Prehospital Factors Research Articles

Abstract 235: More Than Doubled Survival in Out-of-Hospital Cardiac Arrest After the Implementation of a Dual Dispatch System is Attributable to Pre-Hospital Rather Than In-Hospital Factors

Introduction: In 2005, a dual dispatch system using fire fighters as first responders in addition to emergency medical service in out-of-hospital cardiac arrest (OHCA) was implemented in Stockholm, Sweden. A pilot study from 2006 showed doubled survival in witnessed OHCA compared to historical controls. The aim of this study was to determine the short and long term impact of the intervention and to investigate the additional effect on survival of in-hospital interventions such as therapeutic hypothermia and acute catheterization. Methods and Results: OHCA from 2004 (historical controls, n=620) and 2006-2009 (intervention period, n=2863). Fire fighters performed CPR in 90 % of the patients. They were first on scene and connected an automated external defibrillator in 41% of the cases. The median time from dispatch to arrival of first responder shortened from 7.7 minutes in the control period to 6.7 minutes (p<0.001). Survival to 1 month improved from 3.9 % to 7.4 % (p=0.002). Logistic regression (adjustments for: sex, age, place, etiology, witnessed status, bystander-CPR, first rhythm) gave adjusted OR 2.7 (CI 1.5-4.6). Survival to 3 years increased from 2.4% to 6.2% (p<0.001), adjusted OR 3.5 (CI 1.8-7.0). In the logistic regression analysis including in-hospital factors we found no additional outcome benefit of therapeutic hypothermia, adjusted OR 1.5 (CI 0.7-3.2) and acute catheterization/thrombolysis, adjusted OR 1.7 (CI 0.9-3.1). Conclusions: The implementation of a dual dispatch system using fire-fighters has significantly increased survival after 1 month and 3 year in OHCA. Only pre-hospital factors had an impact on outcome.

Abstract 315: Characterization of Out of Hospital Resuscitation Utilizing Blood Transfusion

Introduction: While blood transfusion in the hospital setting has been extensively studied, little data exists on out of hospital administration of blood products. We aimed to characterize patients receiving out of hospital blood product transfusion in a critical care transport network that carries blood products. Methods: We performed a retrospective review of patients transported by a regional critical care transport service from 1/1/2003 to 6/30/2012 who received blood products during transport. This service carries two units of un-crossmatched Packed Red Blood Cells (pRBCs) on every transport. We describe prehospital factors (vital signs, mechanism of injury, volume and type of blood product transfused) associated with blood transfusion. We further categorized out of hospital transfusions of blood products into three groups based on the volume transfused (lt350 ml, 350-700ml, gt700ml). We compared in-hospital outcomes (mortality, volume and type of subsequent blood transfusion, and need for emergent surgery [lt24 hours]) among these three groups to ascertain the impact of prehospital blood product transfusion. Results: We reviewed 1441 transports in which blood products were transfused. Most transfusions were inter-facility transfers (92%, CI 91-93%) and for non-traumatic illness (75%, CI 73-77%). The most common reason for transport was upper gastrointestinal bleeding (20%, 18-22%). A vast majority, 80% (CI 78-82%), of patients required subsequent in-hospital blood transfusion. In hospital 30-day mortality was high, 22% (CI 20-25%), as was need for emergent surgery 27% (CI 25-29%). Mean length of stay was 10.6 days and mean ICU length of stay was 7.2 days. Among those receiving blood products, those transfused with &gt700ml had higher heart rates (94 vs. 103, p=0.01), whole blood lactate levels (3.5 vs. 6.2, p&lt0.01), and lower systolic blood pressure (108 vs.122, p&lt0.01) Conclusions: In this sample, the majority of patients receiving blood during critical care transport are during inter-facility transports and for non-traumatic conditions. Gastrointestinal hemorrhage is the most common indication for transfusion and 30-day mortality in this cohort is high.

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.

Factors correlating with delayed trauma center admission following traumatic brain injury.

BackgroundDelayed admission to appropriate care has been shown increase mortality following traumatic brain injury (TBI). We investigated factors associated with delayed admission to a hospital with neurosurgical expertise in a cohort of TBI patients in the intensive care unit (ICU).MethodsA retrospective analysis of all TBI patients treated in the ICUs of Helsinki University Central Hospital was carried out from 1.1.2009 to 31.12.2010. Patients were categorized into two groups: direct admission and delayed admission. Patients in the delayed admission group were initially transported to a local hospital without neurosurgical expertise before inter-transfer to the designated hospital. Multivariate logistic regression was utilized to identify pre-hospital factors associated with delayed admission.ResultsOf 431 included patients 65% of patients were in the direct admission groups and 35% in the delayed admission groups (median time to admission 1:07h, IQR 0:52–1:28 vs. 4:06h, IQR 2:53–5:43, p <0.001). In multivariate analysis factors increasing the likelihood of delayed admission were (OR, 95% CI): male gender (3.82, 1.60-9.13), incident at public place compared to home (0.26, 0.11-0.61), high energy trauma (0.05, 0.01-0.28), pre-hospital physician consultation (0.15, 0.06-0.39) or presence (0.08, 0.03-0.22), hypotension (0.09, 0.01-0.93), major extra cranial injury (0.17, 0.05-0.55), abnormal pupillary light reflex (0.26, 0.09-0.73) and severe alcohol intoxication (12.44, 2.14-72.38). A significant larger proportion of patients in the delayed admission group required acute craniotomy for mass lesion when admitted to the neurosurgical hospital (57%, 21%, p< 0.001). No significant difference in 6-month mortality was noted between the groups (p= 0.814).ConclusionDelayed trauma center admission following TBI is common. Factors increasing likelihood of this were: male gender, incident at public place compared to home, low energy trauma, absence of pre-hospital physician involvement, stable blood pressure, no major extra cranial injuries, normal pupillary light reflex and severe alcohol intoxication. Focused educational efforts and access to physician consultation may help expedite access to appropriate care in TBI patients.

Pre-hospital management and risk factors in children with acute diarrhoea admitted to a short-stay ward in an urban South African hospital with a high HIV burden

Background. Diarrhoea remains a major cause of childhood morbidity and mortality in the developing world. Implementation of World Health Organization Integrated Management of Childhood Illness (IMCI) guidelines and pre-hospital use of oral rehydration therapy (ORT) in the Western Cape Province of South Africa are not well described. Objectives. To document pre-hospital home and primary care management of diarrhoea, and certain risk factors and complications of diarrhoea. Methods. We used a prospective descriptive convenience sample of children admitted to the short-stay ward at Tygerberg Hospital, Parow, Cape Town, between 1 February 2007 and 31 May 2008. Caregivers were interviewed, and demographic, clinical and laboratory variables were collected. Results. We recruited 142 children, median age 8.9 months. A third had moderate malnutrition. Twenty–four (16.9%) were HIV-exposed, with 9 (6.3%) HIV-infected. HIV-exposed children were significantly younger than unexposed children ( p =0.03). Weight-for-age Z -scores (WAZ) were significantly lower in HIV-infected than in HIV-exposed, uninfected children ( p =0.02). Eighty per cent of caregivers gave ORT and 35.2% stopped feeds. Only 1 of 43 children aged under 6 months was exclusively breastfed. Advice at primary care level rarely complied with IMCI guidelines. Conclusions. Most caregivers do give ORT, but advice given at primary care level is often suboptimal. Many hospitalised children with diarrhoea are malnourished. Children with HIV infection are at increased risk of diarrhoeal disease and malnutrition, and HIV exposure appears to increase the risk of early presentation with diarrhoea. Ongoing strategies are needed to ensure optimal prevention policies, pre-hospital management and nutritional rehabilitation.

Prehospital factors associated with favorable neurological outcomes in out-of-hospital cardiac arrest patients without a prehospital return of spontaneous circulation

Prehospital factors associated with favorable neurological outcomes in out-of-hospital cardiac arrest patients without a prehospital return of spontaneous circulation

Emergency medical services versus private transport of trauma patients in the Sultanate of Oman: a retrospective audit at the Sultan Qaboos University Hospital

This study aims to assess the differences in the outcome of road traffic trauma patients between those transported by emergency medical services (EMS) and those privately transported to the Sultan Qaboos University Hospital in the Sultanate of Oman in 2011. This is a retrospective study of road traffic trauma patients admitted to the Sultan Qaboos University Hospital between January to December 2011. Data for all cases were retrieved from the emergency department database. The general linear multivariate regression analysis model was performed to test the differences in outcome. The analysis controlled for age, gender, ethnicity, weekend injury, time of injury, triage status, Injury Severity Score, existence of head injury, need for intensive care unit admission and need for surgical management. There were 821 trauma cases in 2011. 66.7% were transported by EMS. Male patients represented 65.7% of the cases. There was no significant difference in the characteristics of EMS and non-EMS trauma patients. In terms of inhospital mortality, the relative ratio of inhospital mortality between EMS and non-EMS groups was 0.64 (0.36-1.13), and p value 0.13. There is no significant difference in all other secondary outcomes tested. EMS transported trauma patients had a statistically non-significant 36% reduction in mortality compared with privately transported patients admitted to the Sultan Qaboos University Hospital in 2011. Further, research that incorporates prehospital factors such as crash to arrival of EMS services and transport time to definitive healthcare facility should be conducted to evaluate the effectiveness of such a system in trauma care. Since non-EMS transport is likely to continue, public first aid training is critical to reduce mortality and morbidity of road traffic trauma in Oman.

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.

Neurological outcomes in patients transported to hospital without a prehospital return of spontaneous circulation after cardiac arrest.

IntroductionAs emergency medical services (EMS) personnel in Japan are not allowed to perform termination of resuscitation in the field, most patients experiencing an out-of-hospital cardiac arrest (OHCA) are transported to hospitals without a prehospital return of spontaneous circulation (ROSC). As the crucial prehospital factors for outcomes are not clear in patients who had an OHCA without a prehospital ROSC, we aimed to determine the prehospital factors associated with 1-month favorable neurological outcomes (Cerebral Performance Category scale 1 or 2 (CPC 1–2)).MethodsWe analyzed the data of 398,121 adult OHCA patients without a prehospital ROSC from a prospectively recorded nationwide Utstein-style Japanese database from 2007 to 2010. The primary endpoint was 1-month CPC 1–2.ResultsThe rate of 1-month CPC 1–2 was 0.49%. Multivariate logistic regression analysis indicated that the independent variables associated with CPC 1–2 were the following nine prehospital factors: (1) initial non-asystole rhythm (ventricular fibrillation (VF): adjusted odds ratio (aOR), 9.37; 95% confidence interval (CI), 7.71 to 11.4; pulseless ventricular tachycardia (VT): aOR, 8.50; 95% CI, 5.36 to 12.9; pulseless electrical activity (PEA): aOR, 2.75; 95% CI, 2.40 to 3.15), (2) age <65 years (aOR, 3.90; 95% CI, 3.28 to 4.67), (3) arrest witnessed by EMS personnel (aOR, 2.82; 95% CI, 2.48 to 3.19), (4) call-to-hospital arrival time <24 minutes (aOR, 2.58; 95% CI, 2.22 to 3.01), (5) arrest witnessed by any layperson, (6) physician-staffed ambulance, (7) call-to-response time <5 minutes, (8) prehospital shock delivery, and (9) presumed cardiac cause. When four crucial key factors (with an aOR >2.0 in the regression model: initial non-asystole rhythm, age <65 years, EMS-witnessed arrest, and call-to-hospital arrival time <24 minutes) were present, the rates of 1-month CPC 1–2 and 1-month survival were 16.1% and 23.2% in initial VF, 8.3% and 16.7% in pulseless VT, and 3.8% and 9.4% in PEA, respectively.ConclusionsIn OHCA patients transported to hospitals without a prehospital ROSC, nine prehospital factors were significantly associated with 1-month CPC 1–2. Of those, four are crucial key factors: initial non-asystole rhythm, age <65 years, EMS-witnessed arrest, and call-to-hospital arrival time <24 minutes.

A 6-year experience of CPR outcomes in an emergency department in Thailand

PurposeSudden cardiac arrest is a common emergency condition found in the emergency department of the hospital. The survival rate of out-of-hospital cardiac arrest patients is 2.0%–10.0% and 7.4%–27.0% percent for in-hospital cardiac arrest patients. The factors for survival outcome are divided into three main groups: patient characteristics, pre-hospital factors, and resuscitated information. The objective of this study was to evaluate the related factors, outcome, and survival rate in patients with cardiac arrest who received cardiopulmonary resuscitation (CPR) at Ramathibodi Emergency Medicine Department. There are limited data for this issue in Thailand and other Asian countries.MethodsThis retrospective study included all patients who were older than 15 years with sudden cardiac arrest and who were resuscitated in the emergency room between January 2005 and December 2010. Descriptive analytic statistics and logistic regressions were used to analyze factors that related to the sustained return of spontaneous circulation (ROSC) and survival at discharge.ResultsThere were 181 patients enrolled. The overall sustained ROSC rate was 34.8% and the survival rate at discharge was 11.1%. There were 145 out-of-hospital cardiac arrest patients, in whom the survival rate was 52.4% and the survival to discharge rate was 7.6%. For inhospital cardiac arrest, there were 36 patients with a survival rate of 86.1% and the survival to discharge rate was 25.0%. Statistically significant factors related to sustained ROSC were good and moderate cerebral performance, in-hospital cardiac arrest, beginning of CPR in less than 30 minutes, and cardiopulmonary cause of arrest. The factors influencing survival to discharge were cardiopulmonary causes of cardiac arrest.ConclusionFactors associated with sustained ROSC were functional status before cardiac arrest, location of cardiac arrest, duration of CPR, and cause of cardiac arrest. Survival rate was related to the cause of cardiac arrest.

Exploring gender differences and the “oestrogen effect” in an Australian out-of-hospital cardiac arrest population

BackgroundRecent studies have suggested gender differences in out-of-hospital cardiac arrests (OHCA) including outcomes favouring young women. We aimed to investigate these findings in an Australian OHCA population using the Victorian Ambulance Cardiac Arrest Registry (VACAR). Methods and resultsThe VACAR was searched for adult presumed cardiac OHCAs between 2003 and 2010 where Emergency Medical Services (EMS) attempted resuscitation. Gender and age differences in survival to hospital arrival and to hospital discharge were examined using logistic regression adjusting for known predictors of survival. There were 10,453 OHCA meeting inclusion criteria (863 aged between 18 and 44 years). Women were less likely to be younger, have a witnessed arrest, receive bystander CPR, arrest in a public place, have an initial shockable rhythm or receive transport to 24-h cardiac interventional hospital. After adjusting for differences in pre-hospital factors, women were more likely to survive to hospital arrival than men (aOR 3.47, 95% CI: 2.19–5.50), but no gender differences were seen in survival to hospital discharge either overall or specifically in women aged between 18 and 44 years. Both younger men and younger women were more likely to survive to hospital discharge compared to older men and women. ConclusionWomen were more likely to survive to hospital arrival despite less favourable baseline variables. However, this initial improvement in survival did not translate to better survival to hospital discharge either overall, or in women of a reproductive age. Further study is required to determine gender differences in the underlying causes of OHCA and in EMS transportation practices.

Abstract 257: Clinical Decision Tree Model in Patients with Out-of-Hospital Cardiac Arrest for Predicting Neurological Outcome at the Emergency Department

Introduction: The ideal factors for predicting neurological outcomes in patients with out-of-hospital cardiac arrest (OHCA) remain elusive. Hypothesis: We hypothesized that a novel decision tree model using 4 pre-hospital variables can predict neurological outcome after OHCA at the emergency department. Methods: We analyzed 390226 adults in whom resuscitation was attempted after non-traumatic OHCAs in a prospectively recorded nationwide Utstein-style database in Japan over 5 years (2005-2009). The endpoint was 1-month survival with good neurological outcome (cerebral performance category scale, 1-2). We developed a prediction model using data from 4 years (2005-2008, n = 307896), with validation using external data from 2009 ( n = 82330). Results: Overall 1-month survival and good neurological outcome rates were 4.19% and 1.99%, respectively. Multivariate logistic regression analysis indicated the following pre-hospital factors to be significant: shockable initial rhythm (odds ratio [OR] 5.87; 95% confidence interval [CI] 5.23-6.60), emergency medical service (EMS) personnel witnessed (OR 3.40; 95%CI 3.15-3.69), witnessed arrest (OR 3.05; 95%CI 2.83-3.28), and age (OR 3.24; 95%CI 2.97-3.53). Using recursive partitioning analysis with these 4 predictors, we developed a clinical decision tree model: if a witnessed OHCA patient had shockable initial rhythm, the probability of good outcome was 20.0% (age&lt;71) or 10.3% (age&gt;or=71); if an unwitnessed OHCA patient had shockable initial rhythm, the probability of good outcome was 6.8% (age&lt;81) or 1.8% (age&gt;or=81); if a witnessed OHCA patient had unshockable initial rhythm, the probability of good outcome was 3.8% (EMS personnel witnessed arrest) or 1.1% (EMS personnel unwitnessed arrest); if an unwitnessed OHCA patient had unshockable initial rhythm, the probability of good outcome was 0.5% (age&lt;71) or 0.2% (age&gt;or=71). The c-statistics for this model in the groups for development and validation were 0.867 (95%CI 0.861-0.873) and 0.887 (95%CI 0.877-0.896), respectively. Conclusions: Stratification of patients using a decision tree model accurately provides the severity of OHCA classification rules and can predict good neurological outcomes after OHCA at the emergency department.

Abstract 195: Survival in Out-of-Hospital Cardiac Arrest Patients Without a Prehospital Return of Spontaneous Circulation

Background: Survival rates are low in out-of-hospital cardiac arrest (OHCA) patients transported without a prehospital return of spontaneous circulation (ROSC). Few studies have examined the patient characteristics and prehospital factors associated with improved survival in this unique cohort. Objective: This study aims to describe patient and prehospital factors associated with survival to hospital discharge when patients fail to achieve ROSC in the field. Methods: This was a retrospective observational study of consecutive adult (≥18 years) OHCA patients without a prehospital ROSC from December 1, 2005 to March 30, 2012 who were attended to and transported by emergency medical services (EMS) from urban and rural regions employing the current termination of resuscitation (TOR) guidelines. EMS witnessed cardiac arrests, and cardiac arrests of non-cardiac etiology were excluded. Bivariate analyses were used to determine associations of patient characteristics and prehospital variables with survival to hospital discharge. Results: There were 17,488 OHCA treated by EMS, with 4,892 (28.0%) transported to hospital without a prehospital ROSC. Of these patients, only 42 (0.86%) survived to hospital discharge. Survivors were often younger with initial shockable rhythms, had OHCA that were more often witnessed by bystanders and occurred in public locations, compared to non-survivors (table). No differences were noted in the proportion of male gender, bystander CPR rates, EMS response time, advanced airway, or ALS provider level. Three patients (0.06%) did not meet the criteria for transport in accordance with current TOR guidelines however were transported at the discretion of EMS and survived. Conclusion: Less than 1% (the threshold for futility) of OHCA patients without a prehospital ROSC survived to hospital discharge. Survival in this cohort was associated with younger age, shockable initial rhythms, bystander-witnessed arrests, and public location.

Do we need cardiac arrest centres in Australia?

The mortality rate post admission to hospital after successful resuscitation from out-of-hospital cardiac arrest is high, with significant variation between regions and individual institutions. While prehospital factors such as age, bystander cardiopulmonary resuscitation and total cardiac arrest time are known to influence outcome, several aspects of post-resuscitative care including therapeutic hypothermia, coronary intervention and goal-directed therapy may also influence patient survival. Regional systems of care have improved provider experience and patient outcomes for those with ST elevation myocardial infarction and life-threatening traumatic injury. In particular, hospital factors such as hospital size and interventional cardiac care capabilities have been found to influence patient mortality. This paper reviews the evidence supporting the possible development and implementation of Australian cardiac arrest centres.

Factors Associated With the Interfacility Transfer of the Pediatric Trauma Patient

The goal of this study was to identify prehospital factors associated with increased likelihood of interfacility transfer of pediatric trauma patients. Such factors might serve as a basis for improvements in future field pediatric trauma triage guidelines. This was a retrospective cohort study of children aged 12 years or younger with blunt, penetrating, or thermal injuries who were transported by ground emergency medical services from the scene to the emergency department of a Level I, II, or III trauma center within the Denver metropolitan area from January 1, 2000, to December 31, 2008. Characteristics predicting subsequent interfacility transfer to a pediatric trauma center (PTC) were assessed. A total of 1673 patients were included in the analysis. Variables hypothesized to be most commonly associated with interfacility transfer were age, sex, mechanism of injury, body region of injury, and Glasgow Coma Scale score. The cohort included 1079 males and 593 females. Logistic regression analysis yielded the following as significant predictors of transfer: younger age (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.15-1.25), lower Glasgow Coma Scale score (OR, 1.08; 95% CI, 1.01-1.16), the presence of burns (OR, 37.52; 95% CI, 7.3-191.7), non-accidental trauma (OR, 6.09; 95% CI, 2.44-15.25), falls (OR, 1.62; 95% CI, 1.06-2.48), other motor vehicle-related incidents (OR, 2.37; 95% CI, 1.08-5.19), abdominal injury (OR, 5.39; 95% CI, 2.31-12.55), head/neck injury (OR, 7.89; 95% CI, 4.21-14.77), limb injury (OR, 5.31; 95% CI, 2.78-10.16), and multiple injuries (OR, 13.01; 95% CI, 5.0-33.8). Factors highly associated with transfer of an injured child from a non-PTC to a PTC included younger age, burns, non-accidental trauma, head/neck injury, and multiple injuries in younger children. Further investigation is warranted to determine whether these factors may have applicability in future improvements in field pediatric trauma patient triage guidelines.

Letter by Duyff and Groeneveld Regarding Article, “Proportion of Patients Treated With Thrombolysis in a Centralized Versus a Decentralized Acute Stroke Care Setting”

HomeStrokeVol. 43, No. 8Letter by Duyff and Groeneveld Regarding Article, “Proportion of Patients Treated With Thrombolysis in a Centralized Versus a Decentralized Acute Stroke Care Setting” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Duyff and Groeneveld Regarding Article, “Proportion of Patients Treated With Thrombolysis in a Centralized Versus a Decentralized Acute Stroke Care Setting” Ruurd F. Duyff, MD and Carel Groeneveld, MD Ruurd F. DuyffRuurd F. Duyff Department of Neurology Ziekenhuis De Tjongerschans Heerenveen The Netherlands (Duyff, Groeneveld) Search for more papers by this author and Carel GroeneveldCarel Groeneveld Department of Neurology Ziekenhuis De Tjongerschans Heerenveen The Netherlands (Duyff, Groeneveld) Search for more papers by this author Originally published7 Jun 2012https://doi.org/10.1161/STROKEAHA.112.660167Stroke. 2012;43:e73Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2012: Previous Version 1 To the Editor:Being one of the centers participating in the study, we read the article by Lahr et al,1 published online March 16, 2012 in Stroke, with great interest. They concluded that patients are more likely to be treated with thrombolysis in a centralized setting.We would like to make some remarks and add some recent figures from our own institution. First, of course, the authors are to be commended for their collaborative effort to investigate such a complex issue.In this case, the region functions as an instrumental variable,2 the assumption being that the regions are completely comparable in sociodemographic variables and burden of disease, etc. Almost certainly, this assumption is not correct, so there is potential for confounding and the authors hint at some disparities themselves. We would like to draw attention to the fact that the decentralized region is more rural, maybe accounting for the finding that in the decentralized model, use of emergency medical services and high prioritization were significantly lower.1The main difference in our view is the fact that in the decentralized setting, significantly fewer patients arrived in time for tissue-type plasminogen activator treatment, only 28% versus 44% in the centralized setting; whereas the proportion of patients arriving within 4.5 hours after stroke onset who were actually treated with tissue-type plasminogen activator was exactly the same: 50%. Also, functional outcome and complications were similar. This is a remarkable feat, considering it was achieved by many smaller community hospitals compared with 1 tertiary stroke center. It is, however, in line with the findings of the SITS-MOST study.3 As the authors also state, the proportion of patients treated in the decentralized model was higher than was reported previously, and we think it is likely to grow. From our own stroke registry, we have the figure for 2011: 20% of all patients presenting with ischemic stroke were treated with alteplase and the median door-to-needle time was only 35 minutes; these figures compare very favorably with national and international data.1,4,5Another significant finding was the shorter onset-to-door time in the decentralized model, even after compensating for the longer door-to-needle time and leading to a slightly shorter onset-to-needle time in the decentralized model (120 minutes versus 124 minutes, not significant); this is of course the result of significantly shorter travel distances to hospital. Combined with shortening door-to-needle times in community hospitals like ours, this leads to shorter onset-to-needle times and possibly better outcome in the decentralized setting, although this remains to be investigated.We would like to stress the importance of the prehospital factors, as these caused the main differences between the models; public awareness needs to be raised so more patients can benefit from treatment. For policymakers, this should be the main finding of this study and not the hasty conclusion that thrombolysis treatment should be centralized everywhere. This would not only do us wrong, but also other community hospitals like ours, which happen to have 24-hour dedicated stroke care.Essentially, intravenous thrombolysis is a low-tech treatment that can be administered safely in hospitals that are near the patient.3,5Ruurd F. Duyff, MDCarel Groeneveld, MD Department of Neurology Ziekenhuis De Tjongerschans Heerenveen The NetherlandsSources of FundingNone.DisclosuresNone.FootnotesStroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 3 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited. Include a completed copyright transfer agreement form (available online at http://stroke.ahajournals.org and http://submit-stroke.ahajournals.org).Correspondence to Ruurd F. Duyff, MD, Ziekenhuis De Tjongerschans, Neurology, Thialfweg 44, Heerenveen 8441 PW, Netherlands. E-mail [email protected]nl

Can early cardiac troponin I measurement help to predict recent coronary occlusion in out-of-hospital cardiac arrest survivors?

Recent guidelines recommend the immediate performance of a coronary angiography when an acute myocardial infarction is suspected as a cause of out-of-hospital cardiac arrest. However, prehospital factors such as postresuscitation electrocardiogram pattern or clinical features are poorly sensitive in this setting. We searched to evaluate if an early measurement of cardiac troponin I can help to detect a recent coronary occlusion in out-of-hospital cardiac arrest. Retrospective analysis of a prospective electronic registry database. University cardiac arrest center. Between January 2003 and December 2008, 422 out-of-hospital cardiac arrest survivors without obvious extra-cardiac cause have been consecutively studied. An immediate coronary angiography has been systematically performed. The primary outcome was the finding of a recent coronary occlusion. First, blood cardiac troponin I levels at admission were analyzed to assess the optimum cutoff for identifying a recent coronary occlusion. Second, a logistic regression was performed to determine early predictive factors of a recent coronary occlusion (including cardiac troponin I) and their respective contribution. An ST-segment elevation was present in 127 of 422 patients (30%). During coronary angiography, a recent occlusion has been detected in 193 of 422 patients (46%). The optimum cardiac troponin I threshold was determined at 4.66 ng·mL(-1) (sensitivity 66.7%, specificity 66.4%). In multivariate analyses, in addition of smoking and epinephrine initial dose, cardiac troponin I (odds ratio 3.58 [2.03-6.32], p < .001) and ST-segment elevation (odds ratio 10.19 [5.39-19.26], p < .001) were independent predictive factors of a recent coronary occlusion. In this large cohort of out-of-hospital cardiac arrest patients, isolated early cardiac troponin I measurement is modestly predictive of a recent coronary occlusion. Furthermore, the contribution of this parameter even in association with other factors does not seem helpful to predict recent occlusion. As a result and given the high benefit of percutaneous coronary intervention for such patients, the dosage of cardiac troponin I at admission could not help in the decision of early coronary angiogram.

Standard operating procedures: therapeutic hypothermia in CPR and post-resuscitation care

Standard operating procedures: therapeutic hypothermia in CPR and post-resuscitation care

Proportion of Patients Treated With Thrombolysis in a Centralized Versus a Decentralized Acute Stroke Care Setting

Today, treatment of acute stroke consists of tissue-type plasminogen activator (tPA), admission to a stroke unit, and aspirin. Although tPA treatment is the most effective, there is substantial undertreatment. Centralized care may affect rate, timing, and outcome of thrombolysis compared to decentralized treatment in community hospitals. The present study aimed to assess the impact of organizational models on the proportion of patients undergoing tPA treatment. A prospective, multicenter, observational study among 13 hospitals in the North of the Netherlands was conducted. In the centralized model, tPA treatment for 4 hospitals was administered in 1 stroke center. The decentralized model comprised 9 community hospitals. Primary outcome was the proportion of patients treated with tPA. Secondary outcome measures were proportion of patients arriving within 4.5 hours, safety, 90-day functional outcome, and onset-to-door, door-to-needle, and onset-to-needle times. Potential confounders were adjusted using logistic regression analysis. Two hundred eighty-three and 801 ischemic stroke patients were enrolled in the centralized and decentralized settings. Numbers of patients treated with tPA were 62 (21.9%) and 113 (14.1%) (OR, 1.72; 95% CI, 1.22-2.43). Adjusting for potential confounders did not alter results (OR, 2.03; 95% CI, 1.39-2.96). In the centralized setting, significantly more patients arrived at the hospital within the 4.5-hour time window (P<0.01), and shorter door-to-needle times were reached (35 versus 47 minutes). Other secondary outcome measures did not differ across setting. In a centralized setting, the results demonstrate a 50% increased likelihood of treatment. Prehospital factors seem to contribute to this result.

Stroke Code Patients Are More Likely To Arrive at the Hospital by Ambulance on Weekends vs. Weekdays (P07.018)

Objective: To assess the arrival mode of acute ischemic stroke (AIS) patients on weekends compared with weekdays. Background Conflicting data exist on whether there is a weekend vs. weekday effect on AIS care processes and outcomes, but these associations may be affected by several pre-hospital factors including mode of hospital arrival. We assessed the arrival mode of stroke code patients to the hospital on weekends vs. weekdays. Design/Methods: We analyzed the dataset of an AIS network comprising prospectively collected socio-demographic, clinical, discharge and day-90 data on AIS patients presenting within 12 hours of ictus to five hospitals in San Diego between June 2004 and May 2011. Weekend admission was defined as the period from Friday, 17:01, to Monday, 08:59. The main outcome of interest was mode of arrival (ambulance vs. other). Outcomes were adjusted for pre-specified covariates in a multivariable logistic regression model. Pre-specified interactions of arrival mode vs. sex, race-ethnicity, and stroke severity were also evaluated. Results: Of 1238 patients, the mean age was 70 years, with 47% female, 66% Non-Hispanic White, 15% Hispanic White, 11% Black, and 8% other ethnicity. Baseline characteristics were similar in weekend and weekday patients. Patients presenting on weekends vs. weekdays were more likely to arrive at the hospital by ambulance (82.3 vs. 76.8%, p=0.017) and this difference persisted in multivariable analyses (adjusted OR 1.49, 95% CI: 1.10-2.01, p=0.009), but there were no interactions with sex (p=0.67), ethnicity (p=0.66), or index stroke severity (0.65). Conclusions: Stroke code patients in San Diego were more likely to arrive to the hospital by ambulance on weekends compared to weekdays. Further studies will need to investigate the reasons for this arrival mode disparity and its impact on care and outcomes. More community education is warranted to promote calling the ambulance for stroke-like symptoms, especially on weekdays. Supported by: Funding: NIH 5P50NS044148 (Meyer BC). Disclosure: Dr. Schlick has nothing to disclose. Dr. Raman has nothing to disclose. Dr. Hemmen has nothing to disclose. Dr. Meyer has received personal compensation for activities with the National Institues of Health and a community hospital. Dr. Meyer has nothing to disclose. Dr. Ernstrom has nothing to disclose. Dr. Ovbiagele has received personal compensation for activities with Avanir Pharmaceuticals.