Gesell Sabina B, Golden Shannon L, Limkakeng Alexander T, Carr Christine M, Matuskowitz Andrew, Smith Lane M, Mahler Simon A
From the Departments of Social Sciences and Health Policy and Implementation Science, Wake Forest School of Medicine, One Medical Center Boulevard, Winston-Salem, NC.
Department of Social Sciences and Health Policy, and Qualitative and Patient-Reported Outcomes Developing Shared Resource, Wake Forest Baptist Comprehensive Cancer Center, Wake Forest School of Medicine, One Medical Center Boulevard, Winston-Salem, NC.
Crit Pathw Cardiol. 2018 Dec;17(4):191-200. doi: 10.1097/HPC.0000000000000154.
The HEART Pathway is an evidence-based decision tool for identifying emergency department (ED) patients with acute chest pain who are candidates for early discharge, to reduce unhelpful and potentially harmful hospitalizations. Guided by the Consolidated Framework for Implementation Research, we sought to identify important barriers and facilitators to implementation of the HEART Pathway.
Data were collected at 4 academic medical centers.
We conducted semi-structured interviews with 25 key stakeholders (e.g., health system leaders, ED physicians). We conducted interviews before implementation of the HEART Pathway tool to identify potential barriers and facilitators to successful adoption at other regional academic medical centers. We also conducted postimplementation interviews at 1 medical center, to understand factors that contributed to successful adoption.
Interviews were recorded and transcribed verbatim. We used a Consolidated Framework for Implementation Research framework-driven deductive approach for coding and analysis.
Potential barriers to implementation include time and resource burden, challenges specific to the electronic health record, sustained communication with and engagement of stakeholders, and patient concerns. Facilitators to implementation include strength of evidence for reduced length of stay and unnecessary testing and iatrogenic complications, ease of use, and supportive provider climate for evidence-based decision tools.
Successful dissemination of the HEART Pathway will require addressing institution-specific barriers, which includes engaging clinical and financial stakeholders. New SMART-FHIR technologies, compatible with many electronic health record systems, can overcome barriers to health systems with limited information technology resources.
HEART 路径是一种基于证据的决策工具，用于识别急诊科（ED）中可早期出院的急性胸痛患者，以减少无益且可能有害的住院治疗。在实施研究综合框架的指导下，我们试图确定 HEART 路径实施过程中的重要障碍和促进因素。
数据收集于 4 家学术医疗中心。
我们对 25 名关键利益相关者（如卫生系统领导者、急诊科医生）进行了半结构化访谈。在实施 HEART 路径工具之前进行访谈，以确定其他地区学术医疗中心成功采用该工具的潜在障碍和促进因素。我们还在 1 家医疗中心实施后进行了访谈，以了解促成成功采用的因素。
访谈进行了录音并逐字转录。我们采用实施研究综合框架驱动的演绎方法进行编码和分析。
实施的潜在障碍包括时间和资源负担、电子健康记录特有的挑战、与利益相关者的持续沟通和参与以及患者的担忧。实施的促进因素包括缩短住院时间、减少不必要检查和医源性并发症的证据强度、易用性以及支持基于证据的决策工具的医疗服务提供者氛围。
HEART 路径的成功推广需要解决特定机构的障碍，这包括让临床和财务利益相关者参与进来。与许多电子健康记录系统兼容的新型 SMART-FHIR 技术可以克服信息技术资源有限的卫生系统的障碍。
