Table 3 Summary of individual rankings for influence and difficulty
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) |