Delayed Recognition of Acute Stroke by Emergency Department Staff Following Failure to Activate Stroke by Emergency Medical Services

Introduction: Early recognition and pre-notification by emergency medical services (EMS) improves the timeliness of emergency department (ED) stroke care; however, little is known regarding the effects on care should EMS providers fail to pre-notify. We sought to determine if potential stroke patients transported by EMS, but for whom EMS did not provide pre-notification, suffer delays in ED door-to-stroke-team activation (DTA) as compared to the other available cohort of patients for whom the ED is not pre-notified-those arriving by private vehicle. Methods: We queried our prospective stroke registry to identify consecutive stroke team activation patients over 12 months and retrospectively reviewed the electronic health record for each patient to validate registry data and abstract other clinical and operational data. We compared patients arriving by private vehicle to those arriving by EMS without pre-notification, and we employed a multivariable, penalized regression model to assess the probability of meeting the national DTA goal of \u3c /=15 minutes, controlling for a variety of clinical factors. Results: Our inclusion criteria were met by 200 patients. Overall performance of the regression model was excellent (area under the curve 0.929). Arrival via EMS without pre-notification, compared to arrival by private vehicle, was associated with an adjusted risk ratio of 0.55 (95% confidence interval, 0.27-0.96) for achieving DTA \u3c /= 15 minutes. Conclusion: Our single-center data demonstrate that potential stroke patients arriving via EMS without pre-notification are less likely to meet the national DTA goal than patients arriving via other means. These data suggest a negative, unintended consequence of otherwise highly successful EMS efforts to improve stroke care, the root of which may be ED staff over-reliance on EMS for stroke recognition

Door-to-Imaging Time for Acute Stroke Patients Is Adversely Affected by Emergency Department Crowding

BACKGROUND AND PURPOSE: National guidelines call for door-to-imaging time (DIT) within 25 minutes for suspected acute stroke patients. Studies examining factors that affect DIT have focused primarily on stroke-specific care processes and patient-specific factors. We hypothesized that emergency department (ED) crowding is associated with longer DIT. METHODS: We conducted a retrospective investigation of 1 year of consecutive patients in our prospective Code Stroke registry, which included all ED stroke team activations. The registry and electronic health records were abstracted for 27 potential predictors of DIT, including patient, stroke care process, and ED operational factors. We fit a multivariate logistic regression model and calculated odds ratios and 95% confidence intervals. Second, we constructed a random forest recursive partitioning model to cross-validate our findings and explore the proportional importance of each category of predictor. Our primary outcome was the binary variable of DIT within the 25-minute goal. RESULTS: A total of 463 patients met inclusion criteria. In the regression model, ED occupancy rate emerged as a predictor of DIT, with odds ratio of 0.83 (95% confidence interval, 0.75-0.91) of DIT within 25 minutes per 10% absolute increase in ED occupancy rate. The secondary analysis estimated that ED operational factors accounted for nearly 14% of the algorithm\u27s prediction of DIT. CONCLUSIONS: ED crowding is associated with reduced odds of meeting DIT goals for acute stroke. In addition to improving stroke-specific processes of care, efforts to reduce ED overcrowding should be considered central to optimizing the timeliness of acute stroke care