Minutes Of Arrival Research Articles

Abstract WP358: Lightning Fast Stroke Treatment: Recognition Makes a Difference

Background: For acute ischemic stroke patients, reduced door-to-needle (DTN) times are associated with better clinical outcomes. Our Stroke Center evaluated DTN time for thrombolysis cases since 2004 to identify opportunities to reduce time to treatment. In October 2014, the American Heart Association/American Stroke Association introduced Target: Stroke Phase II to challenge Get With the Guidelines-Stroke participating hospitals to reduce time to tPA. In January 2015 our center adopted the goal DTN time of 45 minutes. Many best practice strategies outlined in Target: Stroke Phase II were previously implemented, including: EMS pre-notification, single call activation, rapid evaluation by the Stroke Team, and rapid completion and interpretation of brain imaging. In 2015, our stroke center was able to administer tPA within 45 minutes of Emergency Department (ED) arrival in 29% of cases (n=35). Purpose: The purpose of this project is reduce DTN times by recognizing the efforts of the interdisciplinary team in cases of timely thrombolysis. Methods: A team-based approach is used for all ED Stroke Alerts. Starting January 2016, for each case of tPA administration within 45 minutes of arrival, every team member was recognized for their contribution in providing “Lightning Fast Stroke Care.” A flyer was developed highlighting details of the case, clinical outcome, and recognizing every team member who participated in the care of the patient. Persons recognized include: EMS, ED nurses, techs and physicians, registration, radiology techs, laboratory staff, pharmacists, Stroke Team physicians and trainees. Flyers were distributed and displayed publically. Each team member recognized received a lightning bolt pin, in addition to a copy of the flyer. Results: In 2016, over 500 pins were awarded for Lightning Fast Stroke Treatment, and the lightning bolt pin became a badge of honor recognized throughout the medical center. Our Stroke Center was able to administer tPA within 45 minutes of ED arrival in 58% of cases (n=40). Without making other changes to the process our percent of cases achieving DTN within 45 minutes doubled. Conclusion: Recognition and feedback are important to providing team-based care and have made a significant sustainable impact on DTN times.

Abstract WP370: Breaking Barriers for Fast Acute Stroke Treatment

Background: Timeliness of acute stroke treatment is imperative. Our 384 bed, Midwestern community hospital seeks to treat ischemic stroke tPA patients within 45 minutes of arrival. However, individual staff attitudes toward use of tPA, early treatment and teamwork appeared to be barriers to timely treatment. Purpose: To understand what the barriers are for fast treatment and to give staff tools to overcome. Methods: A carefully designed, but brief, set of survey questions concerning individual views and attitudes toward the timeliness and smooth treatment between EDP/ED nurses/Neurology was completed by EDP’s, ED Nurses and Neurologists. The data from this survey was analyzed and provided information to implement changes: 1] Immediate and collaborative feedback reporting timing and outcomes; 2] Provision of a stroke-alert algorithm attached to tPA; and, 3] Accessible education information for patients and family. Results: 56 staff completed the survey pre intervention (PRE) and 72 post intervention (POST). In most cases the barriers were reduced POST. Top barriers identified were: Slow ED to Neurology Contact time PRE 38% and POST 21%; EDP reluctance to treat PRE 32% and POST 18%; Difficulty identifying stroke patients PRE 30% and POST 26%; Losing track of time PRE 29% and POST 19%; Delay due to time to educate patients PRE 18% and POST 19%. Treatment times PRE were an average of 52 minutes door to needle and POST an average of 45 minutes. Door to neurology contact was PRE an average 20 minutes and POST an average of 11 minutes. There was a shift of the EDP’s attitude towards tPA use for acute stroke. PRE 50% answered that tPA use for stroke is not based on existing science. POST this was reduced to 20%. Conclusions: While treatment time, neurology contact time, and reported barriers were improved, the clear shift in EDP collective attitude toward tPA was most important. Keeping stroke at the forefront by communicating through collaborative feedback reports appeared to keep staff engaged and accountable. Keeping algorithms and tPA education material immediately available also assisted in our treatment goals.

Abstract TP222: Improving the Quality of Acute Stroke Care in regional Australia: The Victorian Stroke Telemedicine Program

Background: The Victorian Stroke Telemedicine (VST) program is the largest stroke telemedicine service operating in Australia. Patients and clinicians at 16 regional hospitals in Victoria are provided with 24/7/365 access to a network of on-call metropolitan-based neurologists via telemedicine. The VST program supports rapid differential diagnosis and enhances access to best-practice treatments for acute stroke, including transfer to comprehensive stroke centres for endovascular clot retrieval (ECR). Method: A historical-controlled cohort design was used to evaluate the VST Program. At each hospital, consecutive patient-level data were obtained 12 months before the VST program commenced (pre) and during the first 12 months of implementing the program (post). Basic clinical data were collected for patients aged 18 years or more and arriving in the Emergency Department (ED) with suspected stroke. Detailed data collection on the patient journey in hospital was conducted for patients with a confirmed ischemic stroke who arrived within 4.5 hours of symptom onset. Aggregated descriptive statistics using the available data for 16 hospitals are presented. Results: Overall, 6099 patients with suspected stroke (2932 pre, 3167 post) have presented up to 28/7/2017. Patients arriving to ED within 4.5 hours of ischemic stroke symptom onset: pre-VST n=358 (54% male; mean age 74 years) and post-VST n=484 (59% male, median age 76 years). The proportion of patients meeting these criteria who received intravenous thrombolysis increased (pre: 30% to post: 38%, p=0.019). The median door-to-needle time was faster (pre: 103 minutes; post: 72 minutes, p<0.001), and more patients received thrombolysis within 60 minutes of arrival (pre: 14%; post: 32%, p<0.001). Symptomatic intracerebral hemorrhage after thrombolysis was reduced (pre: 16%; post: 5%, p=0.002). Since the availability of ECR in May 2015, 25% of cases receiving thrombolysis were transferred for ECR. Conclusion: Telemedicine expedites access to optimal stroke care and immediately facilitated access to the newest intervention, ECR, with more patients safely and efficiently treated.

Abstract TMP65: The Minnesota Stroke System, 2012-2017: Development and Impact of a Statewide System of Stroke Care

Background: The Minnesota Stroke System is comprised of hospitals able to deliver state-of-the-art stroke treatment. The system is designed to increase access to acute stroke treatment and improve outcomes for stroke patients. Between 2011 and 2013, the Minnesota Department of Health convened health care providers and stroke patient advocates to plan and create the components of a statewide stroke system for Minnesota. To launch the system, the Minnesota legislature gave MDH statutory authorization to designate Acute Stroke Ready Hospitals (ASRHs) and recognize Primary and Comprehensive Stroke Centers certified by national accreditation bodies. The ASRHs meet ten criteria corresponding to the 2013 Brain Attack Coalition recommendations. Analysis: Stroke patient data are reported to the Minnesota Stroke Registry by hospital-based abstractors. Data are combined for 2012-2013, 2014-2015, and 2016-2017. Performance metric statistics were calculated using SAS (Cary, NC). The resident population living within 30 minutes of designated hospitals was calculated from 2010 US Census Bureau data using ArcGIS 10.3 Network Analyst. Results: From 2012 to 2017, the number of designated ASRHs increased from zero to 89, out of 111 eligible hospitals. The percentage of residents living within 30 minutes of any designated facility increased from 60% to 90%. The percentage of all stroke patients whose computed tomography image was initiated within 25 minutes of arrival increased from 34.2% to 42.9%. Intravenous thrombolytic therapy increased from 8.8% to 11% of all ischemic stroke patients. Median door-to-imaging time decreased from 40 to 33 minutes. Median door-to-needle time decreased from 56 to 53 minutes. 28.7% of patients in 2012-2013 who received IV tPA were treated within 4.5 hours of time last known well, increasing to 35.6% in 2016-2017. Conclusions: The Minnesota Stroke System has successfully catalyzed and supported significant improvements in acute stroke treatment in Minnesota.

Abstract WP274: Impact of Discontinuation of Telestroke

Introduction: Telestroke can improve access to experts at smaller hospitals to assist with thrombolysis decision making. We trialled a regional telestroke ‘hub’ and ‘spoke’ model that was associated with a substantial increase in thrombolysis rates at ‘spoke’ hospitals. One ‘spoke’ hospital, however, elected to discontinue the telestroke service and returned to providing thrombolysis solely under the guidance of local general physicians. The rationale being that the transient telestroke service helped to upskill local doctors and that the boost in rate was partially or even mainly due to other changes in the local services. Methods: This is a sequential comparison of three periods: 6 months pre-telestroke, 6-months during telestroke, and 6-months post telestroke. Main outcomes were thrombolysis rate and door-to-needle time with versus without telestroke support. Results: Over the 18-month period, 25 patients of 195 admitted ischemic stroke patients were thrombolyzed at this small centre. The thromboloysis rate was 8.5% (6/71) during the 6-months pre, 23.0% (14/61) during the 6-months of, and 7.9% (5/63) during the 6-months post the use of telestroke support from the tertiary centre (with telestroke odds (95% CI) of being thrombolyzed 3.33 (1.41-7.86); p=0.006). Patients receiving thrombolysis within 60 minutes of arrival were 50% before, 64% during, and 20% after telestroke (with telestroke OR (95%CI) 3.15 (0.61-16.3); p=0.16). Careful review of patients not treated after discontinuation of telestroke revealed that nine additional patients would have likely been treated had a stroke specialist been involved in the decision-making process raising treatment rate to 22% (14/63). Conclusion: These finding indicate that the transient implementation of telestroke was insufficient to upskill provincial hospital generalist clinicians to sustain a high thrombolysis rate. It also supports the conclusion that telestroke itself contributed strongly to the increase in treatment rate rather than the rate increase being primarily attributable to other factors. The numbers are small and need to be interpreted with caution. However, interestingly, the rates at centres who have opted to continue with telestroke have been maintained at the much higher level.

Effect of the 4-h target on ‘time-to-ECG’ in patients presenting with chest pain to an emergency department: a pilot retrospective observational study

Objectives The aim of this study was to assess the relationship between compliance with time-based Emergency Department (ED) targets (known as NEAT) and the time taken to collect an electrocardiogram (TTE) in patients presenting with chest pain. Methods This was a pilot descriptive retrospective cohort study completed in a large inner city tertiary ED. Patients who presented with active or recent chest pain between July 2014 and June 2015 were eligible for inclusion. Pregnant patients, inter-hospital transfers, and traumatic chest pain were excluded. A random selection of 300 patients from the eligible cohort comprised the final sample. The differences of TTE between categories of NEAT compliance were compared using Kruskal-Wallis test. Also, the factors affecting with the acquisition of ECG within ten minutes of arrival were explored using proportional hazards regression. Results There was a significant inverse association between the percentage of admitted patients leaving the ED within four hours (admitted NEAT) and TTE. As admitted NEAT compliance increased TTE decreased (p=0.004). A number of variables including triage score, arrival time, total NEAT, first location, doctor wait time, and cardiac diagnosis were all significant predictors of TTE. After adjusting for other variables Admitted NEAT remained as an independent predictor of TTE. Conclusion There is likely to be a relationship between NEAT and TTE that is reflective of overall hospital and not just ED functioning; however the exact relationship remains uncertain. Further study in a multisite study is warranted to further explore the relationship between NEAT, TTE and other important clinical metrics of ED performance. What is known about the topic? The 4-h time target or National Emergency Access Target (NEAT) is implemented in Australia to ease crowding and access block. However, little is known of its effect on important clinical endpoints, particularly 'time-to-ECG' (TTE). What does this paper add? This paper demonstrates a complex relationship between measures of time-based targets, such as time to ECG. It is likely that increasing compliance with admitted NEAT shortens TTE, demonstrating the effect of hospital functioning on the ability to deliver quality care in the emergency department. What are the implications for practitioners? Emergency department flow has an effect on the ability of the department to deliver key assessment. There is a relationship between NEAT compliance and TTE, but the exact relationship requires further exploration in larger multicentre studies.

Post-antibiotic management of immunocompromised children with febrile neutropenia.

39 Background: Febrile neutropenia in immunocompromised children is a medical emergency and requires prompt administration of antibiotics and supportive care management to prevent death from sepsis. We have previously shown that improvement in time to antibiotic administration from a baseline of 108 minutes was decreased to 64 minutes in 67 children in six St. Jude affiliate clinics. The improvement was achieved by designing a unique order set and process for prompt dispensing of antibiotics at each affiliate site. However, the clinical assessment of patients after antibiotic administration to provide early intervention for treatment of septic shock did not improve. Management of fluid status, oxygen therapy, and blood pressure support are critical for optimal outcome. The time from antibiotic administration to clinical assessment remained above the expected time of 15 minutes at an average of 60 minutes. To improve the post-antibiotic management, additional guidelines were established and monitored for compliance. Methods: Clinical guidelines were written. The guidelines included: patient assessed by nurse and vital signs checked within 15 minutes of arrival, patient assessed by a clinician within 30 minutes of arrival, antibiotic administrated within 60 minutes of arrival, nurse completed post-antibiotic assessment and vital signs rechecked within 15 minutes of administration, and clinician completed post antibiotic assessment within 30 minutes of administration. Results: After establishing guidelines, each site developed a process for implementation using a similar approach of automated order sets, time reminders, and staff education of the initial management of septic shock. Chart reviews were done at one year after implementation and all were in compliance. Conclusions: Clinical guidelines, automated order sets, and continued awareness and education in the management of immunocompromised children with febrile neutropenia improved compliance with this quality project. Continued monitoring is needed to ensure the results are sustained.

Abstract WMP92: Quality of Care and Outcomes for Acute Ischemic Stroke Patients Admitted During the International Stroke Conference

Introduction: Patients who present to the hospital during off-hours receive sub-optimal care and experience worse outcomes, often attributed to reduced staffing. It is unknown whether stroke patients receive less guideline-adherent care and experience worse outcomes when medical providers attend scientific meetings. The AHA International Stroke Conference (ISC) is the premier US conference for cerebrovascular disease and is well attended by stroke clinicians. Methods: The national Get With The Guidelines - Stroke (GWTG-Stroke) dataset was analyzed from 2009-2015 to identify acute ischemic stroke (AIS) patients admitted during: 1) the week of ISC, and 2) the 2 weeks before and 2 weeks after ISC. We compared adherence to GWTG-Stroke quality measures and outcomes for AIS patients admitted during these two time periods using univariable and multivariable analysis, including both patient and hospital level variables. Results: Overall, 69,738 AIS patients were included, mean age 72, 52% female, and 29% non-white. There was no difference between the average weekly number of AIS cases admitted during ISC weeks versus non-ISC weeks (1,984 vs 1,997, p= 0.95). Patient and hospital characteristics were also similar between ISC vs. non-ISC time periods. No significant differences were noted in 14 quality of care metrics and 5 clinical outcomes between AIS patients treated during ISC vs. non-ISC weeks (Table). After adjusting for potential confounders, among patients who presented within 2 hours of onset there was no difference in the likelihood of receiving IV tPA within 3 hours (adjusted odds ratio 0.89, 95% confidence interval [CI] 0.77 - 1.03, p=0.13), nor in the likelihood of receiving IV tPA within 60 minutes of arrival (adjusted odds ratio 0.92, 95% CI 0.83 - 1.02, p=0.13). Conclusions: The treatment and outcome of patients who present with AIS to a GWTG-Stroke participating hospital are not degraded during the week of the International Stroke Conference.

Abstract WP305: Uniting Hospital Leaders in a Competitive Region to Improve Intravenous Thrombolysis Rates: Analysis of the SETRAC Stroke Registry

Uniting Hospital Leaders in a Competitive Region To Improve Intravenous Thrombolysis Treatment Rates: Analysis of the SETRAC Stroke Registry Background: The Southeast Texas Regional Advisory Council (SETRAC) convenes representatives from area hospitals belonging to different health systems to discuss how to improve the delivery of stroke care in a nine county area that includes Houston, Texas. In 2014, area hospitals agreed to focus upon improving tissue plasminogen activator (tPA) administration rates in the area. Hypothesis: By sharing stroke metrics in a blinded fashion on a consistent basis, tPA administration rates will improve. The theory was tested by tracking the following metrics: a. percent of ischemic stroke patients receiving tPA. b. percent of treated patients receiving tPA within 60 minutes of arrival at the hospital. Methods: SETRAC aligned regional metrics with stroke treatment and timing metrics in Get With The Guidelines®-Stroke beginning in Q3 2014. SETRAC compiled and shared this data with stroke coordinators and hospital administrators on a quarterly basis. Bar graphs were utilized for benchmarking hospitals in a blinded fashion. Linear tests were performed to validate increases in the percent of patients treated with tPA and the percent of patients treated within 60 minutes of arrival at the hospital. Results from hospitals that consistently reported data for each of the six quarters were included in the analysis. Results: Twenty-six area hospitals reported 10,396 ischemic stroke patients between Q3 2014 through Q4 2015. In that time, tPA administration increased from 10.3% in Q3 2014 to 12.0% in Q4 2015 (p<0.001). Further, tPA administration within 60 minutes of arrival in emergency room increased from 55.3% in Q3 2014 to 66.7% in Q4 2015 (p<0.001). In conclusion, following the uniting of hospital leaders and utilizing nationally aligned stroke metrics, a higher percentage of ischemic stroke patients received tPA. Of those that received tPA, an improvement in the timeliness of administration was also realized.

Abstract 52: Establishing the First Mobile Stroke Unit in the United States

Background: A Mobile Stroke Unit (MSU) delivers Emergency Department (ED) care in the pre-hospital setting. We describe establishing the first MSU in the U.S. Methods: A full time Medical Director and Project Manager took ownership of the project. A funding plan was developed to build,staff and supply the unit for 3 years. An ambulance company donated a standard ambulance. MSU build-out began after purchase of the CT scanner. A consortium of stakeholders was formed including leaders of the stroke programs and EDs of the city’s 3 Comprehensive Stroke Centers (CSCs) and Houston Emergency Medical Services (EMS). Policies and procedures were developed to obtain both state and city health department licensing and inspection, and an accountability system to maintain the unit to standards. Radiation safety certification was obtained from the state health department. Radiation safety experts inspected the vehicle,obtained rad. measurements and designed safety procedures,confirming minimal risk. Insurance on the vehicle and all equipment was obtained. Staffing was hired,and a secure location to park the MSU with electrical hook-up and an office were located. An EMS education program was carried out and communication pathway developed enabling immediate MSU dispatch within a 5 mile radius following a 911 call, as well as for first-responders to activate the MSU. A study protocol was written to evaluate logistics,cost-effectiveness,telemedicine (TM) vs. on-scene decisions and patient outcomes. A HIPPA-compliant technology grid enabled viewing of CT images by the TM team and receiving hospital radiologist. Results: The MSU effort began in March 2013 and the MSU received Feb 4, 2014. The Houston MSU is a standard 12’ ambulance staffed by a neurologist and registered nurse with stroke expertise, CT tech, and paramedic, with TM connectivity, responding to acute stroke dispatches daily from 8a-6p. All MSU management is standard of care; patient consent is not required except to include patient data. This includes a non-con head CT, point of care labs, blood pressure management and if necessary advanced life support. Conclusion: The Houston MSU treated its first patient on May16,2014, and is carrying out acute stroke treatment within 10-18 minutes of arrival on location.

Abstract 16216: Emergency Department Crowding Does Not Predict Door-In-Door-Out Time for Acute Myocardial Infarction Patients Transferred for Acute Coronary Intervention

Introduction: Emergency department (ED) crowding and prolonged length of stay (LOS) are associated with lower quality care. Patients with acute myocardial infarction (AMI) should be transferred to percutaneous coronary intervention capable facilities within 45 minutes of arrival. Hypothesis: Increased ED crowding, as measured by ED LOS, is correlated with longer AMI door-in-door-out (DIDO) times at transferring EDs. Methods: We analyzed the Centers for Medicare and Medicaid Services (CMS) quality data. The outcome, DIDO, was CMS measure OP-3b, ED Median Time to Transfer a Patient with AMI for Acute Coronary Intervention . OP-3b data included hospitals with ≥10 AMI cases annually. To measure ED crowding, we used the CMS ED timeliness measures: discharged LOS, admitted LOS, boarding, and waiting time to be seen by a provider. Our primary measure of interest was ED-1: Median ED LOS for Admitted Patients . We analyzed bivariate associations between DIDO and ED timeliness measures. We used linear regression to evaluate the contribution of hospital characteristics from the American Hospital Association survey (academic, trauma, rural, ED volume) to DIDO. Results: Data were available for 405 out of 4,129 hospitals for the CMS DIDO measure (934 had <10 cases). These facilities were primarily non-academic (99%), non-trauma centers (65%), in metro locations (68.6%). Median DIDO was 54 minutes (IQR 42, 68). Increased DIDO time was associated with longer admitted LOS, and boarding times, but not waiting time or discharged LOS. Mean ED admitted LOS was different between hospitals with average DIDO <45 versus those ≥45 minutes (259 vs. 283 minutes; p=0.008). After adjusting for hospital characteristics, longer ED admitted LOS at referring facilities [coefficient, 0.078 (95% CI 0.042, 0.113); p<0.001] was associated with DIDO. A 13 minute increase in ED admitted LOS was associated with a 1 minute increase in DIDO. Among hospital characteristics only rural status was associated with longer DIDO. Conclusions: Among AMI patients presenting to U.S. EDs, we found that ED crowding has a small but operationally insignificant effect on AMI DIDO times. EDs have found ways to facilitate timely transfer of AMI patients despite crowding.

Secondary preventive measures adopted in the management of patients with Acute Coronary Syndrome admitted to the National Hospital of Sri Lanka

Objective To describe the secondary preventive measures adopted in the management of patients with Acute Coronary Syndrome (ACS) admitted to the National Hospital of Sri Lanka (NHSL), in comparison with standard guidelines. Methods A hospital based, descriptive cross-sectional study was carried out in the Cardiology Unit and medical wards of the NHSL during September to October 2009. A sample of 345 patients diagnosed with ACS was included in the study. Medical records were used as the source of data regarding secondary preventive measures during the in-ward period. Results Among ACS recruited, 168 (48.7%) were diagnosed with unstable angina, 92 (26.7%) with NSTEMI and 85 (24.6%) with STEMI. Acetyl Salicylic Acid (ASA) was given within 3 hours and documented in only 175 (53.7%). Although a twelve-lead ECG within 20 minutes of arrival at hospital is recommended in the guidelines, ECG was performed after 20 minutes in 203 (59%). In 85 with STEMI 66 (77.6%) received re-perfusion/streptokinase therapy. The time of commencing streptokinase was noted in only 49 (57.6%) and only 9 (18%) received streptokinase within 30 minutes of arrival in hospital. Left ventricular function was assessed in only 53 (15.4%) patients. Continuity of treatment with ACE inhibitors was seen in 298 (86.4%), beta- blockers in 213 (61.7%) and statins in 326 (94.5%). In 337 (97.7%) a maintenance dose of ASA was given during the hospital stay. Conclusions Some processes in the management of patients with ACS at NHSL did not meet the standard set by local and international guidelines on secondary preventive measures. DOI: http://dx.doi.org/10.4038/jpgim.7330 Journal of the Postgraduate Institute of Medicine 2014; 1: E2:1-7

TUBE THORACOSTOMY COMPLICATIONS IN PATIENTS WITH ACUTE BLUNT THORACIC TRAUMA DUE TO ROAD TRAFFIC ACCIDENTS – "A COMPARATIVE STUDY"

Abstract: Objective : To determine the differences in the frequency and types of Tube thoracostomy complications (TTCs) between two groups of patients (A and B) with blunt thoracic trauma (BTT), as a result of road traffic accidents (RTA). Study Design : Prospective, comparative study. Place and duration of Study : Dawadmi General Hospital (DGH), a level II trauma center, Riyadh, from December 4, 2011 to December 3, 2012. Methodology : The problem of a high number and variety of TTCs resulting due to various technical aspects of tube thoracostomy (TT) are highlighted in this study. This is a prospective comparative study enrolling a total of 140 patients with BTT due to RTA, referred to this hospital with indwelling Tube thoracostomies (TTs) (group A) or undergoing TTs at this hospital (group B) by a single thoracic surgeon within 10-15 minutes of arrival. Patients' demographic and clinical details were recorded and confirmed with the referring physicians, if necessary. The two groups were matched for age, gender, indications for TTs and the number and types of accompanying injuries. Informed consent was obtained before the procedure. Results were analyzed using SPSS v 19. Statistical significance achieved was translated into p values at 95% confidence interval. Results : Of the 119 patients, who satisfied the inclusion criteria, group A had 49 (41.2%) and group B, 70 (58.8%) patients. Males were in the majority in both groups. A total of 130 chest tubes were placed in 119 patients. Contralateral chest tubes were indicated in 3 patients in group A and 8 patients in group B (table I). The overall TTCs rate was 61.5% (80/130), with the majority in group A (88.7%; p= 0.0001). The number of technical, infective and miscellaneous TTC in group A and B were 47 (92.2%), 6 (85.7%), 18 (81.8%), and 4 (7.8%), 1(14.3%), and 4 (18.2%), respectively (table II). The majority of the chest tubes in group A were smaller than 28 Fr (p=0.0001; RR=2.98; 95% CI=2.17-4.10). Mortality due to TT in groups A and B was 2% and 0%, respectively (P=0.416;RR=2.43;CI=1.96-3.01). Patients were followed up for 56 ±23 days after discharge. Conclusion: There is a significant difference in the frequency and types of TTCs for BTT due to RTA, between groups A and B. There is an urgent need to devise targeted training modules for emergency physicians with special emphasis on recognizing TTCs and having a low threshold for rectifying these before safe transfer to a higher center. In BTT the use of small caliber (< 24 Fr) tubes with trocars should be discouraged to avoid most complications. Key words: Tube thoracostomy complications (TTCs); Blunt thoracic trauma (BTT); Road traffic accident (RTA).

Abstract TP251: The Direct and Indirect Impact of the Acute Stroke Nurse Role on Thrombolysis Treatment Times and Rates

Background: The Acute Stroke Nurse (ASN) role at Box Hill Hospital is a business hours (weekday 8am - 4.30pm) first responder role designed to fast track acute stroke patients through thrombolysis screening in the Emergency Department. Since 2004, this role has been filled in either a full-time (FT) or part-time (PT) capacity, except for a 5-month period in 2010 where the role was vacant. We sought to explore the influence of having a full-time ASN, compared to part-time or no ASN, on thrombolysis rates and times. Methods: Data was extracted from the hospital’s stroke thrombolysis database for the period 2004 to 2012. Comparisons were made for those patients seen by the ASN, when FT and PT and those who saw medical staff only. Statistical comparisons were made using Mann-Whitney Rank Sum test. Results: Almost half (43% n=182) of the 428 thrombolysis cases occurred during business hours, the ASN attended 84% of cases when the role was filled FT and 15% when PT. No difference was seen in median door-to-CT times (25 minutes.) Faster median door-to-needle times were achieved during business hours when the patient was seen by the ASN compared to those who were not (66 mins vs. 83 mins, p=&lt;0.001.) Faster times were seen when the ASN role was FT (68 min) or PT (79 min) compared to vacant (89 mins, p=0.006,) with more patients treated within 60 minutes of arrival (35% FT, 27% PT and 8% vacant, NS). While the ASN only works within business hours, faster door-to-needle times were seen after hours when the ASN role was filled FT and PT compared to vacant (87mins and 100 mins vs. 103 mins, p=0.013;) and treatment was only commenced under 60 minutes when the ASN was employed FT. Conclusion: The Acute Stroke Nurse role seems to have a positive impact on thrombolysis treatment times and rates, with the best results being achieved during and outside business hours when the ASN is employed FT.

Pediatric Sedation in a Community Hospital–Based Outpatient MRI Center

Although the demand for pediatric MRI is increasing, it is uncommon to find sedation being offered at community hospital-based outpatient centers. We present our safety, efficacy, and outcome data at a community hospital-based outpatient imaging center. I.v. dexmedetomidine sedation was administered as a bolus of 3 μg/kg and maintained with a continuous infusion of 1 μg/kg/hr until imaging was complete. The dexmedetomidine bolus could be repeated up to two times, if needed. Quality assurance data were reviewed. From April 2009 to July 2010, 279 children (mean age, 4.2 years; age range, 0.2-17.2 years) were sedated. All received a first bolus, 46 required a second dose, and two received a third. The average time to achieve sedation was 7.8 minutes (SD, ± 3.8 minutes). Total duration of imaging (82% brain MRI) averaged 38.1 minutes (range, 8.0-126.0 minutes). On average, discharge criteria were met within 21.3 minutes of arrival in recovery room (± 17.8 minutes). The heart rate and blood pressure deviated from baseline by more than 20% in 5% and 33% of the patients, respectively. No pharmacologic therapy was administered to treat the hemodynamic variability. There were no adverse respiratory events. All imaging studies were successfully completed. Dexmedetomidine offers an option for pediatric sedation for MRI at community hospital-based outpatient settings. It preserves respiration but elicits deviations in blood pressure and heart rate that have not required pharmacologic intervention. Dexmedetomidine offers a safe, effective, and efficient agent for sedation for children undergoing MRI in an outpatient setting.

Abstract 2993: Effects of Education and Immediate Feedback on Improved rt-PA Door-to-Needle Time

Background &amp; Issues: The American Stroke Association reports earlier administration of intravenous rt-PA following symptom onset is associated with greater functional recovery. The Target: Stroke Campaign has identified a door-to-needle goal of 60 minutes or less. Our adoption of the Target: Stroke guidelines led to the improvement of emergency staff awareness and interventions for immediate feedback and correction of misperceptions of goal time for rt-PA administration and improved results. Purpose: To improve door-to-needle time to 60 minutes or less. Methods: In April 2010, we initiated a process to improve door-to-needle time for rt-PA administration within 60 minutes of arrival to Emergency Department (ED) for anyone presenting with indication of stroke. Target: Stroke guidelines are implemented for initial patient evaluation within 10 minutes of arrival to ED, stroke team activation within 15 minutes of arrival, CT scan within 25 minutes of arrival, and interpretation of CT scan within 45 minutes. First responders notify the Emergency Department of a possible stroke patient enroute. The triage nurse activates the Stroke Team through mass paging the team members. The Stroke Team Nurse assesses the patient, determines the onset of symptom time and possible rt-PA exclusions, follows the patient to CT Scan notifying the neurologist of CT scan results, and initiates the immediate discussion between the Emergency Physician and neurologist to determine if rt-PA is appropriate. If rt-PA is administered, immediate feedback is given to all stroke team members using a door-to-needle tracking form. All time delays are reviewed by the Stroke Team Medical Director to determine causes for delay. The Stroke Team meets to determine where improvements can be made. Results: From April 2010 through June 2011, door-to-needle time was decreased from 107.75 minutes to 52 minutes per quarter average. Conclusions: Improvements were realized following the extensive education of the Emergency Department with clarification of door-to-needle goal. This resulted in the ED staff’s design and implementation of a standardized process for following each stroke emergency, including early stroke team activation for patients presenting with any sign of acute stroke and the early initiation of a second intravenous line.

Abstract 3647: Institution of a Telemedicine for Acute Stroke Protocol in a Major Metropolitan Setting to Decrease iv-tPA Administration Times

Introduction: Telemedicine for Acute Stroke Evaluation and Treatment has been widely used for providing expert stroke neurology advice for patients presenting to rural hospitals. Iv-TPA administration rates in these experiences are high (20-25%). However, national iv-tPA administration rates still are below this level. In addition, less than 30% of patients are receiving iv-tPA in less than 60 minutes. We describe a novel telemedicine network that augments existing on-call neurological support to decrease door to needle times for iv-tPA administration. Methods: Data from 6 metropolitan hospitals in the Denver area were collected to assess rapidity of iv-tPA administration for Acute Ischemic Stroke. All hospitals had existing acute stroke protocols, on-call board certified neurologists, board certified Emergency Room Physicians (EDP) available on a 24/7 basis. Stroke Program leaders including Emergency Room Physicians, Neurologists, and administrators from these hospitals were invited to participate in an initiative to decrease door to needle times. Through this committee, consensus was reached that the arrival of a neurologist be less than 15 minutes from arrival of the patient to the Emergency Room. At times and places where this could not be achieved by physical presence, telemedicine technology was employed. This Telemedicine Intiative (TI) was instituted on May 1st, 2011. Time data regarding patient arrival, time to CT scan, time in CT scan, arrival of neurologist, first Emergency Room physician evaluation, tPA administration will be tracked. Results: Prior to institution of the Telemedicine Initiative, average door to needle times for the six hospital network was 86 minutes. In the first month of institution of TI, average door to needle times decreased to 67 minutes across the network. 102 telemedicine consultations have been performed to date. All telemedicine consultations were instituted within 10 minutes of arrival of the patients to the emergency room. Conclusions: Employing Telemedicine in a metropolitan hospital setting with exisiting neurological coverage, acute stroke protocols and board certified ED Physicians may decrease the time needed to administer iv-TPA in acute ischemic stroke patients.

Abstract 2396: Barriers to Improve IV tPA Door to Needle Time-Comparing Small Rural Hospitals and Primary Stroke Centers

Background and Issues- Stroke continues to be a significant cause of morbidity and mortality in Wisconsin. Research has shown improved outcomes when IV tPA is started as close as possible to the time the patient was last known well. Wisconsin has continued to work on the improvement of stroke systems of care through rural and urban initiatives and the awareness of time critical factors. Purpose- To evaluate the current state of compliance with factors known to increase the percentage of eligible patients receiving IV tPA within 60 minutes of arrival in both rural and urban settings. Methods- Two benchmarking groups were established in Wisconsin through the Get With The Guidelines online Patient Management tool. The Rural hospital benchmark includes an average of 21 hospitals and the Primary Stroke Center (PSC) group includes 24 hospitals. A total of 15,783 patient records between Q1 2008 and Q4 2010 were reviewed. Results- Both groups show similar barriers in getting IV tPA to the patient within 60 minutes of arrival. The measures that showed the greatest opportunity for improvement included pre-notification of an acute stroke from EMS to the receiving hospital allowing the hospital team to prepare and CT turnaround time. The rural group received pre-notification 64.8% between 2008 and 2010 and the PSC group at 66.1% during that same time frame. Another time critical factor is CT &lt;= 25 minutes. The PSC group achieved that timeframe 21.9% of the time, doing slightly better than the rural group at 18.5%. Conclusions- Structured outreach activities utilizing national initiatives such as the American Heart Association’s Target: Stroke has highlighted the distance between the current situation and desired goal. This indicates the need to implement targeted QI programs, with follow up data collection to increase DTN &lt;60. Specifically targeting small rural hospitals has increased awareness of the current barriers in administering IV tPA. Wisconsin hospitals in both benchmarks have committed to work on the identified measures, analyze progress and resolve specific barriers to timely IV tPA administration.

Abstract P306: Physician Directed Nurse Practioner Model of Care Using Get With The GuidelinesSM is Superior in Attaining Centers for Medicare and Medicaid Services Core Measure Compliance for Patients With Acute Myocardial Infarction Amongst Urban Hospitals With Large Minority Populations

The goal of the Centers for Medicare and Medicaid Services acute myocardial infarction core measure program (AMI-CM) is to provide standards of care at the point of service. The American Heart Association's Get With The Guidelines (AHA-GWTG) program has previously been shown to be independently associated with significantly improved adherence to AMI-CM. However, a physician directed nurse practioner managed GWTG model of care (PDNP-GWTG) in an urban hospital with a large minority population (UH-LMP) has not yet been compared to GWTG and non-GWTG hospitals with similar demographics for compliance to AMI-CM. St. Joseph's Regional Medical Center (SJRMC) is an UH-LMP located in Northern NJ with a diverse and large minority composition. The objective of this study was to compare SJRMC's PDNP-GWTG model of care to GWTG and non-GWTG UH-LMP for AMI-CM. Methods: All UH-LMP hospitals' AMI-CM with a percent white population within +/- 5% of SJRMC and a similar Urbanicity Ranking, n= 113, were compared to SJRMC's AMI-CM for 2008. Differences in compliance for each of the 8 AMI-CM and for the composite AMI-CM (8-CM) were assessed using the Chi Square test for contingencies. Results: SJRMC 8-CM compliance of 96% (1275 of 1329) was superior to UH-LMP of 94% (55270 of 58798), p=0.0007. For individual AMI-CM compliance SJRMC was superior to UH-LMP for: Aspirin at arrival (100% (260 of 260) vs. 97% (12060 of 12434), p=0.007); Beta-Blocker (BB) at arrival (99% (230 of 232) vs. 95% (9533 of 10035), p=0.003); BB at discharge (98% (308 of 314) vs. 96% (13279 of 13832), p=0.03); and tobacco counseling (100% (116 of 116) vs. 94% (3870 of 4117), p=0.004). UH-LMP was superior to SJRMC compliance for PCI within 90 minutes of arrival (PCI-AMI) (56% (605 of 1080) vs. 29% (11 of 38), p=0.001). Conclusion: SJRMC PDNP AMI-CM compliance for the composite and 4 of the core measures that are also GWTG performance measures is superior to UH-LMP. UH-LMP PCI-AMI-CM performance (not a GWTG performance measure) was superior to SJRMC.

Abstract P257: Getting to the Golden Hour: Correlating “Door-To” Times with 60-Minute Administration of tPA in an Academic Medical Center

Introduction: The efficacy of intravenous tPA for the treatment of acute stroke diminishes over time. The AHA/ASA and NINDS recommend a goal door to needle time of 60 minutes or less. Objective: Identify potential barriers to tPA administration within 60 minutes of arrival. Methods: Retrospective review of tPA adsinistration using “Get With the Guidelines” (GWTG) and institutional records from January 1, 2009 through December 31, 2010 (n=100). Spearman rank correlation coefficients were calculated for the NINDS recommended time standards, age and NIH Stroke Scale (NIHSS) score. We used a receiver-operator curve (ROC) to identify the door to CT time predictive of tPA administration ≤ 60 minutes. Results: Median door to physician, door to CT, and door to stroke team times were within the recommended goals. Door to CT (ρ=0.53, p&lt;0.0001), and door to stroke team (ρ=0.33, p&lt;0.01) times were positively correlated with door to tPA times. Last known well to arrival (ρ= -0.28, p&lt;0.01) and NIHSS (ρ= -0.32, p&lt;0.01) were negatively correlated with door to tPA times; patients with higher NIHSS and longer last-known-well to arrival times received tPA in a shorter time frame. Age and door to physician time were not correlated with tPA treatment times. After adjusting for the other benchmarks and NIHSS, only door to CT remained significantly correlated with door to IV tPA (partial correlation coefficient=0.40, p&lt;0.001). The ROC curve showed that a goal time of 20 minutes or less for door to CT initiation had the best sensitivity and specificity for predicting tPA administration within 60 minutes. Conclusion: In keeping with the recommended time goals, median times for the intermediate steps were within target. Our median tPA times, however, did not meet the 60 minute goal. Door to CT initiation was the variable that most strongly correlated with door to needle times. Process issues such as order entry and scheduling protocols may be barriers to obtaining CT within the 20 minute time frame identified by our analysis. Other barriers after the CT scan is obtained must be identified to facilitate faster tPA administration. Further evaluation of these factors is warranted to better ensure the timely delivery of tPA to stroke patients, thereby improving patient outcomes.