Factors influencing more timely treatment of aneurysmal subarachnoid haemorrhage across two tertiary referral centres in Australia: A mixed methods study.

Background and Aims: Delays in treatment of aSAH appear common but the causes are not understood. We explored facilitators and barriers to timely treatment of aSAH. Method(s): We used a mixed-methods multiple case study approach including in-depth interviews with stakeholders involved in individual aSAH cases, focusing on events from onset to treatment. Quantitative data were extracted from medical records including date and times. Within-case analysis identified barriers and facilitators in 4 phases (pre-hospital, presentation, transfer, in-hospital), which were then triangulated with the quantified time in each phase to determine significant influencing factors. Finally, we conducted thematic analysis across cases in early (<12h) and delayed (>12h) treatment group using a case-study matrix. Result(s): Twenty-seven cases (74.1% female) with 89 interviewees were included. Median (IQR) time to treatment was 15.1 (9.0, 24.1) hours. Only 37% of cases had treatment within 12 hours of onset. Rigorous mixed-methods data analysis and synthesis allowed identification of key themes influencing timely treatment of aSAH. Early 'recognition of aSAH' at onset and diagnosis, 'availability of resources' for immediate in-hospital treatment, and good 'coordination' across patients' pathway were key facilitators for treatment within 12 hours from onset. Lack of 'recognition of aSAH' at onset and 'unavailability of resources' for definitive treatment were major barriers implicated in delayed treatment. Conclusion(s): We provided a guidance to a new approach to the analysis and synthesis of data from a clinically focused multiple case study. Using a robust mixed-methods approach, we identified the most significant and potentially modifiable factors affecting more timely treatment of aSAH within 12 hours.