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Barriers and facilitators to the administration of prehospital tranexamic acid: a paramedic interview study using the theoretical domains framework
  1. Laura Goodwin1,
  2. Helen Nicholson1,
  3. Maria Robinson2,
  4. Adam Bedson3,
  5. Sarah Black2,
  6. Kim Kirby1,
  7. Hazel Taylor4,
  8. Sarah Voss1,
  9. Jonathan Benger1
  1. 1 Health and Applied Sciences, University of the West of England, Bristol, UK
  2. 2 Research and Audit, South Western Ambulance Service NHS Foundation Trust, Exeter, UK
  3. 3 South Western Ambulance Service NHS Foundation Trust, Exeter, UK
  4. 4 Research Design Service, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
  1. Correspondence to Dr Laura Goodwin, Health and Applied Sciences, University of the West of England, Bristol BS16 1DD, UK; laura.goodwin{at}uwe.ac.uk

Abstract

Background Tranexamic acid (TXA) is an antifibrinolytic drug used to prevent bleeding. It was introduced as an intervention for post-traumatic haemorrhage across emergency medical services (EMS) in the UK during 2012. However, despite strong evidence of effectiveness, prehospital TXA administration rates are low. This study used the theoretical domains framework (TDF) to identify barriers and facilitators to the administration of TXA to trauma patients by EMS providers (paramedics) in the UK.

Methods Interviews were completed with 18 UK paramedics from a single EMS provider organisation. A convenience sampling approach was used, and interviews continued until thematic saturation was reached. Semistructured telephone interviews explored paramedics’ experiences of administering TXA to trauma patients, including identifying whether or not patients were at risk of bleeding. Data were analysed inductively using thematic analysis (stage 1). Themes were mapped to the theoretical domains of the TDF to identify behavioural theory-derived barriers and facilitators to the administration of TXA to trauma patients (stage 2). Belief statements were identified and assessed for importance according to prevalence, discordance and evidence base (stage 3).

Results Barriers and facilitators to paramedics’ administration of TXA to trauma patients were represented by 11 of the 14 domains of the TDF. Important barriers included a lack of knowledge and experience with TXA (Domain: Knowledge and Skills), confusion and restrictions relating to the guidelines for TXA administration (Domain: Social/professional role and identity), a lack of resources (Domain: Environmental context and resources) and difficulty in identifying patients at risk of bleeding (Domain: Memory, attention and decision processes).

Conclusions This study presents a behavioural theory-based approach to identifying barriers and facilitators to the prehospital administration of TXA to trauma patients in the UK. It identifies multiple influencing factors that may serve as a basis for developing an intervention to increase prehospital administration of TXA.

  • trauma
  • clinical assessment
  • emergency ambulance systems
  • paramedics
  • prehospital care

Data availability statement

Data are available upon reasonable request.

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Key messages

What is already known on this subject

  • The administration of tranexamic acid (TXA) for post-traumatic haemorrhage was introduced as an intervention across all emergency medical service (EMS) provider organisations (ambulance services) in the UK during 2012.

  • Despite a strong evidence base, a nationwide approach to implementation and inclusion in UK ambulance guidelines, only around 5% of all patients at risk of haemorrhage following trauma receive TXA in the prehospital setting; this is concerning, as the earlier TXA is given the more effective it is.

  • Paramedics are best placed to administer TXA in the prehospital setting, however, the barriers to TXA administration by paramedics are currently unknown.

What this study adds

  • In this qualitative study of 18 paramedics, important barriers to paramedic TXA administration were described and included a lack of knowledge and experience with TXA (Domain: Knowledge and Skills), confusion and restrictions relating to the guidelines for TXA administration (Domain: Social/professional role and identity), a lack of resources (Domain: Environmental context and resources) and difficulty in identifying patients at risk of bleeding (Domain: Memory, attention and decision processes).

  • This study presents a behavioural theory-based approach to identifying barriers and facilitators to the prehospital administration of TXA to trauma patients in the UK and identifies multiple influencing factors that may serve as a basis for developing an intervention to increase prehospital administration of TXA.

Background

Trauma remains one of the most common causes of death and disability globally.1 Across England and Wales, trauma accounts for around 16 000 deaths per year.2 One of the main causes of death from trauma is bleeding,3 accounting for over half of all trauma deaths.4

Tranexamic acid (TXA) is an antifibrinolytic drug that prevents bleeding and has been used in surgical practice for half a century.5 More recently, TXA has been administered to treat traumatic bleeding after injury, and in a large international trial it was shown to significantly reduce the risk of death from bleeding following trauma.6 This is well supported by other research, in which administration of TXA is shown to effectively control bleeding7 and significantly reduce the development of multiorgan failure,7 8 with no adverse effects.9

Early administration of TXA is critical.5 10 A meta-analysis of two large trials of TXA administration (CRASH-26 and WOMAN11) found that immediate treatment improved survival by more than 70% and that this survival benefit decreased by 10% for every 15 min of treatment delay.12 As such, the administration of TXA for post-traumatic haemorrhage was introduced as an intervention across all emergency medical service (EMS) provider organisations (ambulance services) in the UK during 2012.13 However, despite a strong evidence base, a nationwide approach to implementation and inclusion in the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidelines since 2013, only around 5% of all patients in the UK Trauma Audit and Research Network (TARN) who are at risk of haemorrhage following trauma receive TXA in the prehospital setting.14

EMS providers (paramedics) are therefore best placed to administer TXA, as they are usually the first to attend a trauma patient, and TXA administration occurs sooner when given by paramedics compared with hospital staff.15 Given the clear benefits of prehospital TXA treatment for trauma patients at risk of bleeding, it is important to understand the barriers associated with its administration by paramedics in the UK. A recent systematic review of the literature found no previous work explicitly exploring these barriers (Nicholson H, personal communication, 2021). The research reported in this paper used the theoretical domains Framework16 (TDF) to address this knowledge gap.

Methods

Semistructured telephone interviews were conducted with 18 operational paramedics from the South Western Ambulance Service NHS Foundation Trust (SWASFT) to explore the barriers and facilitators to TXA administration to trauma patients. This qualitative approach was chosen to enable researchers to explore, explain and describe complex processes and behaviours within the context in which they occur.

Setting

SWASFT is a large EMS provider organisation, with responsibility for the provision of ambulance services across an area of 10 000 square miles of South West England, serving a total population of over 5.5 million. The Trust has been a pioneer of TXA in prehospital practice and in 2011 was the first ambulance service in the UK to implement administration of TXA to trauma patients.

Participant recruitment

A convenience sampling approach was used for recruitment. Participants were eligible to take part if they were working operationally as a paramedic, aged 18 years or over and had sufficient proficiency in the English language to be able to engage in an interview. Paramedics with less than 1 year’s experience were excluded.

The study was promoted in the weekly SWASFT news bulletin and eligible participants were invited to contact the research team to take part. Potential participants received a study information sheet, privacy notice and consent form via email and were asked to return the signed consent form if they wished to participate. Verbal confirmation of consent was audio-recorded at the start of the telephone interview. A £10 gift voucher was given to each participant to acknowledge their contribution. Recruitment concluded when interviews ceased yielding new information related to identifying patients at risk of bleeding and TXA administration.

Design

A topic guide (online supplemental appendix 1) was developed by the study team, including three paramedics, two senior academics in emergency care, the research manager of SWASFT and a member of the National Institute for Health Research (NIHR) Research Design Service. Questions explored participants’ experiences of attending trauma patients, in relation to identifying patients at risk of bleeding and administering TXA. Telephone interviews lasted between 20 and 45 min and were conducted by an experienced qualitative researcher (LG) at a time convenient to the participant. Audio-recordings of the interviews were made using Skype for Business. Recordings were transcribed verbatim and anonymised.

Supplemental material

Patient and public involvement

The SWASFT Patient Involvement in Research Group (PIRG) were involved from the early stages of the study; the study team were in regular consultation with the group who advised on key questions, structure of the interviews (including length and incentive offered) and participant recruitment methods.

Data analysis

The TDF was used to explore the data for theory-based influences on behaviour. The TDF is a theory-based validated tool developed by a collaboration of behavioural scientists and implementation researchers, which has been used to help understand the behaviour of health professionals in a variety of settings.16 It synthesises 33 theories of behaviour and behaviour change, clustered into 14 domains which are used for data coding to detect a range of possible theory-based barriers and enablers to behaviour and behaviour change.16

Data were analysed across three stages (table 1), beginning with inductive coding, followed by coding core themes into the domains outlined by the TDF (Insert table 1 here).

Table 1

The three stages of data analysis

Results

Participant characteristics

Eighteen operational paramedics took part in semistructured telephone interviews during December 2019. The majority of participants were male (78%). Participants represented the full range of paramedic qualification routes and experience as a qualified paramedic ranged from 13 months to 34 years. Participants’ job titles comprised: Clinical Lead (n=1); Hazardous Area Response Team Paramedic (n=1); Learning Development Officer (n=1); Lead Paramedic (n=2); Newly Qualified Paramedic (n=4); Operations Officer (n=2) and Paramedic (n=7). All but one participant had experience of administering TXA themselves, while the other participant had not personally administered TXA but had seen it being given by the helicopter emergency medical services (HEMS) team.

Key theoretical domains

A total of 947 utterances from the 18 interviews were coded into the 14 domains of TDF. Eleven domains of the TDF collectively captured the major barriers and facilitators to paramedic administration of TXA to trauma patients: Knowledge; Skills; Social/professional role and identity; Beliefs about capabilities; Beliefs about consequences; Reinforcement; Goals; Memory, attention and decision processes; Environmental context and resources; Social influences; Emotion. The domains of ‘Knowledge’ and ‘Skills’ were combined to form one domain of ‘Knowledge and Skills’ due to the interconnection of the domains in participant responses, therefore 10 domains are presented in the findings of this paper (table 2).

Table 2

Summary of belief statements and illustrative quotes by domain of the TDF

Knowledge and skills

More than half of the participants reported that a lack of knowledge about the physical effect of TXA was a barrier to its use (Q1–2). Additionally, participants emphasised the relative novelty of TXA in paramedic practice and noted that consequently paramedics may not think of using it when attending trauma patients. However, knowledge of the evidence base behind TXA use (ie, effectiveness, timing and indications) was cited as a facilitator to TXA administration (Q3–4).

Training in TXA and its administration were discussed by almost all participants, who felt that the current training was inadequate and that more could be done to raise awareness of the benefits and safety of TXA administration for trauma patients (Q5). Participants also identified a need for additional training on elderly trauma, and how to identify internal bleeding, in order to increase TXA administration rates.

Individual experience was also reported as a major barrier/facilitator in TXA administration (Q6); while some participants felt that their own experience of using the drug (or watching a colleague administer it) had boosted their confidence in administering TXA, others felt that their inexperience acted as a barrier to use and reflected that this was due to a lack of paramedic exposure to trauma patients.

Social/professional role and identity

All participants reported that administering TXA under the current patient group direction (PGD) felt restrictive or confusing and could therefore hinder the administration of TXA to patients who would benefit from it (Q7). A third of participants cited uncertainty over which conditions/injuries TXA is indicated for (Q8–9), and two-thirds felt that paramedics should be able to administer TXA in more instances, such as persistent heavy nosebleeds or where bleeding risk was uncertain (Q10).

There was also discussion regarding the disparity between paramedic TXA guidelines and those of HEMS doctors; participants noted that HEMS doctors did not have to work with the same ‘restrictions’ on TXA administration and that this could cause confusion among paramedics (Q11).

Beliefs about capabilities

Participants differed greatly in their self-perceived confidence and comfort administering TXA to trauma patients, and thus beliefs about capabilities could be either a barrier or a facilitator, depending on participant (Q12–13). For those who expressed a lack of confidence in administering TXA, an additional barrier was the lack of feedback given to paramedics regarding patient outcome (ie, whether TXA was administered/not administered correctly, Q14). However, some participants reported that watching their HEMS colleagues administer TXA had boosted their own confidence and comfort in using the drug, acting as a facilitator to future use (Q15).

Beliefs about consequences

The consequences of administering TXA were discussed in terms of safety, with some participants suggesting that they were unaware of the risks of inappropriate administration (Q16). However the majority of participants felt that the benefits of administering TXA outweighed the risks (Q17).

Some participants felt that the act of administering TXA signalled that their patient was a major trauma patient, who would need to be admitted to a major trauma centre (Q18). Participants noted that this could act as a barrier to TXA administration if there were concerns that their patient may not be accepted by the receiving staff at this facility.

Reinforcement

The most frequent barrier within this domain was the fear of repercussion from administering TXA to patients who did not need it (Q19). Repercussion was spoken about both in terms of formal discipline from the Trust but also judgement from colleagues and/or other clinical staff. A further barrier within this domain was the lack of an immediate visible effect of TXA on trauma patients; participants felt that this inhibited use of the drug, as paramedics rarely saw any positive effects from its administration during the prehospital phase of care (Q20).

Goals

Participants reported that the administration of TXA was often not seen as a priority for trauma patients and that other treatments such as administering fluids would take precedent (Q21). Participants also spoke about the prioritisation of distracting injuries and noted that TXA was often only considered once all of these other issues had been resolved. Some participants also cited the guidelines stating that TXA should be given within 3 hours; reflecting that this 3-hour window reduced the perceived urgency of administering TXA.

Memory, attention and decision processes

This was one of the most frequently populated domains. Within this domain, participants discussed the decision-making process around whether they believed trauma patients were at risk of bleeding or not. A number of factors were used to help paramedics identify whether or not a trauma patient was at risk of bleeding. The most commonly discussed were mechanism of injury and clinical observations. Other factors included patient presentation, type of injury, patient history and clinical judgement (Q22–23).

The majority of participants commented on the difficulty of identifying patients at risk of bleeding after trauma (Q24–25). Generally, it was reported that obvious bleeding or those in severe shock were easily identified, however, less obvious bleeding, including occult/internal haemorrhage, was much harder to identify. This could be compounded by evolving clinical signs, the challenge of more subtle presentations in the elderly, misleading clinical signs and a lack of a mechanism of injury.

Half of the participants reflected that it would be useful to have a decision-making tool, similar to a triage flowchart or major trauma tool, to assist them in identifying a patient’s bleeding risk, and support subsequent decision-making regarding TXA administration (Q26).

Environmental context and resources

A lack of sufficient resources (time and staffing) was one of the most frequently cited barriers to TXA administration (Q27). Participants felt that there were not enough ‘hands’ to administer TXA over 10 min, as in a typical a two-person crew, one person would be busy for 10 min and unable to assist with other treatments (Q28). Participants reported that unless there was obvious significant bleeding that they would instead prioritise transfer of the patient to hospital. This was noted by paramedics to be more likely when there were short transfer times to hospital, as paramedics felt that TXA could be administered on arrival by hospital staff.

The time taken to prepare TXA for administration was also reported as a potential barrier for its use by paramedics. Some participants emphasised the fact that an adult dose of TXA requires two vials to be administered and stated that this could cause confusion or take additional time in stressful or time-pressured situations. Some participants felt that alternative administration could negate these issues and make the presentation of the drug more clinician-friendly to promote use (Q29). For example, participants felt that TXA might be given to patients more frequently by paramedics if it came in a pre-filled syringe or if they were able to administer it as a rapid bolus, or infuse it with fluids.

Increased or better equipment was cited by participants as a possible facilitator to TXA administration, including ideas such as a triage tool, flowchart or ultrasound (Q30).

Social influences

Within this domain, belief statements centred around the influence of Trust culture and colleagues. TXA was seen as something that is only given for major trauma (Q31). Participants reported concern that they may be judged negatively by colleagues if they administered TXA to patients with less severe injuries.

The opinion of colleagues was therefore seen to influence participants’ administration of TXA, and participants noted that they often had clinical discussions with other paramedic colleagues on scene to decide whether or not administration was appropriate (Q32). Others reported checking with a senior colleague/hospital staff before administering TXA (Q33).

Participants noted a more liberal approach to TXA administration by HEMS team members and reported that witnessing this approach encouraged their own use of TXA (Q15). However, it seemed as though the knowledge that HEMS were likely to administer TXA could also act as a barrier to paramedic administration, as some participants expressed a preference to wait for a HEMS team member to administer it.

Emotion

Paramedics emphasised the nature of trauma jobs as stressful, and felt that this stress could lead to TXA administration being overlooked or deprioritised (Q34).

Discussion

Although TXA is recommended as a prehospital intervention for post-traumatic haemorrhage, administration rates remain low.14 We applied the TDF16 to help understand barriers and facilitators to TXA administration from behavioural theory standpoint. The most frequently mentioned influences and related key issues determining administration of TXA were categorised in the TDF domains of: Knowledge and skills (knowledge and experience with TXA); Memory attention and decision processes (difficulty in identifying patients at risk of bleeding); Social/professional role and identity (confusion and restrictions relating to the guidelines for TXA administration); Environmental context and resources (a lack of resources).

Paramedics’ lack of knowledge of, and experience with, TXA was a considerable influencing factor for its use. Although there is little prehospital research on TXA, this issue has been raised in prior literature regarding the administration of other treatments/drugs by ambulance staff.17 18 Not surprisingly, confidence in self-perceived knowledge appears to facilitate administration rates; in our study, paramedics who reported knowledge of research relating to TXA felt that this was a facilitator to its use. This suggests that increasing awareness of findings in TXA research among paramedics may help to increase administration rates. In particular, participants in the current study reported a general lack of awareness among the paramedic community regarding the diminishing survival effect of TXA with delay to treatment. This lack of awareness of the need for early administration could potentially result in under-prioritisation of TXA administration. A case series review of prehospital TXA use by the British Columbia Ambulance Service found that on several occasions TXA was not administered because individual practitioners determined that there were other priorities that required their attention.19

The second key barrier was TXA administration guidelines, which participants perceived to be restrictive and confusing. UK legislation permits all paramedics to administer a limited range of medications to manage emergency conditions.20 NHS ambulance services can also authorise paramedics to use additional prescription-only medications, under PGDs,20 which provide written instructions for the supply or administration of medicine in an identified clinical situation that meets predetermined criteria. Currently, UK paramedics administer TXA under a PGD, which provides a legal mechanism for administration in circumstances where a patient meets the predetermined clinical inclusion criteria.20 In our study, paramedics were concerned that they may be judged as having exceeded their legal privileges if a patient did not clearly meet the predefined criteria, which resulted in reluctance to administer TXA and many reported deferring this decision to senior colleagues or doctors, who were seen to have less restrictive guidelines surrounding TXA use. Similar attitudes towards PGDs were found in a UK survey of specialist paramedics, where a significant minority of participants reported that PGDs could be restrictive and did not always allow them to supply the appropriate medication.20

While a major facilitator to TXA administration was participants’ beliefs that the benefits of giving TXA to a patient who needed it outweighed the potential risks of administering it to someone who did not, many paramedics reported being significantly risk-averse when it came to administering TXA, suggesting a lack of clarity and empowerment surrounding TXA guidelines, training and support.

Third, time and staffing restrictions were seen as a key barrier to TXA administration by paramedics; participants reported that administration recommendations (an intravenous injection delivered over 10 min) limited their ability to perform other necessary interventions and could delay transfer to hospital. Similar issues are discussed in the military literature, with the administration of TXA being seen as incompatible with a tactical situation.21 The paramedics in our study suggested a solution similar to that of the authors of the military study, which is exploring administration via slow intravenous push, to improve administration rates.21

Paramedics in the UK are expected to minimise on-scene time and TXA administration is contraindicated if other critical interventions leave insufficient time to do so.22 It is therefore unsurprising that many of the paramedics in this study reported concerns regarding potential delays as a result of TXA administration and noted that transfer to hospital was sometimes prioritised over this intervention. Similar concerns have been found previously.19 It may help for paramedics to be made aware that the median time from emergency call to hospital arrival in trauma patients conveyed directly to a Major Trauma Centre in England is 1.4 hours,23 leaving ample opportunity to deliver TXA in the pre-hospital phase of care.

The fourth key barrier to TXA administration was the perceived difficulty in identifying whether or not trauma patients were at risk of bleeding; paramedics in our study reported that TXA was often not administered due to uncertainties over the patients’ bleeding risk. Recently published UK data suggest that patients who received TXA from paramedics have physiological observations (such as pulse and blood pressure) more obviously suggestive of bleeding.24 Studies on TXA use in the prehospital military setting in both the UK and the USA also found that those who received TXA had more obvious injuries.21 One of the ideas put forward by participants was the possibility of an assistive ‘tool’ to help them identify which trauma patients are at risk of bleeding. However, it may also help to provide paramedics education that TXA can be safely administered to a wide spectrum of patients with traumatic bleeding and does not need to be restricted to the most severely injured.6

Study limitations, strengths and future directions

Interview data were coded using the TDF approach after inductive thematic analysis had been completed. However, the TDF was not used to design the interview topic guide, as is usually recommended for this approach. This was because the framework was adopted after data had been collected. Consequently, there may have been missed opportunities to prompt paramedics to reflect on barriers that did not spontaneously come to mind.

All participants were from a single EMS provider organisation, whose culture and practices may differ from other EMS providers in the UK and internationally. This is especially important since SWASFT was a pioneer in UK prehospital TXA use, and so paramedics from this ambulance service may hold more positive views towards TXA administration than those from other Trusts.

Implications

Our findings suggest several potential facilitators to TXA administration, including different administration routes, further training on the benefits of TXA and an evidence-based tool to identify patients who might benefit from TXA. This tool, and associated training, could raise awareness of the importance of early TXA administration and provide paramedics with objective support for decision-making and a potential ‘permission to administer’, therefore negating concerns regarding the PGD and Trust policy.

Conclusions

The administration rate of TXA to trauma patients by paramedics in the UK is lower than expected, and there is limited evidence to explain why. This study highlights the factors that influence paramedics’ use of TXA and identifies several potential barriers and facilitators. The results of this study could inform the design of an intervention to improve prehospital TXA administration rates.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

Approval for this study was obtained from the Health Research Authority (19/HRA/5247) and the University of the West of England Faculty of Health and Applied Sciences Research Ethics Committee (HAS.19.08.016).

References

Footnotes

  • Handling editor Ellen J Weber

  • Twitter @laurakgoodwin, @MariaRobo

  • Contributors LG participated in study coordination, performed and coded the interviews, analysed the data and drafted the manuscript. HN participated in study conception, design and coordination, coded the interviews, analysed the data and participated in editing the manuscript. MR participated in study conception, design and coordination and was the chief investigator with overall responsibility for the study. AB, SB, KK and HT participated in study conception and design. SV participated in study conception, design and coordination, and participated in interpretation of the results. JB participated in study conception, design and coordination and was responsible for the overall content as the guarantor. All authors were responsible for the critical revision of the manuscript for publication and approved the final version to be published.

  • Funding This study was supported by Research Capability Funding from the South Western Ambulance Service NHS Foundation Trust (SWASFT/RCF/2019).

  • Disclaimer The funder had no role in the collection or analysis of data, or in the interpretation of the results. Authors from the funding organisation were involved in the design of the study and reviewing the manuscript for submission.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.