title: 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).
abstract: 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.
  
  
  
  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.
  
  
  
  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."
  
  
  
  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.
authors.affiliation: Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Sydney, NSW, Australia. Louise.Craig@acu.edu.au.
authors.forename: Louise E
authors.initials: LE
authors.lastname: Craig
authors.affiliation: Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Sydney, NSW, Australia.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: McInnes
authors.affiliation: Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia.
authors.forename: Natalie
authors.initials: N
authors.lastname: Taylor
authors.affiliation: Sunshine Coast Hospital and Health Service/Sunshine Coast Clinical School, The University of Queensland, Nambour, QLD, Australia.
authors.forename: Rohan
authors.initials: R
authors.lastname: Grimley
authors.affiliation: 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.
authors.forename: Dominique A
authors.initials: DA
authors.lastname: Cadilhac
authors.affiliation: Deakin University, Geelong, VIC, Australia.|Eastern Health - Deakin University Nursing and Midwifery Research Centre, Box Hill, VIC, Australia.
authors.forename: Julie
authors.initials: J
authors.lastname: Considine
authors.affiliation: Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Sydney, NSW, Australia.
authors.forename: Sandy
authors.initials: S
authors.lastname: Middleton
mesh_terms: D000328:Adult; D002983:Clinical Competence / Q000592:standards; D003680:Deglutition Disorders / Q000175:diagnosis; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D004644:Emotions; D005260:Female; D006801:Humans; D033182:Intention; D008297:Male; D008505:Medical Staff, Hospital / Q000523:psychology / Q000592:standards / Q000706:statistics & numerical data; D010360:Patient Transfer / Q000592:standards; D024382:Professional Role; D011785:Quality Assurance, Health Care; D012649:Self Concept; D020521:Stroke / Q000628:therapy*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D014218:Triage / Q000379:methods*
chemical_list: D010959:Tissue Plasminogen Activator
keywords: Acute stroke; Barriers; Emergency department; Enablers; Implementation; Theoretical domains framework