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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Implementation of a clinical pathway based on a computerized physician order entry system for ischemic stroke
Jong Min Yang1, Yoo Seok Park1, Sung Phil Chung1
1Department of Emergency Medicine, Yonsei University College of Medicine, Seoul 135-720, Republic of Korea.
Insights
An organized clinical pathway for ischemic stroke effectively reduces evaluation and treatment times in the emergency department, regardless of arrival time. This approach mitigates disparities and improves outcomes for stroke patients.
Area of Science:
- Neurology
- Emergency Medicine
- Health Services Research
Background:
- Weekend and off-hours hospital admissions are linked to worse outcomes and higher mortality in acute stroke patients.
- Disparities in emergency care exist based on time of arrival, impacting stroke patient prognosis.
- Organized clinical pathways aim to standardize care and improve efficiency in acute conditions.
Purpose of the Study:
- To evaluate if an organized clinical pathway (CP) for ischemic stroke can reduce emergency department (ED) evaluation and treatment times.
- To determine if this CP improves patient outcomes irrespective of ED arrival time (weekdays, weekends, off-hours).
Main Methods:
- Retrospective analysis of a prospective registry database from the Brain Salvage through Emergency Stroke Therapy program.
- Patients were categorized into four groups based on ED arrival time: weekday normal hours, weekday off-hours, weekend normal hours, and weekend off-hours.
- Outcomes assessed included 30-day mortality, in-hospital mortality, and modified Rankin score, utilizing a computerized physician order entry (CPOE) system.
Main Results:
- No significant differences in time intervals for intravenous tissue plasminogen activator (IV-tPA) administration were observed across the four patient groups.
- The use of IV-tPA was not significantly affected by weekend or off-hour arrivals.
- Overall mortality was 3.9%, median length of stay was 7 days, and 30-day survival probabilities did not differ significantly among groups.
Conclusions:
- An organized clinical pathway, supported by CPOE, effectively reduces time disparities for ischemic stroke evaluation and treatment in the ED.
- This standardized pathway can mitigate the negative impact of off-hour and weekend arrivals on stroke patient outcomes.
- Implementation of such pathways is crucial for equitable and timely acute stroke care.
Background:
Admission on weekends and off-hours has been associated with poor outcomes and mortality from acute stroke. The purpose of this study was to investigate whether an organized clinical pathway (CP) for ischemic stroke can effectively reduce the time from arrival to evaluation and treatment in the emergency department (ED) and improve outcomes, regardless of the time from arrival in the ED.
Methods:
We conducted a retrospective analysis of all consecutive patients included in the prospective registry database in the Brain Salvage through Emergency Stroke Therapy program, which uses the computerized physician order entry (CPOE) system. Patients were classified based on their time of arrival in the ED: group 1, normal working hours on weekdays; group 2, off-hours on weekdays; group 3, normal working hours on weekends; and group 4, off-hours on weekends. Clinical outcomes were categorized according to 30 days in-hospital mortality, in-hospital mortality, and the modified Rankin score during a single length of stay (LOS).
Results:
No time intervals differed significantly among the 4 patient groups who received intravenous administration of tissue plasminogen activator (IV-tPA). Use of IV-tPA (P = .5110) was not affected by arrival in the ED on off-days or weekends. The overall mortality rate was 3.9%, and the median LOS was 7 days (Interquartile range (IQR), 5-10). By Kaplan-Meier analysis, the cumulative probability of mortality and survival did not differ significantly among the 4 groups over 30 days (P = .1557).
Conclusion:
An organized CP, based on CPOE, for ischemic stroke can effectively attenuate disparities in the time interval between ED arrival to evaluation and treatment regardless of ED arrival time. This pathway may also help to eliminate off-hour and weekend effects on outcomes from ischemic stroke.
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