Date of Award
5-2024
Document Type
Dissertation
Degree Name
Doctor of Philosophy (PhD)
Program
Nursing Science
Research Advisor
Anne Alexandrov, PhD
Committee
Barbara Brewer, PhD; Carrie Harvey, PhD; Ansley Stanfill, PhD; George Tsivgoulis, PhD
Keywords
acute stroke;delay of transfer;systems of care;treatment ineligibility
Abstract
The intricate process of efficiently transferring patients within the healthcare setting has proven to be complex however, it is a critical component to ensure timely access to essential medical interventions. Navigating these complexities presents a multifaceted challenge that is not fully understood. For patients suffering a stroke, these transfer delays may render them ineligible for treatment and left with disabling disability. This collective work aims to identify contributors to delays in transfer from lower to higher levels of care in the acute stroke populations.
Three papers emerged from this thesis. First, a narrative review of the literature published between January 1996 to April 2020 found that several factors are associated with improved stroke outcomes. The availability of resources such as vascular neurologists or dedicated stroke units, training ambulance personnel in the early identification of stroke symptoms and stroke management, and focusing on internal performance efficiencies in the emergency department to administer clot busing medication for the treatment of ischemic stroke have all improved outcomes. However significant gaps in knowledge of what contributes to delays exist with no objective data available on stroke transfer delays in the published literature.
Summation from the narrative review was used to develop a qualitative study. Web-based interviews with stroke coordinators at primary stroke centers were conducted where they discussed their lived experience in transferring patients from a primary stroke center to a higher level of care. The results were published in Stroke: Vascular and Interventional Neurology journal in March of 2023. Comprising the narrative review of the known causes of transfer delays and gaps in knowledge and the collective insight of stroke coordinators at primary stroke centers across the United States, a data collection instrument was designed and tested at primary stroke centers on patients that required transfer to a higher level of care. The instrument was divided into two main sections. The first section consisted of time process indicators that included information pertinent to activities associated with patient presentation, evaluation, and diagnostic work-up in the emergency department until departure to the higher level of care hospital. The second section consisted of 24-Likert scale questions designed to understand the transferring team’s perception of the quality and timeliness of the entire transfer process.
The data collection instrument allowed us to examine the contributors to door-in, door-out (DIDO) times at a granular level. The median DIDO time for the overall sample was 130 minutes which exceeds the recommended DIDO time of less than 120 minutes. The greatest single contributor to DIDO time was from transport request to actual transport departure times which alone was responsible for 38% or 49.5 minutes of the total DIDO time.
Collectively, these papers have broadened knowledge of why transfer delays exist when moving acute stroke patients from lower to higher level of hospital services. Continued work to further identify contributors to transfer delays within each category is warranted, along with development of interventions to improve efficiency across the entire system of care. In conclusion, delays in transfer continue to be one of the leading causes for stroke treatment ineligibility due to worsening irreversible brain damage. Improving stroke systems of care will improve treatment eligibility, reduce stroke related disability and death, and reduce the financial burden of post-stroke care.
ORCID
0000-0002-4876-7193
DOI
10.21007/etd.cghs.2024.0659
Recommended Citation
Patterson, Jennifer (0000-0002-4876-7193), "Identifying Contributors to Acute Stroke Transfer Delays from Lower to Higher Level Stroke Centers" (2024). Theses and Dissertations (ETD). Paper 675. http://dx.doi.org/10.21007/etd.cghs.2024.0659.
https://dc.uthsc.edu/dissertations/675