Abstract TP240: Missed Ischemic Stroke Diagnosis in the Emergency Department at an Academic Center and Community Hospital

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Allison E Arch ◽  
David C Weisman ◽  
Steven Coca ◽  
Karin V Nystrom ◽  
Charles R Wira ◽  
...  
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Community Hospital ◽  
Retrospective Chart Review ◽  
Therapeutic Window ◽  
Academic Hospital ◽  
Stroke Patients ◽  
Academic Center ◽  
Prevention Therapy ◽  
Stroke Diagnosis

Introduction: The failure to recognize an ischemic stroke in the emergency department (ED) is a missed opportunity for acute interventions and for prompt treatment with secondary prevention therapy. Our study examined the characteristics of misdiagnosed strokes in the ED of an academic teaching hospital and a large community hospital. Methods: A retrospective chart review was performed from February 2013 to February 2014. A stroke was “missed” if practitioners in the ED did not initially consider stroke in the differential, or the diagnosis was delayed causing the patient to miss the therapeutic window for thrombolytic therapy. Results: A total of 465 ischemic stroke patients were included; 280 patients from the academic hospital and 185 patients from the community hospital. One hundred three strokes were initially misdiagnosed. Fifty-five of these were missed at the academic hospital (22%) and 48 were at the community hospital (26%, p=0.11). Of the missed stroke patients, 26 at the academic hospital (47%) and 10 at the community hospital (21%) presented within 3 hours of symptom onset. At the academic hospital where a neurologist is consulted on all potential acute strokes, a neurologist was called for 95% of the accurate stroke diagnoses but only 36% of the stroke misses (p<0.001). Factors independently associated with greater odds of a missed stroke diagnosis were nausea/vomiting (OR=4.02, 95% CI=1.60-10.1), dizziness (OR=1.99, 95% CI=1.03-3.84), and a positive stroke history (OR=2.40, 95% CI=1.30-4.42). Thirty-seven percent of posterior strokes were initially misdiagnosed compared with 16% of anterior strokes (p<0.001). Conclusion: Greater than 20 percent of stroke patients admitted through the ED at both an academic center and community hospital had a missed diagnosis. These strokes were more likely to be posterior circulation strokes and associated with nausea, vomiting and dizziness. A neurologist consultation decreased the likelihood of a missed stroke. Next steps are the development of improved identification systems and tools in the ED to improve the accuracy of stroke diagnosis.

scholarly journals Agreement between Impression of Stroke in the Emergency Department and Diagnosis at the Neurology Department

2019 ◽  
Vol 7 (3) ◽  
pp. 7
Author(s):  
Samad Shams-Vahdati ◽  
Alireza Ala ◽  
Eliar Sadeghi-Hokmabad ◽  
Neda Parnianfard ◽  
Maedeh Gheybi ◽  
...  
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Statistical Significance ◽  
Retrospective Chart Review ◽  
Chi Square ◽  
Prevention Therapy ◽  
Significant Difference ◽  
Chi Square Test ◽  
Academic Teaching Hospital ◽  
The Mean

Background: Missing to detect an ischemic stroke in the emergency department leads to miss acute interventions and treatment with secondary prevention therapy. Our study examined the diagnosis of stroke in the emergency department (ED) and neurology department of an academic teaching hospital. Methods and Materials: A retrospective chart review was performed from March 2017 to March 2018. ED medical document (chart) were reviewed by a stroke neurologist to collect the clinical diagnosis and characteristics of ischemic stroke patients. For determining the cases of misdiagnosed and over diagnosed data, the administrative data codes were compared with the chart adjudicated diagnosis. The adjusted estimate of effect was estimated through testing the significant variables in a multivariable model. The comparisons were done with chi square test. Statistical significance was considered at P < 0.05. Results: Of 861 patients of the study, 54% were males and 43% were females; and the mean age of them was 66.51 ± 15.70. We find no statically significant difference between patient’s Glasgow Coma Scale (GCS) in the emergency department (12.87±3.25) and patients GCS in the neurology department (11.77±5.15). There were 18 (2.2%) overdiagnosed of ischemic stroke, 8 (0.9%) misdiagnosed of ischemic stroke and 36 (4.1%) misdiagnosed of hemorrhagic strokes in the emergency department. Conclusion: There was no significant difference between impression of stroke in the emergency department and diagnosis at the neurology department.

Abstract P119: Factors Influencing Door to Needle Administration for Acute Stroke Patients in the Emergency Department

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Nicolle W Davis ◽  
Meghan Bailey ◽  
Natalie Buchwald ◽  
Amreen Farooqui ◽  
Anna Khanna
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Patient Outcomes ◽  
Time Of Day ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
The Impact ◽  
Iv Tpa

Background/Objective: There is growing importance on discovering factors that delay time to intervention for acute ischemic stroke (AIS) patients, as rapid intervention remains essential for better patient outcomes. The management of these patients involves a multidisciplinary effort and quality improvement initiatives to safely increase treatment with intravenous thrombolytic (IV tPa). The objective of this pilot is to evaluate factors of acute stroke care in the emergency department (ED) and the impact they have on IV tPa administration. Methods: A sample of 89 acute ischemic stroke patients that received IV tPa from a single academic medical institution was selected for retrospective analysis. System characteristics (presence of a stroke nurse and time of day) and patient characteristics (mode of arrival and National Institutes of Health Stroke Scale score (NIHSS) on arrival) were analyzed using descriptive statistics and multiple regression to address the study question. Results: The mean door to needle time is 53.74 minutes ( + 38.06) with 74.2% of patients arriving to the ED via emergency medical services (EMS) and 25.8% having a stroke nurse present during IV tPa administration. Mode of arrival ( p = .001) and having a stroke nurse present ( p = .022) are significant predictors of door to needle time in the emergency department (ED). Conclusion: While many factors can influence door to needle times in the ED, we did not find NIHSS on arrival or time of day to be significant factors. Patients arriving to the ED by personal vehicle will have a significant delay in IV tPa administration, therefore emphasizing the importance of using EMS. Perhaps more importantly, collaborative efforts including the addition of a specialized stroke nurse significantly decreased time to IV tPa administration for AIS patients. With this dedicated role, accelerated triage and more effective management of AIS patients is accomplished, leading to decreased intervention times and potentially improving patient outcomes.

scholarly journals Work of a stroke team: experience of transferring ischemic stroke patients from district hospitals to Krasnoyarsk Regional Vascular Center for thrombectomy

2022 ◽  
Vol 20 (4) ◽  
pp. 218-224
Author(s):  
P. G. Shniakin ◽  
N. V. Isaeva ◽  
V. Y. Kuznetsov ◽  
A. V. Protopopov ◽  
E. E. Korchagin ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Cerebral Arteries ◽  
Therapeutic Window ◽  
High Tech ◽  
Stroke Patients ◽  
Stroke Treatment ◽  
Systemic Thrombolysis ◽  
District Hospitals ◽  
Vascular Center

Modern high-technology methods for ischemic stroke treatment (systemic thrombolysis, mechanical thrombectomy, thrombaspiration, stenting of cerebral arteries) can improve the rehabilitation potential and survival of patients. Important tasks here are selection for reperfusion and its performance on the greatest possible number of peracute patients. Mechanical thrombectomy combined with systemic thrombolysis is the most effective reperfusion strategy in the therapeutic window, but the availability of endovascular methods is limited to highly specialized centres. One way to solve this problem is to organize effective logistics with stroke patients, which will provide high-tech care for patients living far from large treatment centers due to regulated interaction between institutions at different levels.The aim of the study was to improve emergency interaction related to transfer of peracute stroke patients from primary vascular units and district hospitals of the Krasnoyarsk region to Krasnoyarsk Regional Vascular Center for thrombectomy. 

scholarly journals Delayed recanalization in acute ischemic stroke patients: Late is better than never?

2019 ◽  
Vol 39 (12) ◽  
pp. 2536-2538 ◽  
Author(s):  
Jinwei Pang ◽  
John H Zhang ◽  
Yong Jiang
Keyword(s):  
Clinical Trials ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Brain Tissue ◽  
Symptom Onset ◽  
Therapeutic Window ◽  
Stroke Patients ◽  
Narrow Therapeutic Window ◽  
Better Than

Successful recanalization of the occluded vessel as early as possible has been widely accepted as the key principle of acute ischemic stroke (AIS) treatment. Unfortunately, for many years, the vast majority of AIS patients were prevented from receiving effective recanalization therapy because of a narrow therapeutic window. Recently, a series of inspiring clinical trials have indicated that more patients may benefit from delayed recanalization during an expanded therapeutic window, even up to 24 h after symptom onset. However, could potentially salvageable brain tissue (penumbra) in patients who do not receive medication within 24 h still possible to be saved?

Abstract P260: Mind the Time: A Quality Improvement Project to Increase the Percent of Ischemic Stroke Patients Receiving Intravenous Tissue Plasminogen Activator within 60 Minutes after Arrival at the Emergency Department

2011 ◽  
Vol 4 (suppl_2) ◽  
Author(s):  
Janine M Mazabob ◽  
Gerard Brown ◽  
Sarah Livesay ◽  
Sue Freeborg ◽  
Jose Suarez ◽  
...  
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Process Model ◽  
Early Recognition ◽  
Stroke Patients ◽  
Improvement Project ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen

Background and Purpose: Stroke is the third leading cause of death and leading cause of long term disability in the USA. Intravenous administration of tissue plasminogen activator (t-PA) is the only FDA approved medical therapy for treatment of patients with acute ischemic stroke. It is recommended by the American Heart Association that earlier treatment with t-PA within 90 minutes of symptoms may result in a more favorable patient outcome. Initiating t-PA for ischemic stroke patients within 60 minutes after Emergency Department (ED) triage is an indicator tracked by the Get With The Guidelines database. The purpose of our project was to increase the number of ischemic stroke patients receiving t-PA within 60 minutes after triage. Methods: The Six Sigma® process model was applied in order to develop an understanding of variations in the times of triage to initiation of IV t-PA data. We assembled a multidisciplinary team to develop and measure aspects of our current protocols, analyze data, investigate and identify the causes of delays and form action plans to enhance our new process. We tracked the patient flow from first responder contact to thrombolysis time. As a result the team acknowledged that it was imperative to impact the early recognition of ischemic stroke patients in the field. This led to local and regional stroke educational programs. Our neuroscience team of physicians and nurses proceeded to educate over 850 emergency responders. Results: Initial analysis of the baseline data showed that 56 % (5 of 9) of the ischemic stroke patients received intravenous t-PA within 60 minutes of triage. Once the stroke code process was implemented, 79 % (15 of 19) of ischemic stroke patients received intravenous t-PA within 60 minutes after triage. These results were obtained within 9 months of process implementation. Specific process changes included the use of a standard time clock, shorter CT scan turn around times, dedicated 24/7 ED pharmacists, quicker availability of medication administration pumps and ongoing feedback by all team members on the acute stroke process. Conclusions: The stroke team was able to identify barriers, institute process changes and ensure the implementation of change from the prehospital community setting to the acute inhospital care.

Abstract WP246: Acute Ischemic Stroke Patients With a Primary Language Other Than English Do Not Have Significantly Increased Door-to-Needle Times for Intravenous TPA

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Natalie T Cheng ◽  
Elizabeth A Cahill ◽  
Tomas Tesfasilassie ◽  
Molly M Burnett ◽  
Lara Zimmermann ◽  
...  
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Family Member ◽  
San Francisco ◽  
Primary Language ◽  
Stroke Patients ◽  
Discharge Disposition ◽  
Clinical Records ◽  
Iv Tpa

Background: Rapid administration of intravenous alteplase (IV tPA) leads to better outcomes, but language barriers have the potential to introduce delays and to hinder effective communication with patients and collateral historians during the acute evaluation. Hypothesis: Acute ischemic stroke patients with a non-English primary language will have significantly longer door-to-needle times for IV tPA. Methods: We abstracted information on primary language for all adults that received IV tPA for acute ischemic stroke in the emergency department of an academic referral center in San Francisco, CA, from February 2008 to May 2015. Approximately 38% of San Francisco residents speak a language other than English at home. Primary language was determined from the electronic medical record and was confirmed by reviewing specific documentation in subsequent speech therapy evaluations and admission notes. Age, sex, race, presenting NIHSS, aphasia as a presenting symptom, whether the patient was accompanied to the emergency department by a family member or caregiver, discharge disposition, and door-to-needle (DTN) administration time for IV tPA were abstracted from clinical records and quality improvement registries. Results: A total of 237 patients received IV tPA for acute ischemic stroke in the emergency department during the study period. Median age was 76 years (IQR 64-86), 53% were female, and median DTN time was 62 minutes (IQR 48-86). A total of 34% of patients had a primary language other than English (20% Cantonese, 6% Russian, 3% Spanish). These patients were more likely to be older (median age 80 vs. 73 years, p = 0.001), to be accompanied by a family member or caregiver (80% vs. 59%, p = 0.003), and to have a higher NIHSS (median 9 vs. 11, p = 0.03), but DTN times were similar among English and non-English primary language speakers (median 62 vs. 62, p=0.88) and short-term outcomes were not significantly different (in-hospital mortality 9% English primary language vs 14% non-English primary language, p=0.27; discharge to home 43% vs 32%, p=0.16) . Conclusions: At a center serving a multiethnic population, a patient’s primary language did not appear to predict DTN times for acute ischemic stroke.

Abstract WP378: Use of Code Head Bleed to Promote Hemorrhagic Stroke Awareness in the Emergency Department

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Candace J McAlpine ◽  
Rocio Garcia ◽  
Pablo Rojas
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Patient Care ◽  
Stroke Patient ◽  
Hemorrhagic Stroke ◽  
Stroke Patients ◽  
Care Coordinator ◽  
Staff Members ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background and Purpose: Providers recognize the need for quick recognition and allocation of resources when ischemic stroke patients arrive at the emergency department. Hemorrhagic stroke patients have not been always given the same priority. One Comprehensive Stroke Center noticed a deficiency in timely recognition, documentation and mobilization of resources for hemorrhagic stroke patients. The initiation of “code head bleed” in the emergency department was created to correct this deficiency. The purpose of this study was to bring awareness and education to the team initially caring for the hemorrhagic stroke patient. Methods: Using Lean methodology, to bring about quality patient care while reducing wasted time, the “code head bleed” was born. Education was provided for all emergency department staff members and physicians regarding “code head bleed.” When a code head bleed notification is paged out it mobilizes all required resources to the patient’s bedside (Faculty physician, Medical Resuscitation team, Patient Care Coordinator, Respiratory Therapy, Stroke Coordinators and Emergency Department leadership). Results: Since its inception in May, the “code head bleed” is the most used code notification in the hospital (n=163 ), surpassing ischemic stroke alerts (n= 89 ) in the same period. An increase of traumatic hemorrhages has been noticed since they are also included in the notification; which has led to an increased awareness in this population of patients as well. Code head bleed has improved neuro-check documentation by 21 % and documentation of vasoactive drip titration by 15% in the hemorrhagic stroke population. Conclusions: In conclusion, having all essential staff, services and resources lends to optimizing the hemorrhagic stroke patient’s care. The “code head bleed” initiative has been attributed to an increased awareness of the needs of the hemorrhagic stroke patient in the emergency department and an improvement in the documentation of care provided.

scholarly journals BLOOD VISCOSITY AS A DETERMINING FACTOR OF ISCHEMIC STROKE OUTCOMES EVALUATED WITH NIHSS AND MRS ON DAY 7 AND 30 POST-THROMBOLYSIS

2019 ◽  
pp. 73-79
Author(s):  
Al Rasyid ◽  
Salim Harris ◽  
Mohammad Kurniawan ◽  
Taufik Mesiano ◽  
Rakhmad Hidayat ◽  
...  
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Blood Viscosity ◽  
Neurologic Deficit ◽  
National Institutes Of Health ◽  
Modified Rankin Scale ◽  
Stroke Patients ◽  
Stroke Outcomes ◽  
Determining Factor

Objective: This study aimed to analyze blood viscosity as a determining factor of ischemic stroke outcomes evaluated with National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) on day 7 and 30 post-thrombolysis. Methods: This study was a 4-months cohort study taking place in Cipto Mangunkusumo General Hospital from January to April 2017. Subjects were collected at the Emergency Department or Neurology Outpatient Department. Eligible patients gave informed consent. Patients underwent numerous examinations, including blood viscosity test using digital microcapillary (DM) instrument. Outcomes of patients were identified on day 7 and day 30 post-thrombolysis using NIHSS and mRS, respectively. Results: Most acute ischemic stroke patients (88.6%) had blood hyperviscosity. 9.1% patients had poorer neurologic deficit on day 7 evaluated with NIHSS and 18.2% patients had poor outcome on day 30 evaluated with mRS. All patients with normal blood viscosity did not have a poorer neurologic deficit on day-7-evaluation. Conclusion: Blood viscosity determines the outcomes of acute ischemic stroke patients on day 7 and day 30 post-thrombolysis.

Sign in / Sign up

Export Citation Format

Share Document