Interdisciplinary interactions, social systems and technical infrastructure required for successful implementation of mobile stroke units: A qualitative process evaluation

Abstract

Rationale Mobile stroke units (MSUs) are increasingly being implemented to provide acute stroke care in the prehospital environment, but a comprehensive implementation evaluation has not been undertaken. Aim To identify successes and challenges in the pre‐ and initial operations of the first Australian MSU service from an interdisciplinary perspective. Methods Process evaluation of the Melbourne MSU with a mixed‐methods design. Purposive sampling targeted key stakeholder groups. Online surveys (administered June–September 2019) and semistructured interviews (October–November 2019) explored experiences. Directed content analysis (raters' agreement 85%) and thematic analysis results are presented using the Interactive Sociotechnical Analysis framework. Results Participants representing executive/program operations, MSU clinicians and hospital‐based clinicians completed 135 surveys and 38 interviews. Results converged, with major themes addressing successes and challenges: stakeholders, vehicle, knowledge, training/education, communication, work processes and working relationships. Conclusions Successes and challenges of establishing a new MSU service extend beyond technical, to include operational and social aspects across prehospital and hospital environments.

Sustaining a New Model of Acute Stroke Care: A Mixed-Method Process Evaluation of the Melbourne Mobile Stroke Unit

“…This is important as some paramedics had expressed initial concerns about delays in transporting patients while waiting for the MSU. 18 Improved diagnosis and treatment times have been partially explained by the increased efficiencies between pre-hospital paramedics and hospital clinicians. 7 While the reduction in time to thrombolysis treatment is described as “the essence of MSUs,” Audebert and colleagues identified additional advantages including stroke-expert triage and transport to hospitals with stroke units.…”

“…For those considering implementing MSUs in future, these results indicate the importance of working relationships between those working on developing the MSU and working on the MSU with those from receiving hospitals. The pressure of having the MSU go live was reported as contributing to the implementation 18 and in addition, the MSU service was initially a pilot project, limiting the focus on exploring in detail broader integration, for example, establishing changes to receiving hospital’s processes. Additionally, communication across the AV workforce is complex due to the high number, distribution and rotation (roster) of personnel.…”

“… 20 Factors specifically relevant to the pre-operational and initial (18-24 month) operational period are presented elsewhere. 18 In this paper, we present the findings related to the questions explored on the issue of operational sustainability of the MSU as implemented within the context of Melbourne, Australia. The data from this study are drawn as a component of the larger process evaluation.…”

“…Important steps detailed for implementing the Houston MSU included leadership, funding, legal requirements being met including insurance, multidisciplinary staffing and clinical protocols. 12 In our research on the pre- and initial 24 month operations of the Melbourne MSU, 18 we identified that despite the strong perceived benefits of working on the MSU being reported, a challenge was that the MSU workforce had to adjust to a variety of challenges (eg, workplace locations and culture). Concerns included limited resources such as only having one MSU in a city of 5.2 million people, 19 and communication inefficiencies for sharing patient information between ambulance services and hospitals.…”

“…Concerns included limited resources such as only having one MSU in a city of 5.2 million people, 19 and communication inefficiencies for sharing patient information between ambulance services and hospitals. 18 To the best of our knowledge, there has been no research undertaken on the longer-term sustainability of MSUs, including maintaining the MSU workforce. As such, the aims of the current research were to describe and identify:…”