Journal of Medical Toxicology

, Volume 14, Issue 4, pp 283–294 | Cite as

Barriers and Facilitators of Intensivists’ Adherence to Hyperinsulinemia-Euglycemia Therapy in the Treatment of Calcium Channel Blocker Poisoning

  • Eric Brassard
  • Patrick Archambault
  • Guillaume Lacombe
  • Maude St-OngeEmail author
Original Article



Adherence to poison center (PC) recommendations for the management of calcium channel blocker (CCB) poisoning is inconsistent. This study aimed to identify behaviors that determine adherence to hyperinsulinemia-euglycemia therapy (HIET) for CCB poisoning.


Semistructured interviews were conducted involving a convenience sample of 18 intensivists. Interview responses were analyzed using the theoretical domains framework (TDF) to identify relevant domains influencing physician adherence to HIET. Two independent reviewers performed qualitative content analysis of the interview transcripts to identify beliefs influencing decisions to initiate HIET. Initially, beliefs were classified and frequencies reported as being likely to facilitate, likely to decrease, or unlikely to affect adherence. Subsequently, beliefs were linked to a domain within the TDF. Based on the potential impact on physician behavior and frequency of reported behavior, we selected the most relevant domains likely to influence physician adherence to HIET for CCB poisoning.


Positive beliefs were identified in the following domains: “behavioral regulation” (e.g., algorithm for adjustment of perfusions), “belief about capabilities” (e.g., confidence about being able to manage HIET), “belief about consequences” (e.g., fear of clinical deterioration), and “reinforcement” (e.g., clinical instability). Negative beliefs were identified in the following domains as “nature of behavior” (e.g., preference for vasopressors over HIET) and “environmental context and resources” (e.g., accessing dextrose 50% and increased nurse workload).


This qualitative study identified potential behavioral targets for future implementation strategies to address to improve adherence to HIET.


Calcium channel blocker Cardiotoxicity Knowledge transfer Implementation Adherence 



We thank all participants who participated in this study. We thank the Canadian Critical Care Society for sharing access to their electronic mailing list of members.

Sources of Funding


Compliance with Ethical Standards

Conflicts of Interest



  1. 1.
    Gummin DD, Mowry JB, Spyker DA, Brooks DE, Fraser MO, Banner W. Annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 34th annual report. Clin Toxicol. 2016;55(10):1072–254.CrossRefGoogle Scholar
  2. 2.
    Greene SL, Gawarammana I, Wood DM, Jones AL, Dargan PI. Relative safety of hyperinsulinaemia/euglycaemia therapy in the management of calcium channel blocker overdose: a prospective observational study. Intensive Care Med. 2007;33(11):2019–24.CrossRefGoogle Scholar
  3. 3.
    Espinoza T, Bryant SM, Aks SE. Hyperinsulin therapy for calcium channel antagonist poisoning: a seven—year retrospective study. Am J Ther. 2013;20:29–31.CrossRefGoogle Scholar
  4. 4.
    Patel NP, Pugh ME, Goldberg S, Eiger G. Hyperinsulinemic euglycemia therapy for verapamil poisoning: a review. Am J Crit Care. 2007;16(5):498–503.PubMedGoogle Scholar
  5. 5.
    St-Onge M, Archambault P, Lesage N, Guimont C, Poitras J, Blais R. Adherence to calcium channel blocker poisoning treatment recommendations in two Canadian cities. Clin Toxicol (Phila). 2012;50(5):424–30.CrossRefGoogle Scholar
  6. 6.
    Darracq MA, Thornton SL, Do HM BD, Clark RF, Cantrell FL. Utilization of hyperinsulinemia euglycemia and intravenous fat emulsion following poison center recommendations. J Med Toxicol. 2013;9(3):226–30.CrossRefGoogle Scholar
  7. 7.
    St-Onge M, Anseeuw K, Cantrell FL, Gilchrist IC, Hantson P, Bailey B, et al. Experts consensus recommendations for the management of calcium channel blocker poisoning in adults. Crit Care Med. 2017;45(3):e306–15.CrossRefGoogle Scholar
  8. 8.
    Curran J, Brehaut J, Patey A, Osmond M, Stiell I, Grimshaw J. Understanding the Canadian adult CT head rule trial: use of the theoretical domains framework for process evaluation. Implement Sci. 2013;8:25.CrossRefGoogle Scholar
  9. 9.
    Kiyoshi-Teo H, Cabana MD, Froelicher ES, Blegen MA. Adherence to institution-specific ventilator-associated pneumonia prevention guidelines. Am J Crit Care. 2014;23(3):201–14.CrossRefGoogle Scholar
  10. 10.
    Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282(15):1458–65.CrossRefGoogle Scholar
  11. 11.
    Grimshaw J, Eccles M, Thomas R, MacLennan G, Ramsay C, Fraser C, et al. Toward evidence-based quality improvement evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966–1998. J Gen Intern Med. 2006;21:S14–20.PubMedPubMedCentralGoogle Scholar
  12. 12.
    Rello J, Lorente C, Bodí M, Diaz E, Ricart M, Kollef MH. Why do physicians not follow evidence-based guidelines for preventing ventilator-associated pneumonia?: a survey based on the opinions of an international panel of intensivists. Chest. 2002;122(2):656–61.CrossRefGoogle Scholar
  13. 13.
    Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14(1):26–33.CrossRefGoogle Scholar
  14. 14.
    Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7:37.CrossRefGoogle Scholar
  15. 15.
    Roberts N, Hooper G, Lorencatto F, Storr W, Spivey M. Barriers and facilitators towards implementing the Sepsis Six care bundle (BLISS-1): a mixed methods investigation using the theoretical domains framework. Scand J Trauma Resusc Emerg Med. 2017;25(1):96.CrossRefGoogle Scholar
  16. 16.
    Lavallée JF, Gray TA, Dumville J, Cullum N. Barriers and facilitators to preventing pressure ulcers in nursing home residents: a qualitative analysis informed by the Theoretical Domains Framework. Int J Nurs Stud. 2018;82:79–89.CrossRefGoogle Scholar
  17. 17.
    Isenor JE, Minard LV, Stewart SA, Curran JA, Deal H, Rodrigues G, Sketris IS. Identification of the relationship between barriers and facilitators of pharmacist prescribing and self-reported prescribing activity using the theoretical domains framework. Res Soc Adm Pharm. 2017.Google Scholar
  18. 18.
    Joosen MC, van Beurden KM, Terluin B, van Weeghel J, Brouwers EP, van der Klink JJ. Improving occupational physicians’ adherence to a practice guideline: feasibility and impact of a tailored implementation strategy. BMC Med Educ. 2015;15:82.CrossRefGoogle Scholar
  19. 19.
    Ista E, van Dijk M, van Achterberg T. Do implementation strategies increase adherence to pain assessment in hospitals? A systematic review. Int J Nurs Stud. 2013;50(4):552–68.CrossRefGoogle Scholar
  20. 20.
    Cochrane Effective Practice and Organisation of Care Group. Effective Practice and Organisation of Care (EPOC). EPOC Taxonomy. Oslo: Norwegian Knowledge Centre for the Health Services. 2015. Available at:
  21. 21.
    Mazza D, Bairstow P, Buchan H, Chakraborty SP, Van Hecke O, Grech C, et al. Refining a taxonomy for guideline implementation: results of an exercise in abstract classification. Implement Sci. 2013;8:32.CrossRefGoogle Scholar
  22. 22.
    Atkins L, Francis J, Islam R, O’Connor D, Patey A, Ivers N, et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implement Sci. 2017;12:77.CrossRefGoogle Scholar
  23. 23.
    Francis J, Stockton C, Eccles M, Johnston M, Cuthbertson B, Grimshaw J, et al. Evidence-based selection of theories for designing behaviour change interventions: using methods based on theoretical construct domains to understand clinicians' blood transfusion behaviour. Br J Health Psychol. 2009;14:625–46.CrossRefGoogle Scholar
  24. 24.
    Guest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field Methods. 2006;18(1):59–82.CrossRefGoogle Scholar
  25. 25.
    Francis JJ, Johnston M, Robertson C, Glidewell L, Entwistle V, Eccles MP, et al. What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychol Health. 2010;25(10):1229–45.CrossRefGoogle Scholar
  26. 26.
    Temple B, Young A. Qualitative research and translation dilemmas. Qual Res. 2004;4(2):161–78.CrossRefGoogle Scholar
  27. 27.
    van Nes F, Abma T, Jonsson H, Deeg D. Language differences in qualitative research: is meaning lost in translation? Eur J Ageing. 2010;7(4):313–6.CrossRefGoogle Scholar
  28. 28.
    Bussieres AE, Patey AM, Francis JJ, Sales AE, Grimshaw J. Identifying factors likely to influence compliance with diagnostic imaging guideline recommendations for spine disorders among chiropractors in North America: a focus group study using the Theoretical Domains Framework. Implement Sci. 2012;7:82.CrossRefGoogle Scholar
  29. 29.
    Ranieri VM, Thompson BT, Barie PS, Dhainaut JF, Douglas IS, Finfer S, et al. Drotrecogin alfa (activated) in adults with septic shock. N Engl Med. 2012;366(22):2055–64.CrossRefGoogle Scholar
  30. 30.
    Ellington L, Sheldon LK, Matwin S, Smith JA, Poynton MM, Crouch BI, et al. An examination of adherence strategies and challenges in poison control communication. J Emerg Nurs. 2009;35(3):186–274.CrossRefGoogle Scholar
  31. 31.
    Watts M, Fountain JS, Reith D, Schep L. Compliance with poisons center referral advice and implications for toxicovigilance. J Toxicol Clin Toxicol. 2004;42:603–10.CrossRefGoogle Scholar
  32. 32.
    Wezorek CM, Dean BS, Krenzelok EP. Factors influencing non-compliance with poison center recommendations. Vet Hum Toxicol. 1992;34:151–3.PubMedGoogle Scholar
  33. 33.
    Weiss CH, Baker DW, Tulas K, Weiner S, Bechel M, Rademaker A, et al. A critical care clinician survey comparing attitudes and perceived barriers to low tidal volume ventilation with actual practice. Ann Am Thorac Soc. 2017;14(11):1682–9.CrossRefGoogle Scholar
  34. 34.
    Cook D, Duffett M, Lauzier F, Ye C, Dodek P, Paunovic B, et al. Barriers and facilitators of thromboprophylaxis for medical-surgical intensive care unit patients: a multicenter survey. J Crit Care. 2014;29(3):471.e1–9.CrossRefGoogle Scholar
  35. 35.
    Latif A, Kelly B, Edrees H, Kent PS, Weaver SJ, Jovanovic B, et al. Implementing a multifaceted intervention to decrease central line-associated bloodstream infections in SEHA (Abu Dhabi Health Services Company) intensive care units: the Abu Dhabi experience. Infect Control Hosp Epidemiol. 2015;36(7):816–22.CrossRefGoogle Scholar
  36. 36.
    Islam R, Tinmouth AT, Francis JJ, Brehaut JC, Born J, Stockton C, et al. A cross-country comparison of intensive care physicians’ beliefs about their transfusion behaviour: a qualitative study using the theoretical domains framework. Implement Sci. 2012;7:93.CrossRefGoogle Scholar
  37. 37.
    Cuthbertson BH, Francis J, Campbell M, MacIntyre L, Sepelt I, Grimshaw J. A study of the perceived risks, benefits and barriers to the use of SDD in adult critical care units. Trials. 2010;11:117.CrossRefGoogle Scholar
  38. 38.
    Duncan EM, Cuthbertson BH, Prior ME, Marshall AP, Wells EC, Todd LE, et al. The views of health care professionals about selective decontamination of the digestive tract: an international, theoretically-informed study. J Crit Care. 2014;29(4):634–40.CrossRefGoogle Scholar
  39. 39.
    Francis JJ, Duncan EM, Prior ME, MacLennan GS, Dombrowski SU, Bellingan G, et al. Selective decontamination of the digestive tract in critically ill patients treated in intensive care units: a mixed-methods feasibility study. Health Technol Assess. 2014;18(25):1–170.CrossRefGoogle Scholar
  40. 40.
    Romnew W, Salbach N, Parrott JS, Deutsch JE. A knowledge translation intervention designed using audit and feedback and the Theoretical Domains Framework for physical therapists working in inpatient rehabilitation: a case report. Physiother Theory Pract. 2018;16:1–17.CrossRefGoogle Scholar
  41. 41.
    Garbutt JM, Dodd S, Walling E, Lee AA, Kulka K, Lobb R. Theory-based development of an implementation intervention to increase HPV vaccination in pediatric primary care practices. Implement Sci. 2018;13(1):45.CrossRefGoogle Scholar
  42. 42.
    Ciprut S, Sedlander E, Watts KL, Matulewicz RS, Stange KC, Sherman SE, et al. Designing a theory-based intervention to improve the guideline-concordant use of imaging to stage incident prostate cancer. Urol Oncol. 2018;36(5):246–51.CrossRefGoogle Scholar
  43. 43.
    Craig LE, Taylor N, Grimley R, Cadilhac DA, McInnes E, Phillips R, et al. Development of a theory-informed implementation intervention to improve the triage, treatment and transfer of stroke patients in emergency departments using the Theoretical Domains Framework (TDF): the T3 Trial. Implement Sci. 2017;12(1):88.CrossRefGoogle Scholar
  44. 44.
    Riis A, Jensen CE, Bro F, Maindal HT, Petersen KD, Bendtsen MD, et al. A multifaceted implementation strategy versus passive implementation of low back pain guidelines in general practice: a cluster randomised controlled trial. Implement Sci. 2016;11(1):143.CrossRefGoogle Scholar

Copyright information

© American College of Medical Toxicology 2018

Authors and Affiliations

  1. 1.Department of Anesthesiology and Critical CareUniversité LavalQuébecCanada
  2. 2.Centre de Recherche du Centre intégré en santé et services sociaux de Chaudière-AppalachesLévisCanada
  3. 3.Department of Family Medicine and Emergency MedicineUniversité LavalQuébecCanada
  4. 4.Centre antipoison du QuébecCIUSSS Capitale NationaleQuébecCanada
  5. 5.CHU de Québec Research Center, Population Health and Optimal Health PracticesUniversité LavalQuébecCanada

Personalised recommendations