Der Einfluss notärztlicher Beteiligung auf die präklinische Versorgungsqualität und Versorgungszeiten beim akuten ischämischen Schlaganfall
The influence of emergency doctors on prehospital care quality and pre- and in-hospital care intervals in acute ischemic stroke
by Alisa von Seydlitz-Kurzbach
Date of Examination:2024-11-07
Date of issue:2024-10-16
Advisor:PD Dr. Nils Kunze-Szikszay
Referee:PD Dr. Dirk Fitzner
Referee:Prof. Dr. Dieter Kube
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Abstract
English
Cerebrovascular diseases, such as the ischemic stroke, are the third most common cause of death in Germany and the second most common cause of death worldwide (Heuschmann et al. 2010; Moskowitz et al. 2010). One of the main factors for an optimal functional outcome is the shortest possible latency between the appearance of the occlusion and the reperfusion of the affected vascular area, since the benefit of recanalization decreases with every hour that passes. Members of the emergency team play a key role here. It is e.g. their responsibility to inform the „target hospital“ in order to shorten the in-hospital streamlining (Grautoff et al. 2022). In addition, the quality of care of the emergency team influences the course of the disease. Until now, there are no standard recommendations in Germany if an emergency doctor is necessary for an optimal treatment of stroke patients. Since standards of care apply to everyone working in emergency medicine regardless of their education, there should theoretically be no significant difference in the quality of care. This observational study examined whether the care of ischemic stroke patients by an emergency team staffed by an emergency doctor compared to a team consisting solely of paramedics had a relevant influence on pre- and in-hospital care times, vital signs, neurological and neuroradiological scores and the functional outcome. We examined a total of 211 patients with an acute ischemic stroke who were treated at the Universitätsmedizin Göttingen between the 8th of September of 2015 and the 11th of November of 2018. All patients received an endovascular thrombectomy. The cohort was divided into a group consisting of 126 patients who were treated by an additional emergency doctor and another group consisting of 85 patients who were cared for solely by paramedics. With regard to the documented systolic blood pressure, it was noticeable that relevant hypotension of ≥ 120 mmHg was detected in 16% of the times in the group treated by paramedics and in the group who were treated by an emergency doctor. Treatment by an emergency doctor therefore did not appear to have any therapeutic benefit for the patients in this regard. Both groups made the correct diagnosis in 87% (emergency doctor group) and 86% (paramedic group). Showing that both groups were able to identify the stroke reliably. But there was a significant difference considering the quality of care with regard to the number of i.v.´s. Patients treated solely by paramedics were significantly more likely to receive no i.v. and in hardly any case more than one i.v. was established in this group treated in contrast to patients taken care of by an emergency doctor. In this group hardly no patient got no i.v. Study participants who were cared for by an emergency doctor showed a lower GCS and a higher NIHSS, reflecting the - most likely - more severe neurological deficits. In terms of pre-hospital care times, the data showed that patients were treated more quickly at the place were the first symptoms occurred in the group treated by an emergency doctor. Patients treated by an emergency doctor got to the CT more quickly, meaning that the diagnostics were performed faster. The time interval to endovascular thrombectomy did not differ significantly in between the two groups. The One-Stop-Management showed a clear benefit in terms of shortening the in-hospital treatment times. There was no significant difference between the two study groups that were treated using One-Stop-Management. The results of this study do not allow a clear conclusion to be drawn. A structured emergency call query by the responsible „Leitstelle“ is obviously of great relevance. This helps to select the appropriate emergency team. It might be necessary to put more focus on the importance of i.v.´s during the educational career of paramedics as it was shown, that they did not receive i.v.´s as regularly as when an emergency doctor was involved. Patients treated by an emergency doctor were treated faster considering the prehospital interval. As there is more staff around to treat the patients when there is an emergency doctor with another paramedic around, it is likely that this was the reason for this result. The in-hospital care time intervals were most significantly influenced by the One-Stop-Management. This result suggest that standardized procedural instructions that apply to everyone have the greatest effect in in-hospital care intervals.
Keywords: acute ischemic stroke; emergency doctor involvement; endovascular thrombectomy