Abstract TP5: Early Intubation Of Hyperacute Stroke Patients In The Emergency

Background: Stroke patients at times will present to the emergency department in unstable condition necessitating early intubation. Given the time-sensitive nature of thrombolysis for ischemic stroke, we sought to characterize the rates and predictors of intubation on ED arrival for hyperacute stroke patients transported by paramedics.

Methods: Subjects were participating in the NIH Field Administration of Stroke Therapy Magnesium (FAST-MAG) clinical trial. Subjects were enrolled in the field ambulance within 2 hours of last known well and taken to their usual care emergency department. Early intubation was noted by study nurses on their initial NIHSS after ED arrival.

Results: A total of 1700 cases were included, aged 69±13 years, 42.6% were women, median NIHSS on ED arrival was 9 [IQR 3-17], final diagnosis was cerebral ischemia in 73.3%, intracranial hemorrhage (ICH) in 22.8%, and a stroke-mimicking condition in 3.9%. The median time form last known to ED arrival was 59 minutes. Early ED intubation was more common in ICH compared to CI or mimic (18% vs. 1% vs. 3%, p<0.001). Early intubation was associated with higher NIHSS [32 v 9]. The final diagnosis for both stroke mimic cases with early intubation was seizure. Among the 88 cases intubated early in the ED, there were 71 (81%) ICH, 15 (17%) ischemia and 2 (3%) mimics. Rates of TPA utilization in cerebral ischemia cases were 53% in the intubated group and 36% in the non-intubated group.

Conclusion: Early intubation in the ED was more common in the ICH cases and occurred in only 1% of cerebral ischemia cases.

Contributions of Health Professions Students to Health System Needs During the COVID-19 Pandemic: Potential Strategies and Process for U.S. Medical Schools

The COVID-19 pandemic poses an unprecedented challenge to U.S. health systems, particularly academic health centers (AHCs) that lead in providing advanced clinical care and medical education. No phase of AHC efforts is untouched by the crisis, and medical schools, prioritizing learner welfare, are in the throes of adjusting to suspended clinical activities and virtual classrooms. While health professions students are currently limited in their contributions to direct clinical care, they remain the same smart, innovative, and motivated individuals who chose a career in health care and who are passionate about contributing to the needs of people in troubled times. The groundwork for operationalizing their commitment has already been established through the identification of value-added, participatory roles that support learning and professional development in health systems science (HSS) and clinical skills. This pandemic, with rapidly expanding workforce and patient care needs, has prompted a new look at how students can contribute. At the Penn State College of Medicine, staff and student leaders formed the COVID-19 Response Team to prioritize and align student work with health system needs. Starting in mid-March 2020, the authors used qualitative methods and content analysis of data collated from several sources to identify 4 categories for student contributions: the community, the health care delivery system, the workforce, and the medical school. The authors describe a nimble coproduction process that brings together all stakeholders to facilitate work. The learning agenda for these roles maps to HSS competencies, an evolving requirement for all students. The COVID-19 pandemic has provided a unique opportunity to harness the capability of students to improve health.Other AHCs may find this operational framework useful both during the COVID-19 pandemic and as a blueprint for responding to future challenges that disrupt systems of education and health care in the United States.

Factors Associated with Increased Risk of Unplanned Hospital Readmission after Endovascular Aortoiliac Interventions

Objectives  

Readmissions to hospital after surgical procedures are considered as reflective of poor quality of healthcare provided during the index hospitalization and are associated with increased costs of healthcare. Aortoiliac occlusive disease represents an aggressive form of atherosclerotic disease and has been traditionally treated with open surgical bypasses. Endovascular interventions for aortoiliac occlusive disease are associated with comparable outcomes to open surgical procedures. The purpose of this study is to review the factors associated with hospital readmission after aortoiliac endovascular interventions.

Methods

The 2015 procedure targeted American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database and general and vascular surgery NSQIP participant user file (PUF) were used for this analysis. Patient, diagnosis and procedure characteristics of patients undergoing aortoiliac endovascular interventions were reviewed. Bivariate analysis was used to identify the relationship between the independent variables and 30-day readmission. The significant variables from the bivariate analysis were used to generate a multivariable logistic regression model. The predicted probability of readmission was calculated.

Results

Out of 823 patients, 86 were readmitted. Readmission was related to the principal procedure in 48 (73.9%) patients. A total of 61 (7%) patients underwent an unplanned operation within 30 days after the index procedure. A multivariable logistic regression model identified the following variables to be significantly associated with 30-day risk of readmission: the use of pre-procedural beta blocker (OR = 2.06, 95% CI = 1.23 - 3.45, P < 0.01), external/internal iliac intervention (OR = 1.95, 95% CI = 1.18 - 3.20, P <0.01), critical limb ischemia (OR = 1.80, 95% CI = 1.10 - 2.94, P <0.05), and unplanned return to the operating room (OR = 11.65, 95% CI = 6.35 - 21.35, P <0.01). The predicted probability of readmission was as follows: 5.5% for critical limb ischemia, 5.9% for external iliac artery angioplasty/stenting, 6.2% for preoperative beta blockers, 17.7% for patients with cardiac arrest, 27% for unplanned return to the operating room, and 94.7% for patients with all of these risk factors.

Conclusion

Readmissions after endovascular interventions for severe atherosclerotic disease can be used as a quality metric. Several factors place a patient at a high risk for readmission. Unplanned return to the operating room, cardiac arrest, preoperative beta blockers, location of disease, and preoperative symptoms are independent risk factors for hospital readmission. Unplanned return to the operating room is associated with 11.65-fold increase in the risk of hospital readmission.