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Overview

Perspectives From an Emergency Physician on the Front Lines Andy Jagoda, MD, FACEP Professor of Emergency Medicine Mount Sinai School of Medicine. Overview. EM and the American health care system EM and thrombolytics for acute ischemic stroke Future directions and designated stroke centers.

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Overview

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  1. Perspectives From an Emergency Physician on the Front LinesAndy Jagoda, MD, FACEPProfessor of Emergency MedicineMount Sinai School of Medicine

  2. Overview • EM and the American health care system • EM and thrombolytics for acute ischemic stroke • Future directions and designated stroke centers

  3. Emergency Physicians • Three years of specialty training • Specialists in acute medical and surgical resuscitation in patients of all ages • Directors of prehospital care • The link between the community and the hospital • Trained to prioritize care, maximize resource utilization

  4. Emergency Medicine and Access to Care • Approximately 4200 EDs in the USA • 8% decline in past 5 years • Approximately 105 million ED visits / year • 20% increase in past 5 years • EDs are the health care “safety net” • The safety net is currently overwhelmed • Uninsured • Aging population • Decrease in hospital / critical care beds

  5. Emergency Medicine and Access to CareDerlet et al. Acad Emerg Med 2001; 8:151-155 • 91% of ED directors report overcrowding as a major problem: • High volume / high acuity • Radiology delays • Laboratory delays • Consultant delays • Insufficient space • 33% of ED directors report poor outcomes as a result of overcrowding • The majority of acute stroke patients enter the health care system through the ED

  6. Fundamentals of Acute Stroke Care in the ED • Basic acute stroke care must: • Facilitate “rapid” assessment and diagnosis (CT) • Ensure cerebral perfusion and oxygenation: “ABCs” • Exclude mimickers of stroke • Prevent complications • Advanced acute stroke care, i.e., use of fibrinolytics, requires a coordinated, multidisciplinary approach which carefully follows established to protocols • Failure to adhere to protocol increases morbidity up to three times

  7. Emergency Physicians – Access to Care – Acute Stroke • Time sensitive – 3 hours from onset to treatment • Coordination with prehospital care and ED response • Trauma Center Model • Prioritization of resources (away from other sick patients?) • Dedicated physician and nurse • Laboratory services • Neuroimaging • Neurology / Neurosurgery • Inpatient service available to accept the patient

  8. Emergency Medicine and Thrombolytics • Thrombolytics are used routinely by emergency physicians for acute MI • ECG is easy to interpret • Risk of hemorrhage is low • The emergency medicine community has been reserved in its acceptance of thrombolytics in acute stroke • Questions the validity of the NINDS trial • Critical role of other disciplines in time sensitive decision making • Risk of hemorrhage is significant

  9. Canadian Association of Emergency Physicians • “Must be limited to carefully selected patients within established protocols” • “Further evidence is necessary to support the widespread application . . . outside of research settings”

  10. American Academy of Emergency Medicine • “t-PA for acute ischemic stroke is insufficient to warrant its classification as standard of care” citing two methodological concerns with the NINDS trial • Greater benefit was shown in the 0-90 min group • Stroke severity in the group treated in the later time group was greater in the placebo group biasing results in favor of t-PA • Concern over external validity

  11. American College of Emergency Physicians • IV tPA may be an efficacious therapy . . . if properly used following strict guidelines • The decision to use tPA should begin at the institutional level with commitments from hospital administration, the ED, neurology, neurosurgery, radiology, and laboratory services to ensure that the systems necessary for the safe use of fibrinolytic agents are in place. • Hospitals should work with EMS and the community

  12. Perspectives from the Front Line • Much of the EM community is currently overwhelmed with high acuity patients. • With current resources available many EDs are not prepared to provide advanced acute stroke care • EPs are concerned of being isolated care providers in acute stroke with the inherent liability • Acute stroke care requires a coordinated, multi-disciplinary response. Hospitals that chose to provide thrombolytic therapy must ensure that the proper staffing, resources, and protocols are in place to maximize care and minimize risk for patients

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