Rattray Nicholas A, Sico Jason J, Cox LeeAnn M, Russ Alissa L, Matthias Marianne S, Frankel Richard M
Jt Comm J Qual Patient Saf. 2017 Mar;43(3):127-137. doi: 10.1016/j.jcjq.2016.11.007. Epub 2016 Nov 15.
Transitions of care from specialty and acute settings to primary care abound. Compared to the continuity in end-of-shift handoffs, care transitions involve provider communication between practices and facilities with their own cultures and bureaucracies. Using the transition from acute care to outpatient primary care for stroke/transient ischemic attack (TIA) patients as a case study, this qualitative research explored communication practices and institutional arrangements among clinical providers responsible for longitudinal management of hypertension. In this study, researchers investigated the barriers and facilitators of effective communication between acute stroke/TIA inpatient and primary care providers at a Veterans Affairs Medical Center.
A multidisciplinary team conducted consensus-based coding and thematic analysis of semistructured interviews with 21 clinical providers (9 with primary responsibilities for inpatient care and 12 with primary responsibilities in outpatient, primary care).
Thematic analysis of responses identified three factors that influenced communication between clinical providers: (1) consistent, concise but complete medication and treatment plans; (2) reliable, standardized discharge documentation; (3) use of multiple modes of communication. Participants identified cultural barriers, including challenges with rotating providers at a teaching hospital and local discharge practices.
Ambiguity about who is being handed off to and time pressures in the acute setting may lead inpatient providers to give lower priority to discharge communication, leaving outpatient providers with low-quality information. While electronic templates have standardized key components of discharge documentation, improvement opportunities remain. Increased awareness of the challenges and opportunities on each side of the care transfer could foster communication practices that systematically account for the information needs of inpatient and outpatient providers.
从专科和急症环境到初级保健的护理过渡情况普遍存在。与轮班交接时的连续性不同，护理过渡涉及不同机构间的提供者沟通，这些机构有着各自的文化和官僚体系。以中风/短暂性脑缺血发作（TIA）患者从急症护理过渡到门诊初级保健为例，本定性研究探讨了负责高血压纵向管理的临床提供者之间的沟通实践和制度安排。在本研究中，研究人员调查了退伍军人事务医疗中心急性中风/TIA住院患者与初级保健提供者之间有效沟通的障碍和促进因素。
一个多学科团队对21名临床提供者进行了半结构化访谈，并基于共识进行编码和主题分析（其中9名主要负责住院护理，12名主要负责门诊初级保健）。
对回答的主题分析确定了影响临床提供者之间沟通的三个因素：（1）一致、简洁但完整的药物和治疗计划；（2）可靠、标准化的出院文件；（3）使用多种沟通方式。参与者指出了文化障碍，包括教学医院轮转提供者带来的挑战以及当地的出院做法。
在急症环境中，对于交接对象的不明确以及时间压力可能导致住院提供者对出院沟通的优先级降低，从而使门诊提供者获得的信息质量较低。虽然电子模板已使出院文件的关键部分标准化，但仍有改进的空间。提高对护理转移双方挑战和机遇的认识，可能会促进沟通实践，系统地考虑住院和门诊提供者的信息需求。
