In-hospital Delays Research Articles

Abstract T P272: Improving Staff Nurse Confidence in Responding to Inpatient Stroke

Background and Issues: Studies reveal greater in-hospital delays on evaluation for stroke when they occur in the hospitalized patient. Only 15 percent of in-hospital strokes are evaluated by a physician within 3 hours of onset. This significantly surpasses the Golden Hour target of 60 minutes to treat eligible patients. The more time that passes in eligible patients, the greater the extent of brain ischemia to be expected. Well-planned and executed stroke response processes must be developed within hospitals so that teams treating hospitalized stroke patients can achieve the time sensitive goal of door to needle within 60 minutes. Purpose: The purpose of this study was to optimize the response of inpatient staff nurses and promote their confidence with executing a newly developed inpatient stroke response process. Sample: Fifty-seven staff RNs in two medical-surgical units of a community hospital Method: The method included educational inservices with pre and post survey data collection. Each survey assessed RN knowledge of responding to inpatients having acute stroke symptoms and their confidence level in implementing the appropriate response. Simulation drills were conducted a month later. The drills assessed the RNs’ response to a stroke scenario and provided opportunities to role play each step of the interdisciplinary process. A post-drill survey assessed the RNs’ confidence with implementing the inpatient stroke response process. Results: Measureable increase in self-reported RN confidence with both recognizing and responding to acute stroke in hospitalized patients. On a 4 point likert-type scale, mean overall confidence in recognizing stroke symptoms went from 2.91 to 3.3 among all experience levels. Mean overall confidence in responding to stroke increased from 2.77 to 3.26. Data was stratified to reflect years of RN experience. Conclusions: RNs who participated in focused education and stroke process drills reported increased confidence in their role in stroke recognition and response. Additional data is needed to determine if increased RN confidence will lead to earlier detection of stroke, earlier interventions, and better outcomes.

Acute appendicitis in the elderly: risk factors for perforation

BackgroundAcute appendicitis is the most common surgical emergency and becomes serious when it perforates. Perforation is more frequent in the elderly patients. The aim of this study was to identify the risk factors of perforation in elderly patients who presented with acute appendicitis.MethodologyThe medical records of 214 patients over the age of 60 years who had a pathologically confirmed diagnosis of acute appendicitis over a period of 10 years (2003-2013) were retrospectively reviewed. Patients were grouped into those with perforated and those with nonperforated appendicitis. Comparison was made between both groups in regard to demography, clinical presentation, and time delay to surgery, diagnosis, hospital stay and postoperative complications. Clinical assessment, Ultrasonography and Computerized tomography, in that order, were used for diagnosis. The incidence of perforation was also compared with a previous report from the same region 10 years earlier.ResultsDuring the study period, a total of 214 patients over the age of 60 years had acute appendicitis, 103 males and 111 females. Appendix was found perforated in 87 (41%) patients, 46 (53%) males and 41 (47%) females. Of all patients, 31% were diagnosed by clinical assessment alone, 40% needed US and 29% CT scan. Of all the risk factors studied, the patient’s pre-hospital time delay was the most important risk factor for perforation. Perforation rate was not dependent on the presence of comorbid diseases or in-hospital time delay. Post operative complications occurred in 44 (21%) patients and they were three times more common in the perforated group, 33 (75%) patients in the perforated and 11 (25%) in the nonperforated group. There were 6 deaths (3%), 4 in the perforated and 2 in the nonperforated group.ConclusionAcute appendicitis in elderly patients is a serious disease that requires early diagnosis and treatment. Appendiceal Perforation increases both mortality and morbidity. All elderly patients presented to the hospital with abdominal pain should be admitted and investigated. The early use of CT scan can cut short the way to the appropriate treatment.

Process improvement to enhance existing stroke team activity toward more timely thrombolytic treatment.

Background and PurposeProcess improvement (PI) is an approach for enhancing the existing quality improvement process by making changes while keeping the existing process. We have shown that implementation of a stroke code program using a computerized physician order entry system is effective in reducing the in-hospital time delay to thrombolysis in acute stroke patients. We investigated whether implementation of this PI could further reduce the time delays by continuous improvement of the existing process.MethodsAfter determining a key indicator [time interval from emergency department (ED) arrival to intravenous (IV) thrombolysis] and conducting data analysis, the target time from ED arrival to IV thrombolysis in acute stroke patients was set at 40 min. The key indicator was monitored continuously at a weekly stroke conference. The possible reasons for the delay were determined in cases for which IV thrombolysis was not administered within the target time and, where possible, the problems were corrected. The time intervals from ED arrival to the various evaluation steps and treatment before and after implementation of the PI were compared.ResultsThe median time interval from ED arrival to IV thrombolysis in acute stroke patients was significantly reduced after implementation of the PI (from 63.5 to 45 min, p=0.001). The variation in the time interval was also reduced. A reduction in the evaluation time intervals was achieved after the PI [from 23 to 17 min for computed tomography scanning (p=0.003) and from 35 to 29 min for complete blood counts (p=0.006)].ConclusionsPI is effective for continuous improvement of the existing process by reducing the time delays between ED arrival and IV thrombolysis in acute stroke patients.

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Introduction: A stroke code system has become implemented in hospitals around the country and now represents the first step in evaluation of patients with a suspected stroke. Various evidence-based literature have shown the benefit of such a rapid-response system in identifying patients who would benefit from reperfusion therapy, improving overall outcomes, and shortening inhospital treatment delays. Most literature studies have supported the use of a focused history (especially discerning whether the patient has a history of CVA/TIA) physical examination, and neurologic testing to risk stratify patients and minimize unnecessary testing. However in clinical practice, this can sometimes be uncommon and physicians can activate stroke codes without proper initial evaluation. Methods: Single-center, retrospective clinical record review of patients who underwent a stroke code between 3/1/2012 to 5/1/2012. Inclusion criteria: a. Stroke code called to evaluate for acute CVA. b. Stroke code ordered by Emergency Department staff and house staff. c. All ages/sex included Exclusion Criteria a. CT head ordered for reasons other than to diagnose acute CVA. b. Patients who presented to ED following an outside diagnostic imaging test, i.e. MRI brain. Methods: We analyzed data from a retrospective cohort of patients at a single medical center who were already admitted or presented to the Emergency Department and underwent a stroke code from 3/1/2012 to 5/1/2012. We reviewed the charts to see what the primary indication was for the stroke code being called. We then reviewed if the patient was presenting to the ED or if they were already admittd. Then we also checked if the ordering physician documented a focused history, physical exam, or neurologic evaluation. A total number of 147 charts were reviewed. We also reviewed if the patients in the ED were admitted following a negative CT scan and if additional tests were ordered. Results: There were 147 patients who underwent a stroke code in the given months. There were a total of 38 positive CVAs. Thus, 26% of stroke codes were positive for an acute infarct or hemorrhage. Out of the 147 total stroke codes, 38 were called by the housestaff (i.e. resident, intern, floor attending). Of these 38 stroke codes, 19 were positive. Thus, 50% of the stroke codes called by the housestaff were positive. On the contrary, out of the 147 total stroke codes, 109 were called by the ED attending. Of those 109 stroke codes, 19 were positive. Thus, 17% of the stroke codes called by the ED staff were positive. It is also important to note that of the 38 total positive stroke codes, 29 of those patients had a prior history of a CVA. This represents 76% of positive stroke codes. As a result, it becomes important to take into consideration a patient’s prior medical history, especially if the presenting signs and symptoms are not as remarkable. Furthermore this study also recorded the most common complaints associated with a positive stroke code. For example, confusion, aphasia, and focal limb weakness made up 21 of the 38 (55%) positive stroke codes. In addition it is also important to note that a large majority of those patients, especially those presenting with confusion and aphasia, had a prior history of CVA/TIA. Conclusions: There is a large discrepancy between stroke codes and their results when called by the ED and housestaff. All physicians should document a patient’s medical history and symptoms along with a relevant neurologic exam. This would allow for better risk assessment for a CVA/TIA. Patients who have persistent symptoms should be admitted to telemetry. Patients who have transient symptoms but with a prior history of a CVA/TIA should also be admitted to telemetry, given their risk of progression. Patients with transient symptoms without a history of CVA/TIA or risk factors may be admitted to a regular bed or discharged from the ED after a focused work-up with extremely close follow up with their PCP and a neurologist.

Time to Hospital Admission and Start of Treatment in Patients with Ischemic Stroke in Northern Italy and Predictors of Delay

Background and Purpose: Early treatment (i.e. thrombolysis) is crucial for a successful care of ischemic stroke. In the management of stroke, two phases are crucial: the pre-hospital and the in-hospital interval. This work investigated factors influencing pre- and in-hospital delay in a large geographic area of Northern Italy. Methods: Enrolled were patients presenting with ischemic stroke in four administrative districts of Northern Italy (Como, Lecco, Sondrio and Varese) over a 4-month period. Pre-hospital time and in-hospital time with single management steps were recorded prospectively. Age, gender, recruiting hospital, EMS transport and triage codes, clinical severity and thrombolytic treatment were also recorded. Univariate and multivariate analysis of factors predicting pre- and in-hospital delay were performed. Results: Median pre-hospital time and in-hospital time were, respectively, 120 min (interquartile range, IQR 62-271) and 150 min (IQR 80-214). Pre-hospital time was halved in patients hospitalized via EMS (p < 0.001) and clinically more severe (p < 0.001). At multivariate analysis, transport code was associated with delay at any time (p < 0.05). Conclusions: EMS use and transport code predicted treatment delay in patients with ischemic stroke. A more intensive use of EMS and high urgency codes could help increase the number of stroke patients treated appropriately.

Introduction of a New Policy of no Nighttime Appendectomies: Impact on Appendiceal Perforation Rates and Postoperative Morbidity

Working hour limitations and tight health care budgets have posed significant challenges to emergency surgical services. Since 1 January 2010, surgical interventions at Berne University Hospital between 23:00 and 08:00 h have been restricted to patients with an expected serious adverse outcome if not operated on within 6 h. This study was designed to assess the safety of this new policy that restricts nighttime appendectomies (AEs). The patients that underwent AE from 1 January 2010 to 31 December 2011 ("2010-2011 group") were compared retrospectively with patients that underwent AE before introduction of the new policy (1 January 2006-31 December 2009; "2006-2009 group"). Overall, 390 patients were analyzed. There were 255 patients in the 2006-2009 group and 135 patients in the 2010-2011 group. Patients' demographics did not differ statistically between the two study groups; however, 45.9 % of the 2006-2009 group and 18.5 % of the 2010-2011 group were operated between 23:00 and 08:00 h (p < 0.001). The rates of appendiceal perforations and surgical site infections did not differ statistically between the 2006-2009 group and the 2010-2011 group (20 vs. 18.5 %, p = 0.725 and 2 vs. 0 %, p = 0.102). Additionally, no difference was found for the hospital length of stay (3.9 ± 7.4 vs. 3.4 ± 6.0 days, p = 0.586). However, the proportion of patients with an in-hospital delay of >12 h was significantly greater in the 2010-2011 group than in the 2006-2009 group [55.6 vs. 43.5 %, p = 0.024, odds ratio (95 % confidence interval 1.62 (1.1-2.47)]. Restricting AEs from 23:00 to 08:00 h does not increase the perforation rates and occurrence of clinical outcomes. Therefore, these results suggest that appendicitis may be managed safely in a semielective manner.

Thrombolysis in Acute Ischemic Stroke: A Simulation Study to Improve Pre- and in-Hospital Delays in Community Hospitals

BackgroundVarious studies demonstrate better patient outcome and higher thrombolysis rates achieved by centralized stroke care compared to decentralized care, i.e. community hospitals. It remains largely unclear how to improve thrombolysis rate in decentralized care. The aim of this simulation study was to assess the impact of previously identified success factors in a central model on thrombolysis rates and patient outcome when implemented for a decentral model.MethodsBased on a prospectively collected dataset of 1084 ischemic stroke patients, simulation was used to replicate current practice and estimate the effect of re-organizing decentralized stroke care to resemble a centralized model. Factors simulated included symptom onset call to help, emergency medical services transportation, and in-hospital diagnostic workup delays. Primary outcome was proportion of patients treated with thrombolysis; secondary endpoints were good functional outcome at 90 days, Onset-Treatment-Time (OTT), and OTT intervals, respectively.ResultsCombining all factors might increase thrombolysis rate by 7.9%, of which 6.6% ascribed to pre-hospital and 1.3% to in-hospital factors. Good functional outcome increased by 11.4%, 8.7% ascribed to pre-hospital and 2.7% to in-hospital factors. The OTT decreased 17 minutes, 7 minutes ascribed to pre-hospital and 10 minutes to in-hospital factors. An increase was observed in the proportion thrombolyzed within 1.5 hours; increasing by 14.1%, of which 5.6% ascribed to pre-hospital and 8.5% to in-hospital factors.ConclusionsSimulation technique may target opportunities for improving thrombolysis rates in acute stroke. Pre-hospital factors proved to be the most promising for improving thrombolysis rates in an implementation study.

In-hospital delays for stroke care: losing sight of patient-centered care

The emergence of patient-centered care has offered a challenge for health professionals in some settings to fully engage patients in all stages of the care process. For example, stroke is a condition that requires urgent and comprehensive care. This comprehensive care may be provided to patients who are experiencing compromised cognitive and communication skills. In addition, “in-hospital delays” in care can occur during the process of evaluation and treatment. In-hospital delays in receipt of acute stroke care and the challenges of post-stroke cognitive and communication functioning can result in some patients having negative perceptions of the care process. This brief communication is an exploration of focus group data that suggest achieving the key elements of patient-centered care is challenging in acute care settings that provide care for complex conditions such as stroke.

Minimising time to treatment: targeted strategies to minimise time to thrombolysis for acute ischaemic stroke

Time to thrombolysis is a critical determinant of favourable outcomes in acute ischaemic stroke. It is not infrequent that patient outcomes are compromised due to out-of-hospital and in-hospital time delays. On the other hand, time delays could be minimised through the identification of barriers and the implementation of targeted solutions. This review outlines the different strategies in minimising treatment delays and offers recommendations. Literature search in PubMed, Medline and EBSCO Host was conducted to identify studies that are relevant to reduction of time to treatment from January 1995 to December 2012. Strategies to reduce time to thrombolysis are categorised into pre-hospital strategies, in-hospital strategies and post-treatment decision strategies. Proposed pre-hospital strategies include public education on stroke symptoms awareness, prioritising stroke by emergency medical services, increasing ease of access to medical records, pre-hospital notification, and mobile computed tomography scanning. In-hospital strategies include a streamlined code stroke system, computed tomography scanner co-location with emergency department, 24/7 availability of stroke physicians, point-of-care laboratory testing and access to expert neuroimaging interpretation. Post-decision strategies include increasing availability of intravenous thrombolysis and simplification of informed consent procurement. Time to thrombolysis delays is multifactorial. Effective reduction of time delays for acute ischaemic stroke requires the correct identification of and targeted strategies to overcome time barriers.

Excessively Long Hospital Stays After Trauma Are Not Related to the Severity of Illness

Reduction in length of hospital stay is a veritable target in reducing the overall costs of health care. However, many existing approaches are flawed because the assumptions of what cause excessive length of stay are incorrect; we methodically identified the right targets in this study. To identify the causes of excessively prolonged hospitalization (ExProH) in trauma patients. The trauma registry, billing databases, and medical records of trauma admissions were reviewed. Excessively prolonged hospitalization was defined by the standard method used by insurers, which is a hospital stay that exceeds the Diagnosis Related Group-based trim point. The causes of ExProH were explored in a unique potentially avoidable days database, used by our hospital's case managers to track discharge delays. Level I academic trauma center. Adult trauma patients admitted between January 1, 2006, and December 31, 2010. Excessively prolonged hospitalization and hospital cost. Of 3237 patients, 155 (5%) had ExProH. The patients with ExProH compared with non-ExProH patients were older (mean [SD] age, 53 [21] vs 47 [22] years, respectively; P = .001), were more likely to have blunt trauma (92% vs 84%, respectively; P = .03), were more likely to be self-payers (16% vs 11%, respectively; P = .02) or covered by Medicare/Medicaid (41% vs 30%, respectively; P = .002), were more likely to be discharged to post-acute care facilities than home (65% vs 35%, respectively; P < .001), and had higher hospitalization cost (mean, $54 646 vs $18 444, respectively; P < .001). Both groups had similar Injury Severity Scores, Revised Trauma Scores, baseline comorbidities, and in-hospital complication rates. Independent predictors of mortality were discharge to a rehabilitation facility (odds ratio = 4.66; 95% CI, 2.71-8.00; P < .001) or other post-acute care facility (odds ratio = 5.04; 95% CI, 2.52-10.05; P < .001) as well as insurance type that was Medicare/Medicaid (odds ratio = 1.70; 95% CI, 1.06-2.72; P = .03) or self-pay (odds ratio = 2.43; 95% CI, 1.35-4.37; P = .003). The reasons for discharge delays were clinical in only 20% of the cases. The remaining discharges were excessively delayed because of difficulties in rehabilitation facility placement (47%), in-hospital operational delays (26%), or payer-related issues (7%). System-related issues, not severity of illness, prolong hospital stay excessively. Cost-reduction efforts should target operational bottlenecks between acute and postacute care.

Pre-hospital antibiotics for open fractures: Is there time? A descriptive study

Infection is a complication of open fractures. Early administration of intravenous (IV) antibiotics providing cover against gram positive and negative organisms has been shown to be the single most important factor in reducing infection rate in patients with open (compound) fractures. A delay of more than three hours from injury (open fractures or war wounds including fractures) to antibiotic administration is associated with a significantly higher infection rate. The purpose of this study is to identify the proportion of patients in a suburban sample that experience delay of more than 3 hours in antibiotic administration after open fracture. The authors hope to clarify if there would be opportunity and value in pre-hospital antibiotic administration in significantly shortening the delay. A retrospective and prospective descriptive study was conducted of all patients with open fractures of the limbs or girdles arriving via ambulance at a single district hospital in a suburban area in KwaZulu-Natal, South Africa from May to December 2012. Data analysed with descriptive statistics using STATA 11. 38 patients were identified from May to December 2012. The median total time from injury to antibiotics was 465 min (7.5 h) (Q1 = 230 min, Q3 = 615). Administration of antibiotics was delayed beyond 3 h in 78.9% (95% confidence interval (CI) 65.3 – 92.52) of patients and beyond 6 h in 60.5% (95% CI 44.2 – 76.8). A median of 164 min (Q1 = 115, Q3 = 222) was spent out of hospital with emergency medical care practitioners (EMCPs) being in attendance for a median of 56 min (Q1 = 37, Q3 = 64). The longest delay occurred after arrival at the hospital with a median of 363 min (Q1 = 171, Q3 = 505) until antibiotic administration. 26.3% of patients were transported directly from scene of injury to the hospital, while the remainder first presented to a clinic. There is much room for improvement within the study hospital and its drainage clinics in preventing delay in antibiotic administration. However, although much of the delay occurred due to clinic and in-hospital delays, there is also a hypothetical window available to pre-hospital healthcare providers where antibiotics may be administered which would dramatically decrease the time interval and bypass many of the difficulties encountered in-hospital. It would be safer to consider introducing IV antibiotics to the advanced scope of EMCP practise only; due to need to manage complications of antibiotics. Before considering introducing antibiotics to EMCP spectrum of care, efficacy, safety and cost-effectiveness studies would need to be undertaken. Randomised controlled trials are also recommended to determine the effect on reducing delay, infection and occurrence of adverse events.

Differences in process management and in-hospital delays in treatment with iv thrombolysis.

ObjectivesRapid initiation of intravenous thrombolysis improves patient’s outcome in acute stroke. We analyzed inter-center variability and factors that influence the door-to-needle time with a special focus on process measurements in all Austrian stroke units.MethodsCase level data of patients receiving intravenous thrombolysis in the Austrian Stroke Unit Registry were enriched with information of a structured questionnaire on center specific process measures of all Austrian stroke units. Influence of case and center specific variables was determined by LASSO procedure.ResultsCenter specific median door-to-needle time ranged between 30 and 78 minutes. Between April 2004 and November 2012, 6246 of 57991 patients treated in Austrian stroke units with acute ischemic stroke received intravenous thrombolysis. An onset-to-door time >120 minutes, patients with total anterior circulation stroke, recent year of admission, patient transportation with ambulance crew and emergency physician, the use of point of care tests reduced the door-to-needle time, whereas onset-to-door ≤60 minutes, unknown onset-to-door, patients with an NIHSS ≤4 or posterior circulation stroke, initial admission to a general emergency department, a distant radiology department, primary imaging modality other than plain CT and waiting for the lab results were associated with an increase in door-to-needle time. Case level and center specific factors could explain the inter center variability of door-to-needle times in 31 of 34 stroke units in Austria.ConclusionsIn light of our results it seems crucial that every single stroke center documents and critically reviews possibilities of optimizing practice strategies in acute stroke care.

Relationship Between Onset-to-Door Time and Door-to-Thrombolysis Time

Inverse relationship between onset-to-door time (ODT) and door-to-needle time (DNT) in stroke thrombolysis was reported from various registries. We analyzed this relationship and other determinants of DNT in dedicated stroke centers. Prospectively collected data of consecutive ischemic stroke patients from 10 centers who received IV thrombolysis within 4.5 hours from symptom onset were merged (n=7106). DNT was analyzed as a function of demographic and prehospital variables using regression analyses, and change over time was considered. In 6348 eligible patients with known treatment delays, median DNT was 42 minutes and kept decreasing steeply every year (P<0.001). Median DNT of 55 minutes was observed in patients with ODT ≤30 minutes, whereas it declined for patients presenting within the last 30 minutes of the 3-hour time window (median, 33 minutes) and of the 4.5-hour time window (20 minutes). For ODT within the first 30 minutes of the extended time window (181-210 minutes), DNT increased to 42 minutes. DNT was stable for ODT for 30 to 150 minutes (40-45 minutes). We found a weak inverse overall correlation between ODT and DNT (R(2)=-0.12; P<0.001), but it was strong in patients treated between 3 and 4.5 hours (R(2)=-0.75; P<0.001). ODT was independently inversely associated with DNT (P<0.001) in regression analysis. Octogenarians and women tended to have longer DNT. DNT was decreasing steeply over the last years in dedicated stroke centers; however, significant oscillations of in-hospital treatment delays occurred at both ends of the time window. This suggests that further improvements can be achieved, particularly in the elderly.

Patient–Provider Delays in Superior Vena Caval Obstruction of Lung Cancer and Outcomes

This retrospective study investigates the types of delay in the initiation of palliative thoracic radiotherapy for superior vena caval obstruction (SVCO) of lung cancer (LCa) and the effect of treatment delay on patient outcomes. Treatment delays were categorized as patient delay (duration of symptoms), in-hospital delay, and professional delay and were determined in 42 people treated by radiation for palliation of the complicated neoplastic condition between 1981 and 2009. The median period of patient delay was 26.2 days, in-hospital delay was 3.5 days, and professional delay was 1.5 days. The majority (80%) of these individuals were uninsured or underinsured, and 69% presented with locally advanced LCa. The overall response rate was 84%, and the 1-year survival rate was 24%. Despite the longest patient-related delay, symptomatic individuals overall derived palliation from conventional treatment. Improved efforts toward early diagnosis and treatment of patients with SVCO-LCa need to be continued.

Prenotification and Other Factors Involved in Rapid tPA Administration

In acute ischemic stroke, time is brain. Current guidelines recommend that the time from arrival at hospital to initiation of administration of tissue plasminogen activator, also known as the door-to-needle (DTN) time, should be 60 min or less. However, DTN times in practice usually exceed this recommended time. The median DTN times from the American Heart Association/American Stroke Association Get With The Guidelines-Stroke program and the multinational Safe Implementation of Treatment in Stroke International Stroke Thrombolysis Register are 75 min and 65 min, respectively. Prehospital factors associated with delays include patient-related factors such as poor recognition of stroke symptoms, poor use of emergency medical services, and complex psychosocial factors. Accurate recognition of stroke symptoms at a dispatcher and paramedic level is associated with shorter onset-to-arrival times. Prenotification of regional stroke centers by paramedics is strongly associated with shorter DTN times. In-hospital delays resulting in prolonged DTN times can be attenuated by having well-defined rapid triage pathways, defined stroke teams, single-call stroke team activation, established code stroke protocols, rapid access to diagnostic imaging, and laboratory services. In this review we summarize factors associated with prolonged DTN times and processes that allow faster onset-to-treatment times. Recent developments in the field are highlighted.

What are the Most Important Barriers for Thrombolytic Therapy in Ischemic Stroke Patients?

Dear Editor We pose the question what are the most important barriers for thrombolytic therapy in ischemic stroke patients? Cerebrovascular disease is the second common cause of the death in the world. Intravenous thrombolysis is the only approved therapy for acute ischemic stroke patients and its safety and efficacy has been established (1), Nonetheless, in developing countries, thrombolytic therapy for acute ischemic stroke patients is available only for 1–3% of patients and mostly in urban areas (2). Iran is a developing country with stroke prevalence of more than 100 per 100 000 population (3); however, a very limited number of centers are providing this treatment to patients. For finding the most important barriers for thrombolytic therapy, during a one-year study period, any patient who met the Cinncinati Stroke Scale enrolled at our study. Six hundred forty-seven patients (mean age was 69 and 52·2% were female) enrolled. After lab study and CT scanning, 515(79·4%) patients were diagnosed as ischemic stroke. One hundred fifty-nine (31·3%) patients were arrived at the hospital in the first three-hours of symptoms onset. Among these patients, 131 (82·3%) missed thrombolytic therapy due to delayed performance of brain CT scanning and laboratory tests and 61 (38·3%) due to having other tissue plasminogen activator contraindications (some of patients had both). Mean time interval between hospital arrival to completing CT scan was 91 min, and hospital arrival to complete investigations (door to needle time) was 147 min. Exclusion criteria for early arrived patients are shown in Table 1. Only 16 (3·1%) patients of all cases remained eligible for thrombolytic therapy. The main barriers for implementation of thrombolytic therapy in developing countries are: delay in arrival of patients at the emergency department after symptoms onset, which is mainly due to poor recognition of stroke symptoms among public and lack of rapid transportation to the hospital; financial constraints because of high cost of the drug; lack of proper treatment facilities; physicians fear of serious side effects of the drug specially intracranial hemorrhage; and lack of faith of the part of physicians regarding the efficacy of thrombolytic therapy (2). Based on results of this study, the most important barrier to implementing thrombolytic therapy for acute ischemic stroke patients were in-hospital delays such as initial patient assessment, performing CT scan, and lab studies and shows that in hospitals which has the required infrastracture, initiating a fasttrack system could have a significant impact on rising the eligibility rate of this patients.

Shortest door-to-balloon time in primary percutaneous coronary intervention for a young resident physician suffering from in-hospital inferior ST-segment elevation myocardial infarction

Percutaneous coronary intervention (PCI) for patients with ST-segment myocardial infarction (STEMI) significantly improves clinical outcomes but can't possibly be accomplished in less than 20min for pre- and in-hospital delays[1]. Here we report a young resident physician of a tertiary referral hospital who suffered acute inferior STEMI and junctional bradycardia during working hours and was successfully rescued by primary PCI within a very short door-to-balloon period of 11min. Thus, with the patient's rapid presentation and the system's availability, acute STEMI could be intervened by primary PCI speedily, especially for those working in tertiary referral hospitals and having easier access to medical facilities.

Factors Associated With Pre-hospital Delay in Patients With Acute Myocardial Infarction

BackgroundTreatment of patients with acute myocardial infarction (AMI) is time related, so delay in treatment could affect prognosis. Recognizing pre-hospital or in-hospital delays in initiating treatment and reducing these factors is very efficacious in treatment of these patients.ObjectivesThe aim of this study is evaluate the causes of pre-hospital delay just as other studies on effect of different variables such as socioeconomic and personal factors on pre-hospital delay in with patients with AMI.Materials and MethodsA cross sectional study was carried out on 227 patients with acute myocardial infarction and demographic data, educational level, marital status, type of transfer to hospital and delay in arrival to hospital were recorded.Results35.7% patients arrived during one hour of symptom onset, and 7.9% arrived after 24 hours. Patients having high level education (P = 0.0492) and with a family history of coronary artery disease (P = 0.01) had significantly less delay in arriving to hospital. Age, marital status, gender, and route of transfer to hospital were not related with pre-hospital delay (P > 0.05). Patients thought most common cause of delay in arrival was unawareness of coronary artery disease (38.8%) and self-medication (34.3%).ConclusionsIncreasing awareness of patients about cardiovascular symptoms and their risk factors could be helpful in patient's decision in seeking medical help. So general education via media and primary and middle schools could be helpful.

Abstract P204: Tissue Plasminogen Activator (tPA) Eligibility for Acute Stroke in Urban and Rural Hospitals in North Carolina: The North Carolina Stroke Care Collaborative

Introduction: Thrombolytic therapy was approved over a decade ago for the treatment of acute ischemic stroke, yet administration remains infrequent in clinical practice partly due to pre- and in-hospital delays and patient contraindications. Reports of urban-rural differences in eligibility for and treatment with tPA are few. Understanding differences by hospital location may help identify quality improvement strategies unique to particular hospital systems, particularly those in non-metropolitan areas of North Carolina in which nearly one-third of the population resides. Methods: We included all acute ischemic strokes in the NC Stroke Care Collaborative, a voluntary state-wide quality improvement program, from Jan 2008 - Aug 2012 with valid, non-missing times from symptom onset to hospital arrival. Location of the 60 participating hospitals was classified as metropolitan, micropolitan, or smalltown using Rural-Urban Commuting Area codes. Rates of intravenous tPA eligibility and receipt were calculated by hospital location. Pre-hospital (onset to arrival) and CT (arrival to CT interpretation) delay times were compared using Wilcoxon tests. Reasons for non-eligibility by hospital location were compared using chi-squared statistics. Results: We identified 16,050 ischemic stroke patients (13,913 metropolitan, 1897 micropolitan, and 240 smalltown). Pre-hospital delay was longer among patients treated at smalltown compared with metropolitan hospitals (median hours [IQR] 3.8 [1.0-9.9] vs. 3.3 [1.3-8.2], p=0.04) but the proportion arriving within 2 hours of symptom onset was similar (38%). CT delay was slightly longer for patients at metropolitan compared with smalltown hospitals (1.1 [0.6-1.7] vs. 0.8 [0.5-1.2]; p&lt;0.0001). Thirty-eight percent (2004 of 5276) of patients arriving within 2 hours were eligible for tPA at metropolitan hospitals compared with 41% (304 of 741) at micropolitan and 46% (42 of 92) at smalltown hospitals (p=0.1). Patients in smalltown compared with metropolitan hospitals had higher rates of ineligibility due to advanced age (5% vs. 3%) and family/patient refusal (9% vs. 3%), whereas patients in metropolitan hospitals had higher rates of contraindications (35% vs. 12%) and rapid improvement/symptom resolution (20% vs. 12%). Rece ipt of tPA among eligible patients was highest in metropolitan (70%, 1399 of 2004) compared with micropolitan (37%, 113 of 304) and smalltown hospitals (33%, 14 of 42; p&lt;0.001). Conclusion: Receipt of tPA within 3 hours of symptom onset remains below guideline recommendations. Pre-hospital and CT delay times and eligibility for tPA were largely similar across hospital locations. Despite this, tPA administration was considerably lower at smalltown hospitals compared with hospitals in urban settings, suggesting the need for quality improvements targeted at smalltown hospitals that may have less stroke care capability.

Appendicitis in children: an ongoing debate

The aim of the study by Lee et al. (ref) was to evaluate determinants (co-morbidities) and outcomes of in-hospital delay in treatment of children with acute appendicitis. This retrospective evaluation was done using a database of 683,016 children hospitalised with appendicitis between 2000 and 2008 in the USA. Out of these, 17,737 children (2.6 %) experienced a delay in treatment of 2 days or more (Median 3 days; IQR 2–5 days). The underlying hypothesis is that ‘Increased time interval from the onset of symptoms to intervention is associated with increased rate of rupture’ as the authors state in their introduction. This hypothesis, however, has never been proven, and has even been disputed by several investigators [1–3]. It has been demonstrated that the majority of patients with ruptured appendicitis have the perforation already at the time of presentation at the hospital [3]. Several authors envisage two types of appendicitis: simple (non-perforated) appendicitis, with no tendency to progress, and complex (perforated) appendicitis, in which perforation occurs early in the course of the disease [3, 4]. The authors reported significant differences between the groups with and without delay in terms of age, sex, ethnicity and presence of co-morbidities (Table 1). Significantly more patients with a delay in treatment (57.3 %) had a complicated disease course, including perforation, than was seen in the early treatment group (28.9 %) (Table 3). Not surprisingly, therefore, the authors demonstrate an association between delayed treatment and adverse outcome, such as mortality, length of stay and increased cost (Table 4). The implicit but not proven assumption of the authors is that perforation of the appendix occurred during the delay between admission and treatment and, therefore, could have been prevented. There is no argument that early diagnosis and treatment (whether operative or antibiotic) of acute appendicitis actually results in reduction of pain, anxiety, complications and costs.