Table 1 Stages of implementation

Initial AGRIS Study information

For the substantive AGRIS study, clinicians representing the 43 sites enrolled in the Cooperative National Registry of Acute Coronary care, Guideline Adherence, and Clinical Events (CONCORDANCE registry) were briefed on the study protocol during an annual CONCORDANCE Investigator meeting

Inclusion criteria for AGRIS

Twenty-four CONCORDANCE sites were invited to participate based on: 1) an Emergency Department with 24/7 access, 2) without an existing, embedded ACS risk-stratification/decision-support tool, and 3) cardiology/medical units willing to implement the GRACE Risk Tool and associated treatment plan into the routine care processes. Further considerations were adequate perceived clinical leadership, perceived openness to change, existing measurement for system and process evaluation, and networks for support and referral between rural, regional and metropolitan hospitals [8]

Implementation team development

Strategic teams and role descriptions were developed, internal and external to the CONCORDANCE team and participating sites [8]. The CONCORDANCE staff were not to be involved in implementing the GRACE Risk Tool; their role was restricted to data collection

Implementation planning

In the pre-implementation phase, initial meetings between the study implementation steering committee and senior hospital staff (the implementation team) identified and engaged all affected multidisciplinary staff within the emergency and cardiology departments of all hospitals (n = 12) randomised to the active arm of AGRIS to discuss strategies to facilitate implementation

Implementation phase

In the implementation phase, the GRACE Risk Tool and associated treatment plan was introduced into hospital workflow at these 12 hospitals. All 12 hospitals reached the threshold for inclusion as an active site (defined as 90% completion of the GRACE Risk Tool in consecutive patients also enrolled in the CONCORDANCE registry in any one month: the CONCORDANCE registry seeks to recruit the first ten consecutive ACS patients per month presenting to participating facilities) [8]. The CONCORDANCE Registry functioned as the data spine for AGRIS. The intention was that all patients presenting with ACS would be assessed using the GRACE Risk Tool, and uptake would be confirmed by the presence of that completed worksheet in the subset enrolled in CONCORDANCE. This smaller CONCORDANCE cohort would be the group analysed for outcomes. Data collection was to be undertaken by CONCORDANCE study coordinators who were to be independent of clinicians and others involved in the intervention roll-out [8]

Post-implementation

Further ethical approval was obtained for the process evaluation (CH62/6/2013–154). Key stakeholders from five of the 12 hospitals to engage in an in-depth interview to provide feedback on implementation processes at their site, and to consider barriers and enablers to effective and sustained implementation of the intervention into wider cardiology practice