Staff experience of delivering hyper-acute stroke care in Ireland – a multi-site mixed methods study of hospital and ambulance staff

Abstract Background The Irish National Stroke Strategy 2022-2027 recommends that acute stroke services have adequate staffing and diagnostic resources to provide 24/7 acute stroke care and treatment, with a national Key Performance Indicator (KPI) to treat at least 12% of patients presenting with acute ischaemic stroke with thrombolysis. This study aimed to explore the challenges described by hospital staff providing hyper-acute stroke care in Ireland, and by the National Ambulance Service (NAS) staff involved in the triage and transport of patients with stroke symptoms. Methods An explanatory, sequential, mixed methods study design was adopted. Four hospitals were identified according to their thrombolysis rate using the Irish National Audit of Stroke report 2020. All identified sites agreed to participate. Interdisciplinary staff members at each site participated in semi-structured interviews. Staff members from NAS were also recruited. Interview transcripts were analysed using reflexive thematic analysis with themes mapped using a unifying matrix approach. Results Staff described many challenges to acute stroke care delivery with unifying themes including patient volume outpacing proficiency of staff; generalists providing specialist care; radiology as a bottleneck to treatment; inadequate infrastructure; inappropriate call prioritisation systems; communication and collegiality; and stroke championing as a facilitator of improvement. Conclusion Many of the challenges identified in this work related to organisational and infrastructural structures and processes both locally and nationally. In particular, access to urgent neuro-radiology, a corner-stone of acute stroke care, was seen as a barrier to treatment decisions and contributing to lower treatment rates. Equitable delivery of acute stroke services in Ireland requires equitable access to radiology and specialist senior decision makers. Irish stroke services, particularly at Model 3 hospitals, face significant infrastructural, demographic and staffing challenges that impact current acute stroke service organisation and acute care delivery. These challenges will impact future stroke service sustainability.