01 Dec Dedicated Neuro Emergency Department Improves Stroke Outcomes
Medical Research: What is the background for this study?
Dr. Greenberg: Capital Health Regional Medical Center in Trenton, NJ opened the first dedicated Neurologic Emergency Department in the country in January of 2011. Dr. Veznedaroglu, our chief neurosurgeon, recognized the importance and emergent nature of patients with neurologic complaints. He recruited dedicated Emergency Medicine Physicians, one of which is myself, who would be assigned to see patients with neurologic complaints during peak hours of 7a-6p daily seven days a week. Having a section of the ED dedicated to identifying, triaging, and treating patients with neurologic emergencies has led to more advanced and efficient care. Due to the initial success of the neuro ED, 5 dedicated physicians became educated and comfortable in administering IV-tPA to acute ischemic stroke patients. This decision was made to eliminate delays associated with teleneurology or neurology consultation prior to administering thrombolytics in order to improve door-to-needle times and outcomes in acute stroke patients. As far as we know, we are still the only dedicated Neuro ED in the country.
Medical Research: What are the main findings?
Dr. Greenberg: From 2012-2014, 67 acute stroke patients received IV tpa in either our Neuro ED which is run from 7a-6p, or the main ED from 6p-7a. 35 patients were evaluated in the Neuro ED and 32 in the main ED. Average door-to-needle times (DTN) were significantly faster in the neurologic ED at 35 minutes, compared to main ED DTN times of 83 minutes. Discharge NIHSS score was significantly lower and more patients were discharged to home in the Neurologic ED group compared to the main ED group. There were no cases of symptomatic intracranial hemorrhage in either group.
Medical Research: What should clinicians and patients take away from your report?
Dr. Greenberg: Many emergency medicine physicians and patients recognize airway and circulation problems as true emergencies, but there is still a lack of urgency when it comes to recognizing and treating acute stroke symptoms. For every minute that treatment is delayed in a typical large vessel stroke, nearly 2 million neurons die. Therefore, rapid treatment is a critical factor in the outcomes of patients with acute stroke who are treated with IV-tPA. Physicians and patients alike need to respond quickly: Patients by getting themselves to an emergency department as quickly as possible, and ED physicians by having an extreme sense of urgency to consider treatment with IV-tPA and then administer rapidly.
The current guidelines of the American Heart Association/American Stroke Association (AHA/ASA) recommend the delivery of thrombolytic therapy within 60 minutes of hospital arrival,. However, less than 30% of patients treated with IV tPA have a DTN of the recommended less than 60 minutes here in the United States. With the unique, independent ability of the Neuro ED physicians to adminster IV-tPA without specialty consultation, DTN averaged 35 minutes, well below the recommended delivery time of 60 minutes.
It is well known that ultra-early thrombolysis has been shown to cut long term disability in mild to moderate stroke. Our study is again unique in that we demonstrate a short term benefit as well:
-If treated in the Neuro ED, average discharge NIHSS score was 2, compared to discharge NIHSS of 6 for the Main ED.
-In addition, more patients were able to be discharged to home, rather than subacute rehabilitation or extended care facility, when treated by the Neuro ED compared to the Main ED.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Greenberg: Our recent publication is a retrospective study. We hope to next continue our study in a prospective manner that can continue to show improved short term outcomes, but also evaluate patients’ long term outcome at 90 days along the lines of the NINDs trial.
Karen Greenberg, Christina R. Maxwell, Keisha D. Moore, Michael D’Ambrosio, Kenneth Liebman, Erol Veznedaroglu, Geri Sanfillippo MSN, Cynthia Diaz, Mandy J. Binning
Publication stage: In Press Accepted Manuscript Published online: November 28, 2014