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Born C, Schwarz R, Böttcher TP, Hein A, Krcmar H. The role of information systems in emergency department decision-making-a literature review. J Am Med Inform Assoc 2024; 31:1608-1621. [PMID: 38781289 PMCID: PMC11187435 DOI: 10.1093/jamia/ocae096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/11/2024] [Accepted: 04/15/2024] [Indexed: 05/25/2024] Open
Abstract
OBJECTIVES Healthcare providers employ heuristic and analytical decision-making to navigate the high-stakes environment of the emergency department (ED). Despite the increasing integration of information systems (ISs), research on their efficacy is conflicting. Drawing on related fields, we investigate how timing and mode of delivery influence IS effectiveness. Our objective is to reconcile previous contradictory findings, shedding light on optimal IS design in the ED. MATERIALS AND METHODS We conducted a systematic review following PRISMA across PubMed, Scopus, and Web of Science. We coded the ISs' timing as heuristic or analytical, their mode of delivery as active for automatic alerts and passive when requiring user-initiated information retrieval, and their effect on process, economic, and clinical outcomes. RESULTS Our analysis included 83 studies. During early heuristic decision-making, most active interventions were ineffective, while passive interventions generally improved outcomes. In the analytical phase, the effects were reversed. Passive interventions that facilitate information extraction consistently improved outcomes. DISCUSSION Our findings suggest that the effectiveness of active interventions negatively correlates with the amount of information received during delivery. During early heuristic decision-making, when information overload is high, physicians are unresponsive to alerts and proactively consult passive resources. In the later analytical phases, physicians show increased receptivity to alerts due to decreased diagnostic uncertainty and information quantity. Interventions that limit information lead to positive outcomes, supporting our interpretation. CONCLUSION We synthesize our findings into an integrated model that reveals the underlying reasons for conflicting findings from previous reviews and can guide practitioners in designing ISs in the ED.
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Affiliation(s)
- Cornelius Born
- School of Computation, Information and Technology, Technical University of Munich, 85748 Garching bei München, Germany
| | - Romy Schwarz
- School of Computation, Information and Technology, Technical University of Munich, 85748 Garching bei München, Germany
| | - Timo Phillip Böttcher
- School of Computation, Information and Technology, Technical University of Munich, 85748 Garching bei München, Germany
| | - Andreas Hein
- Institute of Information Systems and Digital Business, University of St. Gallen, 9000 St. Gallen, Switzerland
| | - Helmut Krcmar
- School of Computation, Information and Technology, Technical University of Munich, 85748 Garching bei München, Germany
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2
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Ndai AM, Allen BR, Wynn TT, Rajasekhar A, Saqr Z, Sandeli I, Vouri SM, Reise R. Rapid recognition and optimal management of hemophilia in the emergency department: A quality improvement project. J Am Coll Emerg Physicians Open 2024; 5:e13168. [PMID: 38699223 PMCID: PMC11065154 DOI: 10.1002/emp2.13168] [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: 12/19/2023] [Revised: 03/05/2024] [Accepted: 03/25/2024] [Indexed: 05/05/2024] Open
Abstract
Objectives This study aimed to assess the effectiveness of a continuous quality improvement initiative at the University of Florida Health Physicians practice in reducing the time to administer factor replacement therapy (FRT) for hemophilia patients presenting with bleeding in the emergency department (ED). Methods The study, a quasi-experimental, interventional design, was conducted between January 2020 and January 2023. The intervention, implemented in September 2021, involved training ED physicians, creating a specialized medication order set within the electronic health record (EHR), and a rapid triage system. The effectiveness was measured by comparing the time from ED arrival to factor administration before and after the intervention and benchmarking it against the National Bleeding Disorders Foundation's Medical and Scientific Advisory Council (MASAC)-recommended 1-hour timeline for factor administration. An interrupted time series (ITS) analysis with a generalized least squares model assessed the intervention's impact. Results A total of 43 ED visits (22 pre-intervention and 21 post-intervention) were recorded. Post-intervention, the average time from ED arrival to factor administration decreased from 5.63 to 3.15 hours. There was no significant increase (27% vs. 29%) in the patients receiving factor within 1-hour of ED arrival. The ITS analysis predicted a 20-hour reduction in the average quarterly time to administer factor by the end of the study, an 84% decrease. Conclusions The quality improvement program decreased the time to administer FRT for patients with hemophilia in the ED. However, the majority of patients did not achieve the 1-hour MASAC-recommended timeline for factor administration after ED arrival.
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Affiliation(s)
- Asinamai M. Ndai
- Department of Pharmaceutical Outcomes and PolicyCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
- University of Florida Health PhysiciansGainesvilleFloridaUSA
| | - Brandon R. Allen
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Tung T. Wynn
- Division of Pediatric Hematology/OncologyDepartment of PediatricsUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Anita Rajasekhar
- Division of Hematology/OncologyDepartment of MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Ziad Saqr
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Ina Sandeli
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Scott M. Vouri
- Department of Pharmaceutical Outcomes and PolicyCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
- University of Florida Health PhysiciansGainesvilleFloridaUSA
| | - Rachel Reise
- Department of Pharmaceutical Outcomes and PolicyCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
- University of Florida Health PhysiciansGainesvilleFloridaUSA
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3
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Yuan G, Xia H, Xu J, Long C, Liu L, Huang F, Zeng J, Yuan L. Reducing intravenous thrombolysis delay in acute ischemic stroke through a quality improvement program in the emergency department. Front Neurol 2022; 13:931193. [PMID: 36226088 PMCID: PMC9548581 DOI: 10.3389/fneur.2022.931193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/26/2022] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Guangxiong Yuan
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Hong Xia
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Jun Xu
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Chen Long
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Lei Liu
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Feng Huang
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Jianping Zeng
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, China
- *Correspondence: Jianping Zeng
| | - Lingqing Yuan
- National Clinical Research Center for Metabolic Diseases, Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Lingqing Yuan
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4
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Hasnain MG, Attia JR, Akter S, Rahman T, Hall A, Hubbard IJ, Levi CR, Paul CL. Effectiveness of interventions to improve rates of intravenous thrombolysis using behaviour change wheel functions: a systematic review and meta-analysis. Implement Sci 2020; 15:98. [PMID: 33148294 PMCID: PMC7641813 DOI: 10.1186/s13012-020-01054-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 10/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite being one of the few evidence-based treatments for acute ischemic stroke, intravenous thrombolysis has low implementation rates-mainly due to a narrow therapeutic window and the health system changes required to deliver it within the recommended time. This systematic review and meta-analyses explores the differential effectiveness of intervention strategies aimed at improving the rates of intravenous thrombolysis based on the number and type of behaviour change wheel functions employed. METHOD The following databases were searched: MEDLINE, EMBASE, PsycINFO, CINAHL and SCOPUS. Multiple authors independently completed study selection and extraction of data. The review included studies that investigated the effects of intervention strategies aimed at improving the rates of intravenous thrombolysis and/or onset-to-needle, onset-to-door and door-to-needle time for thrombolysis in patients with acute ischemic stroke. Interventions were coded according to the behaviour change wheel nomenclature. Study quality was assessed using the QualSyst scoring system for quantitative research methodologies. Random effects meta-analyses were used to examine effectiveness of interventions based on the behaviour change wheel model in improving rates of thrombolysis, while meta-regression was used to examine the association between the number of behaviour change wheel intervention strategies and intervention effectiveness. RESULTS Results from 77 studies were included. Five behaviour change wheel interventions, 'Education', 'Persuasion', 'Training', 'Environmental restructuring' and 'Enablement', were found to be employed among the included studies. Effects were similar across all intervention approaches regardless of type or number of behaviour change wheel-based strategies employed. High heterogeneity (I2 > 75%) was observed for all the pooled analyses. Publication bias was also identified. CONCLUSION There was no evidence for preferring one type of behaviour change intervention strategy, nor for including multiple strategies in improving thrombolysis rates. However, the study results should be interpreted with caution, as they display high heterogeneity and publication bias.
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Affiliation(s)
- Md Golam Hasnain
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
| | - John R. Attia
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
- John Hunter Hospital, New Lambton Heights, New South Wales Australia
| | - Shahinoor Akter
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Department of Anthropology, Jagannath University, Dhaka, Bangladesh
| | - Tabassum Rahman
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Centre for Development, Economics and Sustainability, Monash University, Melbourne, Victoria Australia
| | - Alix Hall
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
| | - Isobel J. Hubbard
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
| | - Christopher R. Levi
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, New South Wales Australia
| | - Christine L. Paul
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
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5
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Jun S, Plint AC, Campbell SM, Curtis S, Sabir K, Newton AS. Point-of-care Cognitive Support Technology in Emergency Departments: A Scoping Review of Technology Acceptance by Clinicians. Acad Emerg Med 2018; 25:494-507. [PMID: 28960689 DOI: 10.1111/acem.13325] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 09/12/2017] [Accepted: 09/23/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Cognitive support technologies that support clinical decisions and practices in the emergency department (ED) have the potential to optimize patient care. However, limited uptake by clinicians can prevent successful implementation. A better understanding of acceptance of these technologies from the clinician perspective is needed. We conducted a scoping review to synthesize diverse, emerging evidence on clinicians' acceptance of point-of-care (POC) cognitive support technology in the ED. METHOD We systematically searched 10 electronic databases and gray literature published from January 2006 to December 2016. Studies of any design assessing an ED-based POC cognitive support technology were considered eligible for inclusion. Studies were required to report outcome data for technology acceptance. Two reviewers independently screened studies for relevance and quality. Study quality was assessed using the Mixed-Methods Appraisal Tool. A descriptive analysis of the features of POC cognitive support technology for each study is presented, illustrating trends in technology development and evaluation. A thematic analysis of clinician, technical, patient, and organizational factors associated with technology acceptance is also presented. RESULTS Of the 1,563 references screened for eligibility, 24 met the inclusion criteria and were included in the review. Most studies were published from 2011 onward (88%), scored high for methodologic quality (79%), and examined POC technologies that were novel and newly introduced into the study setting (63%). Physician use of POC technology was the most commonly studied (67%). Technology acceptance was frequently conceptualized and measured by factors related to clinician attitudes and beliefs. Experience with the technology, intention to use, and actual use were also more common outcome measures of technology acceptance. Across studies, perceived usefulness was the most noteworthy factor impacting technology acceptance, and clinicians generally had positive perceptions of the use of POC cognitive support technology in the ED. However, the actual use of POC cognitive support technology reported by clinicians was low-use, by proportion of patient cases, ranged from 30% to 59%. Of the 24 studies, only two studies investigated acceptance of POC cognitive support technology currently implemented in the ED, offering "real-world" clinical practice data. All other studies focused on acceptance of novel technologies. Technical aspects such as an unfriendly user interface, presentation of redundant or ambiguous information, and required user effort had a negative impact on acceptance. Patient expectations were also found to have a negative impact, while patient safety implications had a positive impact. Institutional support was also reported to impact technology acceptance. CONCLUSIONS Findings from this scoping review suggest that while ED clinicians acknowledge the utility and value of using POC cognitive support technology, actual use of such technology can be low. Further, few studies have evaluated the acceptance and use of POC technologies in routine care. Prospective studies that evaluate how ED clinicians appraise and consider POC technology use in clinical practice are now needed with diverse clinician samples. While this review identified multiple factors contributing to technology acceptance, determining how clinician, technical, patient, and organizational factors mediate or moderate acceptance should also be a priority.
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Affiliation(s)
- Shelly Jun
- Department of Pediatrics University of Alberta Edmonton AlbertaCanada
| | - Amy C. Plint
- Departments of Pediatrics and Emergency Medicine University of Ottawa (ACP) Ottawa OntarioCanada
| | - Sandy M. Campbell
- The John W. Scott Health Sciences Library University of Alberta Edmonton AlbertaCanada
| | - Sarah Curtis
- Department of Pediatrics University of Alberta Edmonton AlbertaCanada
| | - Kyrellos Sabir
- The School of Medicine National University of Ireland Galway (KS) Galway Ireland
| | - Amanda S. Newton
- Department of Pediatrics University of Alberta Edmonton AlbertaCanada
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Zuckerman SL, Magarik JA, Espaillat KB, Ganesh Kumar N, Bhatia R, Dewan MC, Morone PJ, Hermann LD, O'Duffy AE, Riebau DA, Kirshner HS, Mocco J. Implementation of an institution-wide acute stroke algorithm: Improving stroke quality metrics. Surg Neurol Int 2016; 7:S1041-S1048. [PMID: 28144480 PMCID: PMC5234297 DOI: 10.4103/2152-7806.196366] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 09/29/2016] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jordan A Magarik
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Kiersten B Espaillat
- Vanderbilt Comprehensive Stroke Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Nishant Ganesh Kumar
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Ritwik Bhatia
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Michael C Dewan
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Peter J Morone
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Lisa D Hermann
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Anne E O'Duffy
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Derek A Riebau
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Howard S Kirshner
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - J Mocco
- Department of Neurosurgery, Mt. Sinai School of Medicine, New York, USA
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7
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Park YS, Chung SP, You JS, Kim MJ, Chung HS, Hong JH, Lee HS, Wang J, Park I. Effectiveness of a multidisciplinary critical pathway based on a computerised physician order entry system for ST-segment elevation myocardial infarction management in the emergency department: a retrospective observational study. BMJ Open 2016; 6:e011429. [PMID: 27531726 PMCID: PMC5013344 DOI: 10.1136/bmjopen-2016-011429] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES The purpose of this study was to investigate whether a multidisciplinary organised critical pathway (CP) for ST-segment elevation myocardial infarction (STEMI) management can significantly attenuate differences in the duration from emergency department (ED) arrival to evaluation and treatment, regardless of the arrival time, by eliminating off-hour and weekend effects. DESIGN Retrospective observational cohort study. SETTING 2 tertiary academic hospitals. PARTICIPANTS Consecutive patients in the Fast Interrogation Rule for STEMI (FIRST) program. INTERVENTIONS A study was conducted on patients in the FIRST program, which uses a computerised physician order entry (CPOE) system. The patient demographics, time intervals and clinical outcomes were analysed based on the arrival time at the ED: group 1, normal working hours on weekdays; group 2, off-hours on weekdays; group 3, normal working hours on weekends; and group 4, off-hours on weekends. PRIMARY AND SECONDARY OUTCOME MEASURES Clinical outcomes categorised according to 30-day mortality, in-hospital mortality and the length of stay. RESULTS The duration from door-to-data or FIRST activation did not differ significantly among the 4 groups. The median duration between arrival and balloon placement during percutaneous coronary intervention did not significantly exceed 90 min, and the proportions (89.6-95.1%) of patients with door-to-balloon times within 90 min did not significantly differ among the 4 groups, regardless of the ED arrival time (p=0.147). Moreover, no differences in the 30-day (p=0.8173) and in-hospital mortality (p=0.9107) were observed in patients with STEMI. CONCLUSIONS A multidisciplinary CP for STEMI based on a CPOE system can effectively decrease disparities in the door-to-data duration and proportions of patients with door-to-balloon times within 90 min, regardless of the ED arrival time. The application of a multidisciplinary CP may also help attenuate off-hour and weekend effects in STEMI clinical outcomes.
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Affiliation(s)
- Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Je Sung You
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Joung Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyun Soo Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Hwa Hong
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jinwon Wang
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Incheol Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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8
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Yoo J, Song D, Baek JH, Lee K, Jung Y, Cho HJ, Yang JH, Cho HJ, Choi HY, Kim YD, Nam HS, Heo JH. Comprehensive code stroke program to reduce reperfusion delay for in-hospital stroke patients. Int J Stroke 2016; 11:656-62. [DOI: 10.1177/1747493016641724] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 01/17/2016] [Indexed: 11/15/2022]
Abstract
Background Stroke may occur during hospital admission (in-hospital stroke). Although patients with in-hospital stroke are potentially good candidates for reperfusion therapy, they often do not receive treatment as rapidly as expected. Aims We investigated the effect of a code stroke program for in-hospital stroke, which included the use of computerized physician order entry, specific evaluation and treatment protocols for in-hospital stroke patients, and regular education of medical staffs. Methods We implemented the program in the cardiology and cardiovascular surgery departments/wards (target-ward group) in November 2008. We compared time intervals from symptom onset to evaluation and reperfusion treatment before and after program implementation between the target-ward and other departments/wards (other-ward group). Results Among 70 consecutive in-hospital stroke patients who received reperfusion therapy between July 2002 and February 2015, 28 and 42 were treated before and after program implementation, respectively. After program implementation, time intervals from symptom onset to neurology notification (50 min vs. 28 min; P = 0.033), symptom onset to brain imaging (91 min vs. 41 min; P < 0.001), and symptom recognition to notification (22 min vs. 9 min; P = 0.011) were reduced in the target-ward group. Finally, times from symptom onset to intravenous tissue plasminogen activator administration and to arterial puncture were reduced by 55 min (120 min vs. 65 min; P < 0.001) and 130 min (295 min vs. 165 min; P < 0.001), respectively. However, time reductions in the other-ward group were not significant. Conclusions The comprehensive program for in-hospital stroke that included the use of computerized physician order entry was effective in reducing time intervals to evaluation and reperfusion therapy.
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Affiliation(s)
- Joonsang Yoo
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
| | - Dongbeom Song
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jang-Hyun Baek
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
| | - Kijeong Lee
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
| | - Yohan Jung
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
- Department of Neurology, Changwon Fatima Hospital, Changwon, Korea
| | - Han-Jin Cho
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
- Department of Neurology, Pusan National University College of Medicine, Busan, Korea
| | - Jae Hoon Yang
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Ji Cho
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
- Department of Neurology, The Catholic University of Korea, Incheon St. Mary’s Hospital, Incheon, Korea
| | - Hye-Yeon Choi
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
- Department of Neurology, Kyung Hee University School of Medicine, Kyung Hee University Hospital at Kangdong, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
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Choi HY, Kim EH, Yoo J, Lee K, Song D, Kim YD, Cho HJ, Nam HS, Lee KY, Lee HS, Heo JH. Decision-Making Support Using a Standardized Script and Visual Decision Aid to Reduce Door-to-Needle Time in Stroke. J Stroke 2016; 18:239-41. [PMID: 27283284 PMCID: PMC4901956 DOI: 10.5853/jos.2016.00374] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 04/29/2016] [Accepted: 05/02/2016] [Indexed: 11/11/2022] Open
Affiliation(s)
- Hye-Yeon Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Kyung Hee University Hospital at Kangdong, Kyung Hee University College of Medicine, Seoul, Korea
| | - Eun Hye Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Joonsang Yoo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Kijeong Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Dongbeom Song
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Han-Jin Cho
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Yul Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Department of Biostatistics, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
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10
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Jeong JH, Yang JY, Cha JK, Kim DH, Nah HW, Kang MJ, Choi JH, Huh JT. Feasibility of a Pre-Hospital Notification System Using Direct Calls from Paramedics of 119 EMS Ambulances for Acute Stroke Patients: Accuracy of Diagnosis and Efficacy of Shortening of Door-to-Imaging Time. JOURNAL OF NEUROCRITICAL CARE 2015. [DOI: 10.18700/jnc.2015.8.2.98] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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A systemized stroke code significantly reduced time intervals for using intravenous tissue plasminogen activator under magnetic resonance imaging screening. J Stroke Cerebrovasc Dis 2014; 24:465-72. [PMID: 25524016 DOI: 10.1016/j.jstrokecerebrovasdis.2014.09.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 08/15/2014] [Accepted: 09/16/2014] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND A stroke code can shorten time intervals until intravenous tissue plasminogen activator (IV t-PA) treatment in acute ischemic stroke (AIS). Recently, several reports demonstrated that magnetic resonance imaging (MRI)-based thrombolysis had reduced complications and improved outcomes in AIS despite longer processing compared with computed tomography (CT)-based thrombolysis. METHODS In January 2009, we implemented CODE RED, a computerized stroke code, at our hospital with the aim of achieving rapid stroke assessment and treatment. We included patients with thrombolysis from January 2007 to December 2008 (prestroke code period) and from January 2009 to May 2013 (poststroke code period). The IV t-PA time intervals and 90-day modified Rankin Scale (mRS) scores were collected. RESULTS During the observation period, 252 patients used IV t-PA under the CODE RED (MRI based: 208; CT based: 44). The remaining 71 patients (MRI based: 53; CT based: 18) received it before the implementation of our stroke code. After implementation of CODE RED, door-to-image time, door-to-needle time, and the onset-to-needle time were significantly reduced by 11, 18, and 22 minutes in MRI-based thrombolysis. Particularly, the proportion of favorable outcome (mRS score 0-2) was significantly increased (from 41.5% to 60.1%, P = .02) in poststroke than in prestroke code period in MRI-based thrombolysis. However, in ordinal regression, the presence of stroke code showed just a trend for favorable outcome (odds ratio, .99-2.87; P = .059) at 90 days of using IV t-PA after correction of age, sex, and National Institutes of Health Stroke Scale. CONCLUSIONS In this study, we demonstrated that a systemized stroke code shortened time intervals for using IV t-PA under MRI screening. Also, our results showed a possibility that a systemized stroke code might enhance the efficacy of MRI-based thrombolysis. In the future, we need to carry out a more detailed prospective study about this notion.
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Cho HJ, Lee KY, Nam HS, Kim YD, Song TJ, Jung YH, Choi HY, Heo JH. Process improvement to enhance existing stroke team activity toward more timely thrombolytic treatment. J Clin Neurol 2014; 10:328-33. [PMID: 25324882 PMCID: PMC4198714 DOI: 10.3988/jcn.2014.10.4.328] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 03/11/2014] [Accepted: 03/13/2014] [Indexed: 12/04/2022] Open
Abstract
Background and Purpose Process improvement (PI) is an approach for enhancing the existing quality improvement process by making changes while keeping the existing process. We have shown that implementation of a stroke code program using a computerized physician order entry system is effective in reducing the in-hospital time delay to thrombolysis in acute stroke patients. We investigated whether implementation of this PI could further reduce the time delays by continuous improvement of the existing process. Methods After determining a key indicator [time interval from emergency department (ED) arrival to intravenous (IV) thrombolysis] and conducting data analysis, the target time from ED arrival to IV thrombolysis in acute stroke patients was set at 40 min. The key indicator was monitored continuously at a weekly stroke conference. The possible reasons for the delay were determined in cases for which IV thrombolysis was not administered within the target time and, where possible, the problems were corrected. The time intervals from ED arrival to the various evaluation steps and treatment before and after implementation of the PI were compared. Results The median time interval from ED arrival to IV thrombolysis in acute stroke patients was significantly reduced after implementation of the PI (from 63.5 to 45 min, p=0.001). The variation in the time interval was also reduced. A reduction in the evaluation time intervals was achieved after the PI [from 23 to 17 min for computed tomography scanning (p=0.003) and from 35 to 29 min for complete blood counts (p=0.006)]. Conclusions PI is effective for continuous improvement of the existing process by reducing the time delays between ED arrival and IV thrombolysis in acute stroke patients.
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Affiliation(s)
- Han-Jin Cho
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea. ; Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Kyung Yul Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae-Jin Song
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea. ; Department of Neurology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Yo Han Jung
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea. ; Department of Neurology, Changwon Fatima Hospital, Changwon, Korea
| | - Hye-Yeon Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea. ; Department of Neurology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
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Netherton SJ, Lonergan K, Wang D, McRae A, Lang E. Computerized physician order entry and decision support improves ED analgesic ordering for renal colic. Am J Emerg Med 2014; 32:958-61. [PMID: 24997107 DOI: 10.1016/j.ajem.2014.05.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 04/23/2014] [Accepted: 05/01/2014] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Computerized physician order entry (CPOE) offers the potential for safer, faster patient care, as well as greater use of evidence-based therapy via built-in decision support. However, the effectiveness of CPOE in yielding these benefits has shown mixed results in the emergency department (ED) setting. Our objective was to evaluate the impact of CPOE implementation on analgesic prescribing and dosing practices for renal colic presentations. METHODS This retrospective pre/post comparative study was conducted in 3 tertiary hospitals that implemented CPOE in 2010. Two patient groups were compared: prior to (pre-CPOE) and after (post-CPOE) CPOE implementation. Each group consisted of 230 randomly selected, high-acuity patients presenting to the ED with renal colic. The primary outcome was the proportion of patients receiving ketorolac in the ED. Secondary outcomes included choice of analgesic and average morphine dose. RESULTS The proportion of patients receiving ketorolac significantly increased after CPOE implementation (65.6% pre-CPOE vs 76.5% post-CPOE, P = .015), as did the proportion of patients receiving fentanyl (pre, 9.7%; post, 16.7%; P = .047). Differences in morphine use (pre, 66.0%; post, 69.1%) and average morphine dose (pre, 10.09 mg; post, 12.28 mg) did not reach statistical significance. CONCLUSIONS The introduction of CPOE is associated with an increase in ketorolac use for ED renal colic visits. This may reflect the inclusion of ketorolac in the renal colic order set. Computerized physician order entry implementation with condition-specific electronic order sets and decision support may improve evidence-based practice.
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Affiliation(s)
- Stuart J Netherton
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta
| | - Kevin Lonergan
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta
| | - Dongmei Wang
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta
| | - Andrew McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta.
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Yang JM, Park YS, Chung SP, Chung HS, Lee HS, You JS, Lee SH, Park I. Implementation of a clinical pathway based on a computerized physician order entry system for ischemic stroke attenuates off-hour and weekend effects in the ED. Am J Emerg Med 2014; 32:884-9. [PMID: 24928408 DOI: 10.1016/j.ajem.2014.04.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 04/18/2014] [Accepted: 04/23/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Admission on weekends and off-hours has been associated with poor outcomes and mortality from acute stroke. The purpose of this study was to investigate whether an organized clinical pathway (CP) for ischemic stroke can effectively reduce the time from arrival to evaluation and treatment in the emergency department (ED) and improve outcomes, regardless of the time from arrival in the ED. METHODS We conducted a retrospective analysis of all consecutive patients included in the prospective registry database in the Brain Salvage through Emergency Stroke Therapy program, which uses the computerized physician order entry (CPOE) system. Patients were classified based on their time of arrival in the ED: group 1, normal working hours on weekdays; group 2, off-hours on weekdays; group 3, normal working hours on weekends; and group 4, off-hours on weekends. Clinical outcomes were categorized according to 30 days in-hospital mortality, in-hospital mortality, and the modified Rankin score during a single length of stay (LOS). RESULTS No time intervals differed significantly among the 4 patient groups who received intravenous administration of tissue plasminogen activator (IV-tPA). Use of IV-tPA (P = .5110) was not affected by arrival in the ED on off-days or weekends. The overall mortality rate was 3.9%, and the median LOS was 7 days (Interquartile range (IQR), 5-10). By Kaplan-Meier analysis, the cumulative probability of mortality and survival did not differ significantly among the 4 groups over 30 days (P = .1557). CONCLUSION An organized CP, based on CPOE, for ischemic stroke can effectively attenuate disparities in the time interval between ED arrival to evaluation and treatment regardless of ED arrival time. This pathway may also help to eliminate off-hour and weekend effects on outcomes from ischemic stroke.
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Affiliation(s)
- Jong Min Yang
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul 135-720, Republic of Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul 135-720, Republic of Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul 135-720, Republic of Korea
| | - Hyun Soo Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul 135-720, Republic of Korea
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul 135-720, Republic of Korea
| | - Je Sung You
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul 135-720, Republic of Korea; Department of Emergency Medicine, Gangwon National University, Graduate School of Medicine, Chuncheon, 200-701, Republic of Korea.
| | - Shin Ho Lee
- Department of Emergency Medicine, National Health Insurance Corporation Ilsan Hospital, Goyang, 410-719, Republic of Korea
| | - Incheol Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul 135-720, Republic of Korea
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Jang J, Chung SP, Park I, You JS, Lee HS, Park JW, Chung TN, Chung HS, Lee HS. The usefulness of the Kurashiki prehospital stroke scale in identifying thrombolytic candidates in acute ischemic stroke. Yonsei Med J 2014; 55:410-6. [PMID: 24532511 PMCID: PMC3936632 DOI: 10.3349/ymj.2014.55.2.410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The severity of a stroke cannot be described by widely used prehospital stroke scales. We investigated the usefulness of the Kurashiki Prehospital Stroke Scale (KPSS) for assessing the severity of stroke, compared to the National Institutes of Health Stroke Scale (NIHSS), in candidate patients for intravenous or intra-arterial thrombolysis who arrived at the hospital within 6 hours of symptom onset. MATERIALS AND METHODS We retrospectively analyzed a prospective registry database of consecutive patients included in the Emergency Stroke Therapy program. In the emergency department, the KPSS was assessed by emergency medical technicians. A cutoff KPSS score was estimated for candidates of thrombolysis by comparing KPSS and NIHSS scores, as well as for patients who actually received thrombolytic therapy. Clinical outcomes were compared between patients around the estimated cut-off. The independent predictors of outcomes were determined using multivariate logistic regression analysis. RESULTS Excellent correlations were demonstrated between KPSS and NIHSS within 6 hours (R=0.869) and 3 hours (R=0.879) of hospital admission. The optimal threshold value was a score of 3 on the KPSS in patients within 3 hours and 6 hours by Youden's methods. Significant associations with a KPSS score≥3 were revealed for actual intravenous administration of tissue plasminogen activator (IV-tPA) usage [odds ratio (OR) 125.598; 95% confidence interval (CI) 16.443-959.368, p<0.0001] and actual IV-tPA or intra-arterial urokinase (IA-UK) usage (OR 58.733; 95% CI 17.272-199.721, p<0.0001). CONCLUSION The KPSS is an effective prehospital stroke scale for identifying candidates for IV-tPA and IA-UK, as indicated by excellent correlation with the NIHSS, in the assessment of stroke severity in acute ischemic stroke.
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Affiliation(s)
- Jieun Jang
- Department of Emergency Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 135-720, Korea.
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Yoo JW, Kim SJ, Geng Y, Shin HP, Nakagawa S. Quality and innovations for caring hospitalized older persons in the unites States. Aging Dis 2014; 5:41-51. [PMID: 24490116 PMCID: PMC3901613 DOI: 10.14366/ad.2014.050041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 10/09/2013] [Accepted: 10/14/2013] [Indexed: 01/22/2023] Open
Abstract
Older persons are occasionally acutely ill and their hospitalizations frequently end up with complications and adverse outcomes. Medicare from U.S. federal government's payment resource for older persons is facing financial strain. Medicare highlights both cost-saving and high quality of care while older persons are hospitalized. Several health policy changes were initiated to achieve Medicare's goals. In response to Medicare's health policy changes, U.S. hospital environments have been changed and these resulted in hospital quality measurements' improvement. American seniors are facing the challenges during and around their hospital care. Several innovative measures are suggested to overcome these challenges.
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Affiliation(s)
- Ji Won Yoo
- Center for Senior Health and Longevity, Aurora Health Care, Milwaukee, WI, USA
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Sun Jung Kim
- Department of Public Health, College of Medicine, Yonsei University Seoul, Korea
- Institute of Health Services Research, College of Medicine, Yonsei University Seoul, Korea
| | - Yan Geng
- Center for Senior Health and Longevity, Aurora Health Care, Milwaukee, WI, USA
| | - Hyun Phil Shin
- Department of Internal Medicine, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Shunichi Nakagawa
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY. USA
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Price CI, Clement F, Gray J, Donaldson C, Ford GA. Systematic review of stroke thrombolysis service configuration. Expert Rev Neurother 2014; 9:211-33. [DOI: 10.1586/14737175.9.2.211] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Nam HS, Heo J, Kim J, Kim YD, Song TJ, Park E, Heo JH. Development of smartphone application that aids stroke screening and identifying nearby acute stroke care hospitals. Yonsei Med J 2014; 55:25-9. [PMID: 24339283 PMCID: PMC3874898 DOI: 10.3349/ymj.2014.55.1.25] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
PURPOSE The benefits of thrombolytic treatment are time-dependent. We developed a smartphone application that aids stroke patient self-screening and hospital selection, and may also decrease hospital arrival time. MATERIALS AND METHODS The application was developed for iPhone and Android smartphones. Map data for the application were adopted from the open map. For hospital registration, a web page (http://stroke119.org) was developed using PHP and MySQL. RESULTS The Stroke 119 application includes a stroke screening tool and real-time information on nearby hospitals that provide thrombolytic treatment. It also provides information on stroke symptoms, thrombolytic treatment, and prescribed actions when stroke is suspected. The stroke screening tool was adopted from the Cincinnati Prehospital Stroke Scale and is displayed in a cartoon format. If the user taps a cartoon image that represents abnormal findings, a pop-up window shows that the user may be having a stroke, informs the user what to do, and directs the user to call emergency services. Information on nearby hospitals is provided in map and list views, incorporating proximity to the user's location using a Global Positioning System (a built-in function of smartphones). Users can search for a hospital according to specialty and treatment levels. We also developed a web page for hospitals to register in the system. Neurology training hospitals and hospitals that provide acute stroke care in Korea were invited to register. Seventy-seven hospitals had completed registration. CONCLUSION This application may be useful for reducing hospital arrival times for thrombolytic candidates.
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Affiliation(s)
- Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea.
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You JS, Chung SP, Chung HS, Lee HS, Park JW, Kim HJ, Lee SH, Park I, Lee HS. Predictive value of the Cincinnati Prehospital Stroke Scale for identifying thrombolytic candidates in acute ischemic stroke. Am J Emerg Med 2013; 31:1699-702. [DOI: 10.1016/j.ajem.2013.08.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 08/13/2013] [Accepted: 08/15/2013] [Indexed: 11/16/2022] Open
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Nam HS, Park E, Heo JH. Facilitating Stroke Management using Modern Information Technology. J Stroke 2013; 15:135-43. [PMID: 24396807 PMCID: PMC3859007 DOI: 10.5853/jos.2013.15.3.135] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 09/08/2013] [Accepted: 09/09/2013] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND PURPOSE Information technology and mobile devices may be beneficial and useful in many aspects of stroke management, including recognition of stroke, transport and triage of patients, emergent stroke evaluation at the hospital, and rehabilitation. In this review, we address the contributions of information technology and mobile health to stroke management. SUMMARY OF ISSUES Rapid detection and triage are essential for effective thrombolytic treatment. Awareness of stroke warning signs and responses to stroke could be enhanced by using mobile applications. Furthermore, prehospital assessment and notification could be streamlined for use in telemedicine and teleradiology. A mobile telemedicine system for assessing the National Institutes of Health Stroke Scale scores has shown higher correlation and fast assessment comparing with face-to-face method. Because the benefits of thrombolytic treatment are time-dependent, treatment should be initiated as quickly as possible. In-hospital communication between multidisciplinary team members can be enhanced using information technology. A computerized in-hospital alert system using computerized physician-order entry was shown to be effective in reducing the time intervals from hospital arrival to medical evaluations and thrombolytic treatment. Mobile devices can also be used as supplementary tools for neurologic examination and clinical decision-making. In post-stroke rehabilitation, virtual reality and telerehabilitation are helpful. Mobile applications might be useful for public awareness, lifestyle modification, and education/training of healthcare professionals. CONCLUSIONS Information technology and mobile health are useful tools for management of stroke patients from the acute period to rehabilitation. Further improvement of technology will change and enhance stroke prevention and treatment.
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Affiliation(s)
- Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Eunjeong Park
- Wireless Health Institute, University of California Los Angeles (UCLA), Los Angeles, United States. ; Embedded Software Research Center, Ewha Woman's University, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
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The Effect of Computerized Provider Order Entry Systems on Clinical Care and Work Processes in Emergency Departments: A Systematic Review of the Quantitative Literature. Ann Emerg Med 2013; 61:644-653.e16. [DOI: 10.1016/j.annemergmed.2013.01.028] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 01/22/2013] [Accepted: 01/30/2013] [Indexed: 11/30/2022]
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Hong KS, Bang OY, Kim JS, Heo JH, Yu KH, Bae HJ, Kang DW, Lee JS, Kwon SU, Oh CW, Lee BC, Yoon BW. Stroke Statistics in Korea: Part II Stroke Awareness and Acute Stroke Care, A Report from the Korean Stroke Society and Clinical Research Center For Stroke. J Stroke 2013; 15:67-77. [PMID: 24324942 PMCID: PMC3779666 DOI: 10.5853/jos.2013.15.2.67] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 05/04/2013] [Accepted: 05/05/2013] [Indexed: 02/04/2023] Open
Abstract
The aim of the current Part II of Stroke Statistics in Korea is to summarize nationally representative data on public awareness, pre-hospital delay, thrombolysis, and quality of acute stroke care in a single document. The public's knowledge of stroke definition, risk factors, warning signs, and act on stroke generally remains low. According to studies using open-ended questions, the correct definition of stroke was recognized in less than 50%, hypertension as a stroke risk factor in less than 50%, and other well-defined risk factors in less than 20%. Among stroke warning signs, sudden paresis or numbness was best appreciated, with recognition rates ranging in 36.9-73.7%, but other warning signs including speech disturbance were underappreciated. In addition, less than one third of subjects in a representative population survey were aware of thrombolysis and had knowledge of the appropriate act on stroke, calling emergency medical services (EMS). Despite EMS being an essential element in the stroke chain of survival and outcome improvement, EMS protocols for field stroke diagnosis and prehospital notification for potential stroke patients are not well established. According to the Assessment for Quality of Acute Stroke Care, the median onset-to-door time for patients arriving at the emergency room was 4 hours (mean, 17.3 hours) in 2010, which was not reduced compared to 2005. In contrast, the median door-to-needle time for intravenous tissue plasminogen activator (IV-TPA) treatment was 55.5 minutes (mean, 79.5 minutes) in 2010, shorter than the median time of 60.0 minutes (mean, 102.8 minutes) in 2008. Of patients with acute ischemic stroke, 7.9% were treated with IV-TPA in 2010, an increase from the 4.6% in 2005. Particularly, IV-TPA use for eligible patients substantially increased, from 21.7% in 2005 to 74.0% in 2010. The proportion of hospitals equipped with a stroke unit has increased from 1.1% in 2005 to 19.4% in 2010. Performance, as measured by quality indicators, has steadily improved since 2005, and the performance rates for most indicators were greater than 90% in 2010 except for early rehabilitation consideration (89.4%) and IV-TPA use for eligible patients (74.0%). In summary, the current report indicates a substantial improvement in in-hospital acute stroke care, but also emphasizes the need for enhancing public awareness and integrating the prehospital EMS system into acute stroke management. This report would be a valuable resource for understanding the current status and implementing initiatives to further improve public awareness of stroke and acute stroke care in Korea.
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Affiliation(s)
- Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
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Impact of a Computerized Order Set on Adherence to Centers for Disease Control Guidelines for the Treatment of Victims of Sexual Assault. J Emerg Med 2013; 44:528-35. [DOI: 10.1016/j.jemermed.2012.06.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 01/09/2012] [Accepted: 06/28/2012] [Indexed: 01/22/2023]
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You JS, Chung YE, Park JW, Lee W, Lee HJ, Chung TN, Chung SP, Park I, Kim S. The usefulness of rapid point-of-care creatinine testing for the prevention of contrast-induced nephropathy in the emergency department. Emerg Med J 2012; 30:555-8. [PMID: 22833599 DOI: 10.1136/emermed-2012-201285] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Renal dysfunction is the most important factor to consider when predicting a patient's risk of developing contrast-induced nephropathy (CIN). Measurement of creatinine (Cr) via rapid point-of-care blood urea nitrogen/creatinine testing (POCT-BUN/Cr) to determine CIN risk could potentially reduce the time required to achieve an accurate diagnosis and to initiate and complete treatment in the emergency department (ED). The aim of our study was to compare the results of POCT-BUN/Cr and reference laboratory tests for BUN and serum Cr. MATERIALS AND METHODS A retrospective analysis of suspected stroke patients who presented between November 2009 and November 2010, and had BUN and Cr levels measured by POCT-BUN/Cr, and the reference laboratory tests performed with the blood sample which was transferred to the central laboratory by an air-shoot system. Two assays were conducted on the whole blood (POCT) and serum (reference) by trained technicians. The time interval from arrival at the ED to reporting of the results was assessed for both assays via a computerised physician order entry system. RESULTS The mean standard deviation (SD) interval from arrival at the ED to reporting of the results was 11.4 (4.9) min for POCT-BUN/Cr and 46.8 (38.5) min for the serum reference laboratory tests (p<0.001). Intra-class correlation coefficient (ICC) analysis demonstrated a high level of agreement (the consistency agreement) between POCT and the serum reference tests for both BUN (ICC=0.914) and Cr (ICC=0.980). CONCLUSIONS This study suggests that POCT-BUN/Cr results correlate well with those of serum reference tests in terms of BUN and Cr levels and, in turn, predicting CIN. POCT-BUN/Cr is easily performed with a rapid turnaround time, suggesting its use in the ED may have substantial clinical benefit.
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Affiliation(s)
- Je Sung You
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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Kim MJ, Park JM, Je SM, You JS, Park YS, Chung HS, Chung SP, Lee HS. Effects of a short text message reminder system on emergency department length of stay. Int J Med Inform 2012; 81:296-302. [DOI: 10.1016/j.ijmedinf.2012.01.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Revised: 10/20/2011] [Accepted: 01/01/2012] [Indexed: 10/14/2022]
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Choi HY, Cha MJ, Nam HS, Kim YD, Hong KS, Heo JH. Stroke units and stroke care services in Korea. Int J Stroke 2012; 7:336-40. [PMID: 22510228 DOI: 10.1111/j.1747-4949.2012.00788.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Organized stroke care systems improve stroke outcomes, but require resources and quality-improvement programs. This study was aimed at understanding the current status of stroke care services and stroke units in Korea. An on-line survey to investigate stroke services was conducted using a structured questionnaire for physicians who were in charge of stroke services or neurology departments of Korean hospitals that had neurology resident training programs. Of the 86 neurology training hospitals in Korea, 67 (78·0%) participated in this study. Brain computed tomography and computed tomography angiography were available 24 h a day and seven days a week (24/7) in all hospitals. More than 95% of hospitals offered transcranial Doppler, carotid duplex sonography, echocardiography, and conventional catheter angiography. Intravenous thrombolysis and hemicraniectomy for ischemic brain edema were provided 24/7 in all hospitals, and 50 hospitals (74·6%) were capable of intra-arterial thrombolysis. Stent or angioplasty was more frequently performed than endarterectomy. Performance measures were monitored in 57 hospitals (85·1%). Twenty-nine (43·3%) hospitals had stroke units. Stroke units were more common as the number of beds in the hospital increased (P = 0·001). When compared with hospitals without stroke units, stroke coordinators, use of general management protocol and education program for stroke team were more frequently available in the hospitals with stroke units. Most neurology training hospitals in Korea offered competent acute stroke care services. However, stroke units have not been widely implemented. Encouragement and support at the government or national stroke society level would promote the implementation of stroke units with little additional effort.
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Affiliation(s)
- Hye-Yeon Choi
- Department of Neurology, Kyung Hee University College of Medicine, Kangdong Hospital, Seoul, Korea
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Structure-Oriented versus Process-Oriented Approach to Enhance Efficiency for Emergency Room Operations: What Lessons Can We Learn? J Healthc Manag 2011. [DOI: 10.1097/00115514-201107000-00007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Impact of computerized physician order entry on ED patient length of stay. Am J Emerg Med 2011; 29:207-11. [DOI: 10.1016/j.ajem.2009.10.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Revised: 09/29/2009] [Accepted: 10/20/2009] [Indexed: 11/18/2022] Open
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Hains IM, Marks A, Georgiou A, Westbrook JI. Non-emergency patient transport: what are the quality and safety issues? A systematic review. Int J Qual Health Care 2010; 23:68-75. [DOI: 10.1093/intqhc/mzq076] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Bae HJ, Kim DH, Yoo NT, Choi JH, Huh JT, Cha JK, Kim SK, Choi JS, Kim JW. Prehospital notification from the emergency medical service reduces the transfer and intra-hospital processing times for acute stroke patients. J Clin Neurol 2010; 6:138-42. [PMID: 20944814 PMCID: PMC2950918 DOI: 10.3988/jcn.2010.6.3.138] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Revised: 06/01/2010] [Accepted: 06/01/2010] [Indexed: 11/23/2022] Open
Abstract
Background and Purpose There is little information available about the effects of Emergency Medical Service (EMS) hospital notification on transfer and intrahospital processing times in cases of acute ischemic stroke. Methods This study retrospectively investigated the real transfer and imaging processing times for cases of suspected acute stroke (AS) with EMS notification of a requirement for intravenous (IV) tissue-type plasminogen activator (t-PA) and for cases without notification. Also we compared the intra-hospital processing times for receiving t-PA between patients with and without EMS prehospital notification. Results Between December 2008 and August 2009, the EMS transported 102 patients with suspected AS to our stroke center. During the same period, 33 patients received IV t-PA without prehospital notification from the EMS. The mean real transfer time after the EMS call was 56.0±32.0 min. Patients with a transfer distance of more than 40 km could not be transported to our center within 60 min. Among the 102 patients, 55 were transferred via the EMS to our emergency room for IV t-PA. The positive predictive value for stroke (90.9% vs. 68.1%, p=0.005) was much higher and the real transfer time was much faster in patients with an EMS t-PA call (47.7±23.1 min, p=0.004) than in those without one (56.3±32.4 min). The door-to-imaging time (17.8±11.0 min vs. 26.9±11.5 min, p=0.01) and door-to-needle time (29.7±9.6 min vs. 42.1±18.1 min, p=0.01) were significantly shorter in the 18 patients for whom there was prehospital notification and who ultimately received t-PA than in those for whom there was no prehospital notification. Conclusions Our results indicate that prehospital notification could enable the rapid dispatch of AS patients needing IV t-PA to a stroke centre. In addition, it could reduce intrahospital delays, particularly, imaging processing times.
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Affiliation(s)
- Hyo-Jin Bae
- Busan-Ulsan Regional Cardio-Cerebral Vascular Center, Dong-A University Hospital, Busan, Korea
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Herlitz J, Wireklintsundström B, Bång A, Berglund A, Svensson L, Blomstrand C. Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities. Scand J Trauma Resusc Emerg Med 2010; 18:48. [PMID: 20815939 PMCID: PMC2944143 DOI: 10.1186/1757-7241-18-48] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 09/06/2010] [Indexed: 12/20/2022] Open
Abstract
Background The two major complications of atherosclerosis are acute myocardial infarction (AMI) and acute ischemic stroke. Both are life-threatening conditions characterised by the abrupt cessation of blood flow to respective organs, resulting in an infarction. Depending on the extent of the infarction, loss of organ function varies considerably. In both conditions, it is possible to limit the extent of infarction with early intervention. In both conditions, minutes count. This article aims to describe differences and similarities with regard to the way patients, bystanders and health care providers act in the acute phase of the two diseases with the emphasis on the pre-hospital phase. Method A literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases. Results In both conditions, symptoms vary considerably. Patients appear to suspect AMI more frequently than stroke and, in the former, there is a gender gap (men suspect AMI more frequently than women). With regard to detection of AMI and stroke at dispatch centre and in Emergency Medical Service (EMS) there is room for improvement in both conditions. The use of EMS appears to be higher in stroke but the overall delay to hospital admission is shorter in AMI. In both conditions, the fast track concept has been shown to influence the delay to treatment considerably. In terms of diagnostic evaluation by the EMS, more supported instruments are available in AMI than in stroke. Knowledge of the importance of early treatment has been reported to influence delays in both AMI and stroke. Conclusion Both in AMI and stroke minutes count and therefore the fast track concept has been introduced. Time to treatment still appears to be longer in stroke than in AMI. In the future improvement in the early detection as well as further shortening to start of treatment will be in focus in both conditions. A collaboration between cardiologists and neurologists and also between pre-hospital and in-hospital care might be fruitful.
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Affiliation(s)
- Johan Herlitz
- Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden.
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Abul-Kasim K, Brizzi M, Petersson J. Hyperdense middle cerebral artery sign is an ominous prognostic marker despite optimal workflow. Acta Neurol Scand 2010; 122:132-9. [PMID: 19804469 DOI: 10.1111/j.1600-0404.2009.01277.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate the association between the hyperdense middle cerebral artery sign (HMCAS) and the functional outcome on one hand, and different predictors such as the National Institutes of Health Stroke Scale (NIHSS), infarct size, ASPECTS Score, intracerebral hemorrhage, and mortality on the other hand. MATERIAL AND METHODS Retrospective analysis of 120 patients with MCA-stroke treated with intravenous thrombolysis. We tested the association between HMCAS and NIHSS, infarct volume, ASPECTS, outcome, level of consciousness, different recorded time intervals, and the day/time of admission. RESULTS Seventy-four percentage of patients treated with thrombolysis developed cerebral infarction. All patients with HMCAS (n = 39) sustained infarction and only 31% showed favorable outcome compared with 62% and 60%, respectively among patients without HMCAS (P < 0.001 and P = 0.002). There was statistically significant association between functional outcome and HMCAS (P = 0.002), infarct volume, NIHSS, and ASPECTS (P < 0.001). The time to treatment was 12 min shorter in patients who developed infarction (P = 0.037). Independent predictors for outcome were NIHSS and the occurrence of cerebral infarction on computed tomography for the whole study population, and infarct volume for patients who sustained cerebral infarction. CONCLUSIONS Despite optimal workflow, patients with HMCAS showed poor outcome after intravenous thrombolysis. The results emphasize the urgent need for more effective revascularization therapies and neuroprotective treatment in this subgroup of stroke patients.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Brain Damage, Chronic/diagnosis
- Brain Damage, Chronic/mortality
- Disability Evaluation
- Female
- Hospitals, University
- Humans
- Infarction, Middle Cerebral Artery/diagnosis
- Infarction, Middle Cerebral Artery/drug therapy
- Infarction, Middle Cerebral Artery/mortality
- Male
- Middle Aged
- Outcome and Process Assessment, Health Care
- Prognosis
- Recombinant Proteins/therapeutic use
- Retrospective Studies
- Survival Analysis
- Sweden
- Thrombolytic Therapy
- Time and Motion Studies
- Tissue Plasminogen Activator/therapeutic use
- Tomography, Spiral Computed
- Tomography, X-Ray Computed
- Workflow
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Affiliation(s)
- K Abul-Kasim
- Faculty of Medicine, University of Lund, Division of Neuroradiology, Department of Radiology, Malmö University Hospital, Malmö, Sweden.
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Park E, Nam HS. A Service-Oriented Medical Framework for Fast and Adaptive Information Delivery in Mobile Environment. ACTA ACUST UNITED AC 2009; 13:1049-56. [DOI: 10.1109/titb.2009.2031495] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kim SK, Lee SY, Bae HJ, Lee YS, Kim SY, Kang MJ, Cha JK. Pre-hospital notification reduced the door-to-needle time for iv t-PA in acute ischaemic stroke. Eur J Neurol 2009; 16:1331-5. [PMID: 19832903 DOI: 10.1111/j.1468-1331.2009.02762.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- S K Kim
- Stroke Center, Dong-A University Hospital, Busan, Korea
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Park HJ, Cho HJ, Kim YD, Lee DW, Choi HY, Kim SM, Heo JH. Comparison of the characteristics for in-hospital and out-of-hospital ischaemic strokes. Eur J Neurol 2009; 16:582-8. [PMID: 19405202 DOI: 10.1111/j.1468-1331.2009.02538.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Patients who are being admitted to a hospital due to diseases other than stroke may develop a stroke (in-hospital stroke; IHS). METHODS We enrolled 111 consecutive patients who developed IHS outside a neurology ward during a 5-year period at a single hospital. The frequency, characteristics, and outcomes for IHS patients were compared with patients who develop ischaemic stroke outside of the hospital (out-of-hospital stroke; OHS). RESULTS Forty-six percent of IHS occurred in the department of cardiology or cardiovascular surgery and 60% were associated with surgery or procedures. In comparison with the OHS patient group, the IHS patient group showed an increased frequency of cardiac disease, leukocytosis, and anemia. Cardioembolism, stroke of other determined etiologies, and an incomplete evaluation were more common in the IHS group, whereas large artery atherosclerosis was more frequent in the OHS group. The IHS group had up to a 10-fold higher mortality than the OHS group, with sepsis being the most common cause of death in the IHS group. CONCLUSIONS IHS has distinct etiologies and stroke mechanisms from OHS. The prevention and management of infection could decrease mortality in IHS patients.
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Affiliation(s)
- H J Park
- Department of Neurology, National Core Research Center for Nanomedical Technology, Yonsei University College of Medicine, Seoul, Korea
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Prediction of long-term outcome by percent improvement after the first day of thrombolytic treatment in stroke patients. J Neurol Sci 2009; 281:69-73. [DOI: 10.1016/j.jns.2009.02.365] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Revised: 02/10/2009] [Accepted: 02/13/2009] [Indexed: 11/21/2022]
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Rose KM, Rosamond WD, Huston SL, Murphy CV, Tegeler CH. Predictors of Time From Hospital Arrival to Initial Brain-Imaging Among Suspected Stroke Patients. Stroke 2008; 39:3262-7. [DOI: 10.1161/strokeaha.108.524686] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
We examined patient demographic and hospital characteristics and clinical predictors of delay time from hospital arrival until CT among 20 374 patients enrolled in the North Carolina Collaborative Stroke Registry (January 2005 to April 2008).
Methods—
Delay time was log-transformed in linear regression analyses and dichotomized (≤25 minutes, >25 minutes) in logistic regression analyses to correspond to a 1999 National Institute of Neurological Disorders and Stroke guideline.
Results—
In multiple linear regression analyses, prehospital delay time, mode of transport, race, gender, presumptive diagnosis, time of day of arrival, weekday versus weekend arrival, and hospital type (defined by Joint Commission Primary Stroke Center certification and teaching status) were significantly associated with CT delay. In analyses of 3549 patients arriving within 2 hours of symptom onset, time of day of arrival and weekday versus weekend arrival were no longer significant. Among patients arriving within 2 hours of symptom onset, the strongest independent predictors of meeting the National Institute of Neurological Disorders and Stroke (NINDS) guideline were arrival by emergency medical services versus other modes of transportation (odds ratio, 95% CI=2.3 [1.9, 2.8]) and a presumptive diagnosis of transient ischemic attack versus unspecified stroke type (odds ratio, 95% CI=0.4 [0.3, 0.5]).
Conclusions—
Most patients do not arrive to the hospital in a timely manner and cannot be considered for time-dependent therapies. Among those that do, disparities exist in time to receipt of CT scan, suggesting room for improvement in hospital-level stroke systems of care.
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Affiliation(s)
- Kathryn M. Rose
- From the Department of Epidemiology (K.M.R., W.D.R., S.L.H., C.V.M.), School of Public Health, University of North Carolina, Chapel Hill; the Heart Disease & Stroke Prevention Branch (S.L.H.), NC Division of Public Health, Raleigh, N.C.; and the Department of Neurology (C.H.T.), Wake Forest University Baptist Medical Center, Winston-Salem, N.C
| | - Wayne D. Rosamond
- From the Department of Epidemiology (K.M.R., W.D.R., S.L.H., C.V.M.), School of Public Health, University of North Carolina, Chapel Hill; the Heart Disease & Stroke Prevention Branch (S.L.H.), NC Division of Public Health, Raleigh, N.C.; and the Department of Neurology (C.H.T.), Wake Forest University Baptist Medical Center, Winston-Salem, N.C
| | - Sara L. Huston
- From the Department of Epidemiology (K.M.R., W.D.R., S.L.H., C.V.M.), School of Public Health, University of North Carolina, Chapel Hill; the Heart Disease & Stroke Prevention Branch (S.L.H.), NC Division of Public Health, Raleigh, N.C.; and the Department of Neurology (C.H.T.), Wake Forest University Baptist Medical Center, Winston-Salem, N.C
| | - Carol V. Murphy
- From the Department of Epidemiology (K.M.R., W.D.R., S.L.H., C.V.M.), School of Public Health, University of North Carolina, Chapel Hill; the Heart Disease & Stroke Prevention Branch (S.L.H.), NC Division of Public Health, Raleigh, N.C.; and the Department of Neurology (C.H.T.), Wake Forest University Baptist Medical Center, Winston-Salem, N.C
| | - Charles H. Tegeler
- From the Department of Epidemiology (K.M.R., W.D.R., S.L.H., C.V.M.), School of Public Health, University of North Carolina, Chapel Hill; the Heart Disease & Stroke Prevention Branch (S.L.H.), NC Division of Public Health, Raleigh, N.C.; and the Department of Neurology (C.H.T.), Wake Forest University Baptist Medical Center, Winston-Salem, N.C
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Asaro PV, Boxerman SB. Effects of computerized provider order entry and nursing documentation on workflow. Acad Emerg Med 2008; 15:908-15. [PMID: 18785946 DOI: 10.1111/j.1553-2712.2008.00235.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective was to measure the effects of the implementation of computerized provider order entry (CPOE) and electronic nursing documentation on provider workflow in the emergency department (ED). METHODS The authors performed a before-and-after time-motion study of the activities of physicians and nurses. The percentages of time spent in task categories were calculated by provider session and averaged across provider sessions. RESULTS There was a shift in physician time from working with paper alone, 13.1% to 9.6% (p = 0.05), to working with paper while using a computer, 1.6% to 4.3% (p = 0.02), and an increase in time spent working on computer and/or paper from 30.0% to 38.9% (p = 0.02). For nurses, the increase in time spent on computer from 9.5% to 25.7% (p < 0.01) was offset by a decrease in time spent working with paper from 16.5% to 1.8% (p < 0.01). Direct care decreased minimally for nurses from 56.9% to 55.3% (p = 0.69), but from 36.8% to 29.1% (p = 0.07) for physicians, approaching statistical significance. Care planning decreased for nurses from 9.4% to 6.4% (p = 0.04) and from 21.7% to 19.5% (p = 0.60) for physicians. CONCLUSIONS The net effects of an implementation on provider workflow depend not only on changes in tasks directly related to the provider-computer interface, but also on changes in underlying patient care processes and information flows. The authors observed an unanticipated shift in physician time from interacting with nurses and patients toward retrieving information from the electronic patient record. Implementers should carefully consider how implementations will affect information flow and then expect the unexpected.
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Affiliation(s)
- Phillip V Asaro
- Washington University School of Medicine, St. Louis, MO, USA.
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