Alexander Isakov

“Picture to Puncture” A Novel Time Metric to Enhance Outcomes in Patients Transferred for Endovascular Reperfusion in Acute Ischemic Stroke

Background— Comprehensive stroke centers allow for regionalization of subspecialty stroke care. Efficacy of endovascular treatments, however, may be limited by delays in patient transfer. Our goal was to identify where these delays occurred and to assess the impact of such delays on patient outcome. Methods and Results— This was a retrospective study evaluating patients treated with endovascular therapy from November 2010 to July 2012 at our institution. We compared patients transferred from outside hospitals with locally treated patients with respect to demographics, imaging, and treatment times. Good outcomes, as defined by 90-day modified Rankin Scale scores of 0 to 2, were analyzed by transfer status as well as time from initial computed tomography to groin puncture (“picture-to-puncture” time). A total of 193 patients were analyzed, with a mean age of 65.8±14.5 years and median National Institutes of Health Stroke Scale score of 19 (interquartile range, 15–23). More than two thirds of the patients (132 [68%]) were treated from referring facilities. Outside transfers were noted to have longer picture-to-puncture times (205 minutes [interquartile range, 162–274] versus 89 minutes [interquartile range, 70–119]; P 7: 50% versus 76%; P <0.001) and significantly worse clinical outcomes (29% versus 51%; P =0.003). In a logistic regression model, picture-to-puncture times were independently associated with good outcomes (odds ratio, 0.994; 95% confidence interval, 0.990–0.999; P =0.009). Conclusions— Delays in picture-to-puncture times for interhospital transfers reduce the probability of good outcomes among treated patients. Strategies to reduce such delays herald an opportunity for hospitals to improve patient outcomes. # Clinical Perspective {#article-title-29}Background— Comprehensive stroke centers allow for regionalization of subspecialty stroke care. Efficacy of endovascular treatments, however, may be limited by delays in patient transfer. Our goal was to identify where these delays occurred and to assess the impact of such delays on patient outcome. Methods and Results— This was a retrospective study evaluating patients treated with endovascular therapy from November 2010 to July 2012 at our institution. We compared patients transferred from outside hospitals with locally treated patients with respect to demographics, imaging, and treatment times. Good outcomes, as defined by 90-day modified Rankin Scale scores of 0 to 2, were analyzed by transfer status as well as time from initial computed tomography to groin puncture (“picture-to-puncture” time). A total of 193 patients were analyzed, with a mean age of 65.8±14.5 years and median National Institutes of Health Stroke Scale score of 19 (interquartile range, 15–23). More than two thirds of the patients (132 [68%]) were treated from referring facilities. Outside transfers were noted to have longer picture-to-puncture times (205 minutes [interquartile range, 162–274] versus 89 minutes [interquartile range, 70–119]; P<0.001), which was attributable to the delays in transfer. This corresponded to fewer patients with favorable Alberta Stroke Program Early CT Scores on preprocedural computed tomographic imaging (Alberta Stroke Program Early CT Scores >7: 50% versus 76%; P<0.001) and significantly worse clinical outcomes (29% versus 51%; P=0.003). In a logistic regression model, picture-to-puncture times were independently associated with good outcomes (odds ratio, 0.994; 95% confidence interval, 0.990–0.999; P=0.009). Conclusions— Delays in picture-to-puncture times for interhospital transfers reduce the probability of good outcomes among treated patients. Strategies to reduce such delays herald an opportunity for hospitals to improve patient outcomes.

Safe Management of Patients With Serious Communicable Diseases: Recent Experience With Ebola Virus

Health care workers (HCWs) in the emergency medical services (EMS) and hospital settings often encounter patients infected with dangerous communicable diseases. Such patients are usually managed without fanfare, but when it was announced on 1 August 2014 that 2 American HCWs infected with Ebola virus disease would return to the United States for treatment, it drew the worlds attention. The means by which Ebola is spread are well-known. Careful adherence to standard, contact, and droplet precautions, as outlined for HCWs by the Centers for Disease Control and Prevention (CDC) (1), prevents exposure to blood or bodily fluids contaminated with this virus. However, images of infected patients arriving at Emory University Hospital looked much different from what might have been expected. How can the sight of HCWs in space suits be reconciled with published CDC infection control guidelines? In this essay, we offer our rationale for adopting the safeguards that were used. Prevention of disease transmission in health care settings, including EMS transport, involves more than the proper use of personal protective equipment (PPE). It also depends on the development and implementation of appropriate administrative policies, work practices, and environmental controls accompanied by focused education, training, and supervision. Health care workers inconsistently adhere to such basic infection control practices as hand hygiene (2), and EMS provider adherence to infection control precautions and equipment disinfection can be suboptimal (3). Environmental samples from clinical settings inside and outside the hospital have revealed contamination with serious pathogens (46). The Grady EMS Biosafety Transport Program and Emory University Hospital Serious Communicable Disease Unit were established more than a decade ago to support the CDC, which is responsible for conducting research and intervening to control the worlds deadliest pathogens. They also support CDCs quarantine station at Hartsfield-Jackson Atlanta International Airport, the busiest airport in the world and a major portal of immigration to the United States. Our goal in creating a special transport and inpatient care team was to close these and other gaps in practice and to facilitate the best care for patients while ensuring the safety of our HCWs and the general public by meticulous adherence to published CDC guidance. The team is educated about serious communicable pathogens, methods of transmission, available vaccines, preexposure and postexposure prophylaxis and treatment for specific infections, and the importance of strict adherence to standard and transmission-based infection control practices. Understanding the nature of the illnesses they confront helps providers overcome apprehension and fear and enables them to render safe and effective care. Training includes special attention to the proper donning and doffing of various PPE. Emergency medical service medics isolate the driver compartment and envelop the interior of the patient compartment with water-impermeable barriers that prevent contamination of surfaces that are difficult to clean and disinfect, which is especially important for patients with active epistaxis, coughing, or vomiting. Patients may be asked to wear a water-impermeable suit to prevent exposure to sites of cutaneous bleeding or an undergarment capable of collecting large volumes of diarrhea. For management of our patients with Ebola, the team met the PPE standard by wearing a Tyvek suit (DuPont); gloves; and a hooded, powered, air-purifying respirator. Tyvek suits afford a high degree of splash protection, an important consideration in light of the copious bodily fluids involved in Ebola infection, which pose a serious risk for exposure. The hooded, powered, air-purifying respirator provided greater splash protection and was cooler and more comfortable to use. It averted eyewear fogging and prevented HCWs from inadvertently touching their face. Should the patients have suddenly required an aerosol-producing procedure, such as airway suctioning or endotracheal intubation, the team would have been properly protected. Although not strictly required, this approach was practical and allowed our HCWs to confidently focus on safely caring for and transporting these patients without needless anxiety and distraction. Patient delivery directly into the isolation unit limited exposure to other patients or visitors at the hospital. Decontamination and disinfection of the ambulance was facilitated by barrier drapes. All environmental surfaces and waste bags were disinfected with an agent approved by the U.S. Environmental Protection Agency, with appropriate surface contact time. Disinfection of the ambulance, collection of infectious waste, and removal of PPE were directly supervised to ensure no violation of technique or breach of protocol. Even without a recognized exposure, the health care team was monitored for subjective illness and fever to ensure that developing illness was recognized and swiftly evaluated. Although the successful arrival of these patients at the isolation unit was guided by 12 years of planning, practice, and experience, it still yielded new lessons. Seemingly stable patients arriving from Ebola-endemic areas have probably had large volume losses without benefit of laboratory assessment and may have significant electrolyte abnormalities that require continuous cardiac monitoring and intravenous access, an intervention that might otherwise be deferred in austere settings to limit the risk for HCW exposure if vascular access is difficult to obtain. In our case, both patients were transported without incident. We believe that a dedicated team is best suited for transport of patients with confirmed serious communicable illness. Although this is a particularly relevant consideration in communities that are close to CDC quarantine stations or biocontainment laboratories, HCWs in every community may be called on to assist a traveler who has recently returned from an Ebola-stricken region. For the future, because communicable disease threats may emerge inside or outside the United States with little or no notice, EMS agencies and hospitals would be prudent to implement measures to identify patients with communicable illness and ensure that their personnel can confidently and safely provide care anywhere and for all pathogens.

Web-Based Self-Triage of Influenza-Like Illness During the 2009 H1N1 Influenza Pandemic

The sudden emergence of 2009 H1N1 influenza in the spring of that year sparked a surge in visits to emergency departments in New York City and other communities. A larger, second wave of cases was anticipated the following autumn. To reduce a potential surge of health system utilization without denying needed care, we enlisted the input of experts from medicine, public health, nursing, information technology, and other disciplines to design, test, and deploy clinical algorithms to help minimally trained health care workers and laypeople make informed decisions about care-seeking for influenza-like illness. The product of this collaboration, named Strategy for Off-Site Rapid Triage (SORT) was disseminated in 2 forms. Static algorithms, posted on the Centers for Disease Control and Preventions Web site, offered guidance to clinicians and telephone call centers on how to manage adults and children with influenza-like illness. In addition, 2 interactive Web sites, http://www.Flu.gov and http://www.H1N1ResponseCenter.com, were created to help adults self-assess their condition and make an informed decision about their need for treatment. Although SORT was anchored in a previously validated clinical decision rule, incorporated the input of expert clinicians, and was subject to small-scale formative evaluations during rapid standup, prospective evaluation is lacking. If its utility and safety are confirmed, SORT may prove to be a useful tool to blunt health system surge and rapidly collect epidemiologic data on future disease outbreaks.

A Survey of Emergency Department 2009 Pandemic Influenza A (H1N1) Surge Preparedness—Atlanta, Georgia, July–October 2009

During August through September 2009, a surge in emergency department (ED) visits for 2009 pandemic influenza A (pH1N1) illness occurred in Georgia, particularly among children. To understand surge preparedness and capacity, we obtained influenza-like illness (ILI) ED visit data from the Georgia State Electronic Notifiable Disease Surveillance System (SendSS) and conducted a retrospective, Internet-based survey among all 26 metro Atlanta ED managers with reference to the period 1 July-1 October 2009. SendSS detected a marked and progressive increase in mean monthly ILI visits from 1 July-1 October 2009, which more than tripled (from 399 to 2196) for the 2 participating EDs that cared for pediatric patients during this time. ED managers reported patient volume surges, resulting in space and supply limitations, especially at pediatric EDs. Most (92%) of the facilities had current pandemic influenza plans. Pandemic planning can help to ensure preparedness for natural and man-made disasters and for future influenza pandemics.

Southeastern Center for Emerging Biologic Threats Tabletop Exercise: Foodborne Toxoplasmosis Outbreak on College Campuses

The use of tabletop exercises as a tool in emergency preparedness and response has proven to be an effective means of assessing readiness for unexpected events. Whereas most exercise developers target a population in a defined space (eg, state, county, metropolitan area, hospital), the Southeastern Center for Emerging Biologic Threats (SECEBT) conducted an innovative tabletop exercise involving an unusual foodborne outbreak pathogen, targeting public health agencies and academic institutions in 7 southeastern states. The exercise tested the ability of participants to respond to a simulated foodborne disease outbreak affecting the region. The attendees represented 4 federal agencies, 9 state agencies, 6 universities, 1 nonprofit organization, and 1 private corporation. The goals were to promote collaborative relationships among the players, identify gaps in plans and policies, and identify the unique contributions of each organization-and notably academic institutions-to outbreak recognition, investigation, and control. Participants discussed issues and roles related to outbreak detection and management, risk communication, and coordination of policies and responsibilities before, during, and after an emergency, with emphasis on assets of universities that could be mobilized during an outbreak response. The exercise generated several lessons and recommendations identified by participants and evaluators. Key recommendations included a need to establish trigger points and protocols for information sharing and alerts among public health, academic, and law enforcement; to establish relationships with local, state, and federal stakeholders to facilitate communications during an emergency; and to catalogue and leverage strengths, assets, and priorities of academic institutions to add value to outbreak responses.

Transport and Management of Patients With Confirmed or Suspected Ebola Virus Disease

The foundation of safe care for patients with confirmed or suspected Ebola virus disease is effective infection control practice, which requires implementation of appropriate administrative policies, work practices, and environmental controls, accompanied by focused education, training, and supervision. In 2002, Emory University partnered with the Centers for Disease Control and Prevention to develop a capability for the evaluation and management of individuals with serious communicable disease. In 2005, the University of Nebraska developed a similar isolation capability. In each case, the hospitals partnered with emergency medical services (EMS) professionals to ensure safe out-of-hospital transport and management of their patients. The objectives of these hospital and out-of-hospital collaborations were to close education, training, and practice gaps to best facilitate the care for patients with serious communicable disease while ensuring the safety of the medics and the general public through meticulous implementation of infection control practices as recommended by Centers for Disease Control and Prevention. The description of practices implemented by EMS teams in these communities for the transport of patients with confirmed Ebola virus disease is shared so that others might more readily implement these practices, policies, and procedures as applicable to their mission requirements and system design. Transport of patients with relevant travel history and development of illness (persons under investigation) is also included.

Urgent air-medical transport: Right patient, place and time.

See related research article by Singh and colleagues, page [579][1] Transport of acutely injured and ill patients by air has become an integral part of regionalized systems of health care. Patient outcomes are improved with use of such trauma systems, which rely on well-trained crews and either

Ebola or Not? Evaluating the Ill Traveler From Ebola-Affected Countries in West Africa

Most ill travelers returning from Ebola-affected countries have not had Ebola. However, institutions and public health departments need to be prepared. We present our experience triaging, evaluating and managing 25 ill returned travelers from these countries.

Acute Carpal Tunnel Syndrome in a Diver: Evidence of Peripheral Nervous System Involvement in Decompression Illness

Conclusive evidence for involvement of the peripheral nervous system in decompression illness is lacking. We report a case of decompression illness associated with shoulder pain and the clinical features of median nerve injury at the wrist. Initial recompression and hyperbaric oxygen treatment produced prompt relief of all symptoms and signs, but carpal tunnel syndrome subsequently recurred. Nerve conduction studies confirmed median nerve conduction delay at the wrist. Repeat measurements after treatment with hyperbaric oxygen showed electrophysiologic improvement that was consistent with improvement in symptoms. We believe this is the first objectively substantiated case of injury to the peripheral nervous system caused by decompression illness.

A 24-year-old woman with neck pain

Neck pain and stiffness is a common emergency department (ED) presentation and normal daily activities are usually the inciting cause. Most neck pain cases are benign in nature and can be relieved with rest and mild analgesics. Traumatic events and falls can cause severe neck injuries such as fractures, subluxation, vascular injuries, or paralysis. The following is an unusual case of atlantoaxial rotatory subluxation seen in our ED that initially presented as benign neck pain and torticollis. A 24-year-old woman presented to the emergency department with the complaint of neck pain. Earlier that day, she was stretching her neck in a rightward rotational fashion with her hands while in bed and heard a sudden pop. She reported transient numbness to her left hand but did not report any weakness and did not try to ambulate. She reported her head and neck fixed in a rightward position from which she was unable to move. The patient had an unremarkable past medical history and had no prior episodes of neck stiffness. Her past surgical history was remarkable only for hemorrhoid surgery. She takes no home medications and has no medication allergies. There is also no family history of neck instability and orthopedic or rheumatologic conditions, and her social history is significant only for tobacco and marijuana use. Upon presentation, the patient was in a cervical collar with her head turned to the right at an approximately 60° angle. She was alert and oriented times 4 and in no acute distress. There was an obvious decreased range of motion of the neck, and the patient was tender to palpation in the upper cervical spine. She was able to move all of her extremities and was otherwise neurologically intact. We opted not to obtain plain films on this patient due to the relative long time in obtaining the plain film images and high clinical suspicion of injury we had with this patient. Computed tomography scan (CT) scan of the cervical spine without contrast revealed atlantoaxial rotary subluxation to 0735-6757/