Table 4.

Barriers Internal to the Individual Provider

Barrier	Type of Participant	Representative response
Lack of Guideline Agreement	Emergency Physician	"They were rightfully upset when suddenly, based on one study [NINDS], when you had five previous studies that...had bad outcomes. Three of them they stopped early because of the bad outcomes. And yet here we were asked to change our therapy based on this one study."
	Emergency Physician	"A lot of it has to do with how much influence certain big-shots in emergency medicine have. There are some - one in particular who practices at Hospital X, just 10 miles down the road, he's been very outspoken against the use of tPA. And if you ever go to the national [emergency medicine] meetings and listen to these...docs speak, they can be very convincing. And I think that has had some influence on some people."
Lack of Guideline Awareness	Neurologist	"... when the patient goes to the neuroscience unit, and their blood pressure goes out of the parameters, I mean they don't initially call the neurologist, ...usually it's the family medicine resident. Unless the neurologist has specifically written something else."
Lack of Guideline Familiarity	Emergency Physician	"Did you say, 20 percent of patients that received placebo [in the NINDS trial] die? Twenty percent? That's impossible."
Lack of Outcome Expectancy	Emergency Physician	"And I have used it probably three times, and I've really been unable in the emergency department to see any significant improvement. I don't think I've had any complications, but oftentimes I don't get much feedback on how my patients do later on, so I'm not really sure how they did."
Lack of Self-Efficacy	Emergency Physician	"...some physicians are less comfortable with the whole process. You know, [some physicians would] explain risk-benefits to families, and [would not be] giving the lytics without prior discussion with the neurologist, or some other ER physicians would be comfortable without ever talking to neurologists, and doing everything and then just coordinating care with the intensivists."
Lack of Motivation	Emergency Nurse	"And they'll go back in there and double-check that patient seven times in order to say, oh, they're improving, you know, as one of the relative contraindications... Their stroke scale score was 14 and now it's 12, so they're improving-- we don't have to give it. You know. Whew! That kind of a thing."

Representative responses from participants that were coded as barriers. All internal barrier types are included.