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Research paper thumbnail of Overcrowding and Its Association With Patient Outcomes in a Median-Low Volume Emergency Department

Journal of Clinical Medicine Research, 2017

Background: Crowding occurs commonly in high volume emergency departments (ED) and has been assoc... more Background: Crowding occurs commonly in high volume emergency departments (ED) and has been associated with negative patient care outcomes. We aim to assess ED crowding in a median-low volume setting and evaluate associations with patient care outcomes. Methods: This was a prospective single-center study from November 14, 2016 until December 14, 2016. ED crowding was measured every 2 h by three different estimation tools: National Emergency Department Overcrowding Score (NEDOCS); Community Emergency Department Overcrowding Score (CEDOCS); and Severely-overcrowding Overcrowding and Not-overcrowding Estimation Tool (SONET) categorized under six different levels of crowding (not busy, busy, extremely busy, overcrowded, severely overcrowded, and dangerously overcrowded). Crowding scores were assigned to each patient upon ED arrival. We evaluated the distributions of crowding and patient ED length of stay (ED LOS) across estimation tools. Accelerated failure time models were utilized to estimate time ratios and their corresponding 95% confidence intervals comparing median LOS across levels of crowding within each estimation tool. Results: This study comprised 2,557 patients whose median ED LOS was 150 min. Approximately 2% of patients arrived during 2 h time intervals deemed overcrowded regardless of the crowding tool used. Median ED LOS increased with the increased level of ED crowding and prolonged median ED LOS (> 150 min) occurred at ED of extremely busy status. Time ratios ranged from 1.09 to 1.48 for NE-DOCS, 1.25-1.56 for CEDOCS, and 1.26-1.72 for SONET. Conclusion: Overcrowding rarely occurred in study ED with median-low annual volume and might not be a valuable marker for ED crowding report. Though similar patterns of prolonged ED LOS occurred with increased levels of ED crowding, it seems crowding alerts should be initiated during extremely busy status in this ED setting.

Research paper thumbnail of Abstract NS9: Two Level Stroke Activation: Fine Tuning Stroke Criteria

Stroke, Feb 1, 2022

Background: The burden of acute stroke alerts on hospital resources and staff have grown with exp... more Background: The burden of acute stroke alerts on hospital resources and staff have grown with expanding treatment timelines. The purpose of this project is to develop a nurse activated acute stroke process to accurately capture ischemic and hemorrhage stroke amendable for acute treatment with a two level activation model for 0-4 hours (level 1) and 4-24 hours (level 2) from last known well. Methods: Prospective quality improvement data abstracted on patients in a five-hospital regional telestroke network from October 2020 thru June 2021 with the current single level 24-hour stroke symptom protocol. We retrospectively applied our proposed two level activation model to our data to look for accuracy in stroke diagnosis, proportion of stroke mimics, missed stroke interventions, including intracerebral hemorrhage (ICH), and telestroke provider time spent. We used standard error of mean (SEM) to measure discrepancy of process. Results: A total of 340 stroke activation were captured. Of those, 54% (183/340) were discharged without a stroke diagnosis, 27% (93/340) ischemic, 14% (48/340) transient ischemic attack, 4% (13/340) ICH, 1% (3/340) subarachnoid hemorrhage, and 34% (117/340) arrived in the level 2 window. We excluded 5 ICH patients due to arriving comatose necessitating emergent imaging outside of stroke alert process. Comparing single activation versus two level activation resulted in a reduction of stroke alerts (117 versus 21), telestroke provider time (2501 minutes versus 713 minutes), increase in accurate stroke diagnosis (46% versus 76%), decrease in stroke mimics (54% versus 29%), with 1 missed ICH and 1 missed thrombectomy (5%). The single activation showed a mean 11.11% and SEM of 0.023 compared to the two level activation mean 1.99% and SEM of 0.006. Conclusion: Two level stroke activation process was validated to reduce stroke mimics, improve accurate stroke diagnoses, maximize resources utilization, and capture 95% of all ischemic strokes with large vessel occlusions, therefore the new process will be implemented within our large telestroke system following staff education.

Research paper thumbnail of MK-801-induced sprouting by CGRP immunoreactive primary afferent fibers in the dorsal spinal cord of the rat

Neuroscience Letters, Jul 1, 1990

In the present study, rats received daily injections of the N-methyl-t)-aspartate (NMDA) receptor... more In the present study, rats received daily injections of the N-methyl-t)-aspartate (NMDA) receptor antagonist, MK-801, over 30 consecutive days. The effects of MK-801 on the distribution of calcitonin generelated peptide (CGRP)-immunoreactive fibers in the dorsal spinal cord of the rat were subsequently examined. In addition to the normal immunostaining pattern in laminae I, II and lateral V, a dense network of CGRP-immunoreactive fibers was observed along the medial border of the dorsal horn and within the dorsal grey commissure. This marked increase in immunoreactivity was virtually eliminated following dorsal rhizotomy. These observations suggest that MK-801 induces intraspinal sprouting by CGRP immunoreactive primary afferent fibers in vivo.

Research paper thumbnail of Overcrowding and Its Association With Patient Outcomes in a Median-Low Volume Emergency Department

Journal of clinical medicine research, 2017

Crowding occurs commonly in high volume emergency departments (ED) and has been associated with n... more Crowding occurs commonly in high volume emergency departments (ED) and has been associated with negative patient care outcomes. We aim to assess ED crowding in a median-low volume setting and evaluate associations with patient care outcomes. This was a prospective single-center study from November 14, 2016 until December 14, 2016. ED crowding was measured every 2 h by three different estimation tools: National Emergency Department Overcrowding Score (NEDOCS); Community Emergency Department Overcrowding Score (CEDOCS); and Severely-overcrowding Overcrowding and Not-overcrowding Estimation Tool (SONET) categorized under six different levels of crowding (not busy, busy, extremely busy, overcrowded, severely overcrowded, and dangerously overcrowded). Crowding scores were assigned to each patient upon ED arrival. We evaluated the distributions of crowding and patient ED length of stay (ED LOS) across estimation tools. Accelerated failure time models were utilized to estimate time ratios ...

Research paper thumbnail of MK-801-induced sprouting by CGRP immunoreactive primary afferent fibers in the dorsal spinal cord of the rat

Neuroscience Letters, 1990

In the present study, rats received daily injections of the N-methyl-t)-aspartate (NMDA) receptor... more In the present study, rats received daily injections of the N-methyl-t)-aspartate (NMDA) receptor antagonist, MK-801, over 30 consecutive days. The effects of MK-801 on the distribution of calcitonin generelated peptide (CGRP)-immunoreactive fibers in the dorsal spinal cord of the rat were subsequently examined. In addition to the normal immunostaining pattern in laminae I, II and lateral V, a dense network of CGRP-immunoreactive fibers was observed along the medial border of the dorsal horn and within the dorsal grey commissure. This marked increase in immunoreactivity was virtually eliminated following dorsal rhizotomy. These observations suggest that MK-801 induces intraspinal sprouting by CGRP immunoreactive primary afferent fibers in vivo.

Research paper thumbnail of Overcrowding and Its Association With Patient Outcomes in a Median-Low Volume Emergency Department

Journal of Clinical Medicine Research, 2017

Background: Crowding occurs commonly in high volume emergency departments (ED) and has been assoc... more Background: Crowding occurs commonly in high volume emergency departments (ED) and has been associated with negative patient care outcomes. We aim to assess ED crowding in a median-low volume setting and evaluate associations with patient care outcomes. Methods: This was a prospective single-center study from November 14, 2016 until December 14, 2016. ED crowding was measured every 2 h by three different estimation tools: National Emergency Department Overcrowding Score (NEDOCS); Community Emergency Department Overcrowding Score (CEDOCS); and Severely-overcrowding Overcrowding and Not-overcrowding Estimation Tool (SONET) categorized under six different levels of crowding (not busy, busy, extremely busy, overcrowded, severely overcrowded, and dangerously overcrowded). Crowding scores were assigned to each patient upon ED arrival. We evaluated the distributions of crowding and patient ED length of stay (ED LOS) across estimation tools. Accelerated failure time models were utilized to estimate time ratios and their corresponding 95% confidence intervals comparing median LOS across levels of crowding within each estimation tool. Results: This study comprised 2,557 patients whose median ED LOS was 150 min. Approximately 2% of patients arrived during 2 h time intervals deemed overcrowded regardless of the crowding tool used. Median ED LOS increased with the increased level of ED crowding and prolonged median ED LOS (> 150 min) occurred at ED of extremely busy status. Time ratios ranged from 1.09 to 1.48 for NE-DOCS, 1.25-1.56 for CEDOCS, and 1.26-1.72 for SONET. Conclusion: Overcrowding rarely occurred in study ED with median-low annual volume and might not be a valuable marker for ED crowding report. Though similar patterns of prolonged ED LOS occurred with increased levels of ED crowding, it seems crowding alerts should be initiated during extremely busy status in this ED setting.

Research paper thumbnail of Abstract NS9: Two Level Stroke Activation: Fine Tuning Stroke Criteria

Stroke, Feb 1, 2022

Background: The burden of acute stroke alerts on hospital resources and staff have grown with exp... more Background: The burden of acute stroke alerts on hospital resources and staff have grown with expanding treatment timelines. The purpose of this project is to develop a nurse activated acute stroke process to accurately capture ischemic and hemorrhage stroke amendable for acute treatment with a two level activation model for 0-4 hours (level 1) and 4-24 hours (level 2) from last known well. Methods: Prospective quality improvement data abstracted on patients in a five-hospital regional telestroke network from October 2020 thru June 2021 with the current single level 24-hour stroke symptom protocol. We retrospectively applied our proposed two level activation model to our data to look for accuracy in stroke diagnosis, proportion of stroke mimics, missed stroke interventions, including intracerebral hemorrhage (ICH), and telestroke provider time spent. We used standard error of mean (SEM) to measure discrepancy of process. Results: A total of 340 stroke activation were captured. Of those, 54% (183/340) were discharged without a stroke diagnosis, 27% (93/340) ischemic, 14% (48/340) transient ischemic attack, 4% (13/340) ICH, 1% (3/340) subarachnoid hemorrhage, and 34% (117/340) arrived in the level 2 window. We excluded 5 ICH patients due to arriving comatose necessitating emergent imaging outside of stroke alert process. Comparing single activation versus two level activation resulted in a reduction of stroke alerts (117 versus 21), telestroke provider time (2501 minutes versus 713 minutes), increase in accurate stroke diagnosis (46% versus 76%), decrease in stroke mimics (54% versus 29%), with 1 missed ICH and 1 missed thrombectomy (5%). The single activation showed a mean 11.11% and SEM of 0.023 compared to the two level activation mean 1.99% and SEM of 0.006. Conclusion: Two level stroke activation process was validated to reduce stroke mimics, improve accurate stroke diagnoses, maximize resources utilization, and capture 95% of all ischemic strokes with large vessel occlusions, therefore the new process will be implemented within our large telestroke system following staff education.

Research paper thumbnail of MK-801-induced sprouting by CGRP immunoreactive primary afferent fibers in the dorsal spinal cord of the rat

Neuroscience Letters, Jul 1, 1990

In the present study, rats received daily injections of the N-methyl-t)-aspartate (NMDA) receptor... more In the present study, rats received daily injections of the N-methyl-t)-aspartate (NMDA) receptor antagonist, MK-801, over 30 consecutive days. The effects of MK-801 on the distribution of calcitonin generelated peptide (CGRP)-immunoreactive fibers in the dorsal spinal cord of the rat were subsequently examined. In addition to the normal immunostaining pattern in laminae I, II and lateral V, a dense network of CGRP-immunoreactive fibers was observed along the medial border of the dorsal horn and within the dorsal grey commissure. This marked increase in immunoreactivity was virtually eliminated following dorsal rhizotomy. These observations suggest that MK-801 induces intraspinal sprouting by CGRP immunoreactive primary afferent fibers in vivo.

Research paper thumbnail of Overcrowding and Its Association With Patient Outcomes in a Median-Low Volume Emergency Department

Journal of clinical medicine research, 2017

Crowding occurs commonly in high volume emergency departments (ED) and has been associated with n... more Crowding occurs commonly in high volume emergency departments (ED) and has been associated with negative patient care outcomes. We aim to assess ED crowding in a median-low volume setting and evaluate associations with patient care outcomes. This was a prospective single-center study from November 14, 2016 until December 14, 2016. ED crowding was measured every 2 h by three different estimation tools: National Emergency Department Overcrowding Score (NEDOCS); Community Emergency Department Overcrowding Score (CEDOCS); and Severely-overcrowding Overcrowding and Not-overcrowding Estimation Tool (SONET) categorized under six different levels of crowding (not busy, busy, extremely busy, overcrowded, severely overcrowded, and dangerously overcrowded). Crowding scores were assigned to each patient upon ED arrival. We evaluated the distributions of crowding and patient ED length of stay (ED LOS) across estimation tools. Accelerated failure time models were utilized to estimate time ratios ...

Research paper thumbnail of MK-801-induced sprouting by CGRP immunoreactive primary afferent fibers in the dorsal spinal cord of the rat

Neuroscience Letters, 1990

In the present study, rats received daily injections of the N-methyl-t)-aspartate (NMDA) receptor... more In the present study, rats received daily injections of the N-methyl-t)-aspartate (NMDA) receptor antagonist, MK-801, over 30 consecutive days. The effects of MK-801 on the distribution of calcitonin generelated peptide (CGRP)-immunoreactive fibers in the dorsal spinal cord of the rat were subsequently examined. In addition to the normal immunostaining pattern in laminae I, II and lateral V, a dense network of CGRP-immunoreactive fibers was observed along the medial border of the dorsal horn and within the dorsal grey commissure. This marked increase in immunoreactivity was virtually eliminated following dorsal rhizotomy. These observations suggest that MK-801 induces intraspinal sprouting by CGRP immunoreactive primary afferent fibers in vivo.