Crowded ERs don't hinder stroke care: study

NEW YORK (Reuters Health) - Crowded emergency rooms have been linked to delays in various treatments, but does that also apply to stroke care?

A new study suggests the answer is no-provided patients arrive at the hospital within three hours of developing symptoms of a stroke.

"Emergency departments are designed to take care of patients who are critically ill, and patients who are explicitly prioritized (for stroke treatment) are not impacted by the crowding," said Dr. Jesse M. Pines, Director of the Center for Health Care Quality at George Washington University Medical Center in Washington, D.C., who helped conduct the research.

"But those who are not prioritized do experience delays of up to an hour or more at crowded times," Pines told Reuters Health.

The consequences of those delays could be significant, added Pines, whose group published its results online this month in the journal Stroke. As the study found, in some cases crowding may push back the time it takes certain stroke patients to receive a computed tomography (CT) scan of their brain.

Such scans are crucial for determining not only whether someone truly had a stroke but whether the problem involves blocked or leaking blood vessels, a key consideration for deciding what treatment the patient needs.

Strokes affect an estimated 800,000 people in the United States each year, causing 140,000 deaths and many more cases of permanent disability, according to the American Stroke Association.

For their study, Pines and his colleagues reviewed the medical records of more than 500 stroke patients treated at two Philadelphia hospitals. One was a large teaching facility that specialized in stroke. The other was a nearby community hospital with a medium sized emergency room (ER) but no team of stroke experts.

At the stroke center, a team of experts is available to respond within minutes to a new case, according to the researchers. In addition, a CT scanner sits next to the ER-while at the other hospital the machine is three floors up and requires an elevator trip to transport patients.

Half the patients received treatment within three hours of their stroke symptoms being recognized; the other half did not arrive until three hours after symptoms appeared.

For those in the first group, a crowded ER-defined by the number of patients admitted, in the waiting room and other measures of occupancy-did not appear to affect the speed with which they received treatment, the researchers reported. That was true even at the stroke center, whose ER sees nearly twice the number of patients each year than the other hospital, 57,000 versus 30,000.

But when patients arrived at the ER more than 3 hours after their symptoms started, crowding seemed to slow the pace of care somewhat. In particular, these patients were more likely to have to wait more than 25 minutes for a CT scan and to wait more than 45 minutes after arrival to have that scan interpreted.

The three-hour period was the "golden window" for getting clot-busting drugs. About 90 percent of all strokes are due to blood clots. That period recently was pushed to four and a half hours after the onset of stroke symptoms-which include sudden paralysis, loss of vision and difficulty speaking.

Pines said the findings might look better in the context of the extended window. "More people would be prioritized and fewer people's care would be impacted by crowding," he explained.

"There are many treatments that stroke patients who don't get clot-busting drugs still need," such as brain surgery or other procedures, Pines said. "While there is no clear evidence that delaying their care worsens outcomes, in general we want to figure out as early as possible who has particular types of strokes, like ones that involve brain bleeding and ones that don't."

"Right now we can't get away without doing a brain scan of some kind" on patients suspected of having suffered a stroke, said Dr. Larry Goldstein, professor of medicine and director of the Duke Stroke Center at Duke University Medical Center in Durham, North Carolina, and a spokesperson for the American Stroke Association.

"That's always going to be a rate-limiting step," said Goldstein, who was not involved in the research.

SOURCE: http://bit.ly/f1PW0Y Stroke, online February 10, 2011.