Agreement with evidence for tissue Plasminogen Activator use among emergency physicians: a cross-sectional survey

Grady, Alice; Bryant, Jamie; Carey, Mariko; Paul, Christine; Sanson‐Fisher, Rob; Levi, Christopher

doi:10.1186/s13104-015-1242-5

Cited by 10 publications

(18 citation statements)

References 23 publications

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“…Overcoming clinician ‘mindlines’ and beliefs about the evidence is a vexing challenge in implementation science [ 28 ] and in acute stroke management. This is particularly so in relation to the administration of thrombolysis, a key nursing and medical responsibility [ 29 , 30 ] and a protocol element with clear evidence of effectiveness [ 4 , 5 ]. As stated by some interviewees, bias against the use of tissue Plasminogen Activator in some sites, also resulted in low acceptance of other elements of the T 3 clinical protocols.…”

Section: Discussionmentioning

confidence: 99%

“…From the perspective of normalisation process theory, an individual appraisal by clinicians of the applicability of the evidence to the ED setting worked against the collective action needed to facilitate use and to normalise the use of the protocols in the ED. Other recent research has shown that ED clinicians express low agreement with the evidence supporting tissue Plasminogen Activator use in acute stroke [ 29 , 30 ]. It is therefore possible that active and ongoing championing by key medical staff might have helped to reinforce the education given about the evidence that was part of the implementation strategy.…”

Section: Discussionmentioning

confidence: 99%

“…Studies have also demonstrated the inability of staff to prioritise new interventions in the ED where these interventions are considered to be outside the role of ED staff which is focused on hyper-acute patients and maintaining patient workflow [ 31 , 36 ]. Other stroke implementation trials have also experienced similar difficulties in effecting practice change and protocol uptake and cited workforce shortages and the nature of ED workflow as reasons [ 10 , 29 , 30 ]…”

Section: Discussionmentioning

confidence: 99%

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Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study

et al. 2020

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Background The implementation of evidence-based protocols for stroke management in the emergency department (ED) for the appropriate triage, administration of tissue plasminogen activator to eligible patients, management of fever, hyperglycaemia and swallowing, and prompt transfer to a stroke unit were evaluated in an Australian cluster-randomised trial (T3 trial) conducted at 26 emergency departments. There was no reduction in 90-day death or dependency nor improved processes of ED care. We conducted an a priori planned process influential factors that impacted upon protocol uptake. Methods Qualitative face-to-face interviews were conducted with purposively selected ED and stroke clinicians from two high- and two low-performing intervention sites about their views on factors that influenced protocol uptake. All Trial State Co-ordinators (n = 3) who supported the implementation at the 13 intervention sites were also interviewed. Data were analysed thematically using normalisation process theory as a sensitising framework to understand key findings, and compared and contrasted between interviewee groups. Results Twenty-five ED and stroke clinicians, and three Trial State Co-ordinators were interviewed. Three major themes represented key influences on evidence uptake: (i) Readiness to change: reflected strategies to mobilise and engage clinical teams to foster cognitive participation and collective action; (ii) Fidelity to the protocols: reflected that beliefs about the evidence underpinning the protocols impeded the development of a shared understanding about the applicability of the protocols in the ED context (coherence); and (iii) Boundaries of care: reflected that appraisal (reflexive monitoring) by ED and stroke teams about their respective boundaries of clinical practice impeded uptake of the protocols. Conclusions Despite initial high ‘buy-in’ from clinicians, a theoretically informed and comprehensive implementation strategy was unable to overcome system and clinician level barriers. Initiatives to drive change and integrate protocols rested largely with senior nurses who had to overcome contextual factors that fell outside their control, including low medical engagement, beliefs about the supporting evidence and perceptions of professional boundaries. To maximise uptake of evidence and adherence to intervention fidelity in complex clinical settings such as ED cost-effective strategies are needed to overcome these barriers. Trial registration Australian New Zealand Clinical Trials Registry (ACTRN12614000939695).

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study

et al. 2020

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“…Survey items were selected from the previously published literature on behavior change and implementation of evidence-based practice. In addition, the National Stroke Foundation’s Clinical Guidelines for the management of Stroke and its recommendation for hospital facilities and evidence for intravenous thrombolysis was also considered to finalize the survey items [24, 25]. The survey items were also piloted by a team of behavioral researchers, stroke clinicians, emergency physicians, and stroke nurses at the University of Newcastle and the Hunter New England Local Health District [26].…”

Section: Methodsmentioning

confidence: 99%

Can a multicomponent multidisciplinary implementation package change physicians’ and nurses’ perceptions and practices regarding thrombolysis for acute ischemic stroke? An exploratory analysis of a cluster-randomized trial

et al. 2019

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BackgroundThe Thrombolysis ImPlementation in Stroke (TIPS) trial tested the effect of a multicomponent, multidisciplinary, collaborative intervention designed to increase the rates of intravenous thrombolysis via a cluster randomized controlled trial at 20 Australian hospitals (ten intervention, ten control). This sub-study investigated changes in self-reported perceptions and practices of physicians and nurses working in acute stroke care at the participating hospitals.MethodsA survey with 74 statements was administered during the pre- and post-intervention periods to staff at 19 of the 20 hospitals. An exploratory factor analysis identified the structure of the survey items and linear mixed modeling was applied to the final survey domain scores to explore the differences between groups over time.ResultThe response rate was 45% for both the pre- (503 out of 1127 eligible staff from 19 hospitals) and post-intervention (414 out of 919 eligible staff from 18 hospitals) period. Four survey domains were identified: (1) hospital performance indicators, feedback, and training; (2) personal perceptions about thrombolysis evidence and implementation; (3) personal stroke skills and hospital stroke care policies; and (4) emergency and ambulance procedures. There was a significant pre- to post-intervention mean increase (0.21 95% CI 0.09; 0.34; p < 0.01) in scores relating to hospital performance indicators, feedback, and training; for the intervention hospitals compared to control hospitals. There was a corresponding increase in mean scores regarding perceptions about the thrombolysis evidence and implementation (0.21, 95% CI 0.06; 0.36; p < 0.05). Sub-group analysis indicated that the improvements were restricted to nurses’ responses.ConclusionTIPS resulted in changes in some aspects of nurses’ perceptions relating to the evidence for intravenous thrombolysis and its implementation and hospital performance indicators, feedback, and training. However, there is a need to explore further strategies for influencing the views of physicians given limited statistical power in the physician sample.Trial registrationACTRN12613000939796, UTN: U1111–1145-6762.

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“…Attitudinal items were developed from literature regarding knowledge implementation 31 and a prior survey. 35,37 Respondents were asked to rate agreement with a series of statements. Participants were asked to rate their level of agreement with each survey item using a four-point scale of ‘strongly disagree’, ‘disagree’, ‘agree’ and ‘strongly agree’ with a ‘not applicable’ option.…”

Section: Methodsmentioning

confidence: 99%

Staff perspectives from Australian hospitals seeking to improve implementation of thrombolysis care for acute stroke

et al. 2019

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Background:Intravenous thrombolysis is one of few evidence-based treatments for acute stroke. Treatment uptake is low outside major stroke care centres. There is a need for greater understanding of barriers encountered by clinicians when seeking to increase thrombolysis rates.Aim:The aim of this study is to describe physicians’ and nurses’ perceptions regarding thrombolysis for acute stroke at hospitals in the earlier stages of thrombolysis implementation.Methods:A cross-sectional paper survey completed by physicians’ and nurses’ was distributed to 1127 staff at stroke care units, emergency departments or equivalent stroke care facilities at 19 Australian hospitals, as part of a cluster randomised controlled trial for thrombolysis implementation and systems improvement.Results:Of 1127 potential participants, 503 (148 physicians and 355 nurses) completed surveys (45% response rate). Over 90% agreed that thrombolysis improved the odds of independent survival. However, 42% to 58% agreed that there were limitations in the evidence base. A small proportion of staff indicated deficits in technical competencies. Interactive or competency-based training was reported by less than two-thirds of the sample. Challenges such as quick bed availability were identified. Emergency department physicians were less positive towards the treatment compared with nurses (p < 0.001), stroke care unit physicians were more positive than nurses (p = 0.047) and older clinicians were more positive than younger clinicians (p = 0.007).Conclusion:Australian hospitals seeking to address barriers to stroke thrombolysis implementation may benefit from the availability of interactive and competency-based training, staff performance feedback, support to make beds available quickly and bypass arrangements to quickly deliver acute stroke patients to appropriate facilities.

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Agreement with evidence for tissue Plasminogen Activator use among emergency physicians: a cross-sectional survey

Cited by 10 publications

References 23 publications

Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study

Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study

Can a multicomponent multidisciplinary implementation package change physicians’ and nurses’ perceptions and practices regarding thrombolysis for acute ischemic stroke? An exploratory analysis of a cluster-randomized trial

Staff perspectives from Australian hospitals seeking to improve implementation of thrombolysis care for acute stroke

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