abstract: 'IntroductionTranslation of evidence into clinical practice for use of

  intravenous thrombolysis in acute stroke care has been slow, especially

  across low- and middle-income countries. In Malaysia where the average

  national uptake was poor among the public hospitals in 2018, one

  hospital intriguingly showed comparable thrombolysis rates to

  high-income countries. This study aimed to explore and provide in-depth

  understanding of factors and explanations for the high rates of

  intravenous stroke thrombolysis in this hospital. MethodsThis single

  case study sourced data using a multimethod approach: (1)

  semi-structured in-depth interviews and focus group discussions, (2)

  surveys, and (3) review of medical records. The Tailored Implementation

  of Chronic Diseases (TICD) framework was used as a guide to understand

  the determinants of implementation. Twenty-nine participants comprising

  the Hospital Director, neurologists, emergency physicians, radiologists,

  pharmacists, nurses and medical assistants (MAs) were included. Thematic

  analyses were conducted inductively before triangulated with

  quantitative analyses and document reviews. ResultsFavorable factors

  contributing to the uptake included: (1) cohesiveness of team members

  which comprised of positive interprofessional team dynamics, shared

  personal beliefs and values, and passionate leadership, and (2)

  facilitative work process through simplification of workflow and

  understanding the rationale of the sense of urgency. Patient factors was

  a limiting factor. Almost two third of ischemic stroke patients arrived

  at the hospital outside the therapeutic window time, attributing

  patients'' delayed presentation as a main barrier to the uptake of

  intravenous stroke thrombolysis. One other barrier was the availability

  of resources, although this was innovatively optimized to minimize its

  impact on the uptake of the therapy. As such, potential in-hospital

  delays accounted for only 3.8\% of patients who missed the opportunity

  to receive thrombolysis. ConclusionsDespite the ongoing challenges, the

  success in implementing intravenous stroke thrombolysis as standard of

  care was attributed to the cohesiveness of team members and having

  facilitative work processes. For countries of similar settings, plans to

  improve the uptake of intravenous stroke thrombolysis should consider

  the inclusion of interventions targeting on these modifiable factors.'
affiliation: 'Hwong, WY (Corresponding Author), Minist Hlth Malaysia, Natl Inst Hlth,
  Inst Clin Res, Bangi, Selangor, Malaysia.

  Hwong, WY (Corresponding Author), Univ Utrecht, Univ Med Ctr Utrecht, Julius Ctr
  Hlth Sci \& Primary Care, Utrecht, Netherlands.

  Hwong, Wen Yea; Ng, Sock Wen; Ab Rahman, Norazida; Sivasampu, Sheamini, Minist Hlth
  Malaysia, Natl Inst Hlth, Inst Clin Res, Bangi, Selangor, Malaysia.

  Hwong, Wen Yea, Univ Utrecht, Univ Med Ctr Utrecht, Julius Ctr Hlth Sci \& Primary
  Care, Utrecht, Netherlands.

  Tong, Seng Fah, Univ Kebangsaan Malaysia, Dept Family Med, Bangi, Selangor, Malaysia.

  Law, Wan Chung; Kaman, Zurainah, Minist Hlth Malaysia, Sarawak Gen Hosp, Dept Med,
  Neurol Unit, Kuching, Malaysia.

  Wong, Sing Keat; Puvanarajah, Santhi Datuk, Minist Hlth Malaysia, Hosp Kuala Lumpur,
  Dept Neurol, Kuala Lumpur, Malaysia.'
article-number: '1048807'
author: Hwong, Wen Yea and Ng, Sock Wen and Tong, Seng Fah and Ab Rahman, Norazida
  and Law, Wan Chung and Kaman, Zurainah and Wong, Sing Keat and Puvanarajah, Santhi
  Datuk and Sivasampu, Sheamini
author-email: amyhwong@crc.gov.my
author_list:
- family: Hwong
  given: Wen Yea
- family: Ng
  given: Sock Wen
- family: Tong
  given: Seng Fah
- family: Ab Rahman
  given: Norazida
- family: Law
  given: Wan Chung
- family: Kaman
  given: Zurainah
- family: Wong
  given: Sing Keat
- family: Puvanarajah
  given: Santhi Datuk
- family: Sivasampu
  given: Sheamini
da: '2023-09-28'
doi: 10.3389/fneur.2022.1048807
files: []
issn: 1664-2295
journal: FRONTIERS IN NEUROLOGY
keywords: 'acute stroke care; intravenous thrombolysis; developing countries;

  translational research; facilitator; barrier'
keywords-plus: 'ACUTE ISCHEMIC-STROKE; CARE TEAMS; MANAGEMENT; GUIDELINES; TEAMWORK;

  OUTCOMES; TIMES'
language: English
month: NOV 24
number-of-cited-references: '38'
papis_id: a766ebd29ffa716f2076aefcd4993777
ref: Hwong2022strokethrombolysis
times-cited: '0'
title: 'Stroke thrombolysis in a middle-income country: A case study exploring the
  determinants of its implementation'
type: Article
unique-id: WOS:000893743500001
usage-count-last-180-days: '0'
usage-count-since-2013: '1'
volume: '13'
web-of-science-categories: Clinical Neurology; Neurosciences
year: '2022'