Dale Simeon, Levi Christopher, Ward Jeanette, Grimshaw Jeremy M, Jammali-Blasi Asmara, D'Este Catherine, Griffiths Rhonda, Quinn Clare, Evans Malcolm, Cadilhac Dominique, Cheung N Wah, Middleton Sandy
Clinical Research Fellow, Nursing Research Institute, St Vincent's & Mater Health, Sydney and School of Nursing (NSW & ACT), Australian Catholic University, Darlinghurst, NSW, Australia.
Worldviews Evid Based Nurs. 2015 Feb;12(1):41-50. doi: 10.1111/wvn.12078. Epub 2015 Jan 20.
The Quality in Acute Stroke Care (QASC) trial evaluated systematic implementation of clinical treatment protocols to manage fever, sugar, and swallow (FeSS protocols) in acute stroke care. This cluster-randomised controlled trial was conducted in 19 stroke units in Australia.
To describe perceived barriers and enablers preimplementation to the introduction of the FeSS protocols and, postimplementation, to determine which of these barriers eventuated as actual barriers.
Preimplementation: Workshops were held at the intervention stroke units (n = 10). The first workshop involved senior clinicians who identified perceived barriers and enablers to implementation of the protocols, the second workshop involved bedside clinicians. Postimplementation, an online survey with stroke champions from intervention sites was conducted.
A total of 111 clinicians attended the preimplementation workshops, identifying 22 barriers covering four main themes: (a) need for new policies, (b) limited workforce (capacity), (c) lack of equipment, and (d) education and logistics of training staff. Preimplementation enablers identified were: support by clinical champions, medical staff, nursing management and allied health staff; easy adaptation of current protocols, care-plans, and local policies; and presence of specialist stroke unit staff. Postimplementation, only five of the 22 barriers identified preimplementation were reported as actual barriers to adoption of the FeSS protocols, namely, no previous use of insulin infusions; hyperglycaemic protocols could not be commenced without written orders; medical staff reluctance to use the ASSIST swallowing screening tool; poor level of engagement of medical staff; and doctors' unawareness of the trial.
The process of identifying barriers and enablers preimplementation allowed staff to take ownership and to address barriers and plan for change. As only five of the 22 barriers identified preimplementation were reported to be actual barriers at completion of the trial, this suggests that barriers are often overcome whilst some are only ever perceived rather than actual barriers.
急性卒中护理质量（QASC）试验评估了在急性卒中护理中系统实施管理发热、血糖和吞咽的临床治疗方案（FeSS方案）的情况。这项整群随机对照试验在澳大利亚的19个卒中单元进行。
描述在引入FeSS方案之前所察觉到的障碍和促进因素，并在实施之后确定这些障碍中哪些最终成为了实际障碍。
实施前：在干预性卒中单元（n = 10）举办了研讨会。第一次研讨会有高级临床医生参与，他们确定了方案实施过程中察觉到的障碍和促进因素，第二次研讨会有床边临床医生参与。实施后，对来自干预地点的卒中倡导者进行了在线调查。
共有111名临床医生参加了实施前的研讨会，确定了22个障碍，涵盖四个主要主题：（a）需要新政策；（b）劳动力有限（能力）；（c）设备短缺；（d）培训工作人员的教育和后勤问题。确定的实施前促进因素包括：临床倡导者、医务人员、护理管理层和辅助医疗人员的支持；当前方案、护理计划和地方政策易于调整；以及卒中专科单元工作人员的存在。实施后，在实施前确定的22个障碍中，只有5个被报告为采用FeSS方案的实际障碍，即以前未使用过胰岛素输注；没有书面医嘱就无法启动高血糖方案；医务人员不愿使用ASSIST吞咽筛查工具；医务人员的参与度较低；以及医生对试验不知情。
在实施前识别障碍和促进因素的过程使工作人员能够主动承担责任，解决障碍并规划变革。由于在试验结束时，实施前确定的22个障碍中只有5个被报告为实际障碍，这表明障碍往往能够被克服，而有些障碍只是被察觉到，而非实际障碍。
