Development of acute stroke units--a cost effective reconfiguration which benefits patients

Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization-Lancet Neurology Commission

Stroke is the second leading cause of death worldwide. The burden of disability after a stroke is also large, and is increasing at a faster pace in low-income and middle-income countries than in high-income countries. Alarmingly, the incidence of stroke is increasing in young and middle-aged people (ie, age <55 years) globally. Should these trends continue, Sustainable Development Goal 3.4 (reducing the burden of stroke as part of the general target to reduce the burden of non-communicable diseases by a third by 2030) will not be met.

In this Commission, we forecast the burden of stroke from 2020 to 2050. We project that stroke mortality will increase by 50%—from 6·6 million (95% uncertainty interval [UI] 6·0 million–7·1 million) in 2020, to 9·7 million (8·0 million–11·6 million) in 2050—with disability-adjusted life-years (DALYs) growing over the same period from 144·8 million (133·9 million–156·9 million) in 2020, to 189·3 million (161·8 million–224·9 million) in 2050. These projections prompted us to do a situational analysis across the four pillars of the stroke quadrangle: surveillance, prevention, acute care, and rehabilitation. We have also identified the barriers to, and facilitators for, the achievement of these four pillars. Disability-adjusted life-years (DALYs) The sum of the years of life lost as a result of premature mortality from a disease and the years lived with a disability associated with prevalent cases of the disease in a population. One DALY represents the loss of the equivalent of one year of full health

On the basis of our assessment, we have identified and prioritised several recommendations. For each of the four pillars (surveillance, prevention, acute care, and rehabilitation), we propose pragmatic solutions for the implementation of evidence-based interventions to reduce the global burden of stroke. The estimated direct (ie, treatment and rehabilitation) and indirect (considering productivity loss) costs of stroke globally are in excess of US$891 billion annually. The pragmatic solutions we put forwards for urgent implementation should help to mitigate these losses, reduce the global burden of stroke, and contribute to achievement of Sustainable Development Goal 3.4, the WHO Intersectoral Global Action Plan on epilepsy and other neurological disorders (2022–2031), and the WHO Global Action Plan for prevention and control of non-communicable diseases.

Reduction of the global burden of stroke, particularly in low-income and middle-income countries, by implementing primary and secondary stroke prevention strategies and evidence-based acute care and rehabilitation services is urgently required. Measures to facilitate this goal include: the establishment of a framework to monitor and assess the burden of stroke (and its risk factors) and stroke services at a national level; the implementation of integrated population-level and individual-level prevention strategies for people at any increased risk of cerebrovascular disease, with emphasis on early detection and control of hypertension; planning and delivery of acute stroke care services, including the establishment of stroke units with access to reperfusion therapies for ischaemic stroke and workforce training and capacity building (and monitoring of quality indicators for these services nationally, regionally, and globally); the promotion of interdisciplinary stroke care services, training for caregivers, and capacity building for community health workers and other health-care providers working in stroke rehabilitation; and the creation of a stroke advocacy and implementation ecosystem that includes all relevant communities, organisations, and stakeholders.

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Access to acute stroke care: A retrospective descriptive analysis of stroke patients' journey to a district hospital

Introduction

The burden of stroke in Africa has increased in the last two decades, with the population undergoing a rapid epidemiological transition, with a rise in the incidence of stroke risk factors together with the gradual aging of the population. Evidence-based guidelines for acute stroke care are often not feasible in resource challenged settings but even when resources are available, considerable delays to definitive care exists. This study aims to describe the factors that influence time from symptom onset to hospital arrival in patients that present to a district level hospital Emergency Centre with confirmed ischaemic strokes.

Methods

A descriptive analysis was performed using a retrospective folder and database review. All adult patients with a confirmed ischaemic stroke, on Computed Tomography (CT) scan, presenting to Mitchells Plain Hospital Emergency Centre during the study period of 12 months (1^st of January 2019 to 31^st of December 2019), were eligible for inclusion. Data were collected from existing electronic patient databases and the time from onset of symptoms to hospital arrival was extracted from the clinical notes.

Results

A total of 730 (2%) patients presented with a diagnosis of stroke, of which 381 (52%) were included (CT confirmed ischaemic strokes). Only 48 (13%) presented within 4.5 h of symptom onset and the median time from onset of symptoms to presentation to the hospital was 24 h (IQR 12-72 h). The majority of patients (31%) arrived via a primary public emergency medical service (EMS) call, while 29% presented directly to the hospital as self-referrals with private transport. Primary public EMS calls had the shortest call-to-hospital-arrival time (1 hour and 31 minutes), even though the median time from symptom onset to hospital arrival was still 16 h.

Conclusion

The median time from symptom onset to hospital arrival for patients with stroke symptoms is much longer than what evidence-based guidelines suggest. The chain of survival for emergency stroke care is only as strong as its weakest link and the data from this study suggest that improvement campaigns should target stroke education and access to care.

Functional outcome of stroke and the cumulative experience of a stroke unit

OBJECTIVE

Patients with acute stroke are more likely to survive and achieve independence if they are treated in a stroke unit. Available information in our setting is scarce. We analyse the outcomes of our patients on the basis of cumulative experience in a stroke unit.

PATIENTS AND METHODS

A retrospective cohort study of patients admitted to a stroke unit. We differentiate between two groups according to the year of admission: group A (July 2007-December 2009) and group B (January 2010-December 2011), analysing early outcome based on the score on the National Institute of Health stroke scale and mortality at discharge, and medium-term outcome in terms of mortality and functional status according to the modified Rankin scale at three months.

RESULTS

A total 1070 patients were included. There were no differences between groups with respect to favourable outcome (68.3% vs 63.9), hospital mortality (5.1% vs 6.6%), or 90-day mortality (12.8% vs 13.1%). The percentage of patients who were independent at 90 days was greater in group B (56.3% vs 65.5%, P=.03). In the multivariate analysis adjusted for stroke subtype and fibrinolytic therapy, the association between patient independence and admission period remained present.

CONCLUSIONS

The probability of functional independence in our patients increased alongside accumulated experience in our stroke unit with no differences in mortality.