Table 1 T³ Trial intervention components

T³ clinical protocols

 Triage

  • All patients presenting with signs and symptoms of suspected stroke should be triaged to Australasia Triage Scale (ATS) categories 1 or 2 (seen within 10 min)

 Treatment

  Thrombolysis (tissue-type plasminogen activator)

   • All patients to be assessed for thrombolysis eligibility

   • All eligible patients to receive thrombolysis

  Fever

   • All patients to have their temperature taken on admission to emergency department (ED) and then at least four hourly whilst they remain in ED

   • Treat temperature 37.5 °C or greater with paracetamol within 1 h

  Sugar

   • Formal venous (laboratory) blood glucose level (BGL) on admission to ED

   • Record finger prick BGL on ED admission and monitor finger prick BGL every 6 h (or greater if elevated)

   • Administer insulin to all patients with BGL > 10 mmol/L (180 mg/dL) within 1 h

  Swallow

   • Patients remain Nil By Mouth until a swallow screen by non-speech pathologist (SP) or swallow assessment by SP performed, i.e.:

    ◦ No oral food or fluids to be given prior to swallow screen by non-SP or swallow assessment by SP

    ◦ No oral medications administered prior to swallow screen by non-SP or swallow assessment by SP

   • All patients who fail the screen are to be assessed by a SP

 Transfer

  • All patients with stroke to be discharged from ED within 4 h

  • All patients with stroke to be admitted to the hospital’s stroke unit

T³ Implementation strategy

 Multidisciplinary Workshops^a

  Workshop 1 - Barriers and Enablers Assessment (one at each site, 60 min)

   • To present the details of the trial

   • To identify the local barriers and enablers

   • To identify the local site clinical champion

  Workshop 2 - Action Plan (one at each site, 60 min)

   • To discuss the action plan to address the barriers

   • To ascertain the actions already taken to address the barriers

   • To identify the new local barriers

 Didactic and interactive education^a (minimum one at each site, 30 min)

  • A 20-min PowerPoint presentation and a 10-min discussion

  • An 8-min video developed by an academic ED nurse clinician/opinion leader

 Use of clinical opinion leaders

  • Key national clinical opinion leaders at Workshop 1 and available as needed for any site-requested queries

  • Clinical champions from ED and stroke unit

 • Reminders

  • Reminder poster to display in ED- and pocket-sized card to attach to ID lanyard for staff

  • Proactive direct contact every 6 weeks in the form of the following:

   ◦ Site visits every 3 months (face-to-face) using an action plan

   ◦ Teleconferences every 3 months with clinical champions and site coordinator using an action plan

  • Emails—reactive and monthly proactive emails

  • Telephone support—reactive

  • Telephone support—reactive and as needed