Prolonged boarding in emergency department with neurologist coverage does not worse the outcomes for patients with acute ischemic stroke

Shortage of hospital beds is a common phenomenon and some acute ischemic stroke patients have to be cared for in emergency department with their staffs. However, boarding acute stroke patients in emergency department for hospital ward beds has been associated with worse outcomes. Whether an additional coverage of neurologist for them would benefit was not elucidated. All acute ischemic stroke patients admitted to our hospital between January 2016 and December 2018 were retrospectively analyzed. Patients were classified according to the various emergency department length of stay. A binary Logistic regression was used to explore the relationship of coverage of neurologist for acute ischemic stroke patients admitted but boarded in emergency department to their hospital outcomes by adjusting for age, patient gender, comorbidities, triage urgency, initial National Institute of Health Stroke Scale (NIHSS) score, whether underwent thrombosis, admitted to Intensive care unit (ICU) and complications. A total of 1150 acute ischemic stroke patients were evaluated. 24.1% of them were admitted within 4 hours, 10.3% within 4–8 hours while 65.6% patients boarded in emergency department more than 8 hours although they were admitted, due to the shortage ward beds. However, with the neurologist coverage, their prolonged waiting hours in emergency department was not associated with poor patients’ outcomes including Modified Rankin Scale (mRS) ≥4 at discharge, long hospital length of stay and high hospital cost. In summary, with additional neurologist coverage for acute ischemic stroke patients who were admitted but boarded in emergency department, prolonged waiting hours in emergency department was not associated with worse patients’ outcomes including mRS ≥4 at discharge, long hospital length of stay and high hospital cost.

Acute ischemic stroke; Emergency department; Neurocritical care; Survival

[1] Hariharan P, Tariq MB, Grotta JC, Czap AL. Mobile stroke units: current evidence and impact. Current Neurology and Neuroscience Reports. 2022; 22: 71–81.

[2] Cano-Nigenda V, Castellanos-Pedroza E, Manrique-Otero D, Méndez B, Menéndez-Manjarrez MF, Toledo-Treviño R, et al. Barriers to optimal acute management of stroke: perspective of a stroke center in Mexico city. Frontiers in Neurology. 2021; 12: 690946.

[3] Paton A, Mitra B, Considine J. Longer time to transfer from the emergency department after bed request is associated with worse outcomes. Emergency Medicine Australasia. 2019; 31: 211–215.

[4] Rincon F, Mayer SA, Rivolta J, Stillman J, Boden-Albala B, Elkind MSV, et al. Impact of delayed transfer of critically ill stroke patients from the emergency department to the Neuro-ICU. Neurocritical Care. 2010; 13: 75–81.

[5] Kadar RB, Amici DR, Hesse K, Bonder A, Ries M. Impact of telemonitoring of critically ill emergency department patients awaiting ICU transfer. Critical Care Medicine. 2019; 47: 1201–1207.

[6] Zhou J, Pan K, Zhou D, Zheng S, Zhu J, Xu Q, et al. High hospital occupancy is associated with increased risk for patients boarding in the emergency department. The American Journal of Medicine. 2012; 125: 416.e1–416.e7.

[7] Al-Khathaami AM, Abulaban AA, Mohamed GE, Alamry AM, Kojan SM, Aljumah MA. The impact of “admit no bed” and long boarding times in the emergency department on stroke outcome. Saudi Medical Journal. 2014; 35: 993–998.

[8] Grotta JC, Yamal JM, Parker SA, Rajan SS, Gonzales NR, Jones WJ, et al. Prospective, multicenter, controlled trial of mobile stroke units. The New England Journal of Medicine. 2021; 385: 971–981.

[9] Akhtar N, Kamran S, Singh R, Cameron P, Bourke P, Khan R, et al. Prolonged stay of stroke patients in the emergency department may lead to an increased risk of complications, poor recovery, and increased mortality. Journal of Stroke and Cerebrovascular Diseases. 2016; 25: 672–678.

[10] Chen BY, Gupta H, Yacas C, Snyder HE, Lee C, Bharwani A, et al. Effects of delay to stroke unit admission in patients with ischemic and hemorrhagic stroke. Canadian Journal of Neurological Sciences. 2023; 50: 10–16.

[11] Mouthon-Reignier C, Bonnaud I, Gaudron M, Vannier-Bernard S, Bodin JF, Cottier JP, et al. Impact of a direct-admission stroke pathway on delays of admission, care, and rates of intravenous thrombolysis. Revue Neurologique. 2016; 172: 756–760.

[12] Herpich F, Rincon F. Management of acute ischemic stroke. Critical Care Medicine. 2020; 48: 1654–1663.

[13] Nasi LA, Ferreira-Da-Silva AL, Martins SCO, Furtado MV, Almeida AG, Brondani R, et al. Implementation of a dedicated cardiovascular and stroke unit in a crowded emergency department of a tertiary public hospital in Brazil: effect on mortality rates. Academic Emergency Medicine. 2014; 21: 40–46.

[14] Cereda CW, George PM, Pelloni LS, Gandolfi-Decristophoris P, Mlynash M, Biancon Montaperto L, et al. Beneficial effects of a semi-intensive stroke unit are beyond the monitor. Cerebrovascular Diseases. 2015; 39: 102–109.

[15] SAUKKONEN KA, VARPULA M, RÄSÄNEN P, ROINE RP, VOIPIO-PULKKI LM, PETTILÄ V. The effect of emergency department delay on outcome in critically ill medical patients: evaluation using hospital mortality and quality of life at 6 months. Journal of Internal Medicine. 2006; 260: 586–591.

[16] Verma A, Towfighi A, Brown A, Abhat A, Casillas A. Moving towards equity with digital health innovations for stroke care. Stroke. 2022; 53: 689–697.