Network professional interaction in the care of patients with stroke

to understand the professional interaction in the Emergency Care Network in the care of patients with acute ischemic stroke in the city of Salvador/Bahia.

Methods:

the Grounded Theory methodological framework, Straussian strand, and the health networks theoretical framework were used. An in-depth interview was used, between October 2019 and October 2020, with 75 professionals from the Mobile Emergency Care Service, Emergency Care Units and reference hospital.

Results:

5 categories and 24 subcategories point to shared goals among professionals, but they show elements of fragmentation of connections between services, such as the absence of a single language and conduct, obstacles to professional relationships and lack of knowledge of the other’s role.

Conclusions:

to improve network relationships and care of patients with stroke, there is a need for well-established connecting elements, such as flows and protocols, supported by continuing education actions.

Descriptors:
Stroke; Emergency Medical Services; Interpersonal Relations; Cooperative Behavior; Health Management

Sample group	Hypotheses	Research question
Sample group 1	The organization of care of patients with stroke in the network is poor.	Sample group 1: tell me about the care of patients with suspected stroke.
Sample group 1 to Sample group 2	There is difficulty in the initial assessment of patients with suspected stroke in the ECU. Fluctuations in quality of interpersonal relationship between SAMU and ECU interfere with the quality of network service. The counter-referral from hospital to ECU goes against the Line of Care of Stroke.	Sample group 2: how do you perceive the professional interaction in the care of patients with stroke? How do you perceive the continuity of patient care in the counter-referral from the hospital to the ECU?
Sample group 1 to Sample group 3	The lack of acceptance of SAMU teams in the hospital, evidenced by the difficulties encountered in the interpersonal relationship, exposes the fragility of network care. The difficulty in seeing roles in the network reflects in conflict between the teams of different services. The variation of hospital conduct, according to the team on duty, makes the service “person-dependent” and suggests the absence of protocols.	Sample group 3: how do you view the hospital’s ability to care for patients with stroke? How do you see the professional interaction in the care of patients with stroke?
Sample group 2 to Sample group 3	Insufficient hospital capacity to absorb high demand from patients with stroke results in counter-referral to ECU, due to non-establishment of roles in the network and ignorance of the other service’s role.

Category (action-interaction)	Development of categories and subcategories	Excerpts of interviews
Perceiving lack of language and unique conduct in the network	It points to the absence of well-established protocols or flows that guide, in an articulated and equitable way, patient care, considering that there is no language and conducts defined collectively in the network, there is no cohesion in established practices and no well-defined flow. The subcategories point to the need to improve the quality of communication, variation in care, according to the team on duty and according to the physician who treats patients in the ECU. There is a loss of care due to conduct inhomogeneity, with the possibility of patients with similar clinical conditions being treated in different ways or that adequate treatment is possible for some, while not for others, depending on who assists.	[...] there is no homogeneity of approach to certain situations within the units, there is no single speech, even though there is a protocol [...]. (IS3) [...] counter-referral is sometimes a little tumultuous [...] I, in particular, do not discuss much with the physician who is there, because SAMU is to assist the patient wherever he is and even the destination, so when he arrives at the destination, he goes be counter-referred, they keep thinking it’s not their job, so I call SAMU’s regulation, tell them what the problem is, so we can try to make a counter-referral. We have an obligation to say that there is no bed, the bosses on duty are in a difficult situation, because then you have to leave the stretcher where the patient is, to pull over there at the reception [...]. (IH10)
Perceiving barriers in professional relationships	It is supported by six subcategories, which list relational difficulties between services and in the services, indicating difficulties in SAMU-ECU, SAMU-HOSP relationship and with the hospital’s Chief of Duty, an element of the network responsible for accepting to receive patients or denying vacancy in the tertiary unit. Moreover, there is an impaired relationship in the reference unit, evidenced by the excessive workload, because it is a reference unit for various pathologies and overcrowding, in addition to obstacles in internal relations to the ECU, which tend to impair care.	[...] I observe that there is a greater resistance to receive SAMU patient in the reference hospital, despite the prior communication from the Regulation Center informing the state in which the patient is [...] and despite this unit being the reference for this type of service, barriers are created to make it difficult and prevent the team from entering the service [...] prolonging the occurrence for an unnecessary time, [...] creating a certain enmity by reference unit professionals with SAMU professionals. (IS25) [...] we do not have medical team support, because if I evaluate this patient [in the RWRS] and if I understand that there is a suspicion there and if he doesn’t listen to me, doesn’t value it, I write and sometimes he doesn’t even read [...]. (IECU24)
Not knowing the role of the other in the network	It brings elements, such as non-recognition of the other and their role in the network, distortion of the other service, not seeing their needs, which seem to distance the concept of network from the reality experienced. Furthermore, isolation of services is noted when professionals refer that patients are from the service of origin (SAMU, ECU, hospital), not understanding that patients belong to the network as a whole. SAMU, a pre-hospital service, when entering the hospital environment with patients, he remains responsible for them, referring them to tomography, looking for hospital professionals, pushing a stretcher and transferring patients from bed in the place of stretcher workers, who usually do not help, remaining a long time in the institution environment without being released until medical conduct is defined or until a stretcher or bed appears or until they decide to counter-refer patients.	[...] the patient is from the network, the network is mine, the network is yours, the network is everyone’s. Sometimes they forget that our goal is the patient. The hospital is not my fiefdom. SAMU is not my fiefdom. My goal is the patient. So, I will help you, you will help me so that together we can treat the patient well, treat the patient well. [...] each one looking at their own navel forgetting that our goal is to assist the patient [...]. (IS10) [...] today, it is not a reality of us, but we have already worked in a situation of being without a stretcher in the emergency room. It’s over for all the stretchers, being with 7 or 8 in the red room that is small and that should fit only half. But the vast majority of them cannot see our other side, the side that we also have these difficulties, that they are in a hurry to release the ambulance and leave the patient with us, but that we do not always get this release immediately [...]. (IH5)
Finding it difficult to regulate patients in the network	It refers to one of the activities of integration between services, which is regulation. It brings in its subcategories the difficulties linked to the restrictions of hospitals in receiving this patient, the fact that there is authorization for hospital referral only for neurological evaluation and not for admission, the difficulty of contacting the Chief of Duty and the greater difficulty in regulating patients that are out of window or that are counter-referred to other units and need new regulation.	[...] when patients are outside the window for thrombolysis, beyond 4.5 hours, the care becomes more difficult in the reception in tertiary units [...]. (IS5) [...] we have difficulty regulating properly. The medical regulator has difficulty speaking with the chief on duty, or with the on-call physician of the hospital unit [...]. (IS23)
Sharing goals on the network	They are related to the association between professionals of services in favor of patients. The subcategories bring that, since SAMU is a connector element, it has its collaboration in the network, noting that hospital pre-notification, for instance, is a factor of improvement in hospital care. Sharing objectives between the stroke unit and SAMU results in better care. The cohesion of professionals in the ECU, mainly due to the long time working together, becomes the foundation for running the unit. To overcome the bad weather, strategies are developed to better relate and to overcome the problems.	[...] when SAMU arrives, I confirm the patient’s name and I already call them [stroke unit physicians]. Usually, when the Chief of Duty communicates that a patient will come, he already leaves the tomography request with name and suspicion, so that no time is wasted in filling out, we gain time like this [...]. (IH3) [...] in my working days, my team is very cohesive, nurses, technicians and the medical team. Teams are warriors and they are the ones who save the service in the ECU. We already do the minimum, because we have no resources, without my team, I could not do anything [...]. (IECU18)

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[1] Corresponding author: Paloma de Castro Brandão E-mail: paloma.brandao@ufba.br