Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study
Abstract 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 stro...
| Main Authors: | , , , , , , , , , , , , , , , , |
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| Format: | Article |
| Language: | English |
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BMC
2020-11-01
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| Series: | Implementation Science |
| Subjects: | |
| Online Access: | http://link.springer.com/article/10.1186/s13012-020-01057-0 |
| _version_ | 1818268697143279616 |
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| author | Elizabeth McInnes Simeon Dale Louise Craig Rosemary Phillips Oyebola Fasugba Verena Schadewaldt N. Wah Cheung Dominique A. Cadilhac Jeremy M. Grimshaw Chris Levi Julie Considine Patrick McElduff Richard Gerraty Mark Fitzgerald Jeanette Ward Catherine D’Este Sandy Middleton |
| author_facet | Elizabeth McInnes Simeon Dale Louise Craig Rosemary Phillips Oyebola Fasugba Verena Schadewaldt N. Wah Cheung Dominique A. Cadilhac Jeremy M. Grimshaw Chris Levi Julie Considine Patrick McElduff Richard Gerraty Mark Fitzgerald Jeanette Ward Catherine D’Este Sandy Middleton |
| author_sort | Elizabeth McInnes |
| collection | DOAJ |
| description | Abstract 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 ). |
| first_indexed | 2024-12-12T20:42:36Z |
| format | Article |
| id | doaj.art-d99efdbda8b0402fad8aaa1e2d47333a |
| institution | Directory Open Access Journal |
| issn | 1748-5908 |
| language | English |
| last_indexed | 2024-12-12T20:42:36Z |
| publishDate | 2020-11-01 |
| publisher | BMC |
| record_format | Article |
| series | Implementation Science |
| spelling | doaj.art-d99efdbda8b0402fad8aaa1e2d47333a2022-12-22T00:12:40ZengBMCImplementation Science1748-59082020-11-0115111310.1186/s13012-020-01057-0Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative studyElizabeth McInnes0Simeon Dale1Louise Craig2Rosemary Phillips3Oyebola Fasugba4Verena Schadewaldt5N. Wah Cheung6Dominique A. Cadilhac7Jeremy M. Grimshaw8Chris Levi9Julie Considine10Patrick McElduff11Richard Gerraty12Mark Fitzgerald13Jeanette Ward14Catherine D’Este15Sandy Middleton16Nursing Research Institute - St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, School of Nursing, Midwifery & Paramedicine, Australian Catholic UniversityNursing Research Institute - St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Level 5, deLacy BuildingNursing Research Institute - St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Level 5, deLacy BuildingNursing Research Institute - St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Level 5, deLacy BuildingNursing Research Institute - St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Level 2, Signadou BuildingDepartment of Neurosurgery, University of Melbourne and Royal Melbourne HospitalCentre for Diabetes and Endocrinology Research, Westmead Hospital and University of SydneyStroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash UniversityClinical Epidemiology Program, Ottawa Health Research Institute, Ottawa Hospital – General Campus, Centre for Practice-Changing Research (CPCR)The Sydney Partnership for Health Education Research & Enterprise (SPHERE), University of New South WalesSchool of Nursing and Midwifery, Deakin UniversitySchool of Medicine and Public Health, University of NewcastleDepartment of Medicine, Monash UniversityDepartment of Surgery, Central Clinical School, Monash UniversityNulungu Research Institute, University of Notre Dame AustraliaNational Centre for Epidemiology and Population Health (NCEPH), Australian National UniversityNursing Research Institute - St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Level 5, deLacy BuildingAbstract 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 ).http://link.springer.com/article/10.1186/s13012-020-01057-0Process evaluationNormalisation process theoryAcute strokeEmergency departmentsQualitative design |
| spellingShingle | Elizabeth McInnes Simeon Dale Louise Craig Rosemary Phillips Oyebola Fasugba Verena Schadewaldt N. Wah Cheung Dominique A. Cadilhac Jeremy M. Grimshaw Chris Levi Julie Considine Patrick McElduff Richard Gerraty Mark Fitzgerald Jeanette Ward Catherine D’Este Sandy Middleton 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 Process evaluation Normalisation process theory Acute stroke Emergency departments Qualitative design |
| title | Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study |
| title_full | Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study |
| title_fullStr | Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study |
| title_full_unstemmed | Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study |
| title_short | Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study |
| title_sort | process evaluation of an implementation trial to improve the triage treatment and transfer of stroke patients in emergency departments t3 trial a qualitative study |
| topic | Process evaluation Normalisation process theory Acute stroke Emergency departments Qualitative design |
| url | http://link.springer.com/article/10.1186/s13012-020-01057-0 |
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