Table 4 Standardised flow and its...

Table 4

Standardised flow and its interaction with operational and professional dependencies (ASU: Acute Stroke Unit, CT = Computed Tomography, SNP = Stroke Nurse Practitioner, SN= Stroke nurse, ED = Emergency department, EDA = Emergency department assistant, EDD = Emergency department doctor, SD = Stroke doctor, RD = Radiologist, R = Radiographer, OPU = Outpatient unit)

Flow	Dependencies
	Operational		Professional
Best practice guidance	Visibility and clarity: 9 versions of pathway map: 4 flow diagrams, 3 scripts and a combination of script/flow diagram. Each department has its own protocols to carry out the work Visibility (KPIs): Overall pathway goal to provide quality care. Individuals also had smaller system targets, (e.g. CT scan within 1 h, etc.) also based on national standards: “We have so many KPIs … and all these are conflicting…” (SR2)	Visibility and clarity: “We have no clear protocol shared between us which complicates our work” (SNP2) Visibility (KPIs): “ED has competing priorities that are conflicting … not having ED/stroke consultant available … to assess patient and make decision delays process.” (SNP2). In many such instances, SNPs spent time walking around, finding doctors, providing a handover for the patient and asking ED doctor to review tests. [Flow interruptions/Changeovers]	Visibility and clarity: “there is no clear defined pathway which makes a huge difference for the ED staff to know what to do and how to thrombolyse” (SNP1) Portfolio: ED staff members report patient data in a different way … they are not as interested in the stroke time targets as we are” (SNP3)	Engagement: Pathway adherence strongly linked with individual professional interests and knowledge: “some ED doctors are extremely good and will manage … as well as any stroke physician. But I know that they are passionate about stroke … but not everybody is like that” (SD2) Stroke doctor added: “it's very variable between ED consultants and I feel that …some of the ED staff seem to have taken a back seat when it comes to stroke. They let the stroke team sort of steering the process.” [Flow interruptions/Changeovers]
Dedicated and scheduled resource	Shared resources: e.g. CT scan, ED, etc. resources shared with multiple patient groups (i.e. trauma, sepsis, etc.) who also need time critical scan/assess: “If it is delayed it's because maybe the radiologist had a trauma patient to report, something more important” (EDD2). [Flow interruptions/Changeovers] Portfolio: Stroke beds reallocated: “often we are on black escalation (full capacity) and it's hard to maintain beds for stroke, a luxury” (EDD1). [Flow interruptions/Changeovers]	Shared resources: One afternoon SNP3 and EDA transferred patient [36] from RD back to ED. At the entrance of ED, ED coordinator informed SNP3 of bed capacity issue and bed manager had allocated a bed in ASU to an OPU patient. SNP3 got angry and immediately contacted the bed manager and explained that [36] will need the stroke bed, they did not succeed. The OPU patient was already moved in ASU and [36] was waiting 3 h in ED until a bed was made available for him in ASU. [Flow interruptions/Changeovers]	Shared resources: SNPs assessing a patient with no ED doctor available to assist: “I can assess but I cannot make the final decision on my own” (SNP2). [Flow interruptions/ Changeovers] Portfolio: “…the general business of the department has an impact because if it is really, really busy and everybody is stretched you might not be able to get your patient seen by the doctor. The doctor might be doing 2 things at once”. (SNP2) [Flow interruptions/Changeovers]	Shared resources: “I feel RD staff set a distance between us (ASUs and ED). They think they own the CT scan and lead the process. Overnight unlikely to get a CT scan within 1h and if they are not thrombolisable sometimes the radiologist will say “How will that change your management?” (EDD1) [Flow interruptions/Changeovers]
Information/knowledge exchange	Portfolio: “ED forget to inform us. I just assume pressure, they have so many things they are trying to do” (R1). Stressful and busy environment often impacted effective use of IT systems. [Flow interruptions/Changeovers] Co-location: Issues more pronounced with distance “…it is difficult to assess the patient through the phone” (SNP2). Transferring complex information regarding a patient's medical status over the phone was not always an easy and efficient task. Stroke doctors, based in ASU (approx. 600 m from the ED)	Portfolio: “ED staff do not always inform us. They are just so busy with volume of work, all the sepsis and other patients that also have… pathways.” (SNP3). [Flow interruptions/Changeovers]	Portfolio: SNP2 returned to ED and no ED staff members available to assist. SNP2, first contacted the stroke team to seek help and then asked ED coordinator: “where has everyone gone? I cannot do everything alone” ED coordinator replied: “I have informed the ED doctor earlier but today is a very busy day…, I will look for the ED doctor and inform him that you are back from RD”. SNP2 concluded assessment of [56] with stroke doctor on phone and transferred patient to ASU. No ED staff members were involved. [Flow interruptions/Changeovers]	Co-location: Stroke doctors based in ASU, had limited interaction with ED staff and found it difficult to adapt to the ED environment: “I do not know how they work down there” (SD2). [Flow interruptions/Changeovers] Judgement: ED doctor/SNP2 start assessing a senior female patient [29] who had arrived in ED earlier. CT scan [results] arrived 5' later. Doctor disagreed with Radiologist judgement. ED contacted stroke doctor to discuss. ED and stroke doctors agreed that CT scan report not accurate. ED doctor walked to RD and discussed with Radiologist. Process lasted more than 1h until a common and final decision for the [29]'s treatment plan was concluded. [Flow interruptions/Changeovers]
		SNP specific

Flow	Dependencies
	Operational		Professional
Best practice guidance	Visibility and clarity: 9 versions of pathway map: 4 flow diagrams, 3 scripts and a combination of script/flow diagram. Each department has its own protocols to carry out the workVisibility (KPIs): Overall pathway goal to provide quality care. Individuals also had smaller system targets, (e.g. CT scan within 1 h, etc.) also based on national standards: “We have so many KPIs … and all these are conflicting…” (SR2)	Visibility and clarity: “We have no clear protocol shared between us which complicates our work” (SNP2)Visibility (KPIs): “ED has competing priorities that are conflicting … not having ED/stroke consultant available … to assess patient and make decision delays process.” (SNP2). In many such instances, SNPs spent time walking around, finding doctors, providing a handover for the patient and asking ED doctor to review tests. [Flow interruptions/Changeovers]	Visibility and clarity: “there is no clear defined pathway which makes a huge difference for the ED staff to know what to do and how to thrombolyse” (SNP1)Portfolio: ED staff members report patient data in a different way … they are not as interested in the stroke time targets as we are” (SNP3)	Engagement: Pathway adherence strongly linked with individual professional interests and knowledge: “some ED doctors are extremely good and will manage … as well as any stroke physician. But I know that they are passionate about stroke … but not everybody is like that” (SD2)Stroke doctor added: “it's very variable between ED consultants and I feel that …some of the ED staff seem to have taken a back seat when it comes to stroke. They let the stroke team sort of steering the process.” [Flow interruptions/Changeovers]
Dedicated and scheduled resource	Shared resources: e.g. CT scan, ED, etc. resources shared with multiple patient groups (i.e. trauma, sepsis, etc.) who also need time critical scan/assess: “If it is delayed it's because maybe the radiologist had a trauma patient to report, something more important” (EDD2). [Flow interruptions/Changeovers]Portfolio: Stroke beds reallocated: “often we are on black escalation (full capacity) and it's hard to maintain beds for stroke, a luxury” (EDD1). [Flow interruptions/Changeovers]	Shared resources: One afternoon SNP3 and EDA transferred patient [36] from RD back to ED. At the entrance of ED, ED coordinator informed SNP3 of bed capacity issue and bed manager had allocated a bed in ASU to an OPU patient. SNP3 got angry and immediately contacted the bed manager and explained that [36] will need the stroke bed, they did not succeed. The OPU patient was already moved in ASU and [36] was waiting 3 h in ED until a bed was made available for him in ASU. [Flow interruptions/Changeovers]	Shared resources: SNPs assessing a patient with no ED doctor available to assist: “I can assess but I cannot make the final decision on my own” (SNP2). [Flow interruptions/ Changeovers]Portfolio: “…the general business of the department has an impact because if it is really, really busy and everybody is stretched you might not be able to get your patient seen by the doctor. The doctor might be doing 2 things at once”. (SNP2) [Flow interruptions/Changeovers]	Shared resources: “I feel RD staff set a distance between us (ASUs and ED). They think they own the CT scan and lead the process. Overnight unlikely to get a CT scan within 1h and if they are not thrombolisable sometimes the radiologist will say “How will that change your management?” (EDD1) [Flow interruptions/Changeovers]
Information/knowledge exchange	Portfolio: “ED forget to inform us. I just assume pressure, they have so many things they are trying to do” (R1). Stressful and busy environment often impacted effective use of IT systems. [Flow interruptions/Changeovers]Co-location: Issues more pronounced with distance“…it is difficult to assess the patient through the phone” (SNP2). Transferring complex information regarding a patient's medical status over the phone was not always an easy and efficient task. Stroke doctors, based in ASU (approx. 600 m from the ED)	Portfolio: “ED staff do not always inform us. They are just so busy with volume of work, all the sepsis and other patients that also have… pathways.” (SNP3). [Flow interruptions/Changeovers]	Portfolio: SNP2 returned to ED and no ED staff members available to assist. SNP2, first contacted the stroke team to seek help and then asked ED coordinator: “where has everyone gone? I cannot do everything alone” ED coordinator replied: “I have informed the ED doctor earlier but today is a very busy day…, I will look for the ED doctor and inform him that you are back from RD”. SNP2 concluded assessment of [56] with stroke doctor on phone and transferred patient to ASU. No ED staff members were involved. [Flow interruptions/Changeovers]	Co-location: Stroke doctors based in ASU, had limited interaction with ED staff and found it difficult to adapt to the ED environment: “I do not know how they work down there” (SD2). [Flow interruptions/Changeovers]Judgement: ED doctor/SNP2 start assessing a senior female patient [29] who had arrived in ED earlier. CT scan [results] arrived 5' later. Doctor disagreed with Radiologist judgement. ED contacted stroke doctor to discuss. ED and stroke doctors agreed that CT scan report not accurate. ED doctor walked to RD and discussed with Radiologist. Process lasted more than 1h until a common and final decision for the [29]'s treatment plan was concluded. [Flow interruptions/Changeovers]
		SNP specific

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