Background
Methods
Target behaviour | Number of barriers | Ranking scale range (influence) (Higher rank = lower influence) | Ranking scale range (difficulty) (Higher rank = least difficult) | Completed by professional group |
---|---|---|---|---|
Triaged as ATS Category 1 or 2 | 6 | 1–6 | 1–6 | EN, EDr, SDr |
Full assessment for rt-PA eligibility | 9 | 1–9 | 1–9 | EN, EDr, SN, SDr |
All eligible patients receive rt-PA | 9 | 1–9 | 1–9 | EN, EDr, SN, SDr |
Temperature taken on arrival | 5 | 1–5 | 1–5 | EN, EDr, SN, SDr |
Treatment with paracetamol | 4 | 1–4 | 1–4 | EN, EDr, SN, SDr |
Finger prick BGL on admission | 2 | 1–2 | 1–2 | EN, EDr, SN, SDr |
Administration of insulin | 7 | 1–7 | 1–7 | EN, EDr, SN, SDr |
NBM until a swallow screena
| 8 | 1–8 | 1–8 | EN, SN, SP |
Discharged to SU within 4 hb
| 4 | 1–4 | 1–4 | EN,SN,BM |
Data analysis
Individual rankings
Aggregating individual rankings into group rankings
Interpretation of group rankings
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The barriers that are both easier to overcome and more influential than any other barrier form the set of the most desirable barriers to target and address.
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In addition to the most desirable barriers, there is a group of barriers that, although not being most desirable, do not have any other barriers that are both more influential and less difficult to overcome. This set of barriers are referred to as desirable barriers to target and can be visualised graphically as the set of barriers that have no other barriers that are both to the right and to the top of these barriers in the scatter plot.
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Finally, barriers that scored lower than other barriers on one measure (either influence or difficulty) and no better on the other measure are referred to as least desirable barriers to target.
Results
Respondent characteristics |
N(%) |
---|---|
Male | 9(52.9) |
Age (years) | |
< 34 | 3(17.6) |
35–54 | 8(47.1) |
> 55 | 6(35.3) |
Principle role | |
Emergency Physician | 3(17.6) |
Stroke Doctors | 3(17.6) |
Emergency Nurse Specialist | 3(17.6) |
Stroke Nurse Specialist | 3(17.6) |
Bed Managers | 2(11.8) |
Speech Pathologists | 3(17.6) |
Academic | 2(11.8) |
Length of time working in stroke/ED care | |
5–10 years | 3(17.6) |
11–15 years | 2(11.8) |
16 years or more | 12(70.6) |
Highest educational qualification | |
Bachelor’s Degree | 3(17.6) |
Medical Degree | 3(17.6) |
Master’s Degree | 6(35.3) |
PhD, DN | 5(29.4) |
Individual rankings
Target behaviour | Barrier ref | Barrier description | Median (IQR) rank for influence Higher rank = higher influence | Median (IQR) rank for difficulty Higher rank = lower difficult |
---|---|---|---|---|
Triaged ATS Category 1 or 2 | 1.1 | Lack of stroke leadership | 6.0(5.0–6.0) | 2.0(1.0–2.0) |
1.2 | No hospital protocol for rapid stroke care | 5.0(4.0–5.0) | 3.0(2.0–4.0) | |
1.3 | Resolving symptoms less likely to be triaged category 1/2 | 3.0(3.0–4.0) | 3.0(3.0–4.0) | |
1.4 | Staff inadequately trained in stroke symptoms | 3.0(2.0–4.0) | 4.0(3.0–5.0) | |
1.5 | ED nurses do not perceive stroke as medical emergency | 2.0(1.0–4.0) | 5.0(2.0–6.0) | |
1.6 | A validated stroke screen tool is not used | 2.0(1.0–2.0) | 5.0(4.0–6.0) | |
Full assessment for rt-PA eligibility | 2.1 | Lack of clinical leadership for tPA | 7.5(5.5–9.0) | 3.0(2.0–4.5) |
2.2 | Stressful and overburdened working conditions | 7.5(5.0–9.0) | 4.5(2.5–7.5) | |
2.3 | Disagreements between staff (ED and neurologists) | 7.0(4.0–9.0) | 2.5(1.0–6.5) | |
2.4 | Physician lack of knowledge/ experience with tPA | 6.0(4.0–8.0) | 4.0(2.0–6.0) | |
2.5 | Lack of staff continuity | 5.5(4.5–8.0) | 7.0(5.0–8.5) | |
2.6 | Delays in obtaining CT scans | 5.5(2.0–8.0) | 5.5(3.0–7.5) | |
2.7 | ED non-triage staff have poor recognition of stroke symptoms | 5.0(3.0–7.0) | 6.5(2.0–7.0) | |
2.8 | Lack of tPA protocol | 4.0(3.0–5.5) | 5.0(4.0–8.5) | |
2.9 | Lack of teamwork | 3.0(1.0–5.0) | 6.5(5.0–8.0) | |
All eligible patients receive rt-PA | 3.1 | Delays associated with CT scan | 6.5(3.5–7.0) | 2.5(2.0–5.0) |
3.2 | ED staff don’t triage stroke as an emergency | 6.5(2.0–8.0) | 4.0(1.0–7.0) | |
3.3 | Lack of appropriately trained staff to monitor tPA patients | 5.5(2.5–6.5) | 3.0(2.0–5.0) | |
3.4 | Out of hour delays | 5.0 (3.5–6.5) | 3.0(1.0–5.0) | |
3.5 | Tasks performed sequentially rather than concurrently | 4.5(3.5–6.0) | 4.5(3.0–5.0) | |
3.6 | Difficulties obtaining informed consent | 4.0(1.5–5.0) | 6.0(4.0–8.0) | |
3.7 | No point of care testing in ED | 3.0 (2.0–5.0) | 6.5(5.0–8.0) | |
3.8 | tPA not stored in ED | 2.5(1.5–5.0) | 6.5(5.0–7.0) | |
Temperature taken on arrival | 4.1 | Lack of fever protocols | 4.0(3.5–5.0) | 3.5(2.5–5.0) |
4.2 | Managing and organising busy nursing workload | 4.0(3.0–5.0) | 1.0 (1.0–2.5) | |
4.3 | Belief that nurse clinical judgement should determine the frequency | 2.5(1.5–4.0) | 2.0(2.0–4.5) | |
4.4 | Longer the stay in ED, the longer interval between assessment | 2.0(1.5–3.0) | 3.0(2.0–4.0) | |
4.5 | Higher triage category monitored less frequently | 2.0(1.0–4.0) | 4.0(3.0–5.0) | |
Treatment with paracetamol | 5.1 | Reluctance to administer paracetamol per rectum | 3.0(2.5–4.0) | 3.5(1.5–4.0) |
5.2 | Concern administering paracetamol ≥ 37.5 °C masks infection | 2.5(1.0–3.5) | 3.0(1.5–4.0) | |
5.3 | Intravenous paracetamol is not prescribed due to cost | 2.0(1.0–3.0) | 1.5 (1.0–2.0) | |
5.4 | Local protocols restrict nurses to 1–2 doses of paracetamol | 2.0(2.0–3.5) | 2.5(2.0–3.0) | |
Finger prick BGL on admission | 6.1 | Enrolled nurse are not assessed to test BGL | 2.0(1.0–2.0) | 2.0(1.0–2.0) |
6.2 | Not enough BGL machines | 1.0(1.0–2.0) | 1.0(1.0–2.0) | |
Administration of insulin | 7.1 | Workforce issues, nurse: patient ratio with insulin infusions | 5.5(4.0–7.0) | 3.0(1.0–4.0) |
7.2 | Lack of consensus treatment of hyperglycaemia in stroke | 5.5(4.0–7.0) | 3.0(1.0–3.5) | |
7.3 | Lack of insulin dosage algorithms | 5.0(2.0–6.0) | 6.0(4.5–6.5) | |
7.4 | EENs not able to adjust insulin | 3.5(1.5–6.0) | 3.5(2.0–4.5) | |
7.5 | Patient requires nurse escort to tests if on insulin infusion | 3.5(3.0–6.0) | 3.5(2.0–5.0) | |
7.6 | ED staff fear of hypoglycaemia | 2.5(1.0–4.5) | 5.0(4.5–6.5) | |
7.7 | Not enough syringe drivers or pumps | 2.0(2.0–4.0) | 5.5(3.0–7.0) | |
NBM until a swallow screen | 8.1 | Doctors prescribing immediate aspirin when patient NBM | 8.0(6.0–8.0) | 2.0(1.0–2.0) |
8.2 | Doctors reluctance to use formal swallowing screen | 5.0(4.0–7.0) | 2.0(2.0–3.0) | |
8.3 | Nurses administering aspirin before a swallow screen | 5.0(2.0–6.0) | 4.0(3.0–6.0) | |
8.4 | Clinicians believing NBM does not include oral medications | 5.0(4.0–6.0) | 5.0(5.0–7.0) | |
8.5 | Swallow screening will add to nurses’ responsibilities in the ED | 5.0(3.0–7.0) | 4.0(2.0–5.0) | |
8.6 | Speech pathology staff shortages delay in training nurses | 4.0(3.0–6.0) | 5.0(3.0–6.0) | |
8.7 | Lack of communication | 3.0(1.0–4.0) | 7.0(4.0–8.0) | |
8.8 | Lack of standardised swallow screening tools in ED | 4.0(2.0–4.0) | 7.0(6.0–8.0) | |
Discharged to SU within 4 h | 9.1 | Unavailability of inpatient beds in stroke unit | 4.0(4.0–4.0) | 1.0(1.0–1.5) |
9.2 | Pressure to transfer out of ED means patients to general wards | 3.0(2.0–3.0) | 2.0(1.5–2.0) | |
9.3 | Administrative procedures for transferring patients too long | 2.0(1.5–2.5) | 3.0(2.5–3.5) | |
9.4 | Delay in obtaining a porter to transport patient from ED to SU | 1.5(1.0–2.0) | 4.0(3.0–4.0) |
Group rankings and interpretation of group rankings
Desired behaviour | Barrier Ref | Group rank (influence) (higher value corresponds to the higher influence) | Group rank (difficulty) (higher value corresponds to the lower difficulty) | Level of desirability |
---|---|---|---|---|
Triaged ATS Category 1 or 2 | 1.1 | 6 | 1 | Desirable |
1.2 | 5 | 3 | Desirable | |
1.4 | 3 | 4 | Desirable | |
1.6 | 2 | 6 | Desirable | |
1.3 | 4 | 2 | Least desirable | |
1.5 | 1 | 5 | Least desirable | |
Assessment for rt-PA eligibility | 2.1 | 9 | 2 | Desirable |
2.5 | 4 | 8 | Desirable | |
2.6 | 6 | 6 | Desirable | |
2.2 | 1 | 4 | Least desirable | |
2.3 | 9 | 1 | Least desirable | |
2.4 | 8 | 2 | Least desirable | |
2.7 | 6 | 5 | Least desirable | |
2.8 | 4 | 6 | Least desirable | |
2.9 | 3 | 8 | Least desirable | |
All eligible patients receive rt-PA | 3.2 | 8 | 3 | Desirable |
3.8 | 3 | 7 | Desirable | |
3.1 | 7 | 2 | Least desirable | |
3.3 | 6 | 3 | Least desirable | |
3.4 | 6 | 1 | Least desirable | |
3.5 | 6 | 3 | Least desirable | |
3.6 | 2 | 6 | Least desirable | |
3.7 | 3 | 6 | Least desirable | |
Temperature taken on arrival | 4.1 | 5 | 4 | Most desirable |
4.2 | 5 | 1 | Least desirable | |
4.3 | 3 | 2 | Least desirable | |
4.4 | 2 | 3 | Least desirable | |
4.5 | 3 | 4 | Least desirable | |
Treatment with paracetamol | 5.1 | 1 | 4 | Desirable |
5.2 | 3 | 3 | Desirable | |
5.3 | 4 | 1 | Desirable | |
5.4 | 2 | 2 | Least desirable | |
Finger prick BGL on admission | 6.2 | 2 | 2 | Most desirable |
6.1 | 1 | 1 | Least desirable | |
Administration of insulin | 7.1 | 7 | 1 | Desirable |
7.2 | 6 | 2 | Desirable | |
7.3 | 5 | 3 | Desirable | |
7.4 | 4 | 5 | Desirable | |
7.6 | 2 | 6 | Desirable | |
7.7 | 2 | 6 | Desirable | |
7.5 | 4 | 3 | Least desirable | |
NBM until a swallow screen | 8.2 | 8 | 1 | Desirable |
8.4 | 5 | 6 | Desirable | |
8.5 | 6 | 4 | Desirable | |
8.8 | 2 | 8 | Desirable | |
8.1 | 5 | 2 | Least desirable | |
8.3 | 5 | 4 | Least desirable | |
8.6 | 3 | 4 | Least desirable | |
8.7 | 2 | 7 | Least desirable | |
Discharged to SU < 4 h | 9.1 | 4 | 1 | Desirable |
9.2 | 3 | 2 | Desirable | |
9.3 | 2 | 3 | Desirable | |
9.4 | 1 | 4 | Desirable |
Least desirable barriers to target | Desirable barriers | Most desirable barriers |
---|---|---|
Triaged as ATS Category 1 or 2 | ||
1.3 Patients presenting with resolving symptoms less likely to be triaged category 1 or 2 1.5 ED nurses do not perceive stroke as medical emergency | 1.1 Lack of stroke leadership 1.2 No hospital protocol for rapid stroke care 1.4 Staff inadequately trained in the recognition of stroke symptoms 1.6 A validated stroke screen tool is not used | |
Full assessment for rt-PA eligibility | ||
2.2 Stressful and overburdened working 2.3 Disagreements between emergency services staff and neurologists regarding benefits of rt-PA 2.4 Physician lack of knowledge/ experience with rt-PA 2.7 ED non-triage staff have poor recognition of stroke symptoms 2.8 Lack of rt-PA protocol 2.9 Lack of teamwork | 2.1 Lack of clinical leadership for rt-PA 2.5 Lack of staff continuity 2.6 Delays in obtaining CT scans | |
All eligible patients receive rt-PA | ||
3.1 Delays associated with CT scan 3.3 Lack of appropriately trained staff to monitor rt-PA patients 3.4 Out of hour delays 3.5 Tasks performed sequentially rather than concurrently 3.6 Difficulties obtaining informed consent 3.7 No point of care testing in ED | 3.2 ED staff don’t triage stroke as an emergency 3.8 rt-PA not stored in ED | |
Temperature taken on arrival | ||
4.2 Managing and organising busy nursing workload 4.3 Belief that individual nurse’s clinical judgement should determine the frequency of patient observations 4.4 The longer the patient stays in the ED, the longer the interval between vital signs’ assessment 4.5 Patients with higher triage category monitored less frequently | 4.1 Lack of fever protocols | |
Treatment with paracetamol | ||
5.3 Local protocols restrict nurses to only initiate 1–2 doses of paracetamol | 5.1 Reluctance to administer paracetamol per rectum 5.2 Concern administering paracetamol at ≥ will 37.5 °C mask infection 5.3 Intravenous paracetamol is not prescried due to cost | |
Finger prick BGL on admission | ||
6.1 Enrolled nurse are not assessed to test BGL | 6.2 Not enough blood glucose levels machines | |
Administration of insulin | ||
7.5 Patient requires nurse escort to tests if on insulin infusion | 7.1 Workforce issues, nurse: patient ratio an issue with insulin infusions 7.2 Lack of consensus treatment of hyperglycaemia in stroke 7.3 Lack of insulin dosage algorithms 7.4 EENs not able to adjust insulin 7.6 ED staff fear of hypoglycaemia 7.7 Not enough syringe drivers or pumps | |
NBM until a swallow screen | ||
8.1 Doctors prescribing immediate aspirin when patient NBM 8.3 Nurses administering aspirin before a swallow screen or assessment 8.6 Speech pathology staff shortages lead to delay in training nurses in swallow screen 8.7 Lack of communication between speech pathologists, doctors & nurses | 8.2 Doctors reluctance to use formal swallowing screen 8.4 Clinicians believing NBM does not include oral medications 8.5 Swallow screening will add to nurses’ already multiple complex care responsibilities in the ED 8.8 Lack of standardised swallow screening tools in ED | |
Discharged to SU within 4 h | ||
9.1 Unavailability of inpatient beds in stroke unit 9.2 Pressure to transfer patients out of ED within hours and where no stroke unit bed available means stroke patients go to general wards or medical assessment units 9.3 Administrative procedures for transferring patients too long 9.4 Delay in obtaining a porter to transport patient from ED to SU |