Emergency care network: stroke care

Brandão, Paloma de Castro; Lanzoni, Gabriela Marcellino de Melo; Pinto, Isabela Cardoso de Matos

doi:10.37689/acta-ape/2023AO000611

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Acta Paulista de Enfermagem

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Sumário

Original Article • Acta Paul Enferm 36 • 2023 • https://doi.org/10.37689/acta-ape/2023AO000611 copy

Emergency care network: stroke care

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To analyze how the care of patients with acute ischemic stroke occurs, considering the care flows and the restrictive and facilitating elements of care in the emergency care network.

Methods

This is a study based on the Grounded Theory methodological framework. We interviewed 75 health professionals from the Brazilian Mobile Emergency Care Service, Emergency Care Unit and reference hospital in the city of Salvador, Bahia.

Results

A total of 14 categories and 66 subcategories emerged that represented the phenomenon studied, revealing causal factors of network fragmentation such as lack of vacancies and resources, need for improvement in the care protocol, hospital bureaucratization, lack of knowledge by the population, despite the efforts of professionals to meet this patient. Professional interaction revealed the absence of a single language, obstacles in professional relationships, lack of knowledge of the other’s role, difficulty in regulating patients and sharing some goals in the network. Consequently, patients left the care line, care for patients outside the therapeutic window, the need to impose a ‘zero vacancy’, and better care when patients had access to specialized unit. Facilitating elements also concern the sharing of goals in the network and the effort of professionals to attend to window patients.

Conclusion

The network fragmentation reveals the need for management interventions to improve care, standardizing it and making care comprehensive and equitable.

Ischemic stroke; Emergency nursing; Emergency service, hospital; Emergency medical services; Patient transfer; Answering services

Categories (Condition)	Development of categories and subcategories
Missing vacancy and resources for stroke patient in the network	Subcategories point to the lack of space for adequate care of patients with stroke at the referral hospital in Stroke Unit for thrombolysis and especially for out-of-window patients.
Needing improvements in Stroke Protocol use	Elements point to the lack of a Stroke Protocol evidenced by professionals’ doubts about its existence. They understand the protocol in different ways, perceive its incipience and poorly incorporated flow, report lack of training for professionals, difficulties in the success of the protocol in ECU, perception of patient flow obstruction.
Compromising treatment by hospital bureaucratization	In hospital dynamics, there is a waste of time in the need for written authorization to make the form, in the slow preparation of the form and in the need to go through the Risk Stratification Reception (RSR) at this moment.
There is loss in care due to the population’s lack of knowledge	There is a perception of window loss for most patients who arrive at health services, due to the lack of prior guidance for the population about care emergency, about suspicion of symptoms, not knowing where to refer patients.
Noting the efforts of professionals from different services to attend to window patients.	It points to professional commitment, sometimes making the protocol work, identifying and prioritizing patients in RSR in ECUs, seeking to perform SAMU care quickly, triggering Stroke Unit specialized team to assess patients in the emergency. In the same way, the SAMU, when entering the hospital, sends patients to tomography to preserve the window.

Categories (Action-interaction)	Development of categories and subcategories
Perceiving lack of language and unique conduct in the network	Failures in communication between services and in health services are related to the perception that care varies according to the team on duty, including variations in medical conduct in the ECU in activating or not Stroke Protocol, and also in the non-homogeneity of care at the reference hospital.
Perceiving impediments in professional relations	Difficulties in the SAMU-ECU, SAMU-hospital relationships with the head of duty responsible for the hospital emergency are indicated, a relationship hampered by the workload in the emergency and in internal relationships with the ECU.
Not knowing the other’s role in the network	Subcategories bring elements, such as distortion of the SAMU role in the network, lack of knowledge of the ECU role in the network, the need to better see the other service’s needs, the act of referring that patients are from the service of origin and not from the network.
Finding it difficult to regulate patients in the network	It evidences hospital restriction in accepting window and out of window patients, criticizes the regulation for the hospital without a right bed, with authorization only for neurological assessment, the difficulty in contacting the head of duty, the difficulty in regulating patients outside the window and the need to regulate after counter-referral.
Sharing goals in the network	It indicates that the network counts on the collaboration of SAMU, that the ECU team cohesion is the foundation for the service operation and that hospital pre-notification is a factor for improving care. The good relationship of professionals with Stroke Unit team stands out.

Categories (Consequences)	Development of categories and subcategories
Leaving Stroke care line and returning to the network	They indicate counter-referral of hospital patients to less complex units, either due to lack of hospital resources or because professionals judge patients without a maintenance profile in the tertiary unit. Sometimes these patients were not assessed by neurologists. Faced with the refusal of hospitals and ECUs, patients remain with the SAMU.
Assisting patients outside the therapeutic window	It is supported by subcategories that indicate compliance with the permanence of patients in the ECU in the face of numerous limitations in care; criticism of limitations of mobile pre-hospital care for out-of-window patients, with variations in the possibility of being assessed by the neurologist or not; often receiving generalist care.
Patients being better served when there is access to Stroke Unit	It reveals that patients with suspected or confirmed stroke have optimal care when there is advice from Stroke Unit. Data indicate that the Unit has material resources and trained personnel for the service, affirming standardization, direction to the pathology and etiological investigation.
Zero vacancy being imposed	It establishes a relationship with the lack of vacancy, being necessary that the SAMU use the ‘zero vacancy’ and that the reference hospital receives the imposition of this regulation, welcoming patients in a reality that is not always conducive.

Escola Paulista de Enfermagem, Universidade Federal de São Paulo R. Napoleão de Barros, 754, 04024-002 São Paulo - SP/Brasil, Tel./Fax: (55 11) 5576 4430 - São Paulo - SP - Brazil
E-mail: actapaulista@unifesp.br

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[1] Corresponding author: Paloma de Castro Brandão E-mail: pahbrandao@gmail.com