Table 3

Identified barriers to and facilitators of the implementation of the therapeutic hypothermia guidelines and illustrative quotes

Themes and subthemesBarriersFacilitatorsQuotes
Healthcare professionals’ perception of the guidelines and protocols of TTM
Knowledge and attitudesLack of awareness
Disagreement with guidelines
Negative attitudes towards the guidelines
Lack of familiarity with protocol
Lack of publicity
Educational activities (internal and external)
Publicity for successfully treated cases
Changes in recommendation
“The staffs of the respective clinical departments are only concerned with their own specialties. Residents are often irritated, ignorant, and uninterested in post-cardiac-arrest patients” (A)
“I think that there was a big change. Although the other specialists do not know the exact details of the guideline changes, they now at least agree that they should implement…well…something should be done for these patients” (A)
“It went much better, because a consensus was formed after conducting an Emergency Grand Round within our hospital. Of course, outside educational symposia and conferences also helped…” (A)
Clinical experiencesLack of clinical experience
Influence of prior experiences of adverse events
Experience with successfully treated cases“Until now, we only experienced post-cardiac-arrest patients with poor neurological outcomes. Then we witnessed the full recovery of a cardiac arrest patient after implementing TTM. Now our perception of TTM is much improved” (M)
“The power of media is huge. It is important that the survivor stories are reported to the hospital marketing team to inform many people” (A)
Interdisciplinary and interprofessional collaboration
Departmental collaborationDifficulty in interdisciplinary collaboration
Conflict of department leadership
Collaborative and supportive hospital culture
Multidisciplinary team approach
“It is difficult to teach residents on an individual basis given the high turnover rate. Therefore, motivated faculties and head nurses should be trained to teach a protocol at the department level” (M)
“In a new hospital such as ours where there are not many old professors, and the departments do not have a long history, the barrier is not significant. As such, the interdisciplinary barrier is not high” (M)
Interprofessional teamworkLack of interprofessional educationSharing experiences through conferences“I think the collaboration has improved significantly after ICU nurses and ED nurses learned together” (A)
Organisational resources and processes
Human resourcesLack of specialists or specialised teams
High workloads
Specialists or specialised teams
Consulting services
“Lack of manpower is the most important barrier in our hospital. Post-cardiac arrest care was one of most difficult jobs in the ED last year but the situation was slightly improved after the use of a new cooling machine this year. However, I still think that manpower is the most difficult problem” (A)
“Most of the interdepartmental conflicts resulted from a limited manpower issue. To overcome this problem, we overstepped our budgetary boundaries to purchase a cooling machine equipped with an auto-regulation system. By purchasing the cooling machine, a significant part of the manpower problem was resolved” (M)
Cooling equipmentLack of equipment with an auto-feedback functionEquipment with an auto-feedback function“The most important facilitator is the cooling device. We cannot leave out equipment in this discussion. We can use the cooling equipment to save other manpower. It is also significant that the cooling equipment greatly decreased the time-consuming factor of conventionally using ice packs…” (A)
CostLow medical treatment fees
High cost of cooling equipment and supplies
“From a long-term perspective, I think that an appropriate medical treatment fee should be set for TTM after cardiac arrest. Although most of the relevant professionals currently work hard with passion, I think that a fee associated with the equipment and treatment must be established for other departments to readily accept the treatment” (M)
“At first, I thought that we would do better with the cooling equipment, but I began to see many people give up after explaining the cost of disposable supplies. It is difficult to convince a patient who would not do it if the chances of survival are very low. And we simply can't afford to resort to the previous method of surface ice packs due to the unmanageable manpower problem…” (A)
ChampionshipLack of executive ability of championsActive and dedicated champions
Passion and efforts of champions
“I think the protocol was set up because one particular champion worked hard with passion and others took notice and became interested. After I took the TTM champion course, I developed the protocol and educated the staffs of related departments in our hospital. However, because people forgot easily, I had to try consistently” (M)
“Because I doubted whether we could actually implement it with the few people that agreed with the concept, I hesitated, and the implementation process has stagnated” (M)
LeadershipLack of awareness and support of leadership
Lack of investment from the organisation
Positive attitudes and support of leadership“The department chair and other faculty members all support my work and want to help disseminate the protocol to other departments. It was a great source of strength” (A)
  • (A) indicates a participant who had the role of acting champion; (M) indicates a participant who had the role of managerial champion; TTM, targeted temperature management.