Table 2 Qualitative themes, codes, and illustrative quotes (ACS QUIK toolkit intervention implementation facilitators and barriers are summarized separately in Tables 3 and 4 (below))

Usefulness/acceptability of ACS QUIK toolkit intervention

a) Overall impressions of the toolkit intervention

b) Audit and feedback report

c) Admission and discharge checklists

d) Patient education materials

e) Guidelines to establish rapid response and code blue team

a) “(F)rom the QUIK kit (ACS QUIK toolkit intervention) point of view, the basic difference the ACS QUIK has done is that we made ourselves a little more efficient by way of transfer of patients from the ER (emergency room) to the ICU (intensive care unit) and the starting of treatment, antiplatelet and medicines.” [Site id: 19; toolkit intervention implementation score: 3]

b) “(In the audit report), (w) e see our hospital stands in the 77th percentile, I am so happy to note that we are giving all the medicines that are required. Similarly, at the time of discharge, we go through the checklist and find that all essential medicines are given to the patient. We have given instruction that as soon as a patient comes with chest pain, ECG should be taken. Any sort of emergency, we shift them to the CCU (coronary care unit). We are routinely giving this one essential medicines. All the parameters mentioned, we are fairly doing it.” [Site id: 25; toolkit intervention implementation score: 4]

c) “(D) efinitely (useful). Because even if everything said and done. Beta blockers, ACE-inhibitors, when discharge checklist come, some will be missing, because BP (blood pressure) will be borderline, so when we see the checklist we initiate it, so there is change in clinical practice.” [Site id: 18; toolkit intervention implementation score: 4]

d) “We keep it (patient education material) on table, every time morning and evening shifts changes so whoever (doctors/nurses) is there uses that stuff (education materials for every patient coming to the cardiac care unit routinely)” [Site id: 4; toolkit intervention implementation score: 3]

e) “No, we do not have a rapid response team in our hospital but we recently applied for NABH (National Accreditation Board for Hospitals), and it’s on the way and shortly we will be getting this approval … . and we will be forming code blue and rapid response team once we get approval from the NABH.” [Site id: 25; toolkit intervention implementation score: 4]

Adaptations to the ACS QUIK toolkit intervention

a) Admission and discharge checklists

b) Patient education materials

f) “Other thing we change (referring to the discharge checklist) the medicine according to the other co-morbidities of the patients like bronchial asthma.” [Site id: 19; toolkit intervention implementation score: 3]

g) “(S) o, we just made exercise and smoking cessation pictures from your material (ACS QUIK toolkit) and made sure that we ask them (junior doctors, nurses, or physiotherapist) to give 15 exercises and give them (patients) general instructions. We made a booklet. Most of our patients are not very educated, and we have some simple instructions on how they (ACS patients) can start walking, how long they can walk, what actions they should take if they (ACS patients) develop some symptoms. We have also given some algorithm also if patient develop some complications due to medications. Those things were framed in simple sentences. Also, for exercise and diet we made simple sentences.” [Site id: 2; toolkit intervention implementation score: 3]

Sustainability of ACS QUIK toolkit intervention

a) Use of toolkit intervention beyond trial period

b) Sustainability of toolkit intervention components

c) Barriers to toolkit intervention implementation: Lack of understanding of quality improvement program

h) “(W) hole heartedly (continued use of toolkit post-trial), as long as I am a cardiologist.” [Site id: 11; toolkit intervention implementation score: 3]

i) “That (sustainability) is very important from the point of view of every person who is involved in patient care. It is not for the study alone. It is for the betterment of your patients.” [Site id: 49; toolkit intervention implementation score: 3]

j) “Yes, it can be sustained but may not continue using the checklists beyond the trial period. I think the educational materials are most useful in long term.” [Site id: 19; toolkit intervention implementation score: 3]

k) “All parts are useful, but the admission and discharge checklist is not very useful. Ours is a hospital run by a group of cardiologists. We have our own practice of prescribing medications at admission and discharge and therefore we do not look into the checklists provided by the study whether the medicines listed have been prescribed or not.” [Site id: 49; toolkit intervention implementation score: 3]

l) “(M) aybe I will weigh that (audit report) as least useful of the four components, from patient management part, checklist certainly has utility, patient education material – yes. Audit report is only making us aware how we are faring in relation to other participating team/units. It is just a comparative data analysis. Nothing more comes out of it. Suddenly, you find that your hospital is at bottom, and then there is natural instinct to come somewhere in middle or top of the order.” [Site id: 19; toolkit intervention implementation score: 3]

m) “I think basically it is the ignorance of the quality improvement program that is creating the issue. Or how to participate in a quality control program that is totally different from the normal trials (drug trials) that we are doing … So this is different and that’s where the problem (understanding the implementation of quality improvement trials) has come.” [Site id: 24; toolkit intervention implementation score: 3]

Recommendation to use toolkit intervention to other hospitals (Scale-up)

d) Tertiary care government and private hospitals

e) Secondary care settings

n) “(Recommend to other hospitals)...100%, then only when others will use it, they (hospitals) will also understand the importance.” [Site id: 11; toolkit intervention implementation score: 3]

o) “(Y) eah of course, that (use of toolkit components in long-run) will definitely change the pattern of the treatment … so I would strongly recommend that toolkit to be implemented in other hospitals also.” [Site id: 61; toolkit intervention implementation score: 0]

p) “I think an ideal setting would be when it is used by non-cardiologist physicians.” [Site id: 49; toolkit intervention implementation score: 3]