title: Creation of an intensive care unit and organizational changes in an adult emergency department: Impact on acute stroke management.
abstract: OBJECTIVE
  Following the reorganization of a University Medical Center onto a single campus, an Intensive Care Unit was created within the adult Emergency Department (ED ICU). We assessed the effects of these organizational changes on acute stroke management and the intravenous administration of recombinant tissue plasminogen activator (IV rtPA), as characterized by the thrombolysis rate, door-to-needle time (DNT) and outcome at 3months.
  
  
  METHODS
  Between October 2013 and September 2015, we performed a retrospective, observational, single-center, comparative study of patients admitted for ischemic stroke and treated with IV rtPA during two 321-day periods (before and after the creation of the ED ICU). All patients with ischemic stroke were included. Multivariable logistic regression models were performed. The DNT was stratified according to a threshold of 60min. A favorable long-term outcome was defined as a modified Rankin score≤2 at 3months.
  
  
  RESULTS
  A total of 1334 ischemic stroke patients were included. Among them, 101 patients received IV rtPA. The frequency of IV rtPA administration was 5.8% (39 out of 676) before the creation of the ED ICU, and 9.3% (62 out of 668) afterwards (odds ratio (OR) [95% confidence interval (CI)]: 1.67 [1.08-2.60]; p=0.02). Additionally, the DNT was shorter (OR [95%CI]: 4.30 [1.17-20.90]; p=0.04) and there was an improvement in the outcome (OR [95%CI]=1.30 [1.01-2.10]; p=0.045).
  
  
  CONCLUSIONS
  Our results highlight the benefits of a separate ED ICU within conventional ED for acute stroke management, with a higher thrombolysis rate, reduced intrahospital delays and better safety.
authors.affiliation: Department of Neurology and Functional Neuroscience Laboratory EA 4559, Amiens University Medical Center, Amiens, France. Electronic address: laurent.puy@hotmail.fr.
authors.forename: Laurent
authors.initials: L
authors.lastname: Puy
authors.affiliation: Department of Neurology and Functional Neuroscience Laboratory EA 4559, Amiens University Medical Center, Amiens, France.
authors.forename: Chantal
authors.initials: C
authors.lastname: Lamy
authors.affiliation: Department of Neurology and Functional Neuroscience Laboratory EA 4559, Amiens University Medical Center, Amiens, France.
authors.forename: Sandrine
authors.initials: S
authors.lastname: Canaple
authors.affiliation: Department of Neurology and Functional Neuroscience Laboratory EA 4559, Amiens University Medical Center, Amiens, France.
authors.forename: Audrey
authors.initials: A
authors.lastname: Arnoux
authors.affiliation: Department of Emergency Medicine, Amiens University Medical Center, Amiens, France.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Laine
authors.affiliation: Department of Emergency Medicine, Amiens University Medical Center, Amiens, France.
authors.forename: Ella
authors.initials: E
authors.lastname: Iacob
authors.affiliation: Department of Neuroimaging, Amiens University Medical Center, Amiens, France.
authors.forename: Jean-Marc
authors.initials: JM
authors.lastname: Constans
authors.affiliation: Department of Neurology and Functional Neuroscience Laboratory EA 4559, Amiens University Medical Center, Amiens, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Godefroy
mesh_terms: D061605:Administration, Intravenous; D000368:Aged; D002545:Brain Ischemia / Q000175:diagnosis / Q000628:therapy; D061345:Early Medical Intervention / Q000458:organization & administration* / Q000592:standards; D004636:Emergency Service, Hospital / Q000458:organization & administration* / Q000639:trends; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage; D005602:France; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration* / Q000639:trends; D008297:Male; D009936:Organizational Innovation; D010043:Outcome and Process Assessment, Health Care; D061214:Patient Safety; D012189:Retrospective Studies; D020521:Stroke / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000379:methods*; D013997:Time Factors; D061665:Time-to-Treatment / Q000706:statistics & numerical data*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Adult emergency department; Managed care; Organizational change; Stroke; Thrombolysis; rt-PA