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Table 3 Summary of individual rankings for influence and difficulty

From: Testing a systematic approach to identify and prioritise barriers to successful implementation of a complex healthcare intervention

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)
  1. Ranking scale for Triaged ATS Category 1 or 2 1–6; Full assessment for tPA eligibility 1–9; All eligible patients receive tPA 1–8; Temperature taken on arrival 1–5; Treatment with paracetamol 1–4; Finger prick BGL on admission 1–2; Administration of insulin 1–7; NBM until a swallow screen 1–8; Discharged to SU within 4 h 1–4
  2. Abbreviations (in order of appearance): ATS Australian Triage Scale, ED Emergency Department, rt-PA Recombinant Tissue Plasminogen Activator, NBM Nil by Mouth, BGL Blood Glucose Level, SU Stroke Unit