Hospital Arrival For Patients Research Articles

Abstract WP172: A Novel Score to Predict Early Time From Symptom Onset to Hospital Arrival in Patients With Intracerebral Hemorrhage

Introduction: Up to 40% of ICH patients have unknown onset time, leading to uncertainty regarding the use of hyperacute ICH treatments and their exclusion from acute ICH treatment trials. We aimed to develop a prediction score that can reliably identify ICH patients presenting within 3 hours of symptom onset. Methods: Spontaneous ICH patients participating in the iDEF trial with available prerequisite data were analyzed. A stepwise multivariable logistic regression model was used to determine predictors of early presentation (symptom onset-to-baseline CT scan time ≤3 hours) with a p-value < 0.15. To develop the prediction score, we allocated scores proportional to the standardized odds ratio (OR) of each binary variable. Continuous variables were dichotomized using the lowest threshold above which there was no additional gain in the positive predictive value (PPV) for early presentation. Results: Of 291 iDEF participants, 132 (45%) presented early. Baseline NIHSS (OR 1.05 per 1-score increase; 95% CI, 0.99-1.11), Glasgow Coma Scale (1.18 per 1-score increase; 1.01-1.39), ICH volume (1.17 per 10-ml increase; 0.98-1.39), absolute perihematomal edema volume (0.81 per 10-ml increase; 0.66-1.00), irregular hematoma shape (2.24; 1.12-4.48), blend sign (0.45; 0.21-0.97), white blood cell count (0.89 per 10 3 cell/ml increase; 0.82-0.96), and blood glucose levels (0.91 per mmol/l increase; 0.82-0.99) were associated with early presentation (c-statistic=0.71). The PPV for an early ICH presentation score (Figure) of >7 was 69%. Conclusion: This novel early ICH presentation score using readily available clinical, neuroimaging, and laboratory data has good performance for identification of ICH patients presenting within 3 hours of symptom onset. If validated in external datasets, the early ICH presentation score can be used to improve recruitment feasibility in acute ICH trials and support clinical decision-making in ICH patients with an unknown symptom onset time.

Prediction of Late Hospital Arrival in Patients with Mild and Rapidly Improving Acute Ischemic Stroke in a Rural Area of China.

Among all ischemic stroke patients, more than half are mild and rapidly improving acute ischemic stroke (MaRAIS) patients. However, many MaRAIS patients do not recognize the disease early on, and thus they delay access to the treatment that would be most effective if provided earlier. This is especially true in rural areas. The aim of this study was to develop and validate a late hospital arrival risk nomogram in a rural Chinese population of patients with MaRAIS. We developed a prediction model based on a training dataset of 173 MaRAIS patients collected from September 9, 2019 to May 13, 2020. Data analyzed included demographics and disease characteristics. A least absolute shrinkage and selection operator (LASSO) regression model was used to optimize feature selection for the late hospital arrival risk model. Multivariable logistic regression analysis was applied to build a prediction model incorporating the features selected in the LASSO regression models. The discrimination, calibration, and clinical usefulness of the prediction model were assessed using the C-index, calibration plot, and decision curve analysis, respectively. Internal validation was then assessed using bootstrapping validation. Variables contained in the prediction nomogram included transportation mode, history of diabetes, knowledge of stroke symptoms, and thrombolytic therapy. The model had moderate predictive power with a C-index of 0.709 (95% confidence interval: 0.636-0.783) and good calibration. In the internal validation, the C-index reached 0.692. The risk threshold was 30-97% according to the analysis of the decision curve, and the nomogram could be applied in clinical practice. This novel nomogram, which incorporates transportation mode, history of diabetes, knowledge of stroke symptoms, and thrombolytic therapy, was conveniently applied to facilitate individual late hospital arrival risk prediction among MaRAIS patients in a rural area of Shanghai, China.

Immediate CT after hospital arrival and decreased in-hospital mortality in severely injured trauma patients.

Immediate whole-body CT (about 10 min after arrival) in an all-in-one resuscitation room equipped with CT has been found to be associated with shorter time to haemostasis and lower in-hospital mortality. The aim of this study was to elucidate the benefits of immediate whole-body CT after hospital arrival in patients with severe trauma with the hypothesis that immediate CT within 10 min is associated with lower in-hospital mortality. This retrospective cohort study of patients with an injury severity score of more than 15 who underwent whole-body CT was conducted using the Japanese Trauma Databank (2019-2020). An immediate CT was conducted within 10 min after arrival. In-hospital mortality, frequency of subsequent surgery, and time to surgery were compared with immediate and non-immediate CT. Inverse probability weighting was conducted to adjust for patient backgrounds, including mechanism and severity of injury, prehospital treatment, vital signs, and institutional characteristics. Among the 7832 patients included, 646 underwent immediate CT. Immediate CT was associated with lower in-hospital mortality (12.5 versus 15.7 per cent; adjusted OR 0.77 (95 per cent c.i. 0.69 to 0.84); P < 0.001) and fewer damage-control surgeries (OR 0.75 (95 per cent c.i. 0.65 to 0.87)). There was a 10 to 20 min difference in median time to craniotomy, laparotomy, and angiography. These benefits were observed regardless of haemodynamic instability on hospital arrival, while they were identified only in elderly patients with severe injury and altered consciousness. Immediate CT within 10 min after arrival was associated with decreased in-hospital mortality in severely injured trauma patients.

Access to acute stroke care: A retrospective descriptive analysis of stroke patients' journey to a district hospital.

The burden of stroke in Africa has increased in the last two decades, with the population undergoing a rapid epidemiological transition, with a rise in the incidence of stroke risk factors together with the gradual aging of the population. Evidence-based guidelines for acute stroke care are often not feasible in resource challenged settings but even when resources are available, considerable delays to definitive care exists. This study aims to describe the factors that influence time from symptom onset to hospital arrival in patients that present to a district level hospital Emergency Centre with confirmed ischaemic strokes. A descriptive analysis was performed using a retrospective folder and database review. All adult patients with a confirmed ischaemic stroke, on Computed Tomography (CT) scan, presenting to Mitchells Plain Hospital Emergency Centre during the study period of 12 months (1st of January 2019 to 31st of December 2019), were eligible for inclusion. Data were collected from existing electronic patient databases and the time from onset of symptoms to hospital arrival was extracted from the clinical notes. A total of 730 (2%) patients presented with a diagnosis of stroke, of which 381 (52%) were included (CT confirmed ischaemic strokes). Only 48 (13%) presented within 4.5h of symptom onset and the median time from onset of symptoms to presentation to the hospital was 24h (IQR 12-72h). The majority of patients (31%) arrived via a primary public emergency medical service (EMS) call, while 29% presented directly to the hospital as self-referrals with private transport. Primary public EMS calls had the shortest call-to-hospital-arrival time (1 hour and 31 minutes), even though the median time from symptom onset to hospital arrival was still 16h. The median time from symptom onset to hospital arrival for patients with stroke symptoms is much longer than what evidence-based guidelines suggest. The chain of survival for emergency stroke care is only as strong as its weakest link and the data from this study suggest that improvement campaigns should target stroke education and access to care.

Prediction of Prehospital Change of the Cardiac Rhythm From Nonshockable to Shockable in Out-of-Hospital Patients With Cardiac Arrest: A Post Hoc Analysis of a Nationwide, Multicenter, Prospective Registry.

BackgroundPredicting a spontaneous rhythm change from nonshockable to shockable before hospital arrival in patients with out‐of‐hospital cardiac arrest can help emergency medical services develop better strategies for prehospital treatment. The aim of this study was to identify predictors of spontaneous rhythm change before hospital arrival in patients with out‐of‐hospital cardiac arrest and develop a predictive scoring system.Methods and ResultsWe retrospectively reviewed data of eligible patients with out‐of‐hospital cardiac arrest with an initial nonshockable rhythm registered in a nationwide registry between June 2014 and December 2017. We performed a multivariable analysis using a Cox proportional hazards model to identify predictors of a spontaneous rhythm change, and a ridge regression model for predicting it. The data of 25 804 patients were analyzed (derivation cohort, n=17 743; validation cohort, n=8061). The rhythm change event rate was 4.1% (724/17 743) in the derivation cohort, and 4.0% (326/8061) in the validation cohorts. Age, sex, presence of a witness, initial rhythm, chest compression by a bystander, shock with an automated external defibrillator by a bystander, and cause of the cardiac arrest were all found to be independently associated with spontaneous rhythm change before hospital arrival. Based on this finding, we developed and validated the Rhythm Change Before Hospital Arrival for Nonshockable score. The Harrell’s concordance index values of the score were 0.71 and 0.67 in the internal and external validations, respectively.ConclusionsSeven factors were identified as predictors of a spontaneous rhythm change from nonshockable to shockable before hospital arrival. We developed and validated a score to predict rhythm change before hospital arrival.

Prognostic tools at hospital arrival in acute myocardial infarction: copeptin and hepatocyte growth factor

BackgroundPrompt evaluation and treatment of acute coronary syndrome has demonstrated to reduce mortality. Although several biomarkers have been studied for risk stratification and prognostic purposes, none is recommended to guide treatment based on its prognostic value. Copeptin and hepatocyte growth factor have been associated with poor outcome in patients with acute myocardial infarction. The aim of this study is to evaluate the early prognostic value of measurements of copeptin and hepatocyte growth factor for hospital mortality risk and 1-year-follow-up mortality, in patients with acute myocardial infarction. In our retrospective observational study, we measured hepatocyte growth factor and copeptin in blood samples collected at hospital arrival in patients with acute myocardial infarction; and follow-up them until 1-year.Results84 patients with were included in the study, mainly male (65%) with a median age of 70.3 ± 13.56 years. Hospital mortality was 11.9%. Plasma levels of copeptin at hospital arrival were statistically significant higher in patients who died during hospital admission (145.60 pmol/L [52.21–588.50] vs. 24.79 pmol/L [10.90–84.82], p 0.01). However, we found no statistically significant association between plasma levels of hepatocyte growth factor and hospital mortality (381.05 pg/ml [189.95–736.65] vs. 355.24 pg/ml [175.55–521.76], p 0.73). 1-year follow-up mortality was 21.4%. Plasma levels of copeptin at hospital arrival were higher in those patients who died in the following year (112.28 pmol/L [25.10–418.27] vs. 23.82 pmol/L [10.96–77.30], p 0.02). In the case of HGF, we also find no association between hepatocyte growth factor plasma levels and 1 -year follow-up mortality (350.00 pg/ml [175.05–555.08] vs. 345.53 pg/ml [183.68–561.15], p 0.68).ConclusionsIn patients with acute myocardial infarction measurement of copeptin at hospital arrival could be a useful tool to assess the prognosis of these patients, since their elevation is associated with a higher hospital mortality and higher 1-year follow-up mortality. We have not found this association in the case of hepatocyte growth factor measurement.

Treatment With Vasopressor Agents for Cardiovascular Shock Patients With Poor Renal Function; Results From the Japanese Circulation Society Cardiovascular Shock Registry.

According to the guidelines for cardiogenic shock, norepinephrine is associated with fewer arrhythmias than dopamine and may be the better first-line vasopressor agent. This study aimed to evaluate the utility of norepinephrine vs. dopamine as first-line vasopressor agent for cardiovascular shock depending on the presence and severity of renal dysfunction at hospitalization. This was a secondary analysis of the prospective, multicenter Japanese Circulation Society Cardiovascular Shock Registry (JCS Shock Registry) conducted between 2012 and 2014, which included patients with shock complicating emergency cardiovascular disease at hospital arrival. The analysis included 240 adult patients treated with norepinephrine alone (n = 98) or dopamine alone (n = 142) as the first-line vasopressor agent. Primary endpoint was mortality at 30 days after hospital arrival. The two groups had similar baseline characteristics, including estimated glomerular filtration rate (eGFR), and similar 30-day mortality rates. The analysis of the relationship between 30-day mortality rate after hospital arrival and vasopressor agent used in patients categorized according to the eGFR-based chronic kidney disease classification revealed that norepinephrine as the first-line vasopressor agent might be associated with better prognosis of cardiovascular shock in patients with mildly compromised renal function at admission (0.0 vs. 22.6%; P = 0.010) and that dopamine as the first-line vasopressor agent might be beneficial for cardiovascular shock in patients with severely compromised renal function [odds ratio; 0.22 (95% confidence interval 0.05–0.88; P = 0.032)]. Choice of first-line vasopressor agent should be based on renal function at hospital arrival for patients in cardiovascular shock.Clinical Trial Registration: http://www.umin.ac.jp/ctr/, Unique identifier: 000008441.

Impact of onset-to-door time on outcomes and factors associated with late hospital arrival in patients with acute ischemic stroke.

Previous studies have reported that early hospital arrival improves clinical outcomes in patients with acute ischemic stroke; however, whether early arrival is associated with favorable outcomes regardless of reperfusion therapy and the type of stroke onset time is unclear. Thus, we investigated the impact of onset-to-door time on outcomes and evaluated the predictors of pre-hospital delay after ischemic stroke. Consecutive acute ischemic stroke patients who arrived at the hospital within five days of onset from September 2019 to May 2020 were selected from the prospective stroke registries of Seoul National University Hospital and Chung-Ang University Hospital of Seoul, Korea. Patients were divided into early (onset-to-door time, ≤4.5 h) and late (>4.5 h) arrivers. Multivariate analyses were performed to assess the effect of early arrival on clinical outcomes and predictors of late arrival. Among the 539 patients, 28.4% arrived early and 71.6% arrived late. Early hospital arrival was significantly associated with favorable outcomes (three-month modified Rankin Scale [mRS]: 0-2, adjusted odds ratio [aOR]: 2.03, 95% confidence interval: [CI] 1.04-3.96) regardless of various confounders, including receiving reperfusion therapy and type of stroke onset time. Furthermore, a lower initial National Institute of Health Stroke Scale (NIHSS) score (aOR: 0.94, 95% CI: 0.90-0.97), greater pre-stroke mRS score (aOR: 1.58, 95% CI: 1.18-2.13), female sex (aOR: 1.71, 95% CI: 1.14-2.58), unclear onset time, and ≤6 years of schooling (aOR: 1.76, 95% CI: 1.03-3.00 compared to >12 years of schooling) were independent predictors of late arrival. Thus, the onset-to-door time of≤4.5 h is crucial for better clinical outcome, and lower NIHSS score, greater pre-stroke mRS score, female sex, unclear onset times, and ≤6 years of schooling were independent predictors of late arrival. Therefore, educating about the importance of early hospital arrival after acute ischemic stroke should be emphasized. More strategic efforts are needed to reduce the prehospital delay by understanding the predictors of late arrival.

End-tidal and arterial carbon dioxide gradient in serious traumatic brain injury after prehospital emergency anaesthesia: a retrospective observational study

ObjectivesIn the UK, 20% of patients with severe traumatic brain injury (TBI) receive prehospital emergency anaesthesia (PHEA). Current guidance recommends an end-tidal carbon dioxide (ETCO2) of 4.0–4.5 kPa (30.0–33.8 mm...

Clinical Outcomes of Direct Interhospital Transfers of Patients with Acute Aortic Syndrome Led by Advanced Practice Nurses

Purpose This study aimed to evaluate the clinical outcomes of direct interhospital transfers (IHTs) of patients with acute aortic syndrome (AAS) led by advanced practice nurses (APNs). Methods From September 2014 to June 2017, the study retrospectively investigated 183 patients with AAS who were transferred to a high-volume tertiary hospital. Results One hundred forty-eight (81%) patients were admitted through direct IHTs, and 35 (19%) patients were admitted through non-direct IHTs. The direct IHT group had a significantly shorter time from symptom onset to hospital arrival than the non-direct IHT group (11.4 vs. 32.1 h, p=.043). There were no significant differences in other clinical outcomes, such as peri-transfer status, mortality, hospital length of stay, and readmission, between the two groups. In the direct IHT group, 55% of transfers were led by APNs. There was no significant difference in outcomes between APN- and physician-led transfers. Conclusions Implementation of direct IHTs markedly shortened the time from symptom onset to hospital arrival in patients with AAS. Finally, direct IHTs can potentially improve the outcomes of patients with AAS, a condition with time-dependent mortality and morbidity. In addition, APNs can effectively lead the direct IHT of patients with AAS. Key Words: Transfer, Nurse practitioner, Aortic aneurysm, Dissection, Treatment outcome 주요어: ì „ì›, ì „ë¬¸ê°„í˜¸ì‚¬, 대동맥류, 박리, 치료 ê²°ê³¼

Cerebral oxygenation monitoring during resuscitation by emergency medical technicians: a prospective multicenter observational study.

AimTo assess the feasibility and predictive ability of regional cerebral oxygen saturation monitoring during cardiopulmonary resuscitation by emergency medical technicians.MethodsThis prospective observational study included 33 cardiac arrest patients who received cardiopulmonary resuscitation in a prehospital setting. Patients were connected to a near‐infrared spectrometer through two disposable probes immediately after entering the ambulance. The monitor, which showed regional cerebral oxygen saturation readings, was obscured by covering it with a sheet of paper. Regional cerebral oxygen saturation was measured continuously until hospital arrival. Outcome variables included the prehospital return of spontaneous circulation, survival to hospital admission, and survival at 90 days.ResultsFor patients who survived >90 days after hospital admission (n = 2), the mean regional cerebral oxygen saturation values upon ambulance and hospital arrival were 24% and 60%, respectively; for patients who did not survive (n = 31), the mean regional cerebral oxygen saturation values were 15% and 17%, respectively. Regional cerebral oxygen saturation values increased to a greater extent between ambulance arrival and hospital arrival in patients who survived >90 days (median, 36%; interquartile range, 32–40%) than in those who did not survive (0; 0–6%; P = 0.07). Additionally, regional cerebral oxygen saturation values were not related to the prehospital return of spontaneous circulation or survival to hospital admission.ConclusionRegional cerebral oxygen saturation could be monitored during resuscitation by emergency medical technicians, and it can be used during physiological monitor‐guided cardiopulmonary resuscitation.

P1703Impact of prehospital epinephrine administration and quality of cardiopulmonary resuscitation on neurologically intact survival in out-of-hospital cardiac arrest patients with non-shockable rhythm

Abstract Background The effects of prehospital epinephrine administration in combination with the quality of cardiopulmonary resuscitation (CPR) on neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients with non-shockable rhythm remains unclear. Purpose This study aimed to elucidate the effects of prehospital epinephrine administration in combination with the quality of CPR on neurologically intact survival in OHCA patients with non-shockable rhythm. Methods We analysed 118,732 adult OHCA patients with non-shockable rhythm from the All-Japan OHCA registry between 2011 and 2016 (29,989 emergency medical service [EMS]-witnessed arrests with EMS-initiated CPR [high-quality CPR] and 88,743 bystander-witnessed arrests with bystander-initiated CPR continued by EMS providers [low-quality CPR]). Patients who achieved prehospital return of spontaneous circulation without prehospital epinephrine administration were excluded. The primary outcome measure was 1-month neurologically intact survival (cerebral performance category 1 or 2; CPC 1–2). Time from collapse to prehospital epinephrine administration for patients with prehospital epinephrine administration, or to hospital arrival for patients without prehospital epinephrine administration was calculated and adjusted collectively in multivariate logistic regression analysis for 1-month CPC 1–2. Results Multivariate logistic regression analysis revealed that the time from collapse to prehospital epinephrine administration or to hospital arrival was negatively associated with 1-month CPC 1–2 (adjusted odds ratio [OR] 0.95 per 1-minute increment, 95% confidence interval [CI] 0.94–0.96). Compared with bystander-witnessed arrests without prehospital epinephrine administration, EMS-witnessed arrests with or without prehospital epinephrine administration were significantly associated with increased chances of 1-month CPC 1–2 (adjusted OR 2.04, 95% CI 1.50–2.75 and adjusted OR 1.97, 95% CI 1.57–2.48, respectively). Prehospital epinephrine administration was significantly associated with an increased chance of 1-month CPC 1–2 among bystander-witnessed arrests (adjusted OR 1.57, 95% CI 1.24–1.98), but not among EMS-witnessed arrests. EMS-witnessed arrests without prehospital epinephrine administration were significantly associated with an increased chance of 1-month CPC 1–2 compared with bystander-witnessed arrests with prehospital epinephrine administration (adjusted OR 1.26, 95% CI 1.01–1.56). Conclusions High-quality CPR is crucial for increasing neurologically intact survival in OHCA patients with non-shockable rhythm. The additional beneficial effects of prehospital epinephrine administration were observed only among OHCA patients with low-quality CPR.

The efficacy and safety of pre-hospital cooling after out-of-hospital cardiac arrest: a systematic review and meta-analysis

BackgroundMild therapeutic hypothermia (TH), or targeted temperature management, improves survival and neurological outcomes in patients after out-of-hospital cardiac arrest (OHCA). International guidelines strongly support initiating TH for all eligible individuals presenting with OHCA; however, the timing of cooling initiation remains uncertain. This systematic review and meta-analysis was conducted with all available randomised controlled trials (RCTs) included to explore the efficacy and safety of initiating pre-hospital TH in patients with OHCA.MethodsThe MEDLINE and Cochrane databases were searched from inception to October 2017. Inclusion criteria for full-text review included RCTs comparing pre-hospital TH with no pre-hospital TH after cardiac arrest, patients > 14 years of age with documented cardiac arrest from any rhythm, and outcome data that included survival to hospital discharge and temperature at hospital arrival. Results of retrieved studies were compared through meta-analysis using random effects modelling.ResultsA total of 10 trials comprising 4220 patients were included. There were no significant differences between the two arms for the primary outcome of neurological recovery (risk ratio [RR] 1.04, 95% CI 0.93–1.15) or the secondary outcome of survival to hospital discharge (RR 1.01, 95% CI 0.92–1.11). However, there was a significantly lower temperature at hospital arrival in patients receiving pre-hospital TH (mean difference − 0.83, 95% CI − 1.03 to − 0.63). Pre-hospital TH significantly increased the risk of re-arrest (RR 1.19, 95% CI 1.00 to 1.41). No survival differences were observed among subgroups of patients who received intra-arrest TH vs post-arrest TH or who had shockable vs non-shockable rhythms.ConclusionsPre-hospital TH after OHCA effectively decreases body temperature at the time of hospital arrival. However, it does not improve rates of survival with good neurological outcome or overall survival and is associated with increased rates of re-arrest.

Abstract TP368: Improving In-House Stroke Code Imaging and Treatment Times

Background: In acute ischemic stroke, a blood vessel in the brain is blocked and brain cells die within minutes; therefore rapid recognition and treatment to restore circulation to the brain is essential. National guidelines call for a CT scan of the brain to be done within 25 minutes of hospital arrival in patients presenting with acute stroke to rule out bleeding in the brain. Findings of a hemorrhage would be a contraindication for thrombolytic therapy. Additional guidelines call for intravenous t-PA (alteplase) to be administered within 60 minutes of arrival and rapid triage to endovascular therapy in appropriate patients. Similar goals for rapid treatment should be followed for patients experiencing a stroke while in the hospital. Urgent treatment with a clot busting medication (alteplase) or with special endovascular techniques to mechanically remove a clot have been shown to improve outcomes. Purpose: A performance improvement plan was developed and initiated in January 2015 to improve the time to CT, time to t-PA administration, and time to endovascular therapy for patients having a stroke while hospitalized for other diagnoses (In-House Stroke). Method s: The following revisions were made to current practice: Mock Stroke Code Drills for In-House Stroke Code responders; creation of an In-House Stroke Code algorithm; addition of CT &amp; MRI screening forms to In-house Stroke Code packet; development of a Stroke Code criteria checklist to assist floor nurses; implementation of a feedback loop to Stroke Code team reporting imaging and treatment times along with patient outcomes; addition of a radiology supervisor to the Stroke Code response team. Results: “Stroke Code called” to “CT initiated“&lt; 25 minutes improved from 32% in 2013, 30% in 2014, to 60% in 2015. “Stroke Code called” to “IV t-PA (alteplase) administered” &lt; 60 minutes improved from 0% in 2013, 25% in 2014, to 100% in 2015. “Stroke Code called” to “groin puncture for endovascular therapy” &lt; 2 hours, 40% for 2013, 43% in 2014 to 50% in 2015. Conclusion: These interventions resulted in faster CT imaging and treatment times, thereby providing the patient with the highest quality patient care.

Infectious complications in obese patients after trauma

BackgroundObesity is a public health concern in the United States due to its increasing prevalence, especially in younger age groups. Trauma is the most common cause of death for people under aged 40 y. The purpose of this study is to determine the association between obesity and specific infectious complications after traumatic injury. Materials and methodsA retrospective analysis was conducted using data from the 2012 National Trauma Data Bank. The National Trauma Data Bank defined obesity as having a body mass index of 30 or greater. Descriptive statistics were calculated and stratified by obesity status. A hierarchical regression model was used to determine the odds of experiencing an infectious complication in patients with obesity while controlling for age, gender, diabetes, number of comorbidities, injury severity, injury mechanism, head injury, and surgical procedure. ResultsPatients with a body mass index of 30 or greater compared with nonobese patients had increased odds of having an infectious complication (Odds Ratio, 1.59; 1.49-1.69). In addition to obesity, injury severity score greater than 29, age 40 y or older, diabetes, comorbid conditions, and having a surgical procedure were also predictive of an infectious complication. ConclusionsOur results indicate that trauma patients with obesity are nearly 60% more likely to develop an infectious complication in the hospital. Infection prevention and control measures should be implemented soon after hospital arrival for patients with obesity, particularly those with operative trauma.

Factors Associated with Early Hospital Arrival in Patients with Acute Ischemic Stroke.

Background and PurposeFactors associated with early arrival may vary according to the characteristics of the hospital. We investigated the factors associated with early hospital arrival in two different stroke centers located in Korea and Japan.MethodsConsecutive patients with ischemic stroke arrived hospital within 48 hours of onset between January 2011 and December 2012 were identified and the clinical and time variables were retrieved from the prospective stroke registries of Severance Hospital of Yonsei University Health System (YUHS; Seoul, Korea) and National Cerebral and Cardiovascular Center (NCVC; Osaka, Japan). Subjects were dichotomized into early (time from onset to arrival ≤4.5 hours) and late (>4.5 hours) arrival groups. Univariate and multivariate analyses were performed to evaluate factors associated with early hospital arrival.ResultsA total of 1,966 subjects (992 from YUHS; 974 from NCVC) were included in this study. The median time from onset to arrival was 6.1 hours [interquartile range, 1.7-17.8 hours]. In multivariate analysis, the factors associated with early arrival were atrial fibrillation (Odds ratio [OR], 1.505; 95% confidence interval [CI], [1.168-1.939]), higher initial National Institute of Health Stroke Scale scores (OR, 1.037; 95% CI [1.023-1.051]), onset during daytime (OR, 2.799; 95% CI [2.173-3.605]), and transport by an emergency medical service (OR, 2.127; 95% CI [1.700-2.661]). These factors were consistently associated with early arrival in both hospitals.ConclusionsDespite differences between the hospitals, there were common factors related to early arrival. Efforts to identify and modify these factors may promote early hospital arrival and improve stroke outcome.

Abstract 101: Educational Level, Emergency Medical Services Activation and Hospital Arrival in Acute Stroke

Background: Several studies report that certain factors such as socioeconomic status, living alone or being alone at onset of symptoms play a role in late arrival at hospitals thereby decreasing the ultimate success of medical interventions for stroke patients. There is little research about the influence of educational level upon early arrival in patients with acute stroke. We hypothesized that higher educational level is associated with early arrivals in patients with acute stroke. Methods: We conducted a prospective cohort study to evaluate consecutive patients admitted with a new stroke in 19 hospitals in Fortaleza, Brazil, from April 2009 to April 2012. Educational attainment was categorized into 5 levels: no school attendance, less than secondary school graduation, secondary school graduation, bachelor's degree and master's or doctorate degree. Multiple logistic regressions were used to investigate the influence of epidemiologic and clinical data on the frequency of early arrival (defined as hospital arrival within 4.5 hours from symptoms onset). Results: We evaluated 4679 patients (48% males, mean age: 67.67± 14.48). Ischemic stroke was the most frequent subtype (74.9%) followed by intraparenchymal hemorrhage (14.5%), subarachnoid hemorrhage (5.1%), transient ischemic attack (2.8%), and undetermined stroke (2.7%). A total of 1128 (24.1%) patients arrived within 4.5 hours from symptoms onset. Higher educational level was a predictor of early hospital arrival (p= 0.01). Other univariate predictors of early hospital arrival included having a decreased level of consciousness at presentation OR 1.36 [1.17-1.58], p&lt;0.01, having a hemorrhagic stroke OR 1.46 [1.19-1.79] p&lt;0.01, having a transient ischemic attack OR 2.2 [1.50-3.49] and arriving by emergency medical services (EMS) OR 0.37 [0.31-0.44]. In the multivariate logistic regression analysis, educational level just remains as an independent predictor of early hospital arrival if arriving by EMS is not included in the model. Conclusions: Educational level is associated with early hospital arrival in patients with acute stroke. The association between educational level and early hospital arrival seems to be mediated by activation of the EMS.

Blood pressure at hospital admission and outcome after primary intracerebral hemorrhage

IntroductionThe importance of the admission blood pressure (BP) for intracerebral hemorrhage (ICH) outcome is not completely clear. Our objective was to analyze the clinical impact of BP at hospital arrival in patients with primary ICH.Material and methodsWe studied 316 patients (50% women, mean age: 64 years, 75% with hypertension history) with acute primary ICH. The first BP reading at admission was evaluated for its association with neuroimaging findings and outcome. A Cox proportional hazards model and Kaplan-Meier analyses were constructed to evaluate factors associated with in-hospital mortality.ResultsIntraventricular irruption occurred in 52% of cases. A high frequency of third ventricle extension was observed in patients with BP readings in the upper quartiles of the distribution (systolic, diastolic, or mean arterial pressure). Blood pressure readings did not correlate with hematoma volumes. In-hospital case fatality rate was 46% (63% among those with ventricular irruption). Systolic BP (SBP) > 190 mm Hg was independently associated with in-hospital mortality in supratentorial (n = 285) ICH (hazard ratio: 1.19, 95% confidence interval: 1.02-1.38, for the highest vs. the lowest quartile) even after adjustment for known strong predictors (age, ICH volume, Glasgow coma scale and ventricular extension). Blood pressure was not significantly associated with ventricular extension or outcome in patients with infratentorial ICH.ConclusionsA high BP on admission is associated with an increased risk of intraventricular extension and early mortality in patients with supratentorial ICH. However, a significant proportion of patients with high BP readings without ventricular irruption still have an increased risk of death.

Abstract 17993: Bystander-Initiated Cardiopulmonary Resuscitation Can Maintain Regional Cerebral Oxygen Saturation Levels on Hospital Arrival in Patients with Refractory Out-of-Hospital Cardiac Arrest

Background: Bystander-initiated cardiopulmonary resuscitation (B-CPR) plays a key role in the chain of survival for out-of-hospital cardiac arrest (OHCA) patients. We have previously reported that a low regional cerebral oxygen saturation (rSO2) level is a strong predictor of poor neurological outcome in OHCA patients. Objectives: To assess the association between B-CPR and rSO2 levels measured immediately on hospital arrival. Methods: This study was a prospective cohort study. Of 418 OHCA patients, 186 consecutive non-traumatic, cardiac arrest on arrival (CAOA) patients were prospectively registered. The rSO2 levels were measured with sensors placed on either side of their forehead using a near-infrared spectroscopy (NIRS) device (INVOS, Covidien, US) within 3 minutes after hospital arrival. We monitored rSO2 levels at least for more than one minute and used the lower of the 2 measured rSO2 levels for analysis. Clinical staff performed ordinary post-cardiac-arrest interventions (PCAIs) regardless of rSO2 levels. Primary outcome measure was good neurological outcome (CPC 1/2) at hospital discharge according to the “Utstein-style”. After dividing the eligible 186 patients into the two groups (B-CPR group (n=76) and no B-CPR group (n=110)), we compared the rSO2 levels on hospital arrival and the neurological outcome between the two groups. Results: Among 186 CAOA patients in PCAIs era, 18 patients (9.7%) had good neurological outcome. The B-CPR group patients had more maintained rSO2 levels on hospital arrival with a much higher proportion of good neurological outcome as compared with the no B-CPR group patients (33±20% vs. 22±13%, p=0.00003; 21% vs. 2%, p=0.00005, respectively). Conclusion: The findings suggest that B-CPR for CAOA patients after OHCA contributes to maintaining the rSO2 levels on hospital arrival and improving neurological outcome at hospital discharge even in the PCAIs era.

ED Crowding Lengthens Time to Antibiotics for CAP Patients

Administration of antibiotics within 4 hours of hospital arrival for patients with community-acquired pneumonia (CAP) and performance of percutaneous