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Hasnain MG, Levi CR, Ryan A, Hubbard IJ, Hall A, Oldmeadow C, Grady A, Jayakody A, Attia JR, Paul CL. 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. Implement Sci 2019; 14:98. [PMID: 31771599 PMCID: PMC6880372 DOI: 10.1186/s13012-019-0940-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 09/23/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The 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. METHODS A 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. RESULT The 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. CONCLUSION TIPS 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 REGISTRATION ACTRN12613000939796, UTN: U1111-1145-6762.
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Affiliation(s)
- Md Golam Hasnain
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, NSW, Australia
| | - Christopher R Levi
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, NSW, Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, NSW, Australia
| | - Annika Ryan
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, NSW, Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Isobel J Hubbard
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, NSW, Australia
| | - Alix Hall
- Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Christopher Oldmeadow
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, NSW, Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Alice Grady
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, NSW, Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
- Hunter New England Local Health District, Population Health, Wallsend, NSW, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia
| | - Amanda Jayakody
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, NSW, Australia
| | - John R Attia
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, NSW, Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
- John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Christine L Paul
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, NSW, Australia.
- Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia.
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Paul C, D'Este C, Ryan A, Jayakody A, Attia J, Oldmeadow C, Kerr E, Henskens F, Grady A, Levi CR. Staff perspectives from Australian hospitals seeking to improve implementation of thrombolysis care for acute stroke. SAGE Open Med 2019; 7:2050312119865656. [PMID: 31384464 PMCID: PMC6647204 DOI: 10.1177/2050312119865656] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 07/01/2019] [Indexed: 11/20/2022] Open
Abstract
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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Affiliation(s)
- Christine Paul
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Catherine D'Este
- National Centre for Epidemiology & Population Health, The Australian National University, Canberra, ACT, Australia
| | - Annika Ryan
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Amanda Jayakody
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - John Attia
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Christopher Oldmeadow
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Erin Kerr
- Hunter New England Health, New Lambton Heights, NSW, Australia
| | - Frans Henskens
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Alice Grady
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia.,Hunter New England Health, New Lambton Heights, NSW, Australia.,Priority Research Centre for Health Behaviour, The University of Newcastle, Callaghan, NSW, Australia
| | - Christopher R Levi
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia.,Hunter New England Health, New Lambton Heights, NSW, Australia
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Baatiema L, Otim ME, Mnatzaganian G, de-Graft Aikins A, Coombes J, Somerset S. Health professionals' views on the barriers and enablers to evidence-based practice for acute stroke care: a systematic review. Implement Sci 2017; 12:74. [PMID: 28583164 PMCID: PMC5460544 DOI: 10.1186/s13012-017-0599-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 05/08/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Adoption of contemporary evidence-based guidelines for acute stroke management is often delayed due to a range of key enablers and barriers. Recent reviews on such barriers focus mainly on specific acute stroke therapies or generalised stroke care guidelines. This review examined the overall barriers and enablers, as perceived by health professionals which affect how evidence-based practice guidelines (stroke unit care, thrombolysis administration, aspirin usage and decompressive surgery) for acute stroke care are adopted in hospital settings. METHODOLOGY A systematic search of databases was conducted using MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PsycINFO, Cochrane Library and AMED (Allied and Complementary Medicine Database from 1990 to 2016. The population of interest included health professionals working clinically or in roles responsible for acute stroke care. There were no restrictions to the study designs. A quality appraisal tool for qualitative studies by the Joanna Briggs Institute and another for quantitative studies by the Centre for Evidence-Based Management were used in the present study. A recent checklist to classify barriers and enablers to health professionals' adherence to evidence-based practice was also used. RESULTS Ten studies met the inclusion criteria out of a total of 9832 search results. The main barriers or enablers identified included poor organisational or institutional level support, health professionals' limited skills or competence to use a particular therapy, low level of awareness, familiarity or confidence in the effectiveness of a particular evidence-based therapy, limited medical facilities to support evidence uptake, inadequate peer support among health professionals', complex nature of some stroke care therapies or guidelines and patient level barriers. CONCLUSIONS Despite considerable evidence supporting various specific therapies for stroke care, uptake of these therapies is compromised by barriers across organisational, patients, guideline interventions and health professionals' domains. As a result, we recommend that future interventions and health policy directions should be informed by these findings in order to optimise uptake of best practice acute stroke care. Further studies from low- to middle-income countries are needed to understand the barriers and enablers in such settings. TRIAL REGISTRATION The review protocol was registered in the international prospective register of systematic reviews, PROSPERO 2015 (Registration Number: CRD42015023481 ).
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Affiliation(s)
- Leonard Baatiema
- Regional Institute for Population Studies, University of Ghana, P.O Box LG96, Legon-Accra, Ghana.
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Sydney, Australia.
| | - Michael E Otim
- College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - George Mnatzaganian
- College of Science, Health and Engineering, La Trobe Rural Health School, La Trobe University, Melbourne, Australia
| | - Ama de-Graft Aikins
- Regional Institute for Population Studies, University of Ghana, P.O Box LG96, Legon-Accra, Ghana
| | - Judith Coombes
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Shawn Somerset
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Sydney, Australia
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Baatiema L, de-Graft Aikins A, Sav A, Mnatzaganian G, Chan CKY, Somerset S. Barriers to evidence-based acute stroke care in Ghana: a qualitative study on the perspectives of stroke care professionals. BMJ Open 2017; 7:e015385. [PMID: 28450468 PMCID: PMC5719663 DOI: 10.1136/bmjopen-2016-015385] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Despite major advances in research on acute stroke care interventions, relatively few stroke patients benefit from evidence-based care due to multiple barriers. Yet current evidence of such barriers is predominantly from high-income countries. This study seeks to understand stroke care professionals' views on the barriers which hinder the provision of optimal acute stroke care in Ghanaian hospital settings. DESIGN A qualitative approach using semistructured interviews. Both thematic and grounded theory approaches were used to analyse and interpret the data through a synthesis of preidentified and emergent themes. SETTING A multisite study, conducted in six major referral acute hospital settings (three teaching and three non-teaching regional hospitals) in Ghana. PARTICIPANTS A total of 40 participants comprising neurologists, emergency physician specialists, non-specialist medical doctors, nurses, physiotherapists, clinical psychologists and a dietitian. RESULTS Four key barriers and 12 subthemes of barriers were identified. These include barriers at the patient (financial constraints, delays, sociocultural or religious practices, discharge against medical advice, denial of stroke), health system (inadequate medical facilities, lack of stroke care protocol, limited staff numbers, inadequate staff development opportunities), health professionals (poor collaboration, limited knowledge of stroke care interventions) and broader national health policy (lack of political will) levels. Perceived barriers varied across health professional disciplines and hospitals. CONCLUSION Barriers from low/middle-income countries differ substantially from those in high-income countries. For evidence-based acute stroke care in low/middle-income countries such as Ghana, health policy-makers and hospital managers need to consider the contrasts and uniqueness in these barriers in designing quality improvement interventions to optimise patient outcomes.
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Affiliation(s)
- Leonard Baatiema
- Regional Institute for Population Studies, University of Ghana, Accra, Legon, Ghana
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Sydney, Australia
| | - Ama de-Graft Aikins
- Regional Institute for Population Studies, University of Ghana, Accra, Legon, Ghana
| | - Adem Sav
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia
| | - George Mnatzaganian
- College of Science, Health and Engineering, La Trobe Rural Health School, La Trobe University, Melbourne, Australia
| | - Carina K Y Chan
- School of Psychology, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia
| | - Shawn Somerset
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia
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Craig LE, McInnes E, Taylor N, Grimley R, Cadilhac DA, Considine J, Middleton S. 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). Implement Sci 2016; 11:157. [PMID: 27894313 PMCID: PMC5126852 DOI: 10.1186/s13012-016-0524-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 11/18/2016] [Indexed: 11/10/2022] Open
Abstract
Background Clinical 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. Methods Studies 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. Results Five 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.” Conclusions Barriers 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.
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Affiliation(s)
- Louise E Craig
- Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Sydney, NSW, Australia.
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Sydney, NSW, Australia
| | - Natalie Taylor
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Rohan Grimley
- Sunshine Coast Hospital and Health Service/Sunshine Coast Clinical School, The University of Queensland, Nambour, QLD, Australia
| | - Dominique A Cadilhac
- Translational Public Health and Evaluation Division, Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.,Public Health: Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Julie Considine
- Deakin University, Geelong, VIC, Australia.,Eastern Health - Deakin University Nursing and Midwifery Research Centre, Box Hill, VIC, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Sydney, NSW, Australia
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Peek K, Carey M, Sanson-Fisher R, Mackenzie L. Aiding patient adherence to physiotherapist-prescribed self-management strategies: an evidence-based behavioural model in practice. PHYSICAL THERAPY REVIEWS 2016. [DOI: 10.1080/10833196.2016.1226537] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Grady AM, Bryant J, Carey ML, Paul CL, Sanson-Fisher RW, Levi CR. Agreement with evidence for tissue Plasminogen Activator use among emergency physicians: a cross-sectional survey. BMC Res Notes 2015; 8:267. [PMID: 26111807 PMCID: PMC4482289 DOI: 10.1186/s13104-015-1242-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 06/17/2015] [Indexed: 11/21/2022] Open
Abstract
Background Emergency department staff play a crucial role in the triage of stroke patients and therefore the capacity to deliver time-dependent treatments such as tissue Plasminogen Activator. This study aimed to identify among emergency physicians, (1) rates of agreement with evidence supporting tissue Plasminogen Activator use in acute stroke care; and (2) individual and hospital factors associated with high agreement with evidence supporting tissue Plasminogen Activator use. Methods Australian fellows and trainees of the Australasian College for Emergency Medicine were invited to complete an online cross-sectional survey assessing perceptions of tissue Plasminogen Activator use in acute stroke. Demographic and hospital characteristics were also collected. Results 429 Australasian College for Emergency Medicine members responded (13% response rate). Almost half (47.2%) did not agree with any statements regarding the benefits of tissue Plasminogen Activator use for acute stroke. Perceived routine administration of tissue Plasminogen Activator by the head of respondents’ emergency department was significantly associated with high agreement with the evidence supporting tissue Plasminogen Activator use in acute stroke. Conclusions Agreement with evidence supporting tissue Plasminogen Activator use in acute stroke is not high among responding Australian emergency physicians. In order for tissue Plasminogen Activator treatment to become widely accepted and adopted in emergency settings, beliefs and attitudes towards treatment need to be in accordance with clinical practice guidelines. Electronic supplementary material The online version of this article (doi:10.1186/s13104-015-1242-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alice M Grady
- Priority Research Centre for Health Behaviour, Hunter Medical Research Institute (HMRI), University of Newcastle, Callaghan, NSW, 2308, Australia.
| | - Jamie Bryant
- Priority Research Centre for Health Behaviour, Hunter Medical Research Institute (HMRI), University of Newcastle, Callaghan, NSW, 2308, Australia.
| | - Mariko L Carey
- Priority Research Centre for Health Behaviour, Hunter Medical Research Institute (HMRI), University of Newcastle, Callaghan, NSW, 2308, Australia.
| | - Christine L Paul
- Priority Research Centre for Health Behaviour, Hunter Medical Research Institute (HMRI), University of Newcastle, Callaghan, NSW, 2308, Australia.
| | - Rob W Sanson-Fisher
- Priority Research Centre for Health Behaviour, Hunter Medical Research Institute (HMRI), University of Newcastle, Callaghan, NSW, 2308, Australia.
| | - Christopher R Levi
- Department of Neurology, John Hunter Hospital, New Lambton, NSW, 2305, Australia. .,Priority Research Centre for Translational Neuroscience and Mental Health, University of Newcastle, Callaghan, NSW, 2308, Australia.
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