Abstract WP274: Improving Door to Ct Time by a Seven Item Stroke Screening Questionnaire for Patients Arriving to ER with Acute Stroke without Prior Notification

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Roni Eichel ◽  
Penina Ponger ◽  
Nechama Kaufmann ◽  
Natan M Bornstein
Keyword(s):  
Acute Stroke ◽  
Median Time ◽  
Screening Method ◽  
Triage Nurse ◽  
Stroke Patients ◽  
Early Screening ◽  
Time Intervals ◽  
Screening Questionnaire ◽  
Prior Notification ◽  
Suspected Stroke

Background: Arrival to the emergency room (ER) by ambulance services and prior notification have been identified as major factors for reducing Door to CT and Door to needle time with thrombolysis for patients with acute stroke. Unfortunately despite all efforts to increase the awareness of using ambulances, still 40-50% of patients arrive by private transportation without prior notification of the ER. Objective: We evaluated if a standardized seven item screening questionnaire, performed at the admission office of the ER, can reduce time to triage nurse evaluation and subsequently time of arrival to CT, for patients with acute stroke arriving to the ER without prenotification of the ER. Methods: Since April 2016 a standardized screening questionnaire was performed by the admission clerks at the ER arrival for any patient not referred by prior notification for stroke. This questionnaire included seven major stroke symptoms and time of onset of the symptoms. If one of these symptoms started less than 8 hours before the arrival to the ER the patient was urgently referred to the triage nurse which would then evaluate urgently and activate the a Stroke Code. Patient data was collected of all patients admitted to the ER with a suspected stroke between April-June 2015 and April-June 2016 and time intervals for Door to triage nurse and Door to CT were compared for patients admitted to the ER with suspected Stroke between the time period without questionnaire and with. Results: In the relevant time periods 143 stroke patients were admitted to our ER. Median time from arrival to triage nurse was 16 min (n=96) in 2016 compared to 28 min (n=47) in 2015 (p>0.0001). Patients arriving within 8 hours form symptom onset the median time for arrival to triage nurse was 15 min (n=49) and 28min (n=14) respectively (p=0.006). Median time from arrival to ER to CT brain was 29 min(n=18) for the group that was screened by an early seven point questionnaire at ER admission and stroke code activated versus 78 min(n=14)without early screening and stroke code activation(p=0.069). Conclusion: A standardized seven item stroke symptom questionnaire as an early ER admission screening method can reduce time intervals from arrival to CT for self-referral stroke patients without prior notification of the ER.

PP11 The use of prehospital 12-lead electrocardiograms in acute stroke patients

2019 ◽  
Vol 36 (1) ◽  
pp. e5.1-e5
Author(s):  
Scott Munro ◽  
Debbie Cooke ◽  
Mark Joy ◽  
Adam Smith ◽  
Kurtis Poole ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Acute Stroke ◽  
Secondary Analysis ◽  
Vital Role ◽  
Current Guideline ◽  
Hospital Data ◽  
Stroke Patients ◽  
Time Intervals ◽  
Suspected Stroke ◽  
Clinical Records

BackgroundEmergency medical services (EMS) play a vital role in the recognition, management and transportation of acute stroke patients. UK guidelines recommend clinicians consider performing a prehospital 12-lead electrocardiogram (PHECG) in patients with suspected stroke, but this recommendation is based on expert consensus, rather than robust evidence.The aim of this study was to investigate the association between PHECG and modified Rankin scale (mRS). Secondary outcomes included in-hospital mortality, EMS and in-hospital time intervals and rates of thrombolysis received.MethodsA multicentre retrospective cohort study was undertaken.The data collection period spanned from 29/12/2013–30/01/2017. Participants were identified through secondary analysis of hospital data routinely collected as part of the Sentinel Stroke National Audit Programme (SSNAP) and linked to EMS clinical records (PCRs) via EMS incident number.ResultsPHECG was performed in 558 (48%) of study patients. PHECG was associated with an increase in mRS (aOR 1.30, 95% CI 1.01 to 1.66, p=0.04) and in-hospital mortality (aOR 1.83, 95% CI 1.26–2.67, p=0.002). There was no association between PHECG and administration of thrombolysis (aOR 1.06, 95% CI 0.75–1.52, p=0.73).Patients who had a PHECG recorded spent longer under the care of EMS (median 49 vs 43 min, p=0.007). No difference in times to receiving brain scan (Median 28 with PHECG vs 29 min no PHECG, p=0.32) or median door-to-needle time (median 46 min vs 48 min, p=0.37) were observed.ConclusionThis is the first study of its kind to investigate the association between PHECG and functional outcome in stroke patients attended by EMS. Although there are limitations in regard to the retrospective study design, the findings challenge current guideline recommendations regarding PHECG in patients with acute stroke.

Abstract P850: Four C’s Are Vital in Improving Door to Thrombolytic Administration

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Betty A McGee ◽  
Melissa Stephenson
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Median Time ◽  
Survival Data ◽  
Stroke Patients ◽  
Eligibility Criteria ◽  
Before And After ◽  
Administration Time ◽  
System Data ◽  
The Impact

Background and Purpose: Thrombolytic therapy is a key link in the stroke chain of survival. Data suggests that four components are vital in decreasing door to thrombolytic administration in acute stroke patients eligible for treatment. Analysis of system data, pre and post implementation of a Door to Needle Project, afforded the opportunity to assess. Hypothesis: We assessed the hypothesis that commitment, collaboration, communication, and consistency (referred to as Four C’s) are vital in improving door to thrombolytic administration time in ischemic stroke patients. Methods: In this quantitative study, we utilized case data collected by a quality improvement team serving five emergency departments within a healthcare system. We retrospectively reviewed times of thrombolytic administration from admission to the emergency department in acute ischemic stroke patients. Cases were included based on eligibility criteria from American Heart Association’s Get With the Guidelines. Times from 2019 were compared with times through April 2020, before and after implementation of the project, which had multidisciplinary process interventions that reinforced the Four C’s. Results: The data revealed a 13.5 % reduction in median administration time. Cases assessed from 2019 had a median time of 52 minutes from door to thrombolytic administration, 95% CI [47.0, 59.0], n = 52. Cases assessed through April 2020 had a median time of 45 minutes from door to thrombolytic administration, 95% CI [39.0, 57.5], n = 18. Comparing cases through April 2020 to those of 2019, there were improvements of 38.1% fewer cases for administration in greater than 60 minutes and 27.8% fewer cases for administration in greater than 45 minutes. Conclusion: The hypothesis that Four C’s are vital in improving door to thrombolytic administration was validated by a decrease in median administration time as well as a reduction in cases exceeding targeted administration times. The impact to clinical outcomes is significant as improving administration time directly impacts the amount of tissue saved. Ongoing initiatives encompassing the Four C’s, within a Cerebrovascular System of Care, are essential in optimizing outcomes in acute stroke patients.

Ambulance service call handler and clinician identification of stroke in North East Ambulance Service

2021 ◽  
Vol 6 (2) ◽  
pp. 59-65
Author(s):  
Graham McClelland ◽  
Emma Burrow
Keyword(s):  
Acute Stroke ◽  
Early Recognition ◽  
Stroke Care ◽  
Service Evaluation ◽  
Ambulance Service ◽  
Stroke Patients ◽  
Face To Face ◽  
North East ◽  
Audit Data ◽  
Suspected Stroke

Introduction: Emergency medical services (EMS) are the first point of contact for most acute stroke patients. The EMS response is triggered by ambulance call handlers who triage calls and then an appropriate response is allocated. Early recognition of stroke is vital to minimise the call to hospital time as the availability and effectiveness of reperfusion therapies are time dependent. Minimising the pre-hospital phase by accurate call handler stroke identification, short EMS on-scene times and rapid access to specialist stroke care is vital. The aims of this study were to evaluate stroke identification by call handlers and clinicians in North East Ambulance Service (NEAS) and report on-scene times for suspected stroke patients.Methods: A retrospective service evaluation was conducted linking routinely collected data between 1 and 30 November 2019 from three sources: NEAS Emergency Operations Centre; NEAS clinicians; and hospital stroke diagnoses.Results: The datasets were linked resulting in 2214 individual cases. Call handler identification of acute stroke was 51.5% (95% CI 45.3‐57.8) sensitive with a positive predictive value (PPV) of 12.8% (95% CI 11.4‐14.4). Face-to-face clinician identification of stroke was 76.1% (95% CI 70.4‐81.1) sensitive with a PPV of 27.4% (95% CI 25.3‐29.7). The median on-scene time was 33 (IQR 25‐43) minutes, with call handler and clinician identification of stroke resulting in shorter times.Conclusion: This service evaluation using ambulance data linked with national audit data showed that the sensitivity of NEAS call handler and clinician identification of stroke are similar to figures published on other systems but the PPV of call handler and clinician identification stroke could be improved. However, sensitivity is paramount while timely identification of suspected stroke patients and rapid transport to definitive care are the primary functions of EMS. Call handler identification of stroke appears to affect the time that clinicians spend at scene with suspected stroke patients.

scholarly journals Delays in the Presentation of Stroke Patients to Hospital and Possible Ways of Improvement

2003 ◽  
Vol 10 (2) ◽  
pp. 76-80 ◽  
Author(s):  
Kk Lau ◽  
Km Yeung ◽  
Lh Chiu ◽  
B Sheng ◽  
Kw Choi ◽  
...  
Keyword(s):  
Phase I ◽  
Median Time ◽  
Phase Ii ◽  
Time Window ◽  
Time Lag ◽  
Stroke Onset ◽  
Phase Iii ◽  
Stroke Patients ◽  
Time Intervals ◽  
Therapeutic Time Window

Objective Stroke patients often came late to hospital and arrived beyond the therapeutic time window for thrombolytic therapy. We studied the time from stroke onset to arrival at Accident and Emergency (A&E) department and examined what barred them from early medical attendance. Methods All acute stroke patients attending A&E between 15 March 1999 to 14 June 1999 were recruited. For those brought in by ambulance, their time intervals were divided into three: phase I was between stroke onset to call 999; phase II was between call 999 to A&E arrival; and phase III was between A&E arrival to being seen by doctor. For those who did not come by ambulance, they were divided into two groups: those who consulted other doctors and those who did not consult other doctors before coming to A&E. Their time lags from stroke onset to A&E consultation were compared. Results One hundred and fifteen stroke patients were consecutively recruited. Sixty-five ambulance users had median time for phase I as 151 minutes, for phase II as 32 minutes, for phase III as 17 minutes. The total median time lag was 190 minutes. Fifty were ambulance non-users. For those who did not consult other doctors before A&E attendance, the median time lag was 641 minutes. For those who consulted others doctors before A&E attendance, their median time lag was 3,672 minutes. As a group their median time lag was 950 minutes. For the 65 ambulance users, we further studied the time intervals between A&E arrival and being seen by doctors; and the median waiting time for doctors was 17 (range 0 to 60) minutes. Conclusions Public education was of paramount importance. Some common stroke signs could be widely propagated for recognition. Phase I should be less than 80 minutes. The median time for phase II would likely remain to be 32 minutes. Further shortening could be achieved in phase III. As category III & IV patients were most likely potential candidates for thrombolysis, they should be seen within 15 minutes. This would leave only 53 minutes for clinical assessment, CT brain and preparation of thrombolytic agent. These measures could increase the chance of providing thrombolytic treatment within the therapeutic time window.

scholarly journals The Maryland Acute Stroke Emergency Medical Services Routing Pilot: Expediting Access to Thrombectomy for Stroke

2021 ◽  
Vol 12 ◽  
Author(s):  
Taylor Haight ◽  
Burton Tabaac ◽  
Kelly-Ann Patrice ◽  
Michael S. Phipps ◽  
Jaime Butler ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Emergency Medical Services ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Emergency Medical ◽  
Suspected Stroke

Background: Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke caused by large vessel occlusion, but is not available at all stroke centers. Transfers between hospitals lead to treatment delays. Transport directly to a facility capable of MT based on a prehospital stroke severity scale score has been recommended, if transportation time is less than 30 min.Aims: We hypothesized that an Emergency Medical Services (EMS) routing algorithm for stroke, using the Los Angeles Motor Scale (LAMS) in the field, would improve time from last known well to MT, without causing patients to miss the IV Thrombolysis (IVT) window.Methods: An EMS algorithm in the Baltimore metro area using the LAMS was implemented. Patients suspected of having an acute stroke were assessed by EMS using the LAMS. Patients scoring 4 or higher and within 20 h from last known well, were transported directly to a Thrombectomy Center, if transport could be completed within 30 min. The algorithm was evaluated retrospectively with prospectively collected data at the Thrombectomy Centers. The primary outcome variables were proportion of patients with suspected stroke rerouted by EMS, proportion of rerouted ischemic stroke patients receiving MT, time to treatment, and whether the IVT window was missed.Results: A total of 303 patients were rerouted out of 2459 suspected stroke patients over a period of 6 months. Of diverted patients, 47% had acute ischemic stroke. Of these, 48% received an acute stroke treatment: 16.8% IVT, 17.5% MT, and 14% MT+IVT. Thrombectomy occurred 119 min earlier in diverted patients compared to patients transferred from other hospitals (P = 0.006). 55.3% of diverted patients undergoing MT and 38.2% of patients transferred from hospital to hospital were independent at 90 days (modified Rankin score 0–2) (P = 0.148). No patient missed the time window for IVT due to the extra travel time.Conclusions: In this retrospective analysis of prospectively acquired data, implementation of a pre-hospital clinical screening score to detect patients with suspected acute ischemic stroke due to large vessel occlusion was feasible. Rerouting patients directly to a Thrombectomy Center, based on the EMS algorithm, led to a shorter time to thrombectomy.

scholarly journals The Preventive Effect of Dysphagia Screening on Pneumonia in Acute Stroke Patients: A Systematic Review and Meta-Analysis

Healthcare ◽  
2021 ◽  
Vol 9 (12) ◽  
pp. 1764
Author(s):  
Seoyon Yang ◽  
Yoo Jin Choo ◽  
Min Cheol Chang
Keyword(s):  
Acute Stroke ◽  
Meta Analysis ◽  
Cochrane Library ◽  
Inclusion Criteria ◽  
Preventive Effect ◽  
Stroke Patients ◽  
Early Screening ◽  
Funnel Plot ◽  
Significant Difference

(1) Background: Dysphagia is common in acute stroke patients and is a major risk factor for aspiration pneumonia. We investigated whether the early detection of dysphagia in stroke patients through screening could prevent the development of pneumonia and reduce mortality; (2) Methods: We searched the PubMed, Embase, Cochrane Library, and Scopus databases for relevant studies published up to November 2021. We included studies that performed dysphagia screening in acute stroke patients and evaluated whether it could prevent pneumonia and reduce mortality rates. The methodological quality of individual studies was evaluated using the Risk Of Bias In Non-randomized Studies of Interventions tool, and publication bias was evaluated by the funnel plot and Egger’s test; (3) Results: Of the 6593 identified studies, six studies met the inclusion criteria for analysis. The screening group had a significantly lower incidence of pneumonia than the nonscreening group did (odds ratio (OR), 0.60; 95% confidence interval (CI), 0.42 to 0.84; p = 0.003; I2, 66%). There was no significant difference in mortality rate between the two groups (OR, 0.61; 95% CI, 0.33 to 1.13; p = 0.11; I2, 93%); (4) Conclusions: Early screening for dysphagia in acute stroke patients can prevent the development of pneumonia.

scholarly journals A Parallel Thrombolysis Protocol with Nurse Practitioners As Coordinators Minimized Door-to-Needle Time for Acute Ischemic Stroke

2011 ◽  
Vol 2011 ◽  
pp. 1-8 ◽  
Author(s):  
Sheng-Feng Sung ◽  
Ying-Chieh Huang ◽  
Cheung-Ter Ong ◽  
Yu-Wei Chen
Keyword(s):  
Computed Tomography ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Median Time ◽  
Nurse Practitioners ◽  
Stroke Patients ◽  
Study Objective ◽  
Stroke Team ◽  
Computed Tomography Scanning ◽  
Tomography Scanning

Introduction. Quick thrombolysis after stroke improved clinical outcomes. The study objective was to shorten door-to-needle time for thrombolysis.Methods. After identifying the sources of in-hospital delays, we developed a protocol with a parallel algorithm and recruited nurse practitioners into the acute stroke team. We applied the new protocol on stroke patients from October 2009 to September 2010. Patients from the previous two years were used for comparison.Results. For ischemic stroke patients within 3 hours of onset, the median time from arrival to computed tomography scanning was reduced from 29 to 20 minutes () and the median time from arrival to neurology evaluation decreased from 61 to 43 minutes (). For those patients who received thrombolysis, the median door-to-needle time was shortened from 68.5 to 58 minutes ().Conclusions. The parallel thrombolysis protocol successfully improved the median door-to-needle time to below the guideline-recommended 60 minutes.

367: Out-of-Hospital Transport Time Intervals for Acute Stroke Patients

2008 ◽  
Vol 52 (4) ◽  
pp. S154
Author(s):  
P. Ramanujam ◽  
E. Castillo ◽  
E. Patel ◽  
G. Vilke ◽  
M. Wilson ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Stroke Patients ◽  
Time Intervals ◽  
Transport Time ◽  
Hospital Transport

scholarly journals Will Your Stroke Be Treated in Detroit?

Stroke ◽  
2001 ◽  
Vol 32 (suppl_1) ◽  
pp. 368-368
Author(s):  
Anne M Guyot ◽  
Alice Schuster ◽  
Sheila Daley ◽  
Carolyn Ottney-Schweiss ◽  
Susan Skolnik ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Stroke Patient ◽  
Ct Scanning ◽  
Average Response Time ◽  
Stroke Patients ◽  
Fda Approval ◽  
Detroit Area ◽  
Suspected Stroke ◽  
Structured Questionnaire ◽  
Made In

P162 Background: rt-PA is the only currently available FDA approved therapy for acute ischemic stroke. We sought to determine the type and frequency of challenges/barriers to offering this therapy 4 years after FDA approval. Methods: We performed a systematic survey in April, 2000 of all 34 hospitals in the Detoit Metropolitan area (population 3.9 million people) that have an acute care emergency facility. A standardized, structured questionnaire/interview was conducted with the directors of the emergency facilities. Questions included: volume of stroke, priority of care given, relationship with Emergency Medical Services (EMS), use of protocols, pathways, and NIH Stroke Scale,time to processes and personnel involved. Surveys were returned, data was tabulated and analyzed descriptively. Results: All 34(100%) of the hospitals responded and wished to participate. While EMS called the Emergency Department(ED) prior to their transport of a suspected stroke patient in 28 centers (82%)only 19 centers (68%) utilized this information to expedite the care of the stroke patient. Stroke patients are given top priority for CT scanning in only 22 centers (64%). The range of times from ED arrival to CT scan performance ranged from 5 minutes to one hour. CT technicians are available 24hrs/day in-house in 56%. In the 44% with on-call, out-of-the hospital CT technicians, time to their arrival ranges from 30–60 minutes. Only a radiologist reads the CT in 18 Hospital, ED physicians review the CT in 15 and only a neurologist in 1. Only 10 (30%) collected data on stroke patients in the ED. Once the patient is considered for treatment with rt-PA, the number of physicians involved in the process varied from 1 to 3. Most commonly involved were a neurologist (22 centers) and ED physicians(at nearly all the centers). Stroke teams were involved at only two hospitals. If more than one physician is involved the average response time is 27 minutes. An NIHSS is performed in 53% of the hospitals. Conclusions: While considerable progress has been made in many Detroit-area hospitals to deliver rt-PA therapy for acute stroke, several key process improvement areas have been identified that could increase the percentage of acute stroke patients treated with rt-PA.

Abstract WP279: Concordance of Paramedic and Hospital Documented Last Known Well Times for EMS Transported Acute Ischemic Stroke Patients

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Lucas Ramirez ◽  
Nichole Bosson ◽  
Marianne Gausche-Hill ◽  
Jeffery L Saver ◽  
Sid Starkman ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Patient Characteristics ◽  
Final Diagnosis ◽  
Multivariate Regression Analysis ◽  
Stroke Patients ◽  
Hospital Arrival ◽  
Median Difference ◽  
Suspected Stroke ◽  
Stroke Center

Background: Last known well time (LKWT) is increasingly used by EMS systems to identify acute stroke patients appropriate for direct routing to Stroke Centers. However, determining LKWT in the field is challenging, as patients may be aphasic, witnesses may not be available on scene, and rapid departure from the scene is desirable. Objective: To characterize the concordance and degree of discordance between prehospital-determined LKWT and final LKWT documented at the hospital. Methods: This is a retrospective analysis of consecutive patients with positive prehospital stroke screens transported to an approved stroke center in a large metropolitan system from January 2011 to December 2014. Data was abstracted from the regional EMS Agency stroke database. Patients with missing prehospital or hospital documentation of LKWT were excluded. The percent concordance and the median difference were calculated for prehospital versus final hospital documented LKWT. The effect of patient characteristics on discordance was also explored via multivariate regression analysis. Result: Among the 9,810 patients transported for suspected stroke, the median age was 75 (Interquartile range [IQR] 62-85) years, 53% were women, 67% White, 11% Asian, 9% Black and 27% Hispanic. The median NIHSS was 11 (IQR 4 to 20). 83% had a cerebrovascular final diagnosis, ischemic stroke (IS) being the most common (n=5160, 53%), whereas 17% had a non-stroke-related diagnosis. There were 6873 patients missing either prehospital or hospital documentation of LKWT leaving 9810 patients for the analysis. Prehospital and hospital documented LKWTs were exactly equal in 42% of patients (36% for IS), within 15 minutes in 53% (48% for IS), within 1 hour in 66% (63% in IS) and within 2 hours in 70% (68% in IS). The median difference in LKWT between documented prehospital and hospital values was 0 minutes (IQR -6 to 18). The degree of discordance in LKWT did not vary with patient sex, race, or Hispanic ethnicity. Conclusions: Paramedic-documented LKWT was within 15 minutes of the final hospital documented LKWT in just over half of acute stroke EMS transports and within 1 hour in two-thirds.. As accurate LKWT determination in the field is challenging, time of symptom onset should be confirmed after hospital arrival.

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