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Randomized Controlled Trial
. 2011 May 6:11:5.
doi: 10.1186/1471-227X-11-5.

Provider perceptions of barriers to the emergency use of tPA for acute ischemic stroke: a qualitative study

William J Meurer  1 , Jennifer J Majersik, Shirley M Frederiksen, Allison M Kade, Annette M Sandretto, Phillip A Scott
Affiliations
Randomized Controlled Trial

Provider perceptions of barriers to the emergency use of tPA for acute ischemic stroke: a qualitative study

William J Meurer et al. BMC Emerg Med. .

Abstract

Background: Only 1-3% of ischemic stroke patients receive thrombolytic therapy. Provider barriers to adhering with guidelines recommending tPA delivery in acute stroke are not well known. The main objective of this study was to describe barriers to thrombolytic use in acute stroke care.

Methods: Twenty-four hospitals were randomly selected and matched into 12 pairs. Barrier assessment occurred at intervention sites only, and utilized focus groups and structured interviews. A pre-specified taxonomy was employed to characterize barriers. Two investigators independently assigned themes to transcribed responses. Seven facilitators (three emergency physicians, two nurses, and two study coordinators) conducted focus groups and interviews of emergency physicians (65), nurses (62), neurologists (15), radiologists (12), hospital administrators (12), and three others (hospitalists and pharmacist).

Results: The following themes represented the most important external barriers: environmental and patient factors. Important barriers internal to the clinician included familiarity with and motivation to adhere to the guidelines, lack of self-efficacy and outcome expectancy. The following themes were not substantial barriers: lack of awareness of the existence of acute stroke guidelines, presence of conflicting guidelines, and lack of agreement with the guidelines.

Conclusions: Healthcare providers perceive environmental and patient-related factors as the primary barriers to adherence with acute stroke treatment guidelines. Interventions focused on increasing physician familiarity with and motivation to follow guidelines may be of highest yield in improving adherence. Improving self-efficacy in performing guideline concordant care may also be useful.

Trial registration: ClinicalTrials.gov NCT00349479.

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Figures

Figure 1
Figure 1
Overview of INSTINCT trial. Process of barrier assessments and interventions at INSTINCT hospitals.
Figure 2
Figure 2
Relationship of acute stroke care process to barriers external to the emergency physician. The pathway shows the process a patient would go through when presenting with an acute stroke. The relationship of the identified external barriers to each point on this pathway is demonstrated here.
Figure 3
Figure 3
Distribution of cited barriers by individual hospital. Overall, the dominant barriers reported were external barriers and patient related factors.
Figure 4
Figure 4
Distribution of cited barriers by acute stroke care provider type. In general, nurses perceived lack of guideline familiarity as the biggest barrier whereas physicians (both EM and neurologists) perceived physician motivation as the primary barrier.
See this image and copyright information in PMC

References

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