BACKGROUND: There is growing importance on discovering factors that delay time to intervention for acute ischemic stroke (AIS) patients, as rapid intervention is essential for better patient outcomes. The management of these patients involves a multidisciplinary effort and quality improvement initiatives to safely increase treatment with intravenous (IV) thrombolytic. The objective of this pilot study is to evaluate factors of acute stroke care in the emergency department (ED) and their impact on IV alteplase administration. METHODS: A sample of 89 AIS patients who received IV alteplase 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 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 (38.06) minutes, with 74.2% of patients arriving to the ED via emergency medical services and 25.8% having a stroke nurse present during IV alteplase administration. Mode of arrival (P = .001) and having a stroke nurse present (P = .022) are significant predictors of door-to-needle time in the ED. CONCLUSION: Although many factors can influence door-to-needle times in the ED, we did not find National Institutes of Health Stroke Scale score on arrival and time of day to be significant factors. Patients arriving to the ED by personal vehicle will have a significant delay in IV alteplase administration, therefore emphasizing the importance of using emergency medical services. Perhaps more importantly, collaborative efforts including the addition of a specialized stroke nurse significantly decreased time to IV alteplase 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 improving patient outcomes.
Introduction: Stroke is a medical emergency requiring timely intervention to optimize patient outcomes. Intravenous (IV) thrombolytics, the only treatment currently FDA-approved for acute stroke, require pertinent medical history for treatment decisions. Key details are often missed in the prehospital setting and during hand-off communication between Emergency Medical Services (EMS) and hospital staff, which can delay the time to treatment. We evaluated if utilization of a ‘stroke alert sticker’ by EMS to capture standardized information in the field would decrease time to thrombolytic administration. Methods: A bright orange sticker, to be placed directly on the patient, was disseminated to our local EMS agency for use with all stroke-alert patients. It includes key elements that are important to timely treatment decision, including time last known well, contact information, symptoms, and relevant medications. We evaluated the impact of use of this sticker on acute ischemic stroke treatment metrics, including IV thrombolytic “door to needle” (DTN) time. Results: The study included 220 stroke-alert patients brought to our Comprehensive Stroke Center by EMS from May 2021 through February 2022. Mean NIHSS on arrival was 11 (± 9); mean age was 67 (± 16) years; and 52 % were female. 21 patients were treated with an IV thrombolytic. Overall, sticker utilization rate was 40% in the stroke-alert population, but utilization was 60% in patients administered an IV thrombolytic. With sticker utilization, DTN time was reduced by 20 minutes (31 ± 11 min with sticker vs 51 ± 20 min without, p=0.03). In patients who received IV thrombolytics, pre-hospital notification was 100% with sticker use compared to 75% without (p=0.01). Conclusion: Utilization of the stroke-alert sticker significantly improved DTN times for acute ischemic stroke patients compared to patients without the sticker. This evidence supports continued use of the stroke alert stickers to improve DTN times and improve patient outcomes. Further research is ongoing in a larger patient cohort.
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.
Background: Strokes that occur during inpatient hospitalization require rapid identification and stroke-alert activation from hospital staff in heterogeneous settings, often resulting in overutilization of stroke team resources on stroke mimics. An understanding of the factors that impact accuracy of identification of inpatient strokes would assist in improving care in this population. Methods: This was a retrospective analysis from a single Joint-Commission certified Comprehensive Stroke Center. All patients for whom an inpatient stroke alert was called between 2/1/2019 - 4/30/2021 were included. Metrics captured in our local stroke-alert registry were analyzed, with comparisons made between patients who were determined to have a true stroke versus stroke mimic. Results: Of 705 inpatient alerts, mean patient age was 66 years, 50% were male, 62% occurred in the daytime, and mean NIHSS was 12. The majority of alerts were stroke mimics (76%); most common non-stroke diagnoses were encephalopathy, medical decompensation, and seizure. Among patients with true stroke, 86% were ischemic, with 13 patients receiving thrombolytics and 21 patients undergoing mechanical thrombectomy. One stroke mimic received thrombolytics. Although most alerts originated from medicine units (38%) and floor beds (49%), true stroke was most often diagnosed on cardiology (39%) and hematology/oncology (38%) units, and in the ICU or intermediate care setting (54%). Logistic regression adjusted for age and time of day showed true strokes were significantly associated with male sex, location (stratified by specialty), shorter time to CT completion, and higher initial NIHSS (p<0.05). Conclusions: A majority of inpatient alerts are stroke mimics, particularly on medicine floors. Stroke education could be tailored to staff to incorporate these findings to ensure that stroke patients are not missed, while stroke team resources are not overutilized on mimics.
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