Open Access Open Badges Research article

Barriers and supports to implementation of MDI/spacer use in nine Canadian pediatric emergency departments: a qualitative study

Shannon D Scott1*, Martin H Osmond2, Kathy A O'Leary3, Ian D Graham45, Jeremy Grimshaw67, Terry Klassen3 and the Pediatric Emergency Research Canada (PERC) MDI/spacer Study Group

Author Affiliations

1 Faculty of Nursing, Clinical Sciences Building, University of Alberta, Edmonton, Alberta, Canada

2 Department of Pediatrics, University of Ottawa, Ontario, Canada

3 Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada

4 School of Nursing and Department of Epidemiology and Community Medicine, University of Ottawa, Ontario, Canada

5 Knowledge Translation Portfolio, Canadian Institutes of Health Research, Ottawa, Ontario

6 Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Ontario, Canada

7 Department of Medicine, University of Ottawa, Ontario, Canada

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Implementation Science 2009, 4:65  doi:10.1186/1748-5908-4-65

Published: 13 October 2009



Despite recent research supporting the use of metered dose inhalers with spacer devices (MDI/spacers) in pediatric emergency departments (PEDs) for acute exacerbations of asthma, uptake of this practice has been slow. The objectives of this study were to determine the barriers and supports to implementing MDI/spacer research and to identify factors associated with early and late adoption of MDI/spacers in Canadian PEDs.


Using a comparative case study design, we classified nine tertiary care pediatric hospital PEDs based on their stage of implementation. Data were collected using focus group interviews with physicians, registered nurses (RNs), and respiratory therapists (RTs), and individual interviews with both patient care and medical directors at each site. Initial coding was based on the Ottawa Model of Research Use (OMRU) categories of elements known to influence the uptake of innovations.


One hundred and fifty healthcare professionals from nine different healthcare institutions participated in this study. Lack of leadership in the form of a research champion, a lack of consensus about the benefits of MDI/spacers among staff, perceived resistance from patients/parents, and perceived increased cost and workload associated with MDI/spacer use were the most prevalent barriers to the adoption of the MDI/spacer. Common strategies used by early-adopting sites included the active participation of all professional groups in the adoption process in addition to a well-planned and executed educational component for staff, patients, and families. Early adopter sites were also more likely to have the MDI/spacer included in a clinical protocol/pathway.


Potential barriers and supports to implementation have been identified that will help EDs adopt MDI/spacer use. Future interventions intended to increase MDI/spacer use in PEDs will need to be sensitive to the barriers identified in this study.