Hayes Mitchell, Schlundt David, Bonnet Kemberlee, Vogus Timothy J, Kripalani Sunil, Froehler Michael T, Ward Michael J
Vanderbilt University School of Medicine, Nashville, Tennessee.
Vanderbilt University, Department of Psychology, Nashville, Tennessee.
J Stroke Cerebrovasc Dis. 2019 May;28(5):1219-1228. doi: 10.1016/j.jstrokecerebrovasdis.2019.01.012. Epub 2019 Feb 7.
Acute Ischemic stroke (AIS) is a time-sensitive emergency and patients frequently present to, and are transferred from emergency departments (EDs). We sought to evaluate potential factors, particularly organizational, that may influence the timeliness of interfacility transfer for ED patients with AIS.
We conducted semistructured interviews at 3 EDs that routinely transfer AIS patients. A structured interview guide was developed and piloted prior to use. Staff were asked about perceived facilitators and barriers to timely and high quality emergency care for patients with AIS who require transfer. Each interview was audio recorded, transcribed, coded, and analyzed using an iterative inductive-deductive approach to build a list of themes and subthemes, and identify supporting quotes.
We interviewed 45 ED staff (administrative staff, nurses, and physicians) involved in acute stroke care. We identified 4 major themes influencing the execution of interfacility transfers of AIS patients: (1) processes, (2) historical experiences; (3) communication; and (4) resources. Pre-existing protocols that standardized processes (eg, autoacceptance protocols) and reduced unnecessary communication, combined with direct communication with the neurology team at the comprehensive stroke center, and the flexibility and availability of human and physical resources (eg, staff and equipment) were commonly cited as facilitators. Lack of communication of clinical and operational outcomes back to transferring ED staff was viewed as a lost opportunity for process improvement, interorganization relationship building, and professional satisfaction.
ED staff view the interfacility transfer of AIS patients as highly complex with multiple opportunities for delay. Coordination through the use of protocols and communication pre- and post-transfer represented opportunities to facilitate transfers. Staff and clinicians at transferring facilities identified multiple opportunities to enhance existing processes and ongoing communication quality among facilities involved in the acute management of patients with AIS.
急性缺血性卒中（AIS）是一种对时间敏感的急症，患者常前往急诊科（ED）就诊并从急诊科转出。我们试图评估可能影响AIS急诊患者机构间转运及时性的潜在因素，尤其是组织方面的因素。
我们在3个常规转运AIS患者的急诊科进行了半结构化访谈。在使用前制定并试用了结构化访谈指南。询问工作人员对于需要转运的AIS患者及时、高质量急诊护理的促进因素和障碍的看法。每次访谈都进行录音、转录、编码，并采用迭代归纳-演绎方法进行分析，以构建主题和子主题列表，并找出支持性引述。
我们访谈了45名参与急性卒中护理的急诊科工作人员（行政人员、护士和医生）。我们确定了影响AIS患者机构间转运执行的4个主要主题：（1）流程；（2）历史经验；（3）沟通；（4）资源。标准化流程（如自动接收协议）并减少不必要沟通的现有协议，再加上与综合卒中中心神经科团队的直接沟通，以及人力和物力资源（如工作人员和设备）的灵活性和可用性，通常被认为是促进因素。临床和运营结果未反馈给转出急诊科工作人员被视为错失了改进流程、建立组织间关系和提高职业满意度的机会。
急诊科工作人员认为AIS患者的机构间转运非常复杂，存在多个延误机会。通过使用协议以及转运前后的沟通进行协调是促进转运的机会。转出机构的工作人员和临床医生确定了多个机会来加强现有流程以及参与AIS患者急性管理的机构之间的持续沟通质量。
