WillowV1, Main, Exploration, bibRecord, 000109

Protocolized emergency department observation care improves quality of ischemic stroke care in Haiti.

Identifieur interne : 000109 ( Main/Exploration ); précédent : 000108; suivant : 000110

Protocolized emergency department observation care improves quality of ischemic stroke care in Haiti.

Auteurs : Shada A. Rouhani [États-Unis, Haïti] ; Regan H. Marsh [États-Unis] ; Linda Rimpel [Haïti] ; Kathryn Anderson [États-Unis] ; Malena Outhay [États-Unis] ; Marie Cassandre Edmond [Haïti] ; Keegan A. Checkett [États-Unis, Haïti] ; Aaron L. Berkowitz [États-Unis] ; Gene F. Kwan [États-Unis] ; Christopher W. Baugh [États-Unis] ; Jeremiah D. Schuur [États-Unis]

Source :

African journal of emergency medicine : Revue africaine de la medecine d'urgence [ 2211-4203 ] ; 2020.

RBID : pubmed:32923326

Abstract

Introduction

In many low-income countries, Emergency Medicine is underdeveloped and faces many operational challenges including emergency department (ED) overcrowding and prolonged patient length of stays (LOS). In high-resource settings, protocolized ED observation unit (EDOU) care reduces LOS while preserving care quality. EDOUs are untested in low-income countries. We evaluate the effect protocolized EDOU care for ischemic stroke on the quality and efficiency of care in Haiti.

Methods

We performed a prospective cohort study of protocolized observation care for ischemic stroke at a Haitian academic hospital between January 2014 and September 2015. We compared patients cared for in the EDOU using the ischemic stroke protocol (study group) to eligible patients cared for before protocol implementation (baseline group), as well as to eligible patients treated after protocol introduction but managed without the EDOU protocol (contemporary reference group). We analysed three quality of care measures: aspirin administration, physical therapy consultation, and swallow evaluation. We also analysed ED and hospital LOS as measures of efficiency.

Results

Patients receiving protocolized EDOU care achieved higher care quality compared to the baseline group, with higher rates of aspirin administration (91% v. 17%, p < 0.001), physical therapy consultation (50% v. 9.6%, p < 0.001), and swallow evaluation (36% v. 3.7%, p < 0.001). We observed similar improvements in the study group compared to the contemporary reference group. Most patients (92%) were managed entirely in the ED or EDOU. LOS for non-admitted patients was longer in the study group than the baseline group (28 v. 19 h, p = 0.023).

Conclusion

Protocolized EDOU care for patients with ischemic stroke in Haiti improved performance on key quality measures but increased LOS, likely due to more interventions. Future studies should examine the aspects of EDOU care are most effective at promoting higher care quality, and if similar results are achievable in patients with other conditions.

DOI: 10.1016/j.afjem.2020.05.007
PubMed: 32923326
PubMed Central: PMC7474244

Affiliations:

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<author><name sortKey="Marsh, Regan H" sort="Marsh, Regan H" uniqKey="Marsh R" first="Regan H" last="Marsh">Regan H. Marsh</name>
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<author><name sortKey="Rimpel, Linda" sort="Rimpel, Linda" uniqKey="Rimpel L" first="Linda" last="Rimpel">Linda Rimpel</name>
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<author><name sortKey="Anderson, Kathryn" sort="Anderson, Kathryn" uniqKey="Anderson K" first="Kathryn" last="Anderson">Kathryn Anderson</name>
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<country xml:lang="fr">États-Unis</country>
<wicri:regionArea>University of Chicago, Section of Emergency Medicine, Chicago, IL</wicri:regionArea>
<placeName><region type="state">Illinois</region>
<settlement type="city">Chicago</settlement>
</placeName>
<orgName type="university">Université de Chicago</orgName>
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<author><name sortKey="Outhay, Malena" sort="Outhay, Malena" uniqKey="Outhay M" first="Malena" last="Outhay">Malena Outhay</name>
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<country xml:lang="fr">États-Unis</country>
<wicri:regionArea>Alameda Health System, Highland Hospital, Department of Emergency Medicine, Oakland, CA</wicri:regionArea>
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<author><name sortKey="Edmond, Marie Cassandre" sort="Edmond, Marie Cassandre" uniqKey="Edmond M" first="Marie Cassandre" last="Edmond">Marie Cassandre Edmond</name>
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<country xml:lang="fr">Haïti</country>
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<author><name sortKey="Checkett, Keegan A" sort="Checkett, Keegan A" uniqKey="Checkett K" first="Keegan A" last="Checkett">Keegan A. Checkett</name>
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<country xml:lang="fr">États-Unis</country>
<wicri:regionArea>Partners In Health, Boston, MA</wicri:regionArea>
<placeName><region type="state">Massachusetts</region>
</placeName>
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<affiliation wicri:level="1"><nlm:affiliation>Hôpital Universitaire de Mirebalais, Department of Emergency Medicine, Route Chatulée, Mirebalais, Haiti.</nlm:affiliation>
<country xml:lang="fr">Haïti</country>
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<affiliation wicri:level="4"><nlm:affiliation>University of Chicago, Section of Emergency Medicine, Chicago, IL, USA.</nlm:affiliation>
<country xml:lang="fr">États-Unis</country>
<wicri:regionArea>University of Chicago, Section of Emergency Medicine, Chicago, IL</wicri:regionArea>
<placeName><region type="state">Illinois</region>
<settlement type="city">Chicago</settlement>
</placeName>
<orgName type="university">Université de Chicago</orgName>
</affiliation>
</author>
<author><name sortKey="Berkowitz, Aaron L" sort="Berkowitz, Aaron L" uniqKey="Berkowitz A" first="Aaron L" last="Berkowitz">Aaron L. Berkowitz</name>
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<country xml:lang="fr">États-Unis</country>
<wicri:regionArea>Partners In Health, Boston, MA</wicri:regionArea>
<placeName><region type="state">Massachusetts</region>
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<affiliation wicri:level="2"><nlm:affiliation>Brigham and Women's Hospital, Department of Neurology, Boston, MA, USA.</nlm:affiliation>
<country xml:lang="fr">États-Unis</country>
<wicri:regionArea>Brigham and Women's Hospital, Department of Neurology, Boston, MA</wicri:regionArea>
<placeName><region type="state">Massachusetts</region>
</placeName>
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<affiliation wicri:level="2"><nlm:affiliation>Harvard Medical School, Department of Neurology, Boston, MA, USA.</nlm:affiliation>
<country xml:lang="fr">États-Unis</country>
<wicri:regionArea>Harvard Medical School, Department of Neurology, Boston, MA</wicri:regionArea>
<placeName><region type="state">Massachusetts</region>
</placeName>
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<author><name sortKey="Kwan, Gene F" sort="Kwan, Gene F" uniqKey="Kwan G" first="Gene F" last="Kwan">Gene F. Kwan</name>
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<country xml:lang="fr">États-Unis</country>
<wicri:regionArea>Partners In Health, Boston, MA</wicri:regionArea>
<placeName><region type="state">Massachusetts</region>
</placeName>
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<affiliation wicri:level="2"><nlm:affiliation>Boston University School of Medicine, Section of Cardiovascular Medicine, Boston, MA, USA.</nlm:affiliation>
<country xml:lang="fr">États-Unis</country>
<wicri:regionArea>Boston University School of Medicine, Section of Cardiovascular Medicine, Boston, MA</wicri:regionArea>
<placeName><region type="state">Massachusetts</region>
</placeName>
</affiliation>
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<author><name sortKey="Baugh, Christopher W" sort="Baugh, Christopher W" uniqKey="Baugh C" first="Christopher W" last="Baugh">Christopher W. Baugh</name>
<affiliation wicri:level="2"><nlm:affiliation>Harvard Medical School, Department of Emergency Medicine, Boston, MA, USA.</nlm:affiliation>
<country xml:lang="fr">États-Unis</country>
<wicri:regionArea>Harvard Medical School, Department of Emergency Medicine, Boston, MA</wicri:regionArea>
<placeName><region type="state">Massachusetts</region>
</placeName>
</affiliation>
<affiliation wicri:level="2"><nlm:affiliation>Brigham and Women's Hospital, Department of Emergency Medicine, Boston, MA, USA.</nlm:affiliation>
<country xml:lang="fr">États-Unis</country>
<wicri:regionArea>Brigham and Women's Hospital, Department of Emergency Medicine, Boston, MA</wicri:regionArea>
<placeName><region type="state">Massachusetts</region>
</placeName>
</affiliation>
</author>
<author><name sortKey="Schuur, Jeremiah D" sort="Schuur, Jeremiah D" uniqKey="Schuur J" first="Jeremiah D" last="Schuur">Jeremiah D. Schuur</name>
<affiliation wicri:level="4"><nlm:affiliation>Brown University, Department of Emergency Medicine, Providence, RI, USA.</nlm:affiliation>
<country xml:lang="fr">États-Unis</country>
<wicri:regionArea>Brown University, Department of Emergency Medicine, Providence, RI</wicri:regionArea>
<placeName><region type="state">Rhode Island</region>
<settlement type="city">Providence (Rhode Island)</settlement>
</placeName>
<orgName type="university">Université Brown</orgName>
</affiliation>
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<series><title level="j">African journal of emergency medicine : Revue africaine de la medecine d'urgence</title>
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<front><div type="abstract" xml:lang="en"><p><b>Introduction</b>
</p>
<p>In many low-income countries, Emergency Medicine is underdeveloped and faces many operational challenges including emergency department (ED) overcrowding and prolonged patient length of stays (LOS). In high-resource settings, protocolized ED observation unit (EDOU) care reduces LOS while preserving care quality. EDOUs are untested in low-income countries. We evaluate the effect protocolized EDOU care for ischemic stroke on the quality and efficiency of care in Haiti.</p>
</div>
<div type="abstract" xml:lang="en"><p><b>Methods</b>
</p>
<p>We performed a prospective cohort study of protocolized observation care for ischemic stroke at a Haitian academic hospital between January 2014 and September 2015. We compared patients cared for in the EDOU using the ischemic stroke protocol (study group) to eligible patients cared for before protocol implementation (baseline group), as well as to eligible patients treated after protocol introduction but managed without the EDOU protocol (contemporary reference group). We analysed three quality of care measures: aspirin administration, physical therapy consultation, and swallow evaluation. We also analysed ED and hospital LOS as measures of efficiency.</p>
</div>
<div type="abstract" xml:lang="en"><p><b>Results</b>
</p>
<p>Patients receiving protocolized EDOU care achieved higher care quality compared to the baseline group, with higher rates of aspirin administration (91% v. 17%, p < 0.001), physical therapy consultation (50% v. 9.6%, p < 0.001), and swallow evaluation (36% v. 3.7%, p < 0.001). We observed similar improvements in the study group compared to the contemporary reference group. Most patients (92%) were managed entirely in the ED or EDOU. LOS for non-admitted patients was longer in the study group than the baseline group (28 v. 19 h, p = 0.023).</p>
</div>
<div type="abstract" xml:lang="en"><p><b>Conclusion</b>
</p>
<p>Protocolized EDOU care for patients with ischemic stroke in Haiti improved performance on key quality measures but increased LOS, likely due to more interventions. Future studies should examine the aspects of EDOU care are most effective at promoting higher care quality, and if similar results are achievable in patients with other conditions.</p>
</div>
</front>
</TEI>
<pubmed><MedlineCitation Status="PubMed-not-MEDLINE" Owner="NLM"><PMID Version="1">32923326</PMID>
<DateRevised><Year>2020</Year>
<Month>09</Month>
<Day>28</Day>
</DateRevised>
<Article PubModel="Print-Electronic"><Journal><ISSN IssnType="Electronic">2211-4203</ISSN>
<JournalIssue CitedMedium="Internet"><Volume>10</Volume>
<Issue>3</Issue>
<PubDate><Year>2020</Year>
<Month>Sep</Month>
</PubDate>
</JournalIssue>
<Title>African journal of emergency medicine : Revue africaine de la medecine d'urgence</Title>
<ISOAbbreviation>Afr J Emerg Med</ISOAbbreviation>
</Journal>
<ArticleTitle>Protocolized emergency department observation care improves quality of ischemic stroke care in Haiti.</ArticleTitle>
<Pagination><MedlinePgn>145-151</MedlinePgn>
</Pagination>
<ELocationID EIdType="doi" ValidYN="Y">10.1016/j.afjem.2020.05.007</ELocationID>
<Abstract><AbstractText Label="Introduction" NlmCategory="UNASSIGNED">In many low-income countries, Emergency Medicine is underdeveloped and faces many operational challenges including emergency department (ED) overcrowding and prolonged patient length of stays (LOS). In high-resource settings, protocolized ED observation unit (EDOU) care reduces LOS while preserving care quality. EDOUs are untested in low-income countries. We evaluate the effect protocolized EDOU care for ischemic stroke on the quality and efficiency of care in Haiti.</AbstractText>
<AbstractText Label="Methods" NlmCategory="UNASSIGNED">We performed a prospective cohort study of protocolized observation care for ischemic stroke at a Haitian academic hospital between January 2014 and September 2015. We compared patients cared for in the EDOU using the ischemic stroke protocol (study group) to eligible patients cared for before protocol implementation (baseline group), as well as to eligible patients treated after protocol introduction but managed without the EDOU protocol (contemporary reference group). We analysed three quality of care measures: aspirin administration, physical therapy consultation, and swallow evaluation. We also analysed ED and hospital LOS as measures of efficiency.</AbstractText>
<AbstractText Label="Results" NlmCategory="UNASSIGNED">Patients receiving protocolized EDOU care achieved higher care quality compared to the baseline group, with higher rates of aspirin administration (91% v. 17%, p < 0.001), physical therapy consultation (50% v. 9.6%, p < 0.001), and swallow evaluation (36% v. 3.7%, p < 0.001). We observed similar improvements in the study group compared to the contemporary reference group. Most patients (92%) were managed entirely in the ED or EDOU. LOS for non-admitted patients was longer in the study group than the baseline group (28 v. 19 h, p = 0.023).</AbstractText>
<AbstractText Label="Conclusion" NlmCategory="UNASSIGNED">Protocolized EDOU care for patients with ischemic stroke in Haiti improved performance on key quality measures but increased LOS, likely due to more interventions. Future studies should examine the aspects of EDOU care are most effective at promoting higher care quality, and if similar results are achievable in patients with other conditions.</AbstractText>
<CopyrightInformation>© 2020 African Federation for Emergency Medicine. Publishing services provided by Elsevier.</CopyrightInformation>
</Abstract>
<AuthorList CompleteYN="Y"><Author ValidYN="Y"><LastName>Rouhani</LastName>
<ForeName>Shada A</ForeName>
<Initials>SA</Initials>
<AffiliationInfo><Affiliation>Harvard Medical School, Department of Emergency Medicine, Boston, MA, USA.</Affiliation>
</AffiliationInfo>
<AffiliationInfo><Affiliation>Brigham and Women's Hospital, Department of Emergency Medicine, Boston, MA, USA.</Affiliation>
</AffiliationInfo>
<AffiliationInfo><Affiliation>Partners In Health, Boston, MA, USA.</Affiliation>
</AffiliationInfo>
<AffiliationInfo><Affiliation>Hôpital Universitaire de Mirebalais, Department of Emergency Medicine, Route Chatulée, Mirebalais, Haiti.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y"><LastName>Marsh</LastName>
<ForeName>Regan H</ForeName>
<Initials>RH</Initials>
<AffiliationInfo><Affiliation>Harvard Medical School, Department of Emergency Medicine, Boston, MA, USA.</Affiliation>
</AffiliationInfo>
<AffiliationInfo><Affiliation>Brigham and Women's Hospital, Department of Emergency Medicine, Boston, MA, USA.</Affiliation>
</AffiliationInfo>
<AffiliationInfo><Affiliation>Partners In Health, Boston, MA, USA.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y"><LastName>Rimpel</LastName>
<ForeName>Linda</ForeName>
<Initials>L</Initials>
<AffiliationInfo><Affiliation>Hôpital Universitaire de Mirebalais, Department of Emergency Medicine, Route Chatulée, Mirebalais, Haiti.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y"><LastName>Anderson</LastName>
<ForeName>Kathryn</ForeName>
<Initials>K</Initials>
<AffiliationInfo><Affiliation>University of Chicago, Section of Emergency Medicine, Chicago, IL, USA.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y"><LastName>Outhay</LastName>
<ForeName>Malena</ForeName>
<Initials>M</Initials>
<AffiliationInfo><Affiliation>Alameda Health System, Highland Hospital, Department of Emergency Medicine, Oakland, CA, USA.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y"><LastName>Edmond</LastName>
<ForeName>Marie Cassandre</ForeName>
<Initials>MC</Initials>
<AffiliationInfo><Affiliation>Hôpital Universitaire de Mirebalais, Department of Emergency Medicine, Route Chatulée, Mirebalais, Haiti.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y"><LastName>Checkett</LastName>
<ForeName>Keegan A</ForeName>
<Initials>KA</Initials>
<AffiliationInfo><Affiliation>Partners In Health, Boston, MA, USA.</Affiliation>
</AffiliationInfo>
<AffiliationInfo><Affiliation>Hôpital Universitaire de Mirebalais, Department of Emergency Medicine, Route Chatulée, Mirebalais, Haiti.</Affiliation>
</AffiliationInfo>
<AffiliationInfo><Affiliation>University of Chicago, Section of Emergency Medicine, Chicago, IL, USA.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y"><LastName>Berkowitz</LastName>
<ForeName>Aaron L</ForeName>
<Initials>AL</Initials>
<AffiliationInfo><Affiliation>Partners In Health, Boston, MA, USA.</Affiliation>
</AffiliationInfo>
<AffiliationInfo><Affiliation>Brigham and Women's Hospital, Department of Neurology, Boston, MA, USA.</Affiliation>
</AffiliationInfo>
<AffiliationInfo><Affiliation>Harvard Medical School, Department of Neurology, Boston, MA, USA.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y"><LastName>Kwan</LastName>
<ForeName>Gene F</ForeName>
<Initials>GF</Initials>
<AffiliationInfo><Affiliation>Partners In Health, Boston, MA, USA.</Affiliation>
</AffiliationInfo>
<AffiliationInfo><Affiliation>Boston University School of Medicine, Section of Cardiovascular Medicine, Boston, MA, USA.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y"><LastName>Baugh</LastName>
<ForeName>Christopher W</ForeName>
<Initials>CW</Initials>
<AffiliationInfo><Affiliation>Harvard Medical School, Department of Emergency Medicine, Boston, MA, USA.</Affiliation>
</AffiliationInfo>
<AffiliationInfo><Affiliation>Brigham and Women's Hospital, Department of Emergency Medicine, Boston, MA, USA.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y"><LastName>Schuur</LastName>
<ForeName>Jeremiah D</ForeName>
<Initials>JD</Initials>
<AffiliationInfo><Affiliation>Brown University, Department of Emergency Medicine, Providence, RI, USA.</Affiliation>
</AffiliationInfo>
</Author>
</AuthorList>
<Language>eng</Language>
<PublicationTypeList><PublicationType UI="D016428">Journal Article</PublicationType>
</PublicationTypeList>
<ArticleDate DateType="Electronic"><Year>2020</Year>
<Month>07</Month>
<Day>15</Day>
</ArticleDate>
</Article>
<MedlineJournalInfo><Country>Netherlands</Country>
<MedlineTA>Afr J Emerg Med</MedlineTA>
<NlmUniqueID>101572277</NlmUniqueID>
<ISSNLinking>2211-419X</ISSNLinking>
</MedlineJournalInfo>
<KeywordList Owner="NOTNLM"><Keyword MajorTopicYN="N">Emergency department</Keyword>
<Keyword MajorTopicYN="N">Emergency medicine</Keyword>
<Keyword MajorTopicYN="N">Haiti</Keyword>
<Keyword MajorTopicYN="N">Observation unit</Keyword>
<Keyword MajorTopicYN="N">Stroke</Keyword>
</KeywordList>
<CoiStatement>CWB reports no conflicts of interest relevant to this work. CWB has received funding personally from Salix and Janssen Pharmaceuticals, Roche Diagnostics and Nabriva Therapeutics for advisory board work. CWB has received funding personally from Roche Diagnostics for speaking engagements. CWB has received funding personally from the US Department of Justice for expert testimony. The authors declare no further conflicts of interest.</CoiStatement>
</MedlineCitation>
<PubmedData><History><PubMedPubDate PubStatus="received"><Year>2019</Year>
<Month>11</Month>
<Day>14</Day>
</PubMedPubDate>
<PubMedPubDate PubStatus="revised"><Year>2020</Year>
<Month>04</Month>
<Day>27</Day>
</PubMedPubDate>
<PubMedPubDate PubStatus="accepted"><Year>2020</Year>
<Month>05</Month>
<Day>20</Day>
</PubMedPubDate>
<PubMedPubDate PubStatus="entrez"><Year>2020</Year>
<Month>9</Month>
<Day>14</Day>
<Hour>5</Hour>
<Minute>54</Minute>
</PubMedPubDate>
<PubMedPubDate PubStatus="pubmed"><Year>2020</Year>
<Month>9</Month>
<Day>15</Day>
<Hour>6</Hour>
<Minute>0</Minute>
</PubMedPubDate>
<PubMedPubDate PubStatus="medline"><Year>2020</Year>
<Month>9</Month>
<Day>15</Day>
<Hour>6</Hour>
<Minute>1</Minute>
</PubMedPubDate>
</History>
<PublicationStatus>ppublish</PublicationStatus>
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<affiliations><list><country><li>Haïti</li>
<li>États-Unis</li>
</country>
<region><li>Californie</li>
<li>Illinois</li>
<li>Massachusetts</li>
<li>Rhode Island</li>
</region>
<settlement><li>Chicago</li>
<li>Providence (Rhode Island)</li>
</settlement>
<orgName><li>Université Brown</li>
<li>Université de Chicago</li>
</orgName>
</list>
<tree><country name="États-Unis"><region name="Massachusetts"><name sortKey="Rouhani, Shada A" sort="Rouhani, Shada A" uniqKey="Rouhani S" first="Shada A" last="Rouhani">Shada A. Rouhani</name>
</region>
<name sortKey="Anderson, Kathryn" sort="Anderson, Kathryn" uniqKey="Anderson K" first="Kathryn" last="Anderson">Kathryn Anderson</name>
<name sortKey="Baugh, Christopher W" sort="Baugh, Christopher W" uniqKey="Baugh C" first="Christopher W" last="Baugh">Christopher W. Baugh</name>
<name sortKey="Baugh, Christopher W" sort="Baugh, Christopher W" uniqKey="Baugh C" first="Christopher W" last="Baugh">Christopher W. Baugh</name>
<name sortKey="Berkowitz, Aaron L" sort="Berkowitz, Aaron L" uniqKey="Berkowitz A" first="Aaron L" last="Berkowitz">Aaron L. Berkowitz</name>
<name sortKey="Berkowitz, Aaron L" sort="Berkowitz, Aaron L" uniqKey="Berkowitz A" first="Aaron L" last="Berkowitz">Aaron L. Berkowitz</name>
<name sortKey="Berkowitz, Aaron L" sort="Berkowitz, Aaron L" uniqKey="Berkowitz A" first="Aaron L" last="Berkowitz">Aaron L. Berkowitz</name>
<name sortKey="Checkett, Keegan A" sort="Checkett, Keegan A" uniqKey="Checkett K" first="Keegan A" last="Checkett">Keegan A. Checkett</name>
<name sortKey="Checkett, Keegan A" sort="Checkett, Keegan A" uniqKey="Checkett K" first="Keegan A" last="Checkett">Keegan A. Checkett</name>
<name sortKey="Kwan, Gene F" sort="Kwan, Gene F" uniqKey="Kwan G" first="Gene F" last="Kwan">Gene F. Kwan</name>
<name sortKey="Kwan, Gene F" sort="Kwan, Gene F" uniqKey="Kwan G" first="Gene F" last="Kwan">Gene F. Kwan</name>
<name sortKey="Marsh, Regan H" sort="Marsh, Regan H" uniqKey="Marsh R" first="Regan H" last="Marsh">Regan H. Marsh</name>
<name sortKey="Marsh, Regan H" sort="Marsh, Regan H" uniqKey="Marsh R" first="Regan H" last="Marsh">Regan H. Marsh</name>
<name sortKey="Marsh, Regan H" sort="Marsh, Regan H" uniqKey="Marsh R" first="Regan H" last="Marsh">Regan H. Marsh</name>
<name sortKey="Outhay, Malena" sort="Outhay, Malena" uniqKey="Outhay M" first="Malena" last="Outhay">Malena Outhay</name>
<name sortKey="Rouhani, Shada A" sort="Rouhani, Shada A" uniqKey="Rouhani S" first="Shada A" last="Rouhani">Shada A. Rouhani</name>
<name sortKey="Rouhani, Shada A" sort="Rouhani, Shada A" uniqKey="Rouhani S" first="Shada A" last="Rouhani">Shada A. Rouhani</name>
<name sortKey="Schuur, Jeremiah D" sort="Schuur, Jeremiah D" uniqKey="Schuur J" first="Jeremiah D" last="Schuur">Jeremiah D. Schuur</name>
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<country name="Haïti"><noRegion><name sortKey="Rouhani, Shada A" sort="Rouhani, Shada A" uniqKey="Rouhani S" first="Shada A" last="Rouhani">Shada A. Rouhani</name>
</noRegion>
<name sortKey="Checkett, Keegan A" sort="Checkett, Keegan A" uniqKey="Checkett K" first="Keegan A" last="Checkett">Keegan A. Checkett</name>
<name sortKey="Edmond, Marie Cassandre" sort="Edmond, Marie Cassandre" uniqKey="Edmond M" first="Marie Cassandre" last="Edmond">Marie Cassandre Edmond</name>
<name sortKey="Rimpel, Linda" sort="Rimpel, Linda" uniqKey="Rimpel L" first="Linda" last="Rimpel">Linda Rimpel</name>
</country>
</tree>
</affiliations>
</record>

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Protocolized emergency department observation care improves quality of ischemic stroke care in Haiti.

Protocolized emergency department observation care improves quality of ischemic stroke care in Haiti.

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