From the Yale School of Medicine.
Yale New Haven Health, New Haven, Connecticut.
J Patient Saf. 2022 Mar 1;18(2):77-87. doi: 10.1097/PTS.0000000000000808.
The presentation of critically ill patients to emergency departments often necessitates interhospital transfer (IHT) to a tertiary care center for specialized neurocritical care. Patients with nontraumatic intracranial hemorrhage represent a critically ill population subject to high rates of IHT and who is thus an important target for research and quality improvement of IHT. We describe the use of an innovative simulation methodology engaging transfer staff, clinicians, and stakeholders to refine and facilitate the adoption of a standardized IHT protocol for transferring patients with neurovascular emergencies.
This was a qualitative study using a phenomenological approach. Participants consisted of IHT call center staff members, neurointensivists, neurosurgeons, and emergency physicians. We conducted a standardized telephone-based simulation case to prime participants for feedback on their experiences with IHT for intracranial hemorrhage patients. Facilitators conducted focus groups immediately after the simulation to identify process improvement opportunities. A structured thematic analysis identified overarching concepts from the data.
We achieved data saturation with 7 simulations and a total of 24 participants. Thematic analysis identified 3 IHT-specific themes: (1) challenges unique to multispecialty critical illness, (2) interdisciplinary relationships and dynamics, and (3) communication and information processing for IHT. Three quality improvement initiatives emerged from the debriefings: standardized communication checklist, early acceptance protocol, and structure for telephone-based care handoffs.
We demonstrate the use of telephone-based simulation technology to identify potential pitfalls and accelerate the adoption of a new IHT protocol for patients with nontraumatic intracranial hemorrhage. New quality improvement strategies can organically result through interprofessional debriefings for patients with potentially complex handoffs between hospitals.
危重症患者常需从急诊转入其他医院的三级医疗中心接受神经重症治疗。非创伤性颅内出血患者属于危重症人群，其院内转院（IHT）率较高，因此是研究和改善 IHT 质量的重要目标人群。我们描述了一种创新的模拟方法，该方法涉及转院工作人员、临床医生和利益相关者，以改进和促进神经血管急症患者的标准化 IHT 协议的采用。
这是一项采用现象学方法的定性研究。参与者包括 IHT 呼叫中心工作人员、神经重症医师、神经外科医师和急诊医师。我们进行了标准化的电话模拟病例，以使参与者为反馈他们对颅内出血患者 IHT 的经验做好准备。主持人在模拟后立即进行焦点小组讨论，以确定改进流程的机会。结构主题分析从数据中确定了总体概念。
我们进行了 7 次模拟和总共 24 名参与者，达到了数据饱和。主题分析确定了 3 个与 IHT 相关的主题：（1）多专科重症特有的挑战，（2）跨学科关系和动态，（3）IHT 的沟通和信息处理。从讨论中出现了 3 个质量改进倡议：标准化沟通清单、早期接受协议和电话护理交接结构。
我们证明了电话模拟技术的使用可以识别潜在的陷阱，并加速采用新的非创伤性颅内出血患者的 IHT 协议。通过跨专业的讨论，为可能需要复杂交接的患者提供新的质量改进策略，可以自然而然地产生。
