Factors influencing pre-hospital delay among acute ischemic stroke patients in the midlands of China
Huajie YangJuan ZhangJun XieYang ChenXiaoxin DongYanhong GongShiyi CaoXiaoxv YinZhihong WangZuxun Lu
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Acute stroke
Moral hazard
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Background: Whether patients with acute stroke and large vessel occlusion (LVO) may benefit from prehospital identification and diversion by EMS to a center offering endovascular therapy (EST) is controversial. The accuracy of prehospital scales as predictors of LVO is only one feature of whether EMS can effectively identify patients suitable for EST. Other factors include accuracy of last known well time (LTKW) and identification of stroke mimics. We performed a population-based estimate of potential accuracy of field based identification of potential EST candidates in a large community setting. Methods: In Kaiser Permanente Northern California, all acute stroke patients arriving at its 19 primary stroke centers (PSC) between 7am and 12am were evaluated on arrival by stroke neurologists by video. We reviewed the teleneurology notes to determine the potential accuracy of EST selection based on NIHSS score > 7. Results: For 2016, there were 2546 total potential stroke alerts triaged by EMS as having potential acute strokes [Figure]. Of these, 1268 (50%) were not candidates for acute stroke treatment for various reasons including stroke mimics and inaccurate LTKW. Out of 1241 cases deemed candidates for acute stroke treatment, 638 (25.1%) had potential LVO based on NIHSS > 7. Of these, 116 (4.6% of total “potential strokes” and 18.2% of patients who had “severe” strokes) were diagnosed with LVO and treated with EST. Conclusions: Even if field based tools were as accurate as clinical scoring by stroke neurologists, less than 1 in 4 patients diverted to endovascular stroke centers and away from closer PSC would benefit by receiving EST. Given that 50% of patients triaged by EMS did not qualify for any acute stroke treatment, a lower percentage of patients would actually benefit from field based diversion. Stroke systems may be better served by focusing on rapid treatment, evaluation, and transfer to endovascular centers than field based diversion strategies.
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Background: Recent studies have focused on improving prehospital stroke assessment tools, but specificity and sensitivity have been insufficient to reliably detect stroke in the prehospital setting. To assess the ability of emergency medical services (EMS) personnel to identify acute stroke in the field, we compared EMS stroke recognition with receiving medical center discharge diagnosis from a large community-based stroke dataset, the San Diego County Stroke Registry. The registry was founded in 2010 after San Diego County established 16 diverse stroke receiving centers. EMS uses the Cincinnati Prehospital Stroke Scale for screening. Methods: We captured all EMS transports in San Diego County from 2013 to 2015. Accuracy of stroke detection by the EMS providers was analyzed by: a) coding of stroke related provider impression (PI) by EMS; b) “stroke” recorded as the reason the transport destination was selected. All patients with diagnosis stroke on hospital discharge were considered confirmed stroke, and separated by: Acute Ischemic Stroke (AIS), Subarachnoid Hemorrhage (SAH), Transient Ischemic Attack (TIA) or Intracranial Hemorrhage (ICH). Results: Between 2013 and 2015, we identified 577,643 EMS transports, 7,425 (1.3%) were diagnosed as stroke by the treating facility (68.2% AIS, 14.4% TIA, 13.6% ICH, and 3.9% SAH). a) Of these 7,418 (99.9%) had a coded PI. Stroke related PI was positive in 53.8% (AIS: 55.9%; SAH: 18.1%; TIA: 60.5%; ICH 46.4%). b) A recorded reason for destination was found in 6,813 (91.8%) of all stroke patients. Stroke was the coded reason in 16.4% (AIS 16.4%; SAH 8.0%, TIA 18.0%, ICH 17.3%). Conclusion: In a large community EMS system, using routine stroke screening, 53.8% of all stroke patients were identified by EMS. Stroke was the coded reason for the selected destination in only 16.4% of EMS transported stroke cases. This emphasizes the need for better prehospital stroke detection to improve triage and direct patient care.
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Introduction: Both the American Heart and American Stroke Associations recommend pre-notification of potential stroke patients to receiving facilities. Although Emergency Medical Services (EMS) may identify stroke symptoms in the field, initiation of the stroke code process is often postponed until after the patient arrives in the Emergency Department (ED). This could lead to unnecessary delays in assessment and intervention during an acute stroke. Hypothesis: We hypothesized that initiating a stroke code based on advanced notification of stroke symptoms via EMS and a Stroke Code Pit Stop (SCPS) would lead to decreased time of assessment, diagnosticssitics and IV tPA initiation. Methods: A pre- and post-intervention study of 733 patients presenting to 2 EDs in a 5 campus hospital system. Both EDs initiated a SCPS, with pre-notification of stroke symptoms via EMS and stroke code activation prior to patient arrival. Data were reviewed from January 2013-April 2014, comparing code stroke metrics pre- and post...
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Background and PurposezzThere is little information available about the effects of Emergency Medical Service (EMS) hospital notification on transfer and intrahospital processing times in cases of acute ischemic stroke.MethodszzThis study retrospectively investigated the real transfer and imaging processing times for cases of suspected acute stroke (AS) with EMS notification of a requirement for intravenous (IV) tissue-type plasminogen activator (t-PA) and for cases without notification.Also we compared the intra-hospital processing times for receiving t-PA between patients with and without EMS prehospital notification.ResultszzBetween December 2008 and August 2009, the EMS transported 102 patients with suspected AS to our stroke center.During the same period, 33 patients received IV t-PA without prehospital notification from the EMS.The mean real transfer time after the EMS call was 56.0±32.0min.Patients with a transfer distance of more than 40 km could not be transported to our center within 60 min.Among the 102 patients, 55 were transferred via the EMS to our emergency room for IV t-PA.The positive predictive value for stroke (90.9% vs. 68.1%,p=0.005) was much higher and the real transfer time was much faster in patients with an EMS t-PA call (47.7±23.1 min, p=0.004) than in those without one (56.3±32.4min).The door-to-imaging time (17.8±11.0min vs. 26.9±11.5 min, p=0.01) and door-to-needle time (29.7±9.6 min vs. 42.1±18.1 min, p=0.01) were significantly shorter in the 18 patients for whom there was prehospital notification and who ultimately received t-PA than in those for whom there was no prehospital notification.ConclusionszzOur results indicate that prehospital notification could enable the rapid dispatch of AS patients needing IV t-PA to a stroke centre.In addition, it could reduce intrahospital delays, particularly, imaging processing times.
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Polyembolokoilamania in the Emergency Department Polyembolokoilamania is a rare but serious medical condition that involves the presence of multiple foreign bodies in the patient's body [1]. This condition can be challenging to diagnose and manage in the emergency department. In this chapter, we will discuss the presentation, diagnosis, and management of polyembolokoilamania in the emergency department.
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The prehospital phase is a critical component of delivering high-quality acute stroke care. This topical review discusses the current state of prehospital acute stroke screening and transport, as well as new and emerging advances in prehospital diagnosis and treatment of acute stroke. Topics include prehospital stroke screening, stroke severity screening, emerging technologies to aid in the identification and diagnosis of acute stroke in the prehospital setting, prenotification of receiving emergency departments, decision support for destination determination, and the capabilities and opportunities for prehospital stroke treatment in mobile stroke units. Further evidence-based guideline development and implementation of new technologies are critical for ongoing improvements in prehospital stroke care.
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Stroke is the third leading cause of death in Minnesota. One strategy to reduce the burden of stroke is to implement systems-level improvements in the prehospital and acute care settings. Two surveys conducted in 2006 obtained information about current practices and capacities of emergency medical services and emergency departments in Minnesota.In 2006, the Minnesota Department of Health and the Minnesota Stroke Partnership (the statewide stroke collaborative group) conducted two surveys. The survey for emergency medical services organizations, mailed to every licensed ambulance service in Minnesota, asked about transportation policies and training needs. The survey for hospitals, mailed to every hospital in the state, asked about capacity to treat acute stroke. Results were calculated using simple frequency analyses.Of 257 surveys mailed to ambulance services, 199 (77%) were returned. Ambulance services generally considered stroke an emergency. Training on stroke was reported most effective in person annually or semiannually. Of 133 surveys mailed to hospitals, 120 (90%) were returned. Stroke capacity differed markedly between hospitals in rural areas and hospitals in the large Minneapolis-St. Paul metropolitan area. Many hospitals, particularly small hospitals, reported lacking stroke protocols. Training for stroke is needed overall but particularly in small hospitals.Transport and treatment of people with acute stroke in Minnesota vary by hospital size and location. Standardization of transport and protocols for acute treatment may increase efficiency and overall care for stroke patients. In addition, the need to train ambulance personnel and emergency departments about stroke remains high.
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