When Guidelines Meet the Road A CFIR-Informed Systematic Review of Implementation in Ambulance Services
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Abstract
Introduction: Clinical practice guidelines are central to safe, consistent, and evidence-informed ambulance care, yet their implementation is rarely straightforward. Ambulance services operate across complex, time-sensitive, and geographically dispersed settings, where organizational capacity, local context, and workforce engagement can influence whether guidelines are adopted and sustained in practice. This review aimed to identify and synthesize the barriers and facilitators influencing the implementation of clinical practice guidelines in ambulance services, and to map these determinants using the Consolidated Framework for Implementation Research (CFIR).
Methods: This systematic review followed Joanna Briggs Institute methodology for mixed-methods systematic reviews and was registered with PROSPERO (CRD42024580204). Searches were conducted in MEDLINE (PubMed), CINAHL, EMBASE, Cochrane Library, JBI Database, Scopus, and Web of Science. Qualitative, quantitative, and mixed-methods studies published in English within the past 20 years were included. Data were extracted and mapped to the domains of the CFIR.
Results: Forty-two studies were included, revealing substantial variability in CPG implementation contexts and outcomes. Key barriers included resource limitations, protocol complexity, and organizational resistance, especially in rural and under-resourced areas. Facilitators identified included leadership engagement, effective communication, adaptable protocols, and targeted education. The most frequently reported determinants were within the CFIR’s ‘Inner Setting’ and ‘Process’ domains.
Conclusion: The implementation of clinical practice guidelines in ambulance services depends on more than the quality of the guideline itself. Successful uptake requires organizational readiness, local adaptation, leadership support, workforce engagement and sustained implementation planning. By mapping implementation determinants to the CFIR, this review provides a structured evidence base to guide future implementation strategies, policy development and research in ambulance services.
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