Identifying the barriers and enablers for a triage, treatment, and transfer clinical intervention to manage acute stroke patients in the emergency department: a systematic review using the theoretical domains framework (TDF)

Abstract

BackgroundClinical guidelines recommend that assessment and management of patients with stroke commences early including in emergency departments (ED). To inform the development of an implementation intervention targeted in ED, we conducted a systematic review of qualitative and quantitative studies to identify relevant barriers and enablers to six key clinical behaviours in acute stroke care: appropriate triage, thrombolysis administration, monitoring and management of temperature, blood glucose levels, and of swallowing difficulties and transfer of stroke patients in ED.MethodsStudies of any design, conducted in ED, where barriers or enablers based on primary data were identified for one or more of these six clinical behaviours. Major biomedical databases (CINAHL, OVID SP EMBASE, OVID SP MEDLINE) were searched using comprehensive search strategies. The barriers and enablers were categorised using the theoretical domains framework (TDF). The behaviour change technique (BCT) that best aligned to the strategy each enabler represented was selected for each of the reported enablers using a standard taxonomy.ResultsFive qualitative studies and four surveys out of the 44 studies identified met the selection criteria. The majority of barriers reported corresponded with the TDF domains of “environmental, context and resources” (such as stressful working conditions or lack of resources) and “knowledge” (such as lack of guideline awareness or familiarity). The majority of enablers corresponded with the domains of “knowledge” (such as education for physicians on the calculated risk of haemorrhage following intravenous thrombolysis [tPA]) and “skills” (such as providing opportunity to treat stroke cases of varying complexity). The total number of BCTs assigned was 18. The BCTs most frequently assigned to the reported enablers were “focus on past success” and “information about health consequences.”ConclusionsBarriers and enablers for the delivery of key evidence-based protocols in an emergency setting have been identified and interpreted within a relevant theoretical framework. This new knowledge has since been used to select specific BCTs to implement evidence-based care in an ED setting. It is recommended that findings from similar future reviews adopt a similar theoretical approach. In particular, the use of existing matrices to assist the selection of relevant BCTs.

Health professionals’ views on the barriers and enablers to evidence-based practice for acute stroke care: a systematic review

“…There was also a significant overlap in the reported barriers or enablers, although these characterisations differed between health professionals. Findings from prior reviews on barriers to thrombolysis uptake [41, 44, 45, 70], other studies on the barriers and enablers to triaging, treatment and patients’ transfer in emergency departments (ED) [48] and adherence to general stroke clinical guidelines [40], corroborated with majority of the barriers/enablers identified in this review.…”

Barriers and Facilitators Affecting Implementation of a Clinical Decision aid for the Diagnosis of Acute Aortic Syndrome: A Qualitative Study

“…(3,12) "Getting CAEP to endorse a set of rules is very in uential in getting them incorporated, you know, when a group of emergency positions…a group that represents emergency physicians in Canada publishes the stuff, discusses it and says this is a standard of care-that's obviously very in uential." (3,11) "The fact that my colleagues aren't also using it. I recently sort of polled like, a handful of people, and none of them are using d-dimer except for one, um, to help rule out aortic dissection in, like, low to medium risk patients.…”

“…Knowledge of the scienti c rationale and pre-implementation skills training have repeatedly been cited as enablers to implementation of new guidelines and decision aids in the ER and other contexts. 6,23,11 Effective dissemination of the decision aid is crucial and should include publication in presentation of the guidelines in a variety of media, high quality journals and educational meetings within the department. These challenges can also be addressed by thorough pre-implementation training, continuing medical education (CME) credits and by providing a supporting appraisal of the evidence alongside the decision aid.…”

“…The TDF approach has been used in a variety of studies investigating barrier and facilitators to integration of evidence-based practices into practice in emergency departments and other areas. [11][12][13] Data generated using this approach can be used to inform implementation strategies in order to maximize uptake of and adherence to guidelines and clinical decision aids, and studies have employed this approach to both established guidelines and prior to clinical trials. 7,14…”

Influences on NHS Health Check behaviours: a systematic review

“…[ Figure 1 here] The TDF is used as a framework for synthesising behavioural in uences in systematic literature reviews across qualitative and quantitative studies reporting perceived barriers and facilitators of behaviours. These include increasing attendance to diabetic retinopathy screening and triage (8), treatment and transfer of acute stroke patients in emergency care settings (9) and uptake of weight-management programmes in adults at risk of type 2 diabetes(10).…”