Workflow of Stroke Patients Arriving by Personal Vehicle

Introduction: Stroke is a prevalent acute illness in our society that can cause life-long debilitating deficits and in some cases can be fatal. The administration of recumbent tissue plasminogen activator, also known as Alteplase, is associated with better long-term outcomes, lower mortality rates, and decreased deficits when given rapidly following diagnosis. We aim to decrease the time from patient arrival to Alteplase administration in a small, rural emergency department in Pennsylvania by identifying delays and creating a workflow allowing for seamless identification and treatment of acute ischemic stroke. Methods: Areas of delays were identified following in-unit observation and an extensive literature search. An improved workflow was created and implemented along with a standing order set allowing the patient to obtain CT scan prior to being placed in a room. Findings: On a single patient walk through of the revised workflow the door to stroke alert time, door to CT scan time, and door to Patronus Neurology tele-consult times were all decreased from the previous quarter’s average. Discussion: Through implementation of a nurse-driven stroke alert protocol the triage nurse was empowered to identify a stroke, call a level one stroke alert, and facilitate the CT scan process all independent of physician guidance. Implications: By reducing these time spans and receiving Alteplase administration in a timely fashion, patients will appreciate better long-term outcomes and fewer deficits. Key Words: stroke, alteplase, tPA, ischemic, thrombolytic, door-to-needle, DNT, CT scan, workflow, standing order se

Prehospital identification and priority of acute stroke

Treatment of acute ischemic stroke is time critical and early initiated reperfusion treatment increases the chances of good recovery. However, in 2007, only 3% of ischemic stroke patients were treated with thrombolysis in Sweden. Patients’ late arrival to hospital was considered to be one of the reasons for the low treatment rate. The aim of the first study was to evaluate if delay to treatment could be decreased with high priority dispatch of ambulance and thus increase the number of patients eligible for thrombolytic treatment. As high priority of suspected stroke patients is dependent on identification of stroke, the following studies aimed to evaluate identification of stroke. Study I: Patients (n 942) with suspected stroke within 6 h, aged 18-85 were randomized from EMCC or ambulance to intervention, Priority 1 alarm or control, Priority 2. The intervention group randomized from EMCC arrived to hospital 13 minutes (p <0.001) earlier, and 26 minutes (p <0.001) earlier to stroke unit compared to the control group. Furthermore, twice as many patients in the intervention group (35%, p <0.001) were treated with thrombolysis compared to the patients in the control group (17%). The conclusion of the study was that higher priority, both pre- and in-hospital is favorable for patients with acute stroke. Study II was a descriptive study of the use of the Face-Arm-Speech-Time test (FAST) in identification of stroke by the EMCC and the ambulance in the patients included in Study I. In all, 52% of the patients were correctly identified as stroke/TIA. The EMCC included 71% of the patients with stroke/TIA diagnosis and the ambulance included another 29%. At least one FAST symptom was positive in 64% of the included patients. The positive predictive value, PPV, for FAST was 56% in the EMCC included patients and 74% in the ambulance included patients. The conclusion was that FAST is not enough to support identification of stroke in emergency calls. The study demonstrated that more information of how stroke is expressed in emergency calls concerning stroke is needed to improve identification. Study III was a descriptive study of symptoms expressed by the caller in emergency calls concerning stroke of the 179 emergency calls included 64% were dispatched as stroke. Speech disturbance (54%), fall or lying position (38%) and altered mental status (27%) were the most common symptoms in calls. FAST symptoms were presented in 64% of the calls and were more commonly presented in calls dispatched as stroke. The FAST symptoms were presented spontaneously by the caller in 90 %. Fall or the patient being in a lying position (66%) was the most dominating problem presented in the stroke calls dispatched as non-stroke. These result show that FAST is rarely asked for and that the calls dispatched as non-stroke often were presented as a fall or the patient being in a lying position. Questions about FAST symptoms in emergency calls with fall/lying position or altered mental status presented may improve identification of stroke. Study IV was a qualitative study of obstacles and facilitators in communication and interaction of the participants in emergency calls concerning stroke using interpretive phenomenology. Of the 68 emergency calls from Study III where fall/lying position were presented, 29 calls were analyzed. The dispatch codes were blinded in the first step of analysis, 13 calls were dispatched as stroke and 16 as non-stroke. The nurses’ expertise skills were the identified aspect that could be decisive in identification of stroke. Other important findings were aspects of the first call-taker and nurse that can be influenced to improve identification, such as authority, competence and coaching strategies. The result indicated need of education and training to improve identification of stroke and to support the process of developing expertise skills

The South Carolina Telestroke Program: Does County-level Telestroke Access Increase the Odds that Patients Will Receive t-PA?

Stroke is a disease that is responsible for disabling more of its victims that any other disease in the United States. There are four types of stroke. However, ischemic stroke is responsible for 87% of all strokes. T-PA is a pharmaceutical that has proven an effective treatment for ischemic stroke patients since 1996. T-PA works by dissolving the thrombosis that has become lodged in a brain vessel. This pharmaceutical has its limitations; mainly it must be administered within 4.5 hours of symptom onset. Nationally, the medical field experiences low utilization rates, between 3-5%. The many variables that affect this low usage rate, however, this study focuses on patient’s residence in a county that offers telestroke services compared to counties that do not have telestroke services. In completion, of the necessary research, archival data from the 2013 Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) for South Carolina was utilized. Hospital encounters that had a primary diagnosis code of 424.xx & 436.xx (ICD- 9-CM) were identified for analysis. The analysis revealed 9,311 South Carolinians suffered a stroke in 2013 while a total of 461 patients were administered t-PA (4.95%). The study found a greater percentage of patients living in “Telestroke Access” counties received t-PA compared to those that did not, 5.11% to 4.76%, respectively. However, the county in which patients resides was not a statistically significant indicator because of the p-value = 0.36

Prehospital blood transfusion after combat injury and platelet function in an animal model of complex military trauma

PhD ThesisThe management of trauma has been transformed by recent conflict and by improvements in understanding of the response to injury, particularly coagulopathy. Clotting abnormalities can appear early after trauma and have multiple causes, including tissue injury, shock and the effects of treatment. There is increasing understanding of the contribution of coagulation molecules to these abnormalities. Platelets are recognised as being central to the clotting cascade in the current cell-based model of coagulation but have been incompletely studied after traumatic injury. There has been widespread adoption of the practice of “haemostatic resuscitation” using blood products rather than crystalloid fluids with a high ratio of plasma to red blood cells to correct the coagulopathy of trauma while restoring the patient’s physiology. The British Armed Forces have pushed this forward of the hospital using physician-led medical teams. However, this practice has unquantified benefit and potential for harm, and is a logistical challenge. The first study in this thesis assesses whether available clinical data support the use of prehospital transfusion. It compared recipients of the treatment with similarly injured controls. Although mortality was halved, confounding changes in hospital transfusion practice made it impossible to rely on these data to establish the efficacy of prehospital transfusion. To allow further study, an animal model of complex military trauma was developed. The author focused on developing a flow cytometry assay for the assessment of platelet activation and response to in vitro stimulation. This was successful. The performance of the assay was assessed in the context of the animal model. Surgical preparation of the model appeared to affect the expression of the relevant activation marker. While the assay proved incompatible with unavoidable constraints of the model, its development acted as the basis for the establishment of a human platelet study of combat casualties in Afghanistan

Current trends and future perspectives of stroke management through integrating health care team and nanodrug delivery strategy

Stroke is accounted as the second-most mortality and adult disability factor in worldwide, while causes the bleeding promptly and lifetime consequences. The employed functional recovery after stroke is highly variable, allowing to deliver proper interventions to the right stroke patient at a specific time. Accordingly, the multidisciplinary nursing team, and the administrated drugs are major key-building-blocks to enhance stroke treatment efficiency. Regarding the healthcare team, adequate continuum of care have been declared as an integral part of the treatment process from the pre-hospital, in-hospital, to acute post-discharge phases. As a curative perspective, drugs administration is also vital in surviving at the early step and reducing the probability of disabilities in later. In this regard, nanotechnology-based medicinal strategy is exorbitantly burgeoning. In this review, we have highlighted the effectiveness of current clinical care considered by nursing teams to treat stroke. Also, the advancement of drugs through synthesis of miniaturized nanodrug formations relating stroke treatment is remarked. Finally, the remained challenges toward standardizing the healthcare team and minimizing the nanodrugs downsides are discussed. The findings ensure that future works on normalizing the healthcare nursing teams integrated with artificial intelligence technology, as well as advancing the operative nanodrugs can provide value-based stroke cares

Effect of pre-hospital blood products on Acute Traumatic Coagulopathy in a model of severe military trauma

Acute traumatic coagulopathy (ATC) is seen in 30% to 40% of severely injured civilian and military casualties. Early use of blood products attenuates ATC, but the timing for optimal effect is unknown. Emergent clinical practice has started pre-hospital deployment of blood components (combined packed red blood cells [PRBC] and fresh frozen plasma [FFP]),but this is associated with significant logistical burden and some clinical risk. It is therefore imperative to establish whether pre-hospital use of blood products is likely to confer benefit. This study compared the potential impact of pre-hospital resuscitation with blood components versus 0.9% saline in a model of severe injury. Terminally anaesthetised Large White pigs received controlled soft tissue blunt injury, controlled haemorrhage (35% blood volume) with or without a primary blast injury followed by a 30-min shock phase. The animals were allocated randomly to one of the two injury arms (blast or sham blast). Within each injury arm the animals were allocated randomly to one of two treatment groups as follows: the shock phase was followed by a 60-min prehospital evacuation phase; comprising hypotensive resuscitation (target systolic arterial pressure 80 mmHg) using either 0.9% saline or blood components (PRBCs:FFP in a 1:1 ratio). Following this phase, an inhospital phase involving resuscitation to a normotensive target (110 mmHg systolic arterial blood pressure) using PRBCs:FFP was performed in all four groups. A coagulopathy developed in both pre-hospital saline groups (increase in TEG [thromboelastography] R and K times and aPTT [activated partial thromboplastin time]) that persisted for 60 to 90 minutes into the inhospital phase. The coagulopathy was attenuated in the pre-hospital blood component groups. Pre-hospital blood component resuscitation may therefore attenuate ATC