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Brunser AM, Nuñez JC, Mansilla E, Cavada G, Olavarría V, Muñoz Venturelli P, Lavados PM. Who is in the emergency room matters when we talk about door-to-needle time: a single-center experience. ARQUIVOS DE NEURO-PSIQUIATRIA 2023. [PMID: 37402398 PMCID: PMC10371412 DOI: 10.1055/s-0043-1768672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
BACKGROUND The efficacy of intravenous thrombolysis (IVT) is time-dependent. OBJECTIVE To compare the door-to-needle (DTN) time of stroke neurologists (SNs) versus non-stroke neurologists (NSNs) and emergency room physicians (EPs). Additionally, we aimed to determine elements associated with DTN ≤ 20 minutes. METHODS Prospective study of patients with IVT treated at Clínica Alemana between June 2016 and September 2021. RESULTS A total of 301 patients underwent treatment for IVT. The mean DTN time was 43.3 ± 23.6 minutes. One hundred seventy-three (57.4%) patients were evaluated by SNs, 122 (40.5%) by NSNs, and 6 (2.1%) by EPs. The mean DTN times were 40.8 ± 23, 46 ± 24.7, and 58 ± 22.5 minutes, respectively. Door-to-needle time ≤ 20 minutes occurred more frequently when patients were treated by SNs compared to NSNs and EPs: 15%, 4%, and 0%, respectively (odds ratio [OR]: 4.3, 95% confidence interval [95%CI]: 1.66-11.5, p = 0.004). In univariate analysis DTN time ≤ 20 minutes was associated with treatment by a SN (p = 0.002), coronavirus disease 2019 pandemic period (p = 0.21), time to emergency room (ER) (p = 0.21), presence of diabetes (p = 0.142), hypercholesterolemia (p = 0.007), atrial fibrillation (p < 0.09), score on the National Institutes of Health Stroke Scale (NIHSS) (p = 0.001), lower systolic (p = 0.143) and diastolic (p = 0.21) blood pressures, the Alberta Stroke Program Early CT Score (ASPECTS; p = 0.09), vessel occlusion (p = 0.05), use of tenecteplase (p = 0.18), thrombectomy (p = 0.13), and years of experience of the physician (p < 0.001). After multivariate analysis, being treated by a SN (OR: 3.95; 95%CI: 1.44-10.8; p = 0.007), NIHSS (OR: 1.07; 95%CI: 1.02-1.12; p < 0.002) and lower systolic blood pressure (OR: 0.98; 95%CI: 0.96-0.99; p < 0.003) remained significant. CONCLUSION Treatment by a SN resulted in a higher probability of treating the patient in a DTN time within 20 minutes.
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Affiliation(s)
- Alejandro M Brunser
- Clínica Alemana Universidad del Desarrollo, Facultad de Medicina, Departamento de Neurología y Psiquiatría Santiago, Servicio de Neurología, Unidad de Neurología, Santiago, Chile
| | - Juan-Cristobal Nuñez
- Clínica Alemana Universidad del Desarrollo, Facultad de Medicina, Departamento de Emergencias Generales, Santiago, Chile
| | - Eloy Mansilla
- Clínica Alemana Universidad del Desarrollo, Facultad de Medicina, Departamento de Neurología y Psiquiatría Santiago, Servicio de Neurología, Unidad de Neurología, Santiago, Chile
| | - Gabriel Cavada
- Clínica Alemana Universidad del Desarrollo, Facultad de Medicina, Departamento de Cuidados Críticos, Santiago, Chile
| | - Verónica Olavarría
- Clínica Alemana Universidad del Desarrollo, Facultad de Medicina, Departamento de Neurología y Psiquiatría Santiago, Servicio de Neurología, Unidad de Neurología, Santiago, Chile
- Clínica Alemana Universidad del Desarrollo, Facultad de Medicina, Departamento de Cuidados Críticos, Santiago, Chile
| | - Paula Muñoz Venturelli
- Clínica Alemana Universidad del Desarrollo, Facultad de Medicina, Departamento de Neurología y Psiquiatría Santiago, Servicio de Neurología, Unidad de Neurología, Santiago, Chile
- Clínica Alemana Universidad del Desarrollo, Facultad de Medicina, Instituto de Ciencias e Innovación en Medicina, Centro de Estudios Clínicos, Santiago, Chile
- University of New South Wales, Faculty of Medicine, The George Institute for Global Health, Sydney, Australia
| | - Pablo M Lavados
- Clínica Alemana Universidad del Desarrollo, Facultad de Medicina, Departamento de Neurología y Psiquiatría Santiago, Servicio de Neurología, Unidad de Neurología, Santiago, Chile
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Muacevic A, Adler JR. Knowledge and Attitude of Sudanese Emergency Registrars Towards the Use of Tissue Plasminogen Activator in the Management of Acute Ischemic Stroke. Cureus 2022; 14:e29908. [PMID: 36381832 PMCID: PMC9635934 DOI: 10.7759/cureus.29908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Recent guidelines report that the administration of tissue plasminogen activator (tPA) within 4.5 hours enhances the clinical outcome of ischemic stroke. We assessed the knowledge and attitude of Sudanese emergency medicine registrars towards the use of tissue plasminogen activators in the management of acute ischemic stroke (AIS). METHODS This is a descriptive, cross-sectional, hospital-based study. The study was conducted in emergency departments at Khartoum State Hospitals in Sudan during the period from May to July 2021. The study sample was 150 emergency medicine registrars who fulfilled the inclusion criteria of the study. Data was collected by using a self-administered questionnaire as a Google form that was sent to the study participants by email. RESULTS Knowledge about tPA in the management of AIS at the emergency department was poor, average, and good in 54 (36%), 55 (36.7%), and 41 (27.3%) individuals, respectively. However, there was no significant difference in overall knowledge based on age; nevertheless, good and average knowledge levels were considerably higher among females, level 3 and level 4 of training, and years of experience 5-10 years (p-value = 0.05). The overall attitude of the participants was positive 62 (41.3%), neutral 45 (30%), and negative 43 (28.7%). The positive attitude regarding tPAs for patients with AIS was significantly associated with age 30-40 years, females, levels 3 and 4 of training, and experience 5-10 years (p-value < 0.05). CONCLUSION The overall knowledge and attitude of emergency medicine registrars were average to good, with a significant proportion of participants reporting low knowledge. The issues encountered by participants in the use of tPAs were the absence of a stroke team in hospitals, the absence of a protocol for the care pathway of AIS management in hospitals, and the absence of tPAs.
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Leite KFDS, dos Santos SR, Andrade RLDP, de Faria MGBF, Saita NM, Arcêncio RA, Isaac ISDS, de Rezende CEM, Villa TCS, Pontes Neto OM, Monroe AA. Reducing care time after implementing protocols for acute ischemic stroke: a systematic review. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:725-740. [PMID: 36254446 PMCID: PMC9685828 DOI: 10.1055/s-0042-1755194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Abstract
Background The treatment of acute ischemic stroke with cerebral reperfusion therapy requires rapid care and recognition of symptoms.
Objective To analyze the effectiveness of implementing protocols for acute ischemic stroke in reducing care time.
Methods Systematic review, which was performed with primary studies in Portuguese, English, and Spanish published between 2011 and 2020. Inclusion criteria: study population should comprise people with acute ischemic stroke and studies should present results on the effectiveness of using urgent care protocols in reducing care time. The bibliographic search was conducted in June 2020 in the LILACS, MEDLINE, Embase, Scopus, CINAHL, Academic Search Premier, and SocINDEX databases. The articles were selected, and data were extracted by two independent reviewers; the synthesis of the results was performed narratively. The methodological quality of articles was evaluated through specific instruments proposed by the Joanna Briggs Institute.
Results A total of 11,226 publications were found, of which 35 were included in the study. Only one study reported improvement in the symptoms-onset-to-door time after protocol implementation. The effectiveness of the therapeutic approach protocols for ischemic stroke was identified in improving door-to-image, image-to-needle, door-to-needle and symptoms-onset-to-needle times. The main limitation found in the articles concerned the lack of clarity in relation to the study population.
Conclusions Several advances have been identified in in-hospital care with protocol implementation; however, it is necessary to improve the recognition time of stroke symptoms among those who have the first contact with the person affected by the stroke and among the professionals involved with the prehospital care.
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Affiliation(s)
- Karina Fonseca de Souza Leite
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Samuel Ribeiro dos Santos
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Rubia Laine de Paula Andrade
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Mariana Gaspar Botelho Funari de Faria
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Nanci Michele Saita
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Ricardo Alexandre Arcêncio
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Igor Simões da Silva Isaac
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Carlos Eduardo Menezes de Rezende
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
- Ministério da Saúde, Agência Nacional de Saúde Suplementar, Brasília DF, Brazil
| | - Tereza Cristina Scatena Villa
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Octavio Marques Pontes Neto
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil
| | - Aline Aparecida Monroe
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
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Status of physician education in emergency medicine in four European countries: no primary specialty yet. Eur J Emerg Med 2021; 28:257-259. [PMID: 34187990 DOI: 10.1097/mej.0000000000000837] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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El-khatib MES, El Ahwal SA, Masoud M, El Mously S. Knowledge of the Egyptian emergency physicians about the use of rt-PA in acute ischemic stroke. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2020. [DOI: 10.1186/s41983-020-00194-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The administration of recombinant tissue plasminogen activator (rt-PA) has increased the focus on acute ischemic stroke (AIS) as an emergency condition. The emergency physicians have to rapidly recognize the patients who are candidates for rt-PA and refer them to the specialized stroke team within the proper time window. The knowledge of the emergency physicians about the benefit and the drawbacks of this therapy is crucial and it affects their attitudes towards its use.
Objective
To apply a survey on the Egyptian emergency physicians aiming to investigate their knowledge about the use rt-PA therapy in AIS.
Methodology
A self-administered questionnaire was sent to the emergency physicians who are working in three Egyptian governorates.
Results
Out of 120 emergency physicians, the total knowledge of the study group was good with a score of 7 ± 1.8/11. Most of the participants mentioned the correct answers (over 50%) for all items except for one question regarding the blood glucose control before the use of rt-PA. Significant positive correlation was noted between the knowledge score and the age.
Conclusions
The surveyed emergency physicians had a good knowledge about the use of rt-PA in AIS, yet, this knowledge is mainly theoretical. Therefore, tutorials, clinical training, and active engagement in the stroke care team are warranted to improve their clinical practice.
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Hasnain MG, Attia JR, Akter S, Rahman T, Hall A, Hubbard IJ, Levi CR, Paul CL. Effectiveness of interventions to improve rates of intravenous thrombolysis using behaviour change wheel functions: a systematic review and meta-analysis. Implement Sci 2020; 15:98. [PMID: 33148294 PMCID: PMC7641813 DOI: 10.1186/s13012-020-01054-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 10/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite being one of the few evidence-based treatments for acute ischemic stroke, intravenous thrombolysis has low implementation rates-mainly due to a narrow therapeutic window and the health system changes required to deliver it within the recommended time. This systematic review and meta-analyses explores the differential effectiveness of intervention strategies aimed at improving the rates of intravenous thrombolysis based on the number and type of behaviour change wheel functions employed. METHOD The following databases were searched: MEDLINE, EMBASE, PsycINFO, CINAHL and SCOPUS. Multiple authors independently completed study selection and extraction of data. The review included studies that investigated the effects of intervention strategies aimed at improving the rates of intravenous thrombolysis and/or onset-to-needle, onset-to-door and door-to-needle time for thrombolysis in patients with acute ischemic stroke. Interventions were coded according to the behaviour change wheel nomenclature. Study quality was assessed using the QualSyst scoring system for quantitative research methodologies. Random effects meta-analyses were used to examine effectiveness of interventions based on the behaviour change wheel model in improving rates of thrombolysis, while meta-regression was used to examine the association between the number of behaviour change wheel intervention strategies and intervention effectiveness. RESULTS Results from 77 studies were included. Five behaviour change wheel interventions, 'Education', 'Persuasion', 'Training', 'Environmental restructuring' and 'Enablement', were found to be employed among the included studies. Effects were similar across all intervention approaches regardless of type or number of behaviour change wheel-based strategies employed. High heterogeneity (I2 > 75%) was observed for all the pooled analyses. Publication bias was also identified. CONCLUSION There was no evidence for preferring one type of behaviour change intervention strategy, nor for including multiple strategies in improving thrombolysis rates. However, the study results should be interpreted with caution, as they display high heterogeneity and publication bias.
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Affiliation(s)
- Md Golam Hasnain
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
| | - John R. Attia
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
- John Hunter Hospital, New Lambton Heights, New South Wales Australia
| | - Shahinoor Akter
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Department of Anthropology, Jagannath University, Dhaka, Bangladesh
| | - Tabassum Rahman
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Centre for Development, Economics and Sustainability, Monash University, Melbourne, Victoria Australia
| | - Alix Hall
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
| | - Isobel J. Hubbard
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
| | - Christopher R. Levi
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, New South Wales Australia
| | - Christine L. Paul
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
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Ojakäär A, Purdy M, Kechagias A, Järvelin U, Palomäki A. Immediate effects of urgent reorganisation of emergency department-based treatment pathway in nonperforated appendicitis: a retrospective study. BMC Emerg Med 2020; 20:45. [PMID: 32471363 PMCID: PMC7257164 DOI: 10.1186/s12873-020-00339-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 05/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute appendicitis is a global disease and a very common indication for emergency surgery worldwide. The need for hospital resources is therefore constantly high. The administration in Kanta-Häme Central Hospital, Southern Finland, called for an urgent reorganisation due to shortage of hospital beds at the department of general surgery. Postoperative treatment pathway of patients with nonperforated acute appendicitis was ordered to take place in the Emergency Department (ED). The aim of this study was to assess, whether this reorganisation was feasible and safe, i.e. did it affect the length of in-hospital stay (LOS) and the 30-day complication rate. METHODS This is a retrospective pre- and post-intervention analysis. After the reorganisation, most patients with nonperforated appendicitis were followed postoperatively at the 24-h observation unit of the ED instead of surgical ward. Patients operated during the first 3 months after the reorganisation were compared to those operated during the 3 months before it. A case met inclusion criteria if there were no signs of appendiceal perforation during surgery. Exclusion criteria comprised age < 18 years and perforated disease. RESULTS Appendicectomy was performed on 112 patients, of whom 62 were adults with nonperforated appendicitis. Twenty-seven of the included patients were treated before the reorganisation, and 35 after it. Twenty of the latter were followed only at the ED. Postoperative LOS decreased significantly after the reorganisation. Median postoperative time till discharge was 15.7 h for all patients after the reorganisation compared to 24.4 h before the reorganisation (standard error 6.2 h, 95% confidence interval 2.3-15.2 h, p < 0.01). There were no more complications in the group treated postoperatively in the ED. CONCLUSIONS Early discharge of patients with nonperforated appendicitis after enforced urgent reorganisation of the treatment pathway in the ED observation unit is safe and feasible. Shifting the postoperative monitoring and the discharge policy of such patients to the ED - instead of the surgical ward - occurred in the majority of the cases after the reorganisation. This change may spare resources as in our series it resulted in a significantly shorter LOS without any increase in the 30-day complication rate.
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Affiliation(s)
- Artur Ojakäär
- Department of Surgery, Kanta-Häme Central Hospital, Ahvenistontie 20, FI-13530, Hämeenlinna, Finland.
| | - Martin Purdy
- Department of Surgery, Kanta-Häme Central Hospital, Ahvenistontie 20, FI-13530, Hämeenlinna, Finland.,Department of Emergency Medicine, Kanta-Häme Central Hospital, Ahvenistontie 20, FI-13530, Hämeenlinna, Finland
| | - Aristotelis Kechagias
- Department of Surgery, Kanta-Häme Central Hospital, Ahvenistontie 20, FI-13530, Hämeenlinna, Finland.,Department of Surgery, Rea Hospital, Siggrou Avenue 383, 175 64 P. Faliro, Athens, Greece
| | - Ulla Järvelin
- Department of Emergency Medicine Acuta, Tampere University Hospital, Teiskontie 35, FI-33520, Tampere, Finland
| | - Ari Palomäki
- Department of Emergency Medicine, Kanta-Häme Central Hospital, Ahvenistontie 20, FI-13530, Hämeenlinna, Finland.,Faculty of Medicine and Health Technology, Tampere University, Kauppi Campus, Arvo Ylpön katu 34, FI-33520, Tampere, Finland
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Liu CH, Hsiao CT, Chang TY, Chang YJ, Kuo SH, Chang CW, Chen CJ, Chen CF, Cheng PL, Chin SC, Chiu TF, Hsu JL, Hsu PW, Lee TH, Liao CH, Lin CJ, Lin LH, Seak CJ, Sung PS, Yang TC, Wu YM. Brain computerized tomography reading in suspected acute ischemic stroke patients: what are essentials for medical students? BMC MEDICAL EDUCATION 2019; 19:359. [PMID: 31533703 PMCID: PMC6749686 DOI: 10.1186/s12909-019-1781-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 08/30/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Few systematic methods prioritize the image education in medical students (MS). We hope to develop a checklist of brain computerized tomography (CT) reading in patients with suspected acute ischemic stroke (AIS) for MS and primary care (PC) physicians. METHODS Our pilot group generated the items indicating specific structures or signs for the checklist of brain CT reading in suspected AIS patients for MS and PC physicians. These items were used in a modified web-based Delphi process using the online software "SurveyMonkey". In total 15 panelists including neurologists, neurosurgeons, neuroradiologists, and emergency department physicians participated in the modified Delphi process. Each panelist was encouraged to express feedback, agreement or disagreement on the inclusion of each item using a 9-point Likert scale. Items with median scores of 7-9 were included in our final checklist. RESULTS Fifty-two items were initially provided for the first round of the Delphi process. Of these, 35 achieved general agreement of being an essential item for the MS and PC physicians. The other 17 of the 52 items in this round and another two added items suggested by the panelists were further rated in the next round. Finally, 38 items were included in the essential checklist items of brain CT reading in suspected AIS patients for MS and PC physicians. CONCLUSIONS We established a reference regarding the essential items of brain CT reading in suspected AIS patients. We hope this helps to minimize malpractice and a delayed diagnosis, and to improve competency-based medical education for MS and PC physicians.
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Affiliation(s)
- Chi-Hung Liu
- Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Medical Education, Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Ting Hsiao
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Medical Education, Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
- Chang Gung Medical Education Research Centre, Taoyuan, Taiwan
| | - Ting-Yu Chang
- Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yeu-Jhy Chang
- Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
- Division of Medical Education, Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
- Chang Gung Medical Education Research Centre, Taoyuan, Taiwan.
| | - Sheng-Han Kuo
- Department of Neurology, Columbia University, New York, USA
| | - Chun-Wei Chang
- Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Chi-Jen Chen
- Department of Radiology, Shuang-Ho Hospital, New Taipei City, Taiwan
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chien-Fu Chen
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Liang Cheng
- Emergency Department, Dalin Tzu Chi Hospital, Chiayi, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Shy-Chyi Chin
- Department of Medical Imaging and Intervention, Linkou Medical Center, Chang Gung Memorial Hospital, Chang-Gung University, Taoyuan, Taiwan
| | - Te-Fa Chiu
- Department of Emergency Medicine, China Medical University Hospital, School of Medicine, China Medical University, Taichung, Taiwan
| | - Jung-Lung Hsu
- Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- Graduate Institute of Humanities in Medicine and Research Center for Brain and Consciousness, Taipei Medical University, Taipei, Taiwan
| | - Peng-Wei Hsu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Tsong-Hai Lee
- Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Chih-Hsiang Liao
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Chun-Jen Lin
- Department of Neurology, Taipei Veterans General Hospital, and School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Li-Han Lin
- Department of Radiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chen-June Seak
- Department of Emergency Medicine, Linkou Medical Center, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University Taoyuan, Taoyuan City, Taiwan
| | - Pi-Shan Sung
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tao-Chieh Yang
- Department of Neurosurgery, School of Medicine, Chung Shan Medical University, Hospital, Chung Shan Medical University, Taichung, Taiwan
| | - Yi-Ming Wu
- Emergency Department, Dalin Tzu Chi Hospital, Chiayi, Taiwan
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Knowledge and Attitudes of Saudi Emergency Physicians toward t-PA Use in Stroke. Neurol Res Int 2018; 2018:3050278. [PMID: 30364030 PMCID: PMC6188773 DOI: 10.1155/2018/3050278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/17/2018] [Accepted: 09/09/2018] [Indexed: 01/01/2023] Open
Abstract
Background and Objectives Tissue plasminogen activator (t-PA) within 4.5 hours from onset improves outcome in patients with ischemic stroke and has been recommended by several international guidelines. Since its approval in 1996, the debate among emergency physicians continues particularly around the result interpretation of the first positive randomized controlled trial, the National Institute of Neurological Disorders and Stroke (NINDS) clinical trial. This lack of consensus might negatively affect the delivery of effective stroke care. Here we aimed to assess the knowledge and attitude of Saudi emergency physicians toward t-PA use within 4.5 hours of onset in acute ischemic stroke. Methods A web-based, self-administered, locally designed questionnaire was sent to all emergency physicians practicing in the city of Riyadh from January to September 2017. Results Out of 450 emergency physicians, 122 from ten hospitals in Riyadh participated in the survey, with a 27% response rate. The majority of participants were men (78%), and their mean age was 40 ± 8 years. Half of the participants were board certified, and 36% were consultants. Half of the participants consider the evidence for t-PA use in stroke within 4.5 hours of stroke onset to be controversial, and 41% recommend against its use due to lack of proven efficacy (37%), the risk of hemorrhagic complications (35%), lack of stroke expertise (21%), and medicolegal liability (9%). Nearly half were willing to administer IV t-PA for ischemic stroke in collaboration with remote stroke neurology consultation if telestroke is implemented. Conclusion Our study detected inadequate knowledge and a negative attitude among Saudi emergency physicians toward t-PA use in acute stroke. This might negatively impact patient outcome. Therefore, we recommend developing urgent strategies to improve emergency physicians' knowledge, attitudes, and beliefs in the management of acute stroke.
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Heikkilä I, Kuusisto H, Holmberg M, Palomäki A. Fast Protocol for Treating Acute Ischemic Stroke by Emergency Physicians. Ann Emerg Med 2018; 73:105-112. [PMID: 30236416 DOI: 10.1016/j.annemergmed.2018.07.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 06/01/2018] [Accepted: 06/25/2018] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE Thrombolysis with tissue plasminogen activator should occur promptly after ischemic stroke onset. Various strategies have attempted to improve door-to-needle time. Our objective is to evaluate a strategy that uses an emergency physician-based protocol when no stroke neurologist is available. METHODS This was a retrospective before-after intervention analysis in an urban hospital. Reorganization of the acute ischemic stroke treatment process was carried out in 2013. We evaluated time delay, symptomatic intracerebral hemorrhage, and clinical recovery of patients before and after the reorganization. We used multivariable linear regression to estimate the change in door-to-needle time before and after the reorganization. RESULTS A total of 107 patients with comparable data were treated with tissue plasminogen activator in 2009 to 2012 (group 1) and 46 patients were treated during 12 months in 2013 to 2014 (group 2). Median door-to-needle time was 54 minutes before the reorganization and 20 minutes after it (statistical estimate of difference 32 minutes; 95% confidence interval 26 to 38 minutes). After adjusting for several potential cofounders in multivariable regression analysis, the only factor contributing to a significant reduction in delay was group (after reorganization versus before). Median onset-to-treatment times were 135 and 119 minutes, respectively (statistical estimate of difference 23 minutes; 95% confidence interval 6 to 39 minutes). The rates of symptomatic intracerebral hemorrhage were 4.7% (5/107) and 2.2% (1/46), respectively (difference 2.5%; 95% confidence interval -8.7% to 9.2%). Approximately 70% of treated patients were functionally independent (modified Rankin Scale score 0 to 2) when treated after the reorganization. CONCLUSION Implementation of a stroke protocol with emergency physician-directed acute care decreased both door-to-needle time and onset-to-treatment time without increasing the rate of symptomatic intracerebral hemorrhage.
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Affiliation(s)
- Iiro Heikkilä
- Department of Emergency Medicine, Kanta-Häme Central Hospital, Hämeenlinna, Finland.
| | - Hanna Kuusisto
- Department of Neurology, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - Markus Holmberg
- Department of Emergency Medicine, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - Ari Palomäki
- Department of Emergency Medicine, Kanta-Häme Central Hospital, Hämeenlinna, Finland; Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
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Huang Q, Zhang JZ, Xu WD, Wu J. Generalization of the right acute stroke promotive strategies in reducing delays of intravenous thrombolysis for acute ischemic stroke: A meta-analysis. Medicine (Baltimore) 2018; 97:e11205. [PMID: 29924046 PMCID: PMC6024468 DOI: 10.1097/md.0000000000011205] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The generalization of successful efforts for reducing time delays in intravenous thrombolysis (IVT) could help facilitate its utility and benefits in acute ischemic stroke (AIS) patients.We searched the PubMed and Embase databases for articles reporting interventions to reduce time delays in IVT, published between January 1995 and September 2017. The IVT rate was chosen as the primary outcome, while the compliance rates of onset-to-door time (prehospital delay) and door-to-needle time (in-hospital delay) within the targeted time frame were the secondary outcomes. Interventions designed to reduce prehospital, in-hospital, or total time delays were quantitatively described in meta-analyses. The efficacy of postintervention improvement was illustrated as odds ratios (ORs) and 95% confidence intervals (95% CIs).In total, 86 papers (17 on prehospital, 56 on in-hospital, and 13 on total delay) encompassing 17,665 IVT cases were enrolled, including 28 American, 23 Asian, 30 European, and 5 Australian studies. The meta-analysis revealed statistically significant improvement in promoting IVT delivery after prehospital improvement interventions with an OR of 1.45 (95% CI, 1.23-1.71) for the new transportation protocol, 1.38 (95% CI, 1.11-1.73) for educational and training programs, and 1.83 (95% CI, 1.44-2.32) for comprehensive prehospital stroke code. The benefits of reducing in-hospital delay were much greater in developed western countries than in Asian countries, with ORs of 2.90 (95% CI, 2.51-3.34), 2.17 (95% CI, 1.95-2.41), and 1.89 (95% CI, 1.74-2.04) in American, European, and Asian countries, respectively. And telemedicine (OR, 2.26; 95% CI, 2.08-2.46) seemed to work better than pre-notification alone (OR, 1.94; 95% CI, 1.74-2.17) and in-hospital organizational improvement programs (OR, 2.10; 95% CI, 1.97-2.23). Mobile stroke treatment unit and use of a comprehensive stroke pathway in the pre- and in-hospital settings significantly increased IVT rates by reducing total time delay, with ORs of 2.01 (95% CI, 1.60-2.51) and 1.77 (95% CI, 1.55-2.03), respectively.Optimization of the work flow with organizational improvement or novel technology could dramatically reduce pre- and in-hospital time delays of IVT in AIS. This study provided detailed information on the net and quantitative benefits of various programs for reducing time delays to facilitate the generalization of appropriate AIS management.
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Affiliation(s)
- Qiang Huang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
| | - Jing-ze Zhang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
| | - Wen-deng Xu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
| | - Jian Wu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
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Nagendra CV, Kumar TSS, Bohra V, Wilben V, Karan V, Huded V. Factors Affecting the Effective Management of Acute Stroke: A Prospective Observational Study. Indian J Crit Care Med 2018; 22:138-143. [PMID: 29657369 PMCID: PMC5879854 DOI: 10.4103/ijccm.ijccm_232_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Stroke, characterized by sudden loss of cerebral function, is among one of the leading cause of death and disability world over. The newer treatment modalities have changed the landscape of stroke treatment but are very much time bound. Aim To characterize pre-hospital and in-hospital factors affecting acute stroke management thus defining lacunae in stroke management. Subjects and Methods A prospective observational study, conducted at the emergency department of a tertiary care center in southern India from August 2015 to July 2016. All stroke patients presenting within first 24 hours of onset were included. A pre -defined Knowledge-Attitude-Practice (KAP) questionnaire was used. Results Total of 133 patients were eligible out of which 28 were excluded for various reasons. Majority were >60 years age and male (61%). About 60% arrived within window. Distance from the hospital was one of the major factors for arrival within the window period. When compared by KAP questionnaire, bystanders of those arriving within window period had better awareness of stroke symptoms. Conclusions Improving awareness of stroke symptoms and increasing availability of EMS is likely increase chances of stroke patients receiving appropriate acute management.
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Affiliation(s)
- C V Nagendra
- Department of Emergency Medicine, Narayana Institute of Cardiac Sciences, Bengaluru, Karnataka, India
| | - T S Srinath Kumar
- Department of Emergency Medicine, Narayana Institute of Cardiac Sciences, Bengaluru, Karnataka, India
| | - Vikram Bohra
- Department of Neurology, Narayana Institute of Cardiac Sciences, Bengaluru, Karnataka, India
| | - Viju Wilben
- Department of Emergency Medicine, Narayana Institute of Cardiac Sciences, Bengaluru, Karnataka, India
| | - Vivek Karan
- Department of Neurology, Narayana Institute of Cardiac Sciences, Bengaluru, Karnataka, India
| | - Vikram Huded
- Department of Neurology, Narayana Institute of Cardiac Sciences, Bengaluru, Karnataka, India
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Baldursson J, Björnsson HM, Palomäki A. Emergency medicine for 25 Years in Iceland - history of the specialty in a nutshell. Scand J Trauma Resusc Emerg Med 2018; 26:1. [PMID: 29298710 PMCID: PMC5751896 DOI: 10.1186/s13049-017-0467-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 12/13/2017] [Indexed: 01/08/2024] Open
Abstract
After the early implementation of Emergency Medicine (EM) 25 years ago, Iceland became the first Nordic country to nationally realize the benefits of this specialty. However, the road has been rocky as in many other countries. The early years of EM in Iceland were characterized by a significant shortage of resources, particularly a lack of medical staff dedicated to EM and properly trained for the services required. The main task for the first couple of decades was to build the infrastructure of an operational emergency department based primarily on the model of EM. Although these efforts eventually led to a critical number of specialists becoming certified in EM, recruiting more people remains a priority in order to fully meet the need for specialty trained emergency physicians in Iceland. A key step towards achieving this goal was the initiation of a two-year residency program for specialty training in EM in year 2002. The program was based on a curriculum produced by the Icelandic Society for Emergency Medicine, which had been founded in year 2000. This training program is currently being redeveloped and the curriculum of the Royal College of Emergency Medicine in the UK will be adopted for use in Iceland. Another important milestone was the appointment of the first faculty member dedicated to EM at the University of Iceland. This created an opportunity to teach medical students EM and advance training at the graduate level. Also, conditions for scientific research in EM have been improved, following the establishment of an EM research institute in 2010. Other Nordic countries may be able to benefit from lessons learned and experiences gained from the development of emergency medicine in Iceland during the past quarter of a century.
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Affiliation(s)
- Jón Baldursson
- Emergency Department, Landspítali G-2, Fossvogi, The National University Hospital of Iceland, IS-108, Reykjavík, Iceland.,Quality and Patient Safety Department, Landspítali - The National University Hospital of Iceland, Reykjavík, Iceland
| | - Hjalti Már Björnsson
- Emergency Department, Landspítali G-2, Fossvogi, The National University Hospital of Iceland, IS-108, Reykjavík, Iceland. .,Department of Emergency Medicine, Mayo Clinic Health System, Austin/Albert Lea, MN, USA.
| | - Ari Palomäki
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Department of Emergency Medicine, Kanta-Häme Central Hospital, Hämeenlinna, Finland
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