Provider perceptions of barriers to the emergency use of tPA for Acute Ischemic Stroke: A qualitative study

Twenty-four hospitals were randomly selected and matched into 12 pairs. Barrier assessment occurred at intervention sites only, and utilized focus groups and structured interviews. A pre-specified taxonomy was employed to characterize barriers. Two investigators independently assigned themes to transcribed responses. Seven facilitators (three emergency physicians, two nurses, and two study coordinators) conducted focus groups and interviews of emergency physicians (65), nurses (62), neurologists (15), radiologists (12), hospital administrators (12), and three others (hospitalists and pharmacist).The following themes represented the most important external barriers: environmental and patient factors. Important barriers internal to the clinician included familiarity with and motivation to adhere to the guidelines, lack of self-efficacy and outcome expectancy. The following themes were not substantial barriers: lack of awareness of the existence of acute stroke guidelines, presence of conflicting guidelines, and lack of agreement with the guidelines.Healthcare providers perceive environmental and patient-related factors as the primary barriers to adherence with acute stroke treatment guidelines. Interventions focused on increasing physician familiarity with and motivation to follow guidelines may be of highest yield in improving adherence. Improving self-efficacy in performing guideline concordant care may also be useful.ClinicalTrials.gov identifier: NCT00349479Ischemic stroke is a devastating disease, affecting approximately 600,000 adults in the U.S. every year, leaving many survivors with significant functional limitations[1]. Intravenous administration of tissue plasminogen activator (tPA) is recommended by American Heart Association (AHA) guidelines for the early treatment of acute ischemic stroke[2,3]. However, only 1% to 3% of all ischemic stroke patients in community settings receive thrombolytic therapy; this is estimated to be about half of those eligible[4,