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How Culture Enables Practice: Facilitators and Barriers to the Use of Total Intravenous Anesthesia in Pediatric
Nicholas West1,2, Eleanor Reimer1,3, Asli E Ozer2
1Department of Anesthesia, BC Children's Hospital, Vancouver, British Columbia, Canada.
Insights
Training at an institution that uses total intravenous anesthesia (TIVA) can significantly influence pediatric anesthetic practices. Successful TIVA adoption requires a supportive culture, proper equipment, and tailored approaches.
Area of Science:
- Pediatric Anesthesiology
- Medical Education
- Healthcare Management
Background:
- Total intravenous anesthesia (TIVA) offers potential benefits for pediatric patients, including reduced adverse events and improved recovery.
- British Columbia Children's Hospital (BCCH) is recognized for its expertise and advocacy in TIVA, including intravenous induction techniques.
Purpose of the Study:
- To investigate the impact of institutional culture on the adoption of TIVA in pediatric anesthesia.
- To explore how training at a TIVA-focused institution influences anesthesiologists' practices, particularly concerning intravenous cannulation in awake children.
Main Methods:
- A survey and semi-structured interviews were conducted with current and former anesthesiologists and trainees from BCCH.
- Data collected included demographics, practice settings, anesthesia techniques, and factors influencing TIVA adoption (barriers and facilitators).
- Qualitative data from interviews were analyzed using thematic analysis.
Main Results:
- Most surveyed participants (96%) reported that their BCCH experience altered their anesthetic practice, especially for TIVA maintenance.
- Positive experiences, a supportive environment, and scientific evidence were key influences on practice change.
- Anesthetic technique selection was primarily driven by patient factors, institutional expectations, and pharmacology.
Conclusions:
- Training in a TIVA-promoting institution can significantly shape pediatric anesthetic practices and drive adoption elsewhere.
- Implementing TIVA necessitates a supportive organizational culture, adequate resources, and individualized strategies.
- Understanding change management principles is crucial for successful TIVA integration.
Introduction:
Total intravenous anesthesia (TIVA) in children has gained popularity due to potential advantages, including decreased respiratory adverse events, postoperative nausea and vomiting, and emergence agitation. British Columbia Children's Hospital (BCCH) has a reputation for TIVA use, training, and advocacy, including intravenous induction.
Aim:
To inform practice change and education by exploring how institutional culture impacts TIVA adoption, particularly regarding intravenous cannulation in awake children.
Methods:
Current and former BCCH anesthesiologists and trainees were surveyed and interviewed about TIVA practices at BCCH and at their current institutions. The survey covered demographics, practice settings, past and current methods for induction and maintenance of anesthesia, factors contributing to technique selection, TIVA barriers and facilitators, and implementation factors. Semi-structured interviews conducted with a subset of participants were analyzed using deductive and inductive thematic analysis.
Results:
Twenty-six participants completed the survey: 21 attending physicians, 2 fellows, and 3 residents; 58% with < 10 years' and 23% with > 20 years' anesthesia practice. Most participants (92%) practised in an academic setting, caring for a median [interquartile range] 400 [200-500] children annually. Most (96%) indicated their BCCH experience had changed their practice, with a greater effect on using intravenous anesthesia for maintenance than induction. Changes were influenced by a positive experience (77%), supportive environment (42%), and scientific evidence (42%). Choice of anesthetic technique depended on patient factors (89%), institutional expectations (46%), pharmacology (42%), and patient preference (39%), but not parental preference (15%). Interviews with 11 participants focused on intervention bundles to enable success, expectation-setting, family education, equipment and staff availability, and supportive workflows.
Conclusion:
Training in a TIVA institution can have a profound effect on using TIVA in children and drive changes in anesthetic practice elsewhere. Introducing TIVA requires a supportive culture, appropriate equipment, and the personalization of approaches, and may benefit from understanding factors in change management.
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