Creation of an intensive care unit and organizational changes in an adult emergency department: Impact on acute stroke management.

Laurent Puy (1) , Chantal Lamy (2) , Sandrine Canaple (1, 3) , Audrey Arnoux (4) , Nicolas Lainé (5) , Ella Iacob , Jean-Marc Constans (6) , Olivier Godefroy (1, 3, 2)

1 Service de neurologie [Amiens]
2 CHU Amiens-Picardie
3 LNFP - Laboratoire de Neurosciences Fonctionnelles et Pathologies - UR UPJV 4559
4 LPNC - Laboratoire de Psychologie et NeuroCognition
5 LESC - Laboratoire d'ethnologie et de sociologie comparative
6 Service de Radiologie [CHU Caen]

BACKGROUND AND PURPOSE: Following the reorganization of a University Medical Center onto a single campus, an Intensive Care Unit was created within the adult Emergency Department (ED ICU). We assessed the effects of these organizational changes on acute stroke management and the intravenous administration of recombinant tissue plasminogen activator (IV rtPA), as characterized by the thrombolysis rate, door-to-needle time (DNT) and outcome at 3months. METHODS: Between October 2013 and September 2015, we performed a retrospective, observational, single-center, comparative study of patients admitted for ischemic stroke and treated with IV rtPA during two 321-day periods (before and after the creation of the ED ICU). All patients with ischemic stroke were included. Multivariable logistic regression models were performed. The DNT was stratified according to a threshold of 60min. A favorable long-term outcome was defined as a modified Rankin score≤2 at 3months. RESULTS: A total of 1334 ischemic stroke patients were included. Among them, 101 patients received IV rtPA. The frequency of IV rtPA administration was 5.8% (39 out of 676) before the creation of the ED ICU, and 9.3% (62 out of 668) afterwards (odds ratio (OR) [95% confidence interval (CI)]: 1.67 [1.08-2.60]; p=0.02). Additionally, the DNT was shorter (OR [95%CI]: 4.30 [1.17-20.90]; p=0.04) and there was an improvement in the outcome (OR [95%CI]=1.30 [1.01-2.10]; p=0.045). CONCLUSION: Our results highlight the benefits of a separate ED ICU within conventional ED for acute stroke management, with a higher thrombolysis rate, reduced intrahospital delays and better safety.

Mots clés: Female; Humans; Male; *Organizational Innovation; Administration; Intravenous; Adult emergency department; Aged; Brain Ischemia/diagnosis/therapy; Early Medical Intervention/*organization & administration/standards; Emergency Service; Hospital/*organization & administration/trends; Fibrinolytic Agents/administration & dosage; France; Intensive Care Units/*organization & administration/trends; Managed care; Organizational change; Outcome and Process Assessment; Health Care; Patient Safety; Retrospective Studies; rt-PA; Stroke; Stroke/diagnosis/physiopathology/*therapy; Thrombolysis; Thrombolytic Therapy/*methods; Time Factors; Time-to-Treatment/*statistics & numerical data; Tissue Plasminogen Activator/administration & dosage

Domaines: Sciences du Vivant [q-bio]

Laurent Puy, Chantal Lamy, Sandrine Canaple, Audrey Arnoux, Nicolas Lainé, et al.. Creation of an intensive care unit and organizational changes in an adult emergency department: Impact on acute stroke management.. American Journal of Emergency Medicine, 2017, 35 (5), pp.716--719. ⟨10.1016/j.ajem.2017.01.007⟩. ⟨hal-03669042⟩