Better Early Stroke Treatment

Acute Ischemic Stroke Registry and BEST (Better Early Stroke Treatment)

Latha Stead, M.D.

Every 45 seconds in the U.S. someone has a stroke. It is the leading cause of disability, with 20 percent needing help walking. It has a huge burden on the workforce—70 percent cannot return to their previous jobs, and 51 percent are unable to return to any type of work. It is not only a disease of older persons as one third of those who suffer a stroke are under 65 years old. Each year, stroke kills more than twice as many American women as breast cancer, and among women over 45 years old, stroke is more common than myocardial infarction.

Our division maintains an ongoing registry of patients presenting with acute ischemic stroke as the core of our “BEST” (Better Early Stroke Treatment) project. The study began in 2001, and to–date more than 2,000 patients have been enrolled. Our team is responsible for collecting and analyzing their clinical data. Some of the variables of collected are the NIH stroke scale, time of symptom onset to ED presentation, reasons for delay in seeking medical attention, length of stay, ischemic stroke subtype, functional status, subsequent vascular events, and death.

BEST has been rewarding on several fronts. First and foremost, our research work shapes our clinical practice. BEST has resulted in a streamlined acute stroke protocol, with collaboration across emergency medicine, neurology, and radiology. Prehospital services have been incorporated into the protocol with an acute stroke pager that activates the acute stroke team. Via BEST we have worked to create an effective education program for our patients who suffer from acute brain ischemia. Emphasis is placed on education because we feel it is important to own our processes and do right by our patients. Behind every data point in our registry there is a patient who has graciously consented to participate in our research to improve care for others.

BEST is funded by several Mayo Foundation awards including a Hospital Practice Innovation grant, a CPI–10 award, and the Department of Emergency Medicine small grants program.

Anaphylaxis Registry

Wyatt Decker, M.D.

Anaphylaxis is an acute life–threatening reaction, usually but not always mediated by an immunologic mechanism, that results from the sudden systemic release of mast cells and basophil mediators. Anaphylaxis often produces signs and symptoms within minutes of exposure to an offending, but some reactions may develop later (e.g., greater than 30 minutes after exposure). Late phase or “biphasic” reactions, which occur 1 to 72 hours (most within 10 hours) after the initial attack, have also been reported. Since presentations are varied, cases of anaphylaxis are sometimes difficult to identify and classify.

The National Institute of Allergy and Infectious diseases (NIAID) and Food Allergy and Anaphylaxis Network (FAAN) have established criteria to accurately identify anaphylaxis. Utilizing these criteria we propose to assess the incidence, etiology, clinical features, and outcome of anaphylaxis, both in a population–based study using the Rochester Epidemiology Project (REP) as well as in an Emergency Department cohort.

The research work will be translated into practice with the development of a clinical order set to standardize management of the anaphylaxis patient in the Emergency Department. Further, a patient education and follow–up program will be designed.

The anaphylaxis project is funded by the Food Allergy and Anaphylaxis Network (FAAN) and the Department of Emergency Medicine small grants program.

Capnography in acute bronchiolitis

Jana Anderson, M.D.

Capnography is a non–invasive method of assessing ventilation that gives a graphical representation of the expired breath. Dr. Anderson is conducting a prospective observational cohort study to 1) investigate the relationship between capnogram waveform and the clinical severity graded by the Respiratory Distress Assessment Instrument (RDAI) in infants presenting with acute bronchiolitis to the emergency department and (2) to investigate the relationship between capnogram waveform and hospitalization for infants with acute bronchiolitis. The same principles are also being applied in a cohort of asthmatic patients presenting to the emergency department. The capnography in acute bronchiolitis project is funded by the Department of Emergency Medicine small grants program.

Cardiac arrest

Erik Hess, M.D.

Out–of–hospital cardiac arrest is both a major public health issue and an important problem for the practicing clinician. Approximately 154,800 out–of–hospital cardiac arrests occur annually. Of these, 60 percent are treated by EMS providers and 50 percent occur in individuals with no prior history of cardiac disease.

Current plans are to collect data for out–of–hospital cardiac arrest events from Rochester to ten Mayo–affiliated community EMS systems in Minnesota and Wisconsin. The purpose of the initiative is to both improve patient care and increase the ability to answer meaningful questions in a generalized way so that care is improved for all victims of cardiac arrest.

Cardiopulmonary resuscitation

Tyler Vadeboncoeur, M.D.

Sudden cardiac arrest is the leading cause of death in the United States, with approximately 400,000 events each year. Two–thirds of these deaths occur outside of the hospital and are termed out–of–hospital cardiac arrest (OHCA). In the absence of early defibrillation, survival from OHCA had not improved in thirty years until recently. At Mayo Clinic Arizona and the Arizona Department of Health, Ben Bobrow, M.D., and Lani Clark established the Save Hearts in Arizona Registry and Education (SHARE) program, which includes an OHCA database comprising approximately 80 percent of the state’s population and greater than 3,000 OHCAs. With this database, we determined a baseline survival and measure of the effects of paramedic education and resuscitation protocol changes. We are currently in the process of establishing a similar program in Jacksonville, Florida, to be named the Jacksonville Cardiac Arrest Registry and Education Program: the Jacksonville CAREs Program.

In recent years cardiac arrest researchers have discovered several components of cardiac arrest care that positively impact survival: 1) bystander CPR, 2) an optimal time association between CPR and defibrillation, 3) the minimization of hands–free intervals during chest compressions, 4) the avoidance of over–ventilation, and 5) post–resuscitation care including therapeutic hypothermia. A critical focus of the SHARE program and the Jacksonville CAREs program is to translate these discoveries into clinical practice.

Clinical decision rules

Erik Hess, M.D.

Chest pain is the second most common chief complaint in North American emergency departments. Data from the U.S. suggest that 2.1 percent of patients with acute myocardial infarction and 2.3 percent of patients with unstable angina are misdiagnosed, with slightly higher rates reported in a recent Canadian study (4.6 percent and 6.4 percent, respectively). The 2007 ACC/AHA guidelines for UA/NSTEMI do not identify patients at low risk for adverse cardiac events who can be safely discharged without provocative testing. As a result large numbers of low–risk patients are triaged to chest pain observation units and undergo provocative testing, at significant cost to the healthcare system. The aim of this project is to develop clinical rules to guide triage decisions for patients who present to the Emergency Department with chest pain.

This project has extramural funding from the American Heart Association, the Society of Academic Emergency Medicine, and the Emergency Medicine Foundation (Award ID # 0775030N).

Emergency Department Syncope Registry

Wyatt Decker, M.D. and Luis Serrano, M.D.

Syncope is the sudden loss of consciousness and postural tone followed by return of preexisting neurologic function. More than one in four people will experience syncope in their lifetime, and these events comprise between 1 to 5 percent of emergency department visits and 1 to 6 percent of hospital admissions. While several diagnostic and triaging guidelines have been formulated in an attempt to decrease the approximately 2 billion dollar annual expense created by syncope evaluations, hospital admission and extensive evaluation is still commonplace due to concern about serious and adverse outcomes.

The objective of this prospective observational study is to characterize the patients who present to the Emergency Department with syncope. We are interested in predictors of outcome, incidence of cardiac arrhythmias, and subsequent recurrence. A better understanding of these associations would allow us to more accurately stratify patients.

Please see the American College of Emergency Physicians Clinical Policy on the evaluation and management of syncope authored by the Principal Investigator of this project.

Emergency medical services

Christopher Russi, D.O.

Mayo Clinic Rochester has an enormous EMS system that provides ground ALS, fixed wing services, and rotor wing services primarily for Minnesota, Wisconsin, and Iowa. Our dedicated personnel and expansive, supporting infrastructure provide for a clinical research platform to advance prehospital critical care medicine. We serve as the primary care contact and rural bridge for the regions critically injured and ill. Current clinical projects are evaluating and improving advanced prehospital airway management using new optical and supralaryngeal devices as well as using near–infrared spectroscopy to predict hypovolemic and distributive shock.

Pediatric sedation

Jana Anderson, M.D.

Propofol and opioids are used in the Emergency Department for deep procedural sedation for orthopedic reductions. The objectives are to evaluate the relationship between continuous capnography and observed airway and respiratory adverse effects and the depth of sedation when using propofol. Ketamine and Propofol are two synergistic medications that provide a dissociative, pain–free, deep sedation. The objectives are to evaluate the optimal dosing to produce deep sedation of orthopedic reduction and to evaluate the rate of respiratory, cardiovascular, or other adverse events.

Simulation–based education

Deepi Goyal, M.D., Torrey Laack, M.D. and Annie Sadosty, M.D.

Simulation is a training and feedback method in which learners practice tasks and processes in life–like circumstances using models or virtual reality, with feedback from observers, peers, actor–patients, and video cameras to assist improvement in skills. It allows one to create new and realistic methods of learning without putting patients at risk. Many abilities are learned and developed with time, training, practice, and repetition, and medical simulation technologies are a revolutionizing way to enhance these abilities. The use of medical simulators to teach new skills or procedures, team training, or test competencies is reducing medical errors, improving patient safety, and reducing health care costs overall.

The principal investigators are doing an observational study to evaluate the reliability and validity of a simulation–based assessment instrument, measuring self–evaluation of performance by the residents to see if they are able to identify errors, and compare the simulation–based assessment with the clinical evaluations.

ST Elevation Myocardial Infarction

David M. Nestler, M.D.

I am the Emergency Department’s principal investigator for ST–Segment Elevation Myocardial Infarction (STEMI) research. For the past four years, a multidisciplinary team has been working to improve early management of patients with STEMI. Currently, there are several projects underway, including a quality analysis of our STEMI care, which encompasses our regional system of care; implementation of pre–hospital activation of STEMI; analysis of circadian rhythms for STEMI presentation; and analysis of false positive activations for STEMI care.

Transient Ischemic Attack Registry

Latha Stead, M.D.

The diagnosis of TIA is highly variable; transient neurological symptoms due to seizure, migraine, or syncope might be indistinguishable from those due to ischemia, and most patients are symptom–free at the time of ED presentation.

The goal of this prospective observational cohort study is to identify which patients are at increased risk for subsequent vascular events, including TIA, stroke, and acute coronary syndrome. From these data, a clinical risk score is being developed. Risk stratification on the basis of clinical presentation may open new avenues and help bring about changes in the management of TIA patients.

This research has been translated into clinical practice via the creation of an Emergency Department Observation Unit protocol in partnership with the Department of Neurology, which allows rapid evaluation of the TIA patient within the ED itself, preventing hospitalization for the sole purpose of work up. While in the EDOU, patients receive targeted education on TIA risk factors, stroke prevention, and smoking cessation, during an opportune teaching moment.

80–lead ECG testing

David M. Nestler, M.D.

I am the principal investigator for Mayo's involvement in The BEACON (Best Expert Agreement for Care of Occult MI Nationally), a multi–center registry that will collect data on patients with possible acute coronary syndrome (ACS) for four years. This effort is funded by Heartscape Technologies, the maker of the FDA–approved 80–lead ECG machine referred to as PRIME ECG. The study prospectively collects data on the history, evaluation and findings of patients with possible ACS. The primary objective of this study is to assess — and improve care and outcomes of — patients with ACS, by identifying methods that facilitate final diagnosis. A secondary objective is to assess the impact of PRIME ECG testing on these patients.