RESUMO
INTRODUCTION: With the publication of the recent trials showing the tremendous benefits of mechanical thrombectomy, opportunities exist to refine prehospital processes to identify patients with larger stroke syndromes. MATERIALS AND METHODS: We retrospectively reviewed consecutive patients who were brought via scene flight from rural parts of the region to our institution, from December 1, 2014 to June 5, 2015, with severe hemiparesis or hemiplegia. We assessed the accuracy of the diagnosis of stroke and the number of patients requiring endovascular therapy. Moreover, we reviewed the times along the pathway of patients who were treated with endovascular therapy. RESULTS: 45 patients were brought via helicopter from the field to our institution. 27 (60%) patients were diagnosed with an ischemic stroke. Of these, 12 (26.7%) were treated with mechanical thrombectomy and 6 (13.3%) with intravenous tissue plasminogen activator alone. An additional three patients required embolization procedures for either a dural arteriovenous fistula or cerebral aneurysm. Thus a total of 15 (33%) patients received an endovascular procedure and 21/45 (46.7%) received an acute treatment. For patients treated with thrombectomy, the median time from first medical contact to groin puncture was 101â min, with 8 of the 12 patients (66.7%) being discharged to home. CONCLUSIONS: We have presented a pilot study showing that severe hemiparesis or hemiplegia may be a reasonable prehospital tool in recognizing patients requiring endovascular treatment. Patients being identified earlier may be treated faster and potentially improve outcomes. Further prospective controlled studies are required to assess the impact on outcomes and cost effectiveness using this methodology.
Assuntos
Paresia/diagnóstico , Acidente Vascular Cerebral/diagnóstico , Triagem/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Resgate Aéreo , Isquemia Encefálica/complicações , Malformações Vasculares do Sistema Nervoso Central/cirurgia , Malformações Vasculares do Sistema Nervoso Central/terapia , Embolização Terapêutica , Procedimentos Endovasculares/métodos , Feminino , Humanos , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/cirurgia , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Reprodutibilidade dos Testes , Estudos Retrospectivos , Trombectomia , Tempo para o Tratamento , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do TratamentoRESUMO
BACKGROUND: Rapid delivery of IV tissue plasminogen activator (tPA) in qualifying patients leads to better clinical outcomes. The American Heart Association has reduced target door-to-needle (DTN) times from 60 to 45 min in the hopes of continued process improvements across institutions. OBJECTIVE: To start a quality improvement project called CODE FAST in order to reduce DTN times at our institution. MATERIALS AND METHODS: We retrospectively reviewed data from our internally maintained database of patients treated with intravenous tPA before and after implementation of the CODE FAST protocol. We assessed demographic information, time of day and times of arrival to first image and delivery of tPA in patients from February 2014 to February 2015. Outcomes were assessed based on discharge to home. Univariate analysis was performed to assess for improvement in DTN times before and after implementation of the protocol. RESULTS: A total of 93 patients (41 pre-CODE FAST and 52 post-CODE FAST) received IV tPA during the study period. Patients were equally matched between the two groups except that in the pre-CODE FAST era patients receiving tPA were younger and more likely to be men. There was a substantial reduction in door-to-imaging time from a median of 16 to 8â min (p<0.0001) and DTN time with a reduction in the median from 62 to 25â min (p<0.0001). In logistic regression modeling, there was a trend towards more discharges to home in patients treated during the CODE FAST era. CONCLUSIONS: We present a quality improvement project that has been overwhelmingly successful in reducing DTN time to <30â min. The template we present may be helpful to other institutions looking to reduce their DTN times and may also reduce costs as we note a trend towards more discharges to home.
Assuntos
Fibrinolíticos/uso terapêutico , Melhoria de Qualidade/organização & administração , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/métodos , Tempo para o Tratamento/estatística & dados numéricos , Ativador de Plasminogênio Tecidual/uso terapêutico , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Serviços Médicos de Emergência , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Neuroimagem , Alta do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Fatores Sexuais , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/epidemiologia , Terapia Trombolítica/estatística & dados numéricos , Ativador de Plasminogênio Tecidual/administração & dosagemRESUMO
The purpose of this exploratory study was to examine personal characteristics, socio-environmental conditions, and motivational factors that potentially influence HIV vaccine research community engagement. Specifically, the study identified predictive aspects that may aid in future community program development on HIV vaccine issues. A cross-sectional survey consisting of evaluative measures, demographics, social interaction, and health information-seeking behaviors was conducted. Participants were a diverse group of 452 adults (>or=18 years) at HIV vaccine awareness-building and community education gatherings in Atlanta. The sample included large numbers of women (n=251) and minorities (n=224). In multivariate analysis, the overall logistic regression model was significant, with a resulting coefficient of determination (Nagelkerke R(2)) of .505. Highly significant factors included an excellent activity/event rating (log odds beta = 4.521, P< .001), White race (beta= -.835, P= .005), greater educational attainment (beta= .725, P= .011), travel distance (beta = 1.186, P= .002), and excellent perception of the study site (beta=2.131, P< .001). Subgroup analyses by gender and race revealed similar findings. These data demonstrate the importance of building a favorable study site image and gaining familiarity in the community to aid in the promotion of HIV vaccine research on an ongoing basis.