Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emerge
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RESEARCH
Open Access
Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study Elizabeth McInnes1* , Simeon Dale2 , Louise Craig2 , Rosemary Phillips2, Oyebola Fasugba3, Verena Schadewaldt4,5 , N. Wah Cheung6 , Dominique A. Cadilhac7,8 , Jeremy M. Grimshaw9,10 , Chris Levi11 , Julie Considine12,13 , Patrick McElduff14 , Richard Gerraty15,16, Mark Fitzgerald17,18 , Jeanette Ward19, Catherine D’Este20,21 and Sandy Middleton2
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 90day 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. (Continued on next page)
* Correspondence: [email protected] 1 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, Fitzroy, Victoria 3065, Australia Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropri
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