Intravenous thrombolysis for ischaemic stroke: Short delays and high community-based treatment rates after organisational changes in a previously inexperienced centre
ABSTRACT To evaluate hospital delays in thrombolytic treatment before and after organisational changes and community-based treatment rates in a previously inexperienced centre.
The delays before and after organisational changes made in 2006 were compared using a prospective treatment database. In a 6-month period in 2007, a community-based search was performed for all hospitalisations for ischaemic stroke. The number of patients admitted within the 0-3 h time window and the proportion treated with tissue plasminogen activator were analysed.
The number of treatments increased fourfold from 2005 to 2007 with a significant reduction in mean door-to-needle time from 60 min to 38 min (p = 0.002). In the community-based series, 14/137 patients (10%) hospitalised with ischaemic stroke and 13/32 patients (41%) admitted in the 0-3 h window were treated.
An inexperienced stroke centre can rapidly implement the necessary logistics to deliver thrombolysis to a large proportion of patients with acute stroke with short hospital delays. Important factors are probably prenotification of a team and the initiation of thrombolytic treatment in the emergency room.
Conference Paper: Providing multiclass QoS in shared ATM output multiplexer[Show abstract] [Hide abstract]
ABSTRACT: This paper proposes a mechanism for the provision of multiple classes of QoS (quality of service) in an ATM output multiplexer shared by multiple QoS classes of cell stream. First, we propose a multi-step cell class acceptance controller which controls the acceptance of the source classes based nonlinearly on the state of the queue. After that, we present a queueing analysis using the discrete time finite capacity G/D/1/B queue model and derive some important QoS measures. Finally, we discuss the implications of the work via numerical experimentsGlobal Telecommunications Conference, 1996. GLOBECOM '96. 'Communications: The Key to Global Prosperity; 12/1996
- [Show abstract] [Hide abstract]
ABSTRACT: Despite the proven benefits of thrombolysis for patients presenting with acute ischemic stroke, only a limited number of patients receive thrombolytic therapy. The reason for the low treatment rate is that thrombolysis is only effective a few hours after the onset of ischemic stroke, so delays in patients being admitted to hospital and being diagnosed mean that the therapeutic window is often missed. Major factors that lead to prehospital delay include the general public's lack of knowledge of stroke symptoms and their poor understanding of the appropriate course of action following a stroke. Indeed, the patients who arrive early in hospital tend to be those who recognize the symptoms of stroke and take them seriously. Deficiencies in the identification of stroke by emergency medical services and general practitioners also contribute to prehospital delay. Aggressive, combined educational programs aimed at the general public, general practitioners, and medical and paramedical hospital staff can lead to increased stroke treatment rates. In this Review, we explore the extent of prehospital delay in stroke, identify the factors that affect the time taken for patients to reach hospital, and describe strategies designed to reduce the delay.Nature Reviews Neurology 09/2009; 5(9):477-83. DOI:10.1038/nrneurol.2009.116 · 14.10 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: The benefit of intravenous thrombolytic therapy in acute brain ischemia is strongly time dependent. The Get With the Guidelines-Stroke database was analyzed to characterize ischemic stroke patients arriving at hospital Emergency Departments within 60 minutes of the last known well time from April 1, 2003, to December 30, 2007. During the 4.75-year study period, among 253 148 ischemic stroke patients arriving directly by ambulance or private vehicle at 905 hospital Emergency Departments, 106 924 (42.2%) had documented, exact last known well times. Onset to door time was <or=60 minutes in 30 220 (28.3%), 61 to 180 minutes in 33 858 (31.7%), and >180 minutes in 42 846 (40.1%). Features most strongly distinguishing the patients arriving at <or=60, 61 to 180, and >180 minutes were greater stroke severity (median National Institutes of Health Stroke Scale score, 8.0 vs 6.0 vs 4.0, P<0.0001) and more frequent arrival by ambulance (79.0%. vs 72.2% vs 55.0%, P<0.0001). Compared with patients arriving at 61 to 180 minute, "golden hour" patients received intravenous thrombolytic therapy more frequently (27.1% vs 12.9%; odds ratio=2.51; 95% CI, 2.41-2.61; P<0.0001), but door-to-needle time was longer (mean, 90.6 vs 76.7 minutes, P<0.0001). A door-to-needle time of <or=60 minutes was achieved in 18.3% of golden hour patients. At Get With the Guidelines-Stroke hospital Emergency Departments, more than one quarter of patients with documented onset time and at least one eighth of all ischemic stroke patients arrived within 1 hour of onset, where they received thrombolytic therapy more frequently but more slowly than late arrivers. These findings support public health initiates to increase early presentation and shorten door-to-needle times in patients arriving within the golden hour.Stroke 07/2010; 41(7):1431-9. DOI:10.1161/STROKEAHA.110.583815 · 6.02 Impact Factor