Text added for clarity has been placed in brackets. When

considering the internal barriers, nine of twelve hospitals cited guideline familiarity as most important (see Figure ​Figure3).3). Additionally, for eight of twelve hospitals, the top three cited barriers were guideline familiarity, provider motivation, and provider outcome expectancy. In contrast, lack of agreement with guidelines and lack of awareness of the presence of guidelines were the least important Inhibitors,research,lifescience,medical barriers for ten of the twelve hospitals. Table 4 Barriers Internal to the Individual Provider Figure 3 Distribution of cited barriers by individual hospital. Overall, the dominant barriers reported were external barriers and patient related factors. The external Inhibitors,research,lifescience,medical barriers of environmental Lapatinib in vitro factors and patient factors dominated the barriers discussed

for every hospital (Figure ​(Figure3a)3a) and for all participant types. A great deal of discussion focused on the environmental (or systems based) barrier of radiology, particularly regarding failure of adequate communication of the time sensitive nature of computed tomography (CT) ordering and interpretation. Interestingly, radiologists in some cases also discussed the lack of a specific Inhibitors,research,lifescience,medical process to alert them to the emergent nature of these CT scans. The limited availability of neurology was frequently discussed as well. In some areas this was a general lack of neurologists and in others it reflected a lack of evening/weekend

coverage. Fear of liability both for giving and not giving tPA also received moderate attention as an external barrier. Within the internal barriers (Figure ​(Figure3b),3b), most participants Inhibitors,research,lifescience,medical identified lack of guideline familiarity Inhibitors,research,lifescience,medical as a large component of their hospital’s barriers. Most also had either outcome expectancy or motivation as an important barrier. The lack of self-efficacy appeared to be an important contributing barrier in several hospitals as well. When considering barriers organized by type of provider, the too external barriers of environment and patient-controlled factors again dominated the perceived barriers (see Figure ​Figure4a).4a). Regarding the internal barriers, nurses perceived lack of guideline familiarity as the most important barrier whereas physicians (both EPs and neurologists) perceived physician motivation as the primary barrier (see Figure ​Figure4b).4b). Of the barriers defined as internal to physicians, the most important were familiarity with and motivation to adhere to the guidelines, self-efficacy, and outcome expectancy. Figure 4 Distribution of cited barriers by acute stroke care provider type. In general, nurses perceived lack of guideline familiarity as the biggest barrier whereas physicians (both EM and neurologists) perceived physician motivation as the primary barrier.