PDF(Pubmed)
Abstract：
BACKGROUND: Translation into clinical practice for use of intravenous thrombolysis (IVT) for the management of ischemic stroke remains a challenge especially across low- and middle-income countries, with regional inconsistencies in its rate. This study aimed at identifying factors that influenced the provision of IVT and the variation in its rates in Malaysia.
METHODS: A multiple case study underpinning the Tailored Implementation for Chronic Diseases framework was carried out in three public hospitals with differing rates of IVT using a multiple method design. Twenty-five in-depth interviews and 12 focus groups discussions were conducted among 89 healthcare providers, along with a survey on hospital resources and a medical records review to identify reasons for not receiving IVT. Qualitative data were analysed using reflective thematic method, before triangulated with quantitative findings.
RESULTS: Of five factors identified, three factors that distinctively influenced the variation of IVT across the hospitals were: 1) leadership through quality stroke champions, 2) team cohesiveness which entailed team dynamics and its degree of alignment and, 3) facilitative work process which included workflow simplification and familiarity with IVT. Two other factors that were consistently identified as barriers in these hospitals included patient factors which largely encompassed delayed presentation, and resource constraints. About 50.0 - 67.6% of ischemic stroke patients missed the opportunity to receive IVT due to delayed presentation.
CONCLUSIONS: In addition to the global effort to explore sustainable measures to improve patients\' emergency response for stroke, attempts to improve the provision of IVT for stroke care should also consider the inclusion of interventions targeting on health systems perspectives such as promoting quality leadership, team cohesiveness and workflow optimisation.
METHODS: A multiple case study underpinning the Tailored Implementation for Chronic Diseases framework was carried out in three public hospitals with differing rates of IVT using a multiple method design. Twenty-five in-depth interviews and 12 focus groups discussions were conducted among 89 healthcare providers, along with a survey on hospital resources and a medical records review to identify reasons for not receiving IVT. Qualitative data were analysed using reflective thematic method, before triangulated with quantitative findings.
RESULTS: Of five factors identified, three factors that distinctively influenced the variation of IVT across the hospitals were: 1) leadership through quality stroke champions, 2) team cohesiveness which entailed team dynamics and its degree of alignment and, 3) facilitative work process which included workflow simplification and familiarity with IVT. Two other factors that were consistently identified as barriers in these hospitals included patient factors which largely encompassed delayed presentation, and resource constraints. About 50.0 - 67.6% of ischemic stroke patients missed the opportunity to receive IVT due to delayed presentation.
CONCLUSIONS: In addition to the global effort to explore sustainable measures to improve patients\' emergency response for stroke, attempts to improve the provision of IVT for stroke care should also consider the inclusion of interventions targeting on health systems perspectives such as promoting quality leadership, team cohesiveness and workflow optimisation.
摘要：
背景：将静脉溶栓（IVT）用于缺血性卒中的治疗转化为临床实践仍然是一个挑战，尤其是在低收入和中等收入国家，其费率存在区域不一致。这项研究旨在确定影响马来西亚IVT提供及其比率变化的因素。
方法：采用多重方法设计，在三家具有不同IVT率的公立医院中进行了一项多重案例研究，该研究支持针对慢性病的量身定制实施框架。在89个医疗服务提供者中进行了25次深入访谈和12个焦点小组讨论,以及对医院资源的调查和病历审查，以确定未接受IVT的原因。定性数据采用反思专题法进行分析，在用定量结果进行三角测量之前。
结果：在确定的五个因素中，三个因素对整个医院的IVT变化有显著影响：1)通过高质量的卒中冠军领导，2)团队凝聚力，这需要团队动态及其程度的一致性，3)便利的工作过程，包括工作流程简化和对IVT的熟悉。在这些医院中被一致认为是障碍的另外两个因素包括患者因素，这些因素主要包括延迟就诊。和资源约束。约50.0-67.6%的缺血性卒中患者由于延迟就诊而错过了接受IVT的机会。
结论：除了全球努力探索可持续措施以改善患者对中风的紧急反应之外，尝试改善为中风护理提供IVT的尝试还应考虑纳入针对卫生系统观点的干预措施，例如促进质量领导，团队凝聚力和工作流程优化。
方法：采用多重方法设计，在三家具有不同IVT率的公立医院中进行了一项多重案例研究，该研究支持针对慢性病的量身定制实施框架。在89个医疗服务提供者中进行了25次深入访谈和12个焦点小组讨论,以及对医院资源的调查和病历审查，以确定未接受IVT的原因。定性数据采用反思专题法进行分析，在用定量结果进行三角测量之前。
结果：在确定的五个因素中，三个因素对整个医院的IVT变化有显著影响：1)通过高质量的卒中冠军领导，2)团队凝聚力，这需要团队动态及其程度的一致性，3)便利的工作过程，包括工作流程简化和对IVT的熟悉。在这些医院中被一致认为是障碍的另外两个因素包括患者因素，这些因素主要包括延迟就诊。和资源约束。约50.0-67.6%的缺血性卒中患者由于延迟就诊而错过了接受IVT的机会。
结论：除了全球努力探索可持续措施以改善患者对中风的紧急反应之外，尝试改善为中风护理提供IVT的尝试还应考虑纳入针对卫生系统观点的干预措施，例如促进质量领导，团队凝聚力和工作流程优化。
