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Martin-Gill C, Brown KM, Cash RE, Haupt RM, Potts BT, Richards CT, Patterson PD. 2022 Systematic Review of Evidence-Based Guidelines for Prehospital Care. PREHOSP EMERG CARE 2023; 27:131-143. [PMID: 36369826 DOI: 10.1080/10903127.2022.2143603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Multiple national organizations and federal agencies have promoted the development, implementation, and evaluation of evidence-based guidelines (EBGs) for prehospital care. Previous efforts have identified opportunities to improve the quality of prehospital guidelines and highlighted the value of high-quality EBGs to inform initial certification and continued competency activities for EMS personnel. OBJECTIVES We aimed to perform a systematic review of prehospital guidelines published from January 2018 to April 2021, evaluate guideline quality, and identify top-scoring guidelines to facilitate dissemination and educational activities for EMS personnel. METHODS We searched the literature in Ovid Medline and EMBASE from January 2018 to April 2021, excluding guidelines identified in a prior systematic review. Publications were retained if they were relevant to prehospital care, based on organized reviews of the literature, and focused on providing recommendations for clinical care or operations. Included guidelines were appraised to identify if they met the National Academy of Medicine (NAM) criteria for high-quality guidelines and scored across the six domains of the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. RESULTS We identified 75 guidelines addressing a variety of clinical and operational aspects of EMS medicine. About half (n = 39, 52%) addressed time/life-critical conditions and 33 (44%) contained recommendations relevant to non-clinical/operational topics. Fewer than half (n = 35, 47%) were based on systematic reviews of the literature. Nearly one-third (n = 24, 32%) met all NAM criteria for clinical practice guidelines. Only 27 (38%) guidelines scored an average of >75% across AGREE II domains, with content relevant to guideline implementation most commonly missing. CONCLUSIONS This interval systematic review of prehospital EBGs identified many new guidelines relevant to prehospital care; more than all guidelines reported in a prior systematic review. Our review reveals important gaps in the quality of guideline development and the content in their publications, evidenced by the low proportion of guidelines meeting NAM criteria and the scores across AGREE II domains. Efforts to increase guideline dissemination, implementation, and related education may be best focused around the highest quality guidelines identified in this review.
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Affiliation(s)
- Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kathleen M Brown
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rachel M Haupt
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Benjamin T Potts
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - P Daniel Patterson
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Velilla-Alonso G, García-Pastor A, Rodríguez-López Á, Gómez-Roldós A, Sánchez-Soblechero A, Amaya-Pascasio L, Díaz-Otero F, Fernández-Bullido Y, Iglesias-Mohedano AM, Vázquez-Alén P, Vales-Montero M, Gil-Núñez AC. Acute Stroke Care during the COVID-19 Pandemic: Reduction in the Number of Admissions of Elderly Patients and Increase in Prehospital Delays. Cerebrovasc Dis 2021; 50:310-316. [PMID: 33730715 PMCID: PMC8089401 DOI: 10.1159/000514140] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 12/22/2020] [Indexed: 01/10/2023] Open
Abstract
Introduction We analyzed whether the coronavirus disease 2019 (COVID-19) crisis affected acute stroke care in our center during the first 2 months of lockdown in Spain. Methods This is a single-center, retrospective study. We collected demographic, clinical, and radiological data; time course; and treatment of patients meeting the stroke unit admission criteria from March 14 to May 14, 2020 (COVID-19 period group). Data were compared with the same period in 2019 (pre-COVID-19 period group). Results 195 patients were analyzed; 83 in the COVID-19 period group, resulting in a 26% decline of acute strokes and transient ischemic attacks (TIAs) admitted to our center compared with the previous year (p = 0.038). Ten patients (12%) tested positive for PCR SARS-CoV-2. The proportion of patients aged 65 years and over was lower in the COVID-19 period group (53 vs. 68.8%, p = 0.025). During the pandemic period, analyzed patients were more frequently smokers (27.7 vs. 10.7%, p = 0.002) and had less frequently history of prior stroke (13.3 vs. 25%, p = 0.043) or atrial fibrillation (9.6 vs. 25%, p = 0.006). ASPECTS score was lower (9 [7–10] vs. 10 [8–10], p = 0.032), NIHSS score was slightly higher (5 [2–14] vs. 4 [2–8], p = 0.122), onset-to-door time was higher (304 [93–760] vs. 197 [91.25–645] min, p = 0.104), and a lower proportion arrived within 4.5 h from onset of symptoms (43.4 vs. 58%, p = 0.043) during the COVID-19 period. There were no differences between proportion of patients receiving recanalization treatment (intravenous thrombolysis and/or mechanical thrombectomy) and in-hospital delays. Conclusion We observed a reduction in the number of acute strokes and TIAs admitted during the COVID-19 period. This drop affected especially elderly patients, and despite a delay in their arrival to the emergency department, the proportion of patients treated with recanalization therapies was preserved.
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Affiliation(s)
- Gabriel Velilla-Alonso
- Department of Neurology, Hospital General Universitario Gregorio Marañón, Madrid, Spain,
| | - Andrés García-Pastor
- Department of Neurology, Vascular Neurology Section - Stroke Center, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Ana Gómez-Roldós
- Department of Neurology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Laura Amaya-Pascasio
- Department of Neurology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Fernando Díaz-Otero
- Department of Neurology, Vascular Neurology Section - Stroke Center, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Yolanda Fernández-Bullido
- Department of Neurology, Vascular Neurology Section - Stroke Center, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ana María Iglesias-Mohedano
- Department of Neurology, Vascular Neurology Section - Stroke Center, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Pilar Vázquez-Alén
- Department of Neurology, Vascular Neurology Section - Stroke Center, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marta Vales-Montero
- Department of Neurology, Vascular Neurology Section - Stroke Center, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Antonio-Carmelo Gil-Núñez
- Department of Neurology, Vascular Neurology Section - Stroke Center, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Abstract
PURPOSE OF REVIEW The coronavirus disease 2019 (COVID-19) pandemic has caused a major impact on stroke care. This review synthesizes the available data and provides a framework for optimal management of stroke patients with confirmed or suspected COVID-19 infection and eligible to reperfusion treatments. RECENT FINDINGS Reorganization of health services has led to the conversion of stroke units and relocation of stroke staff to COVID units. During the pandemic surge, there has been a general decline of stroke presentations, increased time delays, and reduced activity across all areas of stroke care, specifically the delivery of acute treatment. Moreover, COVID-19 patients seem to have a worse outcome despite prompt recanalization. Periprocedural monitoring studies are needed in these patients to target a more adequate therapy. SUMMARY The COVID-19 pandemic has jeopardized the ability of stroke centers to provide timely assessment and acute therapies such as reperfusive treatments. Yet, as stroke remains a medical emergency, efforts to maintain stroke teams and safe provision of highly effective stroke treatments should be prioritized despite healthcare systems reorganization. This can be accomplished through the activation of telestroke networks, protected stroke pathways, 24/7 open-access high-quality stroke centers, and stroke awareness programs.
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Affiliation(s)
- Claudio Baracchini
- Stroke Unit and Neurosonology Laboratory, Department of Neuroscience, Padua University Hospital, Padua, Italy
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Ramírez-Moreno JM, Portilla-Cuenca JC, Hariramani-Ramchandani R, Rebollo B, Bermejo Casado I, Macías-Sedas P, Ceberino D, Roa-Montero AM, González-Plata A, Casado I, Fernández de Alarcón L. Slump in Hospital Admissions for Stroke, a Fact of an Uncertain Nature That Requires Explanation. Brain Sci 2021; 11:brainsci11010092. [PMID: 33450843 PMCID: PMC7828369 DOI: 10.3390/brainsci11010092] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/07/2021] [Accepted: 01/11/2021] [Indexed: 01/17/2023] Open
Abstract
(1) Background: The impact of the health crisis caused by coronavirus disease 2019 (COVID-19) has provoked collateral effects in the attention to pathologies with time-dependent treatments such as strokes. We compare the healthcare activity of two stroke units in the same periods of 2019 and 2020, with an emphasis on what happened during the state of alarm (SA). (2) Materials and methods. Hospitals in the region implemented contingency plans to contain the pandemic; in this planning, the stroke units were not limited in their operational capacity. The SA was declared on 15 March and remained in place for 10 weeks. For the analysis, the data were grouped by consecutive calendar weeks. (3) Results. When the SA was declared the number of calls to the emergency telephone went from 1225 to 3908 calls per week (318% increase). However, the activation of the stroke code went from 6.6 to 5.0 (p = 0.04) and the activity in both stroke units decreased. The largest drop in hospitalizations was for transient ischemic attacks (TIAs) with 35.7% less, 28 vs. 18, (p = 0.05). Reperfusion therapies fell by 37.5%; Poisson regression model 0.64; (95% confidence interval (CI), 0.43–0.95). The overall activity of the telestroke suffered a reduction of 28.9%. We also observed an increase in hospital mortality. (4) Conclusion. The excessive duration of the pandemic precludes any hope of resolving this public health crisis in the short or medium term. Further studies should be conducted to better understand the multifactorial nature of this dramatic decline in stroke admissions and its negative impact.
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Affiliation(s)
- José M. Ramírez-Moreno
- Department of Neurology, University Hospital of Badajoz, 06080 Badajoz, Spain; (R.H.-R.); (B.R.); (P.M.-S.); (D.C.); (A.M.R.-M.); (A.G.-P.)
- Department of Biomedical Sciences, Extremadura University, 06080 Badajoz, Spain
- Multidisciplinary Research Group of Extremadura (GRIMEX), 06700 Villanueva de la Serena, Spain
- University Institute of Biosanitary Research of Extremadura (INUBE), 06080 Badajoz, Spain;
- Correspondence:
| | | | - Roshan Hariramani-Ramchandani
- Department of Neurology, University Hospital of Badajoz, 06080 Badajoz, Spain; (R.H.-R.); (B.R.); (P.M.-S.); (D.C.); (A.M.R.-M.); (A.G.-P.)
| | - Belen Rebollo
- Department of Neurology, University Hospital of Badajoz, 06080 Badajoz, Spain; (R.H.-R.); (B.R.); (P.M.-S.); (D.C.); (A.M.R.-M.); (A.G.-P.)
| | - Inés Bermejo Casado
- Department of Neurology, University Hospital of Cáceres, 10003 Cáceres, Spain; (J.C.P.-C.); (I.B.C.)
| | - Pablo Macías-Sedas
- Department of Neurology, University Hospital of Badajoz, 06080 Badajoz, Spain; (R.H.-R.); (B.R.); (P.M.-S.); (D.C.); (A.M.R.-M.); (A.G.-P.)
| | - David Ceberino
- Department of Neurology, University Hospital of Badajoz, 06080 Badajoz, Spain; (R.H.-R.); (B.R.); (P.M.-S.); (D.C.); (A.M.R.-M.); (A.G.-P.)
| | - Ana M. Roa-Montero
- Department of Neurology, University Hospital of Badajoz, 06080 Badajoz, Spain; (R.H.-R.); (B.R.); (P.M.-S.); (D.C.); (A.M.R.-M.); (A.G.-P.)
| | - Alberto González-Plata
- Department of Neurology, University Hospital of Badajoz, 06080 Badajoz, Spain; (R.H.-R.); (B.R.); (P.M.-S.); (D.C.); (A.M.R.-M.); (A.G.-P.)
| | - Ignacio Casado
- University Institute of Biosanitary Research of Extremadura (INUBE), 06080 Badajoz, Spain;
- Department of Neurology, University Hospital of Cáceres, 10003 Cáceres, Spain; (J.C.P.-C.); (I.B.C.)
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Venketasubramanian N. Stroke Care Services in Singapore During COVID-19 Pandemic-A National Perspective. Front Neurol 2020; 11:780. [PMID: 32849231 PMCID: PMC7399214 DOI: 10.3389/fneur.2020.00780] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 06/25/2020] [Indexed: 12/25/2022] Open
Abstract
Stroke is a significant cause of admission to Singapore's acute care hospitals. Because of the current COVID-19 pandemic, there have been major changes in the stroke care system. On calling for the public ambulance, those suspected to have COVID-19 infection are taken to the National Center for Infectious Diseases. Otherwise, on arrival at the emergency room, all cases with fever or respiratory symptoms [COVID-19 suspect patients (CSPs)] are evaluated separately by staff wearing full personal protective equipment (PPE). Triage is not delayed. CSPs needing hyperacute therapies are sent to a specially prepared scanner; if not, imaging is deferred to the latter part of the day. CSPs are managed in isolation rooms, and sent to the acute stroke unit (ASU) if two consecutive COVID-19 swabs are negative. Investigation and rehabilitation are done within the room. ASU rounds are attended by essential members, communication by electronic means. Multidisciplinary team rounds have largely ceased, and discussions are via electronic platforms. Patient transfer and staff movement are minimized. All hospital staff wear face-masks, infection control is strictly enforced. Visitors are not allowed; staff make daily calls to update families. Mild stroke patients may be sent home with rehabilitation advice. Out-patient rehabilitation centers are closed. Patients return for out-patient visits only if needed; medications are sent to their home, and nurses make essential home visits. Stroke support and rehabilitation activities have started on-line. Continuing medical education activities are mainly by webinars. Stroke research has been severely hampered. Overall, evidence-based stroke care is delivered in a re-organized manner, with a clear eye on infection control.
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