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  1. 1. Perspectives From an EmergencyPerspectives From an Emergency Physician on the Front LinesPhysician on the Front Lines Andy Jagoda, MD, FACEPAndy Jagoda, MD, FACEP Professor of Emergency MedicineProfessor of Emergency Medicine Mount Sinai School of MedicineMount Sinai School of Medicine
  2. 2. OverviewOverview • EM and the American health care systemEM and the American health care system • EM and thrombolytics for acute ischemic strokeEM and thrombolytics for acute ischemic stroke • Future directions and designated stroke centersFuture directions and designated stroke centers
  3. 3. Emergency PhysiciansEmergency Physicians • Three years of specialty trainingThree years of specialty training • Specialists in acute medical and surgicalSpecialists in acute medical and surgical resuscitation in patients of all agesresuscitation in patients of all ages • Directors of prehospital careDirectors of prehospital care • The link between the community and theThe link between the community and the hospitalhospital • Trained to prioritize care, maximizeTrained to prioritize care, maximize resource utilizationresource utilization
  4. 4. Emergency Medicine and Access to CareEmergency Medicine and Access to Care • Approximately 4200 EDs in the USAApproximately 4200 EDs in the USA • 8% decline in past 5 years8% decline in past 5 years • Approximately 105 million ED visits / yearApproximately 105 million ED visits / year • 20% increase in past 5 years20% increase in past 5 years • EDs are the health care “safety net”EDs are the health care “safety net” • The safety net is currently overwhelmedThe safety net is currently overwhelmed • UninsuredUninsured • Aging populationAging population • Decrease in hospital / critical care bedsDecrease in hospital / critical care beds
  5. 5. Emergency Medicine and Access to CareEmergency Medicine and Access to Care Derlet et al. Acad Emerg Med 2001; 8:151-155Derlet et al. Acad Emerg Med 2001; 8:151-155 • 91% of ED directors report overcrowding as a91% of ED directors report overcrowding as a major problem:major problem: • High volume / high acuityHigh volume / high acuity • Radiology delaysRadiology delays • Laboratory delaysLaboratory delays • Consultant delaysConsultant delays • Insufficient spaceInsufficient space • 33% of ED directors report poor outcomes as a33% of ED directors report poor outcomes as a result of overcrowdingresult of overcrowding • The majority of acute stroke patients enter theThe majority of acute stroke patients enter the health care system through the EDhealth care system through the ED
  6. 6. Fundamentals of Acute Stroke Care in the EDFundamentals of Acute Stroke Care in the ED • Basic acute stroke care must:Basic acute stroke care must: • Facilitate “rapid” assessment and diagnosis (CT)Facilitate “rapid” assessment and diagnosis (CT) • Ensure cerebral perfusion and oxygenation: “ABCs”Ensure cerebral perfusion and oxygenation: “ABCs” • Exclude mimickers of strokeExclude mimickers of stroke • Prevent complicationsPrevent complications • Advanced acute stroke care, i.e., use of fibrinolytics, requiresAdvanced acute stroke care, i.e., use of fibrinolytics, requires a coordinated, multidisciplinary approach which carefullya coordinated, multidisciplinary approach which carefully follows established to protocolsfollows established to protocols • Failure to adhere to protocol increases morbidity up toFailure to adhere to protocol increases morbidity up to three timesthree times
  7. 7. Emergency Physicians – Access to Care – Acute StrokeEmergency Physicians – Access to Care – Acute Stroke • Time sensitive – 3 hours from onset to treatmentTime sensitive – 3 hours from onset to treatment • Coordination with prehospital care and ED responseCoordination with prehospital care and ED response • Trauma Center ModelTrauma Center Model • Prioritization of resources (away from other sickPrioritization of resources (away from other sick patients?)patients?) • Dedicated physician and nurseDedicated physician and nurse • Laboratory servicesLaboratory services • NeuroimagingNeuroimaging • Neurology / NeurosurgeryNeurology / Neurosurgery • Inpatient service available to accept the patientInpatient service available to accept the patient
  8. 8. Emergency Medicine and ThrombolyticsEmergency Medicine and Thrombolytics • Thrombolytics are used routinely by emergencyThrombolytics are used routinely by emergency physicians for acute MIphysicians for acute MI • ECG is easy to interpretECG is easy to interpret • Risk of hemorrhage is lowRisk of hemorrhage is low • The emergency medicine community has beenThe emergency medicine community has been reserved in its acceptance of thrombolytics in acutereserved in its acceptance of thrombolytics in acute strokestroke • Questions the validity of the NINDS trialQuestions the validity of the NINDS trial • Critical role of other disciplines in time sensitive decisionCritical role of other disciplines in time sensitive decision makingmaking • Risk of hemorrhage is significantRisk of hemorrhage is significant
  9. 9. Canadian Association of Emergency PhysiciansCanadian Association of Emergency Physicians • ““Must be limited to carefully selectedMust be limited to carefully selected patients within established protocols”patients within established protocols” • ““Further evidence is necessary toFurther evidence is necessary to support the widespread application . . .support the widespread application . . . outside of research settings”outside of research settings”
  10. 10. American Academy of Emergency MedicineAmerican Academy of Emergency Medicine • ““t-PA for acute ischemic stroke is insufficientt-PA for acute ischemic stroke is insufficient to warrant its classification as standard ofto warrant its classification as standard of care” citing two methodological concerns withcare” citing two methodological concerns with the NINDS trialthe NINDS trial • Greater benefit was shown in the 0-90 min groupGreater benefit was shown in the 0-90 min group • Stroke severity in the group treated in the laterStroke severity in the group treated in the later time group was greater in the placebo grouptime group was greater in the placebo group biasing results in favor of t-PAbiasing results in favor of t-PA • Concern over external validityConcern over external validity
  11. 11. American College of Emergency PhysiciansAmerican College of Emergency Physicians • IV tPA may be an efficacious therapy . . . if properlyIV tPA may be an efficacious therapy . . . if properly used following strict guidelinesused following strict guidelines • The decision to use tPA should begin at theThe decision to use tPA should begin at the institutional level with commitments from hospitalinstitutional level with commitments from hospital administration, the ED, neurology, neurosurgery,administration, the ED, neurology, neurosurgery, radiology, and laboratory services to ensure that theradiology, and laboratory services to ensure that the systems necessary for the safe use of fibrinolytic agentssystems necessary for the safe use of fibrinolytic agents are in place.are in place. • Hospitals should work with EMS and the communityHospitals should work with EMS and the community
  12. 12. Perspectives from the Front LinePerspectives from the Front Line • Much of the EM community is currently overwhelmedMuch of the EM community is currently overwhelmed with high acuity patients.with high acuity patients. • WithWith current resources availablecurrent resources available many EDs are notmany EDs are not prepared to provide advanced acute stroke careprepared to provide advanced acute stroke care • EPs are concerned of being isolated care providers in acuteEPs are concerned of being isolated care providers in acute stroke with the inherent liabilitystroke with the inherent liability • Acute stroke care requires a coordinated, multi-Acute stroke care requires a coordinated, multi- disciplinary response. Hospitals that chose to providedisciplinary response. Hospitals that chose to provide thrombolytic therapy must ensure that the properthrombolytic therapy must ensure that the proper staffing, resources, and protocols are in place tostaffing, resources, and protocols are in place to maximize care and minimize risk for patientsmaximize care and minimize risk for patients

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