TABLE 2.

Categorized themes and scored subthemes

Barriers to prehospital managment (PHM)	Score
	EP	PARA	CARD	RN
	1. Knowledge of PHM process and protocol
a. Lack of knowledge (or uncertainty) on aspects of the PHM protocol	+ +	0	+	+
b. Perception that focus on PHM will be robbing from trauma	+	0	0	0
c. Perception that some hospital staff are unaware of PHM protocol	0	+ +	0	0
d. Incongruency in literature or understanding of literature on myocardial infarction (MI) therapy	0	+ +	0	0
e. Lack of knowledge of paramedic team protocols	+	0	0	0
2. Practical aspects of PHM
a. Perception that PHM will have no effect and/or will increase overcrowding in emergency department	+	+	0	+
b. Perception that MI patients will avoid taking emergency medical services due to cost	+	+	0	0
c. Perception that patients with MI will avoid going to the hospital due to wait times	0	+	0	0
d. Perception of lack of communication between paramedic and hospital	0	+	0	0
3. Ownership of and taking responsibility for patient
a. Negative perceptions about steps in the protocol (ie, PHM-diagnosed patient stopping at the emergency department for triage)	+	0	0	0
b. Perceptions on ownership of and taking responsibility for patient	+ +	+	+	+
4. Capability and interest of paramedic to provide PHM
a. Skepticism (lack of trust) in some paramedics to carry out PHM effectively	+ +	+ +	0	0
b. Perception that some paramedics in rural areas are not capable of effectively providing PHM	0	0	0	+ +
c. Perception of paramedic misdiagnosis	+ +	+	0	+
d. Perception that paramedics’ inability to handle complications (or situations outside of protocol) will cause problems	+	0	0	0
e. Perception that some physicians may be resistant to PHM	+	0	0	0
f. Perception that some paramedics will be disappointed by Vital Heart Response physicians’ decisions	0	+ +	0	0
5. Technological assistance
a. Perception of technological failures inhibiting ability to manage patient	+	+ +	+	0
b. Knowledge of technical problems as a barrier to PHM	0	+ +	0	0
	Score
Facilitators of PHM	EP	PARA	CARD	RN
1. Benefits of PHM
a. Knowledge that expertise is brought to patients with PHM	+	+	0	0
b. Perception that PHM may increase the flow of in-hospital patient treatment	+	0	0	0
c. Perception that PHM may decrease in-hospital workload	+	0	0	0
d. Perception that PHM may increase the number of people taking ambulances during a heart attack with public awareness programs	+	+	+	0
e. Perception that PHM process will benefit patients even if there are contraindications to drug use	0	+	+	0
f. Perception that PHM will decrease cost to health care system	0	+	0	+
g. Knowledge of clinical benefit (including reducing time to treatment)	+ +	+ +	+	+
2. Medical overview and team relations
a. Integrating key players to form a team approach (accepting paramedic as ‘equals’) or (understanding the importance of a good physician-paramedic relationship)	+	+ +	0	0
b. Perception that medical overview is needed to ensure effective treatment of patient in the field	+ +	+ +	+	+ +
c. Perception that paramedic may have better access to cardiologists than emergency physicians	0	+ +	0	0
d. Perception of sound communication between paramedic and hospital	0	+	0	0
e. Perception that rural paramedics have a closer relationship than urban paramedics with respective hospitals	0	0	+ +	0
3. Practical aspects of PHM process and protocol
a. Knowledge of some emergency medical service protocols	+ +	+ +	0	0
b. Perception that a simplified protocol for the stakeholders will facilitate PHM	0	0	+ +	+
c. Knowledge of real-life field experience or knowledge of source of delays to treatment	0	+ +	0	0
d. Perception that placing cardiologists at peripheral sites will facilitate PHM	+	0	0	+
e. Perception that setting benchmark times for steps in the protocol is needed	0	0	+ +	0
f. Consistency of ST elevation MI treatment protocol (prehospital versus inhospital)	0	+	0	0
4. Training and regular maintenance of competency
a. Perception that continuous training (to maintain skills) by paramedics will facilitate PHM	+ +	+ +	+ +	+ +
b. Perception that simulations may complement real-life exposure to MI cases to maintain competency	+ +	+ +	0	0
c. Perception that increasing the quality of paramedic education program is needed to promote confidence	0	+ +	0	0
d. Knowledge that one must be critical of results published in the literature	0	+	0	0
5. Paramedics’ willingness and capability to manage acute MI patients
a. Perception that paramedics are capable of providing prehospital care to acute MI patients	+ +	+ +	+	+ +
b. Paramedics’ ability to handle bleeding (complication)	+	0	+ +	0
c. Paramedic will find added responsibility of providing PHM to be professionally rewarding	0	+ +	+	0
d. Knowledge that PHF is protocol-driven and perception that ST elevation MI is not too difficult to treat	+ +	+ +	0	0
6. Technological assistance
a. Perception that technology is a positive factor in PHM	0	+	0	0
b. Confidence in electrocardiogram technology and transmission	0	0	+	0

See Table 1 for scoring criteria. CARD Cardiologists; EP Emergency physicians; PARA Paramedics; RN Emergency nurses