Randy James Treadwell
Project title: Introduction of a Portable Cholinesterase Monitoring Kit into Clinical Practice: A Normalization Process Model Approach
Completed in: 2009
Background: In 2002, Washington State initiated a cholinesterase (ChE) monitoring program with the goal of preventing illnesses among agricultural workers who were exposed to organophosphate (OP) and n-methyl-carbamate pesticides. An alternative to the current monitoring protocol entails the introduction of the Test-Mate portable cholinesterase monitoring kit (EQM Research, Inc., Cincinnati, OH) that could be used to obtain ChE activity measurements within a clinical setting.
Methods: Key informant interview data were collected from one large and two small clinics that currently monitor pesticide handlers for ChE activity, as well as one large and one small grower operation. Thematic analysis was utilized to identify descriptive themes in the data. Content analysis was used to group themes stratified by population into the pre-established dimensions of the Normalization Process Model (NPM) in order to identify factors that could dispose or inhibit “normalization” or routine embedding of the Test-Mate kit within a clinical setting. Although the NPM does not attempt to offer absolute predictive power, a rough determination of the Test-Mate kits’ likelihood of normalization was also proposed based on the absolute number of determinations suggesting either disposal or inhibition.
Results: Thematic analysis identified quality assurance, logistical considerations, and interpersonal relations as recurrent themes within clinical interviews, while conceptual preparedness and resource management were identified within grower interviews. I determined through content analysis that nine of the sixteen total disposal determinations suggested potential disposal of the Test-Mate kit to normalization in a clinical setting. Decreased blood volumes, speed of results, and minimal disruption to the current work dynamic were factors identified to potentially promote kit normalization. The possibility of increased exposure to blood products, steep initial learning curves, assurance of kit result quality and little anticipated change in paperwork volume were identified to potentially inhibit normalization. I determined that seven out of the sixteen total disposal determinations alluded to failure of the Test-mate kit to normalize, suggesting that the factors contained within these dimensions discouraged normalization of the kit. Time and financial savings associated with on-site ChE monitoring and less blood volume were factors identified to potentially promote normalization from a grower perspective. Concerns regarding ChE monitoring utility as OP pesticides are phased out and accuracy, calibration, and sanitation issues related to a portable kit were factors that could inhibit normalization from a grower perspective.
Conclusions: Evaluation of the portable kit’s impact on both clinical and grower work practices suggests that the Test-Mate kit is on a trajectory toward not being likely to be disposed to normalization at this time within the clinics that were evaluated for this project. Although the total number of determinations indicating positive disposal was larger than the number of negative determinations, the majority of the former were contributed by responses from growers. This population was observed to have seemingly less disruption of their work related to ChE monitoring with the adoption of a portable kit. This suggests that clinics would most likely experience the greatest disturbance in their work patterns which, depending on the magnitude of the disruption, would render the Test-Mate kit unlikely to become normalized in those settings. Utilization of the kit as a surveillance tool by growers or as a back-up testing procedure by clinics may still be feasible. Evaluation of themes within the dimensions of the NPM may offer clinic and grower managers insight in how to craft their current ChE monitoring programs to be more amenable to successful introduction and normalization of a portable ChE monitoring kit, if such a process is desired.