Impact of Emergency Department Transitions of Care on Thrombolytic Use in Acute Ischemic Stroke
Background and Purpose—In-hospital mortality is higher for certain medical conditions based on the time of presentation to the emergency department. The primary goal of this study was to determine whether patients with acute ischemic stroke who arrived to the emergency department during a nursing shift change had similar rates of thrombolytic use and functional outcomes compared with patients presenting during nonshift change hours.
Methods—A retrospective review of patients with acute ischemic stroke presenting to the emergency department of a primary stroke center from 2005 through 2010. The time to notify the stroke team, perform a head CT scan, and to start intravenous or intra-arterial thrombolysis was assessed. Thrombolysis rates, mortality rate, discharge disposition, change in the National Institutes of Health Stroke Scale, and change in modified Barthel Index at 3 and 12 months were assessed.
Results—Of 3133 patients with acute ischemic stroke, 917 met criteria for inclusion. Arrival during nursing shift change, weekends, and July through September had no impact on process times, thrombolysis rates, and functional outcomes. Arrival at night did result in longer time to intra-arterial but not to intravenous thrombolysis, higher mortality rate, and smaller gain in functional status as measured by the modified Barthel Index at 3 months. The degree of emergency department “busyness” also did not influence tissue-type plasminogen activator treatment times.
Conclusions—Presentation during a nursing shift change, a time of transition of care, did not delay thrombolytic use in eligible patients with acute ischemic stroke. Presentation with acute ischemic stroke at night did result in delays of care for patients undergoing interventional therapies.
Each year approximately 795 000 Americans have a new or recurrent stroke; >137 000 die as a result.1 There was no approved effective medical therapy for acute ischemic stroke (AIS) until 1995 when the National Institute of Neurological Disorders and Stroke published evidence showing at least a 30% greater chance of having minimal or no disability at 3 months after the use of intravenous (IV) tissue-type plasminogen activator (tPA).2 Originally tPA was approved only for use within 3 hours from the onset of symptoms but after results of the European Cooperative Acute Stroke Study III in 2008, the opportunity to treat has been extended to 4.5 hours in many centers given improved clinical outcome without increased mortality from intracerebral hemorrhage.3 Despite this longer therapeutic window, it is imperative that patients receive tPA as early as possible after symptom onset, because it is almost twice as effective when administered within 90 minutes compared with 90 to 180 minutes.4
Use of IV tPA remains low; the most likely exclusion criterion is delayed patient presentation.3,5 This is the case when time of symptom onset is unknown such as when the patient awakens with symptoms or if the patient fails to recognize symptoms in a timely manner. Therefore, short of increasing public awareness of early symptoms, there are few options for improving the time lag to emergency department (ED) arrival. However, once the patient has arrived in the ED, there is greater control over the door-to-needle time of tPA infusion.
Recently, results of the Get With the Guidelines stroke national data set looking at door-to-needle time for patients arriving within 1 hour of symptom onset showed that door-to-needle was surprisingly slower for patients arriving earlier after ictus.6 The authors proposed that for patients arriving well within the 3- to 4.5-hour therapeutic window, there may have been a tendency for clinicians to use “allowed” time for a more complete examination, more detailed review of imaging and tests, and discussion of risks and benefits with the patient, resulting in a longer door-to-needle time.6 Because door-to-needle is crucial for the preservation of brain tissue, it is important to investigate other modifiable risk factors for delayed treatment.
It has been previously demonstrated that in-hospital mortality is higher on the weekend, especially for critical medical and surgical illnesses such as ruptured abdominal aortic aneurysm and pulmonary embolism.7 Subsequent research has shown this to be true for ischemic stroke as well; a 14% increase in mortality was seen in patients admitted on a weekend compared with admission during the week.8 There are less data on whether such a disparity exists for patients with stroke admitted during the night hours versus daytime with only 1 study showing no difference in the management of ischemic stroke at night compared with during the day.9 Along those lines, there is no previous research examining the effect of specific time of day, namely the 2 or 3 shift changes standard in most EDs, on AIS management. Because patients are most vulnerable to delays in care during transition periods, and AIS treatment has such a narrow treatment “window,” investigation of whether treatment times or complication rates vary during shift change is critical.
The aim of this study was to determine whether the arrival of a patient with AIS to the ED during a time when staff is occupied not only by patient care, but by relaying information to other staff such as the shift change, has an effect on patient care and outcome including: time from arrival to notify the stroke team, perform a head CT scan, and start thrombolysis if indicated; the treatment rate for IV and intra-arterial (IA) tPA; and patient mortality, discharge disposition, change in National Institutes of Health Stroke Scale (NIHSS), and modified Barthel Index (BI) at 3 and 12 months after stroke.
Materials and Methods
This was a retrospective, single-center database analysis of all patients with AIS who presented to the ED within 8 hours of symptom onset during a 5-year period from January 2005 through November 2010.
The study site was a Primary Stroke Center approved by the Joint Commission since 2004 with an annual ED census of >90 000 visits. The study was approved by the hospital's Institutional Review Board.
Selection of Participants
Database entries of patients aged ≥18 years were included if they had clinical signs and symptoms consistent with AIS with onset of symptoms <8 hours (the eligibility criteria for IA intervention) before ED arrival. By choosing 8 hours as an inclusion criterion, we aimed to capture all possible patients for IA or other mechanical reperfusion therapies that may have presented within a timeframe feasible for treatment but due to their presentation during shift change were no longer eligible for treatment.
Entries of patients who were not evaluated in the ED such as direct admissions or inpatients at the time of stroke were excluded. Entries of patients transferred from outside hospitals were excluded. Entries other than AIS and those whose deficits resolved before ED arrival were excluded. Entries with unknown time of symptom onset, unknown NIHSS at admission, or those for which we were unable to confirm key data points were also excluded.
Time of symptom onset was defined as the time when the patient or witness first became aware of neurological deficits. ED arrival referred to the time at which the patient was seen in triage.
Patients considered “total eligible” for IV tPA were those aged ≥18 years with a clinical diagnosis of ischemic stroke causing measurable neurological deficit, diagnosis made by a physician with expertise in diagnosis of acute stroke and the use of the NIHSS, noncontrast head CT scan assessed by a physician with stroke imaging expertise, and symptom onset <4.5 hours before arrival. This cohort was further evaluated to determine the cause of ineligibility, resulting in a subset of patients who had no contraindications to tPA use for a cohort of patients “eligible” for tPA.
All patients eligible for IA tPA had symptom onset <8 hours before arrival, NIHSS >8, and documented large vessel occlusion on CT angiogram. Patients presenting within the IV tPA window (<4.5 hours) received IA tPA if contraindications to systemic tPA were present. Those patients with involvement of greater than one third of the middle cerebral artery territory, head CT scan demonstrating hemorrhage, tumor, abscess, or metastasis, serious illness and/or life expectancy <1 year, significant baseline disability that obviates benefit of tPA, symptoms suggestive of subarachnoid hemorrhage, unknown time of symptom onset, and family refusal were considered ineligible for both IV and IA tPA. We report tPA treatment rate as the percentage of eligible patients who actually received tPA. This was to ensure that we could distinguish patients who were not given thrombolytic therapy due to presentation during shift change from those who were already ineligible due to relative contraindications (ie, resolving symptoms, minor deficits, etc).
Methods of Measurement
Every patient with AIS was assessed with the NIHSS immediately after arrival to the ED by a neurology resident and an emergency medicine resident. The head CT was read emergently by a radiology resident (in the ED) and an attending radiologist available 24 hours a day. The final decision on reperfusion therapy is made by the neurology attending in cooperation with the neurology resident and ED attending. The attending neurologist determined if the patient is a candidate for interventional therapy (based on deficits and CT angiographic findings). Historical information was gathered at admission to calculate the prestroke modified BI. Scoring ranges from 0 to 20 with 20 as the maximum score. With a score <4 one would be considered totally dependent on caregivers; those with a score >12 are generally considered physically independent. Poststroke modified BI was obtained by telephone interview with the patient or the patient's family conducted by a trained nurse at 3 and 12 months after stroke.
Data Collection and Processing
The study involved statistical analysis of existing data, which was collected prospectively and in a standardized manner by a trained registered nurse. Data were obtained from ED documents, admission notes, laboratory and radiological reports, and discharge summaries and entered into a Microsoft Access 2003 (Microsoft, Redmond, WA) database.
Specific variables were extracted from an access database and imported into SPSS Version 14 software for analysis (SPSS, Inc, an IBM Co, Somers, NY). Parameters collected included age, sex, medications before admission, prestroke modified BI, last seen well time, NIHSS at presentation, and time and date of ED arrival.
Using time and date of arrival, stroke entries then were stratified into epochs that classified the patient's presentation time. The independent variables used were ED arrival during a nursing shift change compared with within a shift, arrival at night compared with during the day, arrival during the weekend compared with weekday, and arrival during the months of July through September, which was postulated to be a higher risk period of the year due to the start of a new intern/residency year, compared with the rest of the year. Most nurses changed shifts at either 7 am or 7 pm with some nurses arriving at 11 am and 11 pm for reinforcement. ED nurses calculated that approximately 30 minutes was required to exchange information during shift change. Therefore, presentation during shift change was defined as arrival 30 minutes before or after a new shift started. This definition was meant to capture the probable earliest and latest exchanges of information without making the window so wide that actual “nonshift change” entries were placed in the shift change group but also ensuring a large enough sample of shift change entries that comparisons could be made between the groups. We included both the 7 am/pm and 11 am/pm shifts in the study, so total time spent in shift change was 4 hours per day. Night arrival was defined as patient arrival between the hours of 7 pm and 7 am. Presentation during the weekend was defined as patient arrival on a Saturday and Sunday. In our institution, ED attending and resident turnover is staggered. There are variable shifts starting at the following times: 7:30 am day shift until 5 pm, 11 am until 8 pm, 1 pm until 9 pm, 5 pm until 1 am, and midnight until 8 am. Only 1 of the transition times for physicians matched to the times when nurses are transitioning (7–8 am). The first responder to an acute stroke page outside of ED staff is the neurology resident. These change over at noon daily, at different times than ED physicians or nursing staff.
Our ED “busyness” score is based on the published National ED Overcrowding Study (NEDOCS).10 It has been shown to be a reliable method of quantifying real-time “busyness.”11 It uses multiple factors including total number of available ED beds (Bt), total number of patients in beds (Pbed), number of admitted patients in the ED waiting to go to a hospital bed (Padmit), total number of hospital beds (Bh), the waiting time for the last patient put into a bed in the ED (Wtime), longest time since registration for patients waiting to go to a hospital bed (Atime), and the number of patients on a ventilator in the ED (Rn). We replaced the final metric with the number of patients currently in our acute care rooms in the ED. The following weighted equation describes how the score is calculated: NEDOCS=Pbed/Bt×85.8+Padmit/Bh×600+Wtime×5.64+Atime×0.93+Rn×13.4 to 20. This modified NEDOCS score was captured at 15-minute intervals, which were logged into a database available for retrospective review to determine how busy the ED was at any given point in time. Data were analyzed for the cohort of patients seen from 2007, when this program was initiated (for 179 of the treated patients).
The outcome measures were classified into 3 broad categories: process times, hospital outcomes, and patient outcomes. Process times included the time intervals required for: notifying the stroke team, performing head CT scan, starting IV tPA, and introducing an IA catheter for thrombolysis. Hospital outcomes were the percentages of eligible patients who received IV or IA tPA. Patient outcomes were classified as discharge disposition and functional outcome. Discharge disposition included either death (during admission or transferred to hospice care) or discharge home with or without rehabilitation services. The remaining patients were discharged to either an acute or subacute rehabilitation facility and in a small percentage of cases to an extended care facility. Functional outcomes used were change in NIHSS (from presentation to discharge) for patients discharged alive and, for those discharged alive, 2 measures of change in modified BI at 3 and 12 months—loss of function from prestroke levels and gain in function between admit and follow-up. The BI is a well-validated measure of stroke outcome and disability. However, because of the increasing use of the modified Rankin Scale, we (as of September 2010) collect both these measures. Because this was not initiated until 2010, the change in NIHSS and BI was used as an outcome measure in this study.
Primary Data Analysis
Data were analyzed using SPSS Version 14 software (SPSS, Inc).
Descriptive statistics were performed on patient demographics before univariate analysis. Univariate analysis was performed for each independent variable on each outcome variable. Chi-square test of proportions was used for thrombolysis rates and discharge dispositions; Wilcoxon ranked sum for changes in NIHSS and modified BI. Changes in NIHSS scores were also categorized as “improved,” “unchanged,” or “worse” and subsequently analyzed by χ2 tests of proportions or characterized as an ordinal score and analyzed by the Wilcoxon rank sum test between the groups. ED busyness and time to tPA treatment were analyzed with Pearson correlation coefficients. Multivariate logistic regressions for receipt of IV tPA and IA with age, gender, and NIHSS on admit as covariates was assessed against the 4 timing independent variables. Multivariate analysis was also performed for the 2 mortality (died in the hospital and death or hospice) variables, allowing any differences in stroke severity to be controlled.
Characteristics of the Study Subjects
Of 3133 AISs treated at the Stroke Center, a total of 917 were eligible for this study by time of presentation (see the Figure). We included only those patients who could have received either IV or IA tPA by virtue of presenting within 8 hours. Anyone presenting outside of 8 hours is ineligible for treatment at our center. Two hundred seventy-five of 917 received IV tPA (30%), but after excluding all patients who were ineligible for factors other than time of presentation (low NIHSS, improving deficits, etc), only 286 were eligible for thrombolytic treatment. Table 1 shows the demographics of the study population. Among the study population, 17.3% patients presented to the ED during a shift change, 30.1% at night, 26.3% during the weekend, and 28.1% during the months of July through September. There were no significant differences in baseline characteristics across study groups (ie, age, NIHSS, sex, antiplatelet or anticoagulant use) with the exception that there were significantly more patients who presented from home during the night compared with the day and these patients were also more likely to present on weekends compared with weekdays. Patients taking statins were more likely to present at night versus day, and patients presenting during the weekend had higher mean prestroke modified BI, but these were not considered to be clinically meaningful differences (Table 1). There was no affect of gender on tPA use. Both admission NIHSS and increasing age were significant predictors of poor outcome but did effect the lack of effect of the other variables (shift change, weekend, night or July to September) in multivariate analysis.
There was no difference in the length of time from arrival to notify the stroke team, perform a head CT scan, and initiate IV tPA when patients arrived during a shift change (Table 2). It did take longer to initiate IA tPA but this difference was not significant (median time 158.5 versus 184 minutes, P=0.812).
There was no difference in the IV tPA treatment rate for patients with AIS presenting during a shift change (96.2% outside a shift change versus 96.1% during a shift change, P=0.975). A higher percentage of strokes eligible for IA tPA were treated if patients presented outside of a shift change, but again the difference was not statistically significant (16.1% versus 8.5%, P=0.132). Shift change was not a significant predictor of IV tPA or IA treatment in the multivariate analysis.
There was no difference in mortality rate for patients presenting during a shift change (24.5% outside of a shift change versus 25.8% during a shift change, P=0.769). For patients discharged alive, a higher percentage went directly home when they presented during a shift change; however, this difference was not significant (42.4% versus 57.4%, P=0.130). There were no significant differences in functional outcome, change in admission to discharge NIHSS, or gain in the modified BI at 3 and 12 months in patients presenting during a shift change (Table 2).
When patients presented to the ED with acute stroke symptoms at night, the stroke team was notified 2 minutes earlier than during the day and in both cases the team was paged before patient arrival (median time −1 minute during the day versus −3 minutes at night, P=0.029, because stroke alerts often arrive by ambulance with prenotification; Table 3). It did take slightly longer to perform a head CT scan and start IV tPA at night, but these differences were not statistically significant (median head CT time 26 minutes during the day versus 28 minutes at night, P=0.547; median IV tPA time 61.5 minutes during the day versus 69 minutes at night, P=0.054). However, it did take significantly longer to initiate IA tPA when patients presented at night (median 147 minutes versus 214.3 minutes, P<0.001).
The rates of IV and IA tPA administration were the same regardless of day or night presentation (IV rate 96.7% at night versus 94.4% during the day, P=0.383; IA rate 15.3% during the day versus 13.7% at night, P=0.716) and no significant findings for day versus night in multivariate analysis.
Patients who presented at night experienced a higher mortality rate (22.6% day versus 29.7% night, P=0.049). However, for patients discharged alive, there were no differences in discharge location (44.8% day patients went home [considered a “good” outcome] versus 46.6% night patients went home, P=0.474). For those discharged alive, there were also no differences in positive or negative changes to the NIHSS. The mean gain in the modified BI at 3 months was significantly lower for patients presenting at night (3.3 day versus 1.9 night, P=0.043). However, no difference in BI was seen between the 2 groups at 12 months (see Table 3).
Presentation during the weekend compared with weekday did not significantly change the time needed to notify the stroke team, perform a head CT scan, and start IV tPA (Table 4). The median time needed to begin IA tPA was >20 minutes longer on the weekend but this apparent trend was not statistically significant (155 minutes weekday versus 176.5 minutes weekend, P=0.051), which may reflect the lower number of IA-treated patients. Treatment rates both with IV and IA tPA were the same on the weekend as during the week (IV rate 95.7% weekday versus 97.4% weekend, P=0.505; IA rate 14.8% versus 14.8%); again, this was confirmed in multivariate analysis. Presentation during the weekend had no impact on mortality rate or discharge destination if the patient was discharged alive (mortality 25.8% weekday versus 22% weekend, P=0.325; discharged home 46.7% weekday versus 42% weekend, P=0.164). There were no differences in functional outcome (change in NIHSS and gain in modified BI) between weekday and weekend patients (see Table 4).
July Through September
All process times were similar when patients presented during the months of July through September compared with the rest of the year (Table 5). It did not take significantly longer to notify the stroke team (−2 minutes October to June versus −1 minute July to September, P=0.641), to perform a head CT scan (26 minutes October to June versus 28 minutes July to September, P=0.354), start IV tPA (63.5 minutes October to June versus 63 minutes July to September, P=0.252), or start IA tPA (158 minutes October to June versus 161 minutes July to September, P=0.655; see Table 5)
Treatment rates with IV and IA tPA were similar regardless of the time of year (IV rate 95.4% October to June versus 98.5% July to September, P=0.252; IA rate 15.2% October to June versus 13.6% July to September, P=0.722) and this did not change in multivariate analysis.
Unexpectedly, mortality rate was significantly lower when patients presented during the months of July through September (27% October to June versus 18.8% July to September, P=0.027). There were no differences in the percentage of patients discharged to home (46.2% October to June versus 42.4% July to September, P=0.385). There were also no differences between groups in functional outcomes at 3 or 12 months. There were no statistical differences between time of presentation and treatment rates in any of these categories using NIHSS as an ordinal variable.
Busyness Scores and Thrombolytic Use
A subset of the original cohort of 917 patients who were seen between 2007 and 2010 was also evaluated for treatment rates based on ED crowding measures. There was no significant correlation between busyness score on arrival and time to tPA administration. This held for all patients treated with reperfusion therapies (n=179, correlation=−0.038) and for those patients receiving only IV tPA (n=156 correlation=−0.001).
To our knowledge, this is the first study to examine the process of AIS management, including IA thrombolysis rates, and patient outcomes according to the time of ED presentation, specifically examining nursing shift change. In this study population, there was no difference in the length of time to notify the stroke team, perform a head CT scan, and start IV tPA when patients arrived with stroke symptoms at a time of day when ED nurses were changing shifts. Although not statistically significant, it is important to note that fewer patients received IA tPA when arrival was during a shift change, and for those who did, it took longer to start. In this study, this finding was likely not clinically relevant because mortality and functional outcome remained unchanged, but there may have been changes in other outcomes that were impossible to measure using the information available in our database such as quality-of-life measures. This will have to be carefully tracked in the future, especially because interventional therapies are increasingly used. The time to initiate IA thrombolysis was significantly longer when patients arrived at night, resulting in an increased mortality rate, and for patients discharged alive, a smaller gain in the modified BI at 3 months, suggesting that treatment time may have long-term functional consequences. These findings conflict a previous study, which found no delay in IA thrombolysis at night, but this was performed in a large Swiss center with very high IA rates and less strict inclusion for IA treatment than used at our center (ie, NIHSS >4 versus 8 in our center).12 Because most US centers do not have immediate access to an interventional neuroradiologist at night and require “calling in” both nurses and the interventional neuroradiologist, it is not surprising that a delay was seen during nighttime hours. Our findings are also consistent with the previous conclusion that the probability of achieving a good clinical outcome decreases with increased time to angiographic reperfusion.13 There was no decrease in the rate or time to initiate IV thrombolysis at night, which reproduces existing findings.9
When arrival on a Saturday or Sunday was compared with arrival on a weekday, we found no differences in process times or rates of thrombolysis, which supports an earlier finding that rates of thrombolysis are unaffected by day of the week.9 Similar to what was seen for shift change, IA thrombolysis was somewhat delayed, but this had no impact on mortality, discharge disposition, and functional outcome after discharge, arguing against 2 previous studies, which showed increased mortality from ischemic stroke on weekends.8,14 This may be explained by the recent finding that patients admitted on weekends to nonstroke-certified hospitals continued to demonstrate increased mortality at 90 days compared with weekday admission, but importantly, this effect was not seen in patients admitted to comprehensive stroke centers,15 consistent with our findings.
These novel findings are important for several reasons. First, we showed that care for patients with AIS is not impacted by the additional responsibilities required by ED nurses during a shift change at a large community-based stroke center. Rapid identification and treatment of patients with stroke occurs even before this potentially vulnerable transition period in most patients through notification by prehospital transport personnel. Second, we have provided additional support to the existing literature that rates of IV thrombolysis are not reduced by off-hour arrivals, specifically nights and weekends. Finally, our data indicate that although care is not delayed for those patients presenting early enough for IV thrombolysis, it is delayed for those who miss the 3- or 4.5-hour window and require IA thrombolysis at least at night and trended in a similar direction at shift change and weekends. This may become more apparent with a larger sample size and these data will have to be carefully tracked. Many patients with stroke are already ineligible for IV thrombolysis due to delayed presentation, and only one third of patients with AIS arrived to the ED within 3 hours.16 Therefore, identification of barriers that slow down care is critical so that IA thrombolysis can be offered more rapidly to more patients. Options such as in-house coverage by interventional neuroradiologists and catheter laboratory nurses during nighttime hours could be considered because current coverage is now only from 8 am to 5 pm. However, this would be expensive to maintain and should probably be limited to large stroke centers with high IA treatment rates.
Although this study provides some reassurance that in a Joint Commission on Accreditation of Healthcare Organizations-certified stroke center, patients are not deleteriously affected by arrival at shift change, 1 recent study did find an increase in risk of infectious complications and poorer outcomes in patients with ischemic stroke “exposed” to a shift change.17 There are several explanations for why our results differed. Our study was considerably larger (n=366 versus 917), likely reducing bias. In addition, most of the increased risk in the former study was secondary to longer ED length of stay, a known risk factor18 for poor outcome. In this study, we specifically examined presentation during a shift change, not simply the physical presence of the patient in the ED during a shift change, on time to thrombolytic use.
This study has several limitations and these results must be interpreted with these in mind. First, this was a retrospective, single-center study, which reduces the generalizability to other hospitals that may have different clinical practice protocols. This center is high volume and has neurology resident coverage. A stroke triage system is in place that alerts the ED, the resident, the pharmacy, and the CT technician when a potential treatment case arrives. This may reduce the burden on the primary nurse to activate acute stroke protocols and may not be the case in smaller institutions. Second, it is important to recognize the possibility of Type II error due to the relatively small sample sizes and unknown potential confounders. However, there are no existing databases that capture the data in time epochs as we were able to do in this study. The only other existing studies on this topic had much smaller sample sizes (ie, 31)19. The lack of a correlation between thrombolytic use and ED crowding is consistent with a recent smaller (n=253) study and also increases confidence in our findings.20 Although this represents the largest sample to date, the finding that approximately twice as many patients eligible for IA lysis were treated outside a shift change compared with during a shift change (16.1% versus 8.5%, P=0.132) and that times were longer to IA lysis (184 versus 159 minutes, P=0.81) during this time is concerning despite the lack of statistical significance. As an increasing number of patients are treated with IA modalities, future studies assessing for delays in care will have to be very carefully monitored. Third, we chose to include all eligible acute strokes available in the Stroke Database from 2005 to 2010. However, in September 2009, there was a change in practice as the hospital approved the extension of the IV thrombolytic window from 3 hours to 4.5 hours in selected patients based on data and exclusion criteria developed in European Cooperative Acute Stroke Study (ECASS) III. We captured all patients presenting with AIS symptoms within 8 hours to ensure that patients eligible for IA thrombolytic were included. Fourth, our study sample consisted of individual strokes, not patients. There were 25 strokes in our sample, which were recurrent strokes from patients already entered in the database from a previous event. This could raise concern that patients with a known history of stroke are treated differently on arrival to the ED or self-identified themselves as a “stroke” patient. We chose to include these repeat strokes because there was no method of controlling for the patients who may have had strokes before the database's creation in May 2001 or identifying patients who had a previous stroke and were admitted to other outside hospitals in the past. This was thought to be an unlikely source of bias due to the small number of patients; however, the univariate analysis was redone with these 25 entries removed and results were unchanged. Finally, we did not correlate nurse shift change with ED volume, which could have contributed to delays in care.
In summary, we have shown that patient arrival at night is associated with longer time to IA thrombolysis, higher mortality rate, and worse clinical outcome at 3 months compared with presentation during the day. Presentation during a shift change, weekend, or during July through September did not have a negative impact on AIS management and patient outcome.
Sources of Funding
This work was supported by a research grant from Hartford Hospital Research Fund.
- Received October 28, 2011.
- Revision received December 2, 2011.
- Accepted December 5, 2011.
- © 2012 American Heart Association, Inc.
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