The effect of weekends and holidays on stroke outcome in acute stroke units

BACKGROUND AND PURPOSE: In almost all acute stroke units in Japan, staffing level is lower on weekends and holidays and rehabilitative services are provided only on weekdays. We sought to investigate the effects of low-volume care early after stroke resulting from weekends and holidays on the outcome of stroke. METHODS: Patients with completed stroke within 72 h of onset were prospectively registered by 10 acute stroke units in Japan. Main outcome measures were favorable outcomes as indicated by a score of 0-1 on the modified Rankin scale (mRS01) on their 21st hospital day and at discharge and case fatality during the hospital stay. Cox proportional hazardsmodels were used to identify the effects of weekday admission and a weekday ratio (a number of weekdays / total length of hospital stay, or 21 days if hospitalization was longer than 21 days) on the main outcome measures. RESULTS: In a total of 1,134 patients, Cox proportional hazards regression analyses demonstrated that the weekday admission was significantly associated with mRS01 at discharge (hazard ratio, HR: 1.385, 95% CI: 1.087-1.764) and case fatality (HR: 0.477, 95% CI: 0.285-0.798). In 858 patients with rehabilitative therapy, the weekday ratio was significantly associated with mRS01 at discharge (p = 0.014). Compared with the lowest tertile of weekday ratio (<66.6%), the highest tertile (>71.4%) was significantly positively associated with mRS01 at discharge (HR: 1.524, 95% CI: 1.053-2.206; p < 0.026). CONCLUSIONS: Weekday admission was an independent negative predictor of case fatality and a positive predictor of favorable outcome (mRS01) at discharge from acute stroke units. In patients with rehabilitative therapy, a reduction in the weekday ratio was also associated with unfavorable outcome, probably due to a reduction in multidisciplinary care.     

Outcomes of intravenous thrombolytic therapy for acute ischemic stroke with an integrated acute stroke referral network: initial experience of a community-based hospital in a developing country

Some of the literature encourages the use of intravenous (IV) thrombolytic therapy for acute ischemic stroke (AIS) in centers with no previous experience with this therapy. The benefits of an acute stroke referral network for IV thrombolytic therapy remain controversial, however. We present outcomes of IV thrombolytic therapy for AIS with an integrated acute stroke referral network at an institution with no previous experience in stroke thrombolysis and compare the results with previously published data. A total of 458 patients with AIS or transient ischemic attack (TIA), referred from a hospital in the acute stroke referral network or walk-ins, admitted to the stroke unit of Thammasat Hospital between October 2007 and January 2009 (16 months) were prospectively assessed. The main outcome measures were IV thrombolytic treatment rate, initial National Institutes of Health Stroke Scale (NIHSS) score, door-to-needle time, onset-to-treatment time (OTT), intracerebral hemorrhage, and morbidity and mortality at 3 months after onset. A total of 100 patients (59 from hospitals in the stroke referral network) received IV recombinant tissue plasminogen activator (rt-PA) therapy (21% of the admissions with AIS and TIA); 41% of the patients referred from a hospital in the network received IV rt-PA. The median NIHSS score before thrombolysis was 15 (range, 3-34). Mean door-to-needle time was 54 minutes (range, 15-125 minutes), and mean OTT was 160 minutes (range, 60-270 minutes). There were 13 asymptomatic intracerebral hemorrhages and 2 symptomatic intracerebral hemorrhages (1 fatal). By 3 months, 42 patients had achieved excellent recovery (modified Rankin Scale score of 0-1), and 14 had died. These outcomes are comparable to data from the National Institute of Neurological Disorders and Stroke and previous studies of IV rt-PA therapy in Thailand. Our findings indicate that integrating an acute stroke referral network into IV thrombolytic therapy for AIS in a community-based setting is safe and feasible and should help increase the rate of thrombolytic therapy. Previously inexperienced community-based centers can reproduce the experience and outcome measures reported by clinical trials and in the landmark literature of IV thrombolytic therapy in patients with stroke.     

Predictors of acute hospital costs for treatment of ischemic stroke in an academic center

BACKGROUND AND PURPOSE: We sought to determine predictors of acute hospital costs in patients presenting with acute ischemic stroke to an academic center using a stroke management team to coordinate care. METHODS: Demographic and clinical data were prospectively collected on 191 patients consecutively admitted with acute ischemic stroke. Patients were classified by insurance status, premorbid modified Rankin scale, stroke location, stroke severity (National Institutes of Health Stroke Scale score), and presence of comorbidities. Detailed hospital charge data were converted to cost by application of department-specific cost-to-charge ratios. Physician's fees were not included. A stepwise multiple regression analysis was computed to determine the predictors of total hospital cost. RESULTS: Median length of stay was 6 days (range, 1 to 63 days), and mortality was 3%. Median hospital cost per discharge was $4408 (range, $1199 to $59 799). Fifty percent of costs were for room charges, 19% for stroke evaluation, 21% for medical management, and 7% for acute rehabilitation therapies. Sixteen percent were admitted to an intensive care unit. Length of stay accounted for 43% of the variance in total cost. Other independent predictors of cost included stroke severity, heparin treatment, atrial fibrillation, male sex, ischemic cardiac disease, and premorbid functional status. CONCLUSIONS: We conclude that the major predictors of acute hospital costs of stroke in this environment are length of stay, stroke severity, cardiac disease, male sex, and use of heparin. Room charges accounted for the majority of costs, and attempts to reduce the cost of stroke evaluation would be of marginal value. Efforts to reduce acute costs should be monitored for potential cost shifting or a negative impact on quality of care.     

Predictors of survival and functional outcome in acute stroke patients admitted to the stroke intensive care unit

Multivariate models have not been widely used to predict the outcome of acute stroke patients admitted to the intensive care unit (ICU). The purpose of this study was to determine potential measures observed in the first 12 h post-stroke that predict early mortality and functional outcomes in ICU-admitted stroke patients. Eight hundred and fifty acute stroke patients (ischemic stroke, 508; intracerebral hemorrhage, 342) were included in this analysis between November 2002 and December 2006. Measures of interest were obtained in the first 12 h after onset of stroke were analyzed for three types of outcome: 3-month mortality, 3-month mortality or institutional care, and poor functional outcomes at discharge. Poor functional outcomes were defined as a Barthel index <80 or a Rankin scale >2. Multivariate regression models were used to determine the predictive value of the observed measures. After 3 months, 17% of patients had died; 21% were alive but being cared for in institutional settings; and 62% were alive and living at home. Functional status at discharge indicated 16% of patients had died, poor function in 50%, and good function in 34% of patients. Initial stroke severity, measured by National Institute of Health Stroke Scale, and dependence on a ventilator predicts 3-month mortality and poor outcome in all stroke patients. In addition, old age, previous stroke, and total anterior circulatory infarct were associated with poor outcome in ischemic stroke patients; old age, low body mass index and the presence of intraventricular hemorrhage were associated with poor outcomes in intracerebral hemorrhage patients. In conclusion, early stroke mortality and outcome at discharge can be predicted in the first few hours following an acute stroke for moderate to severe ICU-admitted stroke patients.     

Incidence of seizures in the acute phase of stroke: a population-based study

Purpose: The incidence of seizures within 24 h of acute stroke has not been studied extensively. We aimed to establish the incidence of acute poststroke seizures in a biracial cohort and to determine whether acute seizure occurrence differs by race/ethnicity, stroke subtype, and/or stroke localization.
Methods: We identified all stroke cases between July 1993 and June 1994 and in 1999 within the population of the Greater Cincinnati metropolitan region. Patients with a prior history of seizures/epilepsy were excluded from analysis.
Results: A total of 6044 strokes without a history of seizure(s) were identified; 190 (3.1%) had seizures within the first 24 h of stroke onset. Of ICH/SAH patients, 8.4% had a seizure within the first 24 h of stroke onset (p ≤ 0.0001 vs. all other stroke subtype). Of the patients with ischemic stroke, we observed higher incidence of seizures in cardioembolic versus small or large vessel ischemic (p = 0.02) strokes. Patients with seizures experienced higher mortality than patients without seizures (p < 0.001) but seizures were not an independent risk factor of mortality at 30 days after stroke. Independent risk factors for seizure development included hemorrhagic stroke, younger age, and prestroke Rankin score of ≥1. Race/ethnicity or localization of the ischemic stroke did not influence the risk for seizure development in the studied population.
Discussion: The overall incidence of acute seizures after stroke was 3.1%, with a higher incidence seen in hemorrhagic stroke, younger patients, and those presenting with higher prestroke Rankin scores. Acute seizures were associated with a higher mortality at 30 days after stroke.     

Acute stroke units in Austria are being set up on a national level following evidence-based recommendations and structural quality criteria

A system of acute stroke units is being set up in Austria, which will care for 70% of all acute strokes by 2005. This nationwide project has been planned according to evidence-based principles and contains pre-specified structural components for acute stroke care. With some exceptions in remote mountain regions, all stroke units can be reached within 90 min from any community. All units are within neurological departments. An ongoing documentation of quality performance shows that these units are being well accepted by the general population and the medical community alike.     

Treatment of ischemic stroke in 14 neurologic stroke units. An evaluation of the stroke databank of the German Stroke Aid Foundation

This study compares the treatment characteristics of 3,740 patients with acute ischemic stroke in 14 established German stroke units. Follow-up after 3 months in surviving patients additionally assessed functional outcome and risk factor modification. The median age was 68 years and 41.9% were women. Twenty-six percent of all patients were admitted within 3 h after the event, and 4.2% received systemic thrombolysis. The median length of stay of all patients in the stroke unit was 3 days. Thereafter, 63% were transferred to another ward in the documenting clinic. The mean length of stay in the documenting hospital was 12 days. In seven hospitals with a follow-up rate of > 80%, mortality amounted to 10.5%, and 56.2% of the patients regained functional independence. This study demonstrates the relatively favorable prognosis of patients in German stroke units as well as the low standardization of diagnostic work-up and treatment strategies.     

Off-hours admission for acute stroke is not associated with worse outcome--a nationwide Israeli stroke project

Background and purpose: Several studies reported worse outcome for stroke patients arriving on weekends. We compared working hours to off‐work hours throughout the week as there is lack of experienced staff and special services during off‐hours. Methods: A nationwide stroke survey project on acute stroke was carried out in all acute care hospitals in Israel during 2004, 2007 and 2010 (2‐month each). ‘On‐hours’ were defined as regular Israel working hours and the rest, including holidays, were defined as ‘off‐hours’. The modified Rankin scale (mRS) at discharge was used for the main analysis on outcome. Results: A total of 4827 acute strokes patients were analyzed (2139 arrived on‐hours and 2688 during off‐hours). ‘Off‐hours’ patients were 1 year younger (mean 70 vs. 71 years in ‘on‐hours’) had lower rates of prior cardiac interventions, but had higher admission blood pressure levels and had more intracerebral hemorrhages (ICH) (11% vs. 8% in ‘on‐hours’ patients, P < 0.001). Death during hospitalization was recorded in 9% of ‘off‐hours’ vs. 6% of ‘on‐hours’ patient (P = 0.004). Controlling for age, blood pressure, stroke type, pre‐stroke mRS, admission NIHSS, and thrombolysis, the relative odds of poor outcome (i.e. mRS ≥ 2) amongst ‘off‐hours’ admissions compared to on‐hours was 1.09 (95% CI: 0.92–1.30). Odds ratio amongst ischaemic stroke patients was 1.08 (95% CI: 0.88–1.33). Conclusions: Off‐hours stroke admissions were associated with higher short‐term mortality rate, probably due to a higher rate of ICH. After controlling for the latter and other potential confounders, ‘off‐hours’ admissions were not different from ‘on‐hours’ with respect to poor outcome.     

Frequency and characteristics of early seizures in Chinese acute stroke

We retrospectively studied 1200 hospitalized acute strokes of all etiologies between July 1990 and August 1992. Ninety-six % of all strokes underwent computed tomography of the head. Fifty-eight percent of the 1200 strokes were brain infarction, 32% brain hemorrhage, 6% subarachnoid hemorrhage and 4% were other stroke subtypes. Thirty (2.5%) of all strokes suffered from early seizures. The incidences of early seizures were 2.8% in brain hemorrhage, 2.3% in brain infarction, 2.7% in subarachnoid hemorrhage and 2% in other stroke subtypes. Early seizures were documented in 6% of the patients with carotid territory cortical infarctions and 12% of the patients with lobar hemorrhage, whereas only 0.6% of the patients without carotid territory cortical infarctions and 0.6% of the patients without lobar hemorrhage were affected. Sixty- six percent of 30 early seizures were partial seizures, 24% generalized and status epilepticus were seen only in 10%. In conclusion, we found the early seizure incidence was 2.5% in Chinese patients hospitalized with acute strokes. There was no correlation between seizure occurrence and stroke subtypes. Early seizure developed significantly higher in acute stroke patients with lesions of the cortex than those patients without cortical involvement. The partial seizures were the most frequent type occurring in 66% of all acute stroke patients with early seizures.     

Stroke units and stroke services in Portugal

Stroke is the first cause of death in Portugal. In 1999 more than 70,000 patients with a stroke were admitted to public hospitals, with total hospitalisation costs of EUR 188 million. Stroke patients are traditionally treated in the departments of medicine and/or neurology. In 2001 the Department of Health approved a rapid transport system of acute stroke victims to the stroke units as well as 'Stroke Unit Guidelines'. The aim of these guidelines is to define norms facilitating the launch of stroke units in all Portuguese hospitals admitting more than 300 stroke patients a year. By July 2002, five stroke units were already operating.     

Associations between meteorological variables and acute stroke hospital admissions in the west of Scotland

Background –  We combined a large clinical stroke registry with the UK Met Office database to assess the association between meteorological variables and specific clinical subtypes of acute stroke.
Methods –  We used negative binomial regression and Poisson regression techniques to explore the effect of meteorological values to hospital with acute stroke. Differential effects of atmospheric conditions upon stroke subtypes were also investigated.
Results –  Data from 6389 patients with acute stroke were examined. The mean age (SD) was 71.2 (13.0) years. About 5723 (90%) patients suffered ischaemic stroke of which 1943 (34%) were lacunar. Six hundred and sixty-six patients (10%) had haemorrhagic stroke. Every 1°C increase in mean temperature during the preceding 24 h was associated with a 2.1% increase in ischaemic stroke admissions ( P  = 0.004). A fall in atmospheric pressure over the preceding 48 h was associated with increased rate of haemorrhagic stroke admissions ( P  = 0.045). Higher maximum daily temperature gave a greater increase in lacunar stroke admissions than in other ischaemic strokes ( P  = 0.035).
Conclusion –  We report a measurable effect of atmospheric conditions upon stroke incidence in a temperate climate.     

Doppler ultrasound and clinical findings in patients with acute ischemic stroke treated with intravenous thrombolysis

The aim of this study was to assess cerebral hemodynamics in patients with acute ischemic stroke undergoing thrombolytic therapy and to assess the relationship between cerebral hemodynamics and outcome. Forty-one unselected patients admitted to hospital within 3 h received intravenous thrombolytic therapy and were examined by extracranial and transcranial Doppler ultrasound examinations. Their strokes were clinically graded with the National Institute of Health Stroke Scale. Outcome after 3 months was graded with the modified Rankin Scale. Amongst the 27 patients who had an additional ultrasound examination 24 h after treatment, favorable outcome was significantly more common amongst patients with recanalization than amongst those without (P < 0.004). Thirteen patients with middle cerebral artery occlusions were continuously monitored during thrombolysis and frequently up to 5 h after start of thrombolysis. Early recanalization occurred in nine (69%), at a median delay of 178 min (range 140-287) after stroke onset. All of these nine patients had a favorable outcome. Recanalization within 24 h was associated with favorable outcome. Subgroup analysis suggests that this effect is mostly related to early recanalization within the first 5 h after stroke. Transcranial Doppler may therefore help to identify those patients most probably to benefit from thrombolysis, especially in those patients with a higher potential risk of complications.     

A study of the workload and effectiveness of a comprehensive acute stroke service

OBJECTIVE: To study the workload of and use of acute intervention within an established acute stroke service, the Calgary Stroke Programme (CSP). METHODS: Prospective record of all acute referrals, diagnoses, and management decisions over a 4 month period. RESULTS: The CSP received 572 referrals (median: 32 per week), 88% of which were made between 7 am and midnight. Of the 427 patients seen in person, 29% had not had an acute stroke or transient ischaemic attack (TIA). Fifty percent of patients with suspected acute stroke were referred within 3 h of symptom onset and 11% with acute ischaemic stroke (equating to 35% of those referred within 3 h of onset and seen in person) were treated with thrombolysis. CONCLUSION: Centralisation of services facilitates the rapid referral of, and use of acute interventions in, patients with acute stroke and TIA. Centralised services are likely to be busy (although less so at night), to attract large numbers of patients with disorders that mimic stroke and TIA, and yet still likely to treat only the minority of acute strokes using thrombolysis. These observations may help those planning similar services and underline the need to develop more widely applicable treatments for acute stroke.     

Thrombolytic therapy in acute ischaemic stroke

BACKGROUND: The aim of this study was to assess the feasibility, clinical effect and safety of intravenous thrombolysis with tissue plasminogen activator in patients with acute ischaemic stroke treated in an acute stroke unit. METHODS: All patients admitted within 3 h after an acute ischaemic stroke were considered for thrombolysis. Twenty-four patients were treated. RESULTS: Ten patients demonstrated early clinical improvement compatible with a positive effect of thrombolysis. Five patients demonstrated a substantial but slow clinical improvement with an uncertain relationship to thrombolysis. Nine patients did not improve. One patient developed an intracerebral haematoma and 2 developed a haemorrhagic infarction without clinical deterioration. Five patients (21%) died within the first 3 months. At follow-up after 6 months, 10 patients (42%) had achieved independence [modified Rankin Scale (mRS) 0-2], 9 (33%) had an unfavourable outcome (mRS 3-5) and 5 patients (21%) had died. None of these 5 patients died due to a treatment complication. CONCLUSIONS: This study in a small patient population suggests that thrombolysis may be administered relatively safely in an acute stroke unit without intensive care facilities. The clinical effect and safety were similar to those which have been found in large randomised studies and clinical series.     

Regional disparities in acute and post-acute care of stroke patients in France, 2015

Objective

The aim of this study was to assess regional variations of the hospital management of stroke patients during acute and post-acute phases in France in 2015.

Stroke units and stroke services in Germany

BACKGROUND/OBJECTIVES: The German stroke units are sub-intensive units with the possibility of continuous monitoring of vital parameters. This is the main difference to Scandinavian and British non-intensive combined acute and rehabilitation stroke units. Germany has 56 regional and 50 local stroke units, and standards differ between them. Nearly 30% of all strokes in Germany are treated in these units. The German stroke units are cost intensive and unfortunately their effectiveness has not been proven yet.     

In-hospital myocardial infarction following acute ischaemic stroke: an observational study

Background and purpose: Acute myocardial infarction is expected to be an important medical complication following ischaemic stroke. We sought to describe the frequency and clinical impact of in‐hospital myocardial infarction following acute ischaemic stroke. Methods: Consecutive patients with acute ischaemic stroke were identified from the Registry of the Canadian Stroke Network (2003–2006). Stroke severity was measured using the Canadian Neurological Scale (CNS). Functional status at discharge was measured with the modified‐Rankin Scale, and categorized into strokes with no or mild‐moderate dependency (m‐Rankin 0–3) and those with severe dependence or death (m‐Rankin 4–6). Multivariable logistic regression was used to determine the association between myocardial infarction and clinical outcome (death or severe dependence at hospital discharge and 1 year mortality), independent of co‐morbidities and in‐hospital medical complications. Results: In total, 9180 patients with acute ischaemic stroke were included. The mean age was 72 years (SD 13.9) and 48% were female. Overall, 211 (2.3%) patients were reported to have myocardial infarction during hospitalization. At hospital discharge, 64.9% of patients with in‐hospital myocardial infarction had died or were severely disabled, compared with 35.8% in the entire cohort. Mortality at 1 year after ischaemic stroke was 56.4% in patients with myocardial infarction and 21.9% in the entire cohort. On multivariable analyses, myocardial infarction was also associated with death or severe dependence at discharge (OR 2.51; 95%CI 1.75–3.59) and mortality within 1 year (HR 1.83; 95%CI 1.51–2.23). Previous history of myocardial infarction (OR 1.50; 95%CI 1.05–2.15), diabetes mellitus (OR 1.55; 95%CI 1.42–2.10), stroke severity (OR 1.13; 95% CI 1.09–1.17) and peripheral vascular disease (OR 1.61; 95%CI 1.04–2.49) were independently associated with myocardial infarction during hospitalization. Conclusions: Myocardial infarction is an important medical complication after acute ischaemic stroke.     

Epidemiology and management of stroke patients in emergency departments of the Centre region of France

INTRODUCTION: Stroke is a leading cause of death and disability. Patients with suspected stroke are usually managed in emergency departments (ED). Stroke units must be created in our country, but only few French epidemiological data are available to define needs in stroke care. OBJECTIVE: A prospective study was planned to evaluate epidemiology and stroke care for patients with suspected stroke admitted in the 22 ED of our region in the center of France during a two-month period. METHODS: Patients with suspected stroke seen at the 22 ED were prospectively followed until discharge or one month after admission. Data on demographic characteristics, mode of transport, delay of arrival and imaging, clinical findings at arrival, department of admission, diagnosis, Rankin scale at day 7, in-hospital mortality, and outcome at a month were collected. A global statistical analysis and a comparison between rural and urban ED were performed. RESULTS: Five hundred and ninety-eight patients were included. Mean age was 75 years. Median admission delay was 4 hours and 52 minutes. Predominant mode of transport was a private ambulance. A CT scan was obtained in 91 p.cent of cases with a median delay of 2 hours and 30 minutes. Only a third of the patients were admitted in departments of Neurology. Final diagnosis was: ischemic stroke (61 p.cent), transient ischemic attack (16 p.cent), hemorrhagic stroke (10 p.cent), other vascular disease (3 p.cent), non vascular disease (10 p.cent). In-hospital mortality was 20 p.cent, factors significantly associated with death rate were elevated age and a Glasgow coma scale<10 at admission. Mean length of stay was 12 days for stroke patients. At one month, 63 percent of patients were discharged to their home, 28 percent were transferred to an institution or in a rehabilitation unit, and 15 percent were still hospitalized. Significant differences in stroke care were found between rural and urban ED. CONCLUSION: This prospective study provides epidemiological data for our region. Creation of stroke units and definition of acute stroke networks are necessary to improve stroke care.     

Effect of daytime,weekday and year of admission on outcome in acute ischaemic stroke patients treated with thrombolytic therapy

Background: Since doubts were raised, if a challenging medical procedure such as acute stroke treatment including thrombolysis with recombinant tissue plasminogen activator (rTPA) is available with identical standard and outcome 24 h and 7 days a week our aim was to examine if acute stroke patients defined by onset‐admission time (OAT) of ≤ 3 h were treated differently or had distinct outcome when admitted during off duty hours (day versus night and weekend versus weekdays) and if any differences in treatment or outcome were apparent when comparing patients admitted in the year 2003 with patients admitted in the year 2006. Methods: We analyzed 2003–2006 data of a prospective registry and grouped patients by time, day, and year of admission. The evaluation was limited to patients that were diagnosed with ischaemic stroke and with OAT of ≤ 3 h. Medical and sociodemographic items, use of thrombolytic treatment, complications during clinical course and place of discharge were obtained. Clinical state on admission and discharge was assessed using the modified Rankin scale. Comparison with chi‐square test, t‐test and logistic regression was performed. Results: Patient’s characteristics, rate of thrombolysis, and outcome were independent from time or day of admission. Proportion of patients with good clinical state at discharge increased significantly from 2003 to 2006 together with a higher rate of rTPA treatment without increase of intracranial hemorrhage. Proportion of patients discharged in good clinical condition after rTPA treatment increased from 34% to 44%. Conclusions: Stroke treatment in potential candidates for thrombolytic therapy revealed no impairment on weekend or at night already in 2003. During 4 years, it was possible to increase rate of rTPA treatment from 8.9% to 21.8% without increment of complications or death, confirming that rTPA is safe and can be implemented with full daily and weekly coverage.     

Burden of acute stroke and hospital resources in the Campania region of Italy

We examined all the official hospital records referring to admissions for acute stroke (AS) (DRG 14) from January 1 to December 31, 1996 in Campania (Italy), a large region with 10% of the Italian population. Related healthcare burden and available resources were evaluated. During the study period, a total of 9,003 discharges were reported. We counted 11 neurological care units (NCU) committed to emergency in the region, with 230 hospital beds. The 4,890 admissions in NCU represented 54.3% of the total AS hospitalizations per year. A large number of strokes (45.7%) had no access to specialist assistance and were hospitalized mainly in general wards with a mean hospital stay of 12.7 days, compared with 9.5 days in NCU (p < 0.01). In our region, the number of hospital beds available for neurological emergencies do not meet the demand.