Implementation of evidence-based stroke care: enablers, barriers, and the role of facilitators

Figures & data

Figure 1 Process of analysis of the qualitative data.

Note: Illustrates the process and analysis used for the qualitative data collected.
Abbreviation: SNFs, stroke network facilitators.

Figure 2 Respondent work settings.

Notes: “Other” includes heads of department or executives. “Both” includes those who work in the acute and subacute settings.

Table 1 Main themes, subthemes to emerge from all focus groups interviews and common perceptions about strengths, limitations of stroke care

Theme	Subtheme	Perceived enablers to providing evidence-based stroke care	Perceived barriers to providing evidence-based stroke care
Stroke services	Acute services	Stroke unit providing focus for acute stroke care and team-based approach across all stages of care. Having executive support to enhance stroke service model.	Lack of dedicated stroke unit. Limited number of stroke unit beds can affect access.
	Rehabilitation services	Community rehabilitation program for continuing interventions postdischarge. Good structures, documentation, and framework of rehabilitation.	Lack of resources including equipment and outpatient services for rehabilitation. No systems of care for stroke across the continuum of care.
Use of other evidence-based practicesa	Thrombolysis service	Community awareness surrounding thrombolysis to avoid delays in patient presentation to hospital. Ability to safely and effectively deliver intravenous thrombolysis 24/7.	For sites which have a thrombolysis service, the inability to administer intravenous thrombolysis, or inconsistent administration. Shortage of neurologists and resistance from ED doctors. Lack of formalized guidelines or protocols for the administration of thrombolysis.
	Care pathways	Protocols and guidelines in stroke care to streamline management. Improved awareness of stroke protocols and strategies across the hospital.	Need for constant updating and having a staff member with the capacity to do this. Inconsistent use of care pathways. Generic pathways not as effective as stroke specific.
	Education for patients and family	More comprehensive coverage in subacute setting. Education consistently provided by stroke nurse.	Lack of formalized process led to inconsistent provision of education. Lack of time for staff to provide education in acute setting.
	Professional development for staff	Access to ongoing education and entitlements for professional development leave or grants.	Lack of funding for professional development opportunities for allied health and nursing.
Staff resources and attributes	Access to specialist clinical staff and clinical leaders	Strong medical support improves likelihood of thrombolysis administration or use of stroke pathway. Commitment by staff and a great “teamwork culture” among all disciplines. A stable team.	Lack of strong medical leadership or absence of a neurologist to support the stroke service – leads to delays in clinical decision making. Frequently rotating staff mean more time and resources required to up skill and provide consistent patient care. Limited access to allied health on weekends.
	Workforce demands	Specialist nurses and champions for stroke who can service as a clinical leader and assist the SNF.	Inadequate access to allied health staff, with no replacement for allied health staff when on leave.
SNF role	Scope of responsibilities	Valuable in identifying gaps in current service that provide focus for improvement efforts. Even in first 6 months of SNF tenure, enhancements to stroke care are evident. Assisted in engaging all key stakeholders, required to make changes within hospitals.	Role could be enhanced if additional clinical support was available, eg, to assist with staff education.
	Executive support	Ongoing commitment to the role within the hospital and provided support for SNF initiatives.	Restricts ability to make changes to policy and practice or make resources available to support improvement efforts.
	Part-time employment	Allowed time to facilitate and streamline processes to improve care practices. Not bogged down with clinical workload responsibilities.	Influenced the capacity to meet all the objectives of the role as time limited. Inadequate cover for such large regions with limited time allocation.
	Length of appointment		Insufficient time period to achieve all objectives.

Note:

a In addition to care in a stroke unit.

Abbreviations: SNF, stroke network facilitator; ED, emergency department.

Table 2 Characteristics of stroke care within each hospital

Hospital	Location	Stroke unit	Beds allocated for stroke	Thrombolysis	MDT meetings	Acute stroke care pathways	Access to rehabilitation
1	Metropolitan	Mixed views	None, but capacity for 15–20 patients with stroke in neurology ward	Yes, infrequently	4 times/week	Yes	Offsite inpatient; access to outpatients
2	Metropolitan	No	Mixed views: 0–4 beds	No	Weekly	Yes	Offsite inpatient; access to outpatients
3	Regional	No	4 beds	Yes, infrequently	Weekly	Yes	Offsite inpatient; access to outpatients
4	Metropolitan	No	None	Yes	Daily	Yes	Offsite inpatient; access to outpatients
5	Regional	No	None	No	Weekly	Yes	Onsite inpatient; access to outpatients
6	Regional	Yes	3 beds	Yes, infrequently	Weekly	Yes	Onsite inpatient; access to outpatients
7	Regional	Yes	4 beds	No	Weekly	Yes	Offsite inpatient; access to outpatients

Abbreviation: MDT, multidisciplinary team.