ACT-FAST: a quality improvement project to increase the percentage of acute stroke patients receiving intravenous thrombolysis within 60 minutes of arrival at the emergency department.

INTRODUCTION: Stroke is a leading cause of death and disability, with the administration of recombinant transcriptase-plasminogen activator (rtPA) improving outcomes in a time-dependent manner. Only 52.3% of eligible stroke patients at our institution received rtPA within 60 minutes of arrival. We aimed to improve the percentage of acute stroke patients receiving rtPA within 60 minutes of arrival at the emergency department (ED). METHODS: This study presents results from the first year of a clinical practice improvement project that implemented quality improvement interventions. The primary outcome measure was percentage of acute ischaemic stroke patients receiving rtPA within 60 minutes of arrival at the ED. Secondary outcome measures included components of total door-to-needle (DTN) time and factors for delay to thrombolysis. Interventions were establishment of standardised acute stroke activation guidelines, screening question at ED registration, prehospital notification of stroke activation, public education, scripting for thrombolysis consent and easy access to equipment. RESULTS: The percentage of patients thrombolysed within 60 minutes increased to 60.6% (p = 0.27), and DTN time decreased from 59 minutes to 54.5 minutes (p = 0.15). This was attributable to reduced door-to-physician time, door-to-imaging time and decision time, although the results were not significant. There was no significant increase in symptomatic intracranial haemorrhage or mortality secondary to stroke. Length of stay was significantly reduced by 1.5 days (p < 0.048). CONCLUSION: The interventions resulted in an increasing but non-significant trend of acute stroke patients receiving thrombolysis within 60 minutes. Outcomes will be monitored for a longer duration to demonstrate trends and sustainability.

Who survives cardiac arrest in the intensive care units?

OBJECTIVE: The aim of this study was to evaluate the factors related to outcome regarding in-intensive care unit (ICU) cardiac arrest (IICA) in a university hospital. PATIENTS AND METHODS: Adult nontraumatic ICU patients who sustained IICA were prospectively enrolled. Several patient and event-related variables, as well as outcomes, were recorded and summarized based on the revised Utstein-style template. RESULTS: A total of 202 episodes of IICA happened during the study period. Return of spontaneous circulation (ROSC) was achieved in 127 patients (62.9%), whereas the overall survival-to-discharge rate was 15.3% (31 patients). In univariate analysis, a shorter duration of resuscitation and pulseless ventricular tachycardia/ventricular fibrillation (VT/VF) as initial arrest rhythm represented better outcomes. Independent predictors of survival to hospital discharge were VT/VF as the initial rhythm (odds ratio [OR], 3.81; 95% confidence interval [CI], 1.50-9.67; P = .005), lower Acute Physiology and Chronic Health Evaluation II score (OR 0.92, 95% CI 0.87-0.98, P = .008), and shorter resuscitation durations (OR 0.91, 95% CI 0.87-0.96, P < .001). CONCLUSION: Shorter resuscitation duration and initial VT/VF are predictors for both ROSC and hospital survival, whereas lower Acute Physiology and Chronic Health Evaluation II scores predict the latter.