John-Paul Whitman, BSN, RN – Brain Blogger http://brainblogger.com Health and Science Blog Covering Brain Topics Sat, 30 Dec 2017 16:30:10 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.1 Treating Acute Ischemic Stroke – The Race Is On http://brainblogger.com/2013/06/01/treating-acute-ischemic-stroke-the-race-is-on/ http://brainblogger.com/2013/06/01/treating-acute-ischemic-stroke-the-race-is-on/#comments Sat, 01 Jun 2013 11:00:27 +0000 http://brainblogger.com/?p=14338 As the fourth leading cause of death in the U.S. and a leading cause of permanent disability, stroke has an incredible impact at both the individual and economic level. According to the CDC, an American dies every 4 minutes as the result of an acute stroke. With 87% of these strokes being ischemic in nature, rapid assessment and diagnosis of patients with stroke symptoms is required in order to ensure that eligible patients receive fibrinolytic therapy within the recommended time frame (around 3 hours). Research has shown that although healthcare providers in the inpatient setting are greatly reducing delays to treatment, there is still much work to be done in the pre-hospital setting to ensure that valuable time is not lost.

Researchers in Finland demonstrated that over a two year period hospitals were able to reduce average delays of treatment initiation by approximately 50%. Similar restructuring has occurred within the U.S. as hospitals started to be designated as ‘stroke centers’ by the Joint Commission — the nation’s leading hospital accrediting body. To achieve stroke center accreditation, hospitals have to meet a set of criteria demonstrating they effectively manage acute stroke based on current medical research. These criteria include having an on call neurologist, the availability of CT imaging, and designated critical care units for stroke patients. These criterions have ensured that more patients are able to receive life-saving thrombolytic therapy. Despite these remarkable efforts, however, there is much yet to be done to improve outcomes for patients with acute stroke.

Kwan and his team of researchers analyzed 54 studies that sought to identify barriers to patients receiving thrombolytic therapy. They found that only 37% of patients in the UK arrived in the hospital within three hours of symptom onset. This would seem to suggest that substantial delays occur in the pre-hospital setting. Such delays were the number one reason cited why patients did not receive rt-PA, with 22-94% of patients being rendered ineligible due to lost time. The number one pre-hospital delay cited in the literature was patient or family delay in requesting medical help due to a lack of knowledge on signs of stroke. The logical next step would seem to be the development of advertisement campaigns with the goal of educating the public on the signs and symptoms of stroke.

Unfortunately, such attempts at education have thus far not been remarkably fruitful. Lecouturier found that education programs directed towards a public audience have been shown to increase the awareness of the signs and symptoms of a stroke, but seem to have had little to no impact on behaviors. One study showed that even after education, contacting emergency medical services (EMS) did not occur until almost 2 hours after symptom onset. This extreme delay makes it unlikely that patients will arrive to an inpatient setting within a 3 hour window to begin thrombolytic therapy.

Earlier research by Moser suggests that perhaps educational opportunities are misdirected. Specific educational programs directed at persons of lower socioeconomic status or those of black or Hispanic descent have not been greatly documented while these groups have among the highest delays in seeking treatment for stroke. Likewise, patients with a prior diagnosis of hypertension are at a significant risk for stroke and may benefit from more directed education.

Additionally, Moser’s findings suggest that the best place to improve education may be within the professional realm. To reduce pre-hospital delay to treatment, the researchers suggest that EMS dispatch teams should rearrange protocols to give a higher priority in dispatching units to suspected stroke victims; some research has suggested that more rural areas do not attribute the same triage priority to stroke as they do to acute coronary syndrome.

Another group that may benefit from further education is paramedics. A nationwide survey showed that paramedics were competent on knowledge of stroke symptoms but were unaware of the treatment window for fibrinolysis. Education and protocol reform may help to ensure more rapid diagnosis and transport of stroke victims by EMS.

Medical literature has made it abundantly clear that the number one factor in reducing morbidity and mortality for patients with acute ischemic stroke is final diagnosis and disposition to the stroke unit in under three hours. This rapid sequence ensures that those patients eligible for rt-PA can receive it within the therapeutic time frame. Much research and interventions must still take place if this is to be achieved for the greatest possible number of patients. Population specific education, restructuring of EMS protocols, and continuing education of paramedics may be the first major steps towards successful mitigation of the devastating effects of stroke.

References

Kwan J, Hand P, & Sandercock P (2004). A systematic review of barriers to delivery of thrombolysis for acute stroke. Age and ageing, 33 (2), 116-21 PMID: 14960425

Lecouturier J, Rodgers H, Murtagh MJ, White M, Ford GA, & Thomson RG (2010). Systematic review of mass media interventions designed to improve public recognition of stroke symptoms, emergency response and early treatment. BMC public health, 10 PMID: 21182777

Moser DK, Kimble LP, Alberts MJ, Alonzo A, Croft JB, Dracup K, Evenson KR, Go AS, Hand MM, Kothari RU, Mensah GA, Morris DL, Pancioli AM, Riegel B, & Zerwic JJ (2006). Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on cardiovascular nursing and stroke council. Circulation, 114 (2), 168-82 PMID: 16801458

Puolakka T, Väyrynen T, Häppölä O, Soinne L, Kuisma M, & Lindsberg PJ (2010). Sequential analysis of pretreatment delays in stroke thrombolysis. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 17 (9), 965-9 PMID: 20836777

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Physician Sleep Deprivation – Potential Effects on Patient Care http://brainblogger.com/2013/05/26/physician-sleep-deprivation-potential-effects-on-patient-care/ http://brainblogger.com/2013/05/26/physician-sleep-deprivation-potential-effects-on-patient-care/#comments Sun, 26 May 2013 11:00:45 +0000 http://brainblogger.com/?p=14469 It is well understood that resident, intern and attending physicians do not receive an adequate amount of sleep at night. Long on call hours, 24-hour shifts within the hospital and limited time off all contribute to poor quantity and quality of sleep. Research seems to suggest a potential effect on the quality of patient care as a result of such sleep deprivation.

A 2011 study that took place in Korea scored a number of residents and interns on sleep deprivation. Nearly 71% of participants were sleep deprived with a mean of only 5 (+/- 1.2) hours of sleep per night while working an average of 14.9 (+/- 2.7) hours a day. Among the most sleep deprived of participants, scores for attention deficit were higher than average, suggesting a potential difficulty in focusing on treatment and diagnoses of patient condition. Additionally, sleep deprivation made it more difficult for participants to learn new information, which may make the continuing education of such physicians more difficult.

Further research into sleep deprivation in general may also illustrate another potential barrier in professional performance. A literature analysis by Kamphuis illustrates that there is significant evidence to support a relationship between sleep deprivation and increased levels of aggression. In numerous studies, participants who reported a low quantity and/or quality of sleep also scored higher on indexes of anger, hostility and impulsivity compared to control groups. Interestingly, there appears to be a physiological component to such increased anger.

Prefrontal cortical functioning is impaired in sleep deprived individuals. This functioning is responsible for a person’s ability to regulate emotional and behavioral responses to stimuli. In one particular study, subjects with an average sleep deprivation of 30 hours were less likely to be able to recognize human facial emotions for moderate happiness or anger, suggesting an inability to empathize from sheer lack of recognition alone.

This link between sleep deprivation and aggression could be helpful in explaining the reasons why some physicians are considered short-tempered by non-physician healthcare staff. The inability to empathize could certainly be to blame for this phenomenon; however, this author was unable to find current research attempting to test such a correlation, suggesting a need for further investigation into this specific area.

As the physician shortage in America continues to worsen, the effects of sleep deprivation on physicians could become more marked. To mitigate this potential barrier to quality patient care, healthcare institutions must find ways of filling gaps with more mid-level providers, interns, and residents to spread the workload among a larger group of individuals. Sleep deprivation is linked with a wide range of physical and emotional health problems and may be directly affecting patient care. There is much work still to be done to identify the specific risks to patients as well as strategies to reduce such risks.

References

Kamphuis J, Meerlo P, Koolhaas JM, & Lancel M (2012). Poor sleep as a potential causal factor in aggression and violence. Sleep medicine, 13 (4), 327-34 PMID: 22305407

Kim HJ, Kim JH, Park KD, Choi KG, & Lee HW (2011). A survey of sleep deprivation patterns and their effects on cognitive functions of residents and interns in Korea. Sleep medicine, 12 (4), 390-6 PMID: 21388879

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