Barriers and facilitators to implementing enteral resuscitation for major burn injuries: Reflections from Nepalese care providers

Introduction: Burn injuries present a significant challenge globally, particularly in low- and middle-income countries (LMICs) where access to standard intravenous (IV) fluid resuscitation is often limited. In such austere settings, the feasibility of enteral resuscitation via oral rehydration solution (ORS) as an alternative to burn resuscitation is a critical consideration. We aimed to investigate the barriers and facilitators perceived by burn care providers in Nepal trained to use an enteral resuscitation protocol.

Methods: We conducted seven focus group discussions (FGD) with burn care providers (n = 45) involved in the resuscitation of burn-injured patients. These discussions centered on their experiences using enteral resuscitation in burn patients. We employed a semi-structured interview guide using Consolidated Framework for Implementation Research (CFIR), used deductive thematic analysis of the transcripts, and organized them based on CFIR constructs.

Results: Intensive involvement of stakeholders in the protocol development facilitated acceptance of enteral resuscitation. Stakeholders were motivated by a perceived desire to change practice to improve outcomes. Familiarity with ORS, operational advantages of ORS, and the perceived benefits of enteral resuscitation when struggling to obtain IV access in dehydrated patients furthered acceptance among participants. Recurring formal and informal training sessions aided uptake and fidelity to the protocol. However, challenges emerged in precise volume administration, miscalculations, technical errors, and structural resource limitations (e.g., limited staff time to monitor patients) related to the goal-directed resuscitation strategy.

Conclusion: This study highlights the importance of stakeholder engagement, iterative refinement, and contextual adaptation in implementing an enteral resuscitation protocol for acute burn injuries. Findings offer insights into real-world applications and future clinical and research endeavors, informing the potential scalability and sustainability of enteral resuscitation protocols more broadly, to improve the care of patients with major burns in LMICs.