NEW ORLEANS—A number of barriers hinder clinicians’ adherence to the American Heart Association (AHA)/American Stroke Association acute stroke guidelines for the emergency use of t-PA, according to William J. Meurer, MD, and colleagues. Presenting his group’s results at the 2008 International Stroke Conference, Dr. Meurer cited internal barriers, such as physicians’ attitudes and knowledge, as well as external barriers, including patient and environmental factors.
The Increasing Stroke Treatment Through Interactive Behavioral Change Tactics (INSTINCT) trial was a multicenter, randomized, controlled study to conduct a barrier assessment and interactive educational intervention designed to increase appropriate t-PA use in stroke. Twenty-four hospitals in Michigan that offered acute care for stroke were randomly selected and matched into 12 pairs, each containing both an intervention site and a control site. A discussion guide was developed with a professional focus group consultant. Focus groups were conducted with physician, nursing, and pharmacy representatives from each intervention site.
A predetermined taxonomy was used to characterize barriers to clinical guideline adherence. A pair of investigators independently coded the transcripts into themes. The discussion guides were then revised and streamlined to explore areas of interest identified in the initial six focus groups. Additional focus group discussion involving local emergency physicians and nurses, along with in-depth interviews of neurologists, radiologists, and administrators at each of the 12 intervention hospitals, were also conducted, transcribed, analyzed, and categorized, according to Dr. Meurer, who is a Clinical Lecturer of Emergency Medicine and Neurology at the University of Michigan in Ann Arbor.
Internal Barriers: Attitudes and Knowledge
Overall, the researchers found 1,645 barriers to the delivery of t-PA in patients with stroke, which were coded into main themes. Some of the main themes included the following:
Attitudes of Clinicians
• Lack of Agreement—“They were rightfully upset when suddenly, ... when you had five previous studies … [in which] all five of those had bad outcomes…, [w]e were asked to change our therapy based on this one study (NINDS).”
• Lack of Self-Efficacy—“Some physicians are less comfortable with the whole process. You know, [some physicians] would explain risk-benefits to families and [would not be] giving the lytics without prior discussion with the neurologist, or some other [emergency department (ED)] physicians would be comfortable without ever talking to neurologists … and then just coordinating care with the intensivists.”
• Lack of Outcome Expectancy—“I have used it probably three times, and I’ve really been unable in the ED to see any significant improvement.”
• Lack of Motivation—“And they’ll go back in there and double-check that patient seven times in order to say … [he or she is] improving … as one of the relative contraindications.… [The NIHSS] score was 14 and now it’s 12, so they’re improving; we don’t have to give it.’”
Previous Knowledge
• Lack of Familiarity—“… 20% of patients that receive placebo (in the NINDS trial) die? ... That’s impossible.… Unless you [have] total left-side paralysis, I think [ED physicians] are going to probably withhold. Especially on someone who is younger who … has a chance of recovery…, I don’t think that they’d be inclined to take an all-or-nothing approach on a young healthy person.”
• Lack of Awareness—“When the patient goes to the neuroscience unit and [his or her] blood pressure goes out of the parameters, … they don’t initially call the neurologist.… [They call] the family medicine resident.”
External Barriers
The researchers found three main external barriers to the emergency use of t-PA for acute stroke. Some environmental factors included difficulty arranging for transfer; pharmacy and drug delivery complications; ED overcrowding; financial issues; inpatient/ICU availability; lack of protocol; lack of follow-up feedback; limited neurology or neurosurgery availability; liability; uncertainty regarding patient weight; EMS speed, hospital notification, and symptom recognition; and other factors. Patient factors included delay in presentation, the age of the population, demand for t-PA, criteria not met, family issues, language barriers, symptom recognition, and other factors.
One participant summed up the guideline factors in this way: “You get different academies telling you different things: AHA says one thing, the American College of Emergency Physicians says one thing, the American Academy of Emergency Medicine says one thing….”
“Detailed knowledge of these and other barriers is crucial to designing effective educational interventions for emergency physicians to improve guideline adherence,” reported Dr. Meurer.
—Lawrence Lubiner