Table 3 Emerging themes with subthemes and exemplar quotations

Improvement of local protocols of care

Missing GPGs or part of GPG concerning the following and the monitoring once the patient is admitted in a care unit, after the emergency

Hum, yes yes, for sure during night shift…hum, we use it frequently, otherwise, hum, every day. (Physician no 1)

Adaptation to the local structure

Not necessarily easy to apply, for example when the drugs listed for the disease are not available at the pharmacy, sometimes there are some inconsistencies between what is recommended and what is available. (Resident no 6)

To update local GPGs and notifications each time there is an update or the creation of a new local GPG

And to have an alert when a new protocol is introduced in the app, with…hum…I don’t know, a little message “protocol updated”, hum, with the possibility to consult it. (Resident no 5)

Better ranking of the GPGs

Well, paper, maybe it would be, well, classify protocols, I mean to make more sense, listing in order of topic or even alphabetically. Maybe more by topics, because now I feel like everything is mixed. (Senior no 4)

To extend the local GPGs writers to residents to have another point of view

Maybe concerning the development, it can be good to discuss it with residents. Well, because we use it also, we could…have a say, well if it seems clear for us, the way it’s conceived. Same thing for the use. (Resident no 6)

Patterns of use

Mainly when physicians were going on night shift and also during daily practice

Hum, yes yes, for sure during night shift…hum, we use it frequently, otherwise, hum, every day. (Physician no 1)

Verification for prescription, especially when it concerns an uncommon disease and also to check the general attitude

But I check every time the treatment, even if after a while I get to know it, I check if the posology is right and it is the same for the additional exams, make sure I remember everything. (Resident no 1)

Education use of protocols with juniors

For most part of very standardized protocols like diabetes, I always look at it to make sure I don’t miss anything. (Physician no 6)

On a less frequent or usual reason for consultation, something I have no expertise on. (Physician no 13)

Well, even if I know it, every time I go back to watch and show the residents…which protocol. We use it in a pedagogical way also.(Physician no 1)

Reason for non-implementation

The clinical context was a barrier if it was not a typical situation matching the protocol

I don’t know, for example social context, the treatment implementation, of course it’s a little bit of a mismatch between recommendation and what we’re going to choose for the child. It can be an antibiotic that we could prescribe orally but we believe it will not be given. In that case, we can keep the child to treat him parenteral or this kind of things. (Resident 10)

The lack of updating generated a mistrust of the protocols and physicians felt they lost time checking the existence of new guidelines

I think it is also due to old protocols, thus I pay more attention and I don’t follow the whole protocol and so it seems incomplete.(Physician no 4)

Some protocols are not easy to understand and sometimes residents feel they have contradictory advices from seniors

For example, the guideline concerning metabolic diseases, it is very…well it’s kind of difficult to apprehend it, when we look for an information I think, it’s a little long. It’s not that it is disorganised, but I have the feeling that it is difficult to find information in it. Well, there are also some protocols, for example, well I think of those concerning the hydroelectrolytic inputs, well some protocols like this. It is very very detailed, a little too much, concerning physiopathology or concerning the…the…the articles and bibliography on which they are based and the major information are not apparent. (Resident no 6)

Well sometimes in some units, I observed they did things differently from the protocol, sometimes I saw some chiefs criticizing the protocol, so…hum, I have learned that we had to do things differently. (Resident no 3)

Alternative sources

Sometimes when there is nothing in the local GPGs, I am going to check on the internet or on the Scientific Societies. (Physician no 8)

Perspectives

Frequent updating of protocols and removal of outdated protocols

Then, hum…that they be updated because some local guidelines are very old and no longer relevant so, something…updated with the latest current recommendation (Physician no 6)

Senior physicians wondered if it was adapted to extend protocols beyond the University hospital of Rennes and if this option was selected what the responsibility would become

We are sometimes called by peripheral hospital, local GPGs are about local habits from Rennes and I’m uncomfortable with the availability for other hospitals. (Physician no 7)

The idea of a national protocol to standardize practices on a national scale

So I don’t know if it is to be broadcast, already broadcast it in the university hospital, I find it great. Maybe when there are some regional referrals for example, for some sub-specialties, maybe it’s worth it to broadcast it. It was a point for reflection. (Physician no 4)

Combination of prescription software with protocols

Updating or national pocket books. The attitude should not be different in Marseille, Rennes or Paris. (Senior no 9)

Missing protocols concerning paediatric sur-specialties

It would be great to combine local GPGs with a prescription software. (Physician no 7)

Clear summary and and logical way of categorization

Now there are some missing sub-specialties, common things, we know that we’d use it every day and it is not there. (Resident no 9)

It has to be first handling of a cardiac arrest first, then pain, etc. Just an idea. (Physician no 9)