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Table 5 Barriers classified by least desirable, desirable or most desirable to target

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

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
 
  1. Abbreviations (in order of appearance): ED Emergency Department, rt-PA tissue plasminogen activator, CT Computed Tomography, NBM Nil by Mouth, BGL Blood Glucose Level, EENs Endorsed Enrolled Nurses, SU Stroke Unit