Presyncope Is Associated with Intensive Care Unit Admission in Emergency Department Patients with Acute Pulmonary Embolism

Introduction: Syncope is common among emergency department (ED) patients with acute pulmonary embolism (PE) and indicates a higher acuity and worse prognosis than in patients without syncope. Whether presyncope carries the same prognostic implications has not been established. We compared incidence of intensive care unit (ICU) admission in three groups of ED PE patients: those with presyncope; syncope; and neither.Methods: This retrospective cohort study included all adults with acute, objectively confirmed PE in 21 community EDs from January 2013–April 2015. We combined electronic health record extraction with manual chart abstraction. We used chi-square test for univariate comparisons and performed multivariate analysis to evaluate associations between presyncope or syncope and ICU admission from the ED, reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI).Results: Among 2996 PE patients, 82 (2.7%) had presyncope and 109 (3.6%) had syncope. ICU admission was similar between groups (presyncope 18.3% vs syncope 25.7%) and different than their non-syncope counterparts (either 22.5% vs neither 4.7%; p<0.0001). On multivariate analysis, both presyncope and syncope were independently associated with ICU admission, controlling for demographics, higher-risk PE Severity Index (PESI) class, ventilatory support, proximal clot location, and submassive and massive PE classification: presyncope, aOR 2.79 (95% CI, 1.40, 5.56); syncope, aOR 4.44 (95% CI 2.52, 7.80). These associations were only minimally affected when excluding massive PE from the model. There was no significant interaction between either syncope or presyncope and PESI, submassive or massive classification in predicting ICU admission.Conclusion: Presyncope appears to carry similar strength of association with ICU admission as syncope in ED patients with acute PE. If this is confirmed, clinicians evaluating patients with acute PE may benefit from including presyncope in their calculus of risk assessment and site-of-care decision-making

Thrombolysis ImPlementation in Stroke (TIPS): Evaluating the effectiveness of a strategy to increase the adoption of best evidence practice - protocol for a cluster randomised controlled trial in acute stroke care

Background: Stroke is a leading cause of death and disability internationally. One of the three effective interventions in the acute phase of stroke care is thrombolytic therapy with tissue plasminogen activator (tPA), if given within 4.5 hours of onset to appropriate cases of ischaemic stroke.Objectives: To test the effectiveness of a multi-component multidisciplinary collaborative approach compared to usual care as a strategy for increasing thrombolysis rates for all stroke patients at intervention hospitals, while maintaining accepted benchmarks for low rates of intracranial haemorrhage and high rates of functional outcomes for both groups at three months.Methods and design: A cluster randomised controlled trial of 20 hospitals across 3 Australian states with 2 groups: multi- component multidisciplinary collaborative intervention as the experimental group and usual care as the control group. The intervention is based on behavioural theory and analysis of the steps, roles and barriers relating to rapid assessment for thrombolysis eligibility; it involves a comprehensive range of strategies addressing individual-level and system-level change at each site. The primary outcome is the difference in tPA rates between the two groups post-intervention. The secondary outcome is the proportion of tPA treated patients in both groups with good functional outcomes (modified Rankin Score (mR

Thrombolysis ImPlementation in Stroke (TIPS): evaluating the effectiveness of a strategy to increase the adoption of best evidence practice – protocol for a cluster randomised controlled trial in acute stroke care

BACKGROUND Stroke is a leading cause of death and disability internationally. One of the three effective interventions in the acute phase of stroke care is thrombolytic therapy with tissue plasminogen activator (tPA), if given within 4.5 hours of onset to appropriate cases of ischaemic stroke. OBJECTIVES To test the effectiveness of a multi-component multidisciplinary collaborative approach compared to usual care as a strategy for increasing thrombolysis rates for all stroke patients at intervention hospitals, while maintaining accepted benchmarks for low rates of intracranial haemorrhage and high rates of functional outcomes for both groups at three months. METHODS AND DESIGN A cluster randomised controlled trial of 20 hospitals across 3 Australian states with 2 groups: multi- component multidisciplinary collaborative intervention as the experimental group and usual care as the control group. The intervention is based on behavioural theory and analysis of the steps, roles and barriers relating to rapid assessment for thrombolysis eligibility; it involves a comprehensive range of strategies addressing individual-level and system-level change at each site. The primary outcome is the difference in tPA rates between the two groups post-intervention. The secondary outcome is the proportion of tPA treated patients in both groups with good functional outcomes (modified Rankin Score (mRS <2) and the proportion with intracranial haemorrhage (mRS ≥2), compared to international benchmarks. DISCUSSION TIPS will trial a comprehensive, multi-component and multidisciplinary collaborative approach to improving thrombolysis rates at multiple sites. The trial has the potential to identify methods for optimal care which can be implemented for stroke patients during the acute phase. Study findings will include barriers and solutions to effective thrombolysis implementation and trial outcomes will be published whether significant or not. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12613000939796

Thrombolysis ImPlementation in Stroke (TIPS): evaluating the effectiveness of a strategy to increase the adoption of best evidence practice – protocol for a cluster randomised controlled trial in acute stroke care

BACKGROUND: Stroke is a leading cause of death and disability internationally. One of the three effective interventions in the acute phase of stroke care is thrombolytic therapy with tissue plasminogen activator (tPA), if given within 4.5 hours of onset to appropriate cases of ischaemic stroke. OBJECTIVES: To test the effectiveness of a multi-component multidisciplinary collaborative approach compared to usual care as a strategy for increasing thrombolysis rates for all stroke patients at intervention hospitals, while maintaining accepted benchmarks for low rates of intracranial haemorrhage and high rates of functional outcomes for both groups at three months. METHODS AND DESIGN: A cluster randomised controlled trial of 20 hospitals across 3 Australian states with 2 groups: multi- component multidisciplinary collaborative intervention as the experimental group and usual care as the control group. The intervention is based on behavioural theory and analysis of the steps, roles and barriers relating to rapid assessment for thrombolysis eligibility; it involves a comprehensive range of strategies addressing individual-level and system-level change at each site. The primary outcome is the difference in tPA rates between the two groups post-intervention. The secondary outcome is the proportion of tPA treated patients in both groups with good functional outcomes (modified Rankin Score (mRS <2) and the proportion with intracranial haemorrhage (mRS ≥2), compared to international benchmarks. DISCUSSION: TIPS will trial a comprehensive, multi-component and multidisciplinary collaborative approach to improving thrombolysis rates at multiple sites. The trial has the potential to identify methods for optimal care which can be implemented for stroke patients during the acute phase. Study findings will include barriers and solutions to effective thrombolysis implementation and trial outcomes will be published whether significant or not. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN1261300093979

Exploring openEHR-based clinical guidelines in acute stroke care and research

Largely speaking, health information systems today are not able to exchange data between each other and understand the data’s meaning automatically by means of their information technology components. This lack of ‘interoperability’ also leads to patients experiencing an undesired discontinuity in their care. This thesis is a part of a health informatics field which tackles interoperability barriers by offering standardised information models for electronic health records. More specifically, this work explores possibilities of combining standardised information models offered by the openEHR interoperability approach with knowledge from evidence-based clinical practice guidelines. The applied methodology includes openEHR archetypes, the openEHR reference information model, standard medical terminologies such as SNOMED CT, the international stroke treatment registry SITS, a newly developed model for representing guideline knowledge (the ‘Care Entry-Network Model’), and rules authored in the Guideline Definition Language, a formalism recently endorsed by openEHR as a part of its specifications. The study design used is based on evaluating the work done by means of retrospectively checking the compliance of completed patient cases with guidelines from the domain of acute stroke management in Europe, both experimentally and using thousands of real patient cases from SITS. Our overall findings are that i) the Care Entry-Network Model facilitates an intermediate step between narrative guideline text and computer-interpretable guidelines to be deployed in openEHR systems, ii) the Guideline Definition Language is practicable for creating and automatically running openEHR-based computer-interpretable guidelines, where we also provide detailed accounts of our employed GDL technologies, and iii) the Guideline Definition Language combined with real patient data from patient data registries can generate new clinical knowledge, which in our case has benefited stroke carers and researchers working with acute stroke thrombolysis. In conclusion, using our methodology, health care stakeholders would get evidence-based knowledge components in their electronic health records based on shareable, well maintainable information and knowledge models in the form of archetypes and GDL rules respectively. However, our approach still needs to be tested at the point of clinical decision making and compared to other approaches for providing exchangeable computer-interpretable guidelines

Acute stroke CDS: automatic retrieval of thrombolysis contraindications from unstructured clinical letters

Introduction: Thrombolysis treatment for acute ischaemic stroke can lead to better outcomes if administered early enough. However, contraindications exist which put the patient at greater risk of a bleed (e.g. recent major surgery, anticoagulant medication). Therefore, clinicians must check a patient's past medical history before proceeding with treatment. In this work we present a machine learning approach for accurate automatic detection of this information in unstructured text documents such as discharge letters or referral letters, to support the clinician in making a decision about whether to administer thrombolysis. Methods: We consulted local and national guidelines for thrombolysis eligibility, identifying 86 entities which are relevant to the thrombolysis decision. A total of 8,067 documents from 2,912 patients were manually annotated with these entities by medical students and clinicians. Using this data, we trained and validated several transformer-based named entity recognition (NER) models, focusing on transformer models which have been pre-trained on a biomedical corpus as these have shown most promise in the biomedical NER literature. Results: Our best model was a PubMedBERT-based approach, which obtained a lenient micro/macro F1 score of 0.829/0.723. Ensembling 5 variants of this model gave a significant boost to precision, obtaining micro/macro F1 of 0.846/0.734 which approaches the human annotator performance of 0.847/0.839. We further propose numeric definitions for the concepts of name regularity (similarity of all spans which refer to an entity) and context regularity (similarity of all context surrounding mentions of an entity), using these to analyse the types of errors made by the system and finding that the name regularity of an entity is a stronger predictor of model performance than raw training set frequency. Discussion: Overall, this work shows the potential of machine learning to provide clinical decision support (CDS) for the time-critical decision of thrombolysis administration in ischaemic stroke by quickly surfacing relevant information, leading to prompt treatment and hence to better patient outcomes

Acute Stroke Care: Strategies For Improving Diagnostics

Stroke is one of the leading causes of death and disability, with a high incidence of over 11 million cases annually worldwide. Costs of treatment and rehabilitation, loss of work, and the hardships resulting from stroke are a major burden both at the individual and at the societal level. Importantly, stroke therapies need to be initiated early for them to be effective. Thrombolytic therapy and mechanical thrombectomy are early treatment options of ischemic stroke. In hemorrhagic stroke, optimization of hemodynamic and hemostatic parameters is central, and surgery is considered in a subset of patients. Efficient treatment of stroke requires early and precise recognition of stroke at all stages of the treatment chain. This includes identification of patients with suspected acute stroke by emergency medical dispatchers and emergency medical services staff, and precise admission diagnostics by the receiving on-call stroke team. Success requires grasping the complexity of stroke symptoms that depend on the brain areas affected, and the plethora of medical conditions that can mimic stroke. The Helsinki Ultra-acute Stroke Biomarker Study includes a cohort of 1015 patients transported to hospital due to suspected acute stroke, as candidates for revascularization therapies. Based on this cohort, this thesis work has explored new avenues to improve early stroke diagnostics in all stages of the treatment chain. In a detailed investigation into the identification of stroke by emergency medical dispatchers, we analyzed emergency phone calls with missed stroke identification. We also combined data on dispatch and EMS and hospital records to identify causes for missing stroke during emergency calls. Most importantly, we found that a patient’s fall at onset and patient confusion were strongly associated with missed identification. Regarding the Face Arm Speech Test (FAST), the most likely symptom to be misidentified was acute speech disturbance. Using prehospital blood sampling of stroke patients, and ultrasensitive measurement, we investigated the early dynamics of the plasma biomarkers glial fibrillary acidic protein (GFAP) and total tau. Utilizing serial sampling, we demonstrate for the first time that monitoring the early release rate of GFAP can improve the diagnostic performance of this biomarker for early differentiation between ischemic and hemorrhagic stroke. In our analysis of early GFAP levels, we were able to differentiate with high accuracy two-thirds of all patients with acute cerebral ischemia from those with hemorrhagic stroke, supporting further investigation of this biomarker as a promising point-of-care tool for prehospital stroke diagnostics. We performed a detailed review of the admission diagnostics of our cohort of 1015 patients to explore causes and predictors of admission misdiagnosis. We then investigated the consequences of misdiagnosis on outcomes. We demonstrate in this large cohort that the highly optimized and rapid admission evaluation in our hospital district (door-to-needle times below 20 minutes) did not compromise the accuracy and safety of admission evaluation. In addition, we discovered targets for improving future diagnostics. Finally, our detailed neuropathological investigation of a case of cerebral amyloid angiopathy (CAA) -related hemorrhage after stroke thrombolysis provided unique tissue-level evidence for this common vasculopathy as a notable risk factor for intracranial hemorrhagic complications in the setting of stroke. These findings support research to improve the diagnostics of CAA, and the prediction of hemorrhagic complications associated with stroke thrombolysis. In conclusion, these proposed targets and strategies will aid in the future improvement and development of this highly important field of diagnostics. Our proof-of-concept discoveries on early GFAP kinetics help guide further study into this diagnostic approach just as highly sensitive point-of-care GFAP measurement instruments are becoming available. Finally, our results support the safety of worldwide efforts to optimize emergency department door-to- needle times when care is taken to ensure sufficient expertise is in place, highlighting the role of the on-call vascular neurologist as a central diagnostic asset.Aivohalvaus on yksi yleisimpiä kuolinsyitä ja pitkäkestoisen työkyvyttömyyden aiheuttajia. Aivohalvauksen aiheuttamat hoito- ja kuntoutuskustannukset, työkyvyn menetys ja arkielämän vaikeudet ovat mittava taakka sekä yksilön, läheisten että yhteiskunnan tasoilla. Tehokkaiden hoitojen vaatima nopeus edellyttää aivohalvauksen varhaista ja tarkkaa tunnistamista hoitoketjun kaikilla askelmilla. Tässä väitöskirjatyössä etsittiin uusia keinoja aivohalvauksen varhaisdiagnostiikan kehittämiseksi hätäkeskuksessa, ensihoidossa ja vastaanottavan sairaalan HYKS:n päivystyspoliklinikalla. Yksityiskohtainen analyysi aivohalvauksen tunnistamisesta hätäkeskuksessa osoitti, että potilaan kaatuminen ja sekavuus olivat puutteellisen tunnistamisen keskeisiä tekijöitä. Face Arm Speech Test (FAST) -seulontaoireista puhehäiriö oli todennäköisimmin väärin tunnistettu. Akuuttivaiheen verinäytteitä ja äärimmäisen herkkää määritysmenetelmää hyödyntäen tutkimme kahden verestä mitattavan merkkiaineen, aivojen tukikudoksen tähtisolujen säikeisen happaman proteiinin (GFAP) ja taun varhaista dynamiikkaa aivohalvauspotilailla. Osoitimme ensimmäistä kertaa, että GFAP:n varhaisen vapautumisnopeuden seurantaa sarjanäytteistä voidaan hyödyntää parantamaan tämän merkkiaineen erottelukykyä iskeemisen ja hemorragisen aivokudosvaurion varhaisdiagnostiikassa. Tulokset viittaavat siihen, että GFAP merkkiaine voisi olla jatkossa kehitettävissä ambulansseissa hyödynnettäväksi pikaverikokeeksi, joka auttaisi aivohalvauksen eri muotojen varhaisessa erottelussa. Päivystysdiagnostiikkaan keskittyvässä osatyössä osoitimme ensimmäistä kertaa suuressa aineistossa, että sairaanhoitopiirissämme vuosia optimoitu erittäin nopea vastaanottoarviointi (liuotushoidon mediaaniviive alle 20 minuuttia sisältäen pään kuvauksen) ei vaaranna aivohalvauspotilaiden diagnostiikan tarkkuutta ja hoidon turvallisuutta. Tässä väitöskirjatyössä esitetyt kehityskohteet ja menetelmät auttavat tämän erittäin tärkeän diagnostisen alan tulevassa kehitystyössä. Työssä kuvatut tulokset sisältävät uraauurtavia havaintoja verestä mitattavan GFAP merkkiaineen kinetiikan käytöstä aivohalvauksen varhaisdiagnostiikassa ja tukevat sairaalapäivystysarvion diagnostista tarkkuutta HYKS:n tunnetusti erittäin nopeassa liuotushoitoketjussa

Facilitating Stroke Management using Modern Information Technology

Background and Purpose Information technology and mobile devices may be beneficial and useful in many aspects of stroke management, including recognition of stroke, transport and triage of patients, emergent stroke evaluation at the hospital, and rehabilitation. In this review, we address the contributions of information technology and mobile health to stroke management. Summary of Issues Rapid detection and triage are essential for effective thrombolytic treatment. Awareness of stroke warning signs and responses to stroke could be enhanced by using mobile applications. Furthermore, prehospital assessment and notification could be streamlined for use in telemedicine and teleradiology. A mobile telemedicine system for assessing the National Institutes of Health Stroke Scale scores has shown higher correlation and fast assessment comparing with face-to-face method. Because the benefits of thrombolytic treatment are time-dependent, treatment should be initiated as quickly as possible. In-hospital communication between multidisciplinary team members can be enhanced using information technology. A computerized in-hospital alert system using computerized physician-order entry was shown to be effective in reducing the time intervals from hospital arrival to medical evaluations and thrombolytic treatment. Mobile devices can also be used as supplementary tools for neurologic examination and clinical decision-making. In post-stroke rehabilitation, virtual reality and telerehabilitation are helpful. Mobile applications might be useful for public awareness, lifestyle modification, and education/training of healthcare professionals. Conclusions Information technology and mobile health are useful tools for management of stroke patients from the acute period to rehabilitation. Further improvement of technology will change and enhance stroke prevention and treatment.ope

Quality of Health Care for Medicare Beneficiaries: A Chartbook

Provides the results of a review of recently published studies and reports about the quality of health care for elderly Medicare beneficiaries. Includes examples of deficiencies and disparities in care, and some promising quality improvement initiatives