Prospective randomised comparison between thrombolysis, rescue PTCA, and primary PTCA in patients with extensive myocardial infarction admitted to a hospital without PTCA facilities: a safety and feasibility study. (9/556)

OBJECTIVE: To assess the safety and feasibility of acute transport followed by rescue percutaneous transluminal coronary angioplasty (PTCA) or primary PTCA in patients with acute myocardial infarction initially admitted to a hospital without PTCA facilities. DESIGN: In a multicentre randomised open trial, three regimens of treatment of acute large myocardial infarction were compared for patients admitted to hospitals without angioplasty facilities: thrombolytic treatment with alteplase (75 patients), alteplase followed by transfer to the PTCA centre and (if indicated) rescue PTCA (74 patients), or transfer for primary PTCA (75 patients). RESULTS: Between 1995 and 1997 224 patients were included. Baseline characteristics were distributed evenly. Transport to the PTCA centre was without severe complications in all patients. Mean (SD) delay from onset of symptoms to randomisation was 130 (75) minutes and from randomisation to angiography 90 (25) minutes. Death or recurrent infarction within 42 days occurred in 12 patients in the thrombolysis group, in 10 patients in the rescue PTCA group, and in six patients in the primary PTCA group. These differences were not significant. CONCLUSIONS: Acute transfer for rescue PTCA or primary PTCA in patients with extensive myocardial infarction is feasible and safe. Efficacy of rescue PTCA or primary PTCA in this setting will have to be tested in larger series before this approach can be implemented as "routine treatment" for patients with extensive myocardial infarction.  (+info)

Thrombolysis in acute myocardial infarction: the safety and efficiency of treatment in the accident and emergency department. (10/556)

OBJECTIVES: To assess the safety and efficiency with which the accident and emergency (A&E) department provides thrombolytic treatment for patients with acute myocardial infarction (AMI). METHODS: A prospective observational study based in a teaching hospital for one year. All patients who presented with the clinical and electrocardiographic indications for thrombolytic treatment were studied. Patients were grouped according to route of admission. After logarithmic transformation, the "door to needle times" of the groups were compared using a two tailed Student's t test. Arrhythmias and complications after thrombolytic treatment were noted. The appropriateness of the treatment was assessed retrospectively by review of the clinical records and electrocardiograms, judged against locally agreed eligibility criteria. RESULTS: Data from 153 patients were analysed; 138/153 (90%) patients were admitted via the A&E department. The shortest door to needle times were seen in those patients thrombolysed by A&E staff within the A&E department (mean 43.8 minutes). The transfer of A&E patients to the coronary care unit (CCU) was associated with a significant increase in the door to needle time (mean 58.8 minutes, p = 0.004). Only one malignant arrhythmia occurred during the administration of thrombolysis in the A&E department, and this was managed effectively. No arrhythmias occurred during transfer of thrombolysed patients to the CCU. In every case, the decision to administer thrombolysis was retrospectively judged to have been appropriate. CONCLUSIONS: The A&E department provides appropriate, safe, and timely thrombolytic treatment for patients with AMI. Transferring A&E patients to the CCU before thrombolysis is associated with an unnecessary treatment delay.  (+info)

Direct admission to an extended-care facility from the emergency department. (11/556)

BACKGROUND: Many patients are admitted to acute-care hospitals when their medical needs might be more appropriately met in an extended-care facility (ECF). OBJECTIVE: To describe a cohort of patients who were admitted from an emergency department to an ECF. DESIGN: Observational cohort study. PARTICIPANTS: 121 enrollees of Harvard Vanguard Medical Associates who were admitted directly from an emergency department to an ECF between October 1, 1994, and December 31, 1997. OUTCOME MEASURES: Mean length of stay, charges per patient, and discharge disposition (discharged to home, discharged to a long-term-care facility, died, or transferred to an acute-care hospital within 30 days of ECF admission). RESULTS: Patients admitted directly to an ECF were generally frail and elderly (median age, 75 years). Mean length of stay in the ECF was 11 days; the mean per-patient charge was $3290. Three quarters of patients were discharged from the ECF to their homes. Six percent (seven patients) were transferred from the ECF to an acute-care hospital within 30 days of ECF admission. None of these transfers clearly suggested that the initial decision to directly admit a patient to the ECF was inappropriate. Most patients were satisfied with direct ECF admission: Of the surviving, cognitively intact patients admitted to an ECF in 1997, 71% stated that they would choose direct admission to an ECF over admission to an acute-care hospital if they were "in a similar situation in the future." CONCLUSIONS: For selected patients, direct admission to an ECF seems to be feasible, safe, and acceptable. A randomized, clinical trial is needed to fully assess the safety and cost implications of direct ECF admission.  (+info)

Helicopter transfer offers a potential benefit to patients with acute stroke. (12/556)

BACKGROUND AND PURPOSE: Rapid transport of patients to specialized centers is widely used in the management of myocardial infarction, trauma, and more recently, acute stroke. We evaluated the role of helicopter transportation as it relates to the availability of acute stroke therapies and patients' perceptions of care. METHODS: We reviewed records of all patients transferred to a university hospital within 24 hours of stroke onset from January 1996 to December 1997. Data were collected on demographics, neurological deficit, treatment, and outcome. In addition, a questionnaire was sent to all patients with items about perceived reasons for helicopter transfer, expected and actual treatment, outcome, and overall impression. RESULTS: Helicopter transfer was used for 73 stroke patients. Before transfer, 8 patients (11%) received tissue plasminogen activator (tPA). On arrival, no patient received tPA, 38 patients (52%) were enrolled in acute stroke studies, and 35 patients (48%) received no specific medication. All but 2 patients were managed in a specialized stroke unit. Of the 35 patients who received no specific therapy, 24 (69%) were ineligible for treatment or study enrollment owing to 1 or more exclusion criteria, but rarely (3%) because of time. Of the 45 respondents to the survey, most (84%) were transferred at the suggestion of the physician at the originating hospital because of a possible treatment that was unavailable there. Most patients (93%) believed that there was a benefit from emergent helicopter transfer to a stroke center, although 40% of respondents received no specific therapy. CONCLUSION: Interhospital transfer by air may benefit a substantial number of acute stroke patients by offering potential therapies and intensive management not available elsewhere.  (+info)

Effects of a physiotherapist-led stroke training programme for nurses. (13/556)

AIM: to assess the effects of a physiotherapist-led stroke training programme for nurses working in a rehabilitation ward on clinical practice and patient outcome. METHOD: before and after group comparison with outcome assessment by observational and quantitative methods. Non-participant observation before and after the 5-month training programme recorded patient position, transfers and contact with nursing staff. Quantitative assessments of disability, satisfaction and mood were made at baseline, discharge and 4 months after stroke onset. We also noted selected stroke complications, rehabilitation ward length of stay and discharge destination. RESULTS: there was a significant improvement in the number of observed 'good' transfers of patients undertaken by nurses (chi2 = 9.13, df = 1, P = 0.003) but the training programme had no impact on the time the patients spent in 'poor' positions. There was no significant difference between the two groups for Barthel index scores at discharge and at 4 months. Neither was there any significant difference in the Hospital Anxiety and Depression scale, occurrence of secondary complications, length of stay or the Patient and Carer Satisfaction Questionnaires. CONCLUSION: within the limitations of the research design adopted, some improvements in clinical practice were reported but there were no significant differences in patient outcome. The training programme required no additional resources and should be replicable in most district general hospitals.  (+info)

Premedication before intubation in UK neonatal units. (14/556)

AIMS: To establish the extent and type of premedication used before intubation in neonatal units in the United Kingdom. METHODS: A structured telephone survey was conducted of 241 eligible units. Units were subdivided into those that routinely intubated and ventilated babies (routine group) and those that transferred intubated and ventilated babies (transfer group). RESULTS: Of the units contacted, 239 (99%) participated. Only 88/239 (37%) gave any sedation before intubating on the unit and only 34/239 (14%) had a written policy covering this. Morphine was used most commonly (66%), with other opioids and benzodiazepines used less frequently. Of the 88 units using sedation, 19 (22%) also used paralysis. Suxamethonium was given by 10/19 (53%) but only half of these combined it with atropine. Drug doses varied by factors of up to 200, even for commonly used drugs. CONCLUSION: Most UK neonatal units do not sedate babies before intubating, despite evidence of physiological and practical benefits. Only a minority have written guidelines, which prohibits auditing of practice.  (+info)

Improving outcome after traumatic brain injury--progress and challenges. (15/556)

This article describes the rapid advances in the head injury field which have taken place within the professional lifetime of many doctors in practice today. These have led to a better understanding of what happens in the injured brain and how these events might be manipulated to achieve better outcomes. Clinical tools we now take for granted, like the CT scanner and the Glasgow Coma Scale, were new developments 25 years ago. They provided a foundation on which clinicians and basic scientists could build what we now know: what to assess in the patient, how to respond to certain findings, what imaging to do, how to plan treatment rationally, how to minimise brain damage at different stages after injury, how to predict and measure outcome, what disabled survivors need, and how to organise the service to do the greatest good for the most people. Some of these topics raise as many questions as answers. The head injury field may be broad but it has essential unity. At one extreme, some patients have a life-threatening illness where the acts and omissions of the clinical team can powerfully influence not only survival but its quality. Later the drama of the acute phase gives way to the 'hidden disabilities' of the long-term deficits which so many survivors have. At the other end of the severity spectrum is the relatively vast number of people who suffer an apparently mild head injury, a few of whom deteriorate and need urgent treatment, and many of whom have unspectacular but, nevertheless, disabling problems. The article attempts to address this broad canvas. Clinicians, neuroscientists, policy makers, and service users must work together to address the major scientific, individual, and population challenges posed by head injury. Much has already been achieved, but much remains to be done, especially in translating 'what we know' into 'what we do'.  (+info)

Trends in special (high-security) hospitals. 2: Residency and discharge episodes, 1986-1995. (16/556)

BACKGROUND: It has been argued that many patients in special hospital beds do not need to be there. In the 1990s there were initiatives to discharge women and people with learning difficulties. AIMS: To test for trends in special hospital discharges and to examine annual resident cohorts. METHOD: This study was from case registers and hospital records. The main measures were numbers and annual rates for referrals and beds offered; the Mental Health Act 1983 (MHA) classification of mental disorder; adjusted population rates by region; admission episodes; legal category of detention; admission source and type of offence. RESULTS: The median annual number of residents was 1859 (range 1697-1910), with an 8% fall for the period. This particularly affected people in mental impairment categories. Numbers were sustained in the male mental illness groups. Discharges, mainly to other institutions, increased. There was no overall change over the 10 years in length of stay for treatment, but successive admission cohorts from 1986 did show some reduction, even with solely remand order cases excluded. CONCLUSIONS: Service planners need a longitudinal perspective on service use. Trends over 10 years to both fewer admissions and more discharges have reduced the special hospital population, but despite new treatments for schizophrenia, men under mental illness classification, as well as transfer from other secure settings, have gone against this trend.  (+info)