1
2
3
Tables / Appendices
4
fetal neuroprotection used in data coding and analysis
Panel 1: Discussion forum and course evaluation questions from the e-learning module for MgSO4 for
Discussion forum questions
Is there any additional information that you would like to have before using magnesium sulphate for
fetal neuroprotection in your practice? If ‘yes, please explain.
Do you perceive any barriers that may prevent use of magnesium sulphate for fetal neuroprotection? If
‘yes’, please explain.
Are you concerned about the effects of magnesium sulphate for fetal neuroprotection on the baby in
the newborn period? If ‘yes, please explain.
Following completion of this programme, are you likely to use magnesium sulphate for fetal
neuroprotection?
Course evaluation questions
Can you identify changes you would make in your practice as a result of this program?
Are there any areas related to this topic that you’d like to learn more about in future programs?
5
MgSO4 (magnesium sulphate)
6
7
Table 1: Characteristics of 1608 participants by type of KT method (N (%) or mean±SD of column total
8
unless otherwise specified)
1
e-learning
Site visits
Barriers &
module
(N=146†*)
Facilitators Survey (N=188†)
458 (35.9%)
59 (40.4%)
92 (48.9%)
Maternal-Fetal Medicine
-‡
18
33
General Obs/Gyn
168
26
37
General Practice
200
0
0
Anaesthesia
15
4
2
Pediatrics/Neonatology
75
11
11
Unclassified
0
0
9
439 (34.5%)
57 (39.0%)
87 (46.3%)
Registered nurse
412
56
80
Nurse practitioner
25
1
0
Licensed practical nurse
3
0
0
Unclassified
0
0
7
177 (13.9%)
20 (13.7%)
7 (3.7%)
(N=1274*)
Health care provider type
Physicians
Nurses
Other
2
e-learning
Site visits
Barriers &
module
(N=146†*)
Facilitators Survey (N=188†)
(N=1274*)
Midwife
4
1
2
Medical resident
9
3
2
Medical student
7
1
0
Research staff
5
14
1
150
1
1
2
0
1
200 (15.7%)
10 (6.8%)
2 (1.1%)
British Columbia
162 (12.7%)
10 (6.8%)
21 (11.2%)
Alberta
234 (18.4%)
80 (54.8%)
15 (8.0%)
Saskatchewan
45 (3.5%)
8 (5.5%)
16 (8.5%)
Manitoba
50 (3.9%)
0
0
Ontario
517 (40.6%)
25 (17.1%)
58 (30.9%)
Quebec
87 (6.8%)
5 (3.4%)
14 (7.4%)
Pharmacist
Administration
Unclassified
Province/Territory
3
e-learning
Site visits
Barriers &
module
(N=146†*)
Facilitators Survey (N=188†)
6 (4.1%)
17 (9.0%)
(N=1274*)
Newfoundland
35 (2.7%)
New Brunswick
82 (6.4%)
34 (18.1%)
12 (8.2%)¶
Nova Scotia
35 (2.7%)
Prince Edward Island
6 (0.5%)
0
0
Yukon
6 (0.5%)
0
0
NWT
9 (0.7)
0
0
Nunavut
5 (0.4)
0
0
Unknown
1 (0.0%)
0
0
472 (37.0%)
146 (100%)
188 (100%)
Small (<3000 del/yr)
128/472 (27.1%)
13/146 (8.9%)
51/188 (27.1%)
Medium (3000-4999 del/yr)
52/472 (11.0%)
48/146 (32.9%)
29/188 (15.4%)
Large (≥5000 del/yr)
291/472 (61.7%) 85/146 (58.2%)
108/188 (57.5%)
Works in a tertiary perinatal unit
Missing
9
10
1/472 (0.2%)
13 (6.9%)
0
0
NWT (Northwest Territories), Del (deliveries), KT (knowledge translation), Obs/Gyn (Obstetrics and
Gynaecology)
4
11
Note that the total % is broken down in various ways; each area until a bolded row adds to 100%.
12
* 13 sites were covered by 10 sites visits, as three small sites joined the visit at a larger centre.
13
† Questionnaires were completed at 12/18 MAG-CP sites.
14
‡ Not available as an option in the e-learning module.
15
¶ Representatives from New Brunswick and Nova Scotia attended the site visit in Nova Scotia.
16
Table 2: Barriers to use of MgSO4 for fetal neuroprotection (N (%) responses for all responses that relate
17
to barriers)
Nodes
Sub-nodes
e-learning
Site
Barriers &
module
visits
Facilitators Survey
(N=119)
(N=92)
(N=147)
51 (42.9%)
47
86 (58.5%)
Individual-level
(51.1%)
Unsupportive attitudes and beliefs
12 (10.1%)
3 (3.3%)
12 (8.2%)
Not within provider’s control
4 (3.4%)
0
2 (1.4%)
No experience
3 (2.5%)
1 (1.1%)
3 (2.0%)
15 (12.6%)
18
35 (23.8%)
Overall
(19.6%)
Inadequate knowledge
In self
0
3
18
In others
13
4
9
Unclear who lacks
2
11
8
and understanding
5
knowledge
Forgetting to administer MgSO4
1 (0.8%)
1 (1.1%)
3 (2.0%)
14 (11.8%)
16
13 (8.8%)
Overall
(17.4%)
Legal
0
2
3
Medication error
0
2
0
Adverse effects of
0
3
5
14
9
5
0
1 (1.1%))
4 (2.7%)
2 (1.7%)
7 (7.6%)
14 (9.5%)
64 (53.8%)
34
40 (27.2%)
Fears
withholding MgSO4
Adverse effects of
MgSO4
Failure to implement guidelines
Evidence concerns (sufficiency and validity)
Institutional-level
(37.0%)
Unsupportive institutional culture
2 (1.7%)
3 (3.3%)
3 (2.0%)
20 (16.8%)
17
6 (4.1%)
Timing and transport
(18.5%)
31 (25.2%)
12
20 (13.6%)
Resource constraints
(13.0%)
6
2
11 (9.2%)
11 (7.5%)
Policy development and implementation
(12.0%)
11
4 (3.4%)
21 (14.3%)
Social-level
(12.0%)
Lack of provider-institutional consensus
Inadequate interprovider communication
Educating patients
1 (0.8%)
4 (4.3%)
15 (10.2%)
0
7 (7.6%)
5 (3.4%)
3 (2.5%)
0
1 (0.7%)
18
MgSO4 (magnesium sulphate)
19
Note that the total % is broken down in various ways; each area until a bolded row adds to the % listed in
20
the bolded row.
21
Table 3: Facilitators of use of MgSO4 for fetal neuroprotection (N (%) responses for all responses that
22
relate to facilitators)*
Site visits
Nodes
Sub-nodes
(N=128)
Barriers & Facilitators
Survey
(N=171)
Individual-level
17 (13.3%)
38 (22.2%)
Supportive attitudes and beliefs
4 (3.1%)
9 (5.3%)
Knowledge and understanding
8 (6.3%)
15 (8.8%)
Early adopters/mobilizers
1 (0.8%)
9 (5.3%)
7
Site visits
Nodes
Sub-nodes
(N=128)
Barriers & Facilitators
Survey
(N=171)
Comfort/experience using MgSO4
4 (3.1%)
5 (2.9%)
80 (62.5%)
107 (62.6%)
34 (26.6%)
26 (15.2%)
Pre-printed orders for MgSO4 use
5
6
Pre-mixed bags of MgSO4
8
2
Mechanism for audit and feedback
8
3
Unclassifiable¶
13
15
8 (6.3%)
11 (6.4%)
38 (29.7%)
70 (40.9%)
18
38
Patient load
3
10
Human resource capacity
5
4
Education and professional
12
18
Institutional-level
Overall
Policies and protocols
Local champion/opinion leader
Overall
Supportive institutional
culture/evidence-based
Facility characteristics
development
8
Site visits
Nodes
Sub-nodes
(N=128)
Barriers & Facilitators
Survey
(N=171)
Social-level
31 (24.2%)
26 (15.2%)
4 (3.1%)
2 (1.2%)
17 (13.3%)
5 (2.9%)
Community support
2 (1.6%)
0
Communication and collaboration
8 (6.3%)
19 (11.1%)
Patient voice/awareness
Knowledge translation
23
* When the e-learning module was designed, a specific exploration of facilitators was not planned and
24
therefore, undertaken.
25
¶ Response about general policy/protocol and not specific to pre-printed orders, pre-printed bags, or
26
audit/feedback
27
Note that the total % is broken down in various ways; each area until a bolded row adds to the % listed in
28
the bolded row.
29
30
Table 4: Responses for ‘knowledge needed’ (N (%) responses) for all responses that relate to knowledge
31
needed)
9
e-learning
Nodes
Sub-sub-
module
node
(N=188)
Sub-nodes
Site visits
(N=85)
Barriers &
Facilitators
Survey
(N=65)
Mechanism of action
11 (5.9%)
2 (2.4%)
17 (26.2%)
Administration
Overall
47 (25.0%)
61 (71.8%)
26 (40.0%)
Transfer
0
2
0
Threatened preterm labour vs.
3
10
0
Timing of administration
6
9
7
Standards of practice
4
10
2
Re-treatment
0
7
3
Pre-printed orders
1
0
0
Policies and protocols
8
3
7
Multiple pregnancies
1
0
0
Gestational age
8
7
2
Drug interactions
5
0
0
Contraindications
1
2
0
imminent preterm birth
10
e-learning
Nodes
Sub-sub-
module
node
(N=188)
Sub-nodes
Site visits
(N=85)
Barriers &
Facilitators
Survey
(N=65)
Unclassified
Side effects
and risks
10
11
5
26 (13.8%)
16 (18.8%)
6 (9.2%)
Rapid delivery
1
0
0
Overuse
1
1
0
Interventions as a result of
3
0
0
Increased monitoring needed
5
0
0
Adverse
3
1
0
1
0
0
6
3
0
Overall
MgSO4
physiological
Toxicity
effects –
neonate
Problems
with feeding
Neonatal
respiratory
11
e-learning
Nodes
Sub-sub-
module
node
(N=188)
Sub-nodes
Site visits
(N=85)
Barriers &
Facilitators
Survey
(N=65)
depression
Long-term
0
1
2
1
0
0
0
7
0
4
2
4
7 (3.7%)
0
3 (4.6%)
Audit and feedback
1
0
0
Unclassified
6
0
3
46 (24.5%)
5 (5.9%)
13 (20.0%)
33
3
5
effects
Adverse
neurological
effects
Adverse physiological effects –
general (unspecified
maternal/neonate)
Unclassified
KT tools
Research
Overall
Overall
Further research
12
e-learning
Nodes
Sub-sub-
module
node
(N=188)
Site visits
Sub-nodes
(N=85)
Barriers &
Facilitators
Survey
(N=65)
Evidence to date
6
1
7
Unclassifiable
7
1
1
30 (16.0%)
1 (1.2%)
0
21 (11.2%)
0
0
Other uses and topics (not MgSO4 for fetal
neuroprotection)
None stated
32
MgSO4 (magnesium sulphate)
33
Note that the total is broken down in various ways; each area until a bolded row adds to the total n
34
listed in the bolded row.
35
36
Table 5: Summary of key results / findings unique to each KT format
Respondents accessed
e-learning module
Site visits
B&F survey
• Reached the largest
• Reached fewer
• Most limited in terms
number of participants
practitioners, but of a
of ‘other’ non-physician
across the widest
similar scope in terms
and non-nurse
geographic area
of roles within health
respondents
care
Barriers
• Most restricted
• Greatest spread of
• More social-level
13
breadth of fears listed
barriers across
barriers compared with
• Insufficient
individual, institutional,
other formats
knowledge most often
and social levels
• Insufficient
identified in others
knowledge most often
identified in respondent
Facilitators
• Institutional-level
• Institutional-level
most cited, followed by
most citied, followed by
social-level
individual-level
• Greatest number of
• Information on
• Least amount of
responses calling for
administration cited
information provided
further research
most often
Method
• One-way
• Two-way
• One-way
Approximate cost
• $10,000
• $17,500 (total) or
• Negligible
$1750 per visit†
(assumption)†
Knowledge needed
-*
37
B&F (Barriers and Facilitators)
38
* Facilitators were not included in the e-learning module format which was developed first.
39
† As academic health care centre employees, salaries were considered to cover educational activities
40
such as for MAG-CP. Site visit costs were based on travel expenses.
41
SUPPLEMENTARY APPENDIX
42
43
Table S1: The MAG-CP (MAGnesium sulphate for prevention of Cerebral Palsy) Collaborative Group
MAG-CP site
Location
Local team
membership
14
British Columbia Women’s Hospital and Health
Centre
Vancouver, British
Columbia
Dane De Silva
Peter von Dadelszen
Laura A. Magee
Anne Synnes
Foothills Medical Centre
Calgary, Alberta
Stephanie Cooper
Lorel Derderer
Royal Alexandra Hospital
Edmonton, Alberta
Carmen Young
Cheryl Lux
Royal University Hospital
Saskatoon, Saskatchewan
Femi Olatunbosun
Regina General Hospital
Regina, Saskatchewan
George Carson
London Health Sciences Centre
London, Ontario
Renato Natale
Laura Kennedy
Mount Sinai Hospital
Toronto, Ontario
Wendy Whittle
Karen Muller
Sunnybrook Health Sciences Centre
Toronto, Ontario
Noor Ladhani
The Ottawa Hospital
Ottawa, Ontario
Mark Walker
Melin Peng
Centre Hôspitalier de L’Université Laval
Quebec City, Quebec
Emmanuel Bujold
Katy Gouin
Amelie Tetu
IWK Health Centre
Halifax, Nova Scotia
Victoria Allen
Women’s Health Program, Eastern Health
St. John’s, Newfoundland
Joan Crane
Donna Hutchens
Sandra Adams
Saint John Regional Hospital
Saint John, New
James Andrews
15
Brunswick
Dr. Everett Chalmers Hospital
Fredericton, New
Brunswick
Kimberly Butt
The Moncton Hospital
Moncton, New Brunswick
Lynn MurphyKaulbeck
Laura Gaudet
(previous)
Claire Williams
44
45
Table S2: Ethical approval numbers by site
MAG-CP site
Location
Ethics
British Columbia Women’s Hospital and Health
Centre
Vancouver, British
Columbia
H11-02214
Foothills Medical Centre
Calgary, Alberta
*
Royal Alexandra Hospital
Edmonton, Alberta
MS4_Pro00030586
Royal University Hospital
Saskatoon, Saskatchewan
Bio 12-194
Regina General Hospital
Regina, Saskatchewan
REB-13-55
London Health Sciences Centre
London, Ontario
102889
Mount Sinai Hospital
Toronto, Ontario
12-0259-E
Sunnybrook Health Sciences Centre
Toronto, Ontario
388-2012
The Ottawa Hospital
Ottawa, Ontario
20130143-01H
Centre Hôspitalier de L’Université Laval
Quebec City, Quebec
B12-04-943-21
IWK Health Centre
Halifax, Nova Scotia
1004849
Women’s Health Program, Eastern Health
St. John’s, Newfoundland
12.100
Saint John Regional Hospital
Saint John, New
Brunswick
2013-1816
16
Dr. Everett Chalmers Hospital
Fredericton, New
Brunswick
2012-1735
The Moncton Hospital
Moncton, New Brunswick
2012-1727
46
47
* The one site that participated only in the educational study visit (but not data collection) decided not
to proceed with the rest of the study and they did not pursue local REB approval.
48
Table S3: Barriers and Facilitators Survey
ASSESSMENT OF BARRIERS AND FACILITATORS TO PRACTICE CHANGE
As part of the MAG-CP implementation project, it is important for us to identify and assess factors that
may either help to change practice (a ‘facilitator’) or hinder changes in practice (a ‘barrier’) in your
centre. These factors may be characteristics of: individual care providers, relationships between care
providers, or the organizational culture of your hospital.
Thank you in advance for your anonymous input!
1. Do you feel that you have adequate KNOWLEDGE and UNDERSTANDING of the EVIDENCE for
magnesium sulphate for fetal neuroprotection?
Yes
No  If no, please tell us what you would like to know more about: _______________
______________________________________________________________________________
2. Do you believe that the EVIDENCE is RIGOROUS ENOUGH to warrant use of magnesium sulphate for
fetal neuroprotection in clinical practice?
No
Yes
Don’t know  If no, please share with us your concerns: __________________
______________________________________________________________________________
3. Are you aware of an opinion leader in your centre who has strong views about use of magnesium
sulphate for fetal neuroprotection?
No
Yes  if yes, does he/she believe that magnesium sulphate should be used for fetal
4. Do you consider yourself to be an ‘early adopter’ of evidence?
No
Yes
Don’t know
5. Do you consider yourself to be a ‘late adopter’ of evidence?
No
Yes
Don’t know
6. Do you feel that you have adequate KNOWLEDGE and UNDERSTANDING of the 2011 SOGC
Guideline on use of magnesium sulphate for fetal neuroprotection?
17
No
Yes
7. Are you concerned about MEDICO-LEGAL PROBLEMS related to use magnesium sulphate for fetal
neuroprotection?
No
Yes  if yes, please describe for us your concerns: _____________________________
______________________________________________________________________________
8. Are you aware of women in your centre who have asked for magnesium sulphate for fetal
neuroprotection?
No
Yes
9. Are you aware of an INSTITUTIONAL POLICY at your centre for use of magnesium sulphate for fetal
neuroprotection?
No
Yes  if yes, does this policy recommend use of magnesium sulphate for fetal
neuroprotection in the setting of preterm birth at <32 weeks?
No
Yes
Don’t know
10. Do you have PRE-PRINTED ORDERS for use of magnesium sulphate for fetal neuroprotection?
No
11. For use of magnesium sulphate for fetal neuroprotection in the setting of ‘imminent preterm
birth’ at <32 weeks, how concerned are you about the resource implications in the following areas of
the hospital:
Delivery suite
Not at all concerned
concerned
Somewhat concerned
Concerned
Very concerned
Extremely
Somewhat concerned
Concerned
Very concerned
Extremely
Somewhat concerned
Concerned
Very concerned
Extremely
Neonatal intensive care unit (NICU)
Not at all concerned
concerned
Pharmacy
Not at all concerned
concerned
12. Do you feel that in your centre there is administrative support for use of magnesium sulphate for
fetal neuroprotection?
Yes
No
Don’t know
13. Please share with us any characteristics of your organization that you feel may HELP to implement
the SOGC clinical practice guidelines on magnesium sulphate for fetal neuroprotection.
_______________________________________________________________
______________________________________________________________________________
18
14. Please share with us any characteristics of your organization that you feel may HINDER the
implementation of the SOGC clinical practice guidelines on magnesium sulphate for fetal
neuroprotection. ___________________________________________________________
______________________________________________________________________________
15. Please share with us any other comments that you feel would be helpful. _____________
______________________________________________________________________________
Thank you in advance for answering two brief questions about yourself.
16. What clinical group do you represent? Please choose the ONE best answer.
MFM
General obstetrics and gynaecology
Midwifery
General practice
Nursing
Neonatology
Anaesthesia
Pharmacy
Other (please specify) ___________________
17. What do you spend at least 50% of your time doing? Please check the ONE best answer.
Clinical work (≥50%)
Research (≥50%)
Administration (≥50%)
Education (≥50%)
Other (please specify)__________________________________________________________
49
50
51
Table S4: Comparison of nodes and sub-nodes between final analysis (by KCT and KC) and re-analysis (by
DAD)
Nodes
Sub-nodes
Corresponding node
(KC/KCT)
Barriers
Individual-level
Attitudes and beliefs
Unsupportive attitudes and
beliefs
Practices & Habits
Forgetting to administer
MgSO4
Inadequate knowledge and
understanding
Inadequate knowledge and
understanding
19
Nodes
Sub-nodes
Fears & Medico-legal
Corresponding node
(KC/KCT)
Fears
Institutional-level
Organizational culture
Unsupportive institutional
culture
Resource constraints
Resource constraints
Facilitators
Individual-level
Supportive attitudes and
beliefs
Attitudes and beliefs
Institutional-level
Local champion/opinion
leader
Administrative support
Collaboration
Facility characteristics
Institutional policy
Policies and protocols
Organizational culture
Social-level
Educational activities
Knowledge translation
Knowledge Needed
Further research
Research
Evidence & education
Evidence to-date
Mechanism of action
Mechanism of action
Practices & Habits
Administration
52
20
53
Panel S1: Final NVivo coding list (nodes and sub-nodes) for analysis
Nodes
Sub-nodes
BARRIERS
Individual-level
Unsupportive attitudes and beliefs
Not within provider’s control
No experience
Inadequate knowledge/understanding in self
Inadequate knowledge and
understanding*
Inadequate knowledge/understanding in others
Unclear who respondent is referring to
Forgetting to administer MgSO4
Legal
Medication error
Fears
Adverse effects of withholding MgSO4
Adverse effects of MgSO4
Failure to implement guidelines
Evidence concerns (sufficiency and validity)
21
Nodes
Sub-nodes
Institutional-level
Unsupportive institutional culture
Timing and transport
Resource constraints
Policy development and implementation
Social-level
Lack of provider-institutional consensus
Inadequate inter-provider communication
Educating patients
FACILITATORS
Individual-level
Supportive attitudes and beliefs
Knowledge and understanding
Early adopters/mobilizers
Comfort/experience using MgSO4
Institutional-level
22
Nodes
Sub-nodes
Pre-printed orders for MgSO4 use
Policies and protocols
Pre-mixed bags of MgSO4
Mechanism for audit and feedback
Local champion/opinion leader
Supportive institutional culture/evidence-based
Patient load
Facility characteristics
Human resource capacity
Education and professional development
Social-level
Patient voice/awareness
Knowledge translation
Community support
Communication and collaboration
54
* Please see Panel 3 for details about the nature of knowledge needed.
55
Panel S2: Nature of knowledge identified as needed by respondents (N (%) responses)
Nodes
Sub-nodes
Sub-sub-node
23
Nodes
Sub-nodes
Sub-sub-node
Mechanism of action
Transfer
Threatened preterm labour vs. imminent preterm birth
Timing of administration
Standards of practice
Re-treatment
Administration
Pre-printed orders
Policies and protocols
Multiple pregnancies
Gestational age
Drug interactions
Contraindications
Rapid delivery
Side effects and
Overuse
risks
Interventions as a result of MgSO4
Increased monitoring needed
24
Nodes
Sub-nodes
Sub-sub-node
Toxicity
Problems with feeding
Adverse physiological effects – neonate Neonatal respiratory depression
Long-term effects
Adverse neurological effects
Adverse physiological effects – general (unspecified maternal/neonate)
KT tools
Audit and feedback
Further research
Research
Evidence to date
Other uses and topics (not MgSO4 for fetal neuroprotection)
None stated
56
MgSO4 (magnesium sulphate)
57
25