Outcomes and Experiences of a Fast Track - A direct admission process from ambulance to stroke unit for patients not eligible for acute intervention

Abstract

Background Stroke is a serious medical condition, and the time before acute intervention and care at stroke units is crucial. People who suffer from a stroke and are not eligible for stroke alert are often transported to the emergency department (ED), where they risk experiencing a long length of stay (LOS) before being admitted to the stroke unit. Long LOS in ED is associated with health-associated harms (both bodily and psychological harm), which can be avoided if sufficient measures are taken in the care pathway. For selected patients, a direct admission process (Fast Track) from emergency medical services (EMS) to the stroke unit has been tried to shorten the care pathway LOS, reduce health-associated harms and use resources more efficiently. Overall aim The goal of this thesis was to describe and explore a changed organisational care pathway process from EMS to the stroke unit for patients not eligible for stroke alert, focusing on both patient and organisational perspectives in terms of safety outcomes and factors affecting LOS in the care pathway.

Methods Data were gathered through a case-control design, including both prospective and retrospective data (Study I) and individual explorative descriptive interviews with nurses from the entire care pathway (Studies II and III), and through a case-control design using quality registers (Study IV). Quantitative data were analysed using descriptive and inferential statistics (Studies I and IV), whereas qualitative data were analysed using the critical incident technique (Studies II and III).

Main findings The changed care pathway (i.e. direct transport from nurse-manned EMS to the stroke unit) was indicated to be safe for selected patients and was associated with relatively high diagnostic accuracy. The care pathway LOS was significantly shortened, but there were no significant differences regarding complications or patient-reported outcome measurement (PROM) between the Fast Track patients and patients transported via the ED. The findings showed that the most prevalent critical factors that negatively affected the Fast Track care pathway were connected to the participants’ experiences of how different units other than their own worked, the challenges of assessing patients’ symptoms, workflows/organisational silos, available hospital beds and the atmosphere in this context. The most common enablers of a well-running Fast Track were linked to patients’ and relatives’ involvement/participation, to staff members’ level of experience/skills and to cross-sectional collaboration/professional relations.

To manage delays, staff members took actions by safeguarding the patients, striving to gain an overview of the situation, convincing others to work in different ways and building trust with patients/relatives. The situation affected the staff in all departments by causing unpleasant feelings that they kept to themselves and did not communicate. Over time, the Fast Track showed a decreasing trend regarding the number of contacts from EMS to the stroke coordinator, a decreasing trend regarding the acceptance of the Fast Track and an increasing trend regarding the denial of the Fast Track, associated with the number of hospital beds. The organisational prerequisites for maintaining this direct admission process became more and more limited over the years, and there was a failing degree of obedience to pre-defined guidelines. This might have consequences for the care pathway LOS, health-associated harms and strains on the healthcare resources. Conclusions The Fast Track concept was indicated to be safe for selected patients. It was feasible and was expected to shorten the patients’ time in the care pathway compared to patients transported via the ED. However, there were no significant differences between Fast Track and ED patients regarding complications or PROM. The findings revealed several critical factors related to human and organisational causes that affect the Fast Track process both negatively and positively. In addition, the findings showed a decreasing trend in getting acceptance from the hospital for Fast Track when suggested and consequently fewer Fast Tracks.