运用慢性病框架的定制实施方法理解急性中风溶栓的决定因素：一项定性研究
Understanding determinants of acute stroke thrombolysis using the tailored implementation for chronic diseases framework: a qualitative study.
作者信息
Skolarus Lesli E, Neshewat Gina M, Evans Lacey, Green Molly, Rehman Narmeen, Landis-Lewis Zach, Schrader Jillian Welsh, Sales Anne E
机构信息
Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI, 48109-5856, USA.
School of Public Health, University of Michigan, Ann Arbor, MI, USA.
出版信息
BMC Health Serv Res. 2019 Mar 20;19(1):182. doi: 10.1186/s12913-019-4012-6.
BACKGROUND
The Tailored Implementation in Chronic Disease (TICD) framework is a comprehensive framework describing the determinants of implementation success that has been used extensively in primary care settings. We explored the utility of the TICD to identify determinants of practice in an acute setting, namely guideline concordant acute stroke thrombolysis in a low-resourced, predominately minority serving, large, Emergency Department (ED).
METHODS
Through workshops and expert review, we developed an interview guide informed by the TICD framework. We then conducted semi-structured interviews with data collected through written transcripts, audio transcripts or interviewer notes based on participant availability. Three independent coders then performed a content analysis using template analysis, but open to new determinants that arose from the data, into the TICD framework.
RESULTS
We performed a total of 15 semi-structured interviews with ED acute stroke providers including medical technicians, nurses, and physicians. We found that guideline factors, individual health professional factors, and patient factors domains were barriers to guideline concordant acute stroke thrombolysis. The domain professional interactions was a facilitator to treatment. We identified three determinants, healthcare professional burnout, health care professional turnover and surrogate decision making, that are not part of the TICD framework.
CONCLUSIONS
Most determinants of acute stroke thrombolysis are included within the TICD framework. Inclusion of healthcare professional burnout, healthcare professional turnover and surrogate decision making may assist in expanding the TICD to time-sensitive ED conditions. Further work is needed to confirm this finding and to establish whether the TICD is applicable for use in non-time sensitive ED conditions. Interventions that address guideline, individual health professional and patient factors may improve guideline concordant acute stroke thrombolysis.
背景
慢性病定制实施（TICD）框架是一个全面的框架，描述了实施成功的决定因素，已在初级保健环境中广泛使用。我们探讨了TICD在确定急性环境中实践决定因素方面的效用，即在资源匮乏、主要服务少数族裔、规模较大的急诊科（ED）中遵循指南进行急性中风溶栓治疗。
方法
通过研讨会和专家评审，我们制定了一份受TICD框架启发的访谈指南。然后，我们根据参与者的可用性，通过书面记录、音频记录或访谈者笔记收集的数据进行了半结构化访谈。然后，三名独立编码员使用模板分析进行内容分析，但对数据中出现的新决定因素持开放态度，并将其纳入TICD框架。
结果
我们对急诊科急性中风医护人员进行了总共15次半结构化访谈，包括医学技术员、护士和医生。我们发现，指南因素、个体卫生专业人员因素和患者因素领域是遵循指南进行急性中风溶栓治疗的障碍。专业互动领域是治疗的促进因素。我们确定了三个不属于TICD框架的决定因素，即医护人员职业倦怠、医护人员更替和替代决策。
结论
急性中风溶栓治疗的大多数决定因素都包含在TICD框架内。纳入医护人员职业倦怠、医护人员更替和替代决策可能有助于将TICD扩展到对时间敏感的急诊科情况。需要进一步开展工作来证实这一发现，并确定TICD是否适用于对时间不敏感的急诊科情况。针对指南、个体卫生专业人员和患者因素的干预措施可能会改善遵循指南的急性中风溶栓治疗。
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