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)

Louise Eisten Craig, Australian Catholic University
Elizabeth Catherine McInnes, Australian Catholic University
Natalie Taylor
Rohan Grimley
Dominique A. Cadilhac
Julie Considine
Sandy Jane Middleton, Australian Catholic University

© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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.