22. European Stroke Conference 629 Acute stroke: emergency management, stroke units and complications Thrombolysis candidates with atrial fibrillation have almost exclusively ischemic strokes: a case for pre-hospital thrombolysis? A. Meretoja1, J. Putaala2, S. Mustanoja3, D. Strbian4, M. Kaste5, T. Tatlisumak6 Helsinki University Central Hospital, Helsinki, FINLAND1, Helsinki University Central Hos-pital, Helsinki, FINLAND2, Helsinki University Central Hospital, Helsinki, FINLAND3, Helsinki University Central Hospital, Helsinki, FINLAND4, Helsinki University Central Hospital, Helsinki, FINLAND5, Helsinki University Central Hospital, Helsinki, FINLAND6 BACKGROUND Thrombolytic therapy (tPA) for acute ischemic stroke is highly time-critical. Pre-hospital treatment is only possible if intracerebral hemorrhage (ICH) can be reliably ruled out. We aimed to identify a patient group with high likelihood of ischemic stroke. METHOD We retrospectively analysed the Helsinki Stroke Thrombolysis Registry and the Helsinki ICH Study for consecutive stroke patients admitted to our hospital between 2005 to 2010, having first medical contact within 4 hours of symptom onset, and without clinical exclusion criteria for thrombolysis. We used classification regression trees to identify subgroups of patients where ICH could be ruled out on clinical grounds with high likelihood. RESULTS Most ICH patients with early medical contact had a clinical contraindication to tPA (416/570, 73%). A total of 672 ischemic stroke and 154 ICH patients were clinically candidates for tPA. Of these, atrial fibrillation (AF) patients not on anticoagulation had almost exclusively ischemic strokes (156/163, 96.3%). No other subgroup with <5% likelihood of ICH could be identified. The probabil-ity of stroke patients with a history of AF or AF on presentation, presenting within 4 hours of onset, and no clinical contraindications to tPA having ICH was 3.7% (95% CI 1.8-7.5%). These patients represent 23% of all tPA candidates. The probability of ICH in these patients was 2.5% (1.0-6.1%) if they only had a history of AF but no AF at presentation, 2.9% (1.0-8.1%) with newly diagnosed AF without history of AF, and 0.0% (0.0-4.5%) with previously known AF on presentation. CONCLUSIONS Non-anticoagulated AF patients presenting clinically as thrombolysis candidates seem to have a low likelihood of ICH. Should blood biomarkers help further to exclude ICH, benefits of earlier treat-ment could theoretically be large enough to justify pre-hospital treatment prior to imaging in such patients. Prospective validation of the diagnostic principle in an ambulance setting is warranted. 680 © 2013 S. Karger AG, Basel Scientific Programme 630 Acute stroke: emergency management, stroke units and complications Compulsory training and documentation of nasogastric tube placement: can we improve safe-ty? S. Howie1, A. Crabtree2, K. Tee3, K. Cheung4, R. Rallan5, T. Hunjan6, A. Sogbodjor7, H. Alogaily8, N. Jahangir9, J. Billins10, T. Sri11, W. Zhang12, V. Jones13, P. O’Mahony14 St Helier Hospital, Carshalton, UNITED KINGDOM1, St Helier Hospital, Carshalton, UNITED KINGDOM2, St Helier Hospital, Carshalton, UNITED KINGDOM3, St Helier Hospital, Carshal-ton, UNITED KINGDOM4, St Helier Hospital, Carshalton, UNITED KINGDOM5, St Helier Hos-pital, Carshalton, UNITED KINGDOM6, St Helier Hospital, Carshalton, UNITED KINGDOM7, St Helier Hospital, Carshalton, UNITED KINGDOM8, St Helier Hospital, Carshalton, UNITED KINGDOM9,St Helier Hospital, Carshalton, UNITED KINGDOM10, St Helier Hospital, Carshalton, UNITED KINGDOM11, St Helier Hospital, Carshalton, UNITED KINGDOM12, St Helier Hospital, Carshalton, UNITED KINGDOM13, St Helier Hospital, Carshalton, UNITED KINGDOM14 Background Serious harm caused by a misplaced nasogastric tube (NGT) is a ‘never event’. Staff should docu-ment they have followed the National Patient Safety Agency (NPSA) guidelines when inserting a NGT. We wished to determine compliance with this on a stroke unit. Method Retrospective data were collected from notes of all stroke patients with a NGT inserted during two audits. Audit 1 recorded: insertion procedure compared with the NPSA algorithm, quality of docu-mentation, ‘near misses’ (inability to rule out misplaced NGT due to unsafe procedure or poor doc-umentation) and ‘never events’. To improve safety, we designed an interactive sticker of the NPSA algorithm for the medical notes for all NGT insertions. It was included in NGT packs to ensure compliance. Nurses completed nose-ear-xiphisternum (NEX) length, aspirate and pH then signed if safe to proceed. If necessary, doctors completed a section confirming satisfactory chest x-ray (CXR) position. We also implemented compulsory online training for doctors on CXR interpretation and nurse education. We then re-audited. Fisher’s Exact test was used for statistical analysis. Results We compared the results from audit 1 (58 NGT insertions) with audit 2 (55 insertions):record of NEX length 0/58 (0%) v 38/55 (69%); ability to obtain aspirate 30/58 (52%) v 48/55 (87%); ad-equate documentation of aspiration 38/58 (66%) v 54/55 (98%); appropriate CXR ordering 8/13 (62%) v 7/7 (100%)(p<0.1); documentation of CXR by doctor 0/13 (0%) v 4/7 (57%)(p<0.03); ‘near misses’23/58 (40%) v 1/55 (2%). These results reached statistical significance (p<0.0001) except where indicated. There were no ‘never events’. Conclusion Introducing a sticker of the NPSA algorithm in the NGT pack for documenting the insertion proce-dure and CXR interpretation, alongside staff training, significantly improved NGT placement safety on the stroke ward. The minimal cost and effort required for these interventions supports their fur-ther evaluation on a wider scale.
Karger_ESC London_2013
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