Pan‑Canadian TDF Analysis of Sepsis Recognition and Treatment Barriers

A pan-Canadian explanatory sequential mixed-methods study applied the Theoretical Domains Framework to characterize what frontline clinicians described as barriers and facilitators to earlier sepsis recognition and treatment across paramedic services and emergency departments. By spanning prehospital and ED settings, the study frames delays as arising not only from bedside decisions but also from how patients enter the system, move through it, and are handed over between teams. The authors present the findings as participant-identified constraints and supports rather than as directives for practice.

The authors describe an explanatory sequential design that paired a survey with follow-on qualitative interviews and then merged the datasets. The quantitative component included 545 survey responses, with respondents identifying as paramedics (37%), nurses (20%), and physicians (27%). The qualitative phase added 15 semi-structured interviews, and the authors report triangulating survey and interview findings through thematic analysis mapped to TDF constructs. Methods are presented as an integration exercise, using the qualitative material to elaborate on patterns seen in the survey rather than as a separate parallel inquiry. Taken together, the dataset is presented as capturing multiple professional viewpoints on where recognition and treatment delays can arise across the emergency care pathway.

Across data sources, the authors report six cross-cutting themes: access block, recognition by the public, resource constraints, leveraging scopes of practice, recognition by healthcare providers, and communication. They note these themes mapped largely to the TDF domain “Environment, Context, and Resources,” positioning barriers as features of system flow, staffing and physical capacity, role boundaries, and information transfer rather than as isolated knowledge gaps. Participants’ descriptions link prehospital and ED experiences by emphasizing that earlier identification may still be constrained by downstream capacity and coordination. The themes are presented as system-level constraints that can limit uptake across services even when clinical intent is aligned.

Survey responses also showed interprofessional differences in awareness and understanding of the guidelines and in confidence in the underlying evidence, alongside shared endorsement of sepsis guidance overall. Awareness/understanding was reported as 92% among physicians, 72% among paramedics, and 84% among nurses; confidence in the evidence was 70%, 85%, and 94%, respectively. In the same survey, point-of-care reinforcement was endorsed more often than additional education across groups (reinforcement: 74% physicians, 76% paramedics, 81% nurses; education: 59% physicians, 85% paramedics, 78% nurses), as reported in the study on sepsis recognition and treatment barriers. The pattern is presented as a shared orientation toward reinforcement approaches, with profession-specific differences in perceived needs and confidence.

When respondents described implementation targets, the study reports recurring suggestions that stayed close to workflow and system constraints: visual cues or alerts at the point of care, leveraging paramedic and nursing scope for earlier interventions, and prehospital pre-alerts to support EMS-to-ED communication. Participants also raised system-level approaches aimed at access block and resource shortages as necessary context for any pathway to function as intended. In discussing recognition, the authors report that participants highlighted gaps and limitations in point-of-care screening tools without portraying any single tool element as universally decisive. The paper also notes that prehospital alerts may help ED teams meet the guideline recommendation for antimicrobial treatment within 1 hour. Overall, the reported priorities clustered around point-of-care reinforcement, role-aligned workflow supports (including prearrival communication), and the system conditions that shape throughput.

Key Takeaways:

• The study used a mixed-methods design mapped to the TDF, with reported barriers largely aligning to “Environment, Context, and Resources.”
• Across physicians, nurses, and paramedics, survey responses suggested both shared support for sepsis guidance and profession-specific differences in awareness, confidence, and preferred implementation approaches.
• Participants most often described targets such as point-of-care cues, scope- and workflow-aligned supports (including prearrival notification), and broader constraints like access block/resources, and noted that prehospital alerts may help ED teams meet the guideline recommendation for antimicrobial treatment within 1 hour.