Prehospital paths and hospital arrival time of patients with acute coronary syndrome or stroke, a prospective observational study

Background: Patients with a presumed diagnosis of acute coronary syndrome (ACS) or stroke may have had contact with several healthcare providers prior to hospital arrival. The aim of this study was to describe the various prehospital paths and the effect on time delays of patients with ACS or stroke. Methods: This prospective observational study included patients with presumed ACS or stroke who may choose to contact four different types of health care providers. Questionnaires were completed by patients, general practitioners (GP), GP cooperatives, ambulance services and emergency departments (ED). Additional data were retrieved from hospital registries. Results: Two hundred two ACS patients arrived at the hospital by 15 different paths and 243 stroke patients by ten different paths. Often several healthcare providers were involved (60.8 % ACS, 95.1 % stroke). Almost half of all patients first contacted their GP (47.5 % ACS, 49.4 % stroke). Some prehospital paths were more frequently used, e.g. GP (cooperative) and ambulance in ACS, and GP or ambulance and ED in stroke. In 65 % of all events an ambulance was involved. Median time between start of symptoms and hospital arrival for ACS patients was over 6 h and for stroke patients 4 h. Of ACS patients 47.7 % waited more than 4 h before seeking medical advice compared to 31.6 % of stroke patients. Median time between seeking medical advice to arrival at hospital was shortest in paths involving the ambulance only (60 min ACS, 54 min stroke) or in combination with another healthcare provider (80 to 100 min ACS, 99 to 106 min stroke). Conclusions: Prehospital paths through which patients arrived in hospital are numerous and often complex, and various time delays occurred. Delays depend on the entry point of the health care system, and dialing the emergency number seems to be the best choice. Since reducing patient delay is difficult and noticeable differences exist between various prehospital paths, further research into reasons for these different entry choices may yield possibilities to optimize paths and reduce overall time delay

Variation in decision-making in trauma team activation by emergency nurses at a Dutch level 1 trauma centre

Introduction: Trauma team activation is a kind of triage the staff of an Emergency Department (ED) exerts to determine whether a trauma team needs to be activated for severely injured patients and in what composition the team needs to be deployed. It is a difficult decision-making process which is often performed by ED nurses and influenced by several factors. Objective: Understand the trauma team activation decision-making process at a Dutch ED and obtain insight in the importance of several factors of influence according to ED nurses. Methods: Cross-sectional fractional factorial design. Patient factors (attributes) were identified by literature review and discussed with trauma experts. SPSS® Orthoplan was used to generate a fraction (n=25) of all possible alternative scenarios (n=2304), that consisted of combinations of the attribute levels. Scenarios were presented to 44 ED nurses at a level I trauma centre using a questionnaire with a total of 26 clinical vignettes. ED nurses were asked to rank the attributes according to their perceived importance. Results: 27 ED nurses (61%) completed the questionnaire. The number of team activations per respondent varied for the possible teams. After normalizing the level mean rank scores, the level Airway-Breathing unstable was the most important level for trauma team activation based on the relative rank sum weight (0.115), followed by Mechanism of injury Fall of height >5m (0.171) and Airway-Breathing Intubation (0.172). There was no difference in attribute mean rank scores between two groups of ED nurses, stratified for years of work experience. The ICC for the different levels occurring in the three duplicate vignettes varied. Discussion: We observed variation in decisions for trauma team activation and in consistency of the rank scores among the ED nurses under study. This implies that a decision support system could improve uniformity in the trauma team activation decision-making process