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Dunkley R, Omeaku N, Trickey AW, Tandel MD, Garcia A, Govindarajan P. Growth of Statewide Emergency Medical Services Bypass Policies for Acute Stroke. JAMA HEALTH FORUM 2024; 5:e241752. [PMID: 38967951 PMCID: PMC11227071 DOI: 10.1001/jamahealthforum.2024.1752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 05/03/2024] [Indexed: 07/06/2024] Open
Abstract
This cross-sectional study evaluates growth of transport policies and policy components that directed emergency medical services (EMS) to bypass local emergency departments for the closest certified stroke centers as a proven treatment for stroke.
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Affiliation(s)
| | | | - Amber W. Trickey
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford Medicine, Stanford University, Palo Alto, California
| | - Megha D. Tandel
- Quantitative Sciences Unit, Department of Medicine, Stanford Medicine, Stanford University, Palo Alto, California
| | - Ariadna Garcia
- Quantitative Sciences Unit, Department of Medicine, Stanford Medicine, Stanford University, Palo Alto, California
| | - Prasanthi Govindarajan
- Department of Emergency Medicine, Stanford Medicine, Stanford University, Palo Alto, California
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Meng T, Trickey AW, Harris AHS, Matheson L, Rosenthal S, Traboulsi AAR, Saver JL, Wagner T, Govindarajan P. Lessons Learned From the Historical Trends on Thrombolysis Use for Acute Ischemic Stroke Among Medicare Beneficiaries in the United States. Front Neurol 2022; 13:827965. [PMID: 35309566 PMCID: PMC8931506 DOI: 10.3389/fneur.2022.827965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 01/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background The most recent time trends on intravenous thrombolysis (IVT) utilization for acute ischemic stroke was reported in 2011 using the Get with the Guidelines. Our objectives are to assess and validate the change in IVT utilization through 2014 in a national sample of Medicare beneficiaries and to examine the effect of patient, stroke center designation, and geography on IVT utilization. Methods We built a comprehensive national stroke registry by combining patient-level, stroke center status, and geographical characteristics, using multiple data sources. Using multiple national administrative databases from 2007 to 2014, we generated a mixed-effect logistic regression model to characterize the independent associations of patient, hospital, and geographical characteristics with IVT in 2014. Results Use of IVT increased consistently from 2.8% in 2007 to 7.7% in 2014, P < 0.001. Between group differences persisted, with lower odds of use in patients who were ≥86 years (aOR 0.74, 95% CI 0.65-0.83), Black (aOR 0.73, 95% CI 0.61-0.87), or treated at a rural hospital (aOR 0.88, 95% CI 0.77-1.00). Higher odds of use were observed in patients who arrived by ambulance (aOR 2.67, 95% CI 2.38-3.00), were treated at a hospital certified as a stroke center (aOR 1.96, 95% CI 1.68-2.29), or were treated at hospitals located in the most socioeconomically advantaged areas (aOR 1.27, 95% CI 1.05-1.54). Conclusions Between 2007 and 2014, the frequency of IVT for patients with acute ischemic stroke increased substantially, though differences persisted in the form of less frequent treatment associated with certain characteristics. These findings can inform ongoing efforts to optimize the delivery of IVT to all AIS patients nationwide.
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Affiliation(s)
- Tong Meng
- Department of Emergency Medicine, Stanford University, Stanford, CA, United States
- Stanford–Surgery Policy Improvement Research & Education Center (S-SPIRE), Department of Surgery, Stanford, CA, United States
| | - Amber W. Trickey
- Stanford–Surgery Policy Improvement Research & Education Center (S-SPIRE), Department of Surgery, Stanford, CA, United States
| | - Alex H. S. Harris
- Stanford–Surgery Policy Improvement Research & Education Center (S-SPIRE), Department of Surgery, Stanford, CA, United States
- Veterans Affairs Health Services Research and Development Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, Menlo Park, CA, United States
| | - Loretta Matheson
- Department of Emergency Medicine, Stanford University, Stanford, CA, United States
| | - Sarah Rosenthal
- Department of Emergency Medicine, Stanford University, Stanford, CA, United States
| | | | - Jeffrey L. Saver
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Todd Wagner
- Stanford–Surgery Policy Improvement Research & Education Center (S-SPIRE), Department of Surgery, Stanford, CA, United States
- Veterans Affairs Health Services Research and Development Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, Menlo Park, CA, United States
| | - Prasanthi Govindarajan
- Department of Emergency Medicine, Stanford University, Stanford, CA, United States
- Stanford–Surgery Policy Improvement Research & Education Center (S-SPIRE), Department of Surgery, Stanford, CA, United States
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Development of a Joint Commission Disease-Specific Care Certification Program for Parkinson Disease in an Acute Care Hospital. J Neurosci Nurs 2020; 51:313-319. [PMID: 31626076 DOI: 10.1097/jnn.0000000000000472] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with Parkinson disease (PD) admitted to the hospital for any reason are at a higher risk of hospital-related complications. Frequent causes include delays in administering PD medications or use of contraindicated medications. The Joint Commission Disease-Specific Care (DSC) program has been used to establish a systematic approach to the care of specific inpatient populations. Once obtained, this certification demonstrates a commitment to patient care and safety, which is transparent to the public and can improve quality of care. METHODS We formalized our efforts to improve the care of hospitalized patients with PD by pursuing Joint Commission DSC. An interprofessional team was assembled to include nurses, therapists, physicians, pharmacists, performance improvement specialists, and data analysts. The team identified quality metrics based on clinical guidelines. In addition, a large educational campaign was undertaken. Application to the Joint Commission for DSC resulted in a successful June 15, 2018 site visit. To our knowledge, this is the first DSC program in PD in an acute care hospital. CONCLUSION Using the established platform of DSC certification from the Joint Commission, we developed a program based on relevant metrics that aims to address medication management of patients with PD admitted to the hospital. Our hope is to improve the care of this vulnerable patient population.
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Park IT, Jung YY, Park SH, Hwang JH, Suk SH. Impact of Healthcare Accreditation Using a Systematic Review: Balanced Score Card Perspective. ACTA ACUST UNITED AC 2017. [DOI: 10.14371/qih.2017.23.1.69] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Musallam E, Johantgen M, Connerney I. Hospital Disease-Specific Care Certification Programs and Quality of Care: A Narrative Review. Jt Comm J Qual Patient Saf 2017; 42:364-8. [PMID: 27456418 DOI: 10.1016/s1553-7250(16)42051-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Disease-specific care certification (DSCC) programs have been developed to improve the quality and performance of programs or services that may be based within or associated with a hospital or other health care organization. A comprehensive summary of evidence for DSCC programs and their reported effect on the quality of care was prepared in a narrative review, the first of its kind on this topic. METHODS A systematic search was performed to identify articles that reported about DSCC. Any article that reported DSCC and certifications, published between 2003 and August 2015 (with an update in March 2016), and conducted in the United States was included. Databases searched included PubMed, MEDLINE, and CINAHL. RESULTS The articles were reviewed in terms of four topics: early development of DSCC, the journey toward DSCC, the relationship between DSCC and organizing process of care, and the relationship between DSCC and outcomes of care. Fifteen articles noted a positive relationship between DSCC programs and quality of care, only 6 of which reported empirical data. Therefore, a systematic review and meta-analysis were not warranted. Only 3 articles involved use of sophisticated statistical modeling with adequate control variables to investigate the effect of DSCC, which makes it difficult to conclude that the change in hospitals' or patients' outcomes were related to the certification. CONCLUSIONS The majority (13) of the articles focused on Joint Commission DSCC, with the remaining assessing Society of Cardiovascular Patient Care "accreditation" (certification). Only two studies, each study using a cross-sectional design, that empirically examined the relationship between DSCC and outcomes of care-mortality of care and readmission. More research studies are needed to evaluate the effectiveness of DSCC programs in improving outcomes of care, particularly patient-centered outcome measures, such as patient satisfaction and self-care.
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Affiliation(s)
- Eyad Musallam
- Center for Health Outcomes Research, School of Nursing, University of Maryland, Baltimore, USA
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Domino JS, Baek J, Meurer WJ, Garcia N, Morgenstern LB, Campbell M, Lisabeth LD. Emerging temporal trends in tissue plasminogen activator use: Results from the BASIC project. Neurology 2016; 87:2184-2191. [PMID: 27770075 DOI: 10.1212/wnl.0000000000003349] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 07/27/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To explore temporal trends in tissue plasminogen activator (tPA) administration for acute ischemic stroke (AIS) in a biethnic community without an academic medical center and variation in trends by age, sex, ethnicity, and stroke severity. METHODS Cases of AIS were identified from 7 hospitals in the Brain Attack Surveillance in Corpus Christi (BASIC) project, a population-based surveillance study between January 1, 2000, and June 30, 2012. tPA, demographics, and stroke severity as assessed by the NIH Stroke Scale (NIHSS) were ascertained from medical records. Temporal trends were explored using generalized estimating equations, and adjustment made for age, sex, ethnicity, and NIHSS. Interaction terms were included to test for effect modification. RESULTS There were 5,277 AIS cases identified from 4,589 unique individuals. tPA use was steady at 2% and began increasing in 2006, reaching 11% in subsequent years. Stroke severity modified temporal trends (p = 0.003) such that cases in the highest severity quartile (NIHSS > 8) had larger increases in tPA use than those in lower severity quartiles. Although ethnicity did not modify the temporal trend, Mexican Americans (MAs) were less likely to receive tPA than non-Hispanic whites (NHWs) due to emerging ethnic differences in later years. CONCLUSIONS Dramatic increases in tPA use were apparent in this community without an academic medical center. Primary stroke center certification likely contributed to this rise. Results suggest that increases in tPA use were greater in higher severity patients compared to lower severity patients, and a gap between MAs and NHWs in tPA administration may be emerging.
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Affiliation(s)
- Joseph S Domino
- From the Department of Epidemiology (J.S.D., J.B., L.B.M., L.D.L.), University of Michigan School of Public Health; Department of Emergency Medicine (W.J.M.) and Stroke Program (N.G., L.B.M., L.D.L.), University of Michigan Medical School, Ann Arbor; and private practice (M.C.), Corpus Christi, TX
| | - Jonggyu Baek
- From the Department of Epidemiology (J.S.D., J.B., L.B.M., L.D.L.), University of Michigan School of Public Health; Department of Emergency Medicine (W.J.M.) and Stroke Program (N.G., L.B.M., L.D.L.), University of Michigan Medical School, Ann Arbor; and private practice (M.C.), Corpus Christi, TX
| | - William J Meurer
- From the Department of Epidemiology (J.S.D., J.B., L.B.M., L.D.L.), University of Michigan School of Public Health; Department of Emergency Medicine (W.J.M.) and Stroke Program (N.G., L.B.M., L.D.L.), University of Michigan Medical School, Ann Arbor; and private practice (M.C.), Corpus Christi, TX
| | - Nelda Garcia
- From the Department of Epidemiology (J.S.D., J.B., L.B.M., L.D.L.), University of Michigan School of Public Health; Department of Emergency Medicine (W.J.M.) and Stroke Program (N.G., L.B.M., L.D.L.), University of Michigan Medical School, Ann Arbor; and private practice (M.C.), Corpus Christi, TX
| | - Lewis B Morgenstern
- From the Department of Epidemiology (J.S.D., J.B., L.B.M., L.D.L.), University of Michigan School of Public Health; Department of Emergency Medicine (W.J.M.) and Stroke Program (N.G., L.B.M., L.D.L.), University of Michigan Medical School, Ann Arbor; and private practice (M.C.), Corpus Christi, TX
| | - Morgan Campbell
- From the Department of Epidemiology (J.S.D., J.B., L.B.M., L.D.L.), University of Michigan School of Public Health; Department of Emergency Medicine (W.J.M.) and Stroke Program (N.G., L.B.M., L.D.L.), University of Michigan Medical School, Ann Arbor; and private practice (M.C.), Corpus Christi, TX
| | - Lynda D Lisabeth
- From the Department of Epidemiology (J.S.D., J.B., L.B.M., L.D.L.), University of Michigan School of Public Health; Department of Emergency Medicine (W.J.M.) and Stroke Program (N.G., L.B.M., L.D.L.), University of Michigan Medical School, Ann Arbor; and private practice (M.C.), Corpus Christi, TX.
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Falstie-Jensen AM, Nørgaard M, Hollnagel E, Larsson H, Johnsen SP. Is compliance with hospital accreditation associated with length of stay and acute readmission? A Danish nationwide population-based study. Int J Qual Health Care 2015; 27:451-8. [DOI: 10.1093/intqhc/mzv070] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2015] [Indexed: 01/27/2023] Open
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Rhudy JP, Bakitas MA, Hyrkäs K, Jablonski-Jaudon RA, Pryor ER, Wang HE, Alexandrov AW. Effectiveness of regionalized systems for stroke and myocardial infarction. Brain Behav 2015; 5:e00398. [PMID: 26516616 PMCID: PMC4614047 DOI: 10.1002/brb3.398] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 07/18/2015] [Accepted: 08/16/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Acute ischemic stroke (AIS) and ST-segment elevation myocardial infarction (STEMI) are ischemic emergencies. Guidelines recommend care delivery within formally regionalized systems of care at designated centers, with bypass of nearby centers of lesser or no designation. We review the evidence of the effectiveness of regionalized systems in AIS and STEMI. METHODS Literature was searched using terms corresponding to designation of AIS and STEMI systems and from 2010 to the present. Inclusion criteria included report of an outcome on any dependent variable mentioned in the rationale for regionalization in the guidelines and an independent variable comparing care to a non- or pre-regionalized system. Designation was defined in the AIS case as certification by the Joint Commission as either a primary (PSC) or comprehensive (CSC) stroke center. In the STEMI case, the search was conducted linking "regionalization" and "myocardial infarction" or citation as a model system by any American Heart Association statement. RESULTS For AIS, 17 publications met these criteria and were selected for review. In the STEMI case, four publications met these criteria; the search was therefore expanded by relaxing the criteria to include any historical or anecdotal comparison to a pre- or nonregionalized state. The final yield was nine papers from six systems. CONCLUSION Although regionalized care results in enhanced process and reduced unadjusted rates of disparity in access and adverse outcomes, these differences tend to become nonsignificant when adjusted for delayed presentation and hospital arrival by means other than emergency medical services. The benefits of regionalized care occur along with a temporal trend of improvement due to uptake of quality initiatives and guideline recommendations by all systems regardless of designation. Further research is justified with a randomized registry or cluster randomized design to support or refute recommendations that regionalization should be the standard of care.
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Affiliation(s)
- James P Rhudy
- School of Nursing University of Alabama at Birmingham Alabama
| | - Marie A Bakitas
- School of Nursing University of Alabama at Birmingham Alabama
| | - Kristiina Hyrkäs
- Center for Nursing Research and Quality Outcomes Maine Medical Center Birmingham Alabama
| | | | - Erica R Pryor
- School of Nursing University of Alabama at Birmingham Alabama
| | - Henry E Wang
- Department of Emergency Medicine University of Alabama at Birmingham Birmingham Alabama
| | - Anne W Alexandrov
- College of Nursing University of Tennessee Health Sciences Center Memphis Tennessee
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Falstie-Jensen AM, Larsson H, Hollnagel E, Norgaard M, Svendsen MLO, Johnsen SP. Compliance with hospital accreditation and patient mortality: a Danish nationwide population-based study. Int J Qual Health Care 2015; 27:165-74. [DOI: 10.1093/intqhc/mzv023] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2015] [Indexed: 01/15/2023] Open
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Asimos AW, Ward S, Brice JH, Enright D, Rosamond WD, Goldstein LB, Studnek J. A geographic information system analysis of the impact of a statewide acute stroke emergency medical services routing protocol on community hospital bypass. J Stroke Cerebrovasc Dis 2014; 23:2800-2808. [PMID: 25294057 DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 06/13/2014] [Accepted: 07/02/2014] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Our goal was to determine if a statewide Emergency Medical Services (EMSs) Stroke Triage and Destination Plan (STDP), specifying bypass of hospitals unable to routinely treat stroke patients with thrombolytics (community hospitals), changed bypass frequency of those hospitals. METHODS Using a statewide EMS database, we identified stroke patients eligible for community hospital bypass and compared bypass frequency 1-year before and after STDP implementation. RESULTS Symptom onset time was missing for 48% of pre-STDP (n = 2385) and 29% of post-STDP (n = 1612) cases. Of the remaining cases with geocodable scene addresses, 58% (1301) in the pre-STDP group and 61% (2,078) in the post-STDP group were ineligible for bypass, because a community hospital was not the closest hospital to the stroke event location. Because of missing data records for some EMS agencies in 1 or both study periods, we included EMS agencies from only 49 of 100 North Carolina counties in our analysis. Additionally, we found conflicting hospital classifications by different EMS agencies for 35% of all hospitals (n = 38 of 108). Given these limitations, we found similar community hospital bypass rates before and after STDP implementation (64%, n = 332 of 520 vs. 63%, n = 345 of 552; P = .65). CONCLUSIONS Missing symptom duration time and data records in our state's EMS data system, along with conflicting hospital classifications between EMS agencies limit the ability to study statewide stroke routing protocols. Bypass policies may apply to a minority of patients because a community hospital is not the closest hospital to most stroke events. Given these limitations, we found no difference in community hospital bypass rates after implementation of the STDP.
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Affiliation(s)
- Andrew W Asimos
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina.
| | - Shana Ward
- Dickson Advanced Analytics Group, Carolinas HeathCare System, Charlotte, North Carolina
| | - Jane H Brice
- Department of Emergency Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Dianne Enright
- Health & Spatial Analysis Unit, State Center for Health Statistics, Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, North Carolina
| | - Wayne D Rosamond
- Department of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Larry B Goldstein
- Duke Comprehensive Stroke Center, Duke University Medical Center, Durham, North Carolina
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Hogan TM, Olade TO, Carpenter CR. A profile of acute care in an aging America: snowball sample identification and characterization of United States geriatric emergency departments in 2013. Acad Emerg Med 2014; 21:337-46. [PMID: 24628759 DOI: 10.1111/acem.12332] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 09/06/2013] [Accepted: 09/07/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aging of America poses a challenge to emergency departments (EDs). Studies show that elderly patients have poor outcomes despite increased testing, prolonged periods of observation, and higher admission rates. In response, emergency medicine (EM) leaders have implemented strategies for improved ED elder care, enhancing expertise, equipment, policies, and protocols. One example is the development of geriatric EDs gaining in popularity nationwide. To the authors' knowledge, this is the first research to systematically identify and qualitatively characterize the existence, locations, and features of geriatric EDs across the United States. OBJECTIVES The primary objective was to determine the number, distribution, and characteristics of geriatric EDs in the United States in 2013. METHODS This was a survey with potential respondents identified via a snowball sampling of known geriatric EDs, EM professional organizations' geriatric interest groups, and a structured search of the Internet using multiple search engines. Sites were contacted by telephone, and those confirming geriatric EDs presence received the survey via e-mail. Category questions included date of opening, location, volumes, staffing, physical plant changes, screening tools, policies, and protocols. Categories were reported based on general interest to those seeking to understand components of a geriatric ED. RESULTS Thirty-six hospitals confirmed geriatric ED existence and received surveys. Thirty (83%) responded to the survey and confirmed presence or plans for geriatric EDs: 24 (80%) had existing geriatric EDs, and six (20%) were planning to open geriatric EDs by 2014. The majority of geriatric EDs are located in the Midwest (46%) and Northeast (30%) regions of the United States. Eighty percent serve from 5,000 to 20,000 elder patients annually. Seventy percent of geriatric EDs are attached to the main ED, and 66% have from one to 10 geriatric beds. Physical plant changes include modifications to beds (96%), lighting (90%), flooring (83%), visual aids (73%), and sound level (70%). Seventy-seven percent have staff overlapping with the nongeriatric portion of their ED, and 80% require geriatric staff didactics. Sixty-seven percent of geriatric EDs report discharge planning for geriatric ED patients, and 90% of geriatric EDs had direct follow-up through patient callbacks. CONCLUSIONS The snowball sample identification of U.S. geriatric EDs resulted in 30 confirmed respondents. There is significant variation in the components constituting a geriatric ED. The United States should consider external validation of self-identified geriatric EDs to standardize the quality and type of care patients can expect from an institution with an identified geriatric ED.
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Affiliation(s)
- Teresita M. Hogan
- The Section of Emergency Medicine; Department of Medicine; University of Chicago School of Medicine; Chicago IL
| | | | - Christopher R. Carpenter
- The Division of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
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Lahr MMH, Luijckx GJ, Vroomen PCAJ, van der Zee DJ, Buskens E. The chain of care enabling tPA treatment in acute ischemic stroke: a comprehensive review of organisational models. J Neurol 2012; 260:960-8. [PMID: 22915092 DOI: 10.1007/s00415-012-6647-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 07/31/2012] [Accepted: 08/01/2012] [Indexed: 11/25/2022]
Abstract
Protracted and partial implementation of treatment with intravenous tissue plasminogen activator (tPA) within 4.5 h after acute stroke onset results in potentially eligible patients not receiving optimal treatment. The goal of this study was to review the performance of various organisational models of acute stroke care delivery, and subsequent attempts to improve implementation of tPA treatment. Publications comprehensively reporting on organisational models to improve implementation of i.v. tPA treatment of acute ischemic stroke patients were selected. The efficacy of organisational models was assessed using process outcome measures: thrombolysis rates, time-dependent operational endpoints (time delays), functional outcomes: safety (rate of symptomatic intracranial hemorrhage, mortality rates) and clinical outcome at 90 days (modified Rankin Scale). Fifty-eight published studies assessing organisational models were identified. Four dominant models of acute stroke care delivery were discerned, i.e., primary and comprehensive stroke centres, telemedicine, and the mobile stroke unit. Performance reported for these models suggest a large variation in administration of thrombolytic therapy (0.7-30 %). Time delays and functional outcomes found varied considerably, just like safety and mortality (0.0-11.5 %, and 3.4-31.9 %, respectively). These findings suggest that improving organisational models for tPA treatment may improve acute stroke care. However, implementation may be hampered by regional variation in acute stroke care capacity, expertise, and a fragmented approach towards organising stroke care.
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Affiliation(s)
- Maarten M H Lahr
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, P.O. Box 30001, 9700 RB, Groningen, The Netherlands.
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Affiliation(s)
- Edward C. Jauch
- From the Division of Emergency Medicine, Department of Medicine,
Medical University of South Carolina,
Charleston, SC
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