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stroke triage is a public policy intervention that can have an immediate impact on acute stroke care in a region.OBJECTIVE To evaluate the impact that a citywide policy recommending prehospital triage of patients with suspected stroke to the nearest primary stroke center had on intravenous tissue plasminogen activator (tPA) use in Chicago, Illinois.

Background and Purpose-We evaluated the impact that duration as a primary stroke center (PSC) had on tissue-type plasminogen activator (tPA) utilization for acute ischemic stroke. Methods-A retrospective analysis of the Illinois Hospital Association CompData was performed identifying those patients with primary discharge diagnosis of acute ischemic stroke based on International Classification of Diseases version 9 codes. We assessed utilization of tPA by International Classification of Diseases version 9 procedure code (99.10). We categorized patients as cared for at non-PSC, PSC Ͼ1 year before, Յ1 year before, Յ1 year after, and Ͼ1 year after certification. We used generalized estimating equations to calculate adjusted odds ratios for tPA utilization by PSC category. Results-Among 119 539 acute ischemic stroke patients (mean age, 72 years; 55.2% women), tPA use was 1.9% but increased by PSC category (PϽ0.001): (1) non-PSC 0.9%; (2) Ͼ1 year before PSC certification 1.4%; (3) Յ1 year before certification 3.2%; (4) Յ1 year after certification 4.3%; and (5) Ͼ1 year after certification 6.5%. Adjusting for age, insurance status, admission source, year of study, region of Illinois, and hospital bed size, the odds of tPA utilization increased with advancing stage of PSC certification (highest category: adjusted odds ratio, 2.37; 95% confidence interval, 1.52-3.71). Conclusions-Although increasing over time, stroke thrombolysis is strongly impacted by the PSC certification process.Rather than waning or stagnating, tPA utilization increases at PSC from the earliest phases of preparation through certification and subsequent maintenance. (Stroke. 2012;43:875-877.)

Background-Reduction in door-to-needle (DTN) times in patients with acute ischemic stroke treated with tissue-type plasminogen activator is associated with improved outcomes. We hypothesized that a learning collaborative would rapidly reduce DTN times at Chicago's primary stroke centers. Methods and Results-We analyzed data from all adult patients with out-of-hospital ischemic stroke hospitalized between January 1, 2010 and March 31, 2015 and who received tissue-type plasminogen activator in the emergency department at 15 primary stroke centers in Chicago and 15 primary stroke centers in St. Louis. We implemented a structured learning collaborative in Chicago in quarter 1 of 2013 that included (1) a quality improvement leader, (2) stroke content expert, (3) multidisciplinary teams from each site, (4) a targeted goal for the program (DTN time <60 minutes in >50% of patients treated with tissue-type plasminogen activator), and (5) face-to-face meetings with on-site visits. We used interrupted time-series analysis to compare the impact of the learning collaborative on DTN times in Chicago pre-and post implementation and also concurrently versus St. Louis. We prespecified adjustment for mode of arrival, emergency medical services prenotification, and onset-to-arrival times. P values less than 0.05 were considered significant. In adjusted analysis, the reduction in DTN time within 1 quarter of implementation was 15. MethodsThere are nearly 3 million residents in Chicago (45% white, 33% black, and 29% Hispanic; http://www.census.gov/; accessed July 15, 2015). The Chicago Fire Department is the sole public emergency medical services (EMS) provider for the emergent transportation of patients with stroke. In 2009, Illinois passed a law permitting regional preferential transportation of suspected stroke patients to the nearest PSC. Chicago implemented a stroke triage policy in March 2011. We previously published on the impact of this policy on tPA treatment rates at Chicago PSCs. 20During the study period, 15 PSCs within city limits received suspected stroke patients by EMS ( Figure I in the Data Supplement). All centers use the (GWTG-S) Get With The Guidelines-Stroke registry for quality improvement and aggregate regional data reporting and analysis. Each hospital expressed agreement with the AHA/ASA to share data and report results in aggregate form. We required the following data to be entered in the GWTG-S database for analysis: demographics (age, sex, race, and ethnicity), medical history (hypertension, diabetes mellitus, prior stroke, hyperlipidemia, and atrial fibrillation/flutter), mode of hospital arrival, EMS prenotification, times of symptom onset, CT imaging completed, and thrombolytic administration, initial stroke severity using the NIHSS (National Institutes of Health Stroke Scale), complications of thrombolytic therapy, and discharge outcomes. All data were entered by local site coordinators without central adjudication, interpretation, or review. All participating institutions were required to comply wit...

Among tPA-eligible patients with AIS in Chicago, over 7% refused tPA. Refusal was more common in black patients and accounted for the apparent lower rates of tPA use in black vs nonblack patients. Further research is needed to understand barriers to consent and overcome race-ethnic disparities in tPA treatment for AIS.

Study Design Controlled laboratory study. Background The activity of the rotator cuff muscles has not previously been measured with indwelling electromyography (EMG) comparing ambulation and other movements. Knowledge of the relative contribution of these muscles during various tasks may help to guide rehabilitation progression. Objective To measure activity of the rotator cuff muscles and other shoulder muscles during normal ambulation, shirt and sling donning and doffing, and rehabilitation tasks commonly performed after rotator cuff surgery. Methods In 28 volunteers (15 men, 13 women; mean age, 32.2 years), indwelling EMG activity was measured in the supraspinatus, infraspinatus, teres minor, and subscapularis muscles during various tasks; and surface EMG activity was measured in the middle deltoid, biceps, and upper trapezius muscles. Results Using median EMG activity, in general, donning and doffing a shirt or sling recruited the rotator cuff muscles more than the other 7 tasks tested. Self-ranging motion using pulleys, especially in the scapular plane, was also consistently associated with greater recruitment of the shoulder muscles. Pendulum exercises, passive range of motion by a physical therapist, and self-ranging motion with a dowel recruited the shoulder muscles to a lesser extent. Conclusion Our results demonstrate that rehabilitation tasks such as pendulum exercises, passive range of motion by a physical therapist, and self-ranging motion with a dowel show low EMG activity, whereas pulleys in the sagittal plane and scapular plane show greater activity. Scapular plane activity was consistently higher than sagittal plane activity. Of all the tasks assessed, ambulation without a sling and donning and doffing a sling and a shirt consistently showed the highest activity. J Orthop Sports Phys Ther 2016;46(5):375-383. Epub 6 Apr 2016. doi:10.2519/jospt.2016.6090.

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The research, clinical practice and development needs of urology nurses in the UK are poorly understood. Through a postal questionnaire all current members of the British Association of Urological Nurses (BAUN) were surveyed to obtain baseline data related to their views on research, clinical practice and development needs. Fifty‐one per cent of BAUN members (n = 292) responded. The results of the survey produced a mixed picture of issues in British urological nursing. While the majority of respondents had considerable experience and enthusiasm for their specialty, a number of issues were identified that have implications for the development and delivery of clinical practice in the future. A plethora of different titles used by nurses was uncovered, raising questions on the dual issues of public identity and protection, and the lack of nationally recognized education programmes leading to recognition of nursing practice at an advanced level. Urology nurse specialists were identified as having considerable input into the design and delivery of services in contrast to non‐specialists who suggested that their input was not valued to the same degree. Difficulties were identified in relation to not only the availability of education but also in the areas of employer release and funding to support ongoing clinical development. The findings of the survey have great significance for the development of British urological nursing. The results offer an opportunity to understand urological nursing needs within a political context, offering an opportunity to explore changes that may be required to address areas of need in research, clinical practice and development. The study also offers a view of UK‐ based practices and issues to an international community for comparison and contrast.