Door-to-Skin Time in Patient Undergoing Emergency Trauma Craniotomy.

Background: Traumatic brain injury (TBI) is the third leading cause of death and disability worldwide in 2020. For patients with TBI with significant intracranial bleeds, urgent surgical intervention remains the mainstay treatment. This study aims to evaluate the time to definite surgical intervention since admission and its association with patient outcomes in a neurosurgery referral centre in Malaysia. Methods: This retrospective study was conducted at Hospital Sultanah Aminah Johor Bahru from 1 January 2019 to 31 December 2019. All patients with TBI requiring urgent craniotomy were identified from the operating theatre registry, and the required data were extracted from their clinical notes, including the Glasgow Outcome Score (GCS) at discharge and 6 months later. Logistic regression was performed to identify the factors associated with poor outcomes. Results: A total of 154 patients were included in this study. The median door-to-skin time was 605 (interquartile range = 494-766) min. At discharge, 105 patients (68.2%) had poor outcomes. At the 6-month follow-up, only 58 patients (37.7%) remained to have poor outcomes. Simple logistic regression showed that polytrauma, hypotensive episode, ventilation, severe TBI, and the door-to-skin time were significantly associated with poor outcomes. After adjustments for the clinical characteristics in the analysis, the likelihood of having poor outcomes for every minute delay in the door-to-skin time increased at discharge (adjusted odds ratio [AOR] = 1.005; 95% confidence interval [CI] = 1.002-1.008) and the 6-month follow-up (AOR = 1.008; 95% CI = 1.005-1.011). Conclusion: The door-to-skin time is directly proportional to poor outcomes in patients with TBI. Concerted efforts from all parties involved in trauma care are essential in eliminating delays in surgical interventions and improving outcomes.

Impact of CT scanner location on door to imaging time for emergency department stroke evaluation.

BACKGROUND AND OBJECTIVES: Stroke is a potentially serious condition commonly diagnosed in the ED. Time to diagnosis can be crucial to maximizing outcome in a majority of ischemic stroke cases amenable to thrombolytic therapy. METHODS: An analysis of 148 consecutive adults transported by EMS to an urban emergency department with a diagnosis of cerebro-vascular accident during a 12 month period was performed to determine the impact of CT scanner location on door-to-head CT [DTCT] scan time. The CT scanner was relocated from an upper floor of the hospital to within the ER department midway through the study period. RESULTS: The rate of DTCT scan time ≤20 min increased significantly from 47% [pre-relocation] to 74% [post-relocation]; and the rate of DTCT ultra-rapid scan time ≤10 min more than doubled. CONCLUSIONS: Hospitals providing ED care for stroke patients can expedite management by ensuring CT scanner location is in closest possible proximity to the ED.

Thrombolysis for acute ischemic stroke: do patients treated out of hours have a worse outcome?

INTRODUCTION: Previous studies on the impact of nonworking hours (NWH) have produced conflicting results. We aimed to compare the time to treatment with thrombolysis between NWH and working hours (WH) at an Australian comprehensive stroke center. MATERIALS AND METHODS: All acute ischemic stroke patients treated with intravenous alteplase (IV-alteplase) from January 2003 to December 2011 at the Royal Melbourne Hospital were included. Data collected included demographics, serial time points (including onset, presentation to emergency department, neuroimaging, and thrombolysis), and clinical outcomes (modified Rankin Scale [mRS] and death) at 3 months. NWH were defined as weekdays 5 PM-8 AM, weekends, and public holidays. Comparisons were made in the door-to-computed tomography (CT) time, the door-to-needle time, mRS, and mortality within 3 months between the NWH group and WH group. RESULTS: We recruited 388 consecutive patients who received IV-alteplase, 226 patients were in NWH and 162 patients in WH. The median age was 71 years (Interquartile range [IQR] = 60-79), 54.1% of patients were male, and the median National Institutes of Health Stroke Scale score was 13 (IQR = 8-18). No significant differences were observed at baseline between the NWH and WH groups except for prior stroke. There was a 15-minute increase in the median door-to-needle time (80 minutes in the NWH group versus 64.5 minutes in the WH group, 95% confidence interval [CI]: 6.36-23.64, P = .001). No significant differences were noted in the median door-to-CT time (95% CI: -1.16 to 9.16, P = .128) and clinical outcomes at 3 months (P > .05). Both the door-to-CT time and the door-to-needle time became shorter over the period of the study (P < .001). CONCLUSIONS: Our study showed that the "NWH effect" increased the door-to-needle time. The patients treated out of hours did not have a worse outcome.

Interaction between stroke severity and quality indicators of acute stroke care: a single-center retrospective analysis.

Ischemic stroke leads to substantial mortality and morbidity worldwide. Door-to-CT time, door-to-needle time (DNT), and door-to-groin time (DGT) are important quality indicators of stroke care. However, patient characteristics remain important determinants of outcome as well. In this single-center study, we investigated the interaction between these quality indicators and stroke severity regarding long-term functional outcome. All consecutive stroke patients treated at the ZOL stroke center, Genk, Belgium, between 2017 and 2020 were included in this retrospective observational study. Stroke severity was graded as "mild" if National Institutes of Health Stroke Scale (NIHSS) was equal to or lower than 8, "moderate" if NIHSS was between 9 and 15, and "severe" if NIHSS was higher than 16. Modified Rankin Scale (mRS) scores were collected before and 3 months after stroke. Ordinal regression analysis with correction for patient characteristics of functional outcome was done. A total of 1255 patients were included, of which 84% suffered an ischemic CVA (n = 1052) and 16% a TIA (n = 203). The proportion of patients treated conservatively or with thrombolysis, thrombectomy, or the combination of both differed according to stroke severity (p < 0.0001). Door-to-CT time was longer in mild and moderate stroke (p < 0.0001). Median DNT also differed between stroke categories: 46 (IQR 31-70) min for mild vs. 36 (25-56) min for moderate vs. 30 (21-45) min for severe stroke (p = 0.0002). Median DGT did not differ between stroke severity categories (p = 0.15). NIHSS on admission and pre-stroke mRS were independently associated with mRS at 90 days. Operational performance, reflected in door-to-CT time and DNT, was worse in patients with mild and moderate stroke severity. DNT was also associated with functional outcome in our center, along with pre-stroke mRS, NIHSS on admission and age.

Quality Indicators of Intravenous Thrombolysis from North India.

BACKGROUND: Data on intravenous (IV) thrombolysis using tissue plasminogen activator (tPA) are limited from low- and middle-income countries. We aimed to assess the quality indicators of IV thrombolysis in our stroke unit. METHODS: All stroke patients admitted in our hospital from October 2008 to April 2017 were included in this study. Data were collected prospectively by trained research staff in a detailed case record form. Outcome was assessed using modified Rankin Scale (mRS, 0-1 good outcome). RESULTS: Of the total 4720 stroke patients seen, 944 (20%) came within window period (<4.5 h). Of these, 214 (4.5%) were eligible for thrombolysis and 170 (3.6%) were thrombolysed, relatives of 23 (23/214, 10.7%) patients denied consent, and 21 (9.8%) patients could not afford tPA. The mean age of thrombolysed patients was 58.4 (range 19-95) years. Median NIHSS at admission was 12 (interquartile range 2-24). Average onset-to-door (O-D) time was 76.8 (5-219) min, door-to-examination (D-E) time was 17.8 (5-105) min, door-to-CT (D-CT) time was 48 (1-205) min, and door-to-needle (D-N) time was 90 (20-285) min. At 6 months, 110 (64.7%) patients were contactable and 82 (74.5%) patients had good outcome (mRS 0-1). CONCLUSION: Thrombolysis rate has steadily increased at the center without undue adverse effects even in the elderly. D-E and D-CT times have reduced, but O-D and D-N times need further improvement. More patients could be thrombolysed if the cost of tPA is reduced and the consent process is waived.