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Background: This study aimed to identify which emergency department (ED) factors impact door-to-needle (DTN) time in acute stroke patients eligible for intravenous thrombolysis. The purpose of analyzing emergency department factors is to determine whether any modifiable factors could shorten the time to thrombolytics, thereby increasing the odds of improved clinical outcomes. Methods: This was a prospective observational quality registry study that included all patients that received alteplase for stroke. These data are our hospital data from the national Get With The Guidelines Registry. The Get With The Guidelines® Stroke Registry is a hospital-based program focused on improving care for patients diagnosed with a stroke. The program has over five million patients, and hospitals can access their own program data. The registry promotes the use of and adherence to scientific treatment guidelines to improve patient outcomes. The time of patient arrival to the ED was captured via the timestamp in the electronic health record. Arriving between Friday 6 p.m. and Monday 6 a.m. was classified as "weekend," regardless of the time of arrival. Time to CT, time-to-lab, and presence of a dedicated stroke team were also recorded. Emergency medical services (EMS) run sheets were used to verify arrival via ambulance. Results: Forty-nine percent of the cohort presented during the day shift, 24% during the night shift, and 27% on the weekend. A total of 85% were brought by EMS, and 15% of patients were walk-ins. The median DTN time during the day shift was 37 min (IQR 26-51, range 10-117). The median DTN time during the night shift was 59 min (IQR 39-89, range 34-195). When a dedicated stroke team was present, the median DTN time was 36 min, compared to 51 min when they were not present. The median door-to-CT time was 24 min (IQR 18-31 min). On univariate analyses, arriving during the night shift (P < 0.0001), arriving as a walk-in (P = 0.0080), and longer time-to-CT (P < 0.0001) were all associated with longer DTN time. Conversely, the presence of a dedicated stroke team was associated with a significantly shorter DTN time (P < 0.0001). Conclusion: Factors that contribute most to a delay in DTN time include arrival during the night shift, lack of a dedicated stroke team, longer time-to-CT read, and arrival as a walk-in. All of these are addressable factors from an operational standpoint and should be considered when performing quality improvement of hospital protocols.
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OBJECTIVES: To create an interactive mass casualty incident (MCI) curriculum for emergency medicine residents and to integrate them into the hospital disaster response, thereby creating a "trainee-specific emergency preparedness plan." METHODS: We created an interactive MCI curriculum and "trainee-specific emergency preparedness plan" for emergency medicine residents. The curriculum consisted of lectures, a small focus group, a triage activity, and the designation of a resident disaster champion to collaborate with hospital leadership to implement a "trainee-specific emergency preparedness plan" for the upcoming hospital disaster drill. RESULTS: Residents gave positive feedback on the new curriculum and retained information from the education. All resident teams accurately triaged at least 78% of the disaster scenarios. The residents also created a "trainee-specific emergency preparedness plan" for the upcoming hospital disaster drill, utilizing principles they learned from their MCI lessons. By allowing the residents to have an active role in the design and implementation of the new resident integrated disaster management plan, there was a general consensus of increased interest and retention of what was learned, as well as an increased comfort level in participating in MCI scenarios. Residents did not feel cursory to the planning; they became a part of the planning and felt more involved. Through this exercise, residents were able to give feedback to the hospital leadership that further shaped the disaster response plan. We also found that integration of the emergency medicine residents into the hospital response doubled the amount of active physicians available. CONCLUSION: An interactive-based MCI curriculum is more engaging and may foster more retention than the traditional lecture approach. Resident involvement in the hospital disaster response is paramount as more hospitals are becoming teaching hospitals and mass casualty incidents are inevitable.
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The authors present a case of tension pneumocephalus that occurred secondary to closed head injury and review the etiology and management of this relatively rare entity. This case was managed without invasive neurosurgical intervention, also somewhat rare for this condition.
