A cute ischemic stroke caused by large intracranial arterial occlusion is associated with high morbidity and mortality.1 Arterial recanalization and tissue reperfusion, either by intravenous thrombolysis or endovascular therapy, are the most effective strategy in improving patient outcome. Intravenous tissue-type plasminogen activator (tPA) has proven to be effective in improving clinical outcomes in patients ≤4.5 hours of symptoms onset. 2,3 However, recanalization in the presence of proximal large-vessel occlusion is limited, estimated to be only 5% to 14% for internal carotid artery and 30% to 50% for M1 segment. [4][5][6][7] Endovascular stroke therapy (EST), including the use of mechanical thrombectomy and intra-arterial thrombolytic agents, has emerged as an option for patients who fail to recanalize with or ineligible for intravenous tPA. Although EST has shown effective recanalization rates and a relatively good safety profile, [8][9][10][11][12] most clinical trials have not shown that this strategy improves clinical outcomes. 7,13 This could be explained by either lack of effectiveness or alternatively, by suboptimal patient selection not sufficiently based on the viability of brain tissue.Several neuroimaging techniques, including MRI of the brain, MR perfusion, and computed tomography (CT) perfusion, have been studied to improve patient selection for acute EST by identifying a small core infarct with a large penumbral territory that can be salvaged with reperfusion therapy. [14][15][16] However, these neuroimaging techniques might significantly delay treatment and are not yet proven to improve clinical outcome. 17 Evidence is emerging about possible criteria for selection, such as Yoo et al 15 showing that patients with >70-mL diffusion weighted imaging (DWI) lesion volume in Background and Purpose-The failure of recent trials to show the effectiveness of acute endovascular stroke therapy (EST) may be because of inadequate patient selection. We implemented a protocol to perform pretreatment MRI on patients with large-vessel occlusion eligible for EST to aid in patient selection. In patients considered for EST, we hypothesize that addition of pretreatment MRI to determine the core infarct volume before intervention could improve patient selection. Furthermore, we want to ascertain whether any additional delay to initiation of EST resulted from incorporating the pretreatment MRI into our acute endovascular stroke treatment algorithm. Methods SubjectsUsing our acute stroke endovascular database, between January 2008 and August 2012, we retrospectively identified patients aged ≥18 years who presented to our emergency department or transferred from other hospitals with acute ischemic stroke ≤8 hours since last known well were considered for EST. All patients received acute stroke standard of care treatment, including intravenous tPA if eligible. The institutional review board approved this study.Baseline clinical characteristics and treatment parameters were systematically collected, including demograph...
Introduction After excluding anaesthetic gases, around one-third of carbon emissions from surgical procedures are from consumables. This sustainable quality improvement project revised the laparoscopic appendicectomy surgical set at a large teaching hospital, with the aim of reducing unnecessary usage of disposable laparoscopic ports and surgical instruments. Methods A prospective audit of 25 consecutive laparoscopic appendicectomies (5% of annual appendicectomies performed at the Trust) was conducted to assess use of disposable instruments. The financial and environmental costs of the five most commonly used disposable instruments were calculated and annual cost of current practice determined. A revised surgical set was created to include additional reusable instruments and new reusable ports. A reaudit of disposable surgical instrument usage was conducted and the financial and environmental impact of the new set compared with the results from the initial audit. Results A total of 109 disposable instruments were opened in 25 appendicectomies, costing an estimated £49,656 and 692kg CO2 equivalent (CO2e) annually. Following rollout of the revised appendicectomy set, there was a significant reduction in disposable instrument usage (median four versus one instruments per case, p<0.00001). The revised set is predicted to reduce annual disposable instrument usage from 2,180 to 705 instruments (68% reduction), saving £219,452 and 3.02 tonnes CO2e over the estimated seven-year lifecycle of the reusable instruments. Conclusions Updating a laparoscopic appendicectomy set to include additional/new reusable instruments can lead to a marked reduction in disposable surgical instrument usage. This results in significant projected financial and CO2e savings.
Introduction: In-hospital “stroke alerts” are typically activated when a patient’s neurological status acutely deteriorates. Acute inpatient strokes represent an excellent potential opportunity for definitive treatment, but over triaging causing false alarms was a challenge at our institution, especially in the cardiology/CT surgery units, where many stroke mimic patients were being seen. Our stroke nurse, stroke coordinator, and stroke team physicians designed and implemented a formal collaborative educational initiative to improve quality and timeliness of stroke pager calls. Hypothesis: Non- neurological nurses educated to recognize stroke signs and symptoms who activate the stroke team will identify at least as great a proportion of true stroke patients as physicians. Methods: We retrospectively analyzed prospectively collected inpatient stroke team calls on 93 inpatients over one year’s time. The person (physician versus nurse) calling the stroke alert was identified via shared electronic medical record review. We compared the proportion of patients (via chi-square analysis) who after formal chart review had a true diagnosis of stroke (versus mimic). Neurological floor and neuro-ICU patients were excluded. Results: Nurses initiated 59/93 stroke team calls (63%) during the study period. Overall, 59% (37/59) of nurse- activated calls were for patients whom ultimately were determined to have had a true stroke as compared to 63% of physician-activated calls (20/34); p=0.71; 60% of stroke alerts came from the cardiology/CT surgery nursing units, and the accuracy of nurses on these units was 67% as compared to 53% for other non- neurological nursing units. (p=.323). Nurses activated the stroke team faster (median 2 hours [25 th , 75 th %ile 0.5hr, 6 hrs]) than physicians (median 4.9hrs [25 th , 75 th %ile 1.3, 21.3 hrs]), p=.0096 {Wilcoxon Rank Sum}. Conclusions: Non- neurological nurses educated on stroke recognition and stroke team activation are as accurate at identifying inpatient acute stroke patients as physicians, and do so more than twice as fast on average as physicians. Intensive, focused, collaborative education of nursing staff in high-risk for inpatient stroke units, who typically more frequently assess patients than physicians, may via rapid and accurate identification improve inpatient stroke outcomes.
Background: In evaluating the acute ischemic stroke (AIS) patient, targeting time intervals for imaging and treatment times are paramount in optimizing outcomes. Initial evaluation by skilled providers who can facilitate the extension of a tertiary care facility can positively influence patient outcomes. A collaborative approach with a hospital based Critical Care Transport (CCT) Team can extend primary stroke program care out to a referring facility’s bedside. In the Cleveland Clinic Health System, the suspicion of a large vessel occlusion causing AIS in patients at an outside hospital triggers an “Auto Launch” process, bypassing typical transfer processes to expedite care transitions for patients with time sensitive emergencies. Referring facilities contact a CCT Coordinator, with immediate launching of the transport team that consists of an Acute Care Nurse Practitioner (ACNP) who evaluates the patient at outside facility, performs NIHSS and transitions the patient directly to CT/MRI upon return to Cleveland Clinic facility. Patient is met by the Stroke Neurology Team at CT scanner for definitive care. A CCT Team with an ACNP on board can augment not only door to CT and MRI times, but also time to evaluation by a stroke neurologist and time to intervention, bypassing the Emergency Department upon their arrival and proceeding directly to studies and/or time sensitive intervention as appropriate. Objective: To describe a stroke program with a coordinated approach with a CCT Team to facilitate rapid care transitions as well as decreased time to imaging in patients with AIS by having an ACNP on board during transport and throughout the continuum of care. Methods: A retrospective audit of a database of patients undergoing hyperacute evaluation of acute ischemic stroke symptoms from April 30, 2010 to July 31, 2011 was performed. Demographic information, types of imaging performed, hyperacute therapies administered and time intervals to imaging modalities and treatment were collected and analyzed. Results: 107 patients total, 28 males, and 36 females with a mean age of 70 were included in the analysis. 60% [64] of patients transferred via the CCT Team over 26.42 average nautical miles. The mean time of call to arrival was 1 hr and 19 min. The CCT Team monitored tPA infusion in 27 patients and initiated tPA infusion in 2 patients. 64 patients had CT imaging performed and 64 had MRI performed following the CT. [The average door to CT completion was 22 min, the average door to MRI completion was 1 hr and 29 min, compared to 1 hr and 8 min and 2 hr and 36 min, respectively, in patients not arriving by CCT Team], p<0.05. Conclusion: Collaboration between the Stroke Neurology Team and CCT Team has allowed acute ischemic stroke patients to be taken directly to CT/MRI scanner, allowing for rapid evaluation, definitive treatment decisions, and the potential for improved patient outcomes by decreasing the door to imaging time.
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