):457-465. Teng SC. Use of negative pressure wound therapy in burn patients. Int Wound J. 2016;13 (Sup03):15-18. Singh R, Tripathi D, Jaiswal SP, Singh P, Balar T, Viradiya C. Use of negative pressure wound therapy as a bolster over skin grafts in patients with severe burn injuries at a tertiary care burn centre in India. Burns Open. 2021;5(3):137-140. Munro CL, Savel RH. Narrowing the 17-year research to practice gap. Am J Crit Care. 2016;25(3):194-196. Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J Roy Soc Med. 2011;104(12):510-20. Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation hybrid designs: Combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012;50(3):217-226. Hemming K, Haines TP, Chilton PJ, Girling AJ, Lilford RJ. The stepped wedge cluster randomised trial: Rationale, design, analysis, and reporting. BMJ. 2015;350:h391. doi:10.1136/bmj.h391 Hemming K, Taljaard M. Reflection on modern methods: When is a stepped-wedge cluster randomized trial a good study design choice? Intern J Epidemiol. 2020;49(3):1043-1052. Hemming K, Taljaard M, Grimshaw J. Introducing the new CONSORT extension for stepped-wedge cluster randomised trials. Trials. 2019;20(1):68. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O'Neal L, et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform. 2019;95:103208. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50-. Kirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L. A systematic review of the use of the Consolidated Framework for Implementation Research. Implement Sci. 2016;11(1):72. Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, Proctor EK, Kirchner JE. A refined compilation of implementation strategies: Results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10(1):21. Consolidated Framework for Implementation Research Interview Guide Tool [Accessed 22 November 2022]. Available from: https://cfirguide.org/guide/app/#/. Gale RC, Wu J, Erhardt T, Bounthavong M, Reardon CM, Damschroder LJ, Midboe AM. Comparison of rapid vs in-depth qualitative analytic methods from a process evaluation of academic detailing in the Veterans Health Administration. Implement Sci. 2019;14(1):1-12. Nevedal AL, Reardon CM, Opra Widerquist MA, Jackson GL, Cutrona SL, White BS, Damschroder LJ. Rapid versus traditional qualitative analysis using the Consolidated Framework for Implementation Research (CFIR). Implement Sci. 2021;16(1):67. Waggoner J, Carline JD, Durning SJ. Is there a consensus on consensus methodology? Descriptions and recommendations for future consensus research. Acad Med. 2016;91(5). CFIR-ERIC Implementation Strategy Matching Tool [CFIR-ERIC Barrier Buster Tool V0.53]. Available from: https://cfirguide.org/choosing-strategies/. Silver S, Jones KC, Redmond S, George E, Zornes S, Barwise A, et al. Facilitators and barriers to the implementation of new critical care practices during COVID-19: A multicenter qualitative study using the Consolidated Framework for Implementation Research (CFIR). BMC Health Serv Res. 2023;23(1). Jabbour M, Newton AS, Johnson D, Curran JA. Defining barriers and enablers for clinical pathway implementation in complex clinical settings. Implement Sci. 2018;13(1):139. Frear CC. Interventions in the acute management of paediatric burn injuries: Negative pressure wound therapy & cool running water first aid [PhD Thesis]: The University of Queensland; 2021. Santosa KB, Keller M, Olsen MA, Keane AM, Sears ED, Snyder-Warwick AK. Negative-Pressure Wound Therapy in Infants and Children: A Population-Based Study. J Surg Res. 2019;235:560-568. Tables Table 1. Participant Professional Stream Professional Stream N % Nursing (ED) 10 (16) Nursing (Burns) 15 (24) Medical (ED) 13 (21) Medical (Burns/Surgery) 19 (30) Burns Physiotherapist/Occupational Therapist 6 (10) Table 2. Tailored Implementation Strategies Matched ERIC Implementation Strategies Tailored NPWT Implementation Strategies I. Identify and prepare champions · In-person site visits from the coordinating principal investigator were performed to promote engagement of local opinion leaders · Identification of NPWT champion/s at each participating site II. Conduct local needs assessment · Conducted local needs assessment to determine areas of concern relating to NPWT implementation and use at their local hospital and health service. This was performed via semi-structured interviews with clinical stakeholders across participating sites · Semi-structured interviews were conducted with ED and burns clinicians from the four participating hospitals to gain further information on needed resources for NPWT implementation, how these should be delivered, clinical consensus discussions surrounding exclusion criteria for NPWT, and how best to provide continued education and training at each hospital. Feedback from these interviews were used to develop and tailor resources and material to local needs III. Involve patients, consumers, and family members · Semi-structured interviews were conducted with parents and caregivers of paediatric burn patients who received NPWT within the last 12 months IV. Obtain and use patients, consumers, and family feedback · Feedback from parents and caregivers regarding their experiences with NPWT as part of their child’s treatment acute burn treatment were used to developed additional resources for parents and caregivers. V. Develop a formal implementation blueprint · Development and tailoring of the INPREP toolkit to local hospital guidelines and standards of care for the acute management of paediatric burn injuries · Development of a NPWT Decision Pathway Poster – targeted for clinicians at participating hospitals · Tailoring of implementation strategies to local contexts, and the development of a NPWT implementation protocol · Development of troubleshooting resources for parents and caregivers of children who receive NPWT – based on feedback from semi-structured interviews with families VI. Access new funding · Research funding obtained to employ researchers and clinical facilitators within New South Wales, Western Australia, Queensland, and Victoria to assist with implementation of the INPREP toolkit and data collection within the SW-RCT VII. Conduct educational meetings · Regular education meetings and in-person NPWT training to be provided to all sites – a senior burns nurse practitioner will travel to sites to provide in-person, in-service education VIII. Develop educational materials · Development of educational resources including a NPWT clinician handout document, which contains a QR code linking to a detailed instructional video demonstrating NPWT application using two different NPWT devices · Development and dissemination of electronic educational material to relevant clinical stakeholders IX. Conduct local needs assessment · Conducted local needs assessment to determine areas of concern relating to NPWT use and management from a parent-caregiver perspective. This was performed via semi-structured interviews with parents-caregivers of children who received NPWT as part of their acute burn treatment Table 2. Initial CFIR-ERIC matched implementation strategies were refined and tailored to local needs and contexts during semi-structured interviews with clinicians, and then consolidated in a consensus group meeting with clinical investigators. Supplementary Files SupplementaryMaterial.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3577058","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":247100030,"identity":"d2c350fc-6769-40fa-b83f-999dc7adca9a","order_by":0,"name":"Maleea D Holbert","email":"","orcid":"https://orcid.org/0000-0002-9902-5122","institution":"Griffith University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Maleea","middleName":"D","lastName":"Holbert","suffix":""},{"id":247100031,"identity":"52f3fa5a-780a-4db1-9913-c25bee557a8a","order_by":1,"name":"Jed Duff","email":"","orcid":"https://orcid.org/0000-0003-1427-0303","institution":"QUT","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jed","middleName":"","lastName":"Duff","suffix":""},{"id":247100032,"identity":"45d2ef8c-aa6a-49c3-b4db-074b43f246d8","order_by":2,"name":"Fiona Wood","email":"","orcid":"https://orcid.org/0000-0001-7397-4074","institution":"University of Western Australia","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fiona","middleName":"","lastName":"Wood","suffix":""},{"id":247100033,"identity":"b3f61112-052a-4d55-b714-e43ec743652e","order_by":3,"name":"Andrew Holland","email":"","orcid":"https://orcid.org/0000-0003-0554-822X","institution":"University of Sydner","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Andrew","middleName":"","lastName":"Holland","suffix":""},{"id":247100034,"identity":"847e53c6-4549-4e60-9d97-48bbba7c0cbf","order_by":4,"name":"Warwick Teague","email":"","orcid":"https://orcid.org/0000-0003-4747-6025","institution":"Murdoch Children’s Research Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Warwick","middleName":"","lastName":"Teague","suffix":""},{"id":247100035,"identity":"c543be29-44e0-4eab-a9e3-eb853b41f0e9","order_by":5,"name":"Cody Frear","email":"","orcid":"https://orcid.org/0000-0002-6011-2472","institution":"University of Queensland","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Cody","middleName":"","lastName":"Frear","suffix":""},{"id":247100036,"identity":"c953e62a-7492-40dc-93a7-d48de245343e","order_by":6,"name":"Dianne Crellin","email":"","orcid":"https://orcid.org/0000-0003-2629-0483","institution":"Murdoch Children’s Research Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dianne","middleName":"","lastName":"Crellin","suffix":""},{"id":247100037,"identity":"68b954bf-921e-4f36-ad7b-6cea8ec67c8d","order_by":7,"name":"Natalie Phillips","email":"","orcid":"","institution":"University of Queensland","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Natalie","middleName":"","lastName":"Phillips","suffix":""},{"id":247100038,"identity":"daa43ae4-301f-44ee-b061-bea4819aace9","order_by":8,"name":"Kristen Storey","email":"","orcid":"","institution":"Griffith University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kristen","middleName":"","lastName":"Storey","suffix":""},{"id":247100039,"identity":"8c7cb703-e1e0-480a-ae0a-5f9587c4aa04","order_by":9,"name":"Lisa Martin","email":"","orcid":"","institution":"University of Western Australian","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lisa","middleName":"","lastName":"Martin","suffix":""},{"id":247100040,"identity":"e153eeeb-bfc9-436a-aa0d-f4f2b09fb7b3","order_by":10,"name":"Yvonne Singer","email":"","orcid":"","institution":"Griffith University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yvonne","middleName":"","lastName":"Singer","suffix":""},{"id":247100041,"identity":"1f054665-4c66-4f48-843f-bf43376d139f","order_by":11,"name":"Leila Cuttle","email":"","orcid":"https://orcid.org/0000-0002-2282-4815","institution":"QUT","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Leila","middleName":"","lastName":"Cuttle","suffix":""},{"id":247100042,"identity":"c5e817e4-c6f1-45b8-8b8d-13044ac135ab","order_by":12,"name":"Dimitrios Vagenas","email":"","orcid":"","institution":"QUT","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dimitrios","middleName":"","lastName":"Vagenas","suffix":""},{"id":247100043,"identity":"d7a36678-6543-43a7-99e9-63d3766b05b5","order_by":13,"name":"Steven McPhail","email":"","orcid":"","institution":"QUT","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Steven","middleName":"","lastName":"McPhail","suffix":""},{"id":247100044,"identity":"ab610c36-acbc-475d-9459-efa93e623808","order_by":14,"name":"Pauline Calleja","email":"","orcid":"","institution":"Central Queensland University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Pauline","middleName":"","lastName":"Calleja","suffix":""},{"id":247100045,"identity":"8c8066b6-2b30-4602-aab3-a51f9b8071d4","order_by":15,"name":"Alexandra De Young","email":"","orcid":"","institution":"University of Queensland","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Alexandra","middleName":"","lastName":"De Young","suffix":""},{"id":247100046,"identity":"d7ad30db-677a-4812-8926-5cd971bb24cb","order_by":16,"name":"Roy Kimble","email":"","orcid":"","institution":"Griffith University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Roy","middleName":"","lastName":"Kimble","suffix":""},{"id":247100047,"identity":"1ecc48c2-dc52-48c8-b017-2134cd3c04d0","order_by":17,"name":"Bronwyn Griffin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFklEQVRIie2QPUvEMBiA3yK0S26vFJq/8JZCVfwpLs3SLlaEg+MGhxxCXcq5dvMv2MW5EOhUbna4RQ5ucujkVMSWpIq2J44OeYbwQPLkC0Cj+Yfglxq8WSK4g4TfZ6eTVV4j+ErwLwkYeQ3AuJTDyYkjqt0s3QK9ECteXm/jByntFVi3TzbciJ/J2TqK/Vm6B2/DupW4TwopOAdSLWyoRgnWJHCSVICXGXe7BkVSSEHG7cvABvPXpN9cxEq6hL52yfvhhBKZhEr6U0hgG+n4LZkZOe1GEFSJ9yjFZymJ5qdsHY9+jBxVx/lCuDSzXnjZCqrEZfeWKJ6bt/OpjwbDBILlcNVBzH4IJ4OOFoBy5Z+i0Wg0GsUH3S546uklbNQAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-6182-9125","institution":"Griffith University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Bronwyn","middleName":"","lastName":"Griffin","suffix":""}],"badges":[],"createdAt":"2023-11-08 03:12:51","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":true,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false,"coiExplicitlySet":false},"doi":"10.21203/rs.3.rs-3577058/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3577058/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":46181085,"identity":"65853759-23b5-41fc-b948-646fc193a280","added_by":"auto","created_at":"2023-11-09 19:47:04","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":692090,"visible":true,"origin":"","legend":"\u003cp\u003eData Synthesis and Implementation Strategy Development\u003c/p\u003e\n\u003cp\u003eGeneration of initial barrier data perceived to impact the implementation of adjunctive NPWT into acute paediatric burn care across participating sites, generation of matched implementation strategies (non-tailored), tailoring of implementation strategies, and consolidation and consensus of strategies and processes to form the evidence-based intervention and INPREP toolkit.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3577058/v1/88ef2bc0207350e956614c90.jpg"},{"id":46181084,"identity":"38105f23-759e-4f33-90b2-46e444422a8d","added_by":"auto","created_at":"2023-11-09 19:47:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":4493,"visible":true,"origin":"","legend":"\u003cp\u003eCFIR Barriers \u0026amp; Matched ERIC Implementation Strategies\u003c/p\u003e\n\u003cp\u003eCFIR domains and implementation barriers (constructs) that emerged from online questionnaire data, the associated matched ERIC strategies, and their influence on implementation into clinical practice. Figure 2 has been adapted from Damschroder et al. \u003cem\u003eFigure: Major Domains of the CFIR\u003c/em\u003e (40).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3577058/v1/84c3efd6835ce955f0b5fb85.png"},{"id":46181700,"identity":"d20a4a58-6fab-4a66-976e-96b7a9e47e59","added_by":"auto","created_at":"2023-11-09 19:55:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":725562,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3577058/v1/fc17cc61-5292-436e-bec0-19f0756bc342.pdf"},{"id":46181086,"identity":"d371761c-faac-4596-be21-3975c898aca6","added_by":"auto","created_at":"2023-11-09 19:47:04","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1232088,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-3577058/v1/cd1f1d44812e8ff63f5f556d.docx"}],"financialInterests":"","formattedTitle":"\u003cp\u003eBarriers and Co-Designed Strategies for the Implementation of Negative Pressure Wound Therapy in Acute Paediatric Burn Care in Australia: A Mixed Method Study\u003c/p\u003e","fulltext":[{"header":"Contributions to the Literature","content":"\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eThis research is the first to investigate barriers to the implementation of early adjunctive negative pressure wound therapy (NPWT) for acute burn injuries within a paediatric hospital setting.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eThe Consolidated Framework for Implementation Research and the Expert Recommendations for Implementing Change were used to determine and explore barriers to NPWT implementation and develop matched strategies to overcome identified barriers.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eTo implement adjunctive NPWT into clinical practice for the acute treatment of paediatric burn injuries, additional resources, education, training, and updates to hospital policies and guidelines are required.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Background","content":"\u003cp\u003eBurns rank among the top five most common causes of non-fatal childhood injuries worldwide (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In Australia, thousands of children present to Emergency Departments (EDs) each year with burn injuries that require acute management and definitive wound care (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Accidental scald and contact injuries are the most frequent causes of paediatric burns, often resulting from hot liquid and food spills and contact with hot surfaces (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). A considerable proportion of childhood burn injuries are small to medium in size: the Burns Registry of Australian and New Zealand (BRANZ) reports nearly 90% of paediatric burn injuries were less than 10% total body surface area (TBSA) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Burns less than 5% TBSA were recorded in 62% of paediatric cases (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). While the majority of paediatric burns seen in Australia are relatively small, these injuries demand carefully planned treatment to reduce the risk of infection and improve time to re-epithelialisation (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Infection and scarring remain common problems for paediatric patients, even in those with smaller burns, despite advances in knowledge and treatment including evidence based first aid (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), early debridement (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), burn pain (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), and silver-impregnated dressings (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Previous studies have shown the strongest predictor of scarring in paediatric burn patients is time to healing, defined as 95% burn wound re-epithelialisation (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Burn wounds taking longer than 14\u0026ndash;17 days to re-epithelialise are at significantly increased risk of hypertrophic scarring (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), this affects between 16% and 35% of children who sustain burns [(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) and (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) respectively]. Therefore, a critical goal of burn care is to achieve more rapid re-epithelialisation to reduce the impact of scarring.\u003c/p\u003e \u003cp\u003eNegative pressure wound therapy (NPWT) is a wound dressing system that provides sub-atmospheric pressure within a closed dressing. It is associated with improved patient outcomes in a wide range of complex chronic and acute wounds (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Proposed mechanisms and benefits of NPWT include the induction of macrodeformation (i.e., wound contraction), microdeformation (i.e., tissue and dressing interactions on a microscopic level), stimulation of angiogenesis around the wound bed, promotion of granulation tissue, improved microvascular perfusion, oedema control, wound exudate control, and reduced risk of infection via decreasing bacterial loads (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). There is strong evidence from experimental (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), randomised controlled trials (RCTs) (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), and prospective cohort studies (\u003cspan additionalcitationids=\"CR22 CR23 CR24\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) to support the benefits of adjunctive NPWT in acute burn care. Compared to standard silver-impregnated dressings alone, early adjunctive NPWT (i.e., applied over standard silver dressings) results in significant improvements in time to re-epithelialisation in children with burns, and decreases dressing change requirements and referrals for scar management (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Early adjunctive treatment in this context refers to NPWT application within the first 48-hours post-burn. Adjunctive NPWT applied within the first 48 hours of the initial burn aims to reduce burn wound progression and the development of deeper injuries, as vascular comprise can worsen for up to 48 hours post-burn (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdjunctive NPWT can also offer a cost-effective solution for the acute treatment of paediatric burns. One recent investigation evaluated the healthcare costs of adjunctive NPWT in small-area paediatric burns, and found the mean total cost was \u003cspan\u003e$\u003c/span\u003e765 AUD less per person for those treated with adjunctive NPWT compared to standard silver dressings alone [\u003cspan\u003e$\u003c/span\u003e904 AUD (95% CI 671\u0026ndash;1235) compared to \u003cspan\u003e$\u003c/span\u003e1,669 AUD (95% CI 659\u0026ndash;3269)] (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). NPWT has been used for decades as a non-invasive treatment to bolster skin grafts in burn and non-burn patients to reduce shearing forces and promote graft take (\u003cspan additionalcitationids=\"CR28 CR29 CR30\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Whilst some specialist burn services make selected or ad hoc use of adjunctive NPWT in children during the acute burn phase (i.e., within 48-hours post-burn or after initial wound debridement), a wider and more systematic application informed by evidence-based guidelines is lacking. Any intervention which reliably improves time to re-epithelialisation in paediatric burn patients warrants further consideration for implementation into recommended best practice.\u003c/p\u003e \u003cp\u003eWithin healthcare research, considerable time lags from the identification of evidence-based treatments to their widespread implementation into clinical practice are well recognised (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). This investigation aimed to identify barriers to the application and use of adjunctive NPWT for the acute management of paediatric burn injuries in a hospital setting and co-design implementation strategies to address identified barriers. Co-design in healthcare research is a collaborative and iterative process aiming to bring together relevant stakeholders to address implementation issues, develop targeted solutions, and improve patient outcomes. Our co-design process targeted experienced burn surgeons, burn nurses and nurse practitioners, burn allied health staff, ED doctors, ED nurses, and ED nurse practitioners with a focus on identification of NPWT implementation barriers within their local hospital and health service. In this paper, we discuss themes and strategies relating to barriers to the implementation of adjunctive NPWT into acute burn care at four paediatric hospitals with dedicated burns centres.\u003c/p\u003e \u003cp\u003eA\u003cb\u003eim and Objectives\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis investigation aimed to determine barriers to the implementation of adjunctive NPWT for the acute management of paediatric burn injuries and co-design targeted implementation strategies. To achieve this aim, the following research objectives were completed:\u003c/p\u003e \u003cp\u003e \u003col style=\"list-style-type:upper-roman;\"\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDetermine barriers to acute adjunctive NPWT implementation via a purpose-built electronic questionnaire and semi-structured interviews with relevant clinical stakeholders.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCo-design tailored strategies to overcome the identified barriers in acute adjunctive NPWT implementation. These strategies will serve as the foundation for an NPWT implementation toolkit specifically designed for the acute care of paediatric burn patients.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe co-designed implementation strategies will inform the \u0026ldquo;Implementation of Negative PressuRe for acutE Paediatric burns\u0026rdquo; (INPREP) toolkit. The INPREP toolkit will subsequently undergo testing in a type III hybrid implementation-effectiveness study, utilizing a stepped-wedge cluster randomised controlled trial (SW-RCT) (\u003cspan additionalcitationids=\"CR35 CR36\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) design with results to be reported separately.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eA sequential mixed methods qualitative approach was used to address the study aims comprising: i) electronic questionnaires, ii) semi-structured interviews, and iii) a stakeholder consensus meeting. Procedures for each are outlined below.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Setting\u003c/h2\u003e \u003cp\u003eParticipating sites were distributed across four tertiary children\u0026rsquo;s hospitals, each the nominated statewide burns referral centre for their respective Australian states (New South Wales, Queensland, Victoria, and Western Australia).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eParticipants recruited for this investigation comprised of healthcare professionals involved in the acute treatment and management of paediatric burn injuries across four participating paediatric hospitals. Participants included medical consultants, junior medical officers, registered nurses, clinical nurse consultants, nurse practitioners, and allied health staff from burns and ED departments across the four participating sites. As aforementioned, parents and caregivers of paediatric burn patients who had received adjunctive NPWT within the last 12-months were also invited to participate in a semi-structured interview.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eProcedures\u003c/h2\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eElectronic Questionnaires\u003c/h2\u003e \u003cp\u003eA purpose-built electronic questionnaire was developed and managed using REDCap (Research Electronic Data Capture, Vanderbilt, USA, hosted at Griffith University). REDCap is a secure, web-based software platform designed to support data capture for research studies (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). The questionnaire was disseminated to healthcare professionals involved in the acute treatment of burn injuries at the four participating hospitals (full questionnaire provided in Supplementary File 1). The questionnaire focused on engagement with clinical stakeholders in the identification, specification, and prioritisation of NPWT implementation barriers. The questionnaire contained three paediatric burn clinical case scenarios, and asked participants to record perceived barriers to the application and use of early adjunctive NPWT for that specific patient (via a free text-response box in the online questionnaire). The three clinical case scenarios were developed by a multidisciplinary team of burns experts and piloted on 12 healthcare professionals and burns researchers. The scenarios aimed to capture a variety of clinical and contextual variables, which cover the scope of projected future adjunctive use of NPWT in acute paediatric burn care. Using a free text response box, participants were also prompted to list barriers perceived to impact their ability to deliver optimal, evidence-based acute paediatric burn care at their local hospital and health service.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eElectronic Questionnaire Data Analysis\u003c/h2\u003e \u003cp\u003eDeductive coding based on the Consolidated Framework for Implementation Research (CFIR) was used to evaluate free text data on barriers to NPWT implementation gathered from the electronic REDCap questionnaires (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). The CFIR is a determinant framework and uses five domains (inner setting, outer setting, intervention characteristics, characteristics of individuals, and planning) to understand barriers to implementation in complex systems (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). The CFIR was used to develop a comprehensive understanding of the complex contextual characteristics of acute burn care (EDs/burn centres) across multiple Australian states and contexts so that early adjunctive NPWT implementation strategies can be better targeted. Identified CFIR barriers from questionnaire data were used to generate matched implementation strategies using the Expert Recommendations for Implementing Change (ERIC) matching tool (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eSemi-Structured Interviews\u003c/h2\u003e \u003cp\u003eSemi-structured interviews were then conducted with senior clinicians at each participating hospital, using interview questions derived from the electronic questionnaire data; The CFIR Interview Tool Guide (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) was used to generate interview questions based on identified CFIR domains and constructs from questionnaire data. Interview questions were open-ended and designed to generate detailed responses from clinicians. Semi-structured interviews aimed to determine clinicians\u0026rsquo; level of agreement and consensus with adjunctive NPWT implementation barriers identified in the initial questionnaire, and to further develop the matched implementation strategies tailored to local needs. In addition, these interviews examined for consensus or divergence of clinician opinion on other key clinical aspects of adjunctive NPWT use in acute paediatric burn care (clinician interview guide is provided in Supplementary File 2). Site principal investigators identified senior clinicians within their local hospitals. Potential participants were emailed information about the research and invited to partake in a semi-structured interview (hosted online via Microsoft Teams or in-person). Interviews were recorded and transcribed verbatim. To gain relevant consumer feedback and involvement, two semi-structured telephone interviews were conducted with parents and caregivers of paediatric burn patients who had received adjunctive NPWT as part of their acute burn treatment within the last 12-months. Interviews were conducted with one parent-caregiver of a child treated as an inpatient receiving adjunctive NPWT, and one parent-caregiver of a paediatric patient treated as an outpatient receiving adjunctive NPWT (parent-caregiver interview guide is provided in Supplementary File 3).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eSemi Structured Interview Data Analysis\u003c/h2\u003e \u003cp\u003eSemi-structured interview data were analysed using framework-guided rapid analysis methods (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Verbatim transcripts were summarised using a structured template based on the five CFIR domains and matched ERIC strategies, and then consolidated into matrices with actionable and tailored recommendations for adjunctive NPWT implementation into acute burn care based on hospital sites. This allowed for group comparisons of consolidated data across the four sites to determine core components and themes, and components that need to be tailored to local contexts.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eConsensus Meeting\u003c/h2\u003e \u003cp\u003eFollowing the dissemination of electronic questionnaires and semi-structured interviews with burn and ED clinicians across the four participating sites, a consensus meeting was held to present questionnaire and interview data back to the consensus group \u0026ndash; to ensure relevant stakeholders at participating hospitals were satisfied with the tailored implementation strategies. The consensus meeting was conducted using informal consensus development panel methods (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). An online meeting was held via Microsoft Teams in April 2023. The stakeholder consensus group comprised of experts in burn care, chief investigators, and site principal investigators from New South Wales, Queensland, Victoria, and Western Australia. On meeting commencement, stakeholders were reintroduced to the aims of the consensus meeting (i.e., gaining final consensus tailored implementation strategies). Questionnaire and interview data were presented and whole group discussions occurred until final consensus was reached. Following the consensus meeting, detailed minutes of the discussions were documented and disseminated out to the consensus group participants.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Generation of initial barrier data perceived to impact the implementation of adjunctive NPWT into acute paediatric burn care across participating sites, generation of matched implementation strategies (non-tailored), tailoring of implementation strategies, and consolidation and consensus of strategies and processes to form the evidence-based intervention and INPREP toolkit.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eResults presented below are an integration of findings from electronic questionnaires, semi-structured interviews, and stakeholder consensus meeting data.\u003c/p\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n\u003ch2\u003eCFIR Domains and Constructs \u0026ndash; Barriers to NPWT Implementation\u003c/h2\u003e\n\u003cp\u003eThe following barriers regarding the implementation of NPWT for acute paediatric burn injuries were generated from N\u0026thinsp;=\u0026thinsp;63 healthcare professionals who responded to the electronic REDCap questionnaire; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;18 from New South Wales, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;20 from Queensland, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;16 from Victoria, and \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9 from Western Australia. Participant\u0026rsquo;s professional streams are presented below in Table\u0026nbsp;1.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n\u003cp\u003eEight barriers (CFIR constructs) covering five CFIR domains were identified:\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n\u003ch2\u003e1. INNER SETTING\u003c/h2\u003e\n\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\n\u003ch2\u003eLack of Available Resources\u003c/h2\u003e\n\u003cp\u003eResources (e.g., operating theatre access, bed availability, staff availability, time constraints, and number of available NPWT devices) are insufficient to support implementation of adjunctive NPWT into acute paediatric burn care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes in peak burn seasons (e.g. school holidays), we run out of NPWT pumps, which prevents us from being able to apply NPWT\u0026hellip;\u0026rdquo; (Participant 23)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Time, staff, non-specialty staff, high ED turnover with an already significant learning need, storage of supply, emergent nature of department requiring nurses to be pulled at a moment\u0026rsquo;s notice\u0026rdquo; (Participant 34)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;if operating theatre not available, attempting a NPWT dressing in a burn of this size on a child of this age is going to be very difficult in an ED setting without a GA so may be more prudent to opt for non-NPWT options.\u0026rdquo; (Participant 55)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n\u003ch2\u003eLacking Access to Knowledge and Information\u003c/h2\u003e\n\u003cp\u003eStakeholders lack adequate access to digestible information and knowledge about adjunctive NPWT and how to best incorporate adjunctive NPWT into acute burn care at their hospital and health service (e.g., lack of clinical guidelines surrounding early adjunctive NPWT use, lack of NPWT troubleshooting resources for clinicians and families; lack of trained and experienced staff).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Not all [Participating Hospital Site] ED Nursing staff are proficient in the application of NPWT dressings. Currently ED would rely on Burns Nursing staff for support and education\u0026rdquo; (Participant 18)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;No idea what NPWT is\u0026rdquo; (Participant 42)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I've never heard of NPWT\u0026rdquo; (Participant 44)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n\u003ch2\u003e2. CHARACTERISTICS OF INDIVIDUALS\u003c/h2\u003e\n\u003cdiv id=\"Sec19\" class=\"Section3\"\u003e\n\u003ch2\u003eIndividual Stage of Change\u003c/h2\u003e\n\u003cp\u003eStakeholders acknowledged a lack of skills or enthusiasm about using NPWT in a sustained way (e.g., clinicians view it as extra work).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Nursing concerns over additional time and resources to both apply and monitor NPWT as well as patient discomfort\u0026rdquo; (Participant 10)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;A VAC dressing is time consuming for an ED Department \u0026ndash; takes regular skill from the user to apply\u0026rdquo; (Participant 35)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;Concerned burden of increased workload of new dressings and associated staffing and sedation will fall onto the emergency department\u0026rdquo; (Participant 30)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n\u003ch2\u003eKnowledge \u0026amp; Beliefs about the Intervention\u003c/h2\u003e\n\u003cp\u003eClinical stakeholders have negative attitudes toward early adjunctive NPWT, place low value on implementing adjunctive NPWT into acute paediatric burn care, and/or are not familiar with current evidence supporting early adjunctive NPWT (e.g., clinicians are unsure or sceptical about the benefits of adjunctive NPWT compared to standard care and other adjunctive treatments).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Logistical barriers \u0026ndash; dressing takes longer to place, more difficult for parents to manage at home. Clinician preference \u0026ndash; I am interested in being involved in trials for NPWT and partial thickness burns but I am not aware of enough evidence to change my standard practice, particularly for burns away from limbs\u0026rdquo; (Participant 57)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There is evidence for improved outcomes with the application of Biobrane within 24-hours of mid-dermal burns\u0026rdquo; (Participant 16)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Want to know that significant improvement in wound healing timeframes to make a difference and justify use and change in practice\u0026hellip;\u0026rdquo; (Participant 19)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Unclear evidence for better outcome in this age group\u0026rdquo; (Participant 50)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n\u003ch2\u003e3. OUTER SETTING\u003c/h2\u003e\n\u003cdiv id=\"Sec22\" class=\"Section3\"\u003e\n\u003ch2\u003ePatient Needs and Resources\u003c/h2\u003e\n\u003cp\u003ePatient needs, including barriers and enables to meet those needs, are not accurately known (e.g., clinicians suspect NPWT will cause issues with mobilisation and walking when applied to foot burns, cause pain and discomfort for paediatric patients, and place an additional burden on parents and caregivers).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e \u0026ldquo;\u0026hellip;Parents already have a lot of things going on with an active toddler they are less likely to want to use it\u0026hellip;\u0026rdquo; (Participant 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;Does standard Acticoat dressing provide similar healing results and timeframes, less costly, and easier for patient and family to manage?\u0026rdquo; (Participant 19)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Patient reluctance to carry the machine, restriction on schooling, and whether parents are able to take time off to care for [the] patient\u0026rdquo; (Participant 32)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Age \u0026ndash; would unlikely tolerate the pump device. Parents \u0026ndash; they would find keeping the kid away from the pump difficult\u0026rdquo; (Participant 49)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\n\u003ch2\u003eLack of External Policy \u0026amp; Incentives\u003c/h2\u003e\n\u003cp\u003eExternal policies, regulations, mandates, recommendations, or guidelines do not exist to implement the innovation into acute burn care (e.g., lack of hospital policies surrounding use of adjunctive NPWT for acute paediatric burn management, clinician do not view early adjunctive NPWT as standard treatment for acute burn injuries).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Lack of current policy for NPWT, lack of training, lack of availability\u0026rdquo; (Participant 12)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;decision makers need to update their approaches to burn wound management to prioritise early(ier) debridement AND primary application of NPWT \u0026ndash; new dressing skills need to be learned by a broader population of staff \u0026ndash; health service has to increase financial outlay at the front end of patient care with the prospect (but not guarantee) of a later saving\u0026rdquo; (Participant 55)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\n\u003ch2\u003e4. INTERVENTION CHARACTERISTICS\u003c/h2\u003e\n\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\n\u003ch2\u003eComplexity\u003c/h2\u003e\n\u003cp\u003eClinical stakeholders hold the belief that NPWT is complex, based on their perception of duration, scope, disruptiveness, intricacy, and the number of steps involved in its implementation. For instance, clinicians commonly perceive adjunctive NPWT as challenging and time consuming to apply, anticipating an increased need for analgesia and sedation for patients that receive early adjunctive NPWT in comparison to standard care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Intricacy of application, benefit versus standard dressing, obtaining and maintaining a seal, requirement for analgesia and sedation\u0026rdquo; (Participant 19)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Application is already difficult on tiny toes and feet. I honestly cannot even imagine how negative pressure would work in this way. NPWT would be better suited to a flat surface burn in my experience. Also, you can't even get a sats probe on a 2-year-old without them having a tantrum so I don't think a machine connected to their feet would stay on for very long\u0026rdquo; (Participant 27)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;Unless staff in ED get regular support from these services we cannot take on a more complicated dressing technique such as NPWT\u0026rdquo; (Participant 35)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\n\u003ch2\u003e5. PROCESS\u003c/h2\u003e\n\u003cdiv id=\"Sec27\" class=\"Section4\"\u003e\n\u003ch2\u003ePlanning:\u003c/h2\u003e\n\u003cp\u003eA structured scheme or sequence of tasks necessary to implement adjunctive NPWT into acute burn care has yet to be developed. This is exemplified by the absence of adjunctive NPWT application within the ED processes of certain participating hospitals.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;NPWT not historically an ED treatment. No exposure to education in this space. No idea of how to access NPWT resources or experienced staff\u0026rdquo; (Participant 42)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\n\u003ch2\u003eImplementation Strategies \u0026ndash; Matched ERIC Strategies and Tailored Strategies\u003c/h2\u003e\n\u003cp\u003eThe following implementation strategies presented below in Fig.\u0026nbsp;2 were selected from the CFIR-ERIC Barrier Buster V0.53 tool (\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e) to address identified barriers and challenges to adjunctive NPWT implementation into acute burn care. This tool generates and selects implementation strategies using identified CFIR constructs. Semi-structured interviews were conducted with nine clinicians across New South Wales, Queensland, Victoria, and Western Australia, which were then used to tailor the generated CFIR-ERIC matched implementation strategies to local contexts. Interviews aimed to extrapolate details of identified barriers to define the INPREP toolkit and matched implementation strategies for each participating site. Table\u0026nbsp;2 below presents the initial matched implementation strategies (generic and non-tailored) and the tailored implementation strategies, which incorporated data and feedback from semi-structured clinician interviews.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\n\u003cp\u003eFigure 2. CFIR domains and implementation barriers (constructs) that emerged from online questionnaire data, the associated matched ERIC strategies, and their influence on implementation into clinical practice. Figure\u0026nbsp;2 has been adapted from Damschroder et al. \u003cem\u003eFigure: Major Domains of the CFIR\u003c/em\u003e (\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eTable\u0026nbsp;2. Initial CFIR-ERIC matched implementation strategies were refined and tailored to local needs and contexts during semi-structured interviews with clinicians, and then consolidated in a consensus group meeting with clinical investigators.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e 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\u0026rsquo;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.\u003c/p\u003e \u003cp\u003eResource 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 (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). 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.\u003c/p\u003e \u003cp\u003eLack 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 \u0026ndash; however this barrier is seldom reported in studies assessing NPWT use in burn wound care (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). 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.\u003c/p\u003e \u003cp\u003ePatient 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 \u0026ndash; 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 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Parents and caregivers of burn patients (aged\u0026thinsp;\u0026lt;\u0026thinsp;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 \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;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 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFollowing 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 (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). 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 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). 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 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Despite this, healthcare professionals often report fear of increased pain in children during NPWT procedures (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e 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.\u003c/p\u003e \u003cp\u003e 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 \u0026ndash; 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 \u0026ndash; 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.\u003c/p\u003e \u003cp\u003eThe 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) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In addition, burns clinicians reported adjunctive NPWT application and removal to be more time consuming compared to standard care (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). 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.\u003c/p\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eStrengths 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.\u003c/p\u003e \u003cp\u003eFindings 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 (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Moreover, qualitative methods such as these are susceptible to influence from researchers\u0026rsquo; 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.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe time lag in evidence-to-practice implementation is a well-recognised issue in clinical and healthcare research. This investigation is one of the first to define barriers and co-design tailored strategies and treatment plans for the implementation of adjunctive NPWT for acute paediatric burns. Furthermore, findings from this research can help inform and guide other acute burn related implementation studies in the future, the implementation of other technologies, devices, or treatment pathways for paediatric patients in a healthcare setting. This investigation identified several barriers to adjunctive NPWT implementation in the acute management of paediatric burn injuries and co-designed targeted implementation strategies to address these barriers. The mixed methods co-design approach used in this investigation enabled detailed contextualisation and identification of factors affecting implementation and adoption of early adjunctive NPWT across four Australian states. This ensured that implementation strategies were relevant, comprehensive, and tailored to the specific contexts of each participating hospital. The implementation strategies developed as part of this investigation will be adopted as part of a type III hybrid implementation-effectiveness SW-RCT. Findings and implementation strategies from this research can help inform and guide the implementation of adjunctive NPWT in other acute care settings, leading to improved patient outcomes and quality of care for children who have acquired a burn injury.\u003c/p\u003e"},{"header":"List of Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\"\u003e\n \u003cp\u003e\u003cstrong\u003eANZCTR:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.37770382695507%\"\u003e\n \u003cp\u003eAustralian and New Zealand Clinical Trials Registry\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAUD:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.37770382695507%\"\u003e\n \u003cp\u003eAustralian Dollars\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\"\u003e\n \u003cp\u003e\u003cstrong\u003eBRANZ:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.37770382695507%\"\u003e\n \u003cp\u003eBurns Registry of Australian and New Zealand\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCFIR:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.37770382695507%\"\u003e\n \u003cp\u003eConsolidated Framework for Implementation Research\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCHQHHS:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.37770382695507%\"\u003e\n \u003cp\u003eChildren\u0026rsquo;s Health Queensland Hospital and Health Service\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCI:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.37770382695507%\"\u003e\n \u003cp\u003eConfidence Intervals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\"\u003e\n \u003cp\u003e\u003cstrong\u003eED:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.37770382695507%\"\u003e\n \u003cp\u003eEmergency Departments\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\"\u003e\n \u003cp\u003e\u003cstrong\u003eERIC:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.37770382695507%\"\u003e\n \u003cp\u003eExpert Recommendations for Implementing Change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGCP:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.37770382695507%\"\u003e\n \u003cp\u003eGood Clinical Practice\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHREC:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.37770382695507%\"\u003e\n \u003cp\u003eHuman Research Ethic Committee\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNHMRC:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.37770382695507%\"\u003e\n \u003cp\u003eNational Health and Medical Research Council\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNPWT:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.37770382695507%\"\u003e\n \u003cp\u003eNegative Pressure Wound Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\"\u003e\n \u003cp\u003e\u003cstrong\u003eRCT:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.37770382695507%\"\u003e\n \u003cp\u003eRandomised Controlled Trial\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\"\u003e\n \u003cp\u003e\u003cstrong\u003eREDCap:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.37770382695507%\"\u003e\n \u003cp\u003eResearch Electronic Data Capture\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTBSA:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.37770382695507%\"\u003e\n \u003cp\u003eTotal Body Surface Area\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\"\u003e\n \u003cp\u003e\u003cstrong\u003eUSA:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.37770382695507%\"\u003e\n \u003cp\u003eUnited States of America\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVSM:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.37770382695507%\"\u003e\n \u003cp\u003eVictorian Specific Module\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.622296173044926%\"\u003e\n \u003cp\u003e\u003cstrong\u003eWASM:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.37770382695507%\"\u003e\n \u003cp\u003eWestern Australian Specific Module\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eHuman Research Ethics Committee (HREC) approval has been obtained for this investigation (HREC/21/QCHQ/81002) from Children\u0026rsquo;s Health Queensland Hospital and Health Service HREC. This research was also approved by the Griffith University Human Research Ethics Committee (GU Ref No: 2022/157).\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis project has been awarded funding from the National Health and Medical Research Council (NHMRC) Partnership Projects PRC2 Funding ID: 2006970.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e\n\u003cp\u003eBRG is the lead coordinating principal investigator \u0026ndash; she designed the trial and obtained research funding. JD is the lead implementation scientist. DV is the lead biostatistician. LC is the lead scientist. SM is the lead health economist. ADY is the lead child psychologist. FW, AJAH, WT, NP, KS, DC, YS, LM, CF, PC, and RMK are investigators who contributed to the development and design of the trial at each of the participating paediatric hospitals. MDH wrote the draft manuscript, conducted semi-structured interviews, and analysed the data. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe acknowledge and thank the following partners for their assistance in developing this research; The Children\u0026rsquo;s Hospital at Westmead, Perth Children\u0026rsquo;s Hospital, Queensland Children\u0026rsquo;s Hospital, and The Royal Children\u0026rsquo;s Hospital Melbourne. We would also like to acknowledge and give thanks to Dr Laura Damschroder for providing permission to adapt and reproduce her \u003cem\u003eMajor Domains of the CFIR Figure\u0026nbsp;\u003c/em\u003e\u003cem\u003e(40)\u003c/em\u003e.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organisation. Global Burden of Disease Geneva. 2008. [Accessed September 2023] \u003c/li\u003e\n\u003cli\u003ePeck MD. Epidemiology of burns throughout the world. Part I: Distribution and risk factors. Burns. 2011;37(7):1087-100.\u003c/li\u003e\n\u003cli\u003eBurns Registry of Australia and New Zealand (2022). Annual Report 2020/21. Department of Epidemiology and Preventive Medicine, Monash University. Melbourne, Australia. [Accessed September 2023]\u003c/li\u003e\n\u003cli\u003eGreenhalgh DG. Management of Burns. N Engl J Med. 2019;380(24):2349-59.\u003c/li\u003e\n\u003cli\u003eGriffin BR, Frear CC, Babl F, Oakley E, Kimble RM. Cool Running Water First Aid Decreases Skin Grafting Requirements in Pediatric Burns: A Cohort Study of Two Thousand Four Hundred Ninety-five Children. Ann Emerg Med. 2019;75(1):75-85. \u003c/li\u003e\n\u003cli\u003eGriffin B, Bairagi A, Jones L, Dettrick Z, Holbert M, Kimble R. Early non-excisional debridement of paediatric burns under general anaesthesia reduces time to re-epithelialisation and risk of skin graft. Sci Rep. 2021;11(1).\u003c/li\u003e\n\u003cli\u003eHolbert MD, Kimble RM, Jones LV, Ahmed SH, Griffin BR. Risk factors associated with higher pain levels among pediatric burn patients: A retrospective cohort study. Reg Anesth Pain Med. 2021;46(3):222.\u003c/li\u003e\n\u003cli\u003eWang Y, Beekman J, Hew J, Jackson S, Issler-Fisher AC, Parungao R, Lajevardi SS, Li Z, Maitz PKM. Burn injury: Challenges and advances in burn wound healing, infection, pain and scarring. Adv Drug Deliv Rev. 2018;123:3-17.\u003c/li\u003e\n\u003cli\u003eNunez Lopez O, Cambiaso-Daniel J, Branski LK, Norbury WB, Herndon DN. Predicting and managing sepsis in burn patients: Current perspectives. Ther Clin Risk Manag. 2017;13:1107-17.\u003c/li\u003e\n\u003cli\u003eChipp E, Charles L, Thomas C, Whiting K, Moiemen N, Wilson Y. A prospective study of time to healing and hypertrophic scarring in paediatric burns: Every day counts. Burns Trauma. 2017;5(1):1-6.\u003c/li\u003e\n\u003cli\u003eCubison TCS, Pape SA, Parkhouse N. Evidence for the link between healing time and the development of hypertrophic scars (HTS) in paediatric burns due to scald injury. Burns. 2006;32(8):992-999.\u003c/li\u003e\n\u003cli\u003eKantak NA, Mistry R, Varon DE, Halvorson EG. Negative pressure wound therapy for burns. Clin Plast Surg. 2017;44(3):671-677.\u003c/li\u003e\n\u003cli\u003eAnghel EL, Kim PJ. Negative-pressure wound therapy: A comprehensive review of the evidence. Plast Reconstr Surg. 2016;138(3 Suppl):129S-137S.\u003c/li\u003e\n\u003cli\u003eKrug E, Berg L, Lee C, Hudson D, Birke-Sorensen H, Depoorter M, Dunn R, Jeffery S, Duteille F, Bruhin A, et al. Evidence-based recommendations for the use of negative pressure wound therapy in traumatic wounds and reconstructive surgery: Steps towards an international consensus. Injury. 2011;42(Supplement 1):S1-S12.\u003c/li\u003e\n\u003cli\u003eLalezari S, Lee CJ, Borovikova AA, Banyard DA, Paydar KZ, Wirth GA, Widgerow AD. Deconstructing negative pressure wound therapy. Int Wound J. 2017;14(4):649-657.\u003c/li\u003e\n\u003cli\u003eBorgquist O, Gustafsson L, Ingemansson R, Malmsj\u0026ouml; M. Micro- and macromechanical effects on the wound bed of negative pressure wound therapy using gauze and foam. Ann Plast Surg. 2010;64(6):789-793.\u003c/li\u003e\n\u003cli\u003eDaigle P, Despatis MA, Grenier G. How mechanical deformations contribute to the effectiveness of negative-pressure wound therapy. Wound Repair Regen. 2013;21(4):498-502.\u003c/li\u003e\n\u003cli\u003eMorykwas MJ, David LR, Scneider AM, Whang C, Jennings DA, Canty C, Parker D, White WL, Argenta LC. Use of subatmospheric pressure to prevent progression of partial- thickness burns in a swine model. J Burn Care Rehabil. 1999;20(1 Pt I):15-21.\u003c/li\u003e\n\u003cli\u003eZheng XP, Chen J, Chen TS, Jiang YN, Shen T, Xiao SC, Hu XY. Preliminary effect observation on the application of micro-negative pressure in children with small-area deep partial-thickness burn. Chin J Burns. 2019;35(10):720-5.\u003c/li\u003e\n\u003cli\u003eFrear CC, Cuttle L, McPhail SM, Chatfield MD, Kimble RM, Griffin BR. Randomized clinical trial of negative pressure wound therapy as an adjunctive treatment for small‐area thermal burns in children. Brit J Surg. 2020;107(13):1741-50.\u003c/li\u003e\n\u003cli\u003eKamolz LP, Andel H, Haslik W, Winter W, Meissl G, Frey M. Use of subatmospheric pressure therapy to prevent burn wound progression in human: First experiences. Burns. 2004;30(3):253-258.\u003c/li\u003e\n\u003cli\u003eSchrank C, Mayr M, Overesch M, Molnar J, Henkel VDG, M\u0026uuml;hlbauer W, Ninkovic M. Results of vacuum therapy (V.A.C.) of superficial and deep dermal burns. Zentralbl Chir. 2004;129(Sup01):S59-S61. doi:10.1055/s-2004-822605\u003c/li\u003e\n\u003cli\u003eChen J, Zhou JJ, Su GL, Shi JW, Su SJ. Evaluation of the clinical curative effect of applying vacuum sealing drainage therapy in treating deep partial-thickness burn wound at the initial stage. Chin J Burns. 2010;26(3):170-174.\u003c/li\u003e\n\u003cli\u003eHaslik W, Kamolz LP, Andel H, Meissl G, Frey M. The use of subatmospheric pressure to prevent burn wound progression: first experiences in burn wound treatment. Zentralbl Chir. 2004;129(Sup01):S62-S63.\u003c/li\u003e\n\u003cli\u003eMolnar JA, Heimbach DM, Tredget EE, Hickerson WL, Still JM, Luterman A. Prospective randomized controlled multicenter trial applying subatmospheric pressure to acute hand burns: An interim report. 2\u003csup\u003end\u003c/sup\u003e World Union of Wound Healing Societies\u0026rsquo; Meeting, Paris, 2004.\u003c/li\u003e\n\u003cli\u003eFrear CC, Griffin BR, Cuttle L, Kimble RM, McPhail SM. Cost-effectiveness of adjunctive negative pressure wound therapy in paediatric burn care: evidence from the SONATA in C randomised controlled trial. Sci Rep. 2021;11(1):16650.\u003c/li\u003e\n\u003cli\u003eJiang ZY, Yu XT, Liao XC, Liu MZ, Fu ZH, Min DH, Guo GH. Negative-pressure wound therapy in skin grafts: A systematic review and meta-analysis of randomized controlled trials. Burns. 2021;47(4):747-755.\u003c/li\u003e\n\u003cli\u003eBlackburn JH, Boemi L, Hall WW, Jeffords K, Hauck RM, Banducci DR, Graham WP. Negative-pressure dressings as a bolster for skin grafts. Ann Plast Surg. 1998;40(5):453-457.\u003c/li\u003e\n\u003cli\u003eFischer S, Wall J, Pomahac B, Riviello R, Halvorson EG. Extra-large negative pressure wound therapy dressings for burns - Initial experience with technique, fluid management, and outcomes. Burns. 2016;42(2):457-465.\u003c/li\u003e\n\u003cli\u003eTeng SC. Use of negative pressure wound therapy in burn patients. Int Wound J. 2016;13 (Sup03):15-18.\u003c/li\u003e\n\u003cli\u003eSingh R, Tripathi D, Jaiswal SP, Singh P, Balar T, Viradiya C. Use of negative pressure wound therapy as a bolster over skin grafts in patients with severe burn injuries at a tertiary care burn centre in India. Burns Open. 2021;5(3):137-140.\u003c/li\u003e\n\u003cli\u003eMunro CL, Savel RH. Narrowing the 17-year research to practice gap. Am J Crit Care. 2016;25(3):194-196.\u003c/li\u003e\n\u003cli\u003eMorris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J Roy Soc Med. 2011;104(12):510-20.\u003c/li\u003e\n\u003cli\u003eCurran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation hybrid designs: Combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012;50(3):217-226.\u003c/li\u003e\n\u003cli\u003eHemming K, Haines TP, Chilton PJ, Girling AJ, Lilford RJ. The stepped wedge cluster randomised trial: Rationale, design, analysis, and reporting. BMJ. 2015;350:h391. doi:10.1136/bmj.h391\u003c/li\u003e\n\u003cli\u003eHemming K, Taljaard M. Reflection on modern methods: When is a stepped-wedge cluster randomized trial a good study design choice? Intern J Epidemiol. 2020;49(3):1043-1052.\u003c/li\u003e\n\u003cli\u003eHemming K, Taljaard M, Grimshaw J. Introducing the new CONSORT extension for stepped-wedge cluster randomised trials. Trials. 2019;20(1):68.\u003c/li\u003e\n\u003cli\u003eHarris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)\u0026mdash;A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381.\u003c/li\u003e\n\u003cli\u003eHarris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O\u0026apos;Neal L, et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform. 2019;95:103208.\u003c/li\u003e\n\u003cli\u003eDamschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50-.\u003c/li\u003e\n\u003cli\u003eKirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L. A systematic review of the use of the Consolidated Framework for Implementation Research. Implement Sci. 2016;11(1):72.\u003c/li\u003e\n\u003cli\u003ePowell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, Proctor EK, Kirchner JE. A refined compilation of implementation strategies: Results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10(1):21.\u003c/li\u003e\n\u003cli\u003eConsolidated Framework for Implementation Research Interview Guide Tool [Accessed 22 November 2022]. Available from: https://cfirguide.org/guide/app/#/.\u003c/li\u003e\n\u003cli\u003eGale RC, Wu J, Erhardt T, Bounthavong M, Reardon CM, Damschroder LJ, Midboe AM. Comparison of rapid vs in-depth qualitative analytic methods from a process evaluation of academic detailing in the Veterans Health Administration. Implement Sci. 2019;14(1):1-12.\u003c/li\u003e\n\u003cli\u003eNevedal AL, Reardon CM, Opra Widerquist MA, Jackson GL, Cutrona SL, White BS, Damschroder LJ. Rapid versus traditional qualitative analysis using the Consolidated Framework for Implementation Research (CFIR). Implement Sci. 2021;16(1):67.\u003c/li\u003e\n\u003cli\u003eWaggoner J, Carline JD, Durning SJ. Is there a consensus on consensus methodology? Descriptions and recommendations for future consensus research. Acad Med. 2016;91(5).\u003c/li\u003e\n\u003cli\u003eCFIR-ERIC Implementation Strategy Matching Tool [CFIR-ERIC Barrier Buster Tool V0.53]. Available from: https://cfirguide.org/choosing-strategies/.\u003c/li\u003e\n\u003cli\u003eSilver S, Jones KC, Redmond S, George E, Zornes S, Barwise A, et al. Facilitators and barriers to the implementation of new critical care practices during COVID-19: A multicenter qualitative study using the Consolidated Framework for Implementation Research (CFIR). BMC Health Serv Res. 2023;23(1).\u003c/li\u003e\n\u003cli\u003eJabbour M, Newton AS, Johnson D, Curran JA. Defining barriers and enablers for clinical pathway implementation in complex clinical settings. Implement Sci. 2018;13(1):139.\u003c/li\u003e\n\u003cli\u003eFrear CC. Interventions in the acute management of paediatric burn injuries: Negative pressure wound therapy \u0026amp; cool running water first aid [PhD Thesis]: The University of Queensland; 2021.\u003c/li\u003e\n\u003cli\u003eSantosa KB, Keller M, Olsen MA, Keane AM, Sears ED, Snyder-Warwick AK. Negative-Pressure Wound Therapy in Infants and Children: A Population-Based Study. J Surg Res. 2019;235:560-568.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Participant Professional Stream\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.638629283489095%\" valign=\"top\"\u003e\n \u003cp\u003eProfessional Stream\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.361370716510905%\" valign=\"top\"\u003e\n \u003cp\u003eN %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.638629283489095%\" valign=\"top\"\u003e\n \u003cp\u003eNursing (ED)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.361370716510905%\" valign=\"top\"\u003e\n \u003cp\u003e10 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.638629283489095%\" valign=\"top\"\u003e\n \u003cp\u003eNursing (Burns)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.361370716510905%\" valign=\"top\"\u003e\n \u003cp\u003e15 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.638629283489095%\" valign=\"top\"\u003e\n \u003cp\u003eMedical (ED)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.361370716510905%\" valign=\"top\"\u003e\n \u003cp\u003e13 (21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.638629283489095%\" valign=\"top\"\u003e\n \u003cp\u003eMedical (Burns/Surgery)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.361370716510905%\" valign=\"top\"\u003e\n \u003cp\u003e19 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.638629283489095%\" valign=\"top\"\u003e\n \u003cp\u003eBurns Physiotherapist/Occupational Therapist\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.361370716510905%\" valign=\"top\"\u003e\n \u003cp\u003e6 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 2. Tailored Implementation Strategies\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"312\"\u003e\n \u003cp\u003e\u003cstrong\u003eMatched ERIC Implementation Strategies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"637\"\u003e\n \u003cp\u003e\u003cstrong\u003eTailored NPWT Implementation Strategies\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"312\"\u003e\n \u003cp\u003e\u0026nbsp;I. Identify and prepare champions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"637\"\u003e\n \u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; In-person site visits from the coordinating principal investigator were performed to promote engagement of local opinion leaders\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"312\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"637\"\u003e\n \u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Identification of NPWT champion/s at each participating site\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"312\"\u003e\n \u003cp\u003eII. Conduct local needs assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"637\"\u003e\n \u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Conducted local needs assessment to determine areas of concern relating to NPWT implementation and use at their local hospital and health service. This was performed via semi-structured interviews with clinical stakeholders across participating sites\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"312\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd width=\"637\"\u003e\n \u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Semi-structured interviews were conducted with ED and burns clinicians from the four participating hospitals to gain further information on needed resources for NPWT implementation, how these should be delivered, clinical consensus discussions surrounding exclusion criteria for NPWT, and how best to provide continued education and training at each hospital. Feedback from these interviews were used to develop and tailor resources and material to local needs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"312\"\u003e\n \u003cp\u003eIII. Involve patients, consumers, and family members\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"637\"\u003e\n \u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Semi-structured interviews were conducted with parents and caregivers of paediatric burn patients who received NPWT within the last 12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"312\"\u003e\n \u003cp\u003eIV. Obtain and use patients, consumers, and family feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"637\"\u003e\n \u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Feedback from parents and caregivers regarding their experiences with NPWT as part of their child\u0026rsquo;s treatment acute burn treatment were used to developed additional resources for parents and caregivers.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"312\"\u003e\n \u003cp\u003eV. Develop a formal implementation blueprint\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"637\"\u003e\n \u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Development and tailoring of the INPREP toolkit to local hospital guidelines and standards of care for the acute management of paediatric burn injuries\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"312\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"637\"\u003e\n \u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Development of a NPWT Decision Pathway Poster \u0026ndash; targeted for clinicians at participating hospitals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"312\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"637\"\u003e\n \u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Tailoring of implementation strategies to local contexts, and the development of a NPWT implementation protocol\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"312\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"637\"\u003e\n \u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Development of troubleshooting resources for parents and caregivers of children who receive NPWT \u0026ndash; based on feedback from semi-structured interviews with families\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"312\"\u003e\n \u003cp\u003eVI. Access new funding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"637\"\u003e\n \u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Research funding obtained to employ researchers and clinical facilitators within New South Wales, Western Australia, Queensland, and Victoria to assist with implementation of the INPREP toolkit and data collection within the SW-RCT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"312\"\u003e\n \u003cp\u003eVII. Conduct educational meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"637\"\u003e\n \u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Regular education meetings and in-person NPWT training to be provided to all sites \u0026ndash; a senior burns nurse practitioner will travel to sites to provide in-person, in-service education\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"312\"\u003e\n \u003cp\u003eVIII. Develop educational materials\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"637\"\u003e\n \u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Development of educational resources including a NPWT clinician handout document, which contains a QR code linking to a detailed instructional video demonstrating NPWT application using two different NPWT devices\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"312\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"637\"\u003e\n \u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Development and dissemination of electronic educational material to relevant clinical stakeholders\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"312\"\u003e\n \u003cp\u003eIX. Conduct local needs assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"637\"\u003e\n \u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Conducted local needs assessment to determine areas of concern relating to NPWT use and management from a parent-caregiver perspective. This was performed via semi-structured interviews with parents-caregivers of children who received NPWT as part of their acute burn treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2. Initial CFIR-ERIC matched implementation strategies were refined and tailored to local needs and contexts during semi-structured interviews with clinicians, and then consolidated in a consensus group meeting with clinical investigators.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[{"identity":"68f1382c-fd32-4217-8287-d0b124cb1576","identifier":"10.13039/501100000925","name":"National Health and Medical Research Council","awardNumber":"APP2006970","order_by":0}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Griffith University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Burns, Negative Pressure Wound Therapy, Implementation, Health Service, Child Health","lastPublishedDoi":"10.21203/rs.3.rs-3577058/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3577058/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePaediatric burn injuries pose a major clinical problem worldwide and result in significant morbidity. Early adjunctive application of negative pressure wound therapy (NPWT) significantly improves time to healing by re-epithelialisation in children with burns. This treatment strategy has not been consistently adopted as part of acute paediatric burn care.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis investigation used a sequential mixed methods design to identify and explore barriers to the implementation of adjunctive NPWT in acute paediatric burn care. An online questionnaire was developed and disseminated to healthcare professionals within four major paediatric hospitals in Australia, each with a dedicated burns service. Specific barrier data were coded according to the Consolidated Framework for Implementation Research (CFIR). Semi-structured interviews were then conducted with senior clinicians across the four participating hospitals to tailor implementation strategies to local contexts. A stakeholder consensus meeting was then conducted to consolidate implementation strategies and local processes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 63 healthcare professionals participated in the online questionnaire, and semi-structured interviews were conducted with nine senior burn clinicians. Two interviews were also conducted with parents and caregivers of paediatric burn patients who had received adjunctive NPWT as part of their acute burn treatment within the last 12-months. This investigation identified eight implementation barriers across all five CFIR domains then co-designed targeted strategies to address these identified barriers. Barriers included lack of available resources, limited access to knowledge and information, individual stage of change (which describes clinicians\u0026rsquo; readiness or enthusiasm to change practice), patient needs and resources, limited knowledge and beliefs about the intervention, lack of external policies and incentives, intervention complexity, and poor planning of the intervention implementation.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThere are multiple and inter-related contextual characteristics that influence the uptake of adjunctive NPWT into acute paediatric burn settings in Australia. Results from this investigation will be used within a multi-state stepped-wedge cluster randomised controlled trial. In order to implement adjunctive NPWT into clinical practice for the acute treatment of paediatric burn injuries, additional resources, education, training, and updates to policies and guidelines are required. It is anticipated that adjunctive NPWT, in conjunction with tailored implementation strategies, will enhance adoption and sustainability.\u003c/p\u003e\u003ch2\u003eTrial Registration\u003c/h2\u003e \u003cp\u003eThis trial was prospectively registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR) on the 1st of February 2022 \u0026ndash; registration number ACTRN12622000166774.\u003c/p\u003e","manuscriptTitle":"Barriers and Co-Designed Strategies for the Implementation of Negative Pressure Wound Therapy in Acute Paediatric Burn Care in Australia: A Mixed Method Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-11-09 19:46:59","doi":"10.21203/rs.3.rs-3577058/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6a843142-16f3-4b9e-9162-8267c1383479","owner":[],"postedDate":"November 9th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":26093646,"name":"Critical Care \u0026 Emergency Medicine"}],"tags":[],"updatedAt":"2023-11-09T19:46:59+00:00","versionOfRecord":[],"versionCreatedAt":"2023-11-09 19:46:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3577058","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3577058","identity":"rs-3577058","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}