Factors affecting time between symptom onset and emergency department arrival in stroke patients

Background: American Heart Association/American Stroke Association recommends treatment of eligible acute ischemic stroke patients with intravenous rtPA <60 minutes from emergency department arrival. Purpose: A quality improvement project was designed to reduce the door to needle times for intravenous rtPA administration at Mayo Clinic Florida. We hypothesized that workflow changes in emergency department evaluation of suspected stroke patients would decrease door to needle times. The goal was to treat >75% of patients eligible for IV t-PA within 60 minutes of ED arrival. Methods: We utilized LEAN methods to develop a project charter, identify stakeholders, and visually map the emergency department clinical workflow. Prior to project initiation, suspected stroke patients were taken upon arrival to an exam room for clinical evaluation followed by transport to the CT scanner and return to the exam room for decision-making and rtPA administration. The clinical workflow was changed to obtain patient weight immediately upon arrival, abbreviated patient assessment and lab draws outside of the CT scanner in a holding bay and performing CT scanning prior to transport to an examination room for decision making and rtPA administration. Results: In a 12 month period preceding project initiation, 29 patients were treated with rtPA, 55 % were treated <60 minutes of emergency department arrival. In the 11 month period following implementation of CT scanning prior to neurological evaluation, 57 patients were treated with rtPA, 80 % were treated in <60 minutes of emergency department arrival. The mean door to needle time was reduced from 66 minutes to 46 minutes following the clinical workflow change. No patients experienced clinical deterioration at the time of CT scanning. Conclusions: Non-contrast head CT scan be safely performed prior to comprehensive neurological evaluation and reduces door-to-needle times for intravenous rtPA administration in eligible stroke patients. Validated process improvement paradigms such as LEAN have the potential to reduce door to needle times and improve patient outcomes.

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Abstract 8: Door-to-Imaging Times in Patients Presenting With Acute Stroke

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.4.suppl_1.a8 ◽

2011 ◽

Vol 4 (suppl_1) ◽

Author(s):

Adam G Kelly ◽

Anne S Hellkamp ◽

DaiWai Olson ◽

Eric E Smith ◽

Lee H Schwamm

Keyword(s):

Emergency Department ◽

Acute Stroke ◽

Brain Imaging ◽

Symptom Onset ◽

Temporal Trends ◽

Care Facility ◽

National Guidelines ◽

Predictive Variables ◽

Emergency Department Arrival ◽

History Of

Objectives: National guidelines recommend that patients presenting with acute stroke undergo brain imaging within 25 minutes of emergency department arrival. Delays in brain imaging may prevent or reduce effective stroke treatments such as thrombolysis. Methods: Data from the Get With the Guidelines-Stroke program from 2003 through 2009 were analyzed to determine overall imaging rates, temporal trends, and predictive variables associated with door-to-imaging times in patients who presented to an emergency department within 2 hours of stroke symptom onset and did not have clear contraindications to thrombolytic treatment. Multivariable logistic regression adjusting for within-hospital clustering was performed to identify the independent predictors of brain imaging within 25 minutes of emergency department arrival. Results: The study population consisted of 221,538 patients. Brain imaging was performed within 25 minutes in only 21.6% of patients. Rates of brain imaging <25 minutes were low among all stroke subtypes (ischemic stroke 22.1%, subarachnoid hemorrhage 18.7%, intracerebral hemorrhage 28.3%) and remained low but increased slightly from 2003 to 2009 (18.8% to 21.7%). In the multivariable model, the following variables were associated with less likelihood of brain imaging being completed within 25 minutes of arrival: age > 70 years; female gender; African American race; history of diabetes, carotid stenosis, peripheral vascular disease, or smoking; use of antihypertensive or diabetic medications; symptom onset in another acute care or chronic care facility; transportation to hospital other than ambulance; and hospital location in the Northeast region. History of atrial fibrillation/flutter and use of cholesterol-reducing medications were associated with a higher likelihood of brain imaging completed within 25 minutes. Conclusions: In most patients with acute stroke symptoms, brain imaging is not performed within the recommended 25 minutes. Future quality improvement initiatives should focus on reducing door-to-imaging times, with a specific emphasis on the predictive variables identified in this analysis.

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Is the Cost-Effectiveness of Stroke Thrombolysis Affected by Proportion of Stroke Mimics?

Stroke ◽

10.1161/strokeaha.118.022857 ◽

2019 ◽

Vol 50 (2) ◽

pp. 463-468 ◽

Cited By ~ 4

Author(s):

Ava L. Liberman ◽

Ho-Jun Choi ◽

Dustin D. French ◽

Shyam Prabhakaran

Keyword(s):

Emergency Department ◽

Ischemic Stroke ◽

Cost Effectiveness ◽

Incremental Cost ◽

Symptom Onset ◽

Intravenous Thrombolysis ◽

Cost Effective ◽

Stroke Patients ◽

Stroke Mimics ◽

The Cost

Background and Purpose— Differentiating ischemic stroke patients from stroke mimics (SM), nonvascular conditions which simulate stroke, can be challenging in the acute setting. We sought to model the cost-effectiveness of treating suspected acute ischemic stroke patients before a definitive diagnosis could be made. We hypothesized that we would identify threshold proportions of SM among suspected stroke patients arriving to an emergency department above which administration of intravenous thrombolysis was no longer cost-effective. Methods— We constructed a decision-analytic model to examine various emergency department thrombolytic treatment scenarios. The main variables were proportion of SM to true stroke patients, time from symptom onset to treatment, and complication rates. Costs, reimbursement rates, and expected clinical outcomes of ischemic stroke and SM patients were estimated from published data. We report the 90-day incremental cost-effectiveness ratio of administering intravenous thrombolysis compared with no acute treatment from a healthcare sector perspective, as well as the cost-reimbursement ratio from a hospital-level perspective. Cost-effectiveness was defined as a willingness to pay <$100 000 USD per quality adjusted life year gained and high cost-reimbursement ratio was defined as >1.5. Results— There was an increase in incremental cost-effectiveness ratios as the proportion of SM cases increased in the 3-hour time window. The threshold proportion of SM above which the decision to administer thrombolysis was no longer cost-effective was 30%. The threshold proportion of SM above which the decision to administer thrombolysis resulted in high cost-reimbursement ratio was 75%. Results were similar for patients arriving within 0 to 90 minutes of symptom onset as compared with 91 to 180 minutes but were significantly affected by cost of alteplase in sensitivity analyses. Conclusions— We identified thresholds of SM above which thrombolysis was no longer cost-effective from 2 analytic perspectives. Hospitals should monitor SM rates and establish performance metrics to prevent rising acute stroke care costs and avoid potential patient harms.

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Factors affecting delay from stroke onset to emergency department arrival: The genentech stroke presentation survey

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/s1052-3057(98)80100-6 ◽

1998 ◽

Vol 7 (5) ◽

pp. 378

Author(s):

D. Morris ◽

W. Rosamond ◽

S. Hamilton ◽

K. Madden ◽

C. Schultz

Keyword(s):

Emergency Department ◽

Stroke Onset ◽

Factors Affecting ◽

Emergency Department Arrival

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Factors Affecting Discharges against Medical Advice in an Emergency Department of a Tertiary Care Center

Journal of KIST Medical College ◽

10.3126/jkistmc.v2i2.33576 ◽

2020 ◽

Vol 2 (2) ◽

pp. 31-35

Author(s):

Trishna Shrestha ◽

Sneha Pradhananga ◽

Kabita Hada Batajoo ◽

Manjita Bajracharya

Keyword(s):

Health Care ◽

Emergency Department ◽

Health Care Costs ◽

Medical Advice ◽

Health Concern ◽

Against Medical Advice ◽

Factors Affecting ◽

Tertiary Center ◽

Care Costs ◽

Leaving Against Medical Advice

Introduction: Patients leaving against the advice of the treating team before being certified as fit is a major concern and challenge for the treating professionals as it possesses adverse medical outcomes. This study hence aimed at identifying the prevalence and major factors affecting such discharges so that advocacy can be done to help prevent it. Methods: A descriptive cross-sectional study was conducted at emergency department of a tertiary center in Lalitpur from 15th May 2019 to 15th August 2019. All the patients visiting the emergency department were included in the study and a non-probability purposive sampling method was used excluding the patients who denied giving reasons for them leaving against medical advice. Data was collected using pre-structured questionnaire and analyzed using SPSS-v21 software. Results: A hundred and fifteen patients (4.08%) left against medical advice out of 2812 patients who presented to emergency department. There were 63 male patients (54.8%), 75 patients of the total patients in the age group of 15-44 years (65.2%) and those living within a distance of 1km from the hospital (53%). The most common reason for the patients leaving against medical advice was found to be due to financial constraint (38.3%) followed by preference to other hospitals (16.5%). Conclusion: Patients leaving against medical advice possesses a small percentage of actual hospital admissions but is still a major health concern as it drastically increases the morbidity, re-admission rates and total health-care costs. Hence, understanding the general characteristics and predictors of such discharges is of utmost importance to help improve the patient outcome and reduce the health-care costs.

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Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach

Therapeutic Advances in Neurological Disorders ◽

10.1177/17562864211021182 ◽

2021 ◽

Vol 14 ◽

pp. 175628642110211

Author(s):

Georgios Magoufis ◽

Apostolos Safouris ◽

Guy Raphaeli ◽

Odysseas Kargiotis ◽

Klearchos Psychogios ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Symptom Onset ◽

Time Windows ◽

Intravenous Thrombolysis ◽

Inclusion Criteria ◽

Stroke Patients ◽

Treatment Algorithms ◽

Late Presenters

Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.

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Exploring Factors Affecting the Emergency Specialists’ Decision-Making in Case of Emergencies in Patients

Critical Care Research and Practice ◽

10.1155/2018/9579807 ◽

2018 ◽

Vol 2018 ◽

pp. 1-7 ◽

Cited By ~ 1

Author(s):

Abbasali Ebrahimian ◽

Seyed-Hossein Hashemi-Amrei ◽

Mohammadreza Monesan

Keyword(s):

Decision Making ◽

Emergency Department ◽

Qualitative Content Analysis ◽

Decision Makers ◽

Decision Making Process ◽

Factors Affecting ◽

Emergency Situations ◽

The Core ◽

Semistructured Interviews ◽

Emergency Decision

Introduction. Appropriate decision-making is essential in emergency situations; however, little information is available on how emergency decision-makers decide on the emergency status of the patients shifted to the emergency department of the hospital. This study aimed at explaining the factors that influence the emergency specialists’ decision-making in case of emergency conditions in patients. Methods. This study was carried out with a qualitative content analysis approach. The participants were selected based on purposive sampling by the emergency specialists. The data were collected through semistructured interviews and were analyzed using the method proposed by Graneheim and Lundman. Results. The core theme of the study was “efforts to perceive the acute health threats of the patient.” This theme was derived from the main classes, including “the identification of the acute threats based on the patient’s condition” and “the identification of the acute threats based on peripheral conditions.” Conclusions. The conditions governing the decision-making process about patients in the emergency department differ from the conditions in other health-care departments at hospitals. Emergency specialists may have several approaches to decide about the patients’ emergency conditions. Therefore, notably, the emergency specialists’ working conditions and the others’ expectations from these specialists should be considered.

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Prolonged Emergency Department Length of Stay as a Predictor of Adverse Outcomes in Patients with Intracranial Hemorrhage

Journal of Critical Care Medicine ◽

10.1155/2015/526319 ◽

2015 ◽

Vol 2015 ◽

pp. 1-5 ◽

Cited By ~ 5

Author(s):

Erica M. Jones ◽

Amelia K. Boehme ◽

Aimee Aysenne ◽

Tiffany Chang ◽

Karen C. Albright ◽

...

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Adverse Outcome ◽

Independent Predictor ◽

Adverse Outcomes ◽

Stroke Patients ◽

Significant Independent Predictor ◽

Prolonged Length ◽

Stroke Center ◽

Shift Change

Objectives. Extended time in the emergency department (ED) has been related to adverse outcomes among stroke patients. We examined the associations of ED nursing shift change (SC) and length of stay in the ED with outcomes in patients with intracerebral hemorrhage (ICH). Methods. Data were collected on all spontaneous ICH patients admitted to our stroke center from 7/1/08–6/30/12. Outcomes (frequency of pneumonia, modified Rankin Scale (mRS) score at discharge, NIHSS score at discharge, and mortality rate) were compared based on shift change experience and length of stay (LOS) dichotomized at 5 hours after arrival. Results. Of the 162 patients included, 60 (37.0%) were present in the ED during a SC. The frequency of pneumonia was similar in the two groups. Exposure to an ED SC was not a significant independent predictor of any outcome. LOS in the ED ≥5 hours was a significant independent predictor of discharge mRS 4–6 (OR 3.638, 95% CI 1.531–8.645, and P = 0.0034) and discharge NIHSS (OR 3.049, 95% CI 1.491–6.236, and P = 0.0023) but not death. Conclusions. Our study found no association between nursing SC and adverse outcome in patients with ICH but confirms the prior finding of worsened outcome after prolonged length of stay in the ED.

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