ED crowding tied to potentially fatal delays in stroke care

(Reuters Health) - - Stroke patients may wait longer to get scans needed for treatment when they arrive at an overcrowded emergency department, putting them at increased risk for death or serious disability, a recent study suggests.

Researchers focused on how often patients had a so-called “door-to-imaging” time of 25 minutes or less. Only patients who get brain scans quickly can receive an intravenous therapy known as thrombolysis to dissolve clots and potentially avert severe damage to the brain.

“Timely treatment of certain acute stroke cases is crucial,” said lead study author Dr. Martin Reznek, of the University of Massachusetts School of Medicine and UMassMemorial Health System in Worcester.

“Emergency department crowding can be dangerous,” Reznek added by email.

Globally, 15 million people suffer strokes each year; 5 million of them die and another 5 million are left permanently disabled, according to the World Health Organization. Initial symptoms can include drooping or numbness on one side of the face, lack of feeling or mobility in one arm and slurred or impaired speech.

Within three hours of stroke symptoms starting, patients may be able to receive thrombolysis if they haven’t recently had a heart attack, stroke or head trauma and don’t have other medical complications that could make this treatment unsafe. Some patients under 80 may be able to receive the treatment within 4.5 hours.

While spotting symptoms quickly and getting to the hospital as fast as possible make a big difference in whether patients can get this treatment, door-to-imaging time is also a crucial piece of this puzzle.

For the current study, researchers examined data on 463 patients who received treatment for acute stroke in the emergency department during a one-year period.

Door-to-imaging time ranged from 4 minutes to 3 hours and 41 minutes.

Half of the patients got brain scans within 21 minutes, however, and about 61 percent received imaging within the 25-minute goal, researchers report in the journal Stroke.

Every 10 percent absolute increase in emergency department occupancy rate was associated with a 17 percent reduction in the odds of achieving the 25-minute door-to-imaging goal, researchers calculated.

One limitation of the study is that the small number of patients who received thrombolysis made it impossible to draw statistically meaningful conclusions about the factors that influence which patients get treatment, the authors note.

Even so, the findings add to a growing body of evidence suggesting that emergency department wait times can have a profound impact on stroke outcomes, said Dr. Henry Wang, a researcher at the University of Alabama at Birmingham who wasn’t involved in the study.

“It is crucial that Emergency Departments have efficient overall operations so that they can quickly identify and evaluate potential stroke patients,” Wang said by email.

Doctors can only tell whether patients are candidates for thrombolysis after brain scans to assess the type and severity of the stroke, noted Dr. Daniel Lackland of the Medical University of South Carolina in Charleston.

“The swift diagnosis is essential to implement the time-sensitive therapies and treatment,” Lackland, who wasn’t involved in the study, said by email.

While the responsibility for fixing this lies mainly with hospitals, patients and families can still take steps to ensure faster diagnosis and treatment, said Emily O’Brien, a researcher at Duke University in Durham, North Carolina, who wasn’t involved in the study.

“Calling 911 immediately can save a life,” O’Brien said by email. “Arriving by EMS instead of a private vehicle is associated with shorter in-hospital delays.”

First responders can also boost stroke patients’ survival odds and outcomes by considering emergency department crowding when they decide where to take patients for care, said Dr. Roland Faigle of Johns Hopkins University School of Medicine in Baltimore.

“EMS typically identifies the most appropriate hospital for any given stroke patient based on a number of factors, including proximity, stroke-specific factors, and hospital characteristics,” Faigle said by email.

“Factoring ED occupancy rate into the decision-making process may become a more important part of the process that determines which hospital a given stroke patient is brought to,” Faigle added.

SOURCE: Stroke, online November 17, 2016.