Minimum intravenous thrombolysis utilization rates in acute ischemic stroke to achieve population effects on disability: A discrete-event simulation model

Discrete event simulation model of an acute stroke treatment process at a comprehensive stroke center: Determining the ideal improvement strategies for reducing treatment times

BACKGROUND

Fast treatment is crucial for ischemic stroke patients; the probability of good patient outcomes increases with faster treatment. Treatment times can be improved by making changes to the treatment process. However, it is challenging to identify the benefits of changes prior to implementation. Simulation modelling, which mimics the treatment process, can be used to evaluate changes without patient involvement. This study models the acute stroke treatment process using discrete event simulation (DES) and identifies improvement strategies to reduce treatment times.

METHOD

The model was developed for a comprehensive stroke center in Nova Scotia, using Python. All treatment pathways and sub-tasks were identified via an observational time and motion study conducted in the center. Nine process change scenarios were tested individually and in combinations. The primary outcome measures were door-to-CT time (DTCT), door-to-needle time (DNT), and door-to-groin puncture time (DGPT). The model simulated 500 patients 30 times.

RESULTS

Collecting patient history on the way to the radiology department (rather than in ED) showed the highest reduction among individual scenarios for DTCT (14.2 vs 12.4 min, p < 0.001). Combining all scenarios in the door-to-CT process resulted in a reduction of the DTCT by approximately 28 %. Thrombolysing patients in the imaging department's waiting area resulted in the lowest DNT (39.4 vs 34.8 min, p < 0.001) among all individual scenarios. The highest reduction in DGPT, among all individual scenarios, was achieved by implementing Rapid angiosuite preparation (67.7 vs 51.4 min, p < 0.001). The combinations of all scenarios resulted in the lowest DTCT (14.2 vs 10.1 min, p < 0.001), DNT (39.4 vs 23.0 min, p < 0.001), and DGPT (67.9 vs 38.5 min, p < 0.001).

CONCLUSIONS

The study identified various improvement strategies in the acute stroke treatment process through a discrete-event simulation model. Combining all scenarios resulted in significant reductions for all outcome measures.

Temporal Trends of Intravenous Thrombolysis Utilization in Acute Ischemic Stroke in a Prospective Cohort From 1998 to 2019: Modeling Based on Joinpoint Regression

Introduction

The frequency of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) is lower than it should be in several regions of the world. It is unclear what interventions can produce significant improvements in IVT utilization. We aimed to investigate the temporal trends in IVT in AIS and identify changes in time that could be associated with specific interventions.

Methods

We included patients with AIS who were admitted from January 1998 to December 2019 in our institution. To analyze trends in utilization and time points in which they changed, we performed a Joinpoint regression analysis. Interventions were assigned to a specific category according to the Behavior Change Wheel framework intervention function criteria.

Results

A total of 3,361 patients with AIS were admitted, among which 538 (16%) received IVT. There were 245 (45.5%) women, and the mean age and median National Institutes of Health Stroke Scale (NIHSS) scores were 68.5 (17.2) years and 8 (interquartile range, 4–15), respectively. Thrombolysis use significantly increased by an average annual 7.6% (95% CI, 5.1–10.2), with one Joinpoint in 2007. The annual percent changes were.45% from 1998 to 2007 and 9.57% from 2007 to 2019, concurring with the stroke code organization, the definition of door-to-needle times as an institutional performance measure quality indicator, and the extension of the therapeutic window.

Conclusions

The IVT rates consistently increased due to a continuous process of protocol changes and multiple interventions. The implementation of a complex multidisciplinary intervention such as the stroke code, as well as the definition of a hospital quality control metric, were associated with a significant change in this trend.

Discrete-Event Simulation to Model the Thrombolysis Process for Acute Ischemic Stroke Patients at Urban and Rural Hospitals

Background: Effective treatment with tissue plasminogen activator (tPA) critically relies on rapid treatment. Door-to-needle time (DNT) is a key measure of hospital efficiency linked to patient outcomes. Numerous changes can reduce DNT, but they are difficult to trial and implement. Discrete-event simulation (DES) provides a way to model and determine the impact of process improvements.

Methods: A conceptual framework was developed to illustrate the thrombolysis process; allowing for treatment processes to be replicated using a DES model developed in ARENA. Activity time duration distributions from three sites (one urban and two rural) were used. Five scenarios, three process changes, and two reductions in activity durations, were simulated and tested. Scenarios were tested individually and in combinations. The primary outcome measure is median DNT. The study goal is to determine the largest improvement in DNT at each site.

Results: Administration of tPA in the imaging area resulted in the largest median DNT reduction for Site 1 and Site 2 for individual test scenarios (12.6%, 95% CI 12.4–12.8%, and 8.2%, 95% CI 7.5–9.0%, respectively). Ensuring that patients arriving via emergency medical services (EMS) remain on the EMS stretcher to imaging resulted in the largest median DNT improvement for Site 3 (9.2%, 95% CI 7.9–10.5%). Reducing both the treatment decision time and tPA preparation time by 35% resulted in a 11.0% (95% CI 10.0–12.0%) maximum reduction in median DNT. The lowest median and 90^th percentile DNTs were achieved by combining all test scenarios, with a maximum reduction of 26.7% (95% CI 24.5–28.9%) and 17.1% (95% CI 12.5–21.7%), respectively.

Conclusions: The detailed conceptual framework clarifies the intra-hospital logistics of the thrombolysis process. The most significant median DNT improvement at rural hospitals resulted from ensuring patients arriving via EMS remain on the EMS stretcher to imaging, while urban sites benefit more from administering tPA in the imaging area. Reducing the durations of activities on the critical path will provide further DNT improvements. Significant DNT improvements are achievable in urban and rural settings by combining process changes with reducing activity durations.

Fighting Against Stroke in Latin America: A Joint Effort of Medical Professional Societies and Governments

Introduction: Stroke is one of the leading causes of death in Latin America, a region with countless gaps to be addressed to decrease its burden. In 2018, at the first Latin American Stroke Ministerial Meeting, stroke physician and healthcare manager representatives from 13 countries signed the Declaration of Gramado with the priorities to improve the region, with the commitment to implement all evidence-based strategies for stroke care. The second meeting in March 2020 reviewed the achievements in 2 years and discussed new objectives. This paper will review the 2-year advances and future plans of the Latin American alliance for stroke. Method: In March 2020, a survey based on the Declaration of Gramado items was sent to the neurologists participants of the Stroke Ministerial Meetings. The results were confirmed with representatives of the Ministries of Health and leaders from the countries at the second Latin American Stroke Ministerial Meeting. Results: In 2 years, public stroke awareness initiatives increased from 25 to 75% of countries. All countries have started programs to encourage physical activity, and there has been an increase in the number of countries that implement, at least partially, strategies to identify and treat hypertension, diabetes, and lifestyle risk factors. Programs to identify and treat dyslipidemia and atrial fibrillation still remained poor. The number of stroke centers increased from 322 to 448, all of them providing intravenous thrombolysis, with an increase in countries with stroke units. All countries have mechanical thrombectomy, but mostly restricted to a few private hospitals. Pre-hospital organization remains limited. The utilization of telemedicine has increased but is restricted to a few hospitals and is not widely available throughout the country. Patients have late, if any, access to rehabilitation after hospital discharge. Conclusion: The initiative to collaborate, exchange experiences, and unite societies and governments to improve stroke care in Latin America has yielded good results. Important advances have been made in the region in terms of increasing the number of acute stroke care services, implementing reperfusion treatments and creating programs for the detection and treatment of risk factors. We hope that this approach can reduce inequalities in stroke care in Latin America and serves as a model for other under-resourced environments.

"Hesitating and Puzzling": The Experiences and Decision Process of Acute Ischemic Stroke Patients with Prehospital Delay after the Onset of Symptoms

Despite campaigns to increase public awareness of stroke symptoms by advocating FAST (Face-Arms-Speech-Time), some stroke patients still show delays in the recognition of and response to stroke symptoms and miss the golden first 4.5 h to receive rt-PA (recombinant tissue plasminogen activator) treatment. The aim of this study was to explore how acute ischemic stroke patients with prehospital delay seek help and undergo the decision process before arriving at the hospital. A qualitative approach using a grounded theory was applied. There were 24 ischemic stroke patients recruited by purposive sampling. Our main findings were: “Hesitating and puzzling” was the core category to describe and guide the process of acute ischemic stroke patients with prehospital delay. During the process, “Awareness the sudden change of physical sensation and/or function” was the antecedent category. In the prehospital delay experience, the following five interaction categories were identified: (1) “Self-judgment and interpretation according to previous experience,” (2) “Puzzling and doubting—it may only be a minor problem,” (3) “Self-treatment or seeking medical attention nearby,” (4) “Unexpected symptoms getting worse” needing immediate advanced medical help and (5) “Rushing to ER with different transportation—self-alerting that serious disease is coming.” Eventually, the patients “Regret to delay seeking treatment and become a disable person.” The process of prehospital delay provides some hidden cues for patients to increase their knowledge about strokes. The study emphasizes the importance of educating community residents about identifying stroke symptoms, breaking the myth of folk therapy, and seeking medical attention immediately. These results will assist healthcare providers by offering references for designing patient-centric educational strategies for preventing stroke prehospital delay to improve the quality of stroke medical care.

Poststroke Cognitive Impairment in Model-Based Economic Evaluation: A Systematic Review

INTRODUCTION

Cognitive impairment (CI) is a frequent consequence of stroke and is associated with increased costs and reduced quality of life. However, its inclusion in model-based economic evaluation for stroke is limited.

OBJECTIVE

To identify, review, and critically appraise current models of stroke for use in economic evaluation, and to identify applicability to modeling poststroke CI.

METHODS

PubMed, EMBASE, and the NHS Economic Evaluations Database (NHS EED) were systematically searched for papers published from January 2008 to August 2018. Studies that described the development or design of a model of stroke progression intended for use in economic evaluation were included. Abstracts were screened, followed by full text review of potentially relevant articles. Models that included CI were retained for data extraction, and among the remainder, models that included both stroke recurrence and disability were also retained. Relevance and potential for adaptation for modeling CI were assessed using a standard questionnaire.

RESULTS

Forty modeling studies were identified and categorized into 4 groups: Markov disability/recurrence (k = 29); CI (k = 2); discrete event simulation (k = 4), and other (k = 5). Only 2 modeling studies included CI as an outcome, and both focused on narrow populations at risk of intracranial aneurysm. None of the models allowed for disease progression in the absence of a stroke recurrence. None of the included studies carried out any sensitivity analysis in relation to model design or structure.

CONCLUSIONS

Current stroke models used in economic evaluation are not adequate to model poststroke CI or dementia, and will require adaptation to be used for this purpose.

Factors Associated with Shortening of Prehospital Delay among Patients with Acute Ischemic Stroke

BACKGROUND

Despite recent advances in acute stroke care, only 1-8% of patients can receive reperfusion therapies, mainly because of prehospital delay (PHD).

OBJECTIVE

This study aimed to identify factors associated with PHD from the onset of acute stroke symptoms until arrival at the hospital.

METHODS

A cross-sectional study was conducted including all patients consecutively admitted with stroke symptoms to Burgos University Hospital (Burgos, Spain). Socio-demographic, clinical, behavioral, cognitive, and contextualized characteristics were recorded, and their possible associations with PHD were studied using univariate and multivariable regression analyses.

RESULTS

The median PHD of 322 patients was 138.50 min. The following factors decreased the PHD and time until reperfusion treatment where applicable: asking for help immediately after the onset of symptoms (OR 10.36; 95% confidence interval (CI) 4.47-23.99), onset of stroke during the daytime (OR 7.73; 95% CI 3.09-19.34) and the weekend (OR 2.64; 95% CI 1.19-5.85), occurrence of stroke outside the home (OR 7.09; 95% CI 1.97-25.55), using a prenotification system (OR 6.46; 95% CI 1.71-8.39), patient's perception of being unable to control symptoms without assistance (OR 5.14; 95% CI 2.60-10.16), previous knowledge of stroke as a medical emergency (OR 3.20; 95% CI 1.38-7.40), call to emergency medical services as the first medical contact (OR 2.77; 95% CI 1.32-5.88), speech/language difficulties experienced by the patient (OR 2.21; 95% CI 1.16-4.36), and the identification of stroke symptoms by the patient (OR 1.98; 95% CI 1.03-3.82).

CONCLUSIONS

The interval between the onset of symptoms and arrival at the hospital depends on certain contextual, cognitive, and behavioral factors, all of which should be considered when planning future public awareness campaigns.

Aphasia and reperfusion therapies in hyper-acute settings: A scoping review

Purpose: Reperfusion therapies are medical treatments that restore blood flow either by surgical removal of a blood clot or with medications that dissolve clots. The introduction of reperfusion therapies has the potential to change the presentation of aphasia following acute ischaemic stroke (AIS). This scoping study will explore the relationship between aphasia and reperfusion therapies from a speech-language pathology perspective. Method: A systematic literature search was performed on studies published up until October 2016. Relevant studies that reported on aphasia and reperfusion therapy were assessed for quality and the relationship between the two. Results: Overall, 27 studies were identified, these studies were heterogeneous in nature. Despite speech-language pathologists filling a central role in management of aphasia, only seven of these studies mentioned involvement of speech-language pathologists, with minimal information about the precise nature of the involvement of speech-language pathology services. Conclusion: Based on this scoping review, reperfusion therapy appears to be impacting on the presentation of aphasia. A prospective study into reperfusion therapy and aphasia is required to inform speech-language pathologists on this patient population.

Impact of prehospital stroke code in a public center in Paraguay: A pilot study

Prehospital stroke code activation results in reduced pre- and in-hospital delays and triage and transport of stroke patients to the right centers. In Paraguay, data about acute reper fusion treatment are not available. Recently, a pilot prehospital stroke code program was implemented in the country in November 2016. In an observational, single-center cohort study with a before–after design, from April 2015 to July 2018, we found that 193/832 (23.1%) of stroke patients were stroke code activated, and from these, 54 (6.5%) were brought to hospital under the prehospital stroke code protocol. Fifty-eight patients (58 alteplase and 2 additional endovascular treatment) received reperfusion therapy. Prehospital stroke code patients had a lower mean door-to-CT time (24 vs. 33 min, p = 0.021) and lower mean door-to-needle time (35.3 vs.76.3 min, p < 0.001) compared to in-hospital stroke code patients. Prehospital stroke code is feasible in Paraguay and has a positive impact on in-hospital acute stroke management, reducing delays and increasing the rates of reperfusion treatments.

Factors related to immediate response to symptoms in patients with stroke or transient ischaemic attack

INTRODUCTION

Despite recent advances in the management of acute stroke, fewer than 10% of patients receive reperfusion therapy. One of the main reasons for such a low rate of administration is the delay on the part of patients and their families in seeking medical attention. This study aimed to analyse this delay.

METHODS

A prospective observational study was conducted on consecutive stroke or transient ischaemic attack. Data on sociodemographic and clinical parameters, decision delay, pre-hospital delay, and first medical contact were collected. Descriptive, bivariate, and multivariate logistic regression analyses were performed to determine factors associated with seeking medical attention within the first 15minutes of stroke or TIA occurrence.

RESULTS

A total of 382 patients were included, 24.9% of whom had a decision delay of 15minutes or less. Stroke severity (OR 1.08; 95% CI, 1.04-1.13; P<.001), patient's son/daughter witnessing the event (OR 3.44; 95% CI, 1.88-6.27; P<.001), and insulin treatment (OR 2.89; 95% CI, 1.35-6.20; P=.006) were related to an immediate reaction. Lacunar infarcts (OR 0.41; 95% CI, 0.17-0.97; P=.042), partial anterior circulation infarcts (OR 0.43; 95% CI, 0.22-0.85; P=.015), and monosymptomatic events not involving limb paresis or aphasia (OR 0.15; 95% CI, 0.033-0.724; P=.018) favoured delays longer than 15minutes.

CONCLUSIONS

Severity of the event and presence of a son/daughter are the factors most frequently associated with an immediate response to stroke. Future interventions should emphasise the need for an immediate response irrespective of severity and include a wider spectrum of symptoms.

Response to Symptoms and Prehospital Delay in Stroke Patients. Is It Time to Reconsider Stroke Awareness Campaigns?

BACKGROUND

Despite recent advances in acute stroke care, reperfusion therapies are given to only 1%-8% of patients. Previous studies have focused on prehospital or decision delay. We aim to give a more comprehensive view by addressing different time delays and decisions.

METHODS

A total of 382 patients with either acute stroke or transient ischemic attack were prospectively included. Sociodemographic and clinical parameters and data on decision delay, prehospital delay, and first medical contact were recorded. Multivariate logistic regression analyses were conducted to identify factors related to decision delay of 15 minutes or shorter, calling the Extrahospital Emergency Services, and prehospital delay of 60 minutes or shorter and 180 minutes or shorter.

RESULTS

Prehospital delay was 60 minutes or shorter in 11.3% of our patients and 180 minutes or shorter in 48.7%. Major vascular risk factors were present in 89.8% of patients. Severity was associated with decision delay of 15 minutes or shorter (odds ratio [OR] 1.08; confidence interval [CI] 1.04-1.13), calling the Extrahospital Emergency Services (OR 1.17; CI 1.12-1.23), and prehospital delay of 180 minutes or shorter (OR 1.08; CI 1.01-1.15). Adult children as witnesses favored a decision delay of 15 minutes or shorter (OR 3.44; CI 95% 1.88-6.27; P < .001) and calling the Extrahospital Emergency Services (OR 2.24; IC 95% 1.20-4.22; P = .012). Calling the Extrahospital Emergency Services favored prehospital delay of 60 minutes or shorter (OR 5.69; CI 95% 2.41-13.45; P < .001) and prehospital delay of 180 minutes or shorter (OR 3.86; CI 95% 1.47-10.11; P = .006).

CONCLUSIONS

Severity and the bystander play a critical role in the response to stroke. Calling the Extrahospital Emergency Services promotes shorter delays. Future interventions should encourage immediately calling the Extrahospital Emergency Services, but the target should be redirected to those with known risk factors and their caregivers.