Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Barriers to Evidence Based Stroke care in Emergency Departments
- Mark F Nicol (5 July 2002)
-
ACUTE STROKE CARE IN UK
- ABHAYA GUPTA, I MORGAN, HMS SHETTY (22 August 2002)
-
The role of Accident and Emergency in early diagnosis and management
- Christopher J L Hetherington, Peter Doyle, David F Gorman (4 September 2002)
|
|
|||
|
Mark F Nicol, Specialist /locum consultant Macclesfield, SK10 3BL
Send response to journal:
|
The article by Harraf et al [1] is a welcome addition to much needed hard data on poor delivery of evidence based and patient focused care in the UK. The paper prompts the need to prospectively analyse what exactly are the barriers to timely assessment, investigation and treatment of a patient presenting with a potentially life threatening stroke. The paper would have benefited from providing readers with the subset analysis of time to assessment, senior opinion and CT scan in the (128 hours) 76% of the week that falls outside the current working week of 9-5 Monday –Friday. In a typical emergency department 66% of patients arrived outside these normal working hours. The authors describe that 28% arrive after 1759hr and before 0600hr, and state in their abstract that ”time of presentation did not influence time to evaluation by senior [non Emergency] doctor” but do not provide results to support this. There is in almost every one of the eleven previous UK Accident & Emergency departments I have worked in, a pattern of barriers to rapid head CT scan requested by the SHO in Accident & Emergency department after 5pm Mon –Friday:- Scan radiographer asks-
Radiologist then asks-
Radiologist then asks-
Radiologist then says-
SHO in A&E bleeps the medical SHO twice, before getting a response of: ” I’m still on medical assessment unit seeing three other patients first”. In contrast, my experience in 2 separate emergency departments in Australia was that a pre-registration house officer in “Emergency medicine” was able to make the request to a scan radiographer (not radiologist). The patient usually having been seen and assessed by a middle grade, if not accredited specialist in Emergency medicine. The staff in a British Accident and Emergency department rapidly realise that for a quiet life it is easier to simply write in the notes “CVA-refer medics” and return to the 4hour queue of triage category 4 and 5 patients. It is a big enough challenge to persuade radiology departments to perform a head CT scan out of hours for a young head injured patient who unexpectedly reattends with headache and vomiting and who may need neurosurgery to expect a culture of cooperation for elderly patients who have already exceeded their normal life expectancy! What hope have we got to use an unlicensed medication to thrombolyse patients with stroke when it is difficult to obtain funding and staffing to deliver thrombolytics for myocardial infarction in the setting of the one hospital department which has the obligation to provide timely assessment, investigation and resuscitation for life threatening conditions-the Emergency Department. In an ideal world this paper would change clinicians approach to stroke, but this is not going to happen while National guidance [2] is issued by a working party with neither a representative of the Faculty of Accident and Emergency medicine nor a representative of the Royal College of Radiologists. And while this National Guidance states “Brain imaging should be undertaken in all [stroke] patients within 48 hours of onset”- this is usually manipulated by overstretched radiology department to defer scanning to the next working day. Competing interests:none Reference: 1.Harraf et al A multicentre observational study of presentation and assessment of acute stroke. BMJ 2002; 325:17-20 2.Intercollegiate Working Party on Stroke. National clinical guidelines on stroke. London: Royal College of Physicians |
|||
|
|
|||
|
ABHAYA GUPTA, SPECIALIST REGISTRAR LLANDOUGH HOSPITAL, CARDIFF, UK CF642XX, I MORGAN, HMS SHETTY
Send response to journal:
|
Dear Sir, We read with interest the article on stroke published in the BMJ 6th July 2002 (1). Although we did not participate in this multicentre study we present our data from a study which we carried out at University hospital, Cardiff, United Kingdom. We collected data prospectively on patients admitted with a diagnosis of stroke during three months (September to November 2001). We do not have an Acute stroke unit and the patients are admitted through medical assessment unit or Emergency under the care of different medical teams. During this period a total of 107 patients with diagnosis of stroke were admitted. The mean age was 74.9 (range 41 to 101 years). 56% were females. The time between symptom onset and hospital arrival varied from 1 hour upto 7 days. 32% patients arrived within 3 hours and 60% within 6 hours. 15% patients had their CT brain done within 6 hours and 35% had it done within 24 hours. No CT brain was done in 20% patients. We identified factors associated with delayed arrival to hospital which included – living alone, calling general practitioner (GP) rather than 999 emergency, incorrect stroke identification, dementia and altered consciousness level. We agree with the authors that stroke patients are currently arriving too late at a UK hospital to be eligible for thrombolytic therapy and other acute interventions. Factors associated with the delays will need to be addressed (2). A large number of acute stroke patients will miss the benefits of effective acute treatments unless steps are taken to educate patients, GPs and institute major infrastructural changes in stroke services at all levels (patients, ambulance staff and GPs) (3). References : 1. Harraf F et al. A multicentre observational study of presentation and early assessment of acute stroke. BMJ 2002; 325: 17. 2. Harper GD et al. Factors delaying hospital admission after stroke in Leicestershire. Stroke 1992; 23: 835-838. 3. Lacy CR et al. Delay in presentation and evaluation for acute stroke : Stroke Time Registry for outcomes Knowledge and Epidemiology. Stroke 2001; 32(1): 63-69. Abhaya Gupta, Department of Geriatric Medicine, Llandough hospital, Cardiff, UK I Morgan, Department of Geriatric Medicine, University hospital, Cardiff, UK HMS Shetty, Department of Geriatric Medicine, University hospital, Cardiff, UK |
|||
|
|
|||
|
Christopher J L Hetherington, Specialist Registrar in Emergency Medicine Selly Oak Hospital, Birmingham, B29 6JD, UK, Peter Doyle, David F Gorman
Send response to journal:
|
EDITOR- We read with interest the paper on early assessment of acute stroke published in the BMJ 6th July 2002 [1]. It clearly indicates the way forward if acute stroke management is to be optimised in this country. Delays are clearly identifiable in the pre-hospital setting, in the emergency department and with the admitting medical teams in-house. It is notable that patients present earlier if they call emergency services rather than their GPs. Another of the more obvious findings was that the initial assessment by the emergency doctor occurred much quicker than that of the medical team (64% as opposed to 30% seen within an hour). It would therefore make more sense for the emergency doctors to initiate investigation and treatment in those patients where thrombolysis may be a therapeutic option. In relation to this, it was reported that 65% of patients were seen by "a senior doctor" from the admitting medical team within 3 hours of arrival to hospital, yet this included all grades of doctor from senior house officer upwards. Only 5% of these were evaluated by consultants. The BMA defines a "senior doctor" as a consultant only, with all other grades designated "juniors". Thus we feel that middle grade or senior emergency doctors would often be the most appropriate people to make decisions regarding urgent CT scans and/or initiation of thrombolysis. This would surely expedite definitive management in most cases. References 1. Harraf F et al. A multicentre observational study of presentation and early assessment of acute stroke. BMJ 2002; 325: 17. C J L Hetherington, Accident and Emergency Department, Selly Oak Hospital, Birmingham, B29 6JD, UK. P Doyle, Accident and Emergency Department, Selly Oak Hospital, Birmingham, B29 6JD, UK. D F Gorman, Accident and Emergency Department, Selly Oak Hospital, Birmingham, B29 6JD, UK. |
|||