Table 2

Deductive NASSS-informed themes and examples of illustrative quotations

Theme 1: (Suspected) stroke as a condition (‘complicated’/‘complex’)
(Suspected) stroke is a complicated/complex condition:
  • Symptoms can vary and be misunderstood by both ambulance paramedics and the public.

  • Category 2 ambulance response times for stroke—long waits/delays can have adverse outcomes.

“…the way that strokes present is very variable. Obviously you’ve got your classic sort of FAST positive and those ones are the easy ones, aren’t they? But it’s the perhaps the slightly unusual presentations the stroke mimics, the cerebellar strokes. So, the ones that affect the back of the brain or the base of the brain often present with different symptoms and that are quite nonspecific. So, things like Vertigo and vomiting and balance problems and not the classic facial loss, speech and all that kind of stuff that we sort of associate with stroke…And I think that’s an issue from an ambulance response point of view and also from a public perspective. You know, I think there’s still a little bit of misunderstanding from them as to what constitutes the symptoms of a stroke.” (021 Ambulance manager)
“So, what we find is a lot of our stroke patients experience long waits so they get called in and they go into our stack of jobs that are waiting for dispatch…and because they tend to fall into either cat two or worse from a stroke patients perspective cat three…We see adverse events for stroke patients who waited for long periods of time and have adverse outcomes.” (023 Ambulance manager)
Theme 2: The pathway change (‘complicated’)
Decision-making:
  • Hospital clinicians face complicated issues.

“…(if) I’m fielding the referrals from a hospital five miles away and a hospital 50 miles away and a 27 year old and a 52 year old and there’s all those different things that you need to take in, where are they? What’s their deficit? Do we think it’s going to be an easy procedure when they get there? Are they at 1 hour so we’ve got a bit of time to play with, so even if they're in an ambulance for another hour, they'll still get here within 2 hours or are they at 3 1/2 hours? And even if it’s a half hour ambulance drive, that means they're going to get here at 4 hours and then you’re starting to ‘I’m not having that’ (because patient is outside time window for treatment) and then the juggle with beds…where are we going to put these people? You know, we can’t have bunk beds…” (027 Hospital clinician)
Use of video or telephone to conduct remote assessment:
  • Mixed views but happy to use either.

“So, we’re using video technology, not in stroke at the moment, but certainly in frailty and some other areas where there’ll be that video consultation because it’s the old saying, a picture paints 1000 words. So, you can talk about a patient on the phone but if you see them in front of you, it gives you a lot more information as a clinician.” (001 Ambulance paramedic)
Theme 3: The value participants placed on the new pathway (‘complicated’)
Mostly positive views
Some concerns:
  • Patient/carer experience

“Having seen it from the other side and if we can avoid…where you need that long term rehab, it’s wonderful.” (007 Ambulance paramedic)
“I think it’s (new pathway) feasible…The numbers aren’t huge so the knock-on effect for the ambulance service is going to be minimal…The patient experience, like we discussed before, is going to be better.” (019 Ambulance Paramedic)
“So, yeah…I think a direct access thrombectomy pathway from my service’s perspective, absolutely the right thing for patients.” (012 Hospital clinician)
“…we see the impact it can make…not every case is, you know that spectacular, but the ones where you see an immediate change. That’s what drives you forward…therefore if we can find ways of getting people there quicker.” (016 Hospital clinician)
“Stroke is a life changing event…for that person and for that family it’s a massive change…to be able to visit whenever it’s possible to be able to visit within distance, it’s a major issue…we know at least four out of five are patients over age 50, and therefore their companions are also equally older and frail, and you know that travel to a tertiary centre for visiting, for a stroke mimic, for example, is an absolute travesty.” (011 Hospital clinician)
Theme 4: The possible impact on NHS organisations and adopter systems (‘complicated’)
Welfare of ambulance crews“…we’ve got to think about the welfare of our Crews. You know if they have an hour and a half overrun and they then finish 40/50 miles away from their base station, they’re not coming in the following day. They’re unsafe to drive home and when they do actually get back to base and these issues have resulted in poor outcomes for paramedics when driving home after long overruns.” (014 Ambulance manager)
Who should conduct remote assessment at the CSC:
  • Balance of skills/availability needed.

“From my point of view, having those discussions through a specialist nurse, if they’re not the ones to make the decision to say yes or no to accept, doesn’t feel efficient because I think that we should be speaking directly to another consultant…I think it’s probably important that they speak directly to the person who can give them an answer there and then, now if the specialist nurses at the tertiary centre are trained up to a level of competence or empowered to make those decisions, that’s fine.” (010 Hospital manager)
Resources:
  • Lack of space and hospital beds.

“…and then I think another sort of more recent challenge is just the lack of capacity at the hospitals, so physically not having a space to take a patient even when you’ve pre-alerted and they’ve accepted…But yeah, that’s definitely a real issue…” (005 Ambulance paramedic)
Repatriation of patients:
  • Can overwhelm services.

“…and then they either need repatriation or we end up, you know, kind of it. It would overwhelm our emergency department and our stroke physicians. And then we sort of bat this back and forth.” (016 Hospital clinician)
Potential ‘knock-on’ effects on services of new pathway:
  • For CSCs.

  • For stroke units without a thrombectomy service.

“…so if you are looking at the future, you’re looking at all stroke calls within 24 hours or something like that, so that is, in my view, impossible to triage… it’s possible to try it, but actually to get that workforce to try it and do nothing else, is I think, not sustainable…I think you would also need an extra layer of workforce to actually do extended thrombectomy because those patients now that are just getting aspirin and going to the ward will now have CTA CTP discussion with radiology. So, we’ll take less number of patients, but we’ll take longer…to fund another group of people to run a 24/7 ambulance triage is not a possible solution from a funding and business case point of view.” (002 Hospital clinician)
“So, they would lose some of their hyper acute patients who you know, the other hospitals would lose some of their hyper acute patients, which will obviously impact on the number of admissions they are having and services they provide and for the resources they get for that.” (002 Hospital clinician)
Theme 5: The wider context (‘complicated’)
Regional variations in services and stroke pathways/protocols“One of the things I’d love to see is a standardised national ‘this is what we do’ that would make life so much easier for the paramedics.” (001 Ambulance paramedic)
Lack of standardisation and variable connectivity in information and communications technology“…it’s the actual system to support what you want…and that’s then relying across different hospital trusts and different organisations having access to the same system.” (012 Ambulance paramedic)
Staffing levels/demands“…on the radiologist side, the radiographer side and the nursing side in in all three groups we are struggling to recruit…we’ve got problems acquiring the images and interpreting the images…” (017 Hospital clinician)
“I know often the challenge is increasingly getting them within the window, especially as demands going up, and I will trust the feeling that we’re not getting to patients as quickly as we’d like to be…and I think that we’re, you know, we’re often arriving a couple of hours into the call, and so the actual the window to get them to a HASU is becoming more challenging.” (005 Ambulance clinician)
  • NASSS, Non-adoption, Abandonment and Challenges to Scale-up, Spread and Sustainability, Implementation.