Emergency department arrival times after acute ischemic stroke during the 1990s.
ABSTRACT Only 8% of ischemic stroke (IS) patients are eligible for rt-PA, and the largest exclusion criterion is delayed time of presentation to the ED. We sought to investigate whether patients are arriving to the ED more quickly in 1999 than in 1993/94 within our large biracial population of 1.3 million.
Using ICD-9 codes 430-436, we ascertained all stroke events that presented to a local ED within our population in 7/93-6/94 and again in 1999. Times were recorded as documented in the medical record.
There were 1,792 IS patients that presented to an ED in 1993/94 and 1,973 in 1999. The percentage of patients with documented times arriving in under 3 h improved slightly in 1999 (26% vs. 23% in 93/94, P = 0.03), however, the percentage arriving in under 2 h did not. Blacks significantly improved in arrivals under 3 h: 26% in 1999 compared to 17% in 1993/94 (P = 0.01), while whites did not (26% vs. 25%, P = 0.29). In 1999, only 9% of patients arrived from 3-8 h after symptom onset, the large majority of times were either estimated, unknown, or >8 h.
We found only marginal improvement in arrival times during the 1990s. In our population, blacks improved in early arrival after symptom onset, while whites did not. Very few patients arrive 3-8 h after onset; therefore expansion of the acute treatment time window to 8 h is unlikely to dramatically affect acute treatment of ischemic stroke.
SourceAvailable from: Maarten M H Lahr[Show abstract] [Hide abstract]
ABSTRACT: Various studies demonstrate better patient outcome and higher thrombolysis rates achieved by centralized stroke care compared to decentralized care, i.e. community hospitals. It remains largely unclear how to improve thrombolysis rate in decentralized care. The aim of this simulation study was to assess the impact of previously identified success factors in a central model on thrombolysis rates and patient outcome when implemented for a decentral model. Based on a prospectively collected dataset of 1084 ischemic stroke patients, simulation was used to replicate current practice and estimate the effect of re-organizing decentralized stroke care to resemble a centralized model. Factors simulated included symptom onset call to help, emergency medical services transportation, and in-hospital diagnostic workup delays. Primary outcome was proportion of patients treated with thrombolysis; secondary endpoints were good functional outcome at 90 days, Onset-Treatment-Time (OTT), and OTT intervals, respectively. Combining all factors might increase thrombolysis rate by 7.9%, of which 6.6% ascribed to pre-hospital and 1.3% to in-hospital factors. Good functional outcome increased by 11.4%, 8.7% ascribed to pre-hospital and 2.7% to in-hospital factors. The OTT decreased 17 minutes, 7 minutes ascribed to pre-hospital and 10 minutes to in-hospital factors. An increase was observed in the proportion thrombolyzed within 1.5 hours; increasing by 14.1%, of which 5.6% ascribed to pre-hospital and 8.5% to in-hospital factors. Simulation technique may target opportunities for improving thrombolysis rates in acute stroke. Pre-hospital factors proved to be the most promising for improving thrombolysis rates in an implementation study.PLoS ONE 11/2013; 8(11):e79049. DOI:10.1371/journal.pone.0079049 · 3.53 Impact Factor
Article: Notfall Schlaganfall[Show abstract] [Hide abstract]
ABSTRACT: Zusammenfassung Der Schlaganfall ist die dritthäufigste Todesursache und die häufigste Ursache für eine bleibende Behinderung und Pflegeabhängigkeit in der westlichen Welt. Bisher ist lediglich die Thrombolysetherapie als Therapie des akuten ischämischen Schlaganfalls zugelassen. Ihre Anwendung ist jedoch beschränkt durch ein kurzes Anwendungszeitfenster von 3 h ab Symptombeginn und teilweise erhebliche Nebenwirkungen. Dabei steigt die Chance eines guten neurologischen Outcomes, je früher die Thrombolyse begonnen wird. Neben der Thrombolysetherapie sind die Einrichtung von Schlaganfallstationen (Stroke Units) und die Einführung der kontinuierlichen Monitorüberwachung der Schlaganfallpatienten, entscheidende Faktoren, die zu einer deutlich besseren Behandlung und einem besseren klinischen Outcome der Patienten führen. In der Akuttherapie des ischämischen Schlaganfalls sind neben der Dauer bis zum Beginn der Thrombolyse in der präklinischen Phase und in der Notfallambulanz strukturelle und organisatorische Maßnahmen zu treffen, um einen optimierten Behandlungsablauf zu ermöglichen.Notfall 05/2008; 11(3):166-172. DOI:10.1007/s10049-008-1041-9 · 0.32 Impact Factor
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ABSTRACT: Only a minor proportion of patients with acute ischemic stroke receive treatment with intravenous thrombolysis. The purpose of this study was to explore reasons for not giving thrombolysis and to determine if there was a correlation between prehospital and in-hospital delay in a Norwegian ischemic stroke population. Patients with acute ischemic stroke were included during a 1-year period. Time intervals for prehospital and in-hospital delay, reasons for not treating with thrombolytic therapy in patients admitted within the time window and reasons for late arrival were recorded. In all, 290 patients were included, and 7.6 % were treated with intravenous thrombolysis. The most frequent reasons for not treating eligible patients were: minor symptoms (22.8 %), clinical improvement (17.5 %) and uncertainty about the diagnosis (12.3 %). Patients' reasons for delayed admission were: not attributing their symptoms to stroke (25.4 %), a wait-and-see attitude (25.4 %), and choosing to wait for the GP's office to open (14.3 %). Prehospital delay was strongly correlated to in-hospital delay (p < 0.001). In conclusion, a large percentage of patients with AIS are not treated with thrombolysis because of mild or rapidly improving symptoms, and because patients arrive too late to the hospital. Absolute and relative contraindications account for a minor proportion of reasons for excluding patients.Neurological Sciences 07/2014; 35(12). DOI:10.1007/s10072-014-1876-4 · 1.50 Impact Factor