Abstract
BackgroundDespite regionalization efforts, delays at transferring hospitals for patients transferred with ST-elevation myocardial infarction (STEMI) for primary percutaneous coronary intervention (PCI) persist. These delays primarily occur in the emergency department (ED), and are associated with increased mortality. We sought to use qualitative methods to understand staff and clinician perceptions underlying these delays.MethodsWe conducted semi-structured interviews at 3 EDs that routinely transfer STEMI patients to identify staff perceptions of delays and potential interventions. Interviews were recorded, transcribed, coded, and analyzed using an iterative inductive-deductive approach to build and refine a list of themes and subthemes, and identify supporting quotes.ResultsWe interviewed 43 ED staff (staff, nurses, and physicians) and identified 3 major themes influencing inter-facility transfers of STEMI patients: 1) Processes, 2) Communication; and 3) Resources. Standardized processes (i.e., protocols) reduce uncertainty and can mobilize resources. Use of performance benchmarks can motivate staff but are frequently focused on internal, not inter-organizational performance. Direct use ofcommunication between ORGANIZATIONS can process uncertainty and expedite care. Record sharing and regular post-transfer communication could provide opportunities to discuss and learn from delays and increase professional satisfaction. Finally, characteristics of resources that enhanced their capacity, clarity, experience, and reliability were identified as contributing to timely transfers.ConclusionsProcesses, communication, and resources were identified as modifying inter-facility transfer timeliness. Potential quality improvement strategies include ongoing updates of protocols within and between organizations to account for changes, enhanced post-transfer feedback between organizations, shared medical records, and designated roles for coordination.
Highlights
Despite regionalization efforts, delays at transferring hospitals for patients transferred with STelevation myocardial infarction (STEMI) for primary percutaneous coronary intervention (PCI) persist
While the American College of Cardiology Foundation/American Heart Association (AHA) has a recommendation for inter-facility transfer from a non-PCI to PCI facility with a first medical contact-to-device of ≤120 min (Class I, Level of Evidence B), these are difficult to achieve for transfers even under conditions such as those that occurred during the AHA’s Mission:Lifeline quality improvement program and subsequent Accelerator program [5,6,7]
Given the common delays associated with inter-facility transfer for patients with STEMI, exploring why these delays persist through the use of qualitative methods may facilitate an identification and description of the mechanisms underlying observed delays
Summary
Delays at transferring hospitals for patients transferred with STelevation myocardial infarction (STEMI) for primary percutaneous coronary intervention (PCI) persist. These delays primarily occur in the emergency department (ED), and are associated with increased mortality. We sought to use qualitative methods to understand staff and clinician perceptions underlying these delays. Access to the preferred treatment, primary percutaneous coronary intervention (PCI) is associated with improved outcomes [3], for transfers [4]. Given the common delays associated with inter-facility transfer for patients with STEMI, exploring why these delays persist through the use of qualitative methods may facilitate an identification and description of the mechanisms underlying observed delays
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