Implementation of a prealert to improve in-hospital treatment of anticoagulant-associated strokes: analysis of a prehospital pathway change in a large UK centralised acute stroke system

Ashton, Christopher; Sammut‐Powell, Camilla; Birleson, Emily; Mayoh, Duncan; Sperrin, Matthew; Parry‐Jones, Adrian

doi:10.1136/bmjoq-2019-000883

Cited by 4 publications

(6 citation statements)

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“…Yet, large volumes of mimics can result in delayed care, particularly in centralized services, and reduced resource availability for those that are experiencing a stroke ( 11 , 12 ). Additionally, prehospital stroke care has been shown to affect in-hospital care processes, such as door-to-scan times ( 13 , 14 ). Consequently, the prehospital setting has been identified as an area for improvement in stroke care ( 15 ).…”

Section: Introductionmentioning

confidence: 99%

Differences in Characteristics and Ambulance Pathway Adherence Between Strokes and Mimics Presenting to a Large UK Centralized Hyper Acute Stroke Unit (HASU)

et al. 2021

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Background: In Greater Manchester (GM), prehospital clinicians use the Face Arm Speech Test (FAST) to identify suspected stroke patients alongside pathway exclusions. Within the centralized stroke service, patients with a suspected stroke are taken directly to a Hyper Acute Stroke Unit (HASU), often bypassing their local emergency department (ED). However, many of these patients are experiencing an illness that looks like a stroke but is not a stroke. The data collected in the prehospital setting is rarely used in research yet could give valuable insights into the performance of the pathway.Aim: To evaluate the presenting symptoms and final diagnoses of prehospital suspected strokes and to evaluate the adherence of prehospital stroke pathway exclusions.Methods: We analyzed data from all patients brought in by ambulance and admitted on the stroke pathway between 01/09/15 and 28/02/17. Patient demographics and all data recorded in the prehospital setting were evaluated to identify differences in stroke, TIA, and mimic patients. Pathway adherence was assessed according to whether the patient was local or out-of-area (OOA) and bypassed their local ED.Results: A total of 4,216 suspected strokes were identified: 2,213 (52.5%) had a final diagnosis of stroke, 492 (11.7%) experienced a transient ischemic attack (TIA), and 1,511 (35.8%) were stroke mimics. There were 714 (16.9%) patients that were identified as having at least one pathway exclusion or were FAST negative, of which 270 (37.8%) experienced a stroke. The proportion of strokes was significantly lower in those with a pathway exclusion (41.8 vs. 53.5%; p < 0.001) and the proportion of breaches tended to be comparable or higher in the local population.Discussion: There are high volumes of stroke mimics but identified differences indicate there is an opportunity to better utilize prehospital data. Ambulance clinicians were able to correctly overrule FAST negative results and the volume of these suggest that FAST alone may be too restrictive.

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Section: Introductionmentioning

confidence: 99%

Differences in Characteristics and Ambulance Pathway Adherence Between Strokes and Mimics Presenting to a Large UK Centralized Hyper Acute Stroke Unit (HASU)

et al. 2021

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“…6,19 Because of the potential for rapid deterioration of patients with life-threatening hemorrhage, even the early accurate identification of OAC use history can have important downstream benefits. 20 The identification of OAC use history may prompt earlier notification to receiving hospitals or transportation to specialty care centers; for example, direct transportation to a trauma center. 20 Nishijima, et al found that the addition of OAC use to trauma triaging criteria improved the sensitivity for detection of intracranial hemorrhage and death.…”

Section: Discussionmentioning

confidence: 99%

Oral Anticoagulant Use by Emergency Medical Services Patients in the United States

Wang,

Yu,

Chu

et al. 2023

Preprint

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OBJECTIVEOral anticoagulant (OAC) use raises the risk of death in life-threatening conditions such as hemorrhagic stroke, trauma and traumatic brain injury. We sought to describe the national characteristics of Emergency Medical Services patients with a history of OAC use.METHODSWe used prehospital electronic medical record data from 2018-2020 from the ESO Data Collaborative. We included adults (age≥18 years) receiving 911 EMS care. OAC use included warfarin, dabigatran, rivaroxaban and apixaban. We determined the incidence of EMS calls by OAC users as well as their variation by EMS agency. We compared EMS call, patient, and response characteristics between OAC and non-OAC users, including primary impressions and hospital diagnoses.RESULTSThere were 16,244,550 adult 911 EMS events, including 906,575 by OAC users (56 per 1,000 911 events). Compared with non-OAC users, OAC users were more likely to be older (73.6 vs. 56.9 years), white (78.0% vs. 51.4%) and non-Hispanic (84.5% vs. 78.0%). Incidents involving OAC users were more likely at nursing homes, rehabilitation or long-term care facilities (17.0% vs. 9.2%) but less likely to involve trauma (14.7% vs. 18.1%) or cardiac arrest (1.2% vs. 1.4%). Among OAC users, the most common EMS primary clinical impressions were chest pain (7.4%), altered mental status (7.3%), injury (6.5%), abdominal pain (4.3%), and brain injury (2.8%).CONCLUSIONSIn this national series of prehospital events, 1 in 18 adult EMS encounters involved OAC users. These results provide key perspectives on the presentation of the OAC users in EMS care.

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“…Time is critical in assessing and treating intracranial haemorrhage associated with anticoagulants, so actively inquiring about anticoagulant use is crucial. Prehospital recognition and advance notification of the hospital stroke team can save valuable time, ensuring prompt brain imaging to establish the diagnosis of intracranial haemorrhage [45,46]. Establishing the time of the last dose of anticoagulant can be challenging in patients with intracranial haemorrhage suffering reduced consciousness or communication difficulties.…”

Section: Evaluation and Treatment Of Spontaneous Intracranial Haemorr...mentioning

confidence: 99%

Management of major bleeding for anticoagulated patients in the Emergency Department: an European experts consensus statement

Backus

Beyer‐Westendorf

Body

et al. 2023

European Journal of Emergency Medicine

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An increasing number of patients presenting to the emergency department (ED) with life-threatening bleeding are using oral anticoagulants, such as warfarin, Factor IIa and Factor Xa inhibitors. Achieving rapid and controlled haemostasis is critically important to save the patient’s life. This multidisciplinary consensus paper provides a systematic and pragmatic approach to the management of anticoagulated patients with severe bleeding at the ED. Repletion and reversal management of the specific anticoagulants is described in detail. For patients on vitamin K antagonists, the administration of vitamin K and repletion of clotting factors with four-factor prothrombin complex concentrate provides real-time ability to stop the bleeding. For patients using a direct oral anticoagulant, specific antidotes are necessary to reverse the anticoagulative effect. For patients receiving the thrombin inhibitor dabigatran, treatment with idarucizamab has been demonstrated to reverse the hypocoagulable state. For patients receiving a factor Xa inhibitor (apixaban or rivaroxaban), andexanet alfa is the indicated antidote in patients with major bleeding. Lastly, specific treatment strategies are discussed in patients using anticoagulants with major traumatic bleeding, intracranial haemorrhage or gastrointestinal bleeding.

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Implementation of a prealert to improve in-hospital treatment of anticoagulant-associated strokes: analysis of a prehospital pathway change in a large UK centralised acute stroke system

Abstract: Implementation of a prealert to improve in-hospital treatment of anticoagulant-associated strokes: analysis of a prehospital pathway change in a large UK centralised acute stroke system.

Cited by 4 publications

References 5 publications

Differences in Characteristics and Ambulance Pathway Adherence Between Strokes and Mimics Presenting to a Large UK Centralized Hyper Acute Stroke Unit (HASU)

Differences in Characteristics and Ambulance Pathway Adherence Between Strokes and Mimics Presenting to a Large UK Centralized Hyper Acute Stroke Unit (HASU)

Oral Anticoagulant Use by Emergency Medical Services Patients in the United States

Management of major bleeding for anticoagulated patients in the Emergency Department: an European experts consensus statement

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