Abstract
IntroductionDelays in identification and treatment of acute stroke contribute to significant morbidity and mortality. Multiple clinical factors have been associated with delays in acute stroke care. We aimed to determine the relationship between emergency department (ED) crowding and the delivery of timely emergency stroke care.MethodsWe used prospectively collected data from our institutional Get with the Guidelines-Stroke registry to identify consecutive acute ischemic stroke patients presenting to our urban academic ED from July 2016–August 2018. We used capacity logs to determine the degree of ED crowding at the time of patients’ presentation and classified them as ordinal variables (normal, high, and severe capacity constraints). Outcomes of interest were door-to-imaging time (DIT) among patients potentially eligible for alteplase or endovascular therapy on presentation, door-to-needle time (DTN) for alteplase delivery, and door-to-groin puncture (DTP) times for endovascular therapy. Bivariate comparisons were made using t-tests, chi-square, and Wilcoxon rank-sum tests as appropriate. We used regression models to examine the relationship after accounting for patient demographics, transfer status, arrival mode, and initial stroke severity by the National Institutes of Health Stroke Scale.ResultsOf the 1379 patients with ischemic stroke presenting during the study period, 1081 (78%) presented at times of normal capacity, 203 (15%) during high ED crowding, and 94 (7%) during severe crowding. Median DIT was 26 minutes (interquartile range [IQR] 17–52); DTN time was 43 minutes (IQR 31–59); and median DTP was 58.5 minutes (IQR 56.5–100). Treatment times were not significantly different during periods of higher ED utilization in bivariate or in multivariable testing.ConclusionIn our single institution analysis, we found no significant delays in stroke care delivery associated with increased ED crowding. This finding suggests that robust processes of care may enable continued high-quality acute care delivery, even during times with an increased capacity burden.
Highlights
Delays in identification and treatment of acute stroke contribute to significant morbidity and mortality
In our single institution analysis, we found no significant delays in stroke care delivery associated with increased emergency department (ED) crowding
One study found that among patients presenting with acute symptoms, imaging and thrombolysis times were not affected by ED crowding,[16] whereas another reported that increased crowding was associated with poorer performance on door-to-imaging times (DIT).[17]
Summary
Delays in identification and treatment of acute stroke contribute to significant morbidity and mortality. Delays in timely identification, imaging, and treatment of acute stroke are associated with significant morbidity and mortality.[1,2] To ensure timely delivery of care, hospitals develop robust processes to promptly identify and treat patients presenting with concern for acute stroke.[3,4,5,6,7] National guidelines recommend administration of alteplase within 60 minutes of patient presentation, and achieving this target. Impact of ED Crowding on Delays in Acute Stroke Care is dependent on timely imaging and appropriate utilization of scarce emergency department (ED) resources.[8,9] The availability of many critical resources may be further threatened with the increasing prevalence of ED crowding.[10,11,12] Previous studies have demonstrated the association of ED crowding with patient safety concerns, delays in care, and even patient mortality.[13,14,15]. One study found that among patients presenting with acute symptoms (within three hours), imaging and thrombolysis times were not affected by ED crowding,[16] whereas another reported that increased crowding was associated with poorer performance on door-to-imaging times (DIT).[17]
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