Table 2 Coding Guide and Barrier Definitions

Lack of Guideline Agreement

This barrier is coded when the text relates to the respondent not agreeing with the guidelines. This can include but is not limited to personal interpretation of the evidence, applicability to specific patients, and lack of confidence in the guideline developer or the process by which the guideline was developed. Similarly, this barrier is coded if the respondent cites national or local opinion leaders who disagree with this guideline.

This barrier should also be coded if a general lack of agreement with guidelines in general (i.e. "too cookbook") is observed.

This category also includes being too liberal in treatment despite the presence of absolute contraindications to treatment (such as time.)

Lack of Guideline Awareness

This barrier is coded when physicians are not aware of the existence of guidelines for acute stroke care.

It is also appropriate to code this barrier in cases when the lack of awareness is in other members of the patient care team (i.e. inpatient team being unaware of guidelines regarding blood pressure management); in such an instance, it may also be appropriate to code as an environmental barrier if it appears to be a reflection of institutional politics or common practice.

This code does NOT include not knowing about the existence of stroke scales.

Lack of Guideline Familiarity

This barrier is coded when there is a lack of knowledge of guideline contents or the inability to properly access or apply the guideline. This includes overuse or desire for overuse of tPA outside of the guidelines (i.e. feeling that a strict time window is not necessary to ensure safe treatment).

This category is not meant to reflect a lack of familiarity with emergency care in general or with stroke patients in general. However, if a respondent cites that they only see one eligible stroke patient every 5 years and do not recall all of the inclusion and exclusion criteria, this barrier should be coded.

This barrier is coded for a reluctance to treat those at the extremes of age and at the extremes of severity since the guidelines which do not include these clinical findings as contraindications (other than very low severity and age < 18 years.)

Physicians and nurses who fail to recognize stroke symptoms are included here (but not EMS providers, which are considered external to the ED and are thus coded as an Environmental Factor.).

Lack of Outcome Expectancy

The physician believes that the performance of the guideline will not lead to the desired outcome or there is a prominent, stated fear of a bad outcome.

Lack of Self Efficacy

The respondent believes that they cannot perform the guideline recommendation correctly. This may be a reflection of personal experience or available resources. (However, a lack of available resources generally should be coded as an External Barrier - Environmental Factor.)

This can also reflect a situation in which the physician or nurse feels unable to treat the patient effectively with the tools they are given (i.e. a vague reading from radiology makes it hard to confidently offer tPA).

Lack of Motivation

Inertia can be a powerful force. This barrier should be coded when the discussion includes the difficulty in changing clinician habit and routines.

This should also be coded when it appears that there is "reluctance" to treat. Willingness to treat, whether physicians "like tPA" or not, and other concepts relating to physician perception reflect a lack of motivation to comply with the guideline.

External Barriers - Environmental Factors

This is a large category. It encompasses the environment in which care is delivered. It includes lack of resources, institutional hurdles, lack of consultants, lack of reimbursement, and, of special importance in acute stroke care, liability. In acute stroke care, pre-hospital, triage and overcrowding issues also fall into this category.

Issues surrounding patient geography (e.g. difficulty in EMS covering rural areas) generally should be included here.

Inpatient floor and nursing home issues are also included under Environmental Factors.

External Barriers - Patient (and Family) Factors

There are many patient and family factors. Some examples:

Patients may fail to recognize stroke symptoms or to present in a timely fashion.

Family preferences to receive or not receive tPA and difficulty in finding family for the consent process are Patient Factors.

Difficulty in communication due to language barriers.

Delayed presentation due to geography would usually be an environmental factor; however if the family decides to drive the patient instead of activating EMS this would qualify as a Patient Factor.

If the patient chooses an inappropriate level of care for their symptoms (i.e. presenting to an urgent care center with a dense hemiparesis) that would qualify as a Patient Factor; however if EMS and the urgent care center cannot promptly move that patient to a facility with an appropriate level of care that would then generally be an Environmental Factor.

External Barriers - Guideline Factors

The characteristics of the guideline itself can present a barrier. The presence of contradictory guidelines or "position statements" would fall into this category. This includes lack of confidence in the guideline, the body or bodies which create the guideline, and the guideline development process. If the guidelines are not felt to be clear, this would also be in this category.