Why “Treat First” Stalls: Knowledge, Scope, and System Determinants of Delayed Haemostatic Therapy in the Emergency Department

BACKGROUND: Persons with bleeding disorders (PwBD) frequently experience delays to haemostatic therapy in emergency departments (EDs). Identifying clinician knowledge gaps and workflow barriers is essential to accelerate time-to-treatment. OBJECTIVES: To define educational needs and system constraints shaping the evaluation and management of PwBD in Canadian EDs. METHODS: We conducted an exploratory, sequential mixed-methods study. An online survey of ED nurses and physicians, distributed via national organizations, used four clinical vignettes to probe triage, diagnostic approach, initial management, and self-rated knowledge; quantitative data were summarized descriptively. Virtual focus groups then explored barriers and solutions and were analyzed using reflexive thematic analysis. RESULTS: Three hundred ten clinicians completed the survey (250 nurses; 60 physicians). Most reported prior PwBD experience, but fewer had administered specialized haemostatic products. Across vignettes, respondents assigned high acuity and endorsed a ≤30-min treatment target, yet empiric "treat-first" therapy was inconsistently selected, particularly for non-specific presentations (severe headache, abdominal pain, early pregnancy bleeding). Reported gaps included use of haemostatic therapies; interpretation of coagulation assays; inhibitor management; and limited familiarity with treatment pathways. Barriers included absence of medical directives, treatment release processes, staffing and crowding pressures, and rural resource constraints. Six focus groups (nurses n = 10; physicians n = 4) explained these patterns, revealing a pathway from high perceived acuity to delayed treatment through intersecting knowledge, scope, and system factors, alongside strong preference for concise, point-of-care education, simulation, and web-based learning. CONCLUSIONS: Co-designed education, nurse-initiated directives, streamlined product release, and accessible point-of-care tools are complementary levers to compress triage-to-therapy intervals for PwBD.