Why "Treat First" Stalls: Knowledge, Scope, and System Determinants of Delayed Haemostatic Therapy in the Emergency Department.

BACKGROUND

Persons with bleeding disorders (PwBD) frequently experience delays to haemostatic therapy in emergency departments (EDs). Identifying clinician knowledge gaps and workflow barriers is essential to accelerate time-to-treatment.

OBJECTIVES

To define educational needs and system constraints shaping the evaluation and management of PwBD in Canadian EDs.

METHODS

We conducted an exploratory, sequential mixed-methods study. An online survey of ED nurses and physicians, distributed via national organizations, used four clinical vignettes to probe triage, diagnostic approach, initial management, and self-rated knowledge; quantitative data were summarized descriptively. Virtual focus groups then explored barriers and solutions and were analyzed using reflexive thematic analysis.

RESULTS

Three hundred ten clinicians completed the survey (250 nurses; 60 physicians). Most reported prior PwBD experience, but fewer had administered specialized haemostatic products. Across vignettes, respondents assigned high acuity and endorsed a ≤30-min treatment target, yet empiric "treat-first" therapy was inconsistently selected, particularly for non-specific presentations (severe headache, abdominal pain, early pregnancy bleeding). Reported gaps included use of haemostatic therapies; interpretation of coagulation assays; inhibitor management; and limited familiarity with treatment pathways. Barriers included absence of medical directives, treatment release processes, staffing and crowding pressures, and rural resource constraints. Six focus groups (nurses n = 10; physicians n = 4) explained these patterns, revealing a pathway from high perceived acuity to delayed treatment through intersecting knowledge, scope, and system factors, alongside strong preference for concise, point-of-care education, simulation, and web-based learning.

CONCLUSIONS

Co-designed education, nurse-initiated directives, streamlined product release, and accessible point-of-care tools are complementary levers to compress triage-to-therapy intervals for PwBD.