Volume
5, No. August 8, 2024
p ISSN 2723-6927-e ISSN 2723-4339
Analysis and Improvement of Time Frames
Management for Ischemic Stroke Services in the Emergency Room at Budi Medika
Hospital, Bandar Lampung
Luther Theng1*, Yanuar Jak2, Grace Rumengan2
Respati Indonesia University, Indonesia1,2
Email: dr.luther.theng@gmail.com*
ABSTRACT
Stroke
is a catastrophic disease and a major health problem both in Indonesia and in
the world. Stroke causes a high number of morbidities and mortalities. The
philosophy of stroke"Time Is Brain", it requires good time frames
management according to the world guidelines related to ischemic stroke
services in emergency departments (ED). The design of the study is a
quantitative descriptive with retrospective method within the period from
January to December 2023, continued qualitatively a mix methodf explanatory
sequential sequential. The number of samples is 150 which meets the inclusion
criteria. Quantitative analysis with SPSS V29 for mac and quantitative with
NVIVO 14. The Median of door to triage time at study point was 1(1-5) minutes,
door to physician 2 (0-10) minutes, Door to CT scan 19.5 (2 -50) minutes, Door
To CT interpretation wa 20.5 (2-200) minutes and Door To Drug was 63 (12-267)
minutes. Logistics regression analysis of time frames showed that the most
significant result was door to CT scan (OR:14.5,95%CI5.3-39.4,p<0.001).
Moderated Regression Analysis (MRA) showed significant time frame influences
p<0.001 and R2 96% with ischemic stroke service in IGD. To provide the good
performance of Door to drug time£60 minutes
requires good time frames management, role of five (5) M management (man,
method, material, machine and money) and good stroke code implementation.
Keywords:
ED,
ischemic stroke, time frames
INTRODUCTION
Stroke is a 10% cause of death worldwide and
the sixth cause of disability. Without proper treatment and prevention, stroke
can become the fourth cause of disability in 2030. World Stroke Organization
(WSO) data shows that every year there are 13.7 million cases. new stroke, and
around 5.5 million deaths occur due to stroke. Approximately 70% of strokes and
87% of deaths and disabilities due to stroke occur in low- and middle-income
countries
Successful treatment of acute stroke begins
with the knowledge of the public and health workers that stroke is an emergency
situation, such as acute myocardial infarction and trauma
Patients who
experience a stroke will usually come to the hospital and the first location
they visit is the Emergency Room (IGD). The ER is the main gate of a hospital.
The ER is also the busiest department in the hospital. The accumulation of
patients (overcrowding) in the emergency room can cause hospital losses and
have a negative impact on patient services such as prolonged waiting times,
increased treatment time, increased medical errors and can increase patient
mortality rates
The
importance of maintaining a hospital's preparedness when treating stroke cannot
be underestimated. A guideline developed by the National Institute of
Neurological Disorders and Stroke (NINDS), states that patients with stroke
symptoms should be evaluated by a triage doctor within <5 minutes, and
evaluated by Neurology doctor within 10 minutes of arrival in the ER and
CT-Scan must be started within 25 minutes and interpreted within 45 minutes of
arrival, so that therapy can be optimal
Budi Medika
Hospital is a type C non-educational hospital located in the city of Bandar
Lampung. This hospital was founded in 2020 and has a capacity of 101 beds. Over
time the hospital has accepted general, insurance and BPJS patients. The number
of patient visits is increasing so that there is a diversity of diseases. Among
them, stroke is one of the contributors to disease diagnosis and is in the top
ten in both outpatient and inpatient units for the period January to December
2023. In the outpatient unit, stroke diagnosis is in fifth position, while in
inpatient care it is in sixth position. Stroke management itself at Budi Medika
Hospital still does not have good standards, even though there are several
general practitioners who have undergone stroke code training.
The aim of this research
is to describe, analyse and improve the Time Frame
Management component in accessing ischemic stroke services in the emergency
room at Budi Medika Hospital Bandar Lampung, so that it can provide input to
hospital management regarding deficiencies in the service system, especially
for stroke patients, so that it is hoped that fast, responsive and quality
services can be provided in accordance with existing stroke patient service
standards in the world.
RESEARCH METHODS
The design of this
research is descriptive-quantitative, retrospective data from January to
December 2023 by describing and analysing time frames management and elements
of 5M hospital operational management (man, method, material, machine and
money) in ischemic stroke services in the ER. After getting the results of
quantitative data analysis, it is continued qualitatively, namely explanatory
sequential design, called the mix method.
The inclusion
criteria for the study were:
sufferer³18 years old with symptoms
of acute ischemic stroke Exclusion Criteria that is,
stroke sufferers who brought a CT-Scan from another hospital, received
antiplatelet therapy, GCS<7, oxygen saturation<95% with the threat of respiratory failure
and severe hemodynamic disorders, bleeding stroke, Space Occupying Lession
(SOL), stroke and additional diseases such as fractures and head injuries. All
were recorded in the medical record and were willing to sign informed consent.
Statistical analysis
using SPSS version 29 (IBM Corp, NY, USA). Descriptive, namely the distribution
of basic characteristics of research subjects such as gender, age, education,
employment, arrival, NIHSS, stroke onset and time distribution of various
activities in the ER, distribution of time frames, distribution of 5M
management elements followed by testing the suitability of time frames for
ischemic stroke services. Bivariate using Chi-square whether time frames and
management elements (5M) are significant for ischemic stroke services in the
ER. Next, a multivariate model was carried out using logistic regression and
moderated regression analysis (MRA). The relationship is said to be significant
if the p-value <0.05 and in MRA there is an increase in R square. This was
continued quantitatively by conducting interviews (in depth interviews) with
informants, namely the head of the emergency room, duty doctor, nurse, head of
radiology installation, radiographer, administrative officer (registration) and
pharmacist. Recording was carried out using audio, translation through writing
followed by analysis of NVIVO version 14, a codebook of interview results was
carried out, the informant's codebook obtained project map graphs and hierarchy
charts.
RESULTS AND DISCUSSION
Of the 150 patients with acute ischemic stroke who
came to the emergency room at Budi Medika Hospital Bandar Lampung during the
period January to December 2023 in (Table 1). There were 82 (54.7%) men, 91
(60.7%) aged 45-64 years, 47 (31.3%) had an education level of elementary
school, 47 (31.3%) had other jobs (gojek, parking
attendant and teacher) as many as 49 (32.7%) people and clinical
characteristics in the form of coming without a referral as many as 136 (90.7%)
people, the severity of stroke on the NIHSS scale was moderate (6-14) as many
as 76 (50.7) people and stroke onset was <4.5 hours and 24 hours each by 53
(35.3%) people.
Table 1. Demographic and Clinical Characteristics
|
Subject Characteristics |
Number (n=150) |
|
|
Gender |
|
|
|
|
Man |
82
(54.7) |
|
|
Woman |
68
(45.3) |
|
Age |
|
|
|
|
<45
years |
8
(5.3) |
|
|
45-64
years old |
91
(60.7) |
|
|
>65
years |
51
(34) |
|
Education |
|
|
|
|
No school |
13
(8.7) |
|
|
elementary
school |
47
(31.3) |
|
|
JUNIOR
HIGH SCHOOL |
33
(22) |
|
|
SENIOR
HIGH SCHOOL |
36
(24) |
|
|
D3 |
3
(2) |
|
|
Bachelor |
17
(11.3) |
|
|
S2 |
1
(0.7) |
|
Work |
|
|
|
|
Doesn't
work |
25
(16.7) |
|
|
Farmer |
3
(2) |
|
|
Laborer |
19
(12.7) |
|
|
Self-employed |
15
(10) |
|
|
IRT |
39
(26) |
|
|
Other |
49
(32.7) |
|
Arrival |
|
|
|
|
Reference |
14
(9.3) |
|
|
Come alone |
136
(90.7) |
|
Clinical characteristics |
|
|
|
NIHSS |
|
|
|
|
< 5
Light |
63
(42) |
|
|
6-14
Medium |
76
(50.7) |
|
|
15-24
Weight |
11
(7.3) |
|
Onset |
|
|
|
|
<4.5
hours |
53
(36.3) |
|
|
4.5-6
hours |
19
(12.7) |
|
|
<12
hours |
25
(16.7) |
|
|
>24
hours |
53
(35.3) |
Elementary
School; Junior High School; High School High School; D3 Diploma; Postgraduate
Masters, Housewife Housewife; NIHSS National Institutes of Health Stroke Scale
Others are Gojek, drivers and teachers
In (Table 2) regarding the distribution of time for
various activities in the ER, what is of sufficient concern is timePatient registration (registration) takes 14.19
minutes, with a variation of 0.6 minutes, the fastest is 5 minutes and the
longest registration is 20 minutes with an average time between 12.8 minutes to
15.5 minutes.
Table 2. Distribution of time for various activities
in the ER
|
Activities
in the ER |
Mean (minute) |
elementary
school |
Minimum-Maximum |
95%CI |
|
Examination by a nurse |
1.55 |
0.70 |
1-5 |
1.42-1.69 |
|
Waiting for the doctor
on duty |
1.27 |
0.12 |
0-5 |
1.03-1.52 |
|
Examination by the
attending physician |
4.26 |
0.10 |
2-10 |
4.05-4.47 |
|
Patient
registration registration |
14.19 |
0.67 |
5-20 |
12.87-15.52 |
|
NIHSS examination |
4.25 |
0.12 |
1-10 |
4-4.49 |
|
GDS check |
3.39 |
0.23 |
0-15 |
2.93-3.86 |
|
ECG examination |
2.07 |
0.14 |
0-11 |
1.78-2.35 |
|
IV Line Installation |
3.59 |
0.20 |
0-15 |
3.19-3.99 |
|
Waiting for the porter |
1.73 |
0.20 |
0-10 |
1.32-2.14 |
|
Go to the CT scan room |
1.05 |
0.38 |
1-5 |
0.98-1.13 |
|
Arrive at the CT scan
room |
1 |
0.00 |
1-1 |
1-1 |
|
Carrying out a CT scan |
7.89 |
0.32 |
5-25 |
7.25-8.52 |
|
CT scan interpretation |
38.42 |
3.24 |
2-200 |
02.32-44.82 |
|
Back to the ER |
1 |
0.00 |
1-1 |
1-1 |
|
Re-examination
by Dr. keep |
5.35 |
0.16 |
1-10 |
5.02-5.68 |
|
Administration of
antiplatelet therapy |
10 |
0.60 |
1-35 |
8.81-11.19 |
CT
Computed Tomography; NIHSS National Institutes of Health Stroke Scale; GDS
Current Blood Sugar; ECG Electrocardiography; IV Intravenous IGD Emergency
Department; Dr. doctor
The
distribution of time frames in acute ischemic stroke (Table 3) shows that door
to triage is 1.5 minutes with a variation of 0.07 minutes, the fastest is 1
minute and the longest is 5 minutes with an average time of 1.4 minutes and 1.7
minutes. door to Physician is 2.9 minutes with a variation of 0.17 minutes, the
longest is 10 minutes with an average time of 2.6 and 3.3 minutes. The door to
head CT scan was carried out for 21.3 minutes with a variation of 0.8 minutes,
the fastest was 2 minutes and the longest was 50 minutes with an average time
of 19.7 minutes and 22.9 minutes. door to CT interpretation by a radiology
specialist is 37 minutes with a variation of 3.1 minutes, the fastest is 2
minutes for expertise and the longest is 200 minutes with an average time of 31
minutes and 43.5 minutes. door to drug, which is 73.6 minutes with a variation
of 3.83 minutes, the fastest is 12 minutes and the longest is 267 minutes with
an average of 66 minutes and 81.2 minutes.
Table 3. Distribution of Time Frames in Acute Ischemic
Stroke
|
Time
Frames |
Mean (minute) |
elementary
school |
Minimum
– Maximum |
95%CI |
|
Door to triage |
1.57 |
0.07 |
1-5 |
1.43-1.70 |
|
Door to Physician |
2.98 |
0.17 |
0-10 |
2.64-3.32 |
|
Door to CT scan |
21.34 |
0.82 |
2-50 |
19.71-22.97 |
|
Door to CT
Interpretation |
37.28 |
3.14 |
2-200 |
31.06-43.50 |
|
Door to drugs |
73.67 |
3.83 |
12-267 |
66.08-81.25 |
SD Standard deviation; CI Confidence Interval
The distribution of
management elements (5M) (Table 4) can be seen for the man variable related to
the doctor on duty, nurse in the emergency room, porter in charge of delivering
or pushing the bed (gurney) and radiology officer (radiographer). For the
method variable, it is related to the flow and registration process of patients
in the ER, the material is related to the availability of gurneys and
antiplatelet drugs, both clopidogrel and aspirin. The machine is related to the
CT scan tool and the money is related to the health insurance used by the
patient, namely the BPJS guarantee. In (Table 5), the bivariate chi square
test, the significant variables with a p-value <0.05 are the man variable
related to nurses and porters, the method variable for the registration
process, and the material variable, namely the availability of gurneys and
anti-platelet drugs.
Table 4. Distribution of Management Elements (5M) for Acute
Ischemic Stroke Services
|
Variable |
Observations
in the ER (n=150) |
||
|
Yes |
No |
||
|
Man |
|
|
|
|
1. |
Is
the doctor on duty on site and immediately examining the patient? |
145 (96.7) |
5 (3.3) |
|
2. |
Does
the doctor on duty report the patient's condition to Dr Sp.N Onsite? |
150 (100) |
0 (0) |
|
3. |
Is
the emergency room nurse on site and immediately carrying out the doctor's
order? |
112 (74.7) |
38 (25.3) |
|
4. |
Is
the ER so busy with patients that nurses can't immediately carry out doctor's
orders? |
44 (29.3) |
106 (70.7) |
|
5. |
Is
the porter on site and immediately takes the patient to the radiology room
after the doctor on duty orders it? |
119 (79.3) |
31 (20.7) |
|
6. |
Is
the radiology officer on site? |
150 (100) |
0 (0) |
|
Method |
|
|
|
|
1. |
Do
emergency room staff (health workers/non-medical workers) immediately direct
stroke patients to the doctor on duty? |
150 (100) |
0 (0) |
|
2. |
Does
the registration process take a long-time queuing in the registration room? |
53 (35.3) |
97 (64.7) |
|
Material |
|
|
|
|
1. |
Are
gurneys available in the emergency room? |
140 (93.3) |
10 (6.7) |
|
2. |
Is Aspilet/Clopidogrel
available at TPO ER or pharmacy? |
134 (89.3) |
16 (10.7) |
|
Machine |
|
|
|
|
1. |
Can
a CT scan operate? |
149 (99.3) |
1(0.7) |
|
Money |
|
|
|
|
1. |
Does the patient use
BPJS? |
135 (90) |
15 (10) |
5M
Man, Method, Money, Material and Machine; Dr Sp.N
Neurology Specialist; Emergency Room ER; TPO: Place of Drug Administration; CT
Computed Tomography; BPJS Social Security Administering Body
Table 5. Distribution of Subjects According to
Ischemic Stroke Management and Service Elements
(chi square test)
|
The
Role of Management Elements (5M) |
Ischemic
Stroke Services |
Total |
OR (96%CI) |
P
value |
|||||
|
It
is not in accordance with |
In
accordance |
||||||||
|
n |
% |
n |
% |
n |
% |
||||
|
Man1 Doctor
on duty |
No Yes |
5 74 |
100 51 |
0 71 |
0 49 |
5 145 |
100 100 |
4,649 (1.6-2.2) |
0.089 |
|
Amount |
79 |
52.7 |
71 |
47.3 |
150 |
100 |
|
|
|
|
Man3 Nurse |
No Yes |
32 47 |
84.2 42 |
6 65 |
15.8 58 |
38 112 |
100 100 |
7,376 (2.8-19) |
<0.001 |
|
Amount |
79 |
52.7 |
71 |
47.3 |
150 |
100 |
|
|
|
|
Man4 Nurse |
No Yes |
45 34 |
42.5 77.3 |
61 10 |
57.5 22.7 |
106 44 |
100 100 |
15,122 |
<0.001 |
|
Amount |
79 |
52.7 |
71 |
47.3 |
150 |
100 |
(0.097-0.48) |
|
|
|
Man5 Porter |
No Yes |
24 55 |
77.4 46.2 |
7 64 |
22.6 53.8 |
31 119 |
100 100 |
9,604 (1.5-9.9) |
0.04 |
|
Amount |
79 |
52.7 |
71 |
47.3 |
150 |
100 |
|
|
|
|
Method2 Registration |
No Yes |
44 35 |
45.4 66 |
53 18 |
54.6 34 |
97 53 |
100 100 |
5,878 (0.2-.08) |
0.024 |
|
Amount |
79 |
52.7 |
71 |
71 |
150 |
100 |
|
|
|
|
Materials1 Safe |
No Yes |
9 70 |
90 50 |
1 70 |
10 50 |
10 140 |
100 100 |
5,990 (1.1-72.9) |
0.034 |
|
Amount |
79 |
52.7 |
71 |
47.3 |
150 |
100 |
|
|
|
|
Material2 Drug |
No Yes |
14 65 |
87.5 48.5 |
2 69 |
12.5 51.5 |
16 134 |
100 100 |
8,718 (1.6-33.2) |
0.007 |
|
Amount |
79 |
52.7 |
71 |
47.3 |
150 |
100 |
|
|
|
|
Machine (CT Scan) |
No Yes |
0 79 |
0 53 |
1 70 |
100 47 |
1 149 |
100 100 |
1,120 (1.7-2.5) |
0.957 |
|
Amount |
79 |
52.7 |
71 |
47.3 |
150 |
100 |
|
|
|
|
Money BPJS |
No Yes |
5 74 |
33.3 54.8 |
10 61 |
66.7 45.2 |
15 135 |
100 100 |
2,499 (0.1-1.2) |
0.191 |
|
Amount |
79 |
52.7 |
71 |
47.3 |
150 |
100 |
|
|
|
CT Computed
Tomography; OR Odds ratio; BPJS Social Security Administering Agency
Conformity of time
frames for ischemic stroke services to the guidelines (Table 6), namely door to
triage with a median value of 1 minute and an average of 1.57 minutes with a
variation of 0.07 minutes for a total of 150 (100%) people in accordance with the
NINDS guidelines≤ 5 minutes. In the door to physician variable, the
median value is 2 minutes and the average is 2.98 minutes with a variation of
0.17 minutes, a total of 150 (100%) people comply with the NINDS guideline
≤10 minutes. In the door to CT scan activity, the mean value was 19.5
minutes and the average was 21.34 minutes with a variation of 0.82 minutes
which was suitable for 103 patients (68.7%) and not suitable for 47 (31.3%)
people, according to the NINDS guideline ≤25 minutes. In the door to CT
interpretation activity, the mean value was 20.5 minutes with an average of
37.2 minutes with a variation of 3.1 minutes, namely 108 (72%) people were
suitable, and 42 (28%) people were not suitable, where according to the NINDS
guideline ≤45 minutes. In the door to drug activity, the mean value was
63 minutes with an average of 73.6 minutes with a variation of 3.8 minutes,
namely 79 (47.3%) were suitable and 79 (52.7%) people were not suitable, where
according to the NINDS guidelines ≤60 minutes. In the bivariant chi
square test (Table 7), it was found that there was a significant relationship
between door to CT scan and door to CT interpretation on ischemic stroke
services in the ER, namely with each p-value <0.001 (<0.05).In the door to CT scan,
OR=25,228 was obtained, which means that an appropriate door to CT scan has a
25 times greater chance of producing appropriate ischemic stroke services
compared to an inappropriate door to CT scan. In door to CT
interpretation, OR=52,426 was obtained, which means that an appropriate door to
CT interpretation has a 52.4 times greater chance of producing appropriate
ischemic stroke services than an inappropriate door to CT interpretation.
Table 6. Conformity of Time Frames for Ischemic Stroke
Services to the Guideline
|
Activity (n=150) |
Minute |
Conformity
to Guideline |
|
|
In
accordance (%) |
Elongation
(%) |
||
|
Door to triage |
150 (100) |
0 (0) |
|
|
Median Mean(±elementary school) |
1 1.57 (±0.07) |
||
|
Door to Physician |
150 (100) |
0 (0) |
|
|
Median Mean(±elementary school) |
2 2.98(±0.17)) |
||
|
Door To CT scan |
103 (68.7) |
47 (31.3) |
|
|
Median Mean |
19.50 21.34(±0.82) |
||
|
Door to CT
Interpretation |
108 (72) |
42 (28) |
|
|
Median Mean(±elementary school) |
20.50 37.28 (±3.14) |
||
|
Door to drugs |
71 (47.3) |
79 (52.7) |
|
|
Median Mean(±elementary school) |
63.00 73.67(±3.83) |
||
CT Computed Tomography; SD Standard Deviation
Table 7. Distribution of subjects according to Time
Frames and Ischemic Stroke Services (Chi square test)
|
Time
Frames |
Ischemic
Stroke Services |
Total |
OR (96%CI) |
P
value |
|||||
|
It
is not in accordance with |
In
accordance |
||||||||
|
n |
% |
n |
% |
n |
% |
||||
|
Door
to CT Scan |
It is not in
accordance with In accordance |
39 40 |
83 38.8 |
8 63 |
17 61.2 |
47 103 |
100 100 |
25,228 (3.2-18.1) |
<0.001 |
|
Amount |
79 |
52.7 |
71 |
47.3 |
150 |
100 |
|
|
|
|
Door to CT Interpretation |
It is not in
accordance with In accordance |
42 37 |
100 34.3 |
0 71 |
0 65.7 |
42 108 |
100 100 |
52,426 (2.2-3.7) |
<0.001 |
|
Amount |
79 |
52.7 |
71 |
47.3 |
150 |
100 |
|
|
|
CT
Computed Tomography; OR Odds ratio; CI Confidence Interval
The bivariate correlation test in
this research is conducting bivariate analysis for independent variables of the
numerical type door to triage, door to physician, door to CT initiation and
door to CT interpretation. The results of bivariate analysis with correlation
obtained p-values for the variables door to triage (p=0.128),
door to physician (p=<0.001), door to CT scan (p= 0.06) and door to CT
Interpretation (p=0.06) . From these results we can conclude that the time
frame variables in the form of door to triage, door to physician, door to CT
Initiation and door to CT Interpretation have a p value < 0.25, thus these
four variables can proceed to multivariate modeling.
Table 8. Bivariate Time Frame Correlation Test
|
Correlation
Test (Correlations) |
Door to triage |
Door to physician |
Door to CT scan |
Door to Interpretation |
|
|
Door to
triage |
Pearson
Correlation |
1 |
,660** |
,520** |
.125 |
|
Sig.
(2-tailed) |
|
<.001 |
<.001 |
.128 |
|
|
N |
150 |
150 |
150 |
150 |
|
|
Door to physician |
Pearson
Correlation |
,660** |
1 |
,560** |
,287** |
|
Sig.
(2-tailed) |
<.001 |
|
<.001 |
<.001 |
|
|
N |
150 |
150 |
150 |
150 |
|
|
Door to CT
scan |
Pearson
Correlation |
,520** |
,560** |
1 |
,154 |
|
Sig.
(2-tailed) |
<.001 |
<.001 |
|
,060 |
|
|
N |
150 |
150 |
150 |
150 |
|
|
Door to CT Interpretation |
Pearson
Correlation |
.125 |
,287** |
,154 |
1 |
|
Sig.
(2-tailed) |
.128 |
<.001 |
,060 |
|
|
|
N |
150 |
150 |
150 |
150 |
|
CT
Computed Tomography; Sig. Significance
In the multivariate modeling using
logistic regression (Table 9), it was found that there was 1 variable, namely
door to triage with a p-value of 0.598 (p>0.05) so that in further modeling
the door to triage variable was removed from the model. From the latest
multivariate modeling, it turns out that the time frame variable (X1) that is
most related and significant to ischemic stroke services in the emergency room
at Budi Medika Hospital Bandar Lampung is the door to CT scan variable (X1.3)
with p-value = <0.001 (<0.05) and has an Odds Ratio (OR) of 14.5 (95% CI:
5.3-39.4), meaning that a prolonged door to CT scan is 14 times more likely to
provide inappropriate ischemic stroke services in the ER (Table 10).
Table 9. Logistic Regression Time Frames
|
Variable |
Unstandardized Coefficients |
Standardized Coefficients Beta |
t |
Sig. |
|
|
B |
Std. Error |
||||
|
(Constant) |
7,520 |
1,843 |
|
4,081 |
<0.001 |
|
Door to triage |
-.605 |
1,147 |
-0.11 |
-.528 |
0.598 |
|
Door to physician |
1,506 |
,490 |
,068 |
3,074 |
0.003 |
|
Door to CT scan |
1,020 |
,008 |
,219 |
11,637 |
<0.001 |
|
Door to CT Interpretation |
1,096 |
.019 |
,899 |
56,618 |
<0.001 |
CT
Computed Tomography; Sig. Significance
Table 10. Last Time Frames Logistic Regression Modeling
|
Variable |
Unstandardized Coefficients |
Wald |
Df |
Sig. |
Exp (B) |
95% CI for Exp (B) |
||
|
B |
Std. Error |
|
Lower |
Upper |
||||
|
Door to CT scan |
2,677 |
,509 |
27,616 |
1 |
<0.001 |
14,538 |
5,357 |
39,455 |
|
Door to CTInterprettaion |
22,210 |
5706.430 |
0,000 |
1 |
,997 |
44235940.0 |
,000 |
|
|
Constant |
-48196 |
11412.861 |
,000 |
1 |
,997 |
,000 |
|
|
CT
Computed Tomography; Df degree of freedom; Sig. significance; CI Confidence
Interval
Moderated Regression Analysis (MRA) was carried out in
this study to see whether the 5M management elements strengthen the time frame
variable for ischemic stroke services in the ER. In (Table 11) it is known that
the significance value of the time frames variable is <0.001 (<0.05), so
the conclusion is that the time frames variable has a significant effect on
ischemic stroke services in the emergency room at Budi Medika Hospital Bandar
Lampung and with an R square value of 0.966, it means that The contribution of
time frames to acute ischemic stroke services was 96.6%.
In the MRA regression equation II (Table 12) it is
obtained:
1.
It is known that the significance value of the time
frames variable is 0.002 (<0.05), so it is concluded that the time frames
variable has a significant effect on ischemic stroke services in the emergency
room at Budi Medika Hospital Bandar Lampung.
2.
Y =a+b1x1+b2X2+b1X1X2+e àY= 9.089 + 1.606 –
0.176 – 0.024
It is known that the significance value of the interaction variable
between the 5M management elements and time frames is 0.308 (>0.05), so it
can be concluded that the 5M management element variable (X2) is unable to
moderate the time frames on the acute ischemic stroke service variable in the
Emergency Room at Budi Medika Hospital Bandar Lampung
3.
Because the moderator variable is not significant and
the interaction variable is not significant, the type of moderation is
potential moderation (Homologist Moderator), meaning that this variable has the
potential to become a moderating variable.
4.
It is known that the R square value is 0.967, which
means that the contribution of the influence of time frames and 5M management
elements to acute ischemic stroke services after the moderating variable is
96.7%, where there is an increase from the previous 96.6% to 96.7%, it can be
concluded that after the presence of Moderating variables (5M management
elements) can strengthen the influence of time frames variables and 5M
management elements on ischemic stroke services at IGS Budi Medika Hospital
Bandar Lampung.
After carrying out the quantitative analysis, it was
continued with qualitative analysis (mix method sequential explanatory). The
results of the qualitative analysis were obtained from structured interviews
with several informants. In (Table 13), categories of various variables have
been obtained which have been coded according to interview references and
coding has also been carried out for 7 informants, namely the head of the ER
installation, the head of the radiology installation, the ER attending doctor,
the ER nurse, the radiology officer (radiographer), the administration
(registration).) and pharmacy staff.
From
the coding results, visualization results and data in the form of graphs are
obtained project map (Figure 1). From these results, it can be seen that
there is a relationship between the informants and the time frames variable and
it is also related to the 5M management elements for ischemic stroke services
in the ER.
The hierarchical results of time frames are greater
than the 5M management elements but both have an influence on ischemic stroke
services. This strengthens the previous quantitative analysis where time frames
have an influence on ischemic stroke services in the emergency room at Budi
Medika Hospital Bandar Lampung and time frames coupled with 5M management
elements are able to provide increased acute ischemic stroke services in the
emergency room. In the orange box, if you look at the hierarchy, door to CT
scan has the most influence compared to other variables, while in the gray box, the management elements (5M) man and material
have the most influence, which is also in accordance with the previous
quantitative results.
Discussion
The
distribution of basic characteristics of the subjects in this study was
dominated by male patients. Of the total 150 samples, 82 (54%) people were
male, which is in accordance with several previous studies where stroke cases
were dominated by male patients. In research conducted in Saudi Arabia
regarding "Demographic characteristics and types of strokes in
southwestern Saudi Arabia, and the potential demand of neuro endovascular
specialists" a sample of 562 stroke patients, 352 (62.6%) of whom were
male
Several
other studies say that stroke is usually in the seventh decade and the youngest
is between 30-40 years old
In research
in Thailand for 1 year, it was suspected that work factors related to quality
of life were psychosocial stress and Effort Reward Imbalance (ERI)
Of the
several activities in the ER, there are several which, if you look at the
average (mean) time, are quite long, including the patient registration time,
which is 14.19 minutes, with a variation of 0.6 minutes, the fastest is 5
minutes and the longest registration is 20 minutes. with an average time
between 12.8 minutes to 15.5 minutes. For patients with suspected stroke or
other patients who come to the emergency room who need immediate treatment, the
administration or registration process should be accelerated. Registration time
is the time from patient registration until the medical record book/status is
available.
"...In
my opinion, emergency room registration should be placed in the emergency room
environment, that means it should be one. So sometimes the patient's family
gets lost and ends up queuing at the outpatient registration. Then maybe at the
beginning you need to explain which room the patient wants to be treated in,
whether they need an HCU or ICU or maybe isolation. Because sometimes to be
honest it takes time and communication requires you to call the emergency room
and then confirm with the rooms..."
In several
studies it has been said that registration is an important thing in registering
patients in the emergency room. An effective registration model in the emergency
department can increase patient satisfaction levels
The
influence of human factors, namely, human resources play a very important role
in the emergency installation of a hospital. The emergency department is the
gateway to the hospital where there are crowds, varied cases and emergency
actions
”….Eeee, usually it's because
human resources are lacking, doc. "Because sometimes stroke patients come
in at the same time as other patients, right, doc, together..."
The
influence of method factors, namely, Standard Operating Procedures (SPO) are
procedures carried out chronologically to complete a job which aims to obtain
the most effective work results from workers
The
influence of material factors, namely, means are everything that is used as a
tool to achieve goals, infrastructure is everything that is the main support
for the implementation of a process. The condition of work facilities and
infrastructure that meet the work needs of each employee is one of the elements
that influences employee performance.
The influence of the Machine factor in
terms of stroke services is electronic medical records and head CT scans. Budi
Medika Hospital has been using an electronic medical record (RME) system since
2020 but was further refined using Terra Medic in early 2024. Meanwhile, head
CT scans use a CT scan 192 Multi Slice with Cinematic Rendering which is
operational 24 hours. The procedure is still entered via the electronic medical
record system by the attending doctor.
In this case
money is a financial factor used by the patient. Budi Medika Hospital has
facilitated inpatient and outpatient services in the form of BPJS, general and
insurance services. Of course, stroke is a disease that requires long-term
treatment. Stroke requires laboratory examination, CT scan of the head, chest
X-ray, EKG and others. Stroke also requires treatment for medical
rehabilitation. It cannot be denied that stroke is one of the causes of
patients' length of stay (LOS) in hospital. Several factors cause LOS such as
severity, stroke volume, infection, various complications, demographic factors
and the patient's emergency status
Timely management of acute ischemic stroke
is the key. "Time is brain lost" applies to both ischemic strokes and
haemorrhagic strokes. A fast response time in stroke treatment is associated
with good patient outcomes and reduced hospital mortality.
At door to triage the average (mean) of this study was 1.57 minutes. Based
on the door to needle time quality improvement project initiative target:
Stroke American Heart Association patients with symptoms of acute stroke should
be evaluated by a triage doctor (anamnesis, brief physical examination) in less
than 5 minutes.
The time
required from the patient coming to the ER until being examined by the doctor
on duty is <10 minutes
In this
study, the average door to CT scan time was 21.34 minutes. According to the
guidelines, the time required from when a patient arrives with a suspected
stroke until a CT scan of the head is < 25 minutes
The average
(mean) Door to CT Interpretation time in this study was 37.28 minutes, which
according to the guideline is the time required from when the patient arrives
with a suspected stroke until a CT scan of the head is carried out and
expertise is carried out by a doctor Sp. Rad is < 45 minutes.
Some studies
say that every minute of an acute ischemic stroke, 1.9 million brain cells are
damaged. Diagnostic examination in the form of neuroimaging is the most vital
component in stroke management. According to the American Heart Association
(AHA) guidelines, a CT scan should be performed on patients with suspected
stroke£25 minutes
from arrival to the ER
Researchers
conducted another moderated regression analysis (MRA), namely with time frames
as the independent variable, 5M management elements as the moderator for the
dependent variable, namely ischemic stroke services (door to drug).£60 minutes). The type of
moderation is in the form of potential moderation (Homologist Moderator) where
this variable does not interact with the predictor variable and does not have a
significant relationship with the dependent variable
However, the 5M management elements definitely have an
influence on ischemic stroke services in the emergency room at Budi Medika
Hospital. In this study, stroke services were not good, namely marked by door
to drug³60 minutes. To achieve services in accordance with the NINDS guidelines,
namely£60 minutes requires a comprehensive system or flow, which is currently
determined throughout the world with a stroke code. This study also recommends
that every hospital should try to implement it because it is very simple, very
cost effective and can train health and non-health workers in acute stroke
management with good outcomes
CONCLUSION
To provide acute ischemic stroke services in the
Emergency Department which is well marked with door to drug£60 minutes, good time
frame management is required in accordance with the NINDS guidelines starting
from door to triage£5 minutes, door to physician£10 minutes, door to CT£25 minutes and door to CT interpretation£45 minutes. Hospital management elements in the form
of 5 (M) man, method, material, machine and money strengthen the influence of
time frames on ischemic stroke services. In terms of improving ischemic stroke
services in the emergency room, appropriate SOPs, a special registration
process, implementation of stroke codes, training of human resources and
creating special priorities for special services (VIP stroke) are needed. It is
also important to consider special SOP alternatives if a CT scan cannot be used
so as not to delay immediate treatment and treatment in accordance with the
acute stroke philosophy, namely "Time is Brain".
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Copyright Holder: Luther Theng,
Yanuar Jak, Grace Rumengan
(2024) |
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First Publication Right: Jurnal Health Sains |
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