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Shah A, Diwan A. Stroke Thrombolysis: Beating the Clock. Indian J Crit Care Med 2023; 27:107-110. [PMID: 36865512 PMCID: PMC9973055 DOI: 10.5005/jp-journals-10071-24405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 12/30/2022] [Indexed: 02/04/2023] Open
Abstract
Background Recombinant tissue plasminogen activator (rtPA) has revolutionized the management of acute ischemic stroke. Shorter door-to-imaging and door-to-needle (DTN) times are crucial for improving the outcomes in thrombolysed patients. Our observational study evaluated the door-to-imaging time (DIT) and DTN times for all thrombolysed patients. Materials and methods The study was a cross-sectional observational study over a period of 18 months at a tertiary care teaching hospital and included 252 acute ischemic stroke patients of which 52 underwent thrombolysis with rtPA. The time intervals between arrival to neuroimaging and initiation of thrombolysis were noted. Result Of the total patients thrombolysed, only 10 patients underwent neuroimaging [non-contrast computed tomography (NCCT) head with MRI brain screen] within 30 minutes of their arrival in the hospital, 38 patients within 30-60 minutes and 2 each within the 61-90 and 91-120 minute time frames. The DTN time was 30-60 minutes for 3 patients, while 31 patients were thrombolysed within 61-90 minutes, 7 patients within 91-120 minutes, while 5 each took 121-150 and 151-180 minutes for the same. One patient had a DTN between 181 and 210 minutes. Conclusion Most patients included in the study underwent neuroimaging within 60 minutes and subsequent thrombolysis within 60-90 minutes of their arrival in the hospital. But the time frames did not meet the recommended ideal intervals, and further streamlining of stroke management is needed even at tertiary care centers in India. How to cite this article Shah A, Diwan A. Stroke Thrombolysis: Beating the Clock. Indian J Crit Care Med 2023;27(2):107-110.
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Affiliation(s)
- Aviral Shah
- Department of Medicine, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India,Aviral Shah, Department of Medicine, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India, Phone: +91 9928545135, e-mail:
| | - Arundhati Diwan
- Department of Medicine, Bharati Vidyapeeth (Deemed to be University) Medical College, Pune, Maharashtra, India
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2
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Comparison of door-to-needle time of tenecteplase versus alteplase for acute ischemic stroke. Am J Emerg Med 2023; 63:158-160. [PMID: 36192247 DOI: 10.1016/j.ajem.2022.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 12/13/2022] Open
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Botelho A, Rios J, Fidalgo AP, Ferreira E, Nzwalo H. Organizational Factors Determining Access to Reperfusion Therapies in Ischemic Stroke-Systematic Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192316357. [PMID: 36498429 PMCID: PMC9735885 DOI: 10.3390/ijerph192316357] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/18/2022] [Accepted: 11/19/2022] [Indexed: 06/01/2023]
Abstract
BACKGROUND After onset of acute ischemic stroke (AIS), there is a limited time window for delivering acute reperfusion therapies (ART) aiming to restore normal brain circulation. Despite its unequivocal benefits, the proportion of AIS patients receiving both types of ART, thrombolysis and thrombectomy, remains very low. The organization of a stroke care pathway is one of the main factors that determine timely access to ART. The knowledge on organizational factors influencing access to ART is sparce. Hence, we sought to systematize the existing data on the type and frequency of pre-hospital and in-hospital organizational factors that determine timely access to ART in patients with AIS. METHODOLOGY Literature review on the frequency and type of organizational factors that determine access to ART after AIS. Pubmed and Scopus databases were the primary source of data. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale. RESULTS A total of 128 studies were included. The main pre-hospital factors associated with delay or access to ART were medical emergency activation practices, pre-notification routines, ambulance use and existence of local/regional-specific strategies to mitigate the impact of geographic distance between patient locations and Stroke Unit (SU). The most common intra-hospital factors studied were specific location of SU and brain imaging room within the hospital, and the existence and promotion of specific stroke treatment protocols. Most frequent factors associated with increased access ART were periodic public education, promotion of hospital pre-notification and specific pre- and intra-hospital stroke pathways. In specific urban areas, mobile stroke units were found to be valid options to increase timely access to ART. CONCLUSIONS Implementation of different organizational factors and strategies can reduce time delays and increase the number of AIS patients receiving ART, with most of them being replicable in any context, and some in only very specific contexts.
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Affiliation(s)
- Ana Botelho
- Faculty of Economy, University of Algarve, 8005-139 Faro, Portugal
- Department of Physical Medicine and Rehabilitation, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
- Stroke Unit, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
| | - Jonathan Rios
- Department of Physical Medicine and Rehabilitation, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
| | - Ana Paula Fidalgo
- Stroke Unit, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
| | - Eugénia Ferreira
- Faculty of Economy, University of Algarve, 8005-139 Faro, Portugal
| | - Hipólito Nzwalo
- Stroke Unit, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
- Faculty of Medicine and Biomedical Sciences, University of Algarve, 8005-139 Faro, Portugal
- Algarve Biomedical Research Institute, 8005-139 Faro, Portugal
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4
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Gallardo-Tur A, Carazo-Barrios L, de la Cruz-Cosme C. Door-to-needle times for patients with ischaemic stroke treated with alteplase by on-site and off-site on-duty neurologists. PRISA study. Neurologia 2022; 37:543-549. [PMID: 31780321 DOI: 10.1016/j.nrl.2019.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 07/16/2019] [Accepted: 08/01/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Hospital on-call neurology shifts are frequently on-site, but some on-call services may be off-site or mixed. Intravenous tissue plasminogen activator (tPA) is one of the main reperfusion treatments for acute ischaemic stroke (AIS). This study assesses door-to-needle times (DNT) when the neurologist is on-site or off-site. METHODS We performed a prospective, observational study from 2012 to 2017, including patients with AIS and treated with tPA. Data were collected on sex, age, door-to-scan time, scan-to-needle time, and DNT. The on-duty neurologist was on-site from 08:00 to 20:00, and on call but off-site from 20:00 to 8:00. Three groups were formed: on-site, off-site, and off-site with resident present. RESULTS Our sample included 138 patients. The mean age was 69.7 years, and 45.7% of patients were women. Ninety-six patients were admitted during the on-site shift, 25 during the off-site shift, and 17 during the off-site-resident present shift. Patients admitted during the on-site and off-site shifts presented DNTs of 59 and 72minutes, respectively (P=.003). DNTs were 59, 74, and 68minutes (P=.001), respectively, for the on-site, off-site, and off-site-resident present shifts; the difference between DNTs for on-site and off-site shifts was statistically significant. No differences were observed between DNTs according to time of day (morning, afternoon, or night), or between weekdays and weekends. CONCLUSION DNT is influenced by whether the on-duty neurologist is on- or off-site at the time of code stroke activation. The presence of a neurology resident can reduce DNT.
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Affiliation(s)
- A Gallardo-Tur
- Servicio de Neurología, Hospital Universitario Virgen de la Victoria, Málaga, España.
| | - L Carazo-Barrios
- Servicio de Neurología, Hospital Universitario Virgen de la Victoria, Málaga, España
| | - C de la Cruz-Cosme
- Servicio de Neurología, Hospital Universitario Virgen de la Victoria, Málaga, España
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5
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Ngiam JN, Cheong CWS, Leow AST, Wei YT, Thet JKX, Lee IYS, Sia CH, Tan BYQ, Khoo CM, Sharma VK, Yeo LLL. Stress hyperglycaemia is associated with poor functional outcomes in patients with acute ischaemic stroke after intravenous thrombolysis. QJM 2022; 115:7-11. [PMID: 32810234 DOI: 10.1093/qjmed/hcaa253] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/21/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Transient hyperglycaemia in the context of illness with or without known diabetes has been termed as 'stress hyperglycaemia'. Stress hyperglycaemia can result in poor functional outcomes in patients with acute ischaemic stroke (AIS) who underwent mechanical thrombectomy. We investigated the association between stress hyperglycaemia and clinical outcomes in AIS patients undergoing intravenous thrombolysis (IVT). METHODS We examined 666 consecutive patients with AIS who underwent IVT from 2006 to 2018. All patients had a glycated haemoglobin level (HbA1c) and fasting venous blood glucose measured within 24 h of admission. Stress hyperglycaemia ratio (SHR) was defined as the ratio of the fasting glucose to the HbA1c. Univariate and multivariate analyses were employed to identify predictors of poor functional outcomes (modified Rankin Scale 3-6 at 3 months) after IVT. RESULTS Three-hundred and sixty-one patients (54.2%) had good functional outcomes. These patients tended to be younger (60.7 ± 12.7 vs. 70 ± 14.4 years, P < 0.001), male (70.7% vs. 51.5%, P < 0.001), had lower prevalence of atrial fibrillation (13.0% vs. 20.7%, P = 0.008) and lower SHR (0.88 ± 0.20 vs. 0.99 ± 26, P < 0.001). Patients with high SHR (≥0.97) were slightly older than those with low SHR (<0.97) and were more likely to have diabetes mellitus. On multivariate analysis, higher SHR was independently associated with poor functional outcomes (adjusted odds ratio 3.85, 95% confidence interval 1.59-9.09, P = 0.003). CONCLUSION SHR appears to be an important predictor of functional outcomes in patients with AIS undergoing IVT. This may have important implications on the role of glycaemic control in the acute management of ischaemic stroke.
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Affiliation(s)
- J N Ngiam
- Department of Medicine, National University Health System, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - C W S Cheong
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - A S T Leow
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Y-T Wei
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - J K X Thet
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - I Y S Lee
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - C-H Sia
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore 119228, Singapore
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - B Y Q Tan
- Department of Medicine, National University Health System, 1E Kent Ridge Road, Singapore 119228, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - C-M Khoo
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore 119228, Singapore
- Division of Endocrinology, Department of Medicine, National University Health System, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - V K Sharma
- Department of Medicine, National University Health System, 1E Kent Ridge Road, Singapore 119228, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - L L L Yeo
- Department of Medicine, National University Health System, 1E Kent Ridge Road, Singapore 119228, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore 119228, Singapore
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6
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Lee SH, Ryoo HW, Jin SC, Ahn JY, Sohn SI, Hwang YH, Do Y, Lee YS, Kim JH. Prehospital Notification Using a Mobile Application Can Improve Regional Stroke Care System in a Metropolitan Area. J Korean Med Sci 2021; 36:e327. [PMID: 34904406 PMCID: PMC8668497 DOI: 10.3346/jkms.2021.36.e327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Acute ischemic stroke is a time-sensitive disease. Emergency medical service (EMS) prehospital notification of potential patients with stroke could play an important role in improving the in-hospital medical response and timely treatment of patients with acute ischemic stroke. We analyzed the effects of FASTroke, a mobile app that EMS can use to notify hospitals of patients with suspected acute ischemic stroke at the prehospital stage. METHODS We conducted a retrospective observational study of patients diagnosed with acute ischemic stroke at 5 major hospitals in metropolitan Daegu City, Korea, from February 2020 to January 2021. The clinical conditions and time required for managing patients were compared according to whether the EMS employed FASTroke app and further compared the factors by dividing the patients into subgroups according to the preregistration received by the hospitals when using FASTroke app. RESULTS Of the 563 patients diagnosed with acute ischemic stroke, FASTroke was activated for 200; of these, 93 were preregistered. The FASTroke prenotification showed faster door-to-computed-tomography times (19 minutes vs. 25 minutes, P < 0.001), faster door-to-intravenous-thrombolysis times (37 minutes vs. 48 minutes, P < 0.001), and faster door-to-endovascular-thrombectomy times (82 minutes vs. 119 minutes, P < 0.001). The time was further shortened when the preregistration was conducted simultaneously by the receiving hospital. CONCLUSION The FASTroke app is an easy and useful tool for prenotification as a regional stroke care system in the metropolitan area, leading to reduced transport and acute ischemic stroke management time and more reperfusion treatment. The effect was more significant when the preregistration was performed jointly.
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Affiliation(s)
- Sang-Hun Lee
- Department of Emergency Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Hyun Wook Ryoo
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, Daegu, Korea.
| | - Sang-Chan Jin
- Department of Emergency Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Jae Yun Ahn
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Youngrok Do
- Department of Neurology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Yoon-Soo Lee
- Department of Neurosurgery, Daegu Fatima Hospital, Daegu, Korea
| | - Jung Ho Kim
- Department of Emergency Medicine, Yeungnam University College of Medicine, Daegu, Korea
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7
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El Nahas NM, Shokri HM, Roushdy TM, Dawood NL, Abushady EM, Georgy SS, Zaki AS, Bedros RY, Aref HM. Door to Needle Count Down: A 3-Years Experience in an Egyptian University Stroke Center. Neurologist 2021; 27:61-64. [PMID: 34855665 DOI: 10.1097/nrl.0000000000000372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this study is to share our experience in changing hospital strategies to achieve rapid thrombolysis in acute ischemic stroke (AIS) patients in 2 university stroke centers. Rapid reperfusion by shortening door to needle time (DTN) reduces morbidity and mortality for patients with AIS. Our aim is to evaluate the effect of applying certain logistic strategies to reduce DTN for thrombolysis and its impact on clinical outcome. METHODS In this retrospective registry-based observational study from the SITS-ISTR Dataset, we studied AIS patients admitted to 2 stroke centers in Ain Shams University over 3 successive years from 2016 till 2018. We analyzed change of DTN and outcome at 3 months by modified Rankin scale over these 3 years. RESULTS By the end of the 3 year period there was a 6.1% increase in number of patients receiving thrombolysis. There was a significant decrease of median DTN by 41%, and increase in percentage of patients receiving recombinant tissue plasminogen activator within a shorter DTN. Also, the number of patients with a favorable outcome (modified Rankin scale≤2) increased by 23.3%. There was insignificant difference regarding mortality rate. CONCLUSION Applying a goal-directed corrective strategy to improve quality of service can, in a short time, reduce DTN and improve patient outcome.
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Affiliation(s)
- Nevine M El Nahas
- Department of Neurology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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8
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Sangari A, Akhoundzadeh K, Vahedian M, Sharifipour E. Effect of pre-hospital notification on delays and neurological outcomes in acute ischemic stroke. Australas Emerg Care 2021; 25:172-175. [PMID: 34810150 DOI: 10.1016/j.auec.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 11/08/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Since timely thrombolytic therapy is a crucial variable in acute ischemic stroke recovery, health care systems are trying to find new interventions to reduce treatment delay in order to improve neurological function. In Iran, SAMA code as a pre-hospital notification plan has been developed to help emergent stroke treatment. This study aimed to compare delay to thrombolysis therapy and neurological outcomes between SAMA-transported and self-transported patients in ischemic stroke. METHODS In this retrospective cohort study, the data of 185 stroke patients treated with intravenous thrombolysis from Mar 2016 to May 2020 were collected. P-value < 0.05 was considered as significant. RESULTS The results showed that delays reduced in SAMA-transported patient compared to that in self-transported patients. There was a significant difference in Onset to Needle time, Door to Needle Time, and Door to CT Time but not Onset to Door time between SAMA-transported and self-transported patients (P values: 0.001, 0.000, 0.001, and 0.22 respectively). However, there was no significant difference between two groups in terms of neurologic deficit severity. CONCLUSIONS Although pre-hospital notification could partially reduce treatment delays in stroke, that reduction was not enough to impact on neurologic deficit recovery. It seems more reduction in delay is needed to significantly improve neurological dysfunctions.
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Affiliation(s)
| | - Kobra Akhoundzadeh
- Faculty of Nursing and Midwifery, Qom University of Medical Sciences, Qom, Iran.
| | - Mostafa Vahedian
- Clinical Research Development Center, Qom University of Medical Sciences, Qom, Iran.
| | - Ehsan Sharifipour
- Neuroscience Research Center, Qom University of Medical Sciences, Qom, Iran.
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9
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Door-to-needle times in patients treated by on-site and off-site on-call neurologists. PRISA study. NEUROLOGÍA (ENGLISH EDITION) 2021; 37:543-549. [PMID: 34544671 DOI: 10.1016/j.nrleng.2019.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 08/01/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Hospital on-call neurology shifts are frequently on-site, but some on-call services may be off-site or mixed. Intravenous tissue plasminogen activator (tPA) is one of the main reperfusion treatments for acute ischaemic stroke (AIS). This study assesses door-to-needle times (DNT) when the neurologist is on-site or off-site. METHODS We performed a prospective, observational study from 2012 to 2017, including patients with AIS and treated with tPA. Data were collected on sex, age, door-to-scan time, scan-to-needle time, and DNT. The on-duty neurologist was on-site from 08:00 to 20:00, and on call but off-site from 20:00 to 8:00. Three groups were formed: on-site, off-site, and off-site with resident present. RESULTS Our sample included 138 patients. The mean age was 69.7 years, and 45.7% of patients were women. Ninety-six patients were admitted during the on-site shift, 25 during the off-site shift, and 17 during the off-site-resident present shift. Patients admitted during the on-site and off-site shifts presented DNTs of 59 and 72 minutes, respectively (P = .003). DNTs were 59, 74, and 68 minutes (P = .001), respectively, for the on-site, off-site, and off-site-resident present shifts; the difference between DNTs for on-site and off-site shifts was statistically significant. No differences were observed between DNTs according to time of day (morning, afternoon, or night), or between weekdays and weekends. CONCLUSION DNT is influenced by whether the on-duty neurologist is on- or off-site at the time of code stroke activation. The presence of a neurology resident can reduce DNT.
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10
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Xu ZH, Deng QW, Zhai Q, Zhang Q, Wang ZJ, Chen WX, Gu MM, Jiang T, Zhou JS, Zhang YD. Clinical significance of stroke nurse in patients with acute ischemic stroke receiving intravenous thrombolysis. BMC Neurol 2021; 21:359. [PMID: 34530757 PMCID: PMC8447702 DOI: 10.1186/s12883-021-02375-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/01/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Reports have proven that shorter door-to-needle time (DTN time) indicates better outcomes in AIS patients received intravenous thrombolysis. Efforts have been made by hospitals and centers to minimize DTN time in many ways including introducing a stroke nurse. However, there are few studies to discuss the specific effect of stroke nurse on patients' prognosis. This study aimed to compare consecutive AIS patients before and after the intervention to analyze the effect of stroke nurse on clinical outcome of AIS patients. METHODS In this retrospective study, we observed 1003 patients from November 2016 to December 2020 dividing in two groups, collected and analyzed AIS patients' medical history, clinical assessment information, important timelines, 90 mRS score, etc. Comparative analysis and mediation analysis were also used in this study. RESULTS A total of 418 patients was included in this study, and 199 patients were enrolled in the stroke nurse group and 219 was in the preintervention group. Baseline characteristics of patients showed no significant difference except there seems more patients with previous ischemic stroke history in the group of stroke nurse. (p = 0.008). The median DTN time significantly decreased in the stroke nurse group (25 min versus 36 min, p < 0.001) and multivariate logistic regression analysis showed the 90-day mRS clinical outcome significantly improved in the stroke nurse group (p = 0.001). Mediation analysis indicated the reduction of DTN time plays a partial role on the 90 days mRS score and the stroke nurse has some direct effect on the improvement of clinical outcome (p = 0.006). CONCLUSIONS The introduction of stroke nurse is beneficial to clinical outcome of AIS patients and can be use of reference in other hospitals or centers.
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Affiliation(s)
- Zhao-Han Xu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, 210006, Nanjing, China
| | - Qi-Wen Deng
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, 210006, Nanjing, China
| | - Qian Zhai
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, 210006, Nanjing, China
| | - Qing Zhang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, 210006, Nanjing, China
| | - Zhen-Jie Wang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, 210006, Nanjing, China
| | - Wen-Xia Chen
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, 210006, Nanjing, China
| | - Meng-Meng Gu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, 210006, Nanjing, China
| | - Teng Jiang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, 210006, Nanjing, China.
| | - Jun-Shan Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, 210006, Nanjing, China.
| | - Ying-Dong Zhang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, 210006, Nanjing, China.
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11
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Sundar K, Panwar A, Bhirud L, Paul EM, Alapatt PJ, Kuruttukulam GV. Changing Demographics of Stroke Mimics in Present Day Stroke Code Era: Need of a Streamlined Clinical Assessment for Emergency Physicians. J Neurosci Rural Pract 2021; 12:550-554. [PMID: 34434030 PMCID: PMC8381026 DOI: 10.1055/s-0041-1727419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background
There is an apparently high incidence of stroke mimics in the present-day stroke code era. The reason being is the intense pressure to run with time to achieve the “time is brain”-based goals.
Methods
The present study was a retrospective analysis of the data collected over a duration of 6 months from April 2019 to September 2019. We observed the incidence of stroke mimics among the patients for whom rapid response stroke code was activated during the study period. We also performed a logistic regression analysis to identify the clinical features which can act as strong predictors of stroke and mimics.
Results
A total of 314 stroke codes were activated of which 256 (81.5%) were stroke and 58 (18.5%) were the mimics. Functional disorders and epilepsy were the most common mimics (24.1% each). Female gender (
p
= 0.04; odds ratio [OR] 2.9[1.0–8.8]), isolated impairment of consciousness (
p
< 0.01; OR 4.3[1.5–12.6]), and isolated dysarthria (
p
< 0.001) were the strong independent predictors for a stroke mimic. Hemiparesis was the strong independent predictor for a stroke (
p
< 0.001; OR 0.0[0.0–0.1]).
Conclusion
In the present epoch of rapid response stroke management, a streamlined assessment by the emergency physicians based on the above clinical predictors may help in avoiding the misdiagnosis of a mimic as stroke.
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Affiliation(s)
- Kaushik Sundar
- Department of Neurology, Rabindranath International Institute of Cardiac Sciences, Kolkata, West Bengal, India
| | - Ajay Panwar
- Department of Neurology, Rotary Ambala Cancer and General Hospital, Ambala, Haryana, India
| | - Lomesh Bhirud
- Department of Neurology, Kiran Hospital, Surat, Gujrat, India
| | | | - Paul J Alapatt
- Department of Neurology, Rajagiri Hospital, Kochi, India
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12
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Pines AR, Das DM, Bhatt SK, Shiue HJ, Dawit S, Vanderhye VK, Sands KA. Identifying and Addressing Barriers to Systemic Thrombolysis for Acute Ischemic Stroke in the Inpatient Setting: A Quality Improvement Initiative. Mayo Clin Proc Innov Qual Outcomes 2020; 4:657-666. [PMID: 33367211 PMCID: PMC7749238 DOI: 10.1016/j.mayocpiqo.2020.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objectives To identify barriers to inpatient alteplase administration and implement an interdisciplinary program to reduce time to systemic thrombolysis. Patients and Methods Compared with patients presenting to the emergency department with an acute ischemic stroke (AIS), inpatients are delayed in receiving alteplase for systemic thrombolysis. Institutional AIS metrics were extracted from the electronic medical records of patients presenting as an inpatient stroke alert. All patients who received alteplase for AIS were included in the analysis. A gap analysis was used to assess institutional deficiencies. An interdisciplinary intervention was initiated to address these deficiencies. Efficacy was measured with pre- and postintervention surveys and institutional AIS metric analysis. Statistical significance was determined using the Student t test. We identified 5 patients (mean age, 73 years; 100% (5/5) male; 80% (4/5) white) who met inclusion criteria for the preintervention period (January 1, 2017, to December 31, 2017) and 10 patients (mean age, 71 years; 50% male; 80% white) for the postintervention period (October 31, 2018, to July 1, 2020). Results We found barriers to rapid delivery of thrombolytic treatment to include alteplase availability and comfort with bedside reconstitution. Interdisciplinary intervention strategies consisted of stocking alteplase on additional floors as well as structured education and hands-on alteplase reconstitution simulations for resident physicians. The mean time from stroke alert to thrombolysis was shorter postintervention than preintervention (57.4 minutes vs 77.8 minutes; P=.03). Conclusion A coordinated interdisciplinary approach is effective in reducing time to systemic thrombolysis in patients experiencing AIS in the inpatient setting. A similar program could be implemented at other institutions to improve AIS treatment.
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Key Words
- AHA, American Heart Association
- AIS, acute ischemic stroke
- AMDC, automated medication dispensing cabinet
- CT, computerized tomography
- DTB, decision-to-treat-to-bolus
- ED, emergency department
- EMR, electronic medical record
- IV, intravenous
- NIHSS, National Institutes of Health Stroke Scale
- PCCU, progressive cardiac care unit
- RN, registered nurse
- RRN, rapid response nurse
- STN, stroke-alert-to-needle
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Affiliation(s)
- Andrew R Pines
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ
| | - Devika M Das
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ
| | - Shubhang K Bhatt
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ
| | - Harn J Shiue
- Department of Pharmacy, Mayo Clinic, Phoenix, AZ
| | - Sara Dawit
- Department of Neurology, Mayo Clinic, Phoenix, AZ
| | | | - Kara A Sands
- Department of Neurology, Mayo Clinic, Phoenix, AZ
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Hasnain MG, Attia JR, Akter S, Rahman T, Hall A, Hubbard IJ, Levi CR, Paul CL. Effectiveness of interventions to improve rates of intravenous thrombolysis using behaviour change wheel functions: a systematic review and meta-analysis. Implement Sci 2020; 15:98. [PMID: 33148294 PMCID: PMC7641813 DOI: 10.1186/s13012-020-01054-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 10/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite being one of the few evidence-based treatments for acute ischemic stroke, intravenous thrombolysis has low implementation rates-mainly due to a narrow therapeutic window and the health system changes required to deliver it within the recommended time. This systematic review and meta-analyses explores the differential effectiveness of intervention strategies aimed at improving the rates of intravenous thrombolysis based on the number and type of behaviour change wheel functions employed. METHOD The following databases were searched: MEDLINE, EMBASE, PsycINFO, CINAHL and SCOPUS. Multiple authors independently completed study selection and extraction of data. The review included studies that investigated the effects of intervention strategies aimed at improving the rates of intravenous thrombolysis and/or onset-to-needle, onset-to-door and door-to-needle time for thrombolysis in patients with acute ischemic stroke. Interventions were coded according to the behaviour change wheel nomenclature. Study quality was assessed using the QualSyst scoring system for quantitative research methodologies. Random effects meta-analyses were used to examine effectiveness of interventions based on the behaviour change wheel model in improving rates of thrombolysis, while meta-regression was used to examine the association between the number of behaviour change wheel intervention strategies and intervention effectiveness. RESULTS Results from 77 studies were included. Five behaviour change wheel interventions, 'Education', 'Persuasion', 'Training', 'Environmental restructuring' and 'Enablement', were found to be employed among the included studies. Effects were similar across all intervention approaches regardless of type or number of behaviour change wheel-based strategies employed. High heterogeneity (I2 > 75%) was observed for all the pooled analyses. Publication bias was also identified. CONCLUSION There was no evidence for preferring one type of behaviour change intervention strategy, nor for including multiple strategies in improving thrombolysis rates. However, the study results should be interpreted with caution, as they display high heterogeneity and publication bias.
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Affiliation(s)
- Md Golam Hasnain
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
| | - John R. Attia
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
- John Hunter Hospital, New Lambton Heights, New South Wales Australia
| | - Shahinoor Akter
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Department of Anthropology, Jagannath University, Dhaka, Bangladesh
| | - Tabassum Rahman
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Centre for Development, Economics and Sustainability, Monash University, Melbourne, Victoria Australia
| | - Alix Hall
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
| | - Isobel J. Hubbard
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
| | - Christopher R. Levi
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, New South Wales Australia
| | - Christine L. Paul
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
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Lee KD, Lee SB, Lim JK, Kang YM, Kim IB, Moon HJ, Lee WJ. Providing essential clinical care for non-COVID-19 patients in a Seoul metropolitan acute care hospital amidst ongoing treatment of COVID-19 patients. J Hosp Infect 2020; 106:673-677. [PMID: 33011308 PMCID: PMC7528870 DOI: 10.1016/j.jhin.2020.09.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/14/2020] [Accepted: 09/26/2020] [Indexed: 12/13/2022]
Abstract
We assessed infection control efforts by comparing data collected over 20 weeks during a pandemic under a dual-track healthcare system. A decline in non-COVID-19 patients visiting the emergency department by 37.6% (P<0.01) was observed since admitting COVID-19 cases. However, patients with acute myocardial infarction (AMI), stroke, severe trauma and acute appendicitis presenting for emergency care did not decrease. Door-to-balloon time (34.3 (± 11.3) min vs 22.7 (± 8.3) min) for AMI improved significantly (P<0.01) while door-to-needle time (55.7 (± 23.9) min vs 54.0 (± 18.0) min) in stroke management remained steady (P=0.80). Simultaneously, time-sensitive care involving other clinical services, including patients requiring chemotherapy, radiation therapy and haemodialysis did not change.
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Affiliation(s)
- K D Lee
- Department of Infectious Diseases, Myongji Hospital, Hanyang University College of Medicine, Goyang, Republic of Korea
| | - S B Lee
- Department of Physical Medicine and Rehabilitation, Myongji Hospital, Hanyang University College of Medicine, Goyang, Republic of Korea
| | - J K Lim
- Department of Laboratory Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Republic of Korea
| | - Y M Kang
- Department of Infectious Diseases, Myongji Hospital, Hanyang University College of Medicine, Goyang, Republic of Korea
| | - I B Kim
- Department of Emergency Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Republic of Korea
| | - H J Moon
- New Horizon Cancer Institute, Myongji Hospital, Goyang, Republic of Korea
| | - W J Lee
- Department of General Surgery, Myongji Hospital, Goyang, Republic of Korea.
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15
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Impact of the COVID-19 pandemic on hyperacute stroke treatment: experience from a comprehensive stroke centre in Singapore. J Thromb Thrombolysis 2020; 50:596-603. [PMID: 32661758 PMCID: PMC7358288 DOI: 10.1007/s11239-020-02225-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The Coronavirus disease 2019 (COVID-19) pandemic is rapidly evolving and affecting healthcare systems across the world. Singapore has escalated its alert level to Disease Outbreak Response System Condition (DORSCON) Orange, signifying severe disease with community spread. We aimed to study the overall volume of AIS cases and the delivery of hyperacute stroke services during DORSCON Orange. This was a single-centre, observational cohort study performed at a comprehensive stroke centre responsible for AIS cases in the western region of Singapore, as well as providing care for COVID-19 patients. All AIS patients reviewed as an acute stroke activation in the Emergency Department (ED) from November 2019 to April 2020 were included. System processes timings, treatment and clinical outcome variables were collected. We studied 350 AIS activation patients admitted through the ED, 206 (58.9%) pre- and 144 during DORSCON Orange. Across the study period, number of stroke activations showed significant decline (p = 0.004, 95% CI 6.513 to − 2.287), as the number of COVID-19 cases increased exponentially, whilst proportion of activations receiving acute recanalization therapy remained stable (p = 0.519, 95% CI − 1.605 to 2.702). Amongst AIS patients that received acute recanalization therapy, early neurological outcomes in terms of change in median NIHSS at 24 h (-4 versus -4, p = 0.685) were largely similar between the pre- and during DORSCON orange periods. The number of stroke activations decreased while the proportion receiving acute recanalization therapy remained stable in the current COVID-19 pandemic in Singapore.
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16
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The KEEP SIMPLEST Study: Improving In-House Delays and Periinterventional Management in Stroke Thrombectomy-A Matched Pair Analysis. Neurocrit Care 2020; 31:46-55. [PMID: 30659468 DOI: 10.1007/s12028-018-00667-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Although the treatment window for mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) has been extended in recent years, it has been proven that recanalizing treatment must be administered as soon as possible. We present a new standard operating procedure (SOP) to reduce in-house delay, standardize periinterventional management and improve patient safety during MT. METHODS KEep Evaluating Protocol Simplification In Managing Periinterventional Light Sedation for Endovascular Stroke Treatment (KEEP SIMPLEST) was a prospective, single-center observational study aimed to compare aspects of periinterventional management in AIS patients treated according to our new SOP using a combination of esketamine and propofol with patients having been randomized into conscious sedation (CS) in the Sedation versus Intubation for Endovascular Stroke TreAtment (SIESTA) trial. Primary outcome was early neurological improvement at 24h using the National Institutes of Health Stroke Scale, and secondary outcomes were door-to-recanalization, recanalization grade, conversion rate and modified Rankin Scale (mRS) at 3 months. RESULTS Door-to-recanalization time (128.6 ± 69.47 min vs. 156.8 ± 75.91 min; p = 0.02), mean duration of MT (92.01 ± 52 min vs. 131.9 ± 64.03 min; p < 0.001), door-to-first angiographic image (51.61 ± 31.7 min vs. 64.23 ± 21.53 min; p = 0.003) and computed tomography-to-first angiographic image time (31.61 ± 20.6 min vs. 44.61 ± 19.3 min; p < 0.001) were significantly shorter in the group treated under the new SOP. There were no differences in early neurological improvement, mRS at 3 months or other secondary outcomes between the groups. Conversion rates of CS to general anesthesia were similar in both groups. CONCLUSION An SOP using a novel sedation regimen and optimization of equipment and procedures directed at a leaner, more integrative and compact periinterventional management can reduce in-house treatment delays significantly in stroke patients receiving thrombectomy in light sedation and demonstrated the safety and feasibility of our improved approach.
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17
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Impact of CT scanner location on door to imaging time for emergency department stroke evaluation. Am J Emerg Med 2020; 38:309-310. [PMID: 31488337 DOI: 10.1016/j.ajem.2019.158398] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 08/14/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Stroke is a potentially serious condition commonly diagnosed in the ED. Time to diagnosis can be crucial to maximizing outcome in a majority of ischemic stroke cases amenable to thrombolytic therapy. METHODS An analysis of 148 consecutive adults transported by EMS to an urban emergency department with a diagnosis of cerebro-vascular accident during a 12 month period was performed to determine the impact of CT scanner location on door-to-head CT [DTCT] scan time. The CT scanner was relocated from an upper floor of the hospital to within the ER department midway through the study period. RESULTS The rate of DTCT scan time ≤20 min increased significantly from 47% [pre-relocation] to 74% [post-relocation]; and the rate of DTCT ultra-rapid scan time ≤10 min more than doubled. CONCLUSIONS Hospitals providing ED care for stroke patients can expedite management by ensuring CT scanner location is in closest possible proximity to the ED.
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18
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Nalleballe K, Sharma R, Brown A, Joiner R, Kapoor N, Morgan T, Benton T, Williamson C, Culp W, Lowery C, Onteddu S. Ideal telestroke time targets: Telestroke-based treatment times in the United States stroke belt. J Telemed Telecare 2018; 26:174-179. [PMID: 30352525 DOI: 10.1177/1357633x18805661] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Studying critical time interval requirements can enhance thrombolytic treatment for stroke patients in telestroke networks. We retrospectively examined 12 concurrent months of targeted time interval information in the South Central US telemedicine programme, Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES).Hypothesis: We hypothesised that consult data analysis would highlight areas for improvement to shorten overall door to Intra venous (IV) tissue plasminogen activator (tPA) administration time. Methods We analysed critical time targets for 238 consecutive telestroke neurology consults obtained over 12 months from AR SAVES spoke sites when tPA was administered. The following time intervals were analysed: emergency department (ED) door to Computed Tomography (D-CT); ED door to call centre (D-CC) for initiation of consult; ED door to neurology call (D-NC); neurology call to camera (NC-Cam); tele consult time (Con); ED door to tissue plasminogen activator (tPA)/needle (DTN). Results The median times of D-CT (13 min, inter quartile range (IQR) 6–22 min), D-CC (34 min, IQR 20–45 min), D-NC (40 min, IQR 21–71 min), NC-Cam (4 min, IQR 2–8 min), and Con (25 min, IQR 17–37 min) all contributed to a DTN median time of 71 min (IQR 50–104 min). A total of 238 patients received tPA with a 29.4% treatment rate and a DTN time of ≤60 min was achieved in 25.2% of patients. Conclusions Focusing on reducing D-CC and Con times may help to achieve the DTN time of < 60 min for the majority of patients. Having ideal time targets for telestroke patients akin to traditional patients will help identify and improve the overall goal of a DTN time < 60 min.
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Affiliation(s)
- Krishna Nalleballe
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Rohan Sharma
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Aliza Brown
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, USA.,Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Renee Joiner
- Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Nidhi Kapoor
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Tiffany Morgan
- Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Tina Benton
- Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Conelia Williamson
- Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock, USA
| | - William Culp
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, USA.,Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Curtis Lowery
- Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Sanjeeva Onteddu
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, USA
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