Imbalanced Regional Development of Acute Ischemic Stroke Care in Emergency Departments in China

Stroke nurse-led intravenous thrombolytic therapy strategy for ischemic stroke based on timeline process: A quality improvement program from China

Objective

Early thrombolytic therapy for ischemic stroke within the therapeutic window is associated with improved clinical outcomes. This study investigated whether optimizing intravenous thrombolytic (IVT) therapy strategies for stroke could reduce treatment delays.

Methods

To reduce delays in IVT therapy for ischemic stroke, a series of quality improvement measures were implemented at a tertiary hospital in Hangzhou, Zhejiang Province, from June 2021 to August 2023, which included developing a timeline process management system, forming a nurse-led stroke process management team, providing homogeneous training, standardizing the IVT therapy process for ischemic stroke, and introducing an incentive policy. During the pre- (from June 2021 to February 2022, group A) and post- (from March to November 2022, group B1; from December 2022 to August 2023, group B2 [implementation of an additional incentive policy]) of the implementation the strategy, the door-to-computed tomographic angiography (CTA) time (DCT), CTA time, neurology consultation to consent for IVT, CTA-to-needle time (CNT), and door-to-needle time (DNT), the percentage of people who underwent CTA within 20 min, 15 min, and 10 min and DNT within 60 min, 45 min, and 30 min were collected and compared.

Results

Following the implementation of the standardized IVT process management strategy for stroke, the DNT for group B1 and group B2 were 30 (24, 44) min and 31 (24, 41) min, respectively, both significantly lower than the 46 (38, 58) min in group A (P < 0.001); the median DCT were both 13 min in group B1 and B2 lower than 17min in group A (P < 0.001); the median CTA were 12 min in Group B1 and 9 min in Group B2 lower than 14 min in group A (P < 0.001); similar results were observed during the neurology consultation to obtain consent for IVT and CNT. Compared with group A, the proportion of DCT ≤ 20 min, 15 min, and 10 min was higher in groups B1 and B2 (P < 0.05), and the same result was observed at DNT ≤60 min, 45 min, and 30 min (P < 0.05). However, the additional incentive policy did not significantly differ between Group B2 and Group B1.

Conclusions

Optimizing IVT therapy for ischemic stroke is a feasible approach to limit the DNT to 30 min in ischemic stroke, significantly reducing delays within the therapeutic window and increasing the number of patients meeting target time segments. Additionally, generating a timeline for the IVT therapy process by scanning positioning quick response codes was a significant breakthrough in achieving the informatization of IVT quality management for stroke.

Reducing intravenous thrombolysis delay in acute ischemic stroke through a quality improvement program in the emergency department

Objective

This study aims to investigate the effectiveness of a quality improvement program for reducing intravenous thrombolysis (IVT) delay in acute ischemic stroke (AIS).

Materials and methods

We implement a quality improvement program consisting of 10 interventions for reducing IVT delay, including the establishment of an acute stroke team, standardized management of stroke teams, popularization of stroke and its treatment, emergency bypass route (BER), the achievement of computed tomography (CT) priority, no-delay CT interpretation, intravenous thrombolysis on the CT table, payment after treatment, whole recording, and incentive policy. We retrospectively analyzed the clinical time and outcome data of AIS patients treated with IVT in pre-intervention (108 patients) and post-intervention groups (598 patients), and further compared the differences between the non-emergency bypass route (NBER) and BER in the post-intervention group.

Results

The thrombolysis rate increased from ~29% in the pre-intervention group to 48% in the post-intervention group. Compared with the pre-intervention group, the median of door-to-needle time (DNT) was greatly shortened from 95 to 26 min (P < 0.001), door-to-CT time (DCT) was noticeably decreased from 20 to 18 min (P < 0.001), and onset-to-needle time (OTT) significantly declined from 206 to 133 min (P = 0.001). Under the new mode after the intervention, we further analyzed the IVT delay difference between the NBER (518 patients) and BER groups (80 patients) from the post-intervention group. The median values of DNT (18 vs. 27 min, P < 0.001), DCT (10 vs. 19 min, P < 0.001), and OTT (99 vs. 143 min, P < 0.001) showed significant reductions in the BER group. The quality improvement program under the emergency platform successfully controlled the median of DNT to within 26 min.

Conclusions

Collectively, the BER mode is a feasible scheme that greatly decreased DNT in AIS patients, and the secret to success was to accomplish as much as possible before the patient arrives at the emergency room.

The application of the emergency green channel integrated management strategy in intravenous thrombolytic therapy for AIS

OBJECTIVE

To apply the emergency green channel integrated management strategy in intravenous thrombolytic therapy for acute ischemic stroke (AIS).

METHODS

This retrospective study involved a cohort of 82 AIS patients. Among them, 40 patients admitted to the emergency department of our hospital were treated using the emergency green channel integrated management strategy (the green channel group). Meanwhile, 42 AIS patients were rescued in accordance with the traditional grading and zoning treatment principles (the traditional group). The treatment times, the compliance rates of the times between when the patients entered the emergency department and when they underwent the thrombolysis treatment (the door-to-needle time or DNT), the neurological deficit scores, the Barthel index scores, and the ability of daily living scores before and after the treatment were compared between the two groups.

RESULTS

Compared with the traditional group, the triage times, the DNTs, the thrombolysis times, and the emergency department lengths of stay in the green channel group were significantly shorter (all P<0.001). The DNT compliance rate in the green channel group was significantly higher than it was in the traditional group (P<0.05). The neurological deficit scores in both groups after the treatment were lower than they were before the treatment (both P<0.01). The neurological deficit score in the green channel group after the treatment was lower than the neurological deficit score in the traditional group (P<0.01). The Barthel index and ability of daily living scores in the two groups after the treatment were significantly increased when compared with before the treatment (all P<0.001). The Barthel index and ability of daily living scores in the green channel group after the treatment were higher than they were in the traditional group (both P<0.001). The incidence of complications during the process of thrombolysis in the green channel group was significantly lower when compared with the incidence in the traditional group (P<0.05).

CONCLUSION

The emergency green channel integrated management strategy is more effective at shortening AIS patients' stays in the emergency department, increasing their DNT compliance rates, and at saving time for their thrombolytic therapy, improving patients' neurological function to a greater extent. It is worthy of clinical application.

Challenges Faced by Emergency Physicians in China: An Observation From the Perspective of Burnout

Background: Burnout is considered a global problem, particularly in the emergency health sector; however, no large-sample cross-sectional study has assessed the prevalence of burnout among emergency physicians and its associated factors. Methods: A nationally representative cross-sectional survey of 15,243 emergency physicians was conducted in 31 provinces across China between July and September 2019. Multiple linear regression analysis was performed to identify correlates of burnout. Results: The participants' mean scores were 25.8 (SD = 15.9) on the emotional exhaustion (EE) subscale, 8.1 (SD = 7.9) on the depersonalization (DP) subscale, and 26.80 (SD = 12.5) on the personal accomplishment (PA) subscale, indicating a pattern of moderate EE, moderate DP, and high PA. The results of the large-sample survey found that 14.9% of emergency physicians had a high level of burnout in China, with 46.8% scoring high for EE, 24.1% scoring high for DP, and 60.5% having a high risk of low PA. Having poor self-perceived health status and sleep quality, working in developed regions and governmental hospitals, having an intermediate professional title, experiencing depression, performing shift work and experiencing workplace violence made emergency physicians more likely to experience occupational burnout. Conclusion: Positive measures should be taken to reduce the burnout of emergency physicians and improve their work enthusiasm to maintain the quality of emergency medical services.