Implementation of Primary Care Clinical Practice Guidelines within an Army Combat Support Hospital

Background: In 2017, the 328th Combat Support Hospital (CSH) failed to identify and utilize Clinical Practice Guidelines (CPGs) during a pre-deployment training exercise. In 2018, this failure led to the 328th CSH Battalion Commander to direct all hospital departments to create, update, or revise all CPGs. The military requires the use of CPGs to promote high quality, consistent, and patient-centered care. During deployments, the Emergency Medical Treatment (EMT) medical providers manage the Emergency Department and "sick call". Sick call is how ambulatory soldiers seek medical treatment for non-urgent complaints that includes a large variety of disease and non-battle injuries (DNBIs). Management of DNBIs is a core competency of all medical providers within a CSH. Medical providers refers to all medical specialties within the EMT department: medics, licensed practical nurses (LPNs), registered nurses (RNs), physician assistants (PAs), and physician (MD). Army medicals and/or LPNs manage sick call with minimal oversight by a MD provider. Objective: The objective of this quality improvement project was to improve knowledge of, use of, and accessibility to evidence-based CPGs among EMT medical providers in the 328th CSH. Methods: We adapted and updated five CPGs for common DNBIs, developed educational interventions, and delivered the educational interventions to EMT medical providers from the 328th CSH who volunteered to participate. Designed to improve knowledge of, use of, and accessibility to the five sick call specific CPGs, we delivered the educational interventions at three separate training events conducted over the course of one month. Pre- and post-intervention, we assessed medical provider's knowledge of CPGs as well as their capability, opportunity, and motivation to use CPGs. assessment tested the medical providers' CPG knowledge. Results: Altogether, 43 medical providers participated in the quality improvement project. Medical providers overall scores improved when comparing the pre- (54.3%) and post- (96.9%) CPG knowledge assessment scores (p <0.001). The greatest improvement in assessment scores was among the medics (pre- 50.6% to post- 98.4%) and LPNs (pre- 53.1% to post- 92.5%). We found improvement in medical provider's capability, opportunity, and motivation to use CPGs; however, not all reached statistical significance. Nearly all medical providers indicated that they needed (97.7%) and wanted (93.0%) more department-specific CPG training. Discussion: The educational interventions associated with this lead to knowledge of CPGs and access to them. Given that the CSH did not deploy and thus medical providers did not cared for soldiers with DNBIs, it is not surprising that we did not find any statistically significant difference in their habit of actually using CPGs. Medical providers displayed the greatest improvement in their perceived opportunity to use CPGs. Although medical providers showed improvements in capability, opportunity, and motivation, some did not reach statistical significance, which likely is related to sample size.