BackgroundThis study aimed to identify which emergency department (ED) factors impact door-to-needle (DTN) time in acute stroke patients eligible for intravenous thrombolysis. The purpose of analyzing emergency department factors is to determine whether any modifiable factors could shorten the time to thrombolytics, thereby increasing the odds of improved clinical outcomes.MethodsThis was a prospective observational quality registry study that included all patients that received alteplase for stroke. These data are our hospital data from the national Get With The Guidelines Registry. The Get With The Guidelines® Stroke Registry is a hospital-based program focused on improving care for patients diagnosed with a stroke. The program has over five million patients, and hospitals can access their own program data. The registry promotes the use of and adherence to scientific treatment guidelines to improve patient outcomes. The time of patient arrival to the ED was captured via the timestamp in the electronic health record. Arriving between Friday 6 p.m. and Monday 6 a.m. was classified as “weekend,” regardless of the time of arrival. Time to CT, time-to-lab, and presence of a dedicated stroke team were also recorded. Emergency medical services (EMS) run sheets were used to verify arrival via ambulance.ResultsForty-nine percent of the cohort presented during the day shift, 24% during the night shift, and 27% on the weekend. A total of 85% were brought by EMS, and 15% of patients were walk-ins. The median DTN time during the day shift was 37 min (IQR 26–51, range 10–117). The median DTN time during the night shift was 59 min (IQR 39–89, range 34–195). When a dedicated stroke team was present, the median DTN time was 36 min, compared to 51 min when they were not present. The median door-to-CT time was 24 min (IQR 18–31 min). On univariate analyses, arriving during the night shift (P < 0.0001), arriving as a walk-in (P = 0.0080), and longer time-to-CT (P < 0.0001) were all associated with longer DTN time. Conversely, the presence of a dedicated stroke team was associated with a significantly shorter DTN time (P < 0.0001).ConclusionFactors that contribute most to a delay in DTN time include arrival during the night shift, lack of a dedicated stroke team, longer time-to-CT read, and arrival as a walk-in. All of these are addressable factors from an operational standpoint and should be considered when performing quality improvement of hospital protocols.

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Aneurysmal ruptures are a life-threatening pathology, and while the aorta is the principal location, any aneurysmal rupture can be fatal. Most result from chronic diseases, such as hypertension, diabetes, and vasculitis. Nevertheless, a rupture can result in acute decompensation and must be recognized and addressed quickly to limit morbidity and mortality. The authors describe a case of a 66-year-old female who presented to the emergency department (ED) for abdominal pain and syncope. Even though imaging did not explicitly show the specific site of rupture of the hepatic artery, the positive Rapid Ultrasound for Shock and Hypotension (RUSH) exam and aortic dissection on computed tomography angiography along with her clinical picture (hypotension, abdominal pain, decreased capillary refill, grey skin) raised our suspicions for critical pathology. Exploratory laparotomy revealed a ruptured hepatic artery aneurysm. Her hospital course was complicated by ischemic necrosis of the gallbladder, spleen, and liver, requiring cholecystectomy, splenectomy, and partial hepatectomy, but she was discharged to rehabilitation and expected to make a recovery. This case displays the importance of using ultrasonography early to aid in expedited diagnosis and treatment as well as maintaining a high suspicion for vascular pathology in the setting of hemorrhagic shock.