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

Implementation Science

N. Wah Cheung¹  Jeremy M. Grimshaw²  Richard Gerraty³  Verena Schadewaldt⁴  Mark Fitzgerald⁵  Catherine D’Este⁶  Jeanette Ward⁷  Oyebola Fasugba⁸  Rosemary Phillips⁹  Simeon Dale⁹  Louise Craig⁹  Sandy Middleton⁹  Elizabeth McInnes^1,10  Patrick McElduff^1,11  Julie Considine^1,12  Dominique A. Cadilhac^1,13  Chris Levi^1,14 

[1] Centre for Diabetes and Endocrinology Research, Westmead Hospital and University of Sydney, Westmead, Sydney, New South Wales, Australia;Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa Hospital – General Campus, Centre for Practice-Changing Research (CPCR), 501 Smyth Road, Room 1286, K1H 8 L6, Ottawa, Ontario, Canada;Department of Medicine, University of Ottawa, 451 Smyth Road, K1H 8 M5, Ottawa, Ontario, Canada;Department of Medicine, Monash University, 3800, Melbourne, Victoria, Australia;Neurosciences Clinical Institute, Epworth Hospital, 3121, Richmond, Victoria, Australia;Department of Neurosurgery, University of Melbourne and Royal Melbourne Hospital, Grattan Street, 3050, Parkville, Victoria, Australia;Formerly: Nursing Research Institute - St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Victoria, Australia;Department of Surgery, Central Clinical School, Monash University, 3800, Melbourne, Victoria, Australia;Faculty of Science, Engineering and Technology, Swinburne University of Technology, Melbourne, Australia;National Centre for Epidemiology and Population Health (NCEPH), Australian National University, 0200, Canberra, Australian Capital Territory, Australia;School of Medicine and Public Health, The University of Newcastle, 2308, Callaghan, New South Wales, Australia;Nulungu Research Institute, University of Notre Dame Australia, Broome, Western Australia, Australia;Nursing Research Institute - St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Level 2, Signadou Building, Australian Catholic University, 223 Antill Street, 2602, Watson, Australian Capital Territory, Australia;Nursing Research Institute - St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Level 5, deLacy Building, Victoria Street, 2010, Darlinghurst, New South Wales, Australia;Nursing Research Institute - St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, School of Nursing, Midwifery & Paramedicine, Australian Catholic University, Level 4, Daniel Mannix Building, Brunswick Street, 3065, Fitzroy, Victoria, Australia;School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia;School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia;Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, 3220, Geelong, Victoria, Australia;Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia;Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia;The Sydney Partnership for Health Education Research & Enterprise (SPHERE), University of New South Wales, Liverpool, New South Wales, Australia;

关键词: Process evaluation;    Normalisation process theory;    Acute stroke;    Emergency departments;    Qualitative design;   

DOI  :  10.1186/s13012-020-01057-0

来源: Springer

【 摘 要 】

BackgroundThe 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.MethodsQualitative 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.ResultsTwenty-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.ConclusionsDespite 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 registrationAustralian New Zealand Clinical Trials Registry (ACTRN12614000939695).

【 授权许可】

CC BY