Factor 1—“stability”—includes 10 items (nine items with positive loadings and one with negative). The positive factor loadings for this factor ranged from .33 to .56, and the negative loading was −.50. The items included in this factor generally address temporal concerns associated with maintaining a stable workflow process. Multiple parties involved in emergency stroke management are included in this factor, which include education, quality improvement and management, and the need for a backup plan.
Factor 2—“shared goals”—includes nine items. The factor loadings for this factor ranged from .30 to .60. The items included in this factor generally address the goals of the institution and describe commitment to those goals by management as well as by the stroke team. The items address agreement around the institutional goals and the methods for tracking patient-level data to ensure that time frames are met by the team. The actions of various team members are evaluated within the context of the shared goals of the entire team.
Factor 3—“preparedness”—includes nine items. The factor loadings for this factor ranged from .30 to .61. The items included in this factor describe workflow processes and adequate facilities to support care of the patient with stroke. Items associated with preparedness begin with the Emergency Medical Services (EMS) prearrival communication that precipitates action by the hospital team.
Factor 4—“family”—includes only one item with a positively correlated factor loading of .82. The item included in this factor is a statement about the importance of allowing the family to remain with the patient during assessment and treatment.
Stability was the only factor that included both positively and negatively correlated items. This factor most closely resembles the process domain identified in the qualitative study (Olson et al., 2011). The items address reducing practice or process variation through standard protocols, ongoing education, and review of the team’s performance to optimize patient care. The concept of process variation was first introduced by Deming and has since become an established goal in quality improvement (Batalden, 1991; Olivi, 2007). Documenting variations in systems and personnel performance can identify areas of inefficiency and provide guidance as to where system redesign is beneficial (Batalden & Splaine, 2002). Creating clear processes and training staff on their use can then reduce likelihood of errors and improve outcomes. Salas, Wilson, Burke, and Priest (2005) explored a concept with similar constructs and noted that team adaptability allows the team to recognize variation from the standard and make changes accordingly.
The shared goals factor incorporates elements from two domains identified in the qualitative study: (a) communication and teamwork and (b) organizational culture. Elements addressed include institution-wide agreement on goals, team meetings to review whether goals were met, coordination across departments, and personal responsibility to the team. These findings extend the shared mental models theory of team cognition (Gillespie & Chaboyer, 2009; Mathieu, Heffner, Goodwin, Salas, & Cannon-Bowers, 2000). The foundation for shared mental models, which is largely derived from military team training (Krueger & Banderet, 2007), has been extended to healthcare, most recently in the TeamSTEPPS program (Clancy & Tornberg, 2007; Clark, 2009; Weaver et al., 2010).
Preparedness included items that described the ability to quickly and easily move the patient through the stroke process beginning with the EMS encounter. The qualitative domain of performance monitoring and feedback also addressed the ability of the system to be ready to respond. Much of the preparedness factor revolves around the relationship or plan in place to be acted upon before the patient arrives to the hospital. This is consistent with prior recommendations from the American Stroke Association (Acker et al., 2007). Systematic preparedness is substantiated through integrating EMS into the hospital stroke team protocols, performance measures with frequent and meaningful feedback on the measures, and ongoing collaboration between EMS and hospital providers. Literature indicates that preparedness not only decreases delays in treatment but also increases the proportion of appropriate patients receiving reperfusion therapy (Behrens et al., 2002; Belvis et al., 2005). The one item included in the factor for family addressed both allowing and encouraging the inclusion of family. This is supported by Olson et al. (2011) in their discussion of the process domain, which includes family as part of the care process team. Having family in attendance is important because they can give information on the patient’s history and medications and last known well time (Hughes, 2011). Family members may also provide consent for IV-tPA treatment if the patient is unable to respond. In addition, educating family members during the acute phase of stroke care on the patient’s condition, discharge medications, and community resources helps prepare the family for the patient’s transition to home and reduces the impact of inadequate handoffs to other providers (Black-Schaffer, 2002). Evidence-based practice now supports open visitation models that incorporate family as partners in the acute care of patients (Ciufo, Hader, & Holly, 2011).
The effort to reduce door-to-needle times for AIS is a quality improvement initiative. As Fonarow et al. (2011) note, key strategies to provide early IV-tPA include emergency medical service prenotification, efficient activation of the stroke team, rapid assessment, use of standard protocols, premixing tPA, a team-based approach to providing care, and rapid data feedback. Prior work in performance improvement identified key factors for success including (a) credible performance benchmarks; (b) rapid and on-going feedback on performance, (c) a plan of action using locally designed measures, (d) staff buy-in, (e) management support, and (f) a learning culture (Bradley et al., 2007; Naylor, 1998; Peterson, 2005).
One surprising finding was that the qualitative study identified a domain of “overcoming barriers,” but this domain did not link directly to a singular factor. There were two items (numbers 21 and 40) in the stability factor that at least partially focus on addressing barriers. Recently, Lusardi (2012) noted that education, support (management), and regular meetings are keys to overcome barriers to change. Given that there are items in the stability and shared goals factors that specifically address education, support, and meetings, we propose that overcoming barriers are integrated within these two factors.
There are several limitations that must be recognized. The instrument was developed only using input from hospitals that were participating in GWTG-Stroke. Stroke care is a moving target, and hospital teams who responded to the survey may not be representative of all hospitals; an expanded instrument may be more appropriate for non-GWTG-Stroke hospitals. It is likely that these hospitals have already begun to put into place specific things to reduce door-to-needle times. For example, the statement “We have an order set or stroke pathway that we follow for our stroke codes” was eventually excluded. This does not mean that stroke pathways are not important. Rather, if all GWTG-Stroke hospitals have pathways and agree that pathways are important, then the statement is excluded from the factor analysis because it does not discriminate early IV-tPA administration.
The survey participants were identified as the point of contact for GWTG-Stroke. The survey asked participants to rate their level of agreement, and there is no mechanism to ensure that a different practitioner at the same hospital would have responded exactly the same for each item. Finally, because four of the items must be scored inversely, it may be confusing to some practitioners. Future work on this instrument should explore if these items could be rephrased to facilitate scoring.
We have developed the first instrument for assessing hospital readiness to administer IV-tPA within 60 minutes of patient arrival to the emergency department. This analysis supports the initial validity of an instrument to assess components of care associated with the early administration of thrombolytic therapy for patients with AIS. Additional instrument development and testing will determine if this instrument applies for other reperfusion therapy (i.e., mechanical thrombolysis).
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