ACT-FAST: a quality improvement project to increase the percentage of acute stroke patients receiving intravenous thrombolysis within 60 minutes of arrival at the emergency department

INTRODUCTION

Stroke is a leading cause of death and disability, with the administration of recombinant transcriptase-plasminogen activator (rtPA) improving outcomes in a time-dependent manner. Only 52.3% of eligible stroke patients at our institution received rtPA within 60 minutes of arrival. We aimed to improve the percentage of acute stroke patients receiving rtPA within 60 minutes of arrival at the emergency department (ED).

METHODS

This study presents results from the first year of a clinical practice improvement project that implemented quality improvement interventions. The primary outcome measure was percentage of acute ischaemic stroke patients receiving rtPA within 60 minutes of arrival at the ED. Secondary outcome measures included components of total door-to-needle (DTN) time and factors for delay to thrombolysis. Interventions were establishment of standardised acute stroke activation guidelines, screening question at ED registration, prehospital notification of stroke activation, public education, scripting for thrombolysis consent and easy access to equipment.

RESULTS

The percentage of patients thrombolysed within 60 minutes increased to 60.6% (p = 0.27), and DTN time decreased from 59 minutes to 54.5 minutes (p = 0.15). This was attributable to reduced door-to-physician time, door-to-imaging time and decision time, although the results were not significant. There was no significant increase in symptomatic intracranial haemorrhage or mortality secondary to stroke. Length of stay was significantly reduced by 1.5 days (p < 0.048).

CONCLUSION

The interventions resulted in an increasing but non-significant trend of acute stroke patients receiving thrombolysis within 60 minutes. Outcomes will be monitored for a longer duration to demonstrate trends and sustainability.

Injury patterns in elderly cyclists and motorcyclists presenting to a tertiary trauma centre in Singapore

INTRODUCTION

With Singapore's ageing population, there are increasing numbers of elderly cyclists and motorcyclists. Compared to younger riders, this cohort sustains more injuries and has poorer outcomes. This study aimed to describe and compare patient demographics, injury patterns and outcomes among elderly cyclists and motorcyclists at a Level 1 trauma centre.

METHODS

Data of all cyclists, motorcyclists and pillion riders aged 65 years and above who presented to the emergency department after accidents from 1 January 2013 to 31 December 2017 was extracted from the hospital's trauma registry and reviewed.

RESULTS

Cyclists and motorcyclists formed 42.0% and 58.0%, respectively, of 157 recruited patients. At the time of the accident, 40.8% of the patients were employed. The mean age of the patients was 71.6 ± 5.8 years. Extremities and pelvic girdle injuries (61.1%) were the most frequent, followed by chest injuries (48.4%), and head and neck injuries (40.1%). Among severe injuries (defined as Abbreviated Injury Scale score ≥ 3), chest injuries (39.5%) were the most common, followed by head and neck injuries (36.3%). The overall mortality rate was 9.6%, with cyclists at nearly three times the risk compared to motorcyclists. More cyclists than motorcyclists (18.2% vs. 11.0%) required intensive care. There were no significant differences in the length of hospital stay between cyclists and motorcyclists.

CONCLUSION

Elderly riders have unique injury patterns and consume significant healthcare resources. Trauma systems need to acknowledge this changing injury epidemiology and equip trauma centres with the necessary resources targeted at elderly patients. Future work should focus on strategies to minimise extremity and chest injuries.

Poison Exposure in the Emergency Department: A Singaporean Experience

Introduction

Poison exposure is a significant problem in emergency departments (EDs) with high admission rates. Our study aims were to describe the demographics, exposure patterns and clinical outcomes of our ED patients as well as to explore predictors of Intensive Care Unit (ICU) / High Dependency (HD) admission.

Methods

In this retrospective study, we recruited patients aged over 16 years who presented with poison exposure to our ED over one year. We collected demographical and clinical data using our hospital databases. Primary outcomes were mortality rate and disposition status. Secondary outcomes were predictors for ICU/HD admission. Logistic regression was applied to identify these predictors.

Results

We recruited 615 patients from an ED attendance of 162,159. Four hundred and nineteen (68%) patients were females; the majority [410 (66.7%)] was Chinese. The median age was 33 years [interquartile range (IQR): 24-44]. Four hundred fifty-six (74.1%) and 159 (25.9%) exposures were intentional or accidental respectively. There were no mortalities. The majority [466 (75.8%)] was admitted to the general ward and only 24 (3.9%) cases were ICU/HD admissions. We identified four factors associated with ICU/HD admission. Odds ratios (95% confidence intervals) for hypotension (systolic blood pressure <90 mmHg), pupillary changes, previous psychiatric history and tricyclic antidepressant overdose were 19.7 (5.57-69.65), 31.9 (7.01-145.76), 3.1 (1.08-9.07) and 30.1 (9.40-96.52) respectively.

Conclusions

Poison exposure is an infrequent ED occurrence with high admission rates but low mortality. Our study identified risk factors for ICU/HD admission that could be used in future studies to triage at-risk patients for treatment escalation.

A case of unusual Gram-negative bacilli septic arthritis in an immunocompetent patient

The Gram-negative bacilli Acinetobacter baumannii, Burkholderia cepacia, Ochrobactrum anthropi, Pseudomonas mendocina, Ralstonia spp., Serratia marcescens and Stenotrophomonas maltophilia are ubiquitous environmental organisms of low virulence, and do not usually cause illness in immunocompetent hosts. We report a case of multiple concurrent opportunistic Gram-negative bacilli causing septic arthritis in a healthy patient following trauma to the knee. Repeated operations, including arthroscopy, arthrotomy and debridement, were required before tissue cultures became negative. The patient also required an extended duration of intravenous and oral antibiotic treatment before he was discharged. Gram-negative bacillary septic arthritis is an uncommon but significant condition that requires repeated debridement and washouts in order to achieve bacterial eradication. This case report highlights the importance of an awareness of the external environment at the time of injury, as it impacts the type of organisms causing the infection, and consequently, the choice of empiric antibiotics required for successful treatment.