External validation of stroke mimic prediction scales in the emergency department.

BACKGROUND: Acute ischemic stroke is a time-sensitive emergency where accurate diagnosis is required promptly. Due to time pressures, stroke mimics who present with similar signs and symptoms as acute ischemic stroke, pose a diagnostic challenge to the emergency physician. With limited access to investigative tools, clinical prediction, tools based only on clinical features, may be useful to identify stroke mimics. We aim to externally validate the performance of 4 stroke mimic prediction scales, and derive a novel decision tree, to improve identification of stroke mimics. METHODS: We performed a retrospective cross-sectional study at a primary stroke centre, served by a telestroke hub. We included consecutive patients who were administered intravenous thrombolysis for suspected acute ischemic stroke from January 2015 to October 2017. Four stroke mimic prediction tools (FABS, simplified FABS, Telestroke Mimic Score and Khan Score) were rated simultaneously, using only clinical information prior to administration of thrombolysis. The final diagnosis was ascertained by an independent stroke neurologist. Area under receiver operating curve (AUROC) analysis was performed. A classification tree analysis was also conducted using variables which were found to be significant in the univariate analysis. RESULTS: Telestroke Mimic Score had the highest discrimination for stroke mimics among the 4 scores tested (AUROC = 0.75, 95% CI = 0.63-0.87). However, all 4 scores performed similarly (DeLong p > 0.05). Telestroke Mimic Score had the highest sensitivity (91.3%), while Khan score had the highest specificity (88.2%). All 4 scores had high positive predictive value (88.1 to 97.5%) and low negative predictive values (4.7 to 32.3%). A novel decision tree, using only age, presence of migraine and psychiatric history, had a higher prediction performance (AUROC = 0.80). CONCLUSION: Four tested stroke mimic prediction scales performed similarly to identify stroke mimics in the emergency setting. A novel decision tree may improve the identification of stroke mimics.

The Challenge of Tightening Door-to-Needle Timings in a Telestroke Setting: An Emergency Medicine Driven Initiative.

Introduction Administering intravenous thrombolytic therapy within 60 minutes on arrival in any healthcare facility is challenging, especially when done by Emergency Medicine Physicians (EMP) via telemedicine in centres without onsite neurology cover. Prior quality improvement interventions have improved median Door-to-Needle (DTN) timings in our centre; however, it still falls short of the DTN target of 60 minutes.  Methods Various quality improvement interventions were implemented over four months by a multi-disciplinary telestroke workgroup led by EMPs to improve DTN timings for patients presenting with acute ischaemic strokes. A retrospective observational study was conducted to review if these interventions resulted in an improvement in DTN timings while keeping the rates of stroke mimics given thrombolytic therapy, haemorrhagic conversions and 30-day mortality rates low.  Results A total of 279 patients were evaluated. Median DTN timings significantly improved from 71.0 minutes pre-intervention to 62.0 minutes post-intervention (p=0.012). Correspondingly, the proportion of patients with DTN ≤ 60 minutes increased from 31.7% pre-intervention to 47.0% post-intervention, giving an odds ratio of 1.91 (95% CI 1.17 - 3.11, p=0.009). There were no significant differences found in the rates of stroke mimics, haemorrhagic conversions and 30-day mortality pre and post-intervention. Conclusion The implementation of EMP led to systemic quality improvement interventions is associated with improved DTN timings without compromising clinical quality outcome measures like haemorrhagic conversion rates and 30-day mortality rates. EMPs, with a broad knowledge base and familiarity, interacting with various specialities and co-ordinating care, are uniquely suited in this role to drive change. More work in the public health sector would also have to be done to improve the population's response to acute stroke symptoms.

Improving telestroke treatment times through a quality improvement initiative in a Singapore emergency department.

INTRODUCTION: Telestroke allows for remote determination of suitability for treatment with thrombolysis in patients with acute ischaemic stroke. However, this approach is time-dependent and most centres have yet to achieve the recommended treatment times. We describe a quality improvement initiative aimed at improving the telestroke workflow and treatment times at our centre. METHODS: A multidisciplinary workgroup comprising clinicians, stroke case managers and radiology staff was formed to oversee the initiative. A phase-by-phase review of the existing workflow was done to identify the reasons for delay. Phase-specific measures were then introduced to address these delays, and a data-monitoring system was established to track the impact of these measures. The initiatives were implemented through four Plan-Do-Study-Act cycles. The door-to-needle (DTN) times for thrombolysis and clinical outcomes before and after the interventions were compared. RESULTS: A total of 104 patients were evaluated. The median DTN time improved from 96 minutes to 78 minutes post implementation of initiatives (p = 0.003). Fewer patients had symptomatic intracranial haemorrhages (8.5% vs. 24.2%; p = 0.03), and more patients had improvements in their National Institutes of Health Stroke Scale score (47.9% vs. 25.0%; p = 0.031) after the initiatives were introduced. CONCLUSION: The quality improvement initiative resulted in a reduction in median DTN time. Our approach allowed for a systematic method to resolve delays within the telestroke workflow. This initiative is part of an ongoing effort aimed at providing thrombolysis safely to eligible patients in the shortest possible time.

Telestroke: rapid treatment of acute ischemic stroke patients using telemedicine in a Singapore emergency department.

STUDY OBJECTIVE: In recent years, telemedicine technology has allowed hospitals without an in-house neurology service access to 24-h neurology consultation from specialized centers, thus paving the way for these hospitals to offer thrombolysis treatment for stroke patients. This article will describe the experience of the study hospital's emergency department (ED) in its use of telemedicine technology to facilitate the rapid treatment of acute ischemic stroke patients. METHODS: The ED records, in-patient records, and paramedic records of all patients who presented to the study hospital's ED and received thrombolytic treatment for ischemic strokes were retrospectively reviewed. RESULTS: From 25 October 2010 to 25 May 2011, using the telemedicine system, a total of 18 patients received thrombolytic treatment for acute ischemic strokes. The overall mean door to needle time was 92.7 min (95% CI 80.0 to 105.5), median 86.0 min. The mean onset of symptoms to needle (OTN) time was 154.9 min (95% CI 136.7 to 173.2), median 148 min. Factors such as presentation during office hours, brought in by ambulances as standby cases, and direct management by senior doctors were associated with shorter door to needle times. CONCLUSION: Telemedicine is an invaluable tool that enables hospitals without 24-h onsite neurology service to offer emergency thrombolysis to eligible stroke patients, who otherwise will not be able to benefit from this therapy.

Validation of the San Francisco Syncope Rule in two hospital emergency departments in an Asian population.

OBJECTIVES: The objective was to externally validate the ability of the San Francisco Syncope Rule (SFSR) to accurately identify patients who will experience a 7-day serious clinical event in an Asian population. METHODS: This was a prospective cohort study, with a sample of adult patients with syncope and near-syncope enrolled. Patients 12 years old and below and patients with loss of consciousness after head trauma, a witnessed seizure, with known alcohol or illicit drug ingestion, and altered level of consciousness or persistent new neurologic deficits were excluded. The patients were evaluated for the presence of one or more of the five SFSR variables: shortness of breath, history of heart failure, hematocrit <30%, systolic blood pressure <90 mm Hg, and abnormal electrocardiogram (ECG). The patients were followed up by medical record review or telephone interview. Seven-day outcomes were death, arrhythmia, myocardial infarction, acute pulmonary edema, significant structural heart disease, pulmonary embolism, major cardiac procedure, stroke, subarachnoid hemorrhage, major bleeding, and anemia. RESULTS: A total of 1,250 patients from two centers were recruited. Fifty-six patients were excluded from primary analysis because of incomplete data (n = 55) and/or they were noncontactable for follow-up (n = 32). Of the 1,194 patients analyzed, 138 patients (11.6%) experienced adverse outcomes at 7 days. The rule performed with a sensitivity of 94.2% (95% confidence interval [CI] = 89.0% to 97.0%) and a specificity of 50.8% (95% CI = 47.7% to 53.8%). CONCLUSIONS: In this study, SFSR rule had a sensitivity of 94.2%. This suggests caution on the strict application of the rule to all patients presenting with syncope. It should only be used as an aide in clinical decision-making in this population.

Spinal abscess: a case series.

OBJECTIVE: Spinal abscess is a rare but potentially devastating condition. We present a case series, looking into its presentation, risk factors, management and outcome. METHODS: Five patients over a 10 year period were identified, with a discharge diagnosis code of 'spinal abscess, 324.1' from the hospital computer database. RESULTS: Four out of five patients presented atypically. Prognosis corresponded to early diagnosis and surgical decompression. Risk factors included intravenous drug abuse, a compromised immune system and infection in another organ system. Magnetic resonance imaging was an important diagnostic tool for all. CONCLUSION: The early diagnosis and immediate surgical treatment of spinal abscesses remain cornerstones in improving the outcomes of the disease. From our series, risk factor assessment appear to be more useful than the classical triad of fever, spine pain and neurological deficits to screen ED patients with spine pain for spinal abscess.