The Maryland Acute Stroke Emergency Medical Services Routing Pilot: Expediting Access to Thrombectomy for Stroke.

Background: Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke caused by large vessel occlusion, but is not available at all stroke centers. Transfers between hospitals lead to treatment delays. Transport directly to a facility capable of MT based on a prehospital stroke severity scale score has been recommended, if transportation time is less than 30 min. Aims: We hypothesized that an Emergency Medical Services (EMS) routing algorithm for stroke, using the Los Angeles Motor Scale (LAMS) in the field, would improve time from last known well to MT, without causing patients to miss the IV Thrombolysis (IVT) window. Methods: An EMS algorithm in the Baltimore metro area using the LAMS was implemented. Patients suspected of having an acute stroke were assessed by EMS using the LAMS. Patients scoring 4 or higher and within 20 h from last known well, were transported directly to a Thrombectomy Center, if transport could be completed within 30 min. The algorithm was evaluated retrospectively with prospectively collected data at the Thrombectomy Centers. The primary outcome variables were proportion of patients with suspected stroke rerouted by EMS, proportion of rerouted ischemic stroke patients receiving MT, time to treatment, and whether the IVT window was missed. Results: A total of 303 patients were rerouted out of 2459 suspected stroke patients over a period of 6 months. Of diverted patients, 47% had acute ischemic stroke. Of these, 48% received an acute stroke treatment: 16.8% IVT, 17.5% MT, and 14% MT+IVT. Thrombectomy occurred 119 min earlier in diverted patients compared to patients transferred from other hospitals (P = 0.006). 55.3% of diverted patients undergoing MT and 38.2% of patients transferred from hospital to hospital were independent at 90 days (modified Rankin score 0-2) (P = 0.148). No patient missed the time window for IVT due to the extra travel time. Conclusions: In this retrospective analysis of prospectively acquired data, implementation of a pre-hospital clinical screening score to detect patients with suspected acute ischemic stroke due to large vessel occlusion was feasible. Rerouting patients directly to a Thrombectomy Center, based on the EMS algorithm, led to a shorter time to thrombectomy.

Safety Trial of Low-Intensity Monitoring After Thrombolysis: Optimal Post Tpa-Iv Monitoring in Ischemic STroke (OPTIMIST).

BACKGROUND AND PURPOSE: At present, stroke patients receiving intravenous thrombolysis (IVT) undergo monitoring of their neurological status and vital signs every 15 minutes for the first 2 hours, every 30 minutes for the next 6 hours, and every hour thereafter up to 24 hours post-IVT. The present study sought to prospectively evaluate whether post-IVT stroke patients with low risk for complications may safely be cared for utilizing a novel low-intensity monitoring protocol. METHODS: In this pragmatic, prospective, single-center, open-label, single-arm safety study, we enrolled 35 post-IVT stroke patients. Adult patients were eligible if their NIH Stroke Scale (NIHSS) was less than 10 at the time of presentation, and if they had no critical care needs by the end of the IVT infusion. Patients underwent a low-intensity monitoring protocol during the first 24 hours after IVT. The primary outcome was need for a critical care intervention in the first 24 hours after IVT. RESULTS: The median age was 54 years (range: 32-79), and the median pre-IVT NIHSS was 3 (interquartile range [IQR]: 1-6). None of the 35 patients required transfer to the intensive care unit or a critical care intervention in the first 24 hours after IVT. The median NIHSS at 24 hours after IVT was 1 (IQR: 0-3). Four (11.4%) patients were stroke mimics, and the vast majority was discharged to home (82.9%). At 90 days, the median NIHSS was 0 (IQR: 0-1), and the median modified Rankin Scale was 0 (range: 0-6). CONCLUSION: Post-IVT stroke patients may be safely monitored in the setting of a low-intensity protocol.

The role of whirlpool in wound care.

Evidenced-based-wound management continues to be a cornerstone for advancing patient care. The purpose of this article is to review the use of whirlpool as a wound treatment in light of evidence, outcomes, and potential harm. Whirlpool was initially harnessed as a means to impart biophysical energy to a wound or burn to enhance mechanical debridement and cleansing. Other credible single-patient-use technologies which provide an alternative to whirlpool in wound care are presented.