A Qualitative Study of Risks Related to Interhospital Transfer of Patients with Nontraumatic Intracranial Hemorrhage.

GOAL: Interhospital transfer (IHT) facilitates access to specialized neurocritical care but may also introduce unique risk. Our goal was to describe providers' perceptions of safety threats during IHT for patients with nontraumatic intracranial hemorrhage. MATERIALS AND METHODS: We employed qualitative, semi-structured interviews at an academic medical center receiving critically-ill neurologic transfers, and 5 referring hospitals. Interviewees included physicians, nurses, and allied health professionals with experience caring for patients transferred between hospitals for nontraumatic intracranial hemorrhage. Interviews continued until data saturation was reached. Coding occurred concurrently with interviews. Analysis was inductive, using the constant comparative method. FINDINGS: The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. Insufficient communication highlights the unique communication challenges specific to IHT, which overlay and compound known intrahospital communication barriers. Gaps in clinical practice revolve primarily around the provision of neurocritical care for this patient population, often subject to resource availability, by receiving hospital emergency medicine providers. Lack of structure outlines providers' questions that emerge when institutions fail to identify process channels, expectations, and accountability during complex neurocritical care transitions. CONCLUSIONS: The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. These themes serve as fundamental targets for quality improvement initiatives. To our knowledge, this is the first description of challenges to quality and safety in high-risk neurocritical care transitions through clinicians' voices.

Mass incarceration, race inequality, and health: Expanding concepts and assessing impacts on well-being.

We explore race differences in how individuals experience mass incarceration, as well as in mass incarceration's impacts on measures of well-being that are recognized as major social determinants of health. We draw on baseline data from a sample of 302 men and women recently released from prison/jail or placed directly onto probation in New Haven, Connecticut (CT) for drug related offenses and followed at 6-month intervals for two years (2011-2014). We describe race differences in experiences of mass incarceration and in its impacts on well-being; and we conduct mediation analyses to analyze relationships among race, mass incarceration, and well-being. Blacks reported fewer adult convictions than whites, but an average of 2.5 more adult incarcerations. Blacks were more likely to have been incarcerated as a juvenile, spent time in a juvenile facility and in an adult facility as a juvenile, been on parole, and experienced multiple forms of surveillance. Whites were more likely to report being caught by the police doing something illegal but let go. Blacks were more likely to report any impact of incarceration on education, and dropping out of school, leaving a job, leaving their longest job, and becoming estranged from a family member due to incarceration. Whites were more likely to avoid getting needed health or social services for fear of arrest. Overall, Blacks reported a larger number of impacts of criminal justice involvement on well-being than whites. Number of adult incarcerations and of surveillance types, and being incarcerated as a juvenile, each mediated the relationship among race, mass incarceration, and well-being. Though more research is necessary, experiences of mass incarceration appear to vary by race and these differences, in turn, have implications for interventions aimed at addressing the impacts of mass incarceration on health and well-being.