Table 4

Stages and potential barriers in the implementation of prehospital thrombolysis

StagesPotential barriers
1Identify and involve all stakeholders, ensuring regular consultationScepticism and resistance to change
2Determine current practice: for example, local “pain to needle” times and the number of patients eligible for prehospital thrombolysisLack of reliable information
3Consider the possible options and their relative costs: for example, measures to improve “pain to call” or “door to needle” times, approaches to prehospital thrombolysisLack of reliable financial data
4Plan implementation, determine goals and set a realistic timetable
5Begin paramedic training, regarding the rationale behind thrombolysis and the acquisition/interpretation of the ECG. This should be tailored to local needsLack of funding to support initial and ongoing training
6Purchase equipment and thrombolytic agent
7Continue paramedic training, to include those hospital staff who will be providing ECG interpretation and authorising thrombolysisFear of technology or unfriendly systems. Resistance to change in current working patterns and responsibilities
8Begin “practice” ECG transmission to hospital without prehospital thrombolysis. Eligible patients could be given thrombolysis by the paramedic on arrival in hospital to boost confidence“Teething problems” with equipment and ECG transmission
9Commence prehospital thrombolysis, starting with the most straightforward casesUnwillingness to administer thrombolytic drug: concerns regarding safety and side effects
10Continuing training, audit and formal review by all involved partiesDecline in enthusiasm and interest over time