Enhancing Inter-Facility Transfer for Patients with Acute Myocardial Infarction

 描述(申请人提供)：在美国，每年有近500,000名患者患有ST段抬高心肌梗死(STEMI)。大多数急诊科(EDs)缺乏对心肌再灌注进行直接经皮冠状动脉介入治疗(PCI)的本地能力。因此，患者必须被转移到有能力的机构，但这一过程中的低效会导致延迟及时的心肌再灌注，并恶化患者的预后。转院的STEMI患者再通时间远远落后于直接到PCI中心就诊的患者，90%的患者未能达到国家基准标准。对急诊病人转院的时机和护理过程的测量和了解不足，阻碍了STEMI患者转院及时性的改善。此外，对关系协调、沟通和组织设计的研究，统称为“组织行为”，是研究复杂卫生系统中的绩效和变量的公认方法。它还没有应用于STEMI患者的转移，但可能会揭示干预的重要目标。这份建议书描述了一项职业发展计划，通过为未来的实施研究获取高级定性和定量技能，使应聘者能够获得组织行为如何影响患者护理的专业知识。具体目标是：1)检查转移ED数据与心肌再灌注延迟相关的因素；2)对影响直接经皮冠状动脉介入治疗患者转移的做法进行详细的定性研究；以及3)检查关系协调与转移ED所花费的时间之间的关联。该候选人是唯一有资格作为急诊医生和博士生在运营管理。职业发展计划建立在这一基础上，以提供：a)定性方法(例如，患者和工作人员的访谈技能，以及观察)、生物统计学和组织理论方面的高级技能；b)通过手稿准备、拨款撰写和会议演示进一步发展科学沟通技能；c)与国际专家在护理过渡、定性研究、过程干预开发和试验设计方面的多学科指导研究经验。制度环境非常出色，包括一个质量研究中心；候选人所在领域的全国排名的研究生课程；以及国家CTSA协调中心。这一职业发展奖将使应聘者能够在机构间患者转移过程中培养衡量医疗系统性能的专业知识，深入了解系统性能与患者结果之间的关系，并制定干预目标，以提高心肌梗死患者护理的及时性。这一奖项将使候选人成为R01资助的独立调查者，实施和评估过程干预以改善患者结果。

 DESCRIPTION (provided by applicant): In the U.S., nearly 500,000 patients suffer an ST-elevation myocardial infarction (STEMI) each year. Most emergency departments (EDs) lack the local capabilities to perform primary percutaneous coronary intervention (PCI) for myocardial reperfusion. Thus, patients must be transferred to capable facilities, but inefficiencies in this process cause delays in timely myocardial reperfusion and worsen patient outcomes. The time to reperfusion for transferred STEMI patients greatly lags behind those patients who present directly to PCI centers and fails to meet national benchmark standards in 90% of cases. Inadequate measurement and understanding of the timing and processes of care at transferring EDs has hindered improvement in the timeliness of STEMI patient transfer. Moreover, the study of relational coordination, communication, and organizational design, collectively known as "organizational behavior," is an accepted approach to study performance and variation in complex health systems. It has not yet been applied to the transfer of STEMI patients, but would likely reveal important targets for intervention. This proposal describes a career development plan that enables the candidate to gain expertise in how organizational behavior affects patient care, through the acquisition of advanced qualitative and quantitative skills for future implementation studies. The Specific Aims are: 1) Examine transferring ED data for factors associated with delays to myocardial reperfusion; 2) Conduct a detailed qualitative study of the practices that affect patient transfer for primary PCI; and 3) Examine the association between relational coordination and time spent at transferring EDs. The candidate is uniquely qualified as an emergency physician and PhD candidate in operations management. The career development plan builds on this foundation to provide: a) advanced skills in qualitative methods (e.g., patient and staff interviewing skills, and observation), biostatistics, and organizational theory; b) further development of scientific communication skills through manuscript preparation, grant writing, and conference presentations; and c) a multidisciplinary mentored research experience with international experts in transitions of care, qualitative research, process intervention development, and trial design. The institutional environment is outstanding, including a qualitative research center; nationally ranked graduate programs in the candidate's fields of study; and the national CTSA coordinating center. This career development award will allow the candidate to develop expertise in measuring the performance of healthcare systems during inter-facility patient transfer, a deep understanding of the relationship between system performance and patient outcomes, and targets for intervention to improve the timeliness of patient care for myocardial infarction. This award will position the candidate to become an R01-funded independent investigator who implements and evaluates process interventions to improve patient outcomes.