Strengthening the stroke chain of survival in community emergency departments

Abstract

Strengthening the stroke chain of survival in community emergency departmentsIn this issue of JACEP Open, Zachrison et al 1 of the American College of Emergency Physicians Emergency Quality Network, an educational and quality improvement collaborative of emergency departments (EDs) across the United States, describe the diagnostic and treatment capabilities of community EDs for acute stroke. The study population in Zachrison et al primarily consisted of community EDs without a stroke center certification, and care processes varied widely at the study sites. Most, but not all, had reliable access to computed tomography (CT) imaging and real-time stroke specialist consultation, but only two-thirds of EDs surveyed had written protocols for the care of patients with acute stroke. Most were able to administer thrombolytics, and patients requiring endovascular therapy (EVT) were typically transferred, commonly to the first accepting comprehensive stroke center (CSC) or thrombectomy-capable stroke center (TSC) rather than through an established network of care. Although derived from a selfselected convenience sample, their data are an important contribution to a limited existing evidence base about community hospital ED stroke capabilities.Community hospital EDs are essential to providing high-quality acute stroke care for much of the US population, and their role in acute stroke care cannot be understated. 2,3 Particularly, when a community acute stroke ready hospital (ASRH) or primary stroke center (PSC) is the only hospital capable of facilitating a stroke diagnosis and subsequent thrombolysis in a given geographic area, ensuring efficient high-quality stroke care is of utmost importance. However, Zachrison et al identified important gaps in acute stroke care processes that exist in community hospital EDs. In addition, because survey participants were self-selected and likely highly motivated and engaged community hospital EDs, the reported data may actually represent a high-water mark of how community hospitals approach acute stroke care. Therefore, what does this study reveal about the opportunities to improve acute stroke care in community EDs?Particularly in geographic areas with limited access to stroke centers, the community ED can be conceptualized as the anchor of the larger community's stroke chain of survival. The stroke chain of survival conceptual model has helped frame systems of care improvements in EDs and recently in the prehospital setting to facilitate timely reperfusion. 4 To easily conceptualize the critical action steps that occur

Assessment of stroke knowledge and awareness among primary healthcare providers: A cross-sectional survey from the Kezhou quality improvement in acute stroke care project

“…Acute stroke care is an emergency that is conceptualized as a stroke survival chain occurring between stroke onset and appropriate disposition of the acute stroke patient receiving reperfusion therapy, and includes the eight steps of acute stroke recognition, diagnosis, and treatment ( 6 , 16 ). Delays in any step can lead to delays in overall treatment and may even make the patient ineligible for certain reperfusion therapies ( 16 ). Especially in geographic areas with limited stroke centers, PHPs can be reconceptualized as the backbone of the stroke survival chain in some low- and middle-income countries or regions ( 16 , 17 ).…”

“…Delays in any step can lead to delays in overall treatment and may even make the patient ineligible for certain reperfusion therapies ( 16 ). Especially in geographic areas with limited stroke centers, PHPs can be reconceptualized as the backbone of the stroke survival chain in some low- and middle-income countries or regions ( 16 , 17 ). In the present cross-sectional survey about assessment of stroke knowledge and awareness among PHPs from the KQI-ASC Project, we found that only 115 (39.7%) participants aware that the optimal time window for IVT in acute stroke is less than 4.5 h. Gender of PHPs, stroke management training received, and number of stroke management presentations given at local hospitals per year were the predictors of stroke knowledge and awareness among PHPs.…”

“…Khettar et al conducted a cross-sectional study by administering an electronic standardized self-assessment questionnaire to community pharmacists in the Rhône-Alpes region of France and showed that 104 participants presented moderate levels of stroke management knowledge ( 20 ). Thus, even in a high-functioning pre-hospital stroke care system, optimizing the assessment and treatment of stroke patients in primary healthcare practitioners is necessary to strengthen the entire stroke survivorship chain ( 16 ).…”

The burden of critical illness among adults in a Swedish region—a population-based point-prevalence study

“…The health system requirements need to be specified for these patients, as do the competencies of health workers to care for them, and the clinical systems and routines to prioritize [ 32 , 33 ] for them to be quickly identified as critically ill and promptly treated —even when resources are limited such as at 3 am on a Sunday night [ 34 ]. Re-designing health services to have an increased focus on critical illness, in the same way as the longstanding focus on diagnoses with high mortalities [ 35 – 37 ], would target the highest risk patients and—as they are common—could be favorable for quality improvement, research, and innovation. Improving care of severely ill patients would benefit patients suffering from any underlying condition and have the advantage of improving care for patients lacking a definitive diagnosis, those with multimorbidity and those who have been mis-diagnosed.…”

The burden of critical illness among adults in a Swedish region – a population-based point-prevalence study

“…The health system requirements need to be speci ed for these patients, as do the competencies of health workers to care for them, and the clinical systems and routines to prioritize [31,32] for them to be quickly identi ed as critically ill and promptly treated -even when resources are limited such as at 3am on a Sunday night [33]. Re-designing health services to have an increased focus on critical illness, in the same way as the longstanding focus on diagnoses with high mortalities [34][35][36], would target the highest risk patients and -as they are common -could be favorable for quality improvement, research, and innovation. Improving care of severely ill patients would bene t patients suffering from any underlying condition and have the advantage of improving care for patients lacking a de nitive diagnosis, those with multimorbidity and those who have been mis-diagnosed.…”