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• W2103242801 abstract "HomeStrokeVol. 38, No. 8Solving the Issue of Patient Arrival Time Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBSolving the Issue of Patient Arrival TimeA Call for Vigilant Action Anne W. Alexandrov Anne W. AlexandrovAnne W. Alexandrov From the Comprehensive Stroke Center, The University of Alabama Hospital, Birmingham, AL. Search for more papers by this author Originally published5 Jul 2007https://doi.org/10.1161/STROKEAHA.107.490441Stroke. 2007;38:2219–2220Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: July 5, 2007: Previous Version 1 See related article, pages 2376-2378.Late arrival to the hospital after the onset of acute stroke symptoms is a plague of unheralded proportions that is not easily treated or cured. Contributors to this problem are many, including a lack of urgent response to symptoms on the part of patients and family, patient inability to activate emergency systems attributable to neurologic deficits, and even fear of embarrassment on the part of lay people that they may have made an inappropriate call to 911.1–9 Although clinicians and the lay community have come together to successfully tackle late response to symptoms of myocardial ischemia, no doubt the presence of chest pain and shortness of breath in and of themselves have contributed to a heightened sense of urgency in response to acute coronary symptoms. At more than 10 years from the approval of tissue plasminogen activator for intravenous thrombolysis in ischemic stroke,10 it is discouraging at best to note that public awareness coupled with an urgent community response to stroke symptoms has yet to be realized for victims of this relatively “painless” yet devastating disease.The study by Jarrell and colleagues11 evaluated “healthline” phone service responses to a stroke victim scenario in hospitals with neurology residency teaching programs. After listening to a brief scenario that described typical stroke symptoms, 22% of healthline operators recommended calling a primary care physician instead of advocating for immediate emergency transport to the hospital. Even more discouraging, 24% were also unable to name even one warning sign of stroke. These findings are striking given the fact that these hospitals serve as practice sites for physicians on the forefront of diagnosing and treating stroke along with training the next generation of neurologists.Jarrell et al11 have brought to light one more example of the complexity of building and implementing seamless health systems to support delivery of stroke care.12–15 Hospital systems, let alone community-based health service operations, are significantly complex with multiple access points, varying levels of practitioner expertise and skill, and provision of health services that should be well integrated and orchestrated.15 Although this is easily said on paper, construction of such a system is usually a highly political and challenging endeavor.Assessing health systems’ performance is akin to peeling several onions at the same time and often leads to discovery of what on the surface appear to be small kinks but are capable of unfortunate system impact when not appropriately managed. Jarrell and colleagues11 identify one such example in their article, but many others exist as well. Take for example the problem of hospital ambulance diversion, which is often related to poorly managed inpatient throughput, whereby one service’s slow response to moving patients through the system ties up hospital beds and resources in a domino effect16–18 that ultimately may impact ability to admit patients with acute stroke. The politics surrounding resolution of problems such as this can be stifling, because it is not the addition of patient beds that is usually needed; it is modification of practitioner performance.16,18 Improving emergency medical services performance is another example, especially when high personnel turnover leads to the need for regular retraining to ensure appropriate prehospital care. However, even the best prehospital care does little to affect stroke outcome if receiving hospitals are themselves disorganized in their response to stroke or lacking commitment to provision of evidence-based care.15Most assuredly, healthline programs were created to do the “right thing” for patients and family in need of health information, and these systems are typically supported by some form of quality monitoring to ensure optimal operations. Yet, it is likely that stroke may be overlooked by some program trainers as necessary content for healthline operators. The relative invisibility of the number one cause of adult disability and the third greatest cause of death remains a significant concern, and stroke practitioners and victims must see this as a call to action. Although education of healthline operators and others who intercept the system is a must, perhaps it is also time to consider the addition of 2 new program quality measures: symptom onset to emergency department arrival time and mode of hospital arrival (eg, emergency medical services versus private automobile).It is difficult to gauge on a national level exactly what symptom onset to emergency department arrival times are on average, but late arrival continues to be one of the most common reasons for nontreatment with intravenous tissue plasminogen activator.3,5,7,8 When tissue plasminogen activator treatment numbers are low attributable to late arrival (especially when they fall below the national average), it would seem that stroke programs should then be held accountable for increasing their public presence, creating partnerships with key community stakeholders, and getting the word out that stroke warning signs herald an emergency requiring a call to 911. Similarly, when a significant number of patients with stroke arrive by private automobile in areas that are well served by emergency medical services, something is vastly wrong with the system. Not only should patients and family members be asked why they made such a choice, but the community-at-large needs to be engaged in providing a solution to this problem. The addition of these 2 program metrics may spawn a vigilant approach to addressing the late arrival problem, especially if tied to stroke center certification.The study by Jarrell et al11 provides us with yet another wakeup call about the importance of fully assessing and optimizing each link of the stroke chain of survival. However, it is likely that each of us will need to wipe our eyes as we continue to peel our onions and find other hidden areas for improvement. Still, if we accept community leadership in the fight against stroke as the most important aspect of our jobs, we should welcome the unmasking of problems as opportunities to build excellent stroke systems of care.The opinions in this editorial are not necessarily those of the editors or of the American Heart Association.DisclosuresNone.FootnotesCorrespondence to Anne W. Alexandrov, PhD, RN, CCRN, FAAN, RWUH M226, 619 19th St. South, Birmingham, AL 35249-3280. E-mail [email protected] References 1 Pancioli AM, Broderick J, Kothari R, Brott T, Tuchfarber A, Miller R, Khoury J, Jauch E. Public perception of stroke warning signs and knowledge of potential risk factors. JAMA. 1998; 279: 1288–1292.CrossrefMedlineGoogle Scholar2 Schneider AT, Pancioli AM, Khoury J, Rademacher E, Tuchfarber A, Miller R, Woo D, Kissela B, Broderick JP. Trends in community knowledge of warning signs and risk factors for stroke. JAMA. 2003; 289: 343–346.CrossrefMedlineGoogle Scholar3 Barsan WG, Brott TG, Broderick JP, Haley EC, Levy DE, Marler JR. Time of hospital presentation in patients with acute stroke. Arch Intern Med. 1993; 153: 2558–2561.CrossrefMedlineGoogle Scholar4 Kothari R, Sauerbeck L, Jauch E, Broderick J, Brott T, Khoury J, Liu T. Patients’ awareness of stroke signs, symptoms and risk factors. Stroke. 1997; 28: 1871–1875.CrossrefMedlineGoogle Scholar5 Williams LS, Bruno A, Rouch D, Marriott DJ. Stroke patients’ knowledge of stroke. Influence on time to presentation. Stroke. 1997; 28: 912–915.CrossrefMedlineGoogle Scholar6 Brice JH, Griswell JK, Delbridge TR, Key CB. Stroke: from recognition by the public to management by emergency medical services. Prehosp Emerg Care. 2002; 6: 99–106.CrossrefMedlineGoogle Scholar7 Rosamond WD, Gorton RA, Hinn AR, Hohenhaus SM, Morris DL. Rapid response to stroke symptoms: the Delay in Accessing Stroke Healthcare (DASH) study. Acad Emerg Med. 1998; 5: 45–51.CrossrefMedlineGoogle Scholar8 Schroeder EB, Rosamond WD, Morris DL, Evenson KR, Hinn AR. Determinants of the use of emergency medical services in a population with stroke symptoms: the Second Delay in Accessing Stroke Healthcare (DASH) Study. Stroke. 2000; 31: 2591–2596.CrossrefMedlineGoogle Scholar9 Kothari R, Jauch E, Broderick J, Brott T, Sauerbeck L, Khoury J, Liu T. Acute stroke: delays to presentation and emergency department evaluation. Ann Emerg Med. 1999; 33: 3–8.CrossrefMedlineGoogle Scholar10 NINDS rt-PA Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995; 333: 1581–1587.CrossrefMedlineGoogle Scholar11 Jarrell B, Tadros A, Whiteman C, Crocco T, Davis SM. National healthline responses to a stroke scenario: implications for early intervention. Stroke. 2007: 38: 2376–2378.LinkGoogle Scholar12 The National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stroke Study Group. A systems approach to immediate evaluation and management of hyperacute stroke. Experience at eight centers and implications for community practice and patient care. The National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stroke Study Group. Stroke. 1997; 28: 1530–1540.CrossrefMedlineGoogle Scholar13 National Institute of Neurological Disorders and Stroke. National Institutes of Health. Improving the Chain of Recovery for Acute Stroke in Your Community. Available at: www.ninds.nih.gov/news_and_events/proceedings/acute_stroke_workshop.pdf. 2002. Accessed May 31, 2007.Google Scholar14 Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.Google Scholar15 Schwamm LH, Pancioli A, Acker JE III, Goldstein LB, Zorowitz RD, Shephard TJ, Moyer P, Gorman M, Johnston SC, Duncan PW, Gorelick P, Frank J, Stranne SK, Smith R, Federspiel W, Horton KB, Magnis E, Adams R. Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association’s task force on the development of stroke systems. Stroke. 2005; 36: 690–703.LinkGoogle Scholar16 Han JH, Zhou C, France DJ, Zhong S, Jones I, Sorrow AB, Aronsky D. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007; 14: 338–343.CrossrefMedlineGoogle Scholar17 Pham JC, Patel R, Millin MG, Kirsch TD, Chanmuqam A. The effects of ambulance diversion: a comprehensive review. Acad Emerg Med. 2006; 13: 1220–1227.CrossrefMedlineGoogle Scholar18 Yancer DA, Foshee D, Cole H, Beauchamp R, de la Pena W, Keefe T, Smith W, Zimmerman K, Lavine M, Toops B. Managing capacity to reduce emergency department overcrowding and ambulance diversions. Joint Commission Journal on Quality and Patient Safety. 2006; 32: 239–245.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Byers A, Lamanna L and Rosenberg A (2010) The Effect of Motivational Interviewing After Ischemic Stroke on Patient Knowledge and Patient Satisfaction With Care, Journal of Neuroscience Nursing, 10.1097/JNN.0b013e3181f8a5e7, 42:6, (312-322), Online publication date: 1-Dec-2010. Blacker D (2009) There's more to transient ischaemic attack than ABCD, Internal Medicine Journal, 10.1111/j.1445-5994.2009.01939.x, 39:5, (332-334), Online publication date: 1-May-2009. Wojner Alexandrov A (2008) Methodologic Challenges in the Design and Conduct of Hyperacute Stroke Research, AACN Advanced Critical Care, 10.1097/01.AACN.0000318122.56759.55, 19:2, (186-201), Online publication date: 1-Apr-2008. Hughes S and Eichler E (2008) Progress in Prevention, Journal of Cardiovascular Nursing, 10.1097/01.JCN.0000305080.74269.0d, 23:2, (97-99), Online publication date: 1-Mar-2008. Middleton S, Levi C and Dale S (2007) Arrival Time to Stroke Unit as Crucial a Measure as Arrival Time to Emergency Department, Stroke, 39:1, (e5-e5), Online publication date: 1-Jan-2008. August 2007Vol 38, Issue 8 Advertisement Article InformationMetrics https://doi.org/10.1161/STROKEAHA.107.490441PMID: 17615363 Originally publishedJuly 5, 2007 PDF download Advertisement" @default.
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