A Qualitative Study of Risks Related to Interhospital Transfer of Patients with Nontraumatic Intracranial Hemorrhage

'We are still here, we are survivors': patients' experiences of attending a multidisciplinary group-based support programme following subarachnoid haemorrhage

PURPOSE

People who survive a subarachnoid haemorrhage (SAH) often face enduring health challenges including physical disability, fatigue, cognitive impairments, psychological difficulties, and reduced quality of life. While group interventions have shown positive results in addressing similar issues in chronic conditions, the evidence involving SAH specifically is still sparse. This service evaluation aimed to explore SAH survivors' experiences of attending a multidisciplinary group-based support programme tailored to address unmet needs identified in previous literature, with the ultimate aim to refine future iterations of the programme and improve quality of care post-SAH.

MATERIALS AND METHODS

Semi-structured interviews were carried out with 12 individuals who attended the programme. The resulting data were analysed thematically.

RESULTS

Four overarching themes emerged from the analysis: (1) Barriers to accessing support after a SAH, (2) Factors acting as enablers of recovery, (3) Sharing lived experience to support one another, (4) Feeling connected while navigating a group format.

CONCLUSIONS

Lack of communication, fear, loneliness, and cognitive impairments can act as barriers to engagement with support, while acceptance and adjustment, holistic multidisciplinary input, and psychological support may represent successful enablers of recovery. Implications for future iterations of the programme as well as clinical rehabilitation and service development are discussed.

A Narrative Review of Interhospital Transfers for Intracerebral Hemorrhage

Of the 750,000 strokes in the United States every year, 15% patients suffer from hemorrhagic stroke. Intracerebral hemorrhage (ICH) is a subtype of hemorrhagic stroke. Despite advances in acute management, patients with hemorrhagic stroke continue to suffer from high mortality and survivors suffer from multidomain impairments in the physical, cognitive, and mental health domains which could last for months to years from their index stroke. Long-term prognosis after ICH is critically dependent on the quality and efficacy of care a patient receives during the acute phase of care. With ongoing care consolidation in stroke systems of care, the number of ICH patients who need to undergo interhospital transfers (IHTs) is increasing. However, the associations between IHT and ICH outcomes have not been well described in literature. In this review, we describe the epidemiology of IHT for ICH, the relationship between IHT and ICH patient outcomes, and proposed improvements to the IHT process to ensure better long-term patient outcomes. Our review indicates that evidence regarding the safety and benefit of IHT for ICH patients is conflicting, with some studies reporting poorer outcomes for transferred patients compared to direct admissions via emergency rooms and other studies showing no effect on outcomes. The American Heart Association guidelines for ICH provide recommendations for timely blood pressure control and anticoagulation reversal to improve patient outcomes. The American Heart Association stroke systems of care guidelines provide recommendations for transfer agreements and but do not provide details on how patients should be managed while undergoing IHT. Large, prospective, and multicenter studies comparing outcomes of IHT patients to direct admissions are necessary to provide more definitive guidance to optimize IHT protocols and aid clinical decision-making.

Clinical Performance Measures for Emergency Department Care for Adults With Intracranial Hemorrhage

Though select inpatient-based performance measures exist for the care of patients with nontraumatic intracranial hemorrhage, emergency departments lack measurement instruments designed to support and improve care processes in the hyperacute phase. To address this, we propose a set of measures applying a syndromic (rather than diagnosis-based) approach informed by performance data from a national sample of community EDs participating in the Emergency Quality Network Stroke Initiative. To develop the measure set, we convened a workgroup of experts in acute neurologic emergencies. The group considered the appropriate use case for each proposed measure: internal quality improvement, benchmarking, or accountability, and examined data from Emergency Quality Network Stroke Initiative-participating EDs to consider the validity and feasibility of proposed measures for quality measurement and improvement applications. The initially conceived set included 14 measure concepts, of which 7 were selected for inclusion in the measure set after a review of data and further deliberation. Proposed measures include 2 for quality improvement, benchmarking, and accountability (Last 2 Recorded Systolic Blood Pressure Measurements Under 150 and Platelet Avoidance), 3 for quality improvement and benchmarking (Proportion of Patients on Oral Anticoagulants Receiving Hemostatic Medications, Median ED Length of Stay for admitted patients, and Median Length of Stay for transferred patients), and 2 for quality improvement only (Severity Assessment in the ED and Computed Tomography Angiography Performance). The proposed measure set warrants further development and validation to support broader implementation and advance national health care quality goals. Ultimately, applying these measures may help identify opportunities for improvement and focus quality improvement resources on evidence-based targets.

Quality Improvement in the Management of Subarachnoid Hemorrhage: Current State and Future Directions

PURPOSE OF REVIEW

Aneurysmal subarachnoid hemorrhage carries high mortality and morbidity. Quality improvement (QI) efforts in the management of this disease process are growing as the field of neurocritical care matures. This review provides updates in QI in subarachnoid hemorrhage (SAH) and discusses gaps and future directions.

RECENT FINDINGS

Literature published on the topic over the past 3 years were evaluated. An assessment of current QI practices pertaining to the acute care of SAH was conducted. These include processes surrounding acute pain management, inter-hospital coordination of care, complications during the initial hospital stay, role of palliative care, and quality metrics collection, reporting, and monitoring. SAH QI initiatives have shown promise by decreasing ICU and hospital lengths of stay, health care costs, and hospital complications. The review reveals substantial heterogeneity, variability, and limitations in SAH QI protocols, measures, and reporting. Uniformity in QI research, implementation, and monitoring will be crucial as disease-specific QI develops in neurological care.

Using the ICH score during acute telestroke consults to triage transfer to tertiary centers

OBJECTIVE

Constrained resources at tertiary centers indicate a need for re-exploration of the practice of routinely transferring all community hospital patients with complex conditions such as hemorrhagic stroke (ICH). We addressed the clinical question of whether information available during acute care telestroke consults could identify ICH patients not requiring specialty services or neurosurgical intervention who could safely remain at the local center for care.

DESIGN

Retrospective cohort analysis abstracting clinical factors to identify ICH patients associated with need for tertiary care or neurosurgical intervention.

SETTING

The Duke Telestroke Network (DTN) in Central NC and Southern Virginia.

PATIENTS

All DTN transferred ICH patients January 1, 2017 to December 31, 2018.

INTERVENTIONS

We defined neurosurgical intervention as craniotomy, digital subtraction angiography, or external ventricular drain placement.

MEASUREMENTS AND RESULTS

We identified 116 transferred ICH patients. Sixty-two were female, the median Glasgow coma score (GCS) was 13, and the median ICU and hospital length of stay were 2 and 7 days respectively. Thirty of the patients were offered and 27 ultimately received neurosurgical intervention. Using inclusion/exclusion criteria from two ICH surgical trials would have increased the intervention group to 35 patients (30%). Components of the ICH score differentiated surgical from non-surgical patients; patients with an ICH score of <2 and GCS ≥13 received no interventions. Nearly 50% of patients could receive medical management locally.

CONCLUSIONS

Coupling the ICH score and GCS can provide triage guidance identifying patients for retention at the referring center. This retained population is distinct from patients eligible for current or novel surgical interventions. This approach provides a framework for assessment of transfers across specialty areas and furthers the value of telehealth networks.

Barriers and facilitators to interhospital transfer of acute pulmonary embolism: An inductive qualitative analysis

Background

Interhospital transfer (IHT) of patients with acute life-threatening pulmonary embolism (PE) is necessary to facilitate specialized care and access to advanced therapies. Our goal was to understand what barriers and facilitators may exist during this transfer process from the perspective of both receiving and referring physicians.

Methods

This qualitative descriptive study explored physician experience taking care of patients with life threatening PE. Subject matter expert physicians across several different specialties from academic and community United States hospitals participated in qualitative semi-structured interviews. Interview transcripts were subsequently analyzed using inductive qualitative description approach.

Results

Four major themes were identified as barriers that impede IHT among patients with life threatening PE. Inefficient communication which mainly pertained to difficulty when multiple points of contact were required to complete a transfer. Subjectivity in the indication for transfer which highlighted the importance of physicians understanding how to use standardized risk stratification tools and to properly triage these patients. Delays in data acquisition were identified in regards to both obtaining clinical information and imaging in a timely fashion. Operation barriers which included difficulty finding available beds for transfer and poor weather conditions inhibiting transportation. In contrast, two main facilitators to transfer were identified: good communication and reliance on colleagues and dedicated team for transferring and treating PE patients.

Conclusion

The most prominent themes identified as barriers to IHT for patients with acute life-threatening PE were: (1) inefficient communication, (2) subjectivity in the indication for transfer, (3) delays in data acquisition (imaging or clinical), and (4) operational barriers. Themes identified as facilitators that enable the transfer of patients were: (1) good communication and (2) a dedicated transfer team. The themes presented in our study are useful in identifying opportunities to optimize the IHT of patients with acute PE and improve patient care. These opportunities include instituting educational programs, streamlining the transfer process, and formulating a consensus statement to serve as a guideline regarding IHT of patients with acute PE.

"Our Hands Are Tied Until Your Doctor Gets Here": Nursing Perspectives on Inter-hospital Transfers

BACKGROUND

The transfer of patients between hospitals (inter-hospital transfer, or IHT) is a common occurrence for patients, but guidelines to ensure safe and effective IHTs are lacking. Poor IHTs result in higher rates of mortality, longer lengths of stay, and higher hospitalization costs compared to admissions from the emergency department. Nurses are often the first point of contact for IHT patients and can provide valuable insights on key challenges to IHT processes.

OBJECTIVE

To characterize the experiences of inpatient floor-level bedside nurses caring for IHT patients and identify care coordination challenges and solutions.

DESIGN/PARTICIPANTS/APPROACH

Qualitative study using semi-structured focus groups and interviews conducted from October 2019 to July 2020 with 21 inpatient floor-level nurses caring for adult medicine patients at an academic hospital. Nurses were recruited using a purposive convenience sampling approach. A combined inductive and deductive coding approach guided by thematic analysis was used for data analysis.

KEY RESULTS

Results from this study are mapped to the Agency for Healthcare Research and Quality Care Coordination Measurement Framework domains of communication, assessing needs and goals, and negotiating accountability. The following key themes characterize nurses' experiences with IHT related to these domains: (1) challenges with information exchange and team communication during IHT, (2) environmental and information preparation needed to anticipate transfers, and (3) determining responsibility and care plans after the IHT patient has arrived at the accepting facility.

CONCLUSIONS

Nurses described the absence of standardized processes to coordinate care before or at the time of patient arrival. Challenges to communication and coordination during IHTs negatively impacted patient care and nursing professional satisfaction. To streamline care for IHT patients and reduce nursing stress, future IHT interventions should include standardized handoff reports, timely identification and easy access to admitting clinicians, and timely clinician evaluation and orders.

Improving Safety and Quality During Interhospital Transfer of Patients With Nontraumatic Intracranial Hemorrhage: A Simulation-Based Pilot Program

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Closing the Loop: Program Description and Qualitative Analysis of a Pediatric Posttransfer Follow-up and Feedback Program

OBJECTIVES

Follow-up and feedback foster improvement. General emergency medicine providers working in community hospitals desire follow-up and feedback on pediatric patients transferred to children's hospitals. We implemented a novel program to provide these data to our colleagues. The objective of this study was to explore stakeholder perspectives of our program.

METHODS

We provided secure, electronic reports on transfers from 7 general emergency departments (GEDs). Patient follow-up and feedback data were delivered to the GED's pediatric emergency care coordinator. Seven pediatric emergency care coordinators and 2 children's hospital liaisons participated in semistructured interviews. Five researchers coded and analyzed transcribed data using the constant comparative method of grounded theory. Codes were refined and clustered to develop themes.

RESULTS

Perceived values of the program included GED appreciation of closing the loop on transferred patients, providing education, and informing quality improvement. Participants valued the concise and timely nature of the reports and their empathetic delivery. Facilitators of program implementation included established professional relationships between the GED and the children's hospital liaisons and a GED's culture of self-inquiry. Barriers to program implementation included potential medicolegal exposure and the time burden for report generation and processing. Suggested programmatic improvements included focusing on generalizable, evidence-based learning points and analyzing care trends.

CONCLUSIONS

Stakeholders of our pediatric posttransfer follow-up and feedback program reported many benefits and provided key suggestions that may promote successful dissemination of similar programs nationwide. Examining data trends in transferred children may focus efforts to improve the care of children across all emergency care settings.

A Multimodal Intervention to Improve the Quality and Safety of Interhospital Care Transitions for Nontraumatic Intracerebral and Subarachnoid Hemorrhage

BACKGROUND

Regionalization of care has increased interhospital transfers (IHTs) of nontraumatic intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) to specialized centers yet exposes patients to the latent risks inherent to IHT. The researchers examined how a multimodal quality improvement intervention affected quality and safety measures for patients with ICH or SAH exposed to IHT.

METHODS

Pre and post analyses of timeliness, effectiveness, and communication outcome measures were performed for patients transferred to an urban, academic center with nontraumatic ICH/SAH following implementation of a multimodal intervention. Intervention components included clinical practice guideline dissemination, IHT process redesign, electronic patient arrival notification, electronic imaging exchange, and electronic health record improvements. Three months of preintervention outcomes were compared to six months of postintervention outcomes to assess impact and sustainability of the intervention; t-tests and chi-square tests were used to compare continuous and proportional outcomes, respectively.

RESULTS

The IHT study population included 106 patients (37 preintervention, 69 postintervention). Significant improvements were observed in timeliness outcomes, including emergency department (ED) time to admission order (preintervention median: 66 minutes vs. postintervention: 33 minutes, p = 0.008), ED boarding time (preintervention median: 223 minutes vs. postintervention: 93 minutes, p = 0.001), and ED length of stay (preintervention median: 300 minutes vs. postintervention: 150 minutes, p ≤ 0.0001). Verbal communication between ED and neurocritical care clinicians prior to IHT improved from 40.0% preintervention to 90.9% postintervention.

CONCLUSION

Application of scripted quality improvement interventions as part of the IHT process is feasible and effective at improving the timeliness of care and communication of critical information in patients with nontraumatic ICH/SAH.