Rapid Thrombolysis Protocol: Results from a Before-and-after Study.

Objective: Intravenous thrombolysis within 4.5 hours from time of onset has proven benefit in stroke. Universal standard for the door-to-needle (DTN) time is within 60 minutes from the time of arrival of patients to the emergency department. Our rapid thrombolysis protocol (RTPr) was developed with an aim to reduce the DTN time to a minimum by modifying our stroke post-intervention processes. Materials and methods: This before-and-after study was conducted at a single center on patients who received intravenous thrombolysis in the emergency department. Consecutive patients who were thrombolysed using our RTPr (post-intervention group) were compared to the pre-intervention group who were thrombolysed before the implementation of the protocol. The primary outcomes were DTN time, time to recovery, and modified ranking score (mRS) on discharge. Secondary outcomes were mortality, symptomatic intracerebral hemorrhage, and hospital and intensive care unit length of stay. Results: Seventy-four patients were enrolled in each group. Mean DTN time in pre- and post-intervention group was 56.15 minutes (95% CI 49.98-62.31) and 34.91 minutes (95% CI 29.64-40.17) (p <0.001), respectively. In pre-intervention and post-intervention groups, 43.24% (95% CI 32.57-54.59) and 41.89% (95% CI 31.32-53.26) patients, respectively, showed neurological recovery in 24 hours. About 36.49% (95% CI 26.44-47.87) in pre-intervention group and 54.05% (95% CI 42.78-64.93) in post-intervention group had discharge mRS 0-2. Conclusion: The RTPr can be adapted by clinicians and hospitals to bring down the DTN times and improve outcomes for stroke patients. How to cite this article: Verma A, Sarda S, Jaiswal S, Batra A, Haldar M, Sheikh WR, et al. Rapid Thrombolysis Protocol: Results from a Before-and-after Study. Indian J Crit Care Med 2022;26(5):549-554.

Increased Length of Stay of Critically Ill Patients in the Emergency Department Associated with Higher In-hospital Mortality.

OBJECTIVES: Emergency department (ED) length of stay (LOS) is defined as the time a patient is registered to the time the patient is shifted to a hospital bed or discharged. Increasing demand for quality emergency care has resulted in increased wait times due to demand and supply mismatch. It is perceived that longer LOS in the ED of critical patients leads to poor outcomes. Our goal was to study the impact of LOS in the ED on the patients who required critical care admissions. METHODS: This was a retrospective study conducted in the ED of a tertiary center. Data were collected using electronic health records (EHR) for patients admitted to the intensive care units (ICUs). Patient's LOS in ED was divided into 0-4, 4-8, 8-12, 12-24, and >24 hours. ED LOS was calculated from the registration time to the time patient was handed over in the ICU. Patients were divided into four categories (1-4) based on their criticality. LOS in ED, mortality, and total hospital LOS were analyzed in the study. RESULTS: Three thousand four hundred and twenty-nine patients were enrolled in the study. Mean age was 62.69 years (95% CI 62.11-63.26). A total of 42.09% (95% CI 40.5-43.8) were Category 1 patients. Overall mortality rate was 52.46% (95% CI 50.79-54.13). LOS of 48.15% (95% CI 46.54-49.88) patients in the ED was between 0 and 4 hours, 19.90% (95% CI 18.62-21.29) between 4 and 8 hours, 8.21% (95% CI 7.35-9.19) between 8 and 12 hours, 15.50% (95% CI 14.34-16.77) between 12 and 24 hours, and 8.13% (95% CI 7.27-9.10) >24 hours. Mortality for LOS of 0-4 hours was 51.30% (95% CI 48.89-53.70), 54.03% (95% CI 50.28-57.73) for 4-8 hours, 48.94% (95% CI 43.16-54.75) for 8-12 hours, 51.50% (95% CI 47.26-55.72) for 12-24 hours, and 60.57% (95% CI 54.73-66.13) for >24 hours. CONCLUSION: We concluded that the longer the critically ill patients are boarded in the ED, the higher is the chance for mortality. Processes should be implemented to ease the throughput from the ED. HOW TO CITE THIS ARTICLE: Verma A, Shishodia S, Jaiswal S, Sheikh WR, Haldar M, Vishen A, et al. Increased Length of Stay of Critically Ill Patients in the Emergency Department Associated with Higher In-hospital Mortality. Indian J Crit Care Med 2021;25(11):1221-1225.

Reply to in Response to Guidewire Entrapped in the Right Ventricle.

How to cite this article: Verma A, Jaiswal S, Vishen A, Sheikh WR, Haldar M, Ahuja R, et al. Reply to in Response to Guidewire Entrapped in the Right Ventricle. Indian J Crit Care Med 2020;24(7):608.

Interrater Reliability of Four Neurological Scales for Patients Presenting to the Emergency Department.

BACKGROUND: Altered mental status (AMS) comprises a group of clinical symptoms rather than a specific diagnosis. A variety of neurological scales have been used to monitor these patients, including the Glasgow coma scale (GCS), AVPU (alert, responds to verbal stimuli, responds to painful stimuli, unresponsive) scale, and ACDU (alert, confused, drowsy, unresponsive) scale. The simplified motor scale (SMS) has been found to be a potential replacement for the GCS. In this study, we compare the interrater reliability of the GCS (individual components), AVPU, ACDU, and SMS to patients presenting to the ED with AMS. MATERIALS AND METHODS: This was a prospective observational study conducted in the emergency department of an urban tertiary-care hospital in New Delhi, India. Patients with AMS (traumatic and nontraumatic) presenting to the ED were assessed by two emergency physicians within 10 minutes of each other using the four neurological scales. Percentage agreement and kappa coefficient score were used to determine interrater reliability for SMS, individual components of GCS, AVPU, and ACDU. RESULTS: The SMS had the best inter-rater percent agreement with 83.91% (95% CI 77.7-88.6%), followed by ACDU which was 76.44% (95% CI 69.0-81.6%), AVPU 75.29% (95% CI 67.8-80.6%), GCS Eye 74.14% (95% CI 66.6-79.6%), GCS Verbal 67.82% (95% CI 60.6-74.3%), and GCS Motor was 64.94% (95% CI 57.6-71.6%).The kappa coefficient for SMS was 0.75 (95% CI 0.67-0.83), followed by GCS Eye which was 0.63 (95% CI 0.54-0.72), AVPU 0.62 (95% CI 0.52-0.72), ACDU 0.60 (95% CI 0.49-0.71), and GCS Verbal 0.58 (0.49-0.66) and GCS Motor was 0.53 (95% CI 0.44-0.63). CONCLUSION: It can be said that SMS has the best interrater reliability in the ED and can be recommended for clinical use in the emergency departments for patients presenting with AMS. HOW TO CITE THIS ARTICLE: Haldar M, Verma A, Jaiswal S, Sheikh WR. Interrater Reliability of Four Neurological Scales for Patients Presenting to the Emergency Department. Indian J Crit Care Med 2020;24(12):1198-1200.