Table 2 Key barriers to evidence-based AMI care in the Tanzanian ED and corresponding CFIR constructs
CFIR Domain | CFIR Construct | Key barrier | Stakeholders identifying this barrier (N = 10 for each group) | Illustrative quote |
|---|---|---|---|---|
Innovation | Complexity | Providing timely and evidence-based AMI care would require substantial changes to current ED operations | 5 Administrators 5 Providers 2 Patients | I: “What would have to change to make immediate testing work for patients with chest pain or shortness of breath?” R: “We would need to have doctor in triage. Also we would need advice from you about other tests to do, because we are doing only blood pressure if patient comes in with difficulty breathing.” (Hospital Director, community hospital) |
Innovation | Cost | High-quality AMI care requires substantial hospital investments in expensive diagnostic equipment, treatments, staff, and other infrastructure. | 8 Administrators 8 Providers 1 Patient | “We have a plan to increase [diagnostic] equipment, but for that plan to be accomplished we need money. Therefore, if we get money in time, we can solve that. But also, if we get donors, we would be able to purchase the equipment.” (Clinical Officer, community hospital) |
Inner Setting | Culture | Some participants perceive a lack of urgency, motivation, or attention to detail among ED staff when caring for AMI patients. | 5 Administrators 9 Providers 5 Patients | “There is a sense of urgency in the cardiology practice, and I believe not all levels of health providers have that sense. They might suspect, but not everyone understands the essence of the problem, no one thinks of following patients closely. There are specialists who understand but speaking about health providers including nurses most people do not have the sense of urgency.” (Physician, referral hospital) |
Inner setting | Available resources | Many EDs do not have adequate staff, diagnostic equipment, and treatment capacity to care for AMI patients. | 10 Administrators 10 Providers 6 Patients | “I think one of our challenges is a lack of equipment for [AMI] treatment, and also lack of medication. And we lack enough competent staff to deal with heart attack problems.” (Physician, referral hospital) |
Inner setting | Access to knowledge and information | Many ED providers lack adequate training in the diagnosis and treatment of AMI. | 10 Administrators 10 Providers 4 Patients | I: “The doctors who were attending to you, did they say what the cause was?” R: “They said it was stress or smoking but I said I don’t smoke.” (AMI Patient) “We are not competent in caring for MI patients, but we try our best.” (Hospital Director, community hospital) |
Characteristics of individuals | Knowledge and beliefs about the innovation | Many patients lack basic understanding of AMI, both before and after their diagnosis. | 10 Administrators 10 Providers 10 Patients | I: “Can you tell me more about heart attack; do you know what that is?” R: “To be honest, I can’t explain what that is.” (AMI Patient) |
Process | Formally appointed internal implementation leaders | A formal leader is needed to supervise an AMI quality improvement initiative. | 8 Administrators 8 Providers 0 Patients | “I think when it comes to leadership, understanding is quite important. If you don’t know, you cannot do anything. Therefore as a team we should find a person with good communication skills who can take initiatives to motivate others and who has good organization skills, and they should be able to coordinate others in order to drive the team to succeed.“ (Physician, referral hospital) |
Process | Champions | Multiple staff members are needed to encourage the care team to commit to improving AMI care. | 3 Administrators 7 Providers 0 Patients | “For this, I think everybody should be the leader in their position and an advocate to improve heart attack services.” (Physician, referral hospital) |
Process | Execution | EDs sometimes fail to provide high-quality AMI care, even when diagnostic and treatment capacity is available. | 9 Administrators 7 Providers 6 Patients | “Yes, at first I went to [first hospital] as normal and they advised that I reduce my workload. They asked what I was doing and they told me that I was overworking. That was not the case. Later I decided to go to a private hospital and the doctor said maybe according to your age, it might be that you are hitting menopause.” (AMI Patient) “There is a challenge of quality management because sometimes, some of the clinicians are not following the guidelines to initiate those AMI medicines. […] Someone came to me and said they have a challenge in diagnosing MI patients because they do not have ECG, so we provided an ECG machine, but tomorrow morning all the patients with difficulty breathing, all of them they did not get tested. It is not because they do not know how to use it, and if you ask them they don`t have specific reasons why not.” (Department head, referral hospital) |
Execution | Providers sometimes do not communicate effectively with AMI patients or counsel them. | 6 Administrators 4 Providers 9 Patients | I: “Did the doctors explain what you are suffering from?” P: “They did not give me any explanation.” (AMI patient) “When I saw the doctor and explained what happened, he wrote down some medicines, and they gave me those, he didn’t say much about what could be wrong, I have seen that with a lot of doctors they don’t tell you what you are dealing with.” (AMI patient) | |
Execution | ED systems of care and patient flow processes are sometimes inefficient. | 7 Administrators 6 Providers 1 Patient | “Barriers are in the registration process. It takes a long time because of the large number of patients, more than 120 patients. So patients have to stand for too long, waiting for registration then after that they should go to triage, which also takes time because there are 2 nurses to attend 120 patients and instruments are few. After that there is a queue to see a doctor and doctors are few, so the queue is going very slowly. Then after seeing the doctor patients should go to the pharmacy or laboratory. Again, there is a queue. So patients become very tired due to this system. Another thing, sometimes errors may happen like skipping some codes of medicine or forgetting to fill some medication which takes a long time to resolve. So the challenges are many.” (Charge nurse, referral hospital) |