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Jones SP, Spencer J, Adeniji O, Abd-Allah F, Ogunde G, Ebenezer AA, Kalaria R, Lightbody CE, Langhorne P, Melifonwu R, Naidoo P, Macaire Ossou-Nguiet P, Ogunniyi A, Olowoyo P, Owolabi MO, Sarfo FS, Walker R, Yaria J, Watkins C CL, Akinyemi RO. Towards improving stroke services in Africa: Results from the Africa-UK Stroke Partnership [AUKSP] surveys. J Stroke Cerebrovasc Dis 2024; 33:107891. [PMID: 39094719 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 07/24/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND The African Stroke Organization (ASO) in partnership with the University of Central Lancashire's Stroke Research Team launched the Africa-UK Stroke Partnership (AUKSP). AUKSP undertook two (stroke expert and hospital Stroke Unit (SU)) on-line surveys mapping existing capacity and capability to deliver African stroke care. METHODS An on-line expert survey tool was sent to 139 stroke experts in 54 African countries October 2021-March 2022 and the hospital SU survey to 120 hospital SUs (identified from the expert survey) June-October 2022. Both survey tools were prepared according to the World Stroke Organisation's Roadmap for Delivering Quality Stroke Care. Completed responses were exported from Qualtrics into Microsoft excel and were analysed descriptively. RESULTS Forty-five expert responses and 62 hospital SU responses were analysed, representing 54(87%) public hospitals, 7(11%) private and 1(2%) charitable organization. In both surveys, three main priorities for improvement of stroke services were: a rapid and prompt stroke diagnosis; effective primary and secondary stroke prevention, and acute stroke management. Survey findings suggest that there is a low presence of national stroke surveillance systems and registries, and heterogeneity in availability of diagnostic services, SUs, endovascular treatments, and rehabilitation. CONCLUSION Significant gaps exist in Africa's capacity and capability to deliver essential elements of effective and quality stroke care. Tackling these challenges requires urgent and sustained multi-stakeholder action including: government, administrators, policy makers and other partners. Our survey findings highlight key priority areas for multi-stakeholder engagement and crafting of a pragmatic, prioritized and context-sensitive African Stroke Action Plan.
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Affiliation(s)
| | - Joseph Spencer
- University of Central Lancashire, Preston, Lancashire, UK
| | | | - Foad Abd-Allah
- Department of Neurology, Kasralainy School of Medicine, Cairo University, Cairo, Egypt
| | - Gabriel Ogunde
- College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Ad Adams Ebenezer
- Stroke Association Support Network-Ghana (SASNET-GHANA), Accra, Ghana
| | | | | | - Peter Langhorne
- University of Glasgow, Glasgow, Scotland, UK; Glasgow Royal Infirmary, Glasgow, Scotland, UK
| | | | - Pamela Naidoo
- Heart and Stroke Foundation, South Africa; University of Stellenbosch, South Africa
| | | | - Adesola Ogunniyi
- College of Medicine, University of Ibadan, Ibadan, Nigeria; University College Hospital, Ibadan, Nigeria
| | | | - Mayowa O Owolabi
- College of Medicine, University of Ibadan, Ibadan, Nigeria; University College Hospital, Ibadan, Nigeria
| | - Fred S Sarfo
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | | | | | - Rufus O Akinyemi
- College of Medicine, University of Ibadan, Ibadan, Nigeria; University College Hospital, Ibadan, Nigeria
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Reeves MJ, Fonarow GC, Smith EE, Sheth KN, Messe SR, Schwamm LH. Twenty Years of Get With The Guidelines-Stroke: Celebrating Past Successes, Lessons Learned, and Future Challenges. Stroke 2024; 55:1689-1698. [PMID: 38738376 PMCID: PMC11208062 DOI: 10.1161/strokeaha.124.046527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
The Get With The Guidelines-Stroke program which, began 20 years ago, is one of the largest and most important nationally representative disease registries in the United States. Its importance to the stroke community can be gauged by its sustained growth and widespread dissemination of findings that demonstrate sustained increases in both the quality of care and patient outcomes over time. The objectives of this narrative review are to provide a brief history of Get With The Guidelines-Stroke, summarize its major successes and impact, and highlight lessons learned. Looking to the next 20 years, we discuss potential challenges and opportunities for the program.
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Affiliation(s)
- Mathew J. Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
| | - Gregg C. Fonarow
- Division of Cardiology, Geffen School of Medicine, University of California Los Angeles (G.C.F.)
| | - Eric E. Smith
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada (E.E.S.)
| | - Kevin N. Sheth
- Center for Brain & Mind Health, Departments of Neurology & Neurosurgery (K.N.S.), Yale School of Medicine, New Haven, CT
| | - Steven R. Messe
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia (S.R.M.)
| | - Lee H. Schwamm
- Department of Neurology and Bioinformatics and Data Sciences (L.H.S.), Yale School of Medicine, New Haven, CT
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Rasool A, Bailey M, Lue B, Omeaku N, Popoola A, Shantharam SS, Brown AA, Fulmer EB. Policy implementation strategies to address rural disparities in access to care for stroke patients. FRONTIERS IN HEALTH SERVICES 2023; 3:1280250. [PMID: 38130727 PMCID: PMC10733855 DOI: 10.3389/frhs.2023.1280250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/07/2023] [Indexed: 12/23/2023]
Abstract
Context Stroke systems of care (SSOC) promote access to stroke prevention, treatment, and rehabilitation and ensure patients receive evidence-based treatment. Stroke patients living in rural areas have disproportionately less access to emergency medical services (EMS). In the United States, rural counties have a 30% higher stroke mortality rate compared to urban counties. Many states have SSOC laws supported by evidence; however, there are knowledge gaps in how states implement these state laws to strengthen SSOC. Objective This study identifies strategies and potential challenges to implementing state policy interventions that require or encourage evidence-supported pre-hospital interventions for stroke pre-notification, triage and transport, and inter-facility transfer of patients to the most appropriate stroke facility. Design Researchers interviewed representatives engaged in implementing SSOC across six states. Informants (n = 34) included state public health agency staff and other public health and clinical practitioners. Outcomes This study examined implementation of pre-hospital SSOCs policies in terms of (1) development roles, processes, facilitators, and barriers; (2) implementation partners, challenges, and solutions; (3) EMS system structure, protocols, communication, and supervision; and (4) program improvement, outcomes, and sustainability. Results Challenges included unequal resource allocation and EMS and hospital services coverage, particularly in rural settings, lack of stroke registry usage, insufficient technologies, inconsistent use of standardized tools and protocols, collaboration gaps across SSOC, and lack of EMS stroke training. Strategies included addressing scarce resources, services, and facilities; disseminating, training on, and implementing standardized statewide SSOC protocols and tools; and utilizing SSOC quality and performance improvement systems and approaches. Conclusions This paper identifies several strategies that can be incorporated to enhance the implementation of evidence-based stroke policies to improve access to timely stroke care for all patient populations, particularly those experiencing disparities in rural communities.
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Affiliation(s)
- Aysha Rasool
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, United States
| | - Moriah Bailey
- Applied Science, Research and Technology, Inc., Atlanta, GA, United States
| | - Brittany Lue
- Chenega Corporation, Anchorage, AK, United States
| | - Nina Omeaku
- Applied Science, Research and Technology, Inc., Atlanta, GA, United States
| | - Adebola Popoola
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Sharada S. Shantharam
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Amanda A. Brown
- Applied Science, Research and Technology, Inc., Atlanta, GA, United States
| | - Erika B. Fulmer
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
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4
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Snavely J, Thompson HJ. Nursing and Institutional Responsibilities for In-Hospital Stroke. Stroke 2023; 54:2926-2934. [PMID: 37732490 DOI: 10.1161/strokeaha.123.042868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
In-hospital stroke events occur less often than stroke outside of a health care facility; yet, the need for timely evaluation and treatment is the same regardless of geographic location. During hospitalization, nurses are generally the first to recognize possible symptoms of stroke and activate emergency protocols. Such actions in response to changes in patient condition are critical to optimal patient outcomes. A recent scientific statement from the American Heart Association notes that patients with in-hospital stroke are likely to experience delayed recognition of symptoms, less likely to receive intravenous thrombolysis therapy, and have worse outcomes compared with community-occurring stroke. The aim of this article is to expand upon that scientific statement to assist nurses and acute care hospitals in the United States and elsewhere with similar health care systems to create evidence-based, nurse-driven protocols for in-hospital stroke recognition and management.
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Affiliation(s)
- Josh Snavely
- Virginia Mason Franciscan Health, Tacoma, WA (J.S.)
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5
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Chukwudelunzu FE, Demaerschalk B, Fugoso L, Amadi E, Dexter D, Gullicksrud A, Hagen C. In-Hospital Versus Out-of-Hospital Stroke Onset Comparison of Process Metrics in a Community Primary Stroke Center. Mayo Clin Proc Innov Qual Outcomes 2023; 7:402-410. [PMID: 37719772 PMCID: PMC10504462 DOI: 10.1016/j.mayocpiqo.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Objective To examine in-hospital stroke onset metrics and outcomes, quality of care, and mortality compared with out-of-hospital stroke in a single community-based primary stroke center. Patients and Methods Medical records of in-hospital stroke onset were compared with out-of-hospital stroke onset alert data between January 1, 2013 and December 31, 2019. Time-sensitive stroke process metric data were collected for each incident stroke alert. The primary focus of interest was the time-sensitive stroke quality metrics. Secondary focus pertained to thrombolysis treatment or complications, and mortality. Descriptive and univariable statistical analyses were applied. Kruskal-Wallis and χ2 tests were used to compare median values and categorical data between prespecified groups. The statistical significance was set at α=0.05. Results The out-of-hospital group reported a more favorable response to time-sensitive stroke process metrics than the in-hospital group, as measured by median stroke team response time (15.0 vs 26.0 minutes; P≤.0001) and median head computed tomography scan completion time (12.0 vs 41.0 minutes; P=.0001). There was no difference in the stroke alert time between the 2 groups (14.0 vs 8.0 minutes; P=.089). Longer hospital length of stay (4 vs 3 days; P=.004) and increased hospital mortality (19.3% vs 7.4%; P=.0032) were observed for the in-hospital group. Conclusions The key findings in this study were that time-sensitive stroke process metrics and stroke outcome measures were superior for the out-of-hospital groups compared with the in-hospital groups. Focusing on improving time-sensitive stroke process metrics may improve outcomes in the in-hospital stroke cohort.
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Affiliation(s)
| | - Bart Demaerschalk
- Department of Neurology, Mayo Clinic College of Medicine and Sciences, Phoenix, AZ
| | - Leonardo Fugoso
- Department of Neurology, Mayo Clinic Health System Eau Claire, WI
| | - Emeka Amadi
- Department of Medicine, Section of Hospital Medicine, Mayo Clinic Health System Eau Claire, WI
| | - Donn Dexter
- Department of Neurology, Mayo Clinic Health System Eau Claire, WI
| | | | - Clinton Hagen
- Program for Hypoplastic Left Heart Syndrome, Mayo Clinic, Rochester, MN
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Zachrison KS, Nielsen VM, de la Ossa NP, Madsen TE, Cash RE, Crowe RP, Odom EC, Jauch EC, Adeoye OM, Richards CT. Prehospital Stroke Care Part 1: Emergency Medical Services and the Stroke Systems of Care. Stroke 2023; 54:1138-1147. [PMID: 36444720 PMCID: PMC11050637 DOI: 10.1161/strokeaha.122.039586] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Acute stroke care begins before hospital arrival, and several prehospital factors are critical in influencing overall patient care and poststroke outcomes. This topical review provides an overview of the state of the science on prehospital components of stroke systems of care and how emergency medical services systems may interact in the system to support acute stroke care. Topics include layperson recognition of stroke, prehospital transport strategies, networked stroke care, systems for data integration and real-time feedback, and inequities that exist within and among systems.
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Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (K.S.Z., R.E.C.)
| | | | - Natalia Perez de la Ossa
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias I Pujol, Badalona, Spain and Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain (N.P.d.l.O)
| | - Tracy E Madsen
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI (T.E.M.)
| | - Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (K.S.Z., R.E.C.)
| | | | - Erika C Odom
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (E.C.O.)
| | - Edward C Jauch
- Department of Research, University of North Carolina Health Sciences at Mountain Area Health Education Center, Asheville, NC (E.C.J.)
| | - Opeolu M Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO (O.M.A.)
| | - Christopher T Richards
- Division of EMS, Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH (C.T.R.)
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7
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Reeves MJ, Boden-Albala B, Cadilhac DA. Care Transition Interventions to Improve Stroke Outcomes: Evidence Gaps in Underserved and Minority Populations. Stroke 2023; 54:386-395. [PMID: 36689590 DOI: 10.1161/strokeaha.122.039565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 12/09/2022] [Indexed: 01/24/2023]
Abstract
In many countries hospital length of stay after an acute stroke admission is typically just a few days, therefore, most of a person's recovery from stroke occurs in the community. Care transitions, which occur when there is a change in, or handoff between 2 different care settings or providers, represent an especially vulnerable period for patients and caregivers. For some patients with stroke the return home is associated with substantial practical, psychosocial, and health-related challenges leading to substantial burden for the individual and caregiver. Underserved and minority populations, because of their exposure to poor environmental, social, and economic conditions, as well as structural racism and discrimination, are especially vulnerable to the problems of complicated care transitions which in turn, can negatively impact stroke recovery. Overall, there remain significant unanswered questions about how to promote optimal recovery in the post-acute care period, particularly for those from underserved communities. Evidence is limited on how best to support patients after they have returned home where they are required to navigate the chronic stages of stroke with little direct support from health professionals.
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Affiliation(s)
- Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
| | - Bernadette Boden-Albala
- Department of Health Society and Behavior, Department of Epidemiology and Biostatistics, Program in Public Health, Department of Neurology, School of Medicine, University of California (B.B.-A.)
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia (D.A.C.)
- Stroke theme, the Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia (D.A.C.)
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8
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Sun JJ, Deng YM, Wang DD, Gu HQ, Zhou Q, Wang YJ, Li ZX, Zhao XQ. Assessment of rehabilitation following intracerebral hemorrhage in China: findings from the Chinese stroke center alliance. Neurol Res 2023; 45:103-111. [PMID: 36126147 DOI: 10.1080/01616412.2022.2123174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Evidence shows that rehabilitation is the most effective strategy to reduce the disability rate of patients with stroke. However, there is limited understanding about the factors associated with rehabilitation assessment among patients with intracerebral hemorrhage (ICH) in China. We aimed to investigate the factors associated with rehabilitation assessment in patients with ICH and the relationship between rehabilitation assessment and hospitalization outcomes. METHODS Data from 85,664 patients with ICH admitted to 1,312 hospitals between 1 August 2015 and 31 July 2019 were analyzed. A multivariable logistic regression model accounting for in-hospital clustering was used to identify patient and hospital factors associated with rehabilitation assessment during acute hospitalization. RESULTS A total of 62,228 (72.6%) patients with ICH underwent rehabilitation assessments. In multivariable analyses, factors associated with an increased likelihood of undergoing a rehabilitation assessment (P < .05) included a higher Glasgow Coma Scale score on admission, a history of hypertension, a history of peripheral vascular disease, dysphagia screening, carotid vessel imaging, and a longer length of hospital stay. Conversely, patients admitted to the intensive care unit and tertiary-grade hospitals were less likely to undergo rehabilitation assessments during hospitalization for ICH. DISCUSSION This study showed that the rate of rehabilitation assessment was 74.2%, which is low. Rehabilitation assessment was associated with longer hospital stays and lower mortality. Therefore, patients with acute cerebral haemorrhage should undergo comprehensive and professional rehabilitation assessment.
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Affiliation(s)
- Jin-Ju Sun
- Nursing Department, Beijing TianTan Hospital, Capital Medical University, Beijing, Fengtai, China
| | - Yong-Mei Deng
- Nursing Department, Beijing TianTan Hospital, Capital Medical University, Beijing, Fengtai, China
| | - Dan-Dan Wang
- Vascular Neurology, Department of Neurology, Beijing TianTan Hospital, Capital Medical University, Beijing, Fengtai, China
| | - Hong-Qiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qi Zhou
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yong-Jun Wang
- Vascular Neurology, Department of Neurology, Beijing TianTan Hospital, Capital Medical University, Beijing, Fengtai, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, Fengtai, China
| | - Zi-Xiao Li
- Vascular Neurology, Department of Neurology, Beijing TianTan Hospital, Capital Medical University, Beijing, Fengtai, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, Fengtai, China
| | - Xing-Quan Zhao
- Vascular Neurology, Department of Neurology, Beijing TianTan Hospital, Capital Medical University, Beijing, Fengtai, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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9
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Nasreldein A, Walter S, Mohamed KO, Shehata GA, Ghali AA, Dahshan A, Faßbender K, Abd-Allah F. Pre- and in-hospital delays in the use of thrombolytic therapy for patients with acute ischemic stroke in rural and urban Egypt. Front Neurol 2023; 13:1070523. [PMID: 36742046 PMCID: PMC9895407 DOI: 10.3389/fneur.2022.1070523] [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] [Received: 10/15/2022] [Accepted: 12/22/2022] [Indexed: 01/22/2023] Open
Abstract
Background Reducing pre- and in-hospital delays plays an important role in increasing the rate of intravenous thrombolysis (IVT) in patients with acute ischemic stroke. In Egypt, the IVT rate has increased steadily but is still far away from an ideal rate. Aim The study aimed to investigate the factors associated with pre- and in-hospital delays of IVT among patients with acute ischemic stroke coming from urban and rural communities. Methods This prospective, multicenter, observational cohort study was conducted from January 2018 to January 2019. Patients with acute ischemic stroke, who did not receive IVT, were included in the study. Patients were recruited from three large university stroke centers in Egypt, Assiut (south of Egypt), Tanta (north of Egypt), both serving urban and rural patients, and the University Hospital in Cairo (capital city), only serving an urban community. All participants underwent the National Institutes of Health Stroke Scale and full neurological assessment, urgent laboratory investigations, and computed tomography or magnetic resonance imaging to confirm the stroke diagnosis. The patients were subjected to a structured questionnaire that was designed to determine the parameters and time metrics for the pre- and in-hospital delays among patients from rural and urban regions. Results A total of 618 patients were included in the study, of which 364 patients (58.9%) lived in rural regions and 254 (41.1%) in urban regions. General demographic characteristics were similar between both groups. Approximately 73.3% of patients who arrived within the therapeutic time window were urban patients. The time from symptom onset till hospital arrival (onset to door time, ODT) was significantly longer among rural patients (738 ± 690 min) than urban patients (360 ± 342 min). Delayed onset to alarm time (OAT), initial misdiagnosis, and presentation to non-stroke-ready hospitals were the most common causes of pre-hospital delay and were significantly higher in rural patients. For patients arriving within the time window, the most common causes of in-hospital delays were prolonged laboratory investigations and imaging duration. Conclusion The limited availability of stroke-ready hospitals in rural Egypt leads to delays in stroke management, with subsequent treatment inequality of rural patients with acute stroke.
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Affiliation(s)
- Ahmed Nasreldein
- Department of Neurology, Assiut University Hospitals, Assiut University, Asyut, Egypt
| | - Silke Walter
- Department of Neurology, Saarland University Hospital, Homburg, Germany
| | - Khaled O. Mohamed
- Department of Neurology, Assiut University Hospitals, Assiut University, Asyut, Egypt
| | - Ghaydaa Ahmed Shehata
- Department of Neurology, Assiut University Hospitals, Assiut University, Asyut, Egypt
| | - Azza A. Ghali
- Department of Neurology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ahmed Dahshan
- Department of Neurology, Cairo University Hospitals, Cairo University, Cairo, Egypt
| | - Klaus Faßbender
- Department of Neurology, Saarland University Hospital, Homburg, Germany
| | - Foad Abd-Allah
- Department of Neurology, Cairo University Hospitals, Cairo University, Cairo, Egypt,*Correspondence: Foad Abd-Allah ✉
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10
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Sahakyan G, Orduyan M, Badalyan S, Adamyan A, Hovhannisyan M, Manucharyan H, Egoyan S, Makaryan Y, Manvelyan H. Characteristics of stroke service implementation in Armenia. Front Neurol 2023; 13:1021628. [PMID: 36712450 PMCID: PMC9878671 DOI: 10.3389/fneur.2022.1021628] [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: 08/17/2022] [Accepted: 12/13/2022] [Indexed: 01/13/2023] Open
Abstract
Background Acute stroke care service in Armenia was established in 2019 after the implementation of the National Stroke Program (NSP). This study aimed to provide an up-to-date account of the current image and clinical characteristics of acute stroke service implementation at a tertiary hospital in Armenia by analyzing the quality of care and identifying the areas that need improvement. Methods We analyzed patient data from a single hospital in 1 year after the establishment of acute stroke care service (February 2021-January 2022). We selected patients who were within 0-24 h from symptom onset at admission and included patients who benefited from reperfusion therapies (intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT)). A favorable outcome was defined as a drop in the National Institutes of Health Stroke Scale (NIHSS) by more than four points at discharge and a modified Rankin score (mRS) of 0-2 at 90 days. Results Of the total 385 patients, 155 underwent reperfusion therapies, 91% of patients (141/155) arrived by ambulance, 79.2% (122/155) had neurological improvement at discharge, and 60.6% (94/155) had an mRS of 0-2 at 3 months. Less than 5% of patients had early direct access to the rehabilitation center. Conclusion Our study demonstrated that the implementation of NSP with organized protocol-driven inpatient care led to significant advancement in acute stroke service performance. We believe that our report will serve as a model for achieving advanced and structured stroke care in a resource-limited context and contribute to the future development of the healthcare system in our country.
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Affiliation(s)
- Greta Sahakyan
- Department of Neurology, Astghik Medical Center, Yerevan State Medical University, Yerevan, Armenia
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11
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Farooqui M, Suriya S, Quadri S, Baig A, Khalil MH, Liaquat A, Taqi A. Reduction in Door-to-Groin Puncture Time for Endovascular Treatment in Acute Ischemic Stroke Patients With Large Vessel Occlusion. Cureus 2022; 14:e28348. [PMID: 36168340 PMCID: PMC9506579 DOI: 10.7759/cureus.28348] [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] [Accepted: 08/24/2022] [Indexed: 11/27/2022] Open
Abstract
Background The outcome of mechanical thrombectomy for large vessel occlusion (LVO) in patients with acute ischemic stroke (AIS) is time-dependent. In the current stroke workflow, the pre-hospital delay is one of the most common reasons for an increase in door-to-groin puncture time (DGPT). In the present study, we sought to compare the difference in (DGPT) before and after the implementation of the Ventura Emergent Large Vessel Occlusion Score (VES) protocol for LVO. Methods VES was implemented in the Ventura County of California by Emergency Medical Services (EMS). We performed a retrospective analysis to compare DGPT of patients undergoing endovascular treatment (EVT) pre- and post-VES implementation. Mean and standard deviation was reported for the continuous variable 'time for intra-arterial (IA) treatment' in minutes. The Mann-Whitney test was used for the comparison of the variable between the two groups. analyses were performed using SAS v9.4 (SAS Institute Inc., Cary, NC) with a significant p-value of ≤0.05. Results A total of 304 (males: 142 and females: 162) patients were alerted of the stroke code by the EMS. VES was positive in 139 patients. Of these, 64 (46%) were males and 75 (54%) were females. VES score of 1, 2, 3, and 4 were recorded in 57 (41%), 44 (31.6%), 31 (22.3%), and 7 (5%) patients, respectively. A total of 48 VES-positive patients underwent EVT. There were 62 patients who underwent EVT before the implementation of the VES protocol. The mean DGPT for the EVT among post-VES patients was 65 minutes, which was significantly (p=0.0009) shorter than the mean DGPT of 109 minutes among pre-VES patients. Conclusion VES is a simplified and effective tool for identifying LVO in the field. Implementation of VES showed significantly reduced DGPT in LVO patients.
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Affiliation(s)
| | - Sajid Suriya
- Neurology, University of New Mexico School of Medicine, Albuquerque, USA
| | - Syed Quadri
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Aqsa Baig
- Neurology, Liaquat National Hospital and Medical College, Karachi, PAK
| | | | - Ayesha Liaquat
- Medicine and Surgery, Karachi Medical and Dental College, Karachi, PAK
| | - Asif Taqi
- Neurological Surgery, Vascular Neurology of Southern California, Thousand Oaks, USA
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12
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Alhejily WA. Efficacy of Telemedicine Utilization for Cardiac Outpatients' Care during the Pandemic of COVID-19: A Large Center Experience in the Wave of the Pandemic. Int J Telemed Appl 2022; 2022:4156436. [PMID: 35601051 PMCID: PMC9115730 DOI: 10.1155/2022/4156436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 04/16/2022] [Accepted: 04/24/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Synchronous telemedicine using teleconferencing may play a role in clinical care. In a tertiary care center, video conferencing-enhanced virtual clinics were established via a new application platform. They were introduced during COVID-19 pandemic to connect patients to trained health-care providers via a secured line. While maintaining patients' privacy, they were theorized to offer effective communications and continuous clinical care. In this cross-sectional cohort study, we ought to examine the impact of service and the assistance they may offer to cardiac patients in the outpatient setup. Methods A prospective cohort study looking at all video-conferencing virtual clinics' visits during the pandemic with primary focus on cardiac outpatient clinic, addressing primary endpoints of need for admission or emergency visits from cardiac demises during the pandemic and secondary endpoint of patient satisfaction based on patients' experiences. Results A total of 6000 live care video-based chats were made over 10 months period from March 10th, 2020, to January 30th, 2021, among which 277 patients were evaluated in the virtual cardiac clinic, of these 193 (69.7%) were males, with mean age of 48 ± 15.60 (22.3%), patients were requested to present to clinic for further evaluation and testing, 20 (7.2%) patients were asked to visit the emergency room, of whom 8 (2.8%) patients were hospitalized. All 8 were admitted for high-risk findings that require immediate medical attention, 4/8 underwent cardiac catheterization, mean duration of admission was 2 ± 1 days. When compared to regular walk-in care, there was a statistical difference in admission rate and emergency visits p = 0.001 and p = 0.0001, respectively, both were statistically higher in the virtual clinic. The satisfaction rate in a 5-scale grading system was 97% of 4 and above recommending the continuation of the service beyond pandemic time. Conclusions Video-enhanced virtual cardiology clinic works safely and efficiently during COVID-19 pandemic with a difference in admission rate and ER visits when compared to walk-in clinic. It can be used during nonpandemic time to reduce load on hospital and clinic crowdedness. It also decreases the chances of COVID-19 transmission indirectly by reenforcing physical distance.
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Affiliation(s)
- Wesam A. Alhejily
- Departments of Medicine (Division of Cardiology) Faculty of Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
- Cardiology Division at Dr Sulaiman Alhabib Medical Group, Saudi Arabia
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13
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Zachrison KS, Schwamm LH. Strategic Opportunities to Improve Stroke Systems of Care. JAMA 2022; 327:1765-1767. [PMID: 35510400 DOI: 10.1001/jama.2022.3820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Lee H Schwamm
- Harvard Medical School, Boston, Massachusetts
- Stroke Division, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
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14
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Roushdy T, Aref H, Kesraoui S, Temgoua M, Nono KP, Gebrewold MA, Peter W, Gopaul U, Belahsen MF, Ben-Adji D, Melifonwu R, Pugazhendhi S, Woodcock N, Mohamed MH, Rossouw A, Matuja S, Ruanda MK, Mhiri C, Saylor D, Nahas NE, Shokri H. Stroke services in Africa: What is there and what is needed. Int J Stroke 2022; 17:972-982. [PMID: 35034522 DOI: 10.1177/17474930211066416] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Over the past few years, the incidence and prevalence of stroke has been rising in most African countries and has been reported as one of the leading causes of morbidity and mortality. To study this problem, we need to realize the quality and availability of stroke care services as a priori to improve them. METHODS AND RESULTS In this study, we investigated the availability of different stroke-related services in 17 countries from different African regions. An online survey was conducted and fulfilled by stroke specialists and included primary prevention, acute management, diagnostic tools, medications, postdischarge services, and stroke registries. The results showed that although medications for secondary prevention are available, yet many other services are lacking in various countries. CONCLUSION This study displays the deficient aspects of stroke services in African countries as a preliminary step toward active corrective procedures for the improvement of stroke-related health services.
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Affiliation(s)
- Tamer Roushdy
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Hany Aref
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Selma Kesraoui
- Department of Neurology, Blida Hospital University, Blida, Algeria
| | - Michael Temgoua
- Institute of Applied Neurosciences and Functional Rehabilitation, Bethesda Hospital, Yaoundè, Cameroon
| | - Kiatoko Ponte Nono
- Initiative Plus Hospital Center, Kinshasa, Democratic Republic of the Congo
| | | | - Waweru Peter
- Kenyatta University Teaching, Referral & Research Hospital, Nairobi, Kenya
| | - Urvashy Gopaul
- University of Mauritius, Moka, Mauritius.,KITE-University Health Network (UHN), Toronto, ON, Canada
| | - Mohammed Faouzi Belahsen
- Neurology Department, Hassan II University Hospital, Sidi Mohamed Ben Abdellah University, Fez, Morocco
| | | | - Rita Melifonwu
- Stroke Rehabilitation, Stroke Action Nigeria, Abuja, Nigeria
| | | | | | | | | | - Sarah Matuja
- Department of Internal Medicine, Bugando Medical Centre/Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Mark Koba Ruanda
- Emergency Medicine Department, Mnazi Mmoja Hospital, Zanzibar, Tanzania
| | - Chokri Mhiri
- Department of Neurology, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Deanna Saylor
- Department of Medicine, University Teaching Hospital, Lusaka, Zambia.,Department of Neurology, School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Nevine El Nahas
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Hossam Shokri
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Tatlisumak T, Putaala J. General Stroke Management and Stroke Units. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00055-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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16
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Xian Y, Xu H, Smith EE, Saver JL, Reeves MJ, Bhatt DL, Hernandez AF, Peterson ED, Schwamm LH, Fonarow GC. Achieving More Rapid Door-to-Needle Times and Improved Outcomes in Acute Ischemic Stroke in a Nationwide Quality Improvement Intervention. Stroke 2021; 53:1328-1338. [PMID: 34802250 DOI: 10.1161/strokeaha.121.035853] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The benefits of tPA (tissue-type plasminogen activator) in acute ischemic stroke are time-dependent. However, delivery of thrombolytic therapy rapidly after hospital arrival was initially occurring infrequently in hospitals in the United States, discrepant with national guidelines. METHODS We evaluated door-to-needle (DTN) times and clinical outcomes among patients with acute ischemic stroke receiving tPA before and after initiation of 2 successive nationwide quality improvement initiatives: Target: Stroke Phase I (2010-2013) and Target: Stroke Phase II (2014-2018) from 913 Get With The Guidelines-Stroke hospitals in the United States between April 2003 and September 2018. RESULTS Among 154 221 patients receiving tPA within 3 hours of stroke symptom onset (median age 72 years, 50.1% female), median DTN times decreased from 78 minutes (interquartile range, 60-98) preintervention, to 66 minutes (51-87) during Phase I, and 50 minutes (37-66) during Phase II (P<0.001). Proportions of patients with DTN ≤60 minutes increased from 26.4% to 42.7% to 68.6% (P<0.001). Proportions of patients with DTN ≤45 minutes increased from 10.1% to 17.7% to 41.4% (P<0.001). By the end of the second intervention, 75.4% and 51.7% patients achieved 60-minute and 45-minute DTN goals. Compared with the preintervention period, hospitals during the second intervention period (2014-2018) achieved higher rates of tPA use (11.7% versus 5.6%; adjusted odds ratio, 2.43 [95% CI, 2.31-2.56]), lower in-hospital mortality (6.0% versus 10.0%; adjusted odds ratio, 0.69 [0.64-0.73]), fewer bleeding complication (3.4% versus 5.5%; adjusted odds ratio, 0.68 [0.62-0.74]), and higher rates of discharge to home (49.6% versus 35.7%; adjusted odds ratio, 1.43 [1.38-1.50]). Similar findings were found in sensitivity analyses of 185 501 patients receiving tPA within 4.5 hours of symptom onset. CONCLUSIONS A nationwide quality improvement program for acute ischemic stroke was associated with substantial improvement in the timeliness of thrombolytic therapy start, increased thrombolytic treatment, and improved clinical outcomes.
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Affiliation(s)
- Ying Xian
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX. (Y.X.)
| | - Haolin Xu
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (H.X., A.F.H.)
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (E.E.S.)
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles (J.L.S.)
| | - Mathew J Reeves
- Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (H.X., A.F.H.)
| | - Eric D Peterson
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX. (E.D.P.)
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.)
| | - Gregg C Fonarow
- Division of Cardiology, University of California at Los Angeles (G.C.F.)
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Camicia M, Lutz B, Summers D, Klassman L, Vaughn S. Nursing's Role in Successful Stroke Care Transitions Across the Continuum: From Acute Care Into the Community. Stroke 2021; 52:e794-e805. [PMID: 34727736 DOI: 10.1161/strokeaha.121.033938] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Facilitating successful care transitions across settings is a key nursing competency. Although we have achieved improvements in acute stroke care, similar advances in stroke care transitions in the postacute and return to community phases have lagged far behind. In the current delivery system, care transitions are often ineffective and inefficient resulting in unmet needs and high rates of unnecessary complications and avoidable hospital readmissions. Nurses must use evidence-based approaches to prepare stroke survivors and their family caregivers for postdischarge self-management, rehabilitation, and recovery. The purpose of this article is to provide evidence on the important nursing roles in stroke care and transition management across the care continuum, discuss cross-setting issues in stroke care, and provide recommendations to leverage nursing's impact in optimizing outcomes for stroke survivors and their family unit across the continuum. To optimize nursing's influence in facilitating safe, effective, and efficient care transitions for stroke survivors and their family caregivers across the continuum we have the following recommendations (1) establish a system of coordinated and seamless comprehensive stroke care across the continuum and into the community; (2) implement a stroke nurse liaison role that provides consultant case management for the episode of care across all settings/services for improved consistency, communication and follow-up care; (3) implement a validated caregiver assessment tool to systematically assess gaps in caregiver preparedness and develop a tailored caregiver/family care plan that can be implemented to improve caregiver preparedness; (4) use evidence-based teaching and communication methods to optimize stroke survivor/caregiver learning; and (5) use technology to advance stroke nursing care. Nurses must leverage their substantial influence over the health care delivery system to achieve these improvements in stroke care delivery to improve the health and lives of stroke survivors and their families.
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Affiliation(s)
- Michelle Camicia
- Kaiser Foundation Rehabilitation Center, Kaiser Permanente, Vallejo, CA (M.C.)
| | | | | | - Lynn Klassman
- Advocate Lutheran General Hospital, Park Ridge, IL (L.K.)
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Chukwudelunzu FE, Demaerschalk BM, Fugoso L, Amadi E, Dexter D, Gullicksrud A, Hagen C. In-Hospital Stroke Care: A Six-Year Community-Based Primary Stroke Center Experience. Neurohospitalist 2021; 11:326-332. [PMID: 34567393 DOI: 10.1177/19418744211007001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and purpose In-hospital stroke-onset assessment and management present numerous challenges, especially in community hospitals. Comprehensive analysis of key stroke care metrics in community-based primary stroke centers is under-studied. Methods Medical records were reviewed for patients admitted to a community hospital for non-cerebrovascular indications and for whom a stroke alert was activated between 2013 and 2019. Demographic, clinical, radiologic and laboratory information were collected for each incident stroke. Descriptive statistical analysis was employed. When applicable, Kruskal-Wallis and Chi-Square tests were used to compare median values and categorical data between pre-specified groups. Statistical significance was set at alpha = 0.05. Results There were 192 patients with in-hospital stroke-alert activation; mean age (SD) was 71.0 years (15.0), 49.5% female. 51.6% (99/192) had in-hospital ischemic and hemorrhagic stroke. The most frequent mechanism of stroke was cardioembolism. Upon stroke activation, 45.8% had ischemic stroke while 40.1% had stroke mimics. Stroke team response time from activation was 26 minutes for all in-hospital activations. Intravenous thrombolysis was utilized in 8% of those with ischemic stroke; 3.4% were transferred for consideration of endovascular thrombectomy. In-hospital mortality was 17.7%, and the proportion of patients discharged to home was 34.4% for all activations. Conclusion The in-hospital stroke mortality was high, and the proportions of patients who either received or were considered for acute intervention were low. Quality improvement targeting increased use of acute stroke intervention in eligible patients and reducing hospital mortality in this patient cohort is needed.
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Affiliation(s)
| | - Bart M Demaerschalk
- Department of Neurology. Mayo Clinic College of Medicine and Science, Phoenix, USA
| | - Leonardo Fugoso
- Department of Neurology, Mayo Clinic Health System Eau Claire, Wisconsin, USA
| | - Emeka Amadi
- Department of Hospital Medicine, Mayo Clinic Health System Eau Claire, Wisconsin, USA
| | - Donn Dexter
- Department of Neurology, Mayo Clinic Health System Eau Claire, Wisconsin, USA
| | - Angela Gullicksrud
- Department of Neurology, Mayo Clinic Health System Eau Claire, Wisconsin, USA
| | - Clinton Hagen
- Program for Hypoplastic Left Heart Syndrome, Mayo Clinic Rochester Minnesota, MN Minnesota, USA
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Zachrison KS, Richard JV, Wilcock A, Zubizaretta JR, Schwamm LH, Uscher-Pines L, Mehrotra A. Association of Hospital Telestroke Adoption With Changes in Initial Hospital Presentation and Transfers Among Patients With Stroke and Transient Ischemic Attacks. JAMA Netw Open 2021; 4:e2126612. [PMID: 34554236 PMCID: PMC8461501 DOI: 10.1001/jamanetworkopen.2021.26612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
IMPORTANCE It has been proposed that the implementation of telestroke services (a web-based approach to using video telecommunication to treat patients with stroke before hospital admission) changes where patients with stroke symptoms receive care, but this proposal has not been rigorously assessed. OBJECTIVE To assess whether the implementation of telestroke services is associated with changes in where and how patients initially present with stroke symptoms, in their decision to be transferred to another hospital, and which hospitals they are transferred to. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study compared changes in stroke systems of care between a sample of 593 US hospitals that adopted telestroke during the period from 2009 to 2016 but were not comprehensive stroke centers, major teaching hospitals, or thrombectomy-capable hospitals vs 593 matched control hospitals without telestroke based on rural location, critical access hospital status, bed size, primary stroke center status, presence of hospital alternatives in the community, hospital stroke volume, census region, and ownership. With the use of data on 100% of Medicare fee-for-service beneficiaries, all stroke and transient ischemic attack admissions from 2008 to 2018 were identified. EXPOSURES For each hospital pair (telestroke plus matched control), the telestroke hospital's implementation date and difference-in-differences approach were used to quantify the association between telestroke implementation and changes in care from 2 years before implementation to 2 years after implementation. Models also controlled for differences in observed patient characteristics. MAIN OUTCOMES AND MEASURES Hospital stroke volume, patients' ambulance transport distance to initial hospital, hospital case mix, interhospital transfer proportion, and size of the receiving hospital for transferred patients. RESULTS Of the 669 telestroke hospitals and 2143 potential control hospitals, 593 hospital pairs were matched; in each category, 261 hospitals (44.0%) were located in a rural area, 179 (30.2%) were primary stroke centers, and 130 (21.9%) were critical access hospitals. The changes in the preimplementation to postimplementation period were similar at telestroke and control hospitals in mean annual stroke volume (telestroke hospitals, decreased from 79.6 to 76.3 patients; control hospitals, decreased from 78.8 to 75.5 patients [-3.3 patients per year for both; difference-in-differences, 0.009; P ≥ .99]). Similarly, no differences were seen in ambulance transport distance, case mix, interhospital transfers, or bed size of receiving hospitals among transferred patients. CONCLUSIONS AND RELEVANCE This study suggests that, across a national sample of hospitals implementing telestroke, no association between telestroke adoption and changes in stroke systems of care were found.
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Affiliation(s)
- Kori S. Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Jessica V. Richard
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Andrew Wilcock
- Department of Family Medicine, University of Vermont College of Medicine, Burlington
| | - Jose R. Zubizaretta
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston
| | | | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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20
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Fallat ME. Fifteen years beyond Institute of Medicine and the future of emergency care in the US health system: Illusions, delusions, and situational awareness. J Trauma Acute Care Surg 2021; 91:6-13. [PMID: 34144555 DOI: 10.1097/ta.0000000000003242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Mary E Fallat
- From the Division of Pediatric Surgery Hiram C. Polk, Jr., Department of Surgery, University of Louisville, Louisville, Kentucky
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Abstract
BACKGROUND Stroke survivors have higher unmet health care needs than the general population. However, it is unclear whether such needs have changed over time, and whether these have been affected by the introduction of integrated systems of stroke care. METHODS We used data from the Canadian Community Health Surveys between 2000 and 2014. We developed multivariable log-binomial generalized estimating equations to obtain adjusted risk ratios (aRRs) of unmet health care needs in stroke survivors compared to the general population, and over time. We conducted a difference in differences analysis to determine the association between the implementation of integrated systems of stroke care and unmet health care needs. RESULTS Data from 350,084 respondents were included in the study; 8072 (2.3%) were stroke survivors. Compared to the general population, stroke survivors were more likely to report unmet health care needs (aRR 1.27; 95% CI, 1.22-1.32). The unmet health care needs reported by stroke survivors were lower after compared to before 2006 (15.8% vs. 31.9%, P < 0.001). After accounting for temporal trends, there was no association between the implementation of integrated systems of stroke care and change in unmet health care needs of stroke survivors. However, this requires cautious interpretation due to limitations in the data available for this study. CONCLUSIONS Unmet health care needs of stroke survivors have reduced over time but remain higher than the general population. Future research should focus on identifying stroke- and policy-related factors to mitigate disparities in health care access for stroke survivors.
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22
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Sobhani F, Desai S, Madill E, Starr M, Rocha M, Molyneaux B, Jovin T, Wechsler L, Jadhav A. Remote Longitudinal Inpatient Acute Stroke Care Via Telestroke. J Stroke Cerebrovasc Dis 2021; 30:105749. [PMID: 33784522 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105749] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/01/2021] [Accepted: 03/08/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES While telestroke 'hub-and-spoke' systems are a well-established model for improving acute stroke care at spoke facilities, utility beyond the hyperacute phase is unknown. In patients receiving intravenous thrombolysis via telemedicine, care at spoke facilities has been shown to be associated with longer length of stay and worse outcomes. We sought to explore the impact of ongoing stroke care by a vascular neurologist via telemedicine compared to care provided by local neurologists. METHODS A network spoke facility protocol was revised to pilot telestroke consultation with a hub vascular neurologist for all patients presenting to the emergency department with ischemic stroke or transient ischemic attack regardless of time since onset or severity. Subsequent telestroke rounds were performed for patients who received initial telestroke consultation. Key outcome measures were length of stay, 30-day readmission and mortality and 90-day mRS. Results during the pilot (post-cohort) were compared to the same hospital's previous outcomes (pre-cohort). RESULTS Of 257 enrolled patients, 67% were in the post-cohort. Forty percent (69) of the post-cohort received an initial telestroke consult. In spoke-retained patients followed by telestroke rounds (55), median length of stay decreased by 0.8 days (P = 0.01). Readmission and mortality rates did not differ significantly between groups (19.5 vs. 9.1%, P = 0.14 and 3.9 vs. 3.6%, P = 1, respectively). The favorable functional outcome rate was similar between groups (47.3% vs 65.9%, P = 0.50). CONCLUSIONS Longitudinal stroke care via telestroke may be economically viable through length of stay reduction. Randomized prospective studies are needed to confirm our findings and further investigate this model's potential benefits.
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Affiliation(s)
- Fatemeh Sobhani
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA USA.
| | - Shashvat Desai
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA USA.
| | - Evan Madill
- Department of Neurology, Stanford University, Palo Alto, CA USA.
| | - Matthew Starr
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA USA.
| | - Marcelo Rocha
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA USA.
| | - Bradley Molyneaux
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA USA.
| | - Tudor Jovin
- Department of Neurology, Cooper University Health Care, Camden, NJ USA.
| | - Lawrence Wechsler
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA.
| | - Ashutosh Jadhav
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA USA.
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Choi JC, Kim JG, Kang CH, Bae HJ, Kang J, Lee SJ, Park JM, Park TH, Cho YJ, Lee KB, Lee J, Kim DE, Cha JK, Kim JT, Lee BC, Lee JS, Kim AS. Effect of Transport Time on the Use of Reperfusion Therapy for Patients with Acute Ischemic Stroke in Korea. J Korean Med Sci 2021; 36:e77. [PMID: 33754510 PMCID: PMC7985286 DOI: 10.3346/jkms.2021.36.e77] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 01/11/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND We investigated the association between geographic proximity to hospitals and the administration rate of reperfusion therapy for acute ischemic stroke. METHODS We identified patients with acute ischemic stroke who visited the hospital within 12 hours of symptom onset from a prospective nationwide multicenter stroke registry. Reperfusion therapy was classified as intravenous thrombolysis (IVT), endovascular therapy (EVT), or combined therapy. The association between the proportion of patients who were treated with reperfusion therapy and the ground transport time was evaluated using a spline regression analysis adjusted for patient-level characteristics. We also estimated the proportion of Korean population that lived within each 30-minute incremental service area from 67 stroke centers accredited by the Korean Stroke Society. RESULTS Of 12,172 patients (mean age, 68 ± 13 years; men, 59.7%) who met the eligibility criteria, 96.5% lived within 90 minutes of ground transport time from the admitting hospital. The proportion of patients treated with IVT decreased significantly when stroke patients lived beyond 90 minutes of the transport time (P = 0.006). The proportion treated with EVT also showed a similar trend with the transport time. Based on the residential area, 98.4% of Korean population was accessible to 67 stroke centers within 90 minutes. CONCLUSION The use of reperfusion therapy for acute stroke decreased when patients lived beyond 90 minutes of the ground transport time from the hospital. More than 95% of the South Korean population was accessible to 67 stroke centers within 90 minutes of the ground transport time.
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Affiliation(s)
- Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Korea
- Institute of Medical Science, Jeju National University, Jeju, Korea.
| | - Joong Goo Kim
- Department of Neurology, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Korea
| | - Chul Hoo Kang
- Department of Neurology, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Korea
| | - Hee Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jihoon Kang
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Daejeon, Korea
| | - Jong Moo Park
- Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Yong Jin Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Hospital, Daegu, Korea
| | - Dong Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jae Kwan Cha
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Joon Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Byung Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Korea
| | - Anthony S Kim
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
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Neurological Critical Care: The Evolution of Cerebrovascular Critical Care. Crit Care Med 2021; 49:881-900. [PMID: 33653976 DOI: 10.1097/ccm.0000000000004933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kleitsch J, Nistal DA, Romano Spica N, Alkayyali M, Song R, Chada D, Reilly K, Lay C, Reynolds AS, Fifi JT, Bederson JB, Mocco J, Liang JW, Kellner CP, Dangayach NS. Interhospital Transfer of Intracerebral Hemorrhage Patients Undergoing Minimally Invasive Surgery: The Experience of a New York City Hospital System. World Neurosurg 2021; 148:e390-e395. [PMID: 33422715 DOI: 10.1016/j.wneu.2020.12.163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The impact of interhospital transfer (IHT) on outcomes of patients with intracerebral hemorrhage (ICH) has not been well studied. We seek to describe the protocolized IHT and systems of care approach of a New York City hospital system, where ICH patients undergoing minimally invasive surgery (MIS) are transferred to a dedicated ICH center. METHODS We retrospectively reviewed 100 consecutively admitted patients with spontaneous ICH. We gathered information on demographics, variables related to IHT, clinical and radiographic characteristics, and details about the clinical course and outpatient follow-up. We grouped patients into 2 cohorts: those admitted through IHT and those directly admitted through the emergency department. Primary outcome was good functional outcome at 6 months, defined as modified Rankin Scale score 0-3. RESULTS Of 100 patients, 89 underwent IHT and 11 were directly admitted. On multivariable analysis, there were no significant differences in 6-month functional outcome between the 2 cohorts. All transfers were managed by a system-wide transfer center and 24/7 hotline for neuroemergencies. An ICH-specific IHT protocol was followed, in which a neurointensivist provided recommendations for stabilizing patients for transfer. Average transfer time was 199.7 minutes and average distance travelled was 13.6 kilometers. CONCLUSIONS In our hospital system, a centralized approach to ICH management and a dedicated ICH center increased access to specialist services, including MIS. Most patients undergoing MIS were transferred from outside hospitals, which highlights the need for additional studies and descriptions of experiences to further elucidate the impact of and best protocols for the IHT of ICH patients.
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Affiliation(s)
- Julianne Kleitsch
- State University of New York Downstate College of Medicine, Brooklyn, New York, USA; Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - Dominic A Nistal
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | | | - Miryam Alkayyali
- Icahn School of Medicine at Mount Sinai (Beth Israel/Mount Sinai West), Department of Neurology, New York, New York, USA
| | - Rui Song
- State University of New York Downstate College of Medicine, Brooklyn, New York, USA
| | - Deeksha Chada
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - Kaitlin Reilly
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - Cappi Lay
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - Alexandra S Reynolds
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - Johanna T Fifi
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - Joshua B Bederson
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - J Mocco
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - John W Liang
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - Christopher P Kellner
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA
| | - Neha S Dangayach
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA.
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Harris AHS, Barreto NB, Trickey AW, Bereknyei S, Meng T, Wagner TH, Govindarajan P. Are EMS bypass policies effective implementation strategies for intravenous alteplase for stroke? Implement Sci Commun 2020; 1:50. [PMID: 32885206 PMCID: PMC7427915 DOI: 10.1186/s43058-020-00041-5] [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: 05/14/2020] [Accepted: 05/21/2020] [Indexed: 11/10/2022] Open
Abstract
Background Stroke is a leading cause of disability and the fifth leading cause of death in the USA. Intravenous alteplase is a highly effective clot-dissolving stroke treatment that must be given in a hospital setting within a time-sensitive window. To increase the use of intravenous alteplase in stroke patients, many US counties enacted policies mandating emergency medical service (EMS) paramedics to bypass local emergency departments and instead directly transport patients to specially equipped stroke centers. The objective of this mixed-methods study is to evaluate the effectiveness of policy enactment as an implementation strategy, how differences in policy structures and processes impact effectiveness, and to explore how the county, hospital, and policy factors explain variation in implementation and clinical outcomes. This paper provides a detailed description of an Agency for Healthcare Quality and Research (AHRQ)-funded protocol, including the use of the Consolidated Framework for Implementation Research (CFIR) in the qualitative design. Methods/design We will construct the largest-ever national stroke database of Medicare enrollees (~ 1.5 million stroke patients) representing 896 policy counties paired with 1792 non-policy counties, then integrate patient-, hospital-, county-, and state-level covariates from eight different data sources. We will use a difference-in-differences analysis to estimate the overall effect of the policy enactment on intravenous alteplase use (implementation outcome) as well as key patient outcomes. We will also quantitatively examine if variation in the context (urban/rural status) and variation in policy features affect outcomes. Finally, a CFIR-informed multiple case study design will be used to interview informants in 72 stakeholders in 24 counties to identify and validate factors that enable policy effects. Discussion Policies can be potent implementation strategies. However, the effects of EMS bypass policies to increase intravenous alteplase use have not been rigorously evaluated. By learning how context and policy structures impact alteplase implementation, as well as the barriers and facilitators experienced by stakeholders responsible for policy enactment, the results of this study will inform decisions regarding if and how EMS bypass policies should spread to non-policy counties, and if indicated, creation of a "best practices" toolkit.
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Affiliation(s)
- Alex H S Harris
- Department of Surgery, Stanford - Surgery Policy Improvement Research & Education Center (S-SPIRE), Stanford, CA 94305 USA.,Veterans Affairs Health Services Research and Development Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, Menlo Park, CA 94025 USA
| | - Nicolas B Barreto
- Department of Surgery, Stanford - Surgery Policy Improvement Research & Education Center (S-SPIRE), Stanford, CA 94305 USA
| | - Amber W Trickey
- Department of Surgery, Stanford - Surgery Policy Improvement Research & Education Center (S-SPIRE), Stanford, CA 94305 USA
| | - Sylvia Bereknyei
- Department of Surgery, Stanford - Surgery Policy Improvement Research & Education Center (S-SPIRE), Stanford, CA 94305 USA
| | - Tong Meng
- Department of Surgery, Stanford - Surgery Policy Improvement Research & Education Center (S-SPIRE), Stanford, CA 94305 USA
| | - Todd H Wagner
- Department of Surgery, Stanford - Surgery Policy Improvement Research & Education Center (S-SPIRE), Stanford, CA 94305 USA.,Veterans Affairs Health Services Research and Development Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, Menlo Park, CA 94025 USA
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Affiliation(s)
- Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing
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Grimley RS, Rosbergen IC, Gustafsson L, Horton E, Green T, Cadigan G, Kuys S, Andrew NE, Cadilhac DA. Dose and setting of rehabilitation received after stroke in Queensland, Australia: a prospective cohort study. Clin Rehabil 2020; 34:812-823. [PMID: 32389061 DOI: 10.1177/0269215520916899] [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: 11/15/2022]
Abstract
OBJECTIVE The aims of this study were to describe patterns and dose of rehabilitation received following stroke and to investigate their relationship with outcomes. DESIGN This was a prospective observational cohort study. SETTING A total of seven public hospitals and all subsequent rehabilitation services in Queensland, Australia, participated in the study. SUBJECTS Participants were consecutive patients surviving acute stroke between July 2016 and January 2017. METHODS We tracked rehabilitation for six months following stroke and obtained 90- to 180-day outcomes from the Australian Stroke Clinical Registry. MEASURES Dose of rehabilitation - time in therapy by physiotherapy, occupational therapy and speech pathology; modified Rankin Scale (mRS)- premorbid, acute care discharge and 90- to 180-day follow-up. RESULTS We recruited 504 patients, of whom 337 (median age = 73 years, 41% female) received 643 episodes of rehabilitation in 83 different services. Initial rehabilitation was predominantly inpatient (260/337, 77%) versus community-based (77/337, 21%). Therapy time was greater within inpatient services (median = 29 hours) compared to community-based (6 hours) or transition care (16 hours). Median (Quartile 1, Quartile 3) six-month cumulative therapy time was 73 hours (40, 130) when rehabilitation commenced in stroke units and continued in inpatient rehabilitation units; 43 hours (23, 78) when commenced in inpatient rehabilitation units; and 5 hours (2, 9) with only community rehabilitation. In 317 of 504 (63%) with follow-up data, improvement in mRS was most likely with inpatient rehabilitation (OR = 3.6, 95% CI = 1.7-7.7), lower with community rehabilitation (OR = 1.6, 95% CI = 0.7-3.8) compared to no rehabilitation, after adjustment for baseline factors. CONCLUSION Amount of therapy varied widely between rehabilitation pathways. Amount of therapy and chance of improvement in function were highest with inpatient rehabilitation.
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Affiliation(s)
- Rohan S Grimley
- Sunshine Coast Clinical School, Griffith University, Birtinya, QLD, Australia.,Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.,Queensland State-wide Stroke Clinical Network, Clinical Excellence Division, Queensland Department of Health, Brisbane, QLD, Australia
| | - Ingrid Cm Rosbergen
- Queensland State-wide Stroke Clinical Network, Clinical Excellence Division, Queensland Department of Health, Brisbane, QLD, Australia.,Allied Health Services, Sunshine Coast Hospital and Health Service, Birtinya, QLD, Australia.,School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Louise Gustafsson
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia.,School of Allied Health Sciences, Griffith University, Brisbane, QLD, Australia
| | - Eleanor Horton
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Maroochydore, QLD, Australia
| | - Theresa Green
- Faculty of Health School of Nursing, The University of Queensland, Brisbane, QLD, Australia.,Centre for Clinical Nursing, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Greg Cadigan
- Queensland State-wide Stroke Clinical Network, Clinical Excellence Division, Queensland Department of Health, Brisbane, QLD, Australia
| | - Suzanne Kuys
- Faculty of Health Sciences, Australian Catholic University, Brisbane, QLD, Australia
| | - Nadine E Andrew
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.,Department of Medicine, Peninsula Clinical School, Central Clinical School, Monash University, Frankston, VIC, Australia
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia
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Turner AC, Schwamm LH, Etherton MR. Acute ischemic stroke: improving access to intravenous tissue plasminogen activator. Expert Rev Cardiovasc Ther 2020; 18:277-287. [PMID: 32323590 DOI: 10.1080/14779072.2020.1759422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Since approval by the United States Food and Drug Administration in 1996, alteplase utilization rates for acute ischemic stroke have increased. Despite its efficacy for improving stroke outcomes, however, the majority of ischemic stroke patients still do not receive alteplase. To address this issue, different methods for improving access to alteplase have been tested with varying degrees of success. AREAS COVERED This article gives an overview of the recent approaches pursued to improve access to alteplase for acute ischemic stroke patients. Utilization of stroke systems of care, quality metrics, and quality-improvement initiatives to improve alteplase treatment rates are discussed. The implementation of Telestroke networks to improve access and timely evaluation by a stroke specialist are also reviewed. Lastly, this review discusses the use of neuroimaging techniques to identify alteplase candidates in stroke of unknown symptom onset or beyond the 4.5-h treatment window. EXPERT COMMENTARY Expanding access to alteplase therapy for acute ischemic stroke is a multi-faceted approach. Specific considerations based on region, population, and health-care resources should be considered for each strategy. Neuroimaging approaches to identify alteplase-eligible patients beyond the 4.5-h treatment window are a recent development in acute stroke care that holds promise for increasing alteplase treatment rates.
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Affiliation(s)
- Ashby C Turner
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School , Boston, MA, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School , Boston, MA, USA
| | - Mark R Etherton
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School , Boston, MA, USA
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Finch E, Foster M, Fleming J, Cruwys T, Williams I, Shah D, Jaques K, Aitken P, Worrall L. Exploring changing needs following minor stroke. HEALTH & SOCIAL CARE IN THE COMMUNITY 2020; 28:347-356. [PMID: 31568627 DOI: 10.1111/hsc.12866] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/19/2019] [Accepted: 09/06/2019] [Indexed: 06/10/2023]
Abstract
Medical advances have led to many of the severe consequences of stroke being averted. Consequently, more people are being discharged from hospital following treatment for what is classed as minor stroke. The needs of people with minor stroke have received little research attention. The aim of the current study was to conduct an exploratory prospective needs analysis to document the unmet health, rehabilitation and psychosocial needs of a recently hospitalised minor stroke cohort approximately 2 weeks (T1) and 2 months (T2) post-hospital discharge. An exploratory cohort design was used to explore the unmet health, service and social needs of 20 patients with minor stroke. Participants completed questionnaires (Survey of Unmet Needs and Service Use, Mayo-Portland Adaptability Inventory-4, Exeter Identity Transition Scales, RAND 36-Item Health Survey 1.0) at T1 and T2. Nine participants reported unmet needs at T1 and seven participants reported unmet needs at T2. Between T1 and T2, there was a significant improvement in perceived role limitations due to physical health. Participation in society was significantly better at T2. In conclusion, patients with minor stroke report health, service and social needs that are unmet by existing services. This patient cohort urgently requires co-ordinated services to detect and manage these unmet needs.
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Affiliation(s)
- Emma Finch
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Speech Pathology Department, Princess Alexandra Hospital, Metro South Health, Brisbane, Australia
- Centre for Functioning and Health Research, Metro South Health
| | - Michele Foster
- The Hopkins Centre, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Jennifer Fleming
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Tegan Cruwys
- Research School of Psychology, Australian National University, Canberra, Australia
| | | | - Darshan Shah
- Princess Alexandra Hospital, Metro South Health, Brisbane, Australia
- School of Medicine, The University of Queensland, Brisbane, Australia
| | - Katherine Jaques
- Princess Alexandra Hospital, Metro South Health, Brisbane, Australia
| | - Philip Aitken
- Princess Alexandra Hospital, Metro South Health, Brisbane, Australia
| | - Linda Worrall
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
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Shkirkova K, Schuberg S, Balouzian E, Starkman S, Eckstein M, Stratton S, Pratt FD, Hamilton S, Sharma L, Liebeskind DS, Conwit R, Saver JL, Sanossian N. Paramedic Global Impression of Change During Prehospital Evaluation and Transport for Acute Stroke. Stroke 2020; 51:784-791. [PMID: 31955642 DOI: 10.1161/strokeaha.119.026392] [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] [Indexed: 12/26/2022]
Abstract
Background and Purpose- The prehospital setting is a promising site for therapeutic intervention in stroke, but current stroke screening tools do not account for the evolution of neurological symptoms in this early period. We developed and validated the Paramedic Global Impression of Change (PGIC) Scale in a large, prospective, randomized trial. Methods- In the prehospital FAST-MAG (Field Administration of Stroke Therapy-Magnesium) randomized trial conducted from 2005 to 2013, EMS providers were asked to complete the PGIC Scale (5-point Likert scale values: 1-much improved, 2-mildly improved, 3-unchanged, 4-mildly worsened, 5-much worsened) for neurological symptom change during transport for consecutive patients transported by ambulance within 2 hours of onset. We analyzed PGIC concurrent validity (compared with change in Glasgow Coma Scale, Los Angeles Motor Scale), convergent validity (compared with National Institutes of Health Stroke Scale severity measure performed in the emergency department), and predictive validity (of neurological deterioration after hospital arrival and of final 90-day functional outcome). We used PGIC to characterize differential prehospital course among stroke subtypes. Results- Paramedics completed the PGIC in 1691 of 1700 subjects (99.5%), among whom 635 (37.5%) had neurological deficit evolution (32% improvement, 5.5% worsening) during a median prehospital care period of 33 (IQR, 27-39) minutes. Improvement was associated with diagnosis of cerebral ischemia rather than intracranial hemorrhage, milder stroke deficits on emergency department arrival, and more frequent nondisabled and independent 3-month outcomes. Conversely, worsening on the PGIC was associated with intracranial hemorrhage, more severe neurological deficits on emergency department arrival, more frequent treatment with thrombolytic therapy, and poor disability outcome at 3 months. Conclusions- The PGIC scale is a simple, validated measure of prehospital patient course that has the potential to provide information useful to emergency department decision-making. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00059332.
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Affiliation(s)
- Kristina Shkirkova
- From the Keck School of Medicine (K.S., E.B., N.S.), University of Southern California, Los Angeles
| | - Samuel Schuberg
- Department of Emergency Medicine (S. Schuberg, M.E.), University of Southern California, Los Angeles
| | - Emma Balouzian
- From the Keck School of Medicine (K.S., E.B., N.S.), University of Southern California, Los Angeles
| | - Sidney Starkman
- Comprehensive Stroke Center (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles.,Department of Emergency Medicine (S. Starkman, S. Stratton), University of California Los Angeles.,Department of Neurology (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles
| | - Marc Eckstein
- Department of Emergency Medicine (S. Schuberg, M.E.), University of Southern California, Los Angeles
| | - Samuel Stratton
- Department of Emergency Medicine (S. Starkman, S. Stratton), University of California Los Angeles
| | | | - Scott Hamilton
- School of Public Health (S.H.), University of California Los Angeles.,Stanford University, CA (S.H.)
| | - Latisha Sharma
- Comprehensive Stroke Center (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles.,Department of Neurology (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles
| | - David S Liebeskind
- Comprehensive Stroke Center (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles.,Department of Neurology (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles.,Neurovascular Imaging Core (D.S.L.), University of California Los Angeles
| | - Robin Conwit
- National Institute of Neurological Disorders and Stroke (R.C.)
| | - Jeffrey L Saver
- Comprehensive Stroke Center (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles.,Department of Neurology (S. Starkman, L.S., D.S.L., J.L.S.), University of California Los Angeles
| | - Nerses Sanossian
- From the Keck School of Medicine (K.S., E.B., N.S.), University of Southern California, Los Angeles.,Roxanna Todd Hodges Comprehensive Stroke Clinic (N.S.), University of Southern California, Los Angeles
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Chang JC. Stroke Classification: Critical Role of Unusually Large von Willebrand Factor Multimers and Tissue Factor on Clinical Phenotypes Based on Novel "Two-Path Unifying Theory" of Hemostasis. Clin Appl Thromb Hemost 2020; 26:1076029620913634. [PMID: 32584600 PMCID: PMC7427029 DOI: 10.1177/1076029620913634] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 12/17/2022] Open
Abstract
Stroke is a hemostatic disease associated with thrombosis/hemorrhage caused by intracranial vascular injury with spectrum of clinical phenotypes and variable prognostic outcomes. The genesis of different phenotypes of stroke is poorly understood due to our incomplete understanding of hemostasis and thrombosis. These shortcomings have handicapped properly recognizing each specific stroke syndrome and contributed to controversy in selecting therapeutic agents. Treatment recommendation for stroke syndromes has been exclusively derived from the result of laborious and expensive clinical trials. According to newly proposed "two-path unifying theory" of in vivo hemostasis, intracranial vascular injury would yield several unique stroke syndromes triggered by 3 distinctly different thrombogenetic mechanisms depending upon level of intracranial intravascular injury and character of formed blood clots. Five major phenotypes of stroke occur via thrombogenetic paths: (1) transient ischemic attack due to focal endothelial damage limited to endothelial cells (ECs), (2) acute ischemic stroke due to localized ECs and subendothelial tissue (SET) damage extending up to the outer vascular wall, (3) thrombo-hemorrhagic stroke due to localized vascular damage involving ECs and SET and extending beyond SET to extravascular tissue, (4) acute hemorrhagic stroke due to major localized intracranial hemorrhage/hematoma into the brain tissue or space between the coverings of the brain associated with vascular anomaly or obtuse trauma, and (5) encephalopathic stroke due to disseminated endotheliopathy leading to microthrombosis within the brain. New classification of stroke phenotypes would assist in selecting rational therapeutic regimen for each stroke syndrome and designing clinical trials to improve clinical outcome.
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Affiliation(s)
- Jae C. Chang
- Department of Medicine, University of California Irvine School of Medicine, Irvine, CA, USA
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Govindarajan P, Shiboski S, Grimes B, Cook LJ, Ghilarducci D, Meng T, Trickey AW. Effect of Acute Stroke Care Regionalization on Intravenous Alteplase Use in Two Urban Counties. PREHOSP EMERG CARE 2019; 24:505-514. [PMID: 31599705 DOI: 10.1080/10903127.2019.1679303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Importance: Intravenous alteplase is an effective treatment for acute ischemic stroke and is significantly underutilized. It is known that stroke centers with accreditation are more likely to provide intravenous alteplase treatment, and therefore, policies that increase the number of certified stroke centers and the number of acute ischemic stroke patients routed to these centers may be beneficial. Objective: To determine whether increasing access to primary stroke centers (regionalization) led to an increase in intravenous alteplase use in acute ischemic stroke patients. Design: An observational, longitudinal study to examine treatment trends with log-link binomial regression modeling to compare pre-post policy implementation changes in the proportions of patients treated with intravenous alteplase in two counties. Setting: Two urban counties, Santa Clara and San Mateo, in the western region of US that regionalized acute stroke care between 2005 and 2010. Participants: Patients with primary or secondary diagnosis of stroke were identified from the statewide patient discharge database by International Classification of Diseases (ICD-9) codes. We linked ambulance and hospital data to create complete patient care records. Main outcomes and measures: Stroke treatment, defined as a documented primary procedure code for intravenous alteplase administration (ICD-9: 99.10). Results: In Santa Clara County, intravenous alteplase was administered to 35 patients (1.7%) in the pre-regionalization period and 240 patients (2.1%) in the post-regionalization period. In San Mateo County, intravenous alteplase was administered to 29 patients (1.3%) in the pre-policy period and 135 patients (3.2%) in the post-policy period. After regionalization of stroke care, intravenous alteplase increased two-fold in San Mateo County [adjusted RR 2.20, p = 0.003, 95% CI (1.31, 3.69)] but did not show any statistically significant change in Santa Clara County [adjusted RR 1.10, p = 0.55, 95% CI (0.80, 1.51)]. In the post-regionalization phase, when compared with Santa Clara County, we found that San Mateo County had greater change in paramedic stroke detection, higher number of transports to primary stroke centers and more frequent use of intravenous alteplase at stroke centers. Conclusions: Our findings suggest that greater post-regionalization improvements in San Mateo County contributed to significantly better county-level thrombolysis use than Santa Clara County.
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Yarnoff B, Khavjou O, Elmi J, Lowe-Beasley K, Bradley C, Amoozegar J, Wachtmeister D, Tzeng J, Chapel JM, Teixeira-Poit S. Estimating Costs of Implementing Stroke Systems of Care and Data-Driven Improvements in the Paul Coverdell National Acute Stroke Program. Prev Chronic Dis 2019; 16:E134. [PMID: 31580797 PMCID: PMC6795072 DOI: 10.5888/pcd16.190061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Purpose and Objectives We evaluated the costs of implementing coordinated systems of stroke care by state health departments from 2012 through 2015 to help policy makers and planners gain a sense of the potential return on investments in establishing a stroke care quality improvement (QI) program. Intervention Approach State health departments funded by the Paul Coverdell National Acute Stroke Program (PCNASP) implemented activities to support the start and proficient use of hospital stroke registries statewide and coordinate data-driven QI efforts. These efforts were aimed at improving the treatment and transition of stroke patients from prehospital emergency medical services (EMS) to in-hospital care and postacute care facilities. Health departments provided technical assistance and data to support hospitals, EMS agencies, and posthospital care agencies to carry out small, rapid, incremental QI efforts to produce more effective and efficient stroke care practices. Evaluation Methods Six of the 11 PCNASP-funded state health departments in the United States volunteered to collect and report programmatic costs associated with implementing the components of stroke systems of care. Six health departments reported costs paid directly by Centers for Disease Control and Prevention–provided funds, 5 also reported their own in-kind contributions, and 4 compiled data from a sample of their partners’ estimated costs of resources, such as staff time, involved in program implementation. Costs were analyzed separately for PCNASP-funded expenditures and in-kind contributions by the health department by resource category and program activity. In-kind contributions by partners were also analyzed separately. Results PCNASP-funded expenditures ranged from $790,123 to $1,298,160 across the 6 health departments for the 3-year funding period. In-kind contributions ranged from $5,805 to $1,394,097. Partner contributions (n = 22) ranged from $3,912 to $362,868. Implications for Public Health Our evaluation reports costs for multiple state health departments and their partners for implementing components of stroke systems of care in the United States. Although there are limitations, our findings represent key estimates that can guide future program planning and efforts to achieve sustainability.
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Affiliation(s)
- Benjamin Yarnoff
- RTI International, Public Health Economics Program, 3040 E. Cornwallis Rd, Research Triangle Park, NC 27709.
| | - Olga Khavjou
- RTI International, Public Health Economics Program, Research Triangle Park, North Carolina
| | - Joanna Elmi
- Centers for Disease Control and Prevention, Division of Heart Disease and Stroke Prevention, Atlanta, Georgia
| | - Kincaid Lowe-Beasley
- Centers for Disease Control and Prevention, Division of Heart Disease and Stroke Prevention, Atlanta, Georgia
| | - Christina Bradley
- RTI International, Public Health Economics Program, Research Triangle Park, North Carolina
| | - Jacqueline Amoozegar
- RTI International, Public Health Economics Program, Research Triangle Park, North Carolina
| | - Devon Wachtmeister
- RTI International, Public Health Economics Program, Research Triangle Park, North Carolina
| | - Janice Tzeng
- RTI International, Public Health Economics Program, Research Triangle Park, North Carolina
| | - John McCoy Chapel
- Centers for Disease Control and Prevention, Division of Heart Disease and Stroke Prevention, Atlanta, Georgia
| | - Stephanie Teixeira-Poit
- North Carolina Agricultural and Technical State University, College of Health and Human Sciences, Greensboro, North Carolina
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Lehnerer S, Hotter B, Padberg I, Knispel P, Remstedt D, Liebenau A, Grittner U, Wellwood I, Meisel A. Social work support and unmet social needs in life after stroke: a cross-sectional exploratory study. BMC Neurol 2019; 19:220. [PMID: 31492151 PMCID: PMC6729017 DOI: 10.1186/s12883-019-1451-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 08/27/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Stroke patients are often affected by long-term disabilities with needs concerning social issues. There is relatively little consideration of social recovery of patients and the support required to return to work, receive social benefits, participate in daily life activities, maintain contact with family and friends and to organize financial affairs. In our study we aimed to investigate if existing tools record social needs adequately. We analyzed the current provision of social support provided in long-term care after stroke and whether unmet social needs were associated with quality of life, caregiver burden, overall function and degree of disability. METHODS Our analysis is part of the Managing Aftercare of Stroke study (MAS-I), a cross-sectional exploratory study of patient needs 2-3 years after initial stroke. Assessment tools included the Nikolaus-score (social situation), the EuroQoL (quality of life), the German Burden Scale for Family Caregivers (caregiver burden), the modified Rankin Scale (disability / dependence), Stroke Impact Scale (function and degree of disability) and the Stroke Survivor Needs Questionnaire (unmet needs). RESULTS Overall 57 patients were included in MAS-I, with ten patients classified in urgent need of socio-economic support according to the Nikolaus-score. Patients with lower than normal Nikolaus-score had a higher degree of disability. Thirty percent of all patients had never received professional social support. Social worker contact happened mostly during the stay in acute hospital or rehabilitation institution. Only four patients (11%) reported long-term support after discharge. Apart from social worker contact during acute care, 43% of patients had unmet needs in the long-term aftercare. Forty percent of all patients included in MAS-I were recommended for social work intervention after an in-depth analysis of their situation. Finally, we saw that unmet social needs were associated with lower quality of life and higher caregiver burden. CONCLUSIONS Our data suggest significant unmet needs in social care in long-term stroke patients. Screening tools for unmet social needs such as the Nikolaus-score do not holistically report patients' needs. TRIAL REGISTRATION Clinicaltrials.Gov NCT02320994 . Registered 19 December 2014 (retrospectively registered).
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Affiliation(s)
- Sophie Lehnerer
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Benjamin Hotter
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Inken Padberg
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Clinical Epidemiology and Health Services in Stroke, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Petra Knispel
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Stroke Alliance (BSA), Charitéplatz 1, 10117 Berlin, Germany
| | - Dike Remstedt
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Andrea Liebenau
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch 2, 10178 Berlin, Germany
| | - Ian Wellwood
- Department of Public Health and Primary Care, Cambridge Institute of Public Health, University of Cambridge, Cambridge, CB2 0SR UK
| | - Andreas Meisel
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Stroke Alliance (BSA), Charitéplatz 1, 10117 Berlin, Germany
| | - on behalf of the BSA Long Term Care Study Group
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Clinical Epidemiology and Health Services in Stroke, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Stroke Alliance (BSA), Charitéplatz 1, 10117 Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch 2, 10178 Berlin, Germany
- Department of Public Health and Primary Care, Cambridge Institute of Public Health, University of Cambridge, Cambridge, CB2 0SR UK
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Abstract
The landscape of stroke systems of care is evolving as patients are increasingly transferred between hospitals for access to higher levels of care. This is driven by time-sensitive disability-reducing interventions such as mechanical thrombectomy. However, coordination and triage of patients for such treatment remain a challenge worldwide, particularly given complex eligibility criteria and varying time windows for treatment. Network analysis is an approach that may be applied to this problem. Hospital networks interlinked by patients moved from facility to facility can be studied using network modeling that respects the interdependent nature of the system. This allows understanding of the central hubs, the change of network structure over time, and the diffusion of innovations. This topical review introduces the basic principles of network science and provides an overview on the applications and potential interventions in stroke systems of care.
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Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine (K.S.Z.), Massachusetts General Hospital, Boston
| | - Amar Dhand
- Department of Neurology, Brigham and Women's Hospital, Boston, MA (A.D.)
| | - Lee H Schwamm
- Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston
| | - Jukka-Pekka Onnela
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (J.-P.O.)
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Adeoye O, Nyström KV, Yavagal DR, Luciano J, Nogueira RG, Zorowitz RD, Khalessi AA, Bushnell C, Barsan WG, Panagos P, Alberts MJ, Tiner AC, Schwamm LH, Jauch EC. Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update. Stroke 2019; 50:e187-e210. [PMID: 31104615 DOI: 10.1161/str.0000000000000173] [Citation(s) in RCA: 225] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In 2005, the American Stroke Association published recommendations for the establishment of stroke systems of care and in 2013 expanded on them with a statement on interactions within stroke systems of care. The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating stroke systems of care to date and to update the American Stroke Association recommendations on the basis of improvements in stroke systems of care. Over the past decade, stroke systems of care have seen vast improvements in endovascular therapy, neurocritical care, and stroke center certification, in addition to the advent of innovations, such as telestroke and mobile stroke units, in the context of significant changes in the organization of healthcare policy in the United States. This statement provides an update to prior publications to help guide policymakers and public healthcare agencies in continually updating their stroke systems of care in light of these changes. This statement and its recommendations span primordial and primary prevention, acute stroke recognition and activation of emergency medical services, triage to appropriate facilities, designation of and treatment at stroke centers, secondary prevention at hospital discharge, and rehabilitation and recovery.
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Grimley RS, Rosbergen ICM, Gustaffson L, Horton E, Green T, Cadigan G, Cadilhac DA, Kuys S. Assessment and selection for rehabilitation following acute stroke: a prospective cohort study in Queensland, Australia. Clin Rehabil 2019; 33:1252-1263. [DOI: 10.1177/0269215519837585] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Rohan S Grimley
- Sunshine Coast Clinical School, The University of Queensland, Birtinya, QLD, Australia
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
- Queensland State-Wide Stroke Clinical Network, Clinical Excellence Division, Queensland Department of Health, Brisbane, QLD, Australia
| | - Ingrid CM Rosbergen
- Allied Health Services, Sunshine Coast Hospital and Health Service, Birtinya, QLD, Australia
| | - Louise Gustaffson
- School of Allied Health Sciences, Griffith University, Brisbane, QLD, Australia
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Eleanor Horton
- School of Nursing, Midwifery & Paramedicine, University of the Sunshine Coast, Maroochydore, QLD, Australia
| | - Theresa Green
- Faculty of Health, School of Nursing, Queensland University of Technology, Brisbane, QLD, Australia
- Centre for Clinical Nursing, Royal Brisbane and Women’s Hospital, Herston, QLD, Australia
| | - Greg Cadigan
- Queensland State-Wide Stroke Clinical Network, Clinical Excellence Division, Queensland Department of Health, Brisbane, QLD, Australia
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne Heidelberg, VIC, Australia
| | - Suzanne Kuys
- Faculty of Health Sciences, Australian Catholic University, Brisbane, QLD, Australia
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Martins SCO, Brondani R, Friedrich M, Araújo MD, Wartchow A, Passos P, Manenti E, Jaeger C, Rech R, Silveira D, Ruschel K, Nasi LA, Chaves MLF, Ehlers JA. Quatro anos de experiência no tratamento trombolítico do AVC Isquêmico na cidade de Porto Alegre. ACTA ACUST UNITED AC 2019. [DOI: 10.34024/rnc.2006.v14.8784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Embora o benefício do tratamento trombolítico no AVC isquêmico esteja bem demonstrado, o impacto na população geral de pacientes com AVC ainda é limitado, principalmente devido a estreita janela terapêutica. No Brasil, poucos centros estão estruturados para o uso do rtPA no AVC isquêmico agudo. Nós apresentamos os resultados de 4 anos de experiência em terapia trombolítica, com 173 pacientes tratados em 3 Unidades Vasculares implementadas em hospitais gerais no Sul do Brasil.
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Wira CR, Madsen TE, Chang BP, Nomura JT, Marcolini E, Gentile NT, Schreyer KE, Merck LH, Siket M, Greenberg K, Zammit CG, Jauch EC, Fernanda Bellolio M. Is There a Neurologist in the House? A Summary of the Current State of Neurovascular Rotations for Emergency Medicine Residents. AEM EDUCATION AND TRAINING 2018; 2:S56-S67. [PMID: 30607380 PMCID: PMC6304277 DOI: 10.1002/aet2.10200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/20/2018] [Accepted: 09/25/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Neurovascular and neurocritical care emergencies constitute a leading cause of morbidity/mortality. There has been great evolution in this field, including but not limited to extended time-window therapeutic interventions for acute ischemic stroke. The intent of this article is to evaluate the goals and future direction of clinical rotations in neurovascular and neurocritical care for emergency medicine (EM) residents. METHODS A panel of 13 board-certified emergency physicians from the Society for Academic Emergency Medicine (SAEM) neurologic emergencies interest group (IG) convened in response to a call for publications-three with fellowship training/board certification in stroke and/or neurocritical care; five with advanced research degrees; three who have been authors on national practice guidelines; and six who have held clinical duties within neurology, neurosurgery, or neurocritical care. A mixed-methods analysis was performed including a review of the literature, a survey of Council of Emergency Medicine Residency Directors (CORD) residency leaders/faculty and SAEM neuro-IG members, and a consensus review by this panel of select neurology rotations provided by IG faculty. RESULTS Thirteen articles for residency neurovascular education were identified: three studies on curriculum, three studies evaluating knowledge, and seven studies evaluating knowledge after an educational intervention. Intervention outcomes included the ability to recognize and manage acute strokes, manage intracerebral hemorrhage, calculate National Institutes of Health Stroke Scale (NIHSS), and interpret images. In the survey sent to CORD residency leaders and neuro-IG faculty, response was obtained from 48 programs. A total of 52.1% indicated having a required rotation (6.2% general neurology, 2% stroke service, 18.8% neurologic intensive care unit, 2% neurosurgery, 22.9% on a combination of services). The majority of programs with required rotations have a combination rotation (residents rotate through multiple services) and evaluations were positive. CONCLUSIONS Variability exists in the availability of neurovascular/neurocritical care rotations for EM trainees. Dedicated clinical time in neurologic education was beneficial to participants. Given recent advancements in the field, augmentation of EM residency training in this area merits strong consideration.
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Affiliation(s)
- Charles R. Wira
- Yale Department of Emergency MedicineYale Division of Cerebrovascular DiseasesDepartment of NeurologyYale School of MedicineNew HavenCT
| | - Tracy E. Madsen
- Department of Emergency MedicineThe Warren Alpert Medical School of Brown UniversityProvidenceRI
| | - Bernard P. Chang
- Department of Emergency MedicineColumbia University Medical CenterNew YorkNY
| | - Jason T. Nomura
- Christiana Care Health SystemNeurosciences Service LineNewarkDE
| | - Evie Marcolini
- Departments of Surgery and NeurologyUniversity of Vermont College of MedicineBurlingtonVT
| | - Nina T. Gentile
- Department of Emergency MedicineTemple University HospitalPhiladelphiaPA
| | | | - Lisa H. Merck
- Division of Emergency Neurosciences and Critical Care ResearchDepartment of Emergency Medicine and Diagnostic ImagingThe Warren Alpert Medical School of Brown UniversityProvidenceRI
| | - Matthew Siket
- Department of Emergency MedicineThe Warren Alpert Medical School of Brown UniversityProvidenceRI
| | - Karen Greenberg
- Global Neurosciences InstituteCrozer Neurologic Emergency DepartmentCrozer Chester Medical CenterUplandPA
| | - Christopher G. Zammit
- Departments of Emergency MedicineNeurology& NeurosurgeryUniversity of Rochester Medical CenterRochesterNY
| | - Edward C. Jauch
- Mission Research Institute/Mission HealthAshevilleNC
- Department of Emergency MedicineMedical University of South CarolinaCharlestonSC
- Departments of Emergency Medicine and NeurologyUniversity of North Carolina– Chapel HillChapel HillNC
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Ischemic Stroke Transfer Patterns in the Northeast United States. J Stroke Cerebrovasc Dis 2018; 28:295-304. [PMID: 30389376 DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.048] [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] [Received: 07/02/2018] [Revised: 08/29/2018] [Accepted: 09/28/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Little is known about how hospitals are connected in the transfer of ischemic stroke (IS) patients. We aimed to describe differences in characteristics of transferred versus nontransferred patients and between transferring and receiving hospitals in the Northeastern United States, and to describe changes over time. METHODS We used Medicare claims data, and a subset linked with the Get with the Guidelines-Stroke registry from 2007 to 2011. Receiving hospitals were those with annual IS volume greater than or equal to 120 and greater than or equal to 15% received as transfers, and transferring hospitals were nonaccepting hospitals that transferred greater than or equal to 15% of their total (ED plus inpatient) IS patient discharges. A transferring-to-receiving hospital connection was identified if greater than or equal to 5 patients per year were shared. ArcGIS 10.3.1 was used for network visualization. RESULTS Among 177,270 admissions to 402 Northeast hospitals, 6906 (3.9%) patients were transferred. Transferred patients were younger with more severe strokes (78 versus 81 years, P < .001; National Institutes of Health Stroke Severity 7 versus 5, P < .001), and were as likely to receive tissue plasminogen activator as nontransferred (P = .29). From 2007 to 2011, there were more patients transferred (960 [3%] to 1777 [6%], P < .001), and more transferring hospitals (46 [12%] to 91 [24%], P < .001), and receiving hospitals (6 [2%] to 16 [4%], P < .001). Most transferring hospitals were exclusively connected to a single receiving hospital. CONCLUSIONS From 2007 to 2011, hospitals in the United States Northeast became more connected in the care of IS patients, with increasing patient transfers and hospital connections. Yet most hospitals remained unconnected. Further characterization of this transfer network will be important for understanding and improving regional stroke systems of care.
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Catanese L, Gupta R, Griessenauer CJ, Moore JM, Adeeb N, Enriquez-Marulanda A, Alturki AY, Ascanio LC, Lioutas V, Shoamanesh A, Cohen W, Kumar S, Selim M, Thomas AJ, Ogilvy CS. Patterns of Stroke Transfers and Identification of Predictors for Thrombectomy. World Neurosurg 2018; 121:e675-e683. [PMID: 30296622 DOI: 10.1016/j.wneu.2018.09.189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Interhospital transfers for endovascular thrombectomy (EVT) evaluation have increased since the publication of landmark neuroendovascular stroke trials in 2015. The lack of guidelines to select potential EVT candidates prior to transfer can lead to instances where, despite considerable costs and transport risks, transferred patients do not ultimately undergo EVT. Our aim was to characterize the patterns and identify predictors for EVT on transfer. METHODS In this observational cohort study, we retrospectively analyzed patients with acute ischemic stroke (AIS) transferred to our institution for EVT evaluation from January 2015 to March 2016. Clinical and radiographic predictors for EVT on transfer were determined with multivariable logistic regression analysis. RESULTS A total of 103 transfer patients with AIS were included in the study, and 52% were women. A higher collateral score (P < 0.01), a higher National Institutes of Health Stroke Scale (NIHSS) score (P < 0.01), computed tomography angiography (CTA) at referring hospital (P < 0.01), and large vessel occlusion on arrival CTA (P < 0.01) were significant in patients who underwent EVT on univariable analysis. More than half (61.1%) of transfers were futile and primarily related to absence of large vessel occlusion on arrival. A higher collateral score (P = 0.02), a higher NIHSS score (P = 0.006), and having undergone a CTA at the referring center (P = 0.002) remained the independent predictors of EVT. The C statistic for the model was 0.94. CONCLUSIONS A higher collateral score, the acquisition of CTA imaging at the referring centers, and a higher NIHSS score independently predicted EVT on transfer.
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Affiliation(s)
- Luciana Catanese
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA; Population Health Research Institute, McMaster University Medical School, Hamilton, Ontario, Canada
| | - Raghav Gupta
- Department of Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Justin M Moore
- Department of Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nimer Adeeb
- Department of Neurosurgery, Louisiana State University - Shreveport, Shreveport, Louisiana, USA
| | - Alejandro Enriquez-Marulanda
- Department of Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Abdulrahman Y Alturki
- Department of Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Luis C Ascanio
- Department of Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Vasileios Lioutas
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ashkan Shoamanesh
- Population Health Research Institute, McMaster University Medical School, Hamilton, Ontario, Canada
| | - Wendy Cohen
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sandeep Kumar
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Magdy Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Department of Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Department of Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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Mahak C, Shashi, Yashomati, Hemlata, Manisha N, Sandhya G, Dheeraj K, Dhandapani M, Dhandapani SS. Assessment of Utilization of Rehabilitation Services among Stroke Survivors. J Neurosci Rural Pract 2018; 9:461-467. [PMID: 30271034 PMCID: PMC6126306 DOI: 10.4103/jnrp.jnrp_25_18] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Rehabilitation is probably one of the most important phases of recovery for many stroke survivors. The current study was conducted with the objective to assess the utilization of rehabilitation services and factors affecting nonutilization of rehabilitation services among the stroke survivors. MATERIALS AND METHODS The current study was carried out in the Neuro Outpatient Department of a tertiary care hospital in India. It was a descriptive study. Consecutive 55 stroke survivors who had met the inclusion and exclusion criteria were recruited in this study. Self-structured rehabilitation tool was used to collect the data. RESULTS Data were analyzed using the descriptive and inferential statistics. Majority of the patients comprised 70.9% of males and 29.1% of females. Among participants, 70.90% were aware about rehabilitation, 67% were utilizing rehabilitation services, whereas 33% were not utilizing rehabilitation services. In the current study, certain reasons were found behind not utilizing rehabilitation services. There were 83.3% of participants who had lack of awareness about rehabilitation services and 61.1% of participants who had no availability of rehabilitation services. Only 45.5% of rural inhabitants were utilizing rehabilitation services as compared to 81.2% of urban inhabitants and 83.23% of suburban inhabitants. CONCLUSION Rehabilitation is of utmost importance. Hemiparesis, difficulty in performing activity of daily living, difficulty in performing social activities, and difficulty in reasoning were the most common problems faced by people suffering stroke after discharge from the hospital. There was lack of awareness and utilization of rehabilitation services by patients among Indian stroke population. Hence, health workers have an immense role in educating, motivating, and ensuring that rehabilitation services in rural inhabitants.
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Affiliation(s)
- Chandel Mahak
- National Institute of Nursing Education, PGIMER, Chandigarh, India
| | - Shashi
- National Institute of Nursing Education, PGIMER, Chandigarh, India
| | - Yashomati
- National Institute of Nursing Education, PGIMER, Chandigarh, India
| | - Hemlata
- National Institute of Nursing Education, PGIMER, Chandigarh, India
| | - Nagi Manisha
- National Institute of Nursing Education, PGIMER, Chandigarh, India
| | - Ghai Sandhya
- National Institute of Nursing Education, PGIMER, Chandigarh, India
| | | | - Manju Dhandapani
- National Institute of Nursing Education, PGIMER, Chandigarh, India
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Nawrocki PS, Levy M, Tang N, Trautman S, Margolis A. Interfacility Transport of the Pregnant Patient: A 5-year Retrospective Review of a Single Critical Care Transport Program. PREHOSP EMERG CARE 2018; 23:377-384. [PMID: 30188241 DOI: 10.1080/10903127.2018.1519005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Interfacility transport of the pregnant patient poses a challenge for prehospital providers as it is an infrequent but potentially high acuity encounter. Knowledge of clinically significant events (CSEs) that occur during these transports is important both to optimize patient safety and also to help enhance crew training and preparedness. This study evaluated a critical care transport program's 5-year longitudinal experience transporting pregnant patients by ground and air, and described CSEs that occurred during the out-of-hospital phase of care. METHODS This study was a retrospective review of pregnant patients transported by a single critical care transport system into and within a large academic healthcare system. Patients who were pregnant, and were transported from a referring facility to one of the 2 receiving centers within Johns Hopkins Health System between January 1, 2012 and December 31, 2016 were included in this study. The primary outcome of interest was the occurrence of a predefined clinically significant event (CSE) during transport, while a secondary outcome of interest was the indication for transfer. RESULTS During the study period 1,223 pregnant patients were transported by our critical care transport service. There were 1,101 patients who met inclusion criteria; 693 (62.9%) of whom were transported by ground and 408 (37.1%) who were transported by rotor wing aircraft. The top 3 indications for transfer comprised 71.4% of all patients and included; preterm labor, hypertensive disorder of pregnancy, and other maternal life threatening disorder. The most common events that occurred across all transports were: exacerbation of hypertensive disease requiring intervention (4.5%), hypotension (1.3%), and altered mental status (0.2%). CONCLUSIONS Incidence of CSEs during the interfacility transport of pregnant patients within our critical care transport system is low (6.0%). Knowledge of the clinically significant events that occur during EMS transport is a vital component of ensuring system quality and optimizing patient safety. This data can be used to augment and focus provider education and training to mitigate and optimize response to future events.
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Khatib R, Arevalo YA, Berendsen MA, Prabhakaran S, Huffman MD. Presentation, Evaluation, Management, and Outcomes of Acute Stroke in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis. Neuroepidemiology 2018; 51:104-112. [PMID: 30025394 DOI: 10.1159/000491442] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 06/23/2018] [Indexed: 12/22/2022] Open
Abstract
AIMS We performed a systematic review to evaluate stroke presentation, evaluation, management, and outcomes among studies conducted in low- and middle-income countries (LMIC). METHODS We searched MEDLINE (Ovid), Embase (Elsevier), and the Global Health (EBSCOhost) databases between January 2005 and June 2017 for studies conducted in LMICs defined by the World Bank. We pooled prevalence estimates using an inverse-variance weighting method and stratified by the country income group. RESULTS The search identified 36 hospital-based studies (64,256 participants) in LMICs. Mean (SD) age ranged from 51 (14) to 72 (12) years, and 29-56% of patients were women. Hypertension was the most commonly reported risk factor (64% [95% CI 59-69]). In settings where MRI was not used, head CT scans were reported among 90% patients (95% CI 79-97). Overall, 3% (95% CI 2-4) of patients were treated with tissue plasminogen activator, and 78% (95% CI 66-88) were treated with antiplatelet therapy. Overall, the rate of in-hospital mortality was 14% (95% CI 10-19), and the rate of in-hospital pneumonia was 17% (95% CI 14-20). CONCLUSIONS Our review revealed the low use of evidence-based practices for acute stroke care in LMIC. The true use in hospitals that do not conduct this research is probably even lower. Strategies to evaluate and improve health system performance for acute stroke care, including implantation of stroke units and making thrombolysis more available and affordable are needed in LMIC. Registration in Prospero: CRD42017069325.
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Affiliation(s)
- Rasha Khatib
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Yurany A Arevalo
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mark A Berendsen
- Galter Health Sciences Library, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Shyam Prabhakaran
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mark D Huffman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Hotter B, Padberg I, Liebenau A, Knispel P, Heel S, Steube D, Wissel J, Wellwood I, Meisel A. Identifying unmet needs in long-term stroke care using in-depth assessment and the Post-Stroke Checklist - The Managing Aftercare for Stroke (MAS-I) study. Eur Stroke J 2018; 3:237-245. [PMID: 31008354 DOI: 10.1177/2396987318771174] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 03/23/2018] [Indexed: 11/16/2022] Open
Abstract
Introduction Detailed data on the long-term consequences and treatment of stroke are scarce. We aimed to assess the needs and disease burden of community-dwelling stroke patients and their carers and to compare their treatment to evidence-based guidelines by a stroke neurologist. Methods We invited long-term stroke patients from two previous acute clinical studies (n = 516) in Berlin, Germany to participate in an observational, cross-sectional study. Participants underwent a comprehensive interview and examination using the Post-Stroke Checklist and validated standard measures of: self-reported needs, quality of life, overall outcome, spasticity, pain, aphasia, cognition, depression, secondary prevention, social needs and caregiver burden. Results Fifty-seven participants (median initial National Institutes of Health Stroke Scale score 10 interquartile range 4-12.75) consented to assessment (median 41 months (interquartile range 36-50) after stroke. Modified Rankin Scale was 2 (median; interquartile range 1-3), EuroQoL index value was 0.81 (median; interquartile range 0.70-1.00). The frequencies for disabilities in the major domains were: spasticity 35%; cognition 61%; depression 20%; medication non-compliance 14%. Spasticity (p = 0.008) and social needs (p < 0.001) had the strongest impact on quality of life. The corresponding items in the Post-Stroke Checklist were predictive for low mood (p < 0.001), impaired cognition (p = 0.015), social needs (p = 0.005) and caregiver burden (p = 0.031). In the comprehensive interview, we identified the following needs: medical review (30%), optimization of pharmacotherapy (18%), outpatient therapy (47%) and social work input (33%). Conclusion These results suggest significant unmet needs and gaps in health and social care in long-term stroke patients. Further research to develop a comprehensive model for managing stroke aftercare is warranted.Clinical Trial Registration: clinicaltrials.gov NCT02320994.
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Affiliation(s)
- Benjamin Hotter
- Center for Stroke Research Berlin and Department of Neurology, Charité University Hospital Berlin, Berlin, Germany
| | - Inken Padberg
- Center for Stroke Research Berlin and Department of Neurology, Charité University Hospital Berlin, Berlin, Germany
| | - Andrea Liebenau
- Center for Stroke Research Berlin and Department of Neurology, Charité University Hospital Berlin, Berlin, Germany
| | - Petra Knispel
- Center for Stroke Research Berlin and Department of Neurology, Charité University Hospital Berlin, Berlin, Germany
| | - Sabine Heel
- Zentrum für ambulante Neuropsychologie und Verhaltenstherapie, Berlin, Germany
| | | | - Jörg Wissel
- Department Neurorehabilitation and Physical Therapy, Department of Neurology, Vivantes Hospital Spandau, Berlin, Germany
| | - Ian Wellwood
- Department of Public Health and Primary Care, Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Andreas Meisel
- Center for Stroke Research Berlin and Department of Neurology, Charité University Hospital Berlin, Berlin, Germany
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48
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Eisenstein AR, Song S, Mason M, Kandula NR, Richards C, Aggarwal NT, Prabhakaran SK. A Community-Partnered Approach to Inform a Culturally Relevant Health Promotion Intervention for Stroke. HEALTH EDUCATION & BEHAVIOR 2018; 45:697-705. [DOI: 10.1177/1090198117752787] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. The purpose of this study was to generate information from multiethnic, high-risk communities to inform the creation of culturally relevant health promotion intervention for increasing early hospital arrival after stroke. Methods. The study employed a qualitative design, using focus groups with African American, Caucasian, and Hispanic adults in two Chicago community areas. The study relied heavily on stakeholder input in creating the focus group guide, recruiting participants, and interpreting the analysis. Results. Six focus groups gained information from 51 participants, including insights and perspective on participants’ stroke experience and knowledge as well as on facilitators and barriers to calling 9-1-1. Qualitative analysis uncovered themes relating to risk factors, symptoms, knowledge of stroke mechanisms, experience of acute stroke, help seeking, stroke education, recovery, treatment, and emotions. Communities were closely aligned in their knowledge of stroke, but had differing ideas around stroke education and dissemination of education. Discussion. This study identified nuances in real-world barriers to receiving acute stroke services in minority and disadvantaged communities in Chicago neighborhoods. Our findings indicated significant amount of variation by race/ethnicity and, in particular, a lack of similarities based on race/ethnic groups in different communities. These findings underscore the importance of working with communities to fully understand the community-level dynamics that occur.
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Affiliation(s)
- Amy R. Eisenstein
- CJE SeniorLife, Chicago, IL, USA
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sarah Song
- Rush University Medical Center, Chicago, IL, USA
| | - Maryann Mason
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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49
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Abstract
Purpose
Stroke is a leading cause of death and disability in the USA and worldwide. While stroke care has evolved dramatically, many new acute approaches to therapy focus only on the first 3-12 hours. Significant treatment opportunities beyond the first 12 hours can play a major role in improving outcomes for stroke patients. The purpose of this paper is to highlight the issues that affect stroke care delivery for patients and caregivers and describe an integrated care model that can improve care across the continuum.
Design/methodology/approach
This paper details evidence-based research that documents current stroke care and efforts to improve care delivery. Further, an innovative integrated care model is described, and its novel application to stroke care is highlighted.
Findings
Stroke patients and caregivers face fragmented and poorly coordinated care systems as they move through specific stroke nodes of care, from acute emergency and in-hospital stay through recovery post-discharge at a care facility or at home, and can be addressed by applying a comprehensive, technology-enabled Integrated Stroke Practice Unit (ISPU) Model of Care.
Originality/value
This paper documents specific issues that impact stroke care and the utilization of integrated care delivery models to address them. Evidence-based research results document difficulties of current care delivery methods for stroke and the impact of that care delivery on patients and caregivers across each node of care. It offers an innovative ISPU model and highlights specific tenets of that model for readers.
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50
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Herridge MS. Fifty Years of Research in ARDS. Long-Term Follow-up after Acute Respiratory Distress Syndrome. Insights for Managing Medical Complexity after Critical Illness. Am J Respir Crit Care Med 2017; 196:1380-1384. [PMID: 28767270 DOI: 10.1164/rccm.201704-0815ed] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Critical illness is not a discrete disease state or syndrome. It is the culmination of a multiplicity of heterogeneous disease states and their varied health trajectories leading to extreme illness that requires advanced life support in a distinct geographic location in the hospital. It is a marker of newly acquired or worsened medical complexity and multimorbidities. Fifty years ago, distinguished critical care colleagues identified a syndrome of severe lung injury that united a group of patients with disparate admitting diagnoses. Acute respiratory distress syndrome continues to represent an important, incremental insult and risk modifier of acute and longer-term outcome, but it does not solely define our patients or their outcomes in isolation. Over the next 50 years, our research and clinical agenda needs to sharpen our lens on the fundamental importance of our patients' pre-critical illness health status, their intrinsic susceptibilities to tissue injury, and their innate and varied resiliencies. We need to take responsibility for the contribution that we make to morbidity through our practice in the intensive care unit each day. Engagement in frank and transparent communication with our patients and their caregivers about the very real and morbid consequences of being this sick is essential. We must enforce explicit consent about the morbidity of innovative, experimental, or high-risk medical and surgical procedures and ensure that our ongoing level of treatment aligns with patients' and caregivers' goals and values. Interprofessional and multidisciplinary collaboration is crucial to modify existing complex care pathways for our patients and their families to foster optimal rehabilitation and reintegration into the workplace and community.
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Affiliation(s)
- Margaret S Herridge
- 1 Critical Care and Respiratory Medicine.,2 Toronto General Research Institute.,3 Institute of Medical Sciences, and.,4 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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