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Published on: January 18, 2018
Striving toward quality metrics for pediatric stroke: time from door to diagnosis
Rachel Pearson1,2, Nancy K Hills3, Kellie Bacon1
1Rady Children's Health, Orange County, Orange, CA, United States.
Insights
Pediatric stroke diagnosis is delayed by infrequent recognition and slow MRI scans. Improving prehospital awareness and imaging protocols is crucial for better outcomes in children with stroke.
Area of Science:
- Neurology
- Pediatric Medicine
- Emergency Medicine
Background:
- Pediatric stroke survivors often face long-term impairments.
- Rapid restoration of blood flow to brain tissue is vital to minimize injury.
- Timely stroke diagnosis requires prompt recognition by healthcare professionals and swift neuroimaging.
Purpose of the Study:
- To evaluate neuroimaging practices and diagnostic delays in pediatric patients with acute neurological symptoms.
- To identify predictors of Magnetic Resonance Imaging (MRI) acquisition and actionable findings, including stroke.
- To assess the generalizability of findings by analyzing a secondary cohort of pediatric stroke patients.
Main Methods:
- Retrospective study of children aged 1-14 years presenting with acute neurological symptoms via Emergency Medical Services (EMS).
- Analysis of patient characteristics, neuroimaging studies (CT and MRI), and time intervals from presentation to diagnosis.
- Inclusion of a secondary cohort of pediatric stroke patients admitted through various modalities (EMS, ED walk-in, transfer).
Main Results:
- Out of 3,888 pediatric patients with neurological symptoms, only 17.9% received neuroimaging.
- Median time from EMS activation to CT was 2.29 hours, and to MRI was 26.8 hours.
- An EMS "stroke" impression was rare but strongly predicted imaging acquisition; 9 acute strokes were identified among patients with MRI.
Conclusions:
- CT was the predominant imaging modality, with significant delays for MRI in pediatric patients.
- Prehospital providers rarely suspected stroke, highlighting a need for increased awareness.
- Developing pediatric-specific quality metrics, such as "door to diagnosis" time, is recommended for quality improvement.
Background/Objective:
Most pediatric stroke survivors suffer long-term impairments. To minimize injury, it is essential to quickly restore perfusion to viable brain tissue. Minimizing the time to stroke diagnosis requires recognition of a possible stroke by prehospital and emergency healthcare personnel, and rapid neuroimaging. While CT suffices for diagnosing hemorrhagic stroke, MRI is necessary to diagnose acute ischemic stroke (IS), contributing to significant diagnostic delays and potentially missed opportunities for intervention.
Methods:
We conducted a retrospective study of children 1-14 years old with acute neurological symptoms presenting by Emergency Medical Services (EMS) to the study institution from 1/2019-6/2023. We described patient characteristics and neuroimaging studies, then evaluated predictors of MRI acquisition and actionable findings, including stroke. To assess the generalizability of these data we analyzed a secondary retrospective cohort of all children admitted during this period with out-of-hospital strokes regardless of presentation modality [EMS, emergency department (ED) walk-in, and transfer].
Results:
Among 3,888 pediatric patients with acute neurological symptoms presenting via EMS, 695 (17.9%) had neuroimaging: CT only in 570 patients (14.7%); CT and MRI in 125 (3.2%). Median (IQR) times from EMS activation to neuroimaging were 2.29 (1.56, 3.21) hours for CT and 26.8 (16.3, 43.8) hours for MRI. An EMS primary impression of "stroke" was rare (n = 13) but strongly predictive of imaging acquisition: all had CT and 11 had MRI. Thirty-one of the 125 patients with MRI had actionable MRIs, including nine acute strokes. During the study period another 14 stroke patients presented as ED walk-ins. Median time from ED arrival to CT was 0.92 (0.47, 1.08) hours for EMS patients with hemorrhagic stroke and 5.69 (1.50, 9.76) hours for walk-ins; for MRI, median time was 4.15 (3.00, 5.31) hours for EMS patients with ischemic stroke and 10.2 (1.99, 36.3) hours for walk-ins.
Conclusion:
Among children with acute neurological symptoms selected for neuroimaging, CT was the most common modality while MRIs were performed with a substantial time delay. While EMS providers rarely suspected stroke, their diagnosis impacted imaging decisions in the ED, suggesting a need to raise awareness among prehospital providers. To measure quality improvement in pediatric stroke, new pediatric-specific metrics like "door to diagnosis" time, should be further explored.
