Validity of a computerised five-level emergency triage system for patients with acute ischaemic stroke

Characteristics and risk of stroke in emergency department patients with acute dizziness

Background

Acute dizziness is a common symptom in the emergency department (ED), with strokes accounting for 3 %-5 % of cases. We investigated the risk of stroke in ED patients with acute dizziness and compared stroke characteristics diagnosed during and after the ED visit.

Methods

We identified adult patients with acute dizziness, vertigo, or imbalance using a hospital research-based database. Patients with abdominal or flank pain were used as the comparison group. Patients with dizziness were 1:1 matched to comparison patients. Each patient was traced for up to one year until being hospitalized for a stroke.

Results

Out of the 24,266 eligible patients, 589 (2.4 %) were hospitalized for stroke during the ED visit. For the remaining 23,677 patients, the risk of stroke at 7, 30, 90, and 365 days after ED discharge was 0.40 %, 0.52 %, 0.71 %, and 1.25 % respectively. Patients with dizziness had a higher risk of stroke compared to the comparison group at 7, 30, 90, and 365 days. The risk ratios decreased from 5.69 (95 % confidence interval [CI], 3.34-9.68) to 2.03 (95 % CI, 1.65-2.49). Compared to patients hospitalized for stroke during the ED visit, those hospitalized for stroke after the ED visit had greater stroke severity despite a lower initial triage acuity. Patients with early stroke (≤7 days) after ED discharge were less likely to have hypertension, diabetes, hyperlipidemia, and atrial fibrillation. They mostly experienced posterior circulation stroke. Patients with late stroke (>7 days) were older and less likely to have hypertension and hyperlipidemia but more likely to have a history of prior stroke and ischemic heart disease. Their strokes were mainly located in the anterior circulation territory.

Conclusions

The risk of stroke after ED discharge was higher in patients with dizziness than in the comparison group, with gradually decreasing risk ratios in the following year. Patients hospitalized for stroke during and after the ED visit had different profiles of vascular risk factors and clinical characteristics.

Developing a stroke alert trigger for clinical decision support at emergency triage using machine learning

BACKGROUND

Acute stroke is an urgent medical condition that requires immediate assessment and treatment. Prompt identification of patients with suspected stroke at emergency department (ED) triage followed by timely activation of code stroke systems is the key to successful management of stroke. While false negative detection of stroke may prevent patients from receiving optimal treatment, excessive false positive alarms will substantially burden stroke neurologists. This study aimed to develop a stroke-alert trigger to identify patients with suspected stroke at ED triage.

METHODS

Patients who arrived at the ED within 12 h of symptom onset and were suspected of a stroke or transient ischemic attack or triaged with a stroke-related symptom were included. Clinical features at ED triage were collected, including the presenting complaint, triage level, self-reported medical history (hypertension, diabetes, hyperlipidemia, heart disease, and prior stroke), vital signs, and presence of atrial fibrillation. Three rule-based algorithms, ie, Face Arm Speech Test (FAST) and two flavors of Balance, Eyes, FAST (BE-FAST), and six machine learning (ML) techniques with various resampling methods were used to build classifiers for identification of patients with suspected stroke. Logistic regression (LR) was used to find important features.

RESULTS

The study population consisted of 1361 patients. The values of area under the precision-recall curve (AUPRC) were 0.737, 0.710, and 0.562 for the FAST, BE-FAST-1, and BE-FAST-2 models, respectively. The values of AUPRC for the top three ML models were 0.787 for classification and regression tree with undersampling, 0.783 for LR with synthetic minority oversampling technique (SMOTE), and 0.782 for LR with class weighting. Among the ML models, logistic regression and random forest models in general achieved higher values of AUPRC, in particular in those with class weighting or SMOTE to handle class imbalance problem. In addition to the presenting complaint and triage level, age, diastolic blood pressure, body temperature, and pulse rate, were also important features for developing a stroke-alert trigger.

CONCLUSIONS

ML techniques significantly improved the performance of prediction models for identification of patients with suspected stroke. Such ML models can be embedded in the electronic triage system for clinical decision support at ED triage.

A rapid clinic-based service for an emergency department of a tertiary teaching hospital during a dengue outbreak

The 2015 dengue outbreak in southern Taiwan turned into a public health emergency, resulting in a large-scale mobilization of personnel from the emergency department (ED) services operating in and near full capacity to assist with the outbreak. This study aimed to assess a rapid independent clinic-based service (RCS), which was set up and designed to relieve the overcrowding of the regular ambulatory and emergency services during an epidemic of dengue.This is a retrospective cross-sectional study.National Cheng Kung University Hospital, Tainan, Taiwan.Patients with positive test results were enrolled and reviewed to evaluate the efficacy of RCS implementation between August and October 2015. The case-treatment rates stratified by length of stay (LOS) were used to examine the performance of the RCS that was set up outside the ED and designed to relieve the overcrowding of the regular ambulatory and emergency services.Patients with dengue-like illnesses may arrive at the hospital and require optimal ED triage and management thereafter. Although the outbreak resulted in a shortage of spare space in the ED, a proper response from the hospital administration would ameliorate the work overload of the staff and would not decrease the quality of care for critical patients.An early and restrictive intensive intervention was beneficial to health care facilities during a dengue outbreak. Further planning and training of the RCS could be crucial for hospital preparedness for infectious disease outbreaks.

Blood-Brain Barrier Damage in Ischemic Stroke and Its Regulation by Endothelial Mechanotransduction

Ischemic stroke, a major cause of mortality in the United States, often contributes to disruption of the blood-brain barrier (BBB). The BBB along with its supportive cells, collectively referred to as the “neurovascular unit,” is the brain’s multicellular microvasculature that bi-directionally regulates the transport of blood, ions, oxygen, and cells from the circulation into the brain. It is thus vital for the maintenance of central nervous system homeostasis. BBB disruption, which is associated with the altered expression of tight junction proteins and BBB transporters, is believed to exacerbate brain injury caused by ischemic stroke and limits the therapeutic potential of current clinical therapies, such as recombinant tissue plasminogen activator. Accumulating evidence suggests that endothelial mechanobiology, the conversion of mechanical forces into biochemical signals, helps regulate function of the peripheral vasculature and may similarly maintain BBB integrity. For example, the endothelial glycocalyx (GCX), a glycoprotein-proteoglycan layer extending into the lumen of bloods vessel, is abundantly expressed on endothelial cells of the BBB and has been shown to regulate BBB permeability. In this review, we will focus on our understanding of the mechanisms underlying BBB damage after ischemic stroke, highlighting current and potential future novel pharmacological strategies for BBB protection and recovery. Finally, we will address the current knowledge of endothelial mechanotransduction in BBB maintenance, specifically focusing on a potential role of the endothelial GCX.

Implementation of an institution-wide acute stroke algorithm: Improving stroke quality metrics

Background:

In May 2012, an updated stroke algorithm was implemented at Vanderbilt University Medical Center. The current study objectives were to: (1) describe the process of implementing a new stroke algorithm and (2) compare pre- and post-algorithm quality improvement (QI) metrics, specificaly door to computed tomography time (DTCT), door to neurology time (DTN), and door to tPA administration time (DTT).

Methods:

Our institutional stroke algorithm underwent extensive revision, with a focus on removing variability, streamlining care, and improving time delays. The updated stroke algorithm was implemented in May 2012. Three primary stroke QI metrics were evaluated over four separate 3-month time points, one pre- and three post-algorithm periods.

Results:

The following data points improved after algorithm implementation: average DTCT decreased from 39.9 to 12.8 min (P < 0.001); average DTN decreased from 34.1 to 8.2 min (P ≤ 0.001), and average DTT decreased from 62.5 to 43.5 min (P = 0.17).

Conclusion:

A new stroke protocol that prioritized neurointervention at our institution resulted in significant lowering in the DTCT and DTN, with a nonsignificant improvement in DTT.

Applications of a Rapid and Sensitive Dengue DUO Rapid Immunochromatographic Test Kit as a Diagnostic Strategy during a Dengue Type 2 Epidemic in an Urban City

Dengue infection is a major health problem in tropical and subtropical countries. A prospective observational study in a university-affiliated hospital was conducted between August 2015 and September 2015. Patients who visited the emergency department (ED) with a presentation of any symptoms of dengue were eligible for the dengue non-structural protein 1 (NS1), IgM/IgG rapid immunochromatographic tests and real-time polymerase chain reaction (RT-PCR) to evaluate the performance of the rapid tests. Considering the RT-PCR as the gold standard for the dengue diagnosis, the ideal primary results of sensitivity (80–100%), specificity (60–84%), positive predicted value(75%-95%), and negative predicted value (70–100%) suggested that the NS1-based test with or without a combination of IgM and IgG tests have good diagnostic performances in detecting dengue infections, even in the afebrile or elderly populations.

Opinion survey on proposals for improving code stroke in Murcia Health District V, 2014

INTRODUCTION

Stroke is a time-dependent neurological disease. Health District V in the Murcia Health System has certain demographic and geographical characteristics that make it necessary to create specific improvement strategies to ensure proper functioning of code stroke (CS). The study objectives were to assess local professionals' opinions about code stroke activation and procedure, and to share these suggestions with the regional multidisciplinary group for code stroke.

SUBJECTS AND METHOD

This cross-sectional and descriptive study used the Delphi technique to develop a questionnaire for doctors and nurses working at all care levels in Area V. An anonymous electronic survey was sent to 154 professionals. The analysis was performed using the SWOT method (Strengths, Weaknesses, Opportunities, and Threats).

RESULTS

Researchers collected 51 questionnaires. The main proposals were providing training, promoting communication with the neurologist, overcoming physical distances, using diagnostic imaging tests, motivating professionals, and raising awareness in the general population.

CONCLUSIONS

Most of the interventions proposed by the participants have been listed in published literature. These improvement proposals were forwarded to the Regional Code Stroke Improvement Group.

Factors Associated with Blood Culture Contamination in the Emergency Department: Critical Illness, End-Stage Renal Disease, and Old Age

Background

Blood culture contamination in emergency departments (ED) that experience a high volume of patients has negative impacts on optimal patient care. It is therefore important to identify risk factors associated with blood culture contamination in EDs.

Methodology/Principal Findings

A prospectively observational study in a university-affiliated hospital were conducted between August 2011 and December 2012. Positive monomicrobial and negative blood cultures drawn from adult patients in the ED were analyzed to evaluate the possible risk factors for contamination. A total of 1,148 positive monomicrobial cases, 391 contamination cases, and 13,689 cases of negative blood culture were identified. Compared to patients with negative blood cultures, patients in triage levels 1 and 2 (Incidence Rate Ratio, IRR = 2.24), patients with end-stage renal disease (ESRD) (IRR = 2.05), and older patients (IRR: 1.02 per year) were more likely to be associated with ED blood culture contamination.

Conclusions/Significance

Critical patients (triage levels 1 and 2), ESRD patients, and older patients were more commonly associated with blood culture contamination in the ED. Further studies to evaluate whether the characteristics of skin commensals contribute to blood culture contamination is warranted, especially in hospitals populated with high-risk patients.

Speech disturbance at stroke onset is correlated with stroke early mortality

Background

Speech disturbance is a common symptom of stroke and is important as a prompt identifier of the event. The frequency of the symptom among each stroke subtype, differences between patients with and without speech disturbance and its correlation to early mortality remain unclear.

Methods

The Kyoto prefecture of Japan has established a registry to enroll new stroke patients in cooperation with the Kyoto Medical Association and its affiliated hospitals. It is named the Kyoto Stroke Registry (KSR). We confirmed the existence or absence of speech disturbance in 1693 stroke patients registered to the KSR and investigated associations between speech disturbance and other characteristics.

Results

Speech disturbance was observed in 52.6% of cerebral infarction (CI), 47.5% of cerebral hemorrhage (CH), and 8.0% of subarachnoid hemorrhage (SAH) cases. Characteristics showing statistically significant differences between patients with and without speech disturbance and patients were age, blood pressure, history of hypertension, arrhythmia and diabetes mellitus, habit of tobacco and alcohol, and paresis. Mortality rates of patients with/without speech disturbance were 5.2%/1.2% for CI, 12.5% /4.1% for CH, and 62.5%/ 9.0% for SAH. Adjusted hazard ratios were 2.63 (1.14-6.13, p = 0.024) in CI, 4.15 (1.41-12.23, p = 0.010) in CH, and 20.46 (4.40-95.07, p < 0.001) in SAH).

Conclusion

Speech disturbance was frequently observed in stroke patients at the onset and therefore could be useful to identify the problem at the earliest stage. Hazard ratio for death was higher in stroke patients with speech disturbance than patients without. Speech disturbance is a prompt predictor of stroke early mortality.

Hiromi Nakano, Yoshiyuki Watanabe, Tatsuyuki Sekimoto, Kouichiro Shimizu, Akihiko Nishizawa, Atsushi Okumura and Masahiro Makino contributed equally to this work.