Ambulation Protocol Research Articles

Ambulation in patients with peripheral veno-arterial extracorporeal membrane oxygenation and concomitant femoral intra-aortic balloon pump support.

The mobilization and ambulation of patients with severe cardiogenic shock supported with peripheral veno-arterial extracorporeal membrane oxygenation (pVA-ECMO) and concomitant femoral intra-aortic balloon pump (IABP) support is not well-described. This technical paper describes an ambulation protocol to prevent deconditioning in this critically ill patient population. A protocol for the ambulation of patients with pVA-ECMO and concomitant IABP support was created in December 2022 and implemented at a single center. To initiate ambulation, patients were initially placed in a vertical position utilizing the VitalGo Total Lift Bed (VitalGo Systems, Miramar, FL) with mechanical circulatory support device monitoring performed by a critical care multidisciplinary team. Retrospective analysis of successfully ambulated patients was performed from December 2022 to January 2024. A total of 35 patients out of 112 patients with ECMO support were ambulated in the study period. Four of these patients had pVA-ECMO with concomitant IABP support with this cohort completing a total of 11 sessions during the study period. Patients ambulated an average of 200 feet per session without any adverse events, including cannula and balloon pump migration or displacement. Three of the four patients studied were either bridged to an advanced therapy including orthotopic heart transplant or durable left ventricular assist device or were discharged. A protocol for ambulation of CS patients with pVA-ECMO support and concomitant femoral IABP support is feasible and can safely be implemented in this critically ill patient population. Further multicenter studies are necessary to determine the overall impact of ambulation on patient outcomes.

148: An Ambulation Protocol for Patients with VA-ECMO and Femoral IABP Support

148: An Ambulation Protocol for Patients with VA-ECMO and Femoral IABP Support

33 Standardizing an Early Ambulation Protocol for Lower Extremity Grafts

33 Standardizing an Early Ambulation Protocol for Lower Extremity Grafts

Early ambulation protocol after diagnostic transfemoral cerebral angiography: an evidence-based practice project

BackgroundNo uniform consensus has been achieved regarding the ambulation protocol after transfemoral cerebral angiography (TFA). Until now, in most hospitals patients are prescribed 8-12 h strict immobilization along with bed rest in the supine position after TFA in China, which causes great discomfort to patients.ObjectiveTo evaluate the effect of an evidence-based early ambulation protocol on the prevention of vascular complications and general discomfort in patients following transfemoral cerebral angiography (TFA).MethodsA prospective quasi-experimental study was conducted on 214 patients undergoing TFA with manual compression. Patients in the experimental group were placed supine position for 2 h with a sandbag placed on the wound dressing, followed by a semi-seated position for another 2 h. After this period, patients took 2 h bed rest (move freely) with the sandbag removed, and were allowed to get out of bed 6 h after TFA. Patients in the control group were restricted to an 8 h bed rest in a supine position with the affected leg straight and immobilized. The vascular complications (bleeding, hematoma, ecchymosis) and levels of comfort (low back pain, leg pain, and blood pressure) were evaluated after the procedure. Numeric Rating Scale (NRS) pain scores, systolic blood pressure (SBP); diastolic blood pressure (DBP) were measured hourly for 8 h after TFA.ResultsThere was no significant difference in the two groups with regard to vascular complications including bleeding events (P = 0.621), bleeding volume (P = 0.321), and area of hematoma (P = 0.156).The area of ecchymosis in the experimental group was significantly smaller than the control group (P = 0.031). Compared with the control group, the NRS score for low back pain in the 4th, 5th, 6th, 7th, and 8th hour after TFA were significantly lower (P < 0.05), and the NRS score for leg pain in the 5th, 6th, 7th, 8th hour after TFA were significantly lower (P < 0.05). The SBP and DBP in the 6th, 7th, and 8th hour after TFA were significantly lower than the control group (all P < 0.05).ConclusionsThe evidence-based early ambulation protocol can effectively and safely increase comfort and decrease the pain level for patients undergoing TFA, without change in the incidence of vascular complications.

Evaluation of Venous Thromboembolism Prevention Practices in US Hospitals

Background Hospital-associated venous thromboembolism (HA-VTE) is a significant, deadly, costly, and growing public health problem. While as many as 70% of cases of HA-VTE in patients could be prevented, proven VTE prevention strategies are not applied systematically across U.S. hospitals systems. There is a need to assess and better understand the landscape around VTE prevention practices in U.S. hospitals. Methods The Joint Commission and the Centers for Disease Control and Prevention (CDC) collaborated in the development of a probability-based hospital survey collected in accordance with the American Association for Public Opinion Research guidelines. The population comprised all U.S. and territorial general medical, general surgical, and critical-access hospitals in the 2019 American Hospital Association database. Hospitals were stratified by bed size (small ≤100 beds; medium 100-399 beds; and large ≥400 beds), then randomly sampled an equal number of hospitals in each group. The intended respondent was the chief medical officer, director of quality or safety, or person of a similar title. The questionnaire comprised 44 items, including topics on hospital policies and protocols, barriers to implementation of VTE prevention practice, quality monitoring and improvement efforts, and risk assessment activities. The χ2 test was used to examine differences in response rates by hospital characteristics. This project was deemed non-research in accordance with federal regulation for the protection of human subjects in research. Results There were 4605 eligible hospitals, of which 1290 were randomly selected for the sample, and 1212 had available contact information and were presumed reached. Of these, 311 submitted sufficient data for inclusion, a response rate of 25.7%. Response rates did not differ significantly by location (urban vs rural) or bed size, however major teaching hospitals were more likely to respond than minor or non-teaching hospitals (p&amp;lt;.001). (Table 1) More than half of hospitals reported having a VTE prevention policy (58.0%) (Table 2). Most had a hospital-wide VTE prevention protocol (81.5%) and/or unit-specific protocols (59.9%). Less than half had a VTE prevention team, committee, or workgroup and only 21.8% had a designated VTE prevention team and 19.2% reported VTE prevention activities were addressed by another committee. Large hospitals were more likely to have a designated team (p&amp;lt;.001). When a team or committee exists, there is representation from at least 2 departments (96.7%). Almost 80% reported they have clinical decision support (CDS) tools to help guide the selection of appropriate VTE prophylaxis for medical and surgical patients. The availability of CDS was greater in large and medium hospitals for both medical and surgical units (p&amp;lt;.002). Approximately 60% reported that their admission order sets addressed VTE prophylaxis and completion is mandatory. Reminders or alerts are provided for patients by about 60% of hospitals. Missed anticoagulant doses are routinely documented at 80.1% of hospitals. Around 50% of hospitals reported they conduct audits and provide feedback related to VTE prophylaxis for patients. Over 70% of hospitals educate patients about VTE prevention, including the importance of VTE prophylaxis, during the hospitalization; a little more than a third of hospitals provide annual VTE prevention education to clinicians. About half reported they have an ambulation protocol for patients. There were no variations by hospital bed size for education or ambulation protocols. Data on the number of newly diagnosed HA-VTE is collected in 75.6% of hospitals. This was lower in small hospitals (p=.004). Whereas just 44.7% track the number of patients with bleeding events and/or complications related to anticoagulant prophylaxis. Only 43.7% collect data on the patients receiving appropriate VTE prophylaxis and even fewer collect data on of patients receiving risk assessment (29.3%). Conclusion This survey of hospital VTE prevention practices identified numerous areas for improvement in the establishment and implementation of HA-VTE prevention policies and procedures. Overall, there were limited differences in prevention practices based on hospital bed size. Improving the awareness and application of evidence-based guidelines and interventions may reduce the incidence of HA-VTE.

Prediction of large vessel occlusion for ischaemic stroke by the Van scale

ABSTRACT Background: Rapid and accurate detection of stroke by paramedics or emergency clinicians at the time of first contact is crucial for timely initiation of appropriate treatment. Several stroke recognition scales have been developed to support the initial triage Identification of emergent large vessel occlusion (ELVO) stroke has become increasingly important with the recent publications of favorable acute stroke thrombectomy trials. Multiple screening tools exist but the length of the examination and the false positive rate range from good to adequate. A screening tool was designed and tested in the emergency department using nurse responders without a scoring system. Methods: Suspected stroke patients admitted by ambulance paramedics directly to an acute stroke unit through a rapid ambulance protocol were examined by a neurologist or admitting stroke physician. The vision, aphasia, and neglect (VAN) screening tool was designed to quickly assess functional neurovascular anatomy, which was used as an LVO screen for all stroke patients. Results: There were 162 consecutive code stroke activations during the pilot study. 60 (37%) of the patients were VAN positive and 128 (79%) had a National Institutes of Health Stroke Scale (NIHSS) score of ≥ 6. NIHSS &gt; 6 was more sensitive (100% vs 93% for VAN) but VAN was more specific (90% vs 74% for NIHSS ≥ 6). Similarly, VAN had 83% positive predictive value while NIHSS ≥ 6 had only a 42% positive predictive value. No patient that was NIHSS &lt; 6 had an LVO (100% negative predictive value), there were 4 patients with VAN negative who had LVO (97% negative predictive value). However, VAN had 91% specificity versus 32% for NIHSS. Conclusions: VAN assessment performed well in identifying patients with LVO. Keywords: Stroke, VAN, NIHSS, Large vessel occlusion.

Ambulation of Patients With In Situ Femoral Intraaortic Balloon Pump While Awaiting Heart Transplantation.

Ambulation of Patients With In Situ Femoral Intraaortic Balloon Pump While Awaiting Heart Transplantation.

Quality improvement tools to manage emergency callbacks from patients with diabetes in a prehospital setting

Diabetes is rising at an alarming rate, as 1 in 10 adults worldwide now lives with the disease. In Qatar, a middle eastern Arab country, diabetes prevalence is equally concerning...

Early Ambulation of Patients with Post Transfemoral Arteriography with Vascular Closure Device (VCD): A Quality Improvement Project

<h3>Introduction</h3> Post Transfemoral Arteriogram (PTFA) is a minimally invasive diagnostic interventional procedure using venous closure device (VCD) to achieve hemostasis. Post procedure patient discomfort arises due to restrictions in position and prolonged bedrest. The postanesthesia care unit (PACU) nurses conducted an evidence-based practice (EBP) project that recommended early ambulation for PTFA with VCD between May 1, 2021 and December 1, 2021. <h3>Identification of the problem</h3> IR PACU patients' 120 minute supine positioning and 180 minute total bedrest time causes patient discomfort and PACU to go on hold – not allowing the operating room patients to be transferred. <h3>QI question/Purpose of the study</h3> Can supine positioning be reduced from 120 minutes to 60 minutes and total bedrest time be reduced from 180 minutes to 120 minutes without incidence of bleeding or trauma after PTFA with VCD? <h3>Methods</h3> This project compared current practice of IR patients that requires three-hour bedrest while maintaining supine head of bed (HOB) in flat position for two hours then elevating the HOB to 30 degrees for one additional hour vs implementing two-hour bedrest while maintaining supine HOB in flat position for one hour then elevating the HOB to 30 degrees for an additional hour. Data collection involved monitoring BP, HR, RR, femoral pulse check, femoral groin site check, pain score and patient satisfaction. <h3>Outcomes/Results</h3> Data showed reducing the total supination time from 120 minutes to to 69.95 minutes and total bedrest time from 180 minutes to to 108 minutes showed no increased risk for bleeding or trauma in the patient and overwhelmingly increased patient satisfaction related to decrease in back discomfort while supine and ability to void out-of-bed and/or without assistive devices. <h3>Discussion</h3> Cardiac Prep/PACU nurses recover interventional cardiac patients with the early ambulation protocol for one hour and progressively elevate HOB every thirty minutes. These patients safely ambulate after two hours. Further evaluation of this protocol could be cost effective due to decreased utilization of resources, manpower, and length of hospital stay. <h3>Conclusion</h3> PTFA with VCD patients can safely reduce their flat bedrest and ambulation time frames by one hour after PTFA with VCD. <h3>Implications for perianesthesia nurses and future research</h3> The science revealed ten years of research recommending safe ambulation within 120 minutes PTFA with VCD. Dissemination of these findings will advance the IR recovery process and improve patient satisfaction.

Determining the sensitivity of emergency dispatcher and paramedic diagnosis of stroke: statewide registry linkage study.

IntroductionCorrectly identifying people with suspected stroke is essential for ensuring rapid treatment. Our aims were to determine the sensitivity of emergency dispatcher and paramedic identification of patients with stroke, the factors associated with correct identification, and whether there were any implications for hospital arrival times.MethodsObservational study using patient‐level data from the Australian Stroke Clinical Registry (2015–2017) linked with ambulance and emergency department records for the state of Victoria. The registry diagnosis was the reference standard to compare with the provisional diagnoses made by emergency services personnel classified as “suspected” and “not suspected” stroke/transient ischemic attack (TIA). Multivariable logistic and quintile regressions were used to determine factors associated with correct identification and timely arrival to hospital.ResultsOverall, 4717 (64%) were matched to ambulance transport records (median age: 73 years, 43% female). Stroke/TIA was suspected in 56% of registrants by call‐takers and 69% by paramedics. Older patients (75+ years) (adjusted odds ratio [aOR]: 0.61; 95% confidence interval [CI]: 0.49–0.75), females (aOR: 0.86; 95% CI: 0.75–0.99), those with severe stroke or intracerebral hemorrhage were less often suspected as stroke. Cases identified as stroke had a shorter arrival time to hospital (unadjusted median minutes: stroke, 54 [43, 72] vs not stroke, 66 [51, 89]).ConclusionsEmergency dispatchers and paramedics identified over half of patients with stroke in the prehospital setting. Important patient characteristics, such as being female and those having a severe stroke, were found that may enable refinement of prehospital ambulance protocols and dispatcher/paramedic education. Those correctly identified as stroke, arrived earlier to hospital optimizing their chances of receiving time‐critical treatments.

Influence of an Early Mobilization Protocol on the Autonomic Behavior of Patients Undergoing Percutaneous Transluminal Coronary Angioplasty.

ResumoFundamento:Gráficos de recorrência (GR) permitem uma análise não linear da variabilidade de frequência cardíaca (VFC) e fornecem informações sobre o sistema nervoso autônomo (SNA).Objetivos:Avaliar se a mobilização precoce em pacientes submetidos a angioplastia coronária transluminal percutânea (ACTP) influencia os componentes quantitativos e qualitativos dos GR.Métodos:Um total de 32 participantes que foram submetidos a ACTP foram divididos entre um grupo de controle (GC - sem exercícios físicos) e grupo de mobilização precoce (GMP - com exercícios físicos) A frequência cardíaca batimento a batimento foi registrada utilizando um cardiofrequencímetro em ambos os grupos na admissão e na alta. Os índices lineares nos domínios de tempo e frequência foram analisados, bem como os índices não lineares obtidos pelos GR. O protocolo fisioterapêutico de mobilização precoce começou 12-18 horas após a ACTP. Um teste T não pareado bicaudal foi utilizado para as comparações, e p-valores <0,05 foram aceitos como significativos.Resultados:Ao comparar os dois grupos, na alta, o GMP apresentou um aumento no SDNN (23,55 ± 12,05 a 37,29 ± 16,25; p=0,042), índice triangular (8,99 ± 3,03 a 9,66 ± 3,07; p=0,014) e VLF (694,20 ± 468,20 a 848,37 ± 526,51; p=0,004), mas não apresentou alterações significativas na avaliação não linear. Além disso, na análise qualitativa dos GR, observou-se um padrão mais difuso e menos geométrico no GMP, indicando maior variabilidade, enquanto no GC, notou-se um padrão geométrico mais alterado.Conclusão:O protocolo de mobilização precoce promove uma melhoria no comportamento autonômico, conforme avaliado por VFC e GR, e pode ser considerado um procedimento útil para a melhor recuperação de pacientes submetidos a ACTP.

Mobilization of Patients Receiving Extracorporeal Membrane Oxygenation Before Lung Transplant

Extracorporeal membrane oxygenation is increasingly used to provide cardiopulmonary support to patients awaiting lung transplant. Although studies have shown that these patients benefit from early mobilization, the care team often has concerns about related complications, particularly for patients requiring femoral cannulation. To assess the safety of mobilizing patients receiving extracorporeal membrane oxygenation before lung transplant using a standardized mobility protocol. A retrospective review was performed of the electronic health records of patients receiving extracorporeal membrane oxygenation before or immediately after lung transplant who were mobilized according to a standardized protocol from April through October 2018. The setting was an 18-bed cardiothoracic intensive care unit in a Magnet-designated teaching hospital. Patients were helped to ambulate by an interdisciplinary team, with careful assessment for any related complications. During the study period, 37 patients received extracorporeal membrane oxygenation, and 9 were mobilized. Two hundred forty-two therapy sessions were conducted involving 47 700 feet of ambulation. Patients experienced the following complications: chugging (1 patient), decrease in flow rate (2 patients), bleeding at the cannula site (2 patients), neck hyperextension (1 patient), fear/anxiety (1 patient), and shortness of breath (2 patients). Bleeding and neck hyperextension led to discontinuation of therapy until the problems were resolved. No changes were made to the protocol. Patients receiving extracorporeal membrane oxygenation before lung transplant, including those with femoral cannulation, can be mobilized safely with the use of an interprofessional ambulation protocol. Further evaluation is indicated, including research on clinical outcomes.

Single Center Experience with Venoarterial Extracorporeal Membrane Oxygenation as a Bridge to Heart Transplant under the Contemporary UNOS Heart Allocation System

Purpose Venoarterial extracorporeal membrane oxygenation (VA ECMO) use as a bridge to heart transplant (HTx) has been associated with poor long term outcomes. We investigated our most recent experience with VA ECMO as a bridge to HTx under the new UNOS heart allocation system implemented in October 2018. Methods All HTx that occurred via bridge by VA ECMO between October 1, 2018 to September 30, 2020 at our institution were evaluated. Demographics, cannulation strategy, duration of ECMO, and post-operative outcomes were analyzed. Results Seventy nine patients underwent HTx during this time frame, of which six patients (7.6%) were successfully bridged from VA ECMO. These patients ranged from 19 to 62 years of age, and were supported between four and 42 days (mean 12.2 days). The total hospital length stay was between 34 and 162 days (mean 62.5 days). All patients survived to discharge, and our one month and six month survival are 100%. All patients are still within one year of HTx. No patient had evidence of cerebral vascular accident and/or permanent renal injury requiring sustained hemodialysis. One patient was centrally cannulated for VA ECMO at a referring institution prior to transfer. Five patients were cannulated via a percutaneous approach with Proglide arterial and venous preclosure on opposite access sites, a 5 french antegrade perfusion sheath, and an atrial septostomy for venting. Both centrally and peripherally cannulated VA ECMO patients were ambulated while awaiting HTx. None of the patients undergoing femoral cannulation required open exploration at the time of HTx. Conclusion In this single center dataset, only a small proportion (7.6%) of HTx were bridged via VA ECMO under the 2018 UNOS heart allocation system. Still yet, our short-term results of VA ECMO as bridge to HTx have been promising. When patients require VA ECMO support, we favor a strategy of preclosure, percutaneous femoral access with atrial septostomy with ambulation protocol.

Safety First: An Ambulation Protocol for Patients With Pulmonary Artery Catheters.

Patients with indwelling pulmonary artery catheters have historically been excluded from participating in early mobility programs because of the concern for catheter-related complications. However, this practice conflicts with the benefits accrued from early mobilization. The purposes of this quality improvement project were to develop and implement a standardized ambulation protocol for patients with a pulmonary artery catheter in a cardiac surgery intensive care unit and to assess and support safe ambulation practices while preventing adverse events in patients with pulmonary artery catheters. From October 2016 through October 2017, this single-center quality improvement project developed and analyzed the implementation of a safe patient ambulation protocol in the cardiac surgery intensive care unit. Frontline nursing staff and the interdisciplinary team were educated on a standardized protocol that facilitated patient ambulation. Data analyzed included distance of ambulation, catheter migration, presence of cardiac dysrhythmias, and adverse events during ambulation. During this 1-year project, 41 patients participated in 94 walks for a total distance of 13 676.38 m. There were no reported episodes of cardiac dysrhythmia, accidental occlusion of the pulmonary artery, catheter migration, or pulmonary artery rupture related to ambulation with a pulmonary artery catheter. The use of a standardized ambulation protocol can successfully result in safe mobilization of patients with indwelling pulmonary artery catheters.

Effectiveness of ambulation to prevent venous thromboembolism in patients admitted to hospital: a systematic review.

Patient ambulation is frequently recommended to help prevent venous thromboembolism during hospital admission. Our objective was to synthesize the evidence for ambulation as a prophylaxis for venous thromboembolism in hospital. We conducted a systematic review. We searched MEDLINE, Embase, Scopus, Web of Science and Cochrane Central Register of Controlled Trials indexed from their inception through April 2020 for studies of adult patients admitted to hospital, in which ambulation or mobilization alone or concomitant with prophylaxis was indicated for prevention of venous thromboembolism. We searched ClinicalTrials.gov for unpublished trials. We included randomized controlled trials (RCTs) and observational studies. Two reviewers independently screened articles and assessed risk of bias using 2 validated tools. We scored studies on quality of reporting, internal and external validity and study power; combined scores determined the overall quality. Eighteen articles met the inclusion criteria: 8 retrospective and 2 prospective cohorts, 7 RCTs and 1 secondary analysis of an RCT. The intervention (ambulation or mobilized) groups varied across studies. Five studies examined exercise as a therapeutic prophylaxis for thrombosis and 9 described an ambulation protocol. Five studies attempted to quantify amount and duration of patient ambulation and 3 reported ambulation distance. In the 5 studies rated as good or excellent statistical quality, findings were mixed. Incidence of venous thromboembolism was lowest when pharmacologic anticoagulants were added as part of the prescribed prophylaxis regimen. We did not find high-quality evidence supporting ambulation alone as an effective prophylaxis for venous thromboembolism. Ambulation should not be considered an adequate prophylaxis for venous thromboembolism, nor as an adequate reason to discontinue pharmacologic prophylaxis for venous thromboembolism during a patient's hospital admission.

A Multidisciplinary Ambulation Protocol to Reduce Postoperative Venous Thromboembolism After Colorectal Surgery

A Multidisciplinary Ambulation Protocol to Reduce Postoperative Venous Thromboembolism After Colorectal Surgery

834 Early Ambulation Initiative Following LE Grafts in Comparison to Our Center’s Traditional Standard of Care: A Retrospective Data Review

Abstract Introduction Our ambulation guideline following LE grafting is loosely defined as bedrest vs. lateral transfers only until POD#5. Patient’s mobility status is increased POD#5 with WB per physician discretion. A proposal was created to initiate mobility earlier than POD#5 for patients with LE grafts. Two of our three surgeons were in agreement with the early ambulation protocol. The third surgeon wished to follow the traditional ambulation practice guideline. This request was respected and made known to all staff for carryover. This afforded us the opportunity of a comparison group with our center’s traditional standard of care functioning as the control group. Methods The proposed early ambulation protocol was influenced by evidence-based practice guidelines as well as surgeon input. Criteria was based upon the location of grafting, graft crossing a joint, size of wound being grafted (&amp;lt; or = 400 cm), and general medical status of the patient. Our early ambulation protocol was established as follows: POD#1 Lateral transfers with involved LE elevated. POD#2 Dependent LE at edge of bed, WBAT short distance ambulation to chair or bathroom with AD. POD#3–4 Increase ambulation as tolerated, assess need for continued splinting, appropriateness of progressive ambulation, AROM exercises. POD# 4–5 Progress ambulation with AD as needed, stairs as needed for discharge, home exercise program. Our inclusion criteria consisted of patients of any age, LE burns with STSG not involving joints/involving joints with appropriate immobilization. Exclusion criteria consisted of fractures of involved LE, patients who were non-ambulatory at baseline, wounds &amp;gt;400 cm2, STSG to plantar aspect of foot, medically unstable patients, and surgeon discretion. Results Data reviewed over an eight month period of time yielded 27 patients who met our established criteria; 26 had no graft loss on the first dressing change. The patient with graft loss was attributed to graft placement directly over bone of the distal phalanx. Comparatively, no loss was noted in the control group with 10/10 patients ambulating on POD#5. Of note, early ambulation was granted for several patients with larger surface areas with no graft loss demonstrated, but were not included in this study. Conclusions In conclusion, 96% of patients demonstrated no graft loss with first dressing change following our early ambulation guideline. All patients who followed the traditional ambulation guideline demonstrated no graft loss on the first dressing change. Based on our findings, early mobility is not detrimental to graft integrity following specific established guidelines. Applicability of Research to Practice Our data supports early mobility of LE grafting up to 400 cm2 with 96% success rate. This may be supportive of further research with early mobility involving a larger surface area of LE STSG.

Abstract WP303: Laying the Groundwork for Stroke Care in Armenia. Assessment of Ambulance Services in the Republic of Armenia: Current State of Care, Public Perception and Opportunities for Strengthening the Emergency Medical System

Background: The recent creation of the Armenian National Stroke Program has stipulated that all links in the Stroke Chain of Survival are examined and remediated including Emergency Medical Systems (EMS). EMS forms the second link in the chain of survival after early recognition of stroke symptoms by the general public. This study describes the perception of and performance of EMS in Armenia’s capital, Yerevan, and provides the groundwork for nascent stroke care in Armenia. Methods: We used mixed methods to derive a comprehensive picture of the state of Emergency Medical Systems. We administered a survey using random digit telephone number generator to 384 households at three intervals over a 5 year period in 2005, 2009 and 2010. A trend analysis was performed for six questions regarding EMS. We queried knowledge of the 911-equivalent access number, perception of accessibility of emergency services, perception of anticipated care, and financial concerns. The surveys had a 96% response rate. We also performed key stakeholder interviews and focus groups to describe the state and evolution of emergency care in Armenia. Results and Discussion: Appropriate and timely stroke care relies on activation of EMS. EMS in Armenia remains an ambulance-based service following the Franco-German model where ambulances are staffed by a physician, nurse and driver. Utilization of EMS in Armenia is one of the highest in the world. Eighty percent of calls are treated on scene and 20% are transported to surrounding hospitals. There is currently minimal hospital-based emergency care. Over the three survey periods there was a trend towards increased trust in the EMS system. The idea that the ambulance will respond in a timely manner and not request payment before accepting the call (p=0.04) gained traction. Increased trust means more people will wait for the ambulance than drive the patient to the hospital themselves (p=0.01), a key factor for prompt stroke care. Since February of 2019, stroke patients are transferred to two stroke referral centers in Yerevan. EMS systems strengthening starting with public education and trust-building, emergency medicine residency, ambulance and helicopter protocols and tele-stroke development is key in providing timely and quality stroke care.

Abstract TMP61: Improved Routing of Comprehensive Stroke Center Appropriate Patients via Mobile Stroke Unit Conclusive Field Diagnosis

Background: Mobile Stroke Units (MSUs) are capable of rapid initiation of intravenous thrombolysis and have the potential to improve acute stroke patient routing by providing conclusive imaging diagnosis of LVO (arterial sequences) and intracranial hemorrhage (parenchymal/extraparenchymal sequences). However, the incremental increase in diagnostic accuracy and effect on patient disposition have not been well delineated. Methods: Consecutive transports in a regionally-deployed MSU from September 2017-August 2019) were analyzed, comparing patient routing that would have occurred under standard ambulance protocols to routing and process outcomes after CT/CTA MSU imaging. Standard ambulance regional routing policy was direct to nearest PSC if Los Angeles Motor Scale (LAMS) 0-3 and direct to nearest CSC within 30m if LAMS 4-5. Results: Among 83 MSU transports, final diagnosis was acute cerebral ischemia in 68% and intracranial hemorrhage in 10%. Among 57 acute cerebral ischemia patients, Los Angeles Motor Scale (LAMS) score was 0-3 in 65% and 4-5 in 35%. All (100%) of patients with ICA/M1 occlusions had LAMS score 4-5. However, among patients with expanded range endovascular target occlusions (M2, basilar), LAMS scores were 0-3 in 56%, and MSU imaging permitted improved routing. Among 8 intracranial hemorrhage patients (2 IPH, 5 SDH, 1 SAH), MSU imaging permitted improved direct-to-CSC routing in the 62% of patients with LAMS scores 0-3. Among all MSU admissions, 15% (13) were rerouted based solely upon in-vehicle imaging, including 7% for radiographically proven endovascularly treatable occlusion, 7% for neurosurgical/NICU intracranial hemorrhage care, and 1% for neurosurgical tumor care. Transport times for re-routed patients was median 12 minutes, compared to closest stroke center median 6 minutes. Conclusion: More than 1 in 7 MSU evaluations result in improved routing of comprehensive stroke center-appropriate patients directly to a CSC facility, including AIS patients potentially eligible for thrombectomy, intracranial hemorrhage patients, and acutely-presenting brain tumor patients. In addition to speeding start of intravenous thrombolysis, MSUs can substantially improve timely access to CSC care.

Extremity Mobilization After Split-Thickness Skin Graft Application: A Survey of Current Burn Surgeon Practices.

To determine the current postoperative mobilization care practice patterns of burn surgeons after split-thickness skin grafting and to assess potential inconsistencies in management strategies. A cross-sectional study of active burn surgeons was conducted with an online questionnaire (SurveyMonkey) comprising 7 demographic and 22 mobilization-related questions. Seventy-three (22%) of the 337 members of the American Burn Association mailing list consented to participate in the study, of whom 71 completed the demographic questions and 59 completed the mobilization-related questions. The majority of respondents had more than 10 years of burn care experience (68%) and practiced in an American Burn Association-verified center (70%). Standardized postoperative autograft mobilization protocols were used by 68% of respondents. Most (66%) never or rarely immobilized the upper extremity without joint involvement. When the elbow or wrist was involved, 73% always or very often immobilized. Similarly, 63% never or rarely immobilized the lower extremity without joint involvement. Most immobilized when the knee (70%) or ankle (63%) was involved. Immobilization duration was most commonly 3 or 5 days. Most respondents (71%) reported following Nedelec and colleagues' recommendation that "early postoperative ambulation protocol should be initiated immediately after lower extremity grafting," although there was practice variability. Our findings reveal that the majority of survey respondents do not immobilize the extremities after autograft without joint involvement. When grafts cross major joints, most surgeons immobilize for 3 or 5 days. Despite some practice variability, surveyed burn surgeons' current lower extremity ambulation practices generally align with the 2012 guidelines of Nedelec et al.