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Stamm B, Royan R, Prabhakaran S. Challenges to Door-In-Door-Out Time Thresholds for Patients With Stroke-Reply. JAMA 2023; 330:2306. [PMID: 38112816 DOI: 10.1001/jama.2023.21491] [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: 12/21/2023]
Affiliation(s)
- Brian Stamm
- Department of Neurology, University of Michigan, Ann Arbor
| | - Regina Royan
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Assistant Editor, JAMA Network Open
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2
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Hsu NC, Yang HL, Hsu CH. Challenges to Door-In-Door-Out Time Thresholds for Patients With Stroke. JAMA 2023; 330:2305-2306. [PMID: 38112819 DOI: 10.1001/jama.2023.21488] [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: 12/21/2023]
Affiliation(s)
- Nin-Chieh Hsu
- National Taiwan University Hospital, Taipei City Hospital Zhongxing Branch, Taipei, Taiwan
| | - Hsin-Lu Yang
- Taipei City Hospital Zhongxing Branch, Taipei, Taiwan
| | - Chia-Hao Hsu
- Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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3
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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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Fulmer EB, Keener Mast D, Godoy Garraza L, Gilchrist S, Rasool A, Xu Y, Brown A, Omeaku N, Ye Z, Donald B, Shantharam S, Coleman King S, Popoola A, Cincotta K. Impact of State Stroke Systems of Care Laws on Stroke Outcomes. Healthcare (Basel) 2023; 11:2842. [PMID: 37957987 PMCID: PMC10648022 DOI: 10.3390/healthcare11212842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/24/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
Since 2003, 38 US states and Washington, DC have adopted legislation and/or regulations to strengthen stroke systems of care (SSOCs). This study estimated the impact of SSOC laws on stroke outcomes. We used a coded legal dataset of 50 states and DC SSOC laws (years 2003-2018), national stroke accreditation information (years 1997-2018), data from the Healthcare Cost and Utilization Project (years 2012-2018), and National Vital Statistics System (years 1979-2019). We applied a natural experimental design paired with longitudinal modeling to estimate the impact of having one or more SSOC policies in effect on outcomes. On average, states with one or more SSOC policies in effect achieved better access to primary stroke centers (PSCs) than expected without SSOC policies (ranging from 2.7 to 8.0 percentage points (PP) higher), lower inpatient hospital costs (USD 610-1724 less per hospital stay), lower age-adjusted stroke mortality (1.0-1.6 fewer annual deaths per 100,000), a higher proportion of stroke patients with brain imaging results within 45 min of emergency department arrival (3.6-5.0 PP higher), and, in some states, lower in-hospital stroke mortality (5 fewer deaths per 1000). Findings were mixed for some outcomes and there was limited evidence of model fit for others. No effect was observed in racial and/or rural disparities in stroke mortality.
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Affiliation(s)
- Erika B. Fulmer
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop MS-S107-1, Atlanta, GA 30341, USA; (A.R.); (Z.Y.); (S.S.); (S.C.K.); (A.P.)
| | - Dana Keener Mast
- ICF, 1902 Reston Metro Plaza, Reston, VA 20190, USA; (D.K.M.); (L.G.G.); (Y.X.); (K.C.)
| | - Lucas Godoy Garraza
- ICF, 1902 Reston Metro Plaza, Reston, VA 20190, USA; (D.K.M.); (L.G.G.); (Y.X.); (K.C.)
| | - Siobhan Gilchrist
- ASRT, Inc., 4158 Onslow Place SE, Smyrna, GA 30080, USA; (S.G.); (A.B.); (N.O.); (B.D.)
| | - Aysha Rasool
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop MS-S107-1, Atlanta, GA 30341, USA; (A.R.); (Z.Y.); (S.S.); (S.C.K.); (A.P.)
- Oak Ridge Institute for Science and Education, P.O. Box 117, Oak Ridge, TN 37831-0117, USA
| | - Ye Xu
- ICF, 1902 Reston Metro Plaza, Reston, VA 20190, USA; (D.K.M.); (L.G.G.); (Y.X.); (K.C.)
| | - Amanda Brown
- ASRT, Inc., 4158 Onslow Place SE, Smyrna, GA 30080, USA; (S.G.); (A.B.); (N.O.); (B.D.)
| | - Nina Omeaku
- ASRT, Inc., 4158 Onslow Place SE, Smyrna, GA 30080, USA; (S.G.); (A.B.); (N.O.); (B.D.)
| | - Zhiqiu Ye
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop MS-S107-1, Atlanta, GA 30341, USA; (A.R.); (Z.Y.); (S.S.); (S.C.K.); (A.P.)
| | - Bruce Donald
- ASRT, Inc., 4158 Onslow Place SE, Smyrna, GA 30080, USA; (S.G.); (A.B.); (N.O.); (B.D.)
| | - Sharada Shantharam
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop MS-S107-1, Atlanta, GA 30341, USA; (A.R.); (Z.Y.); (S.S.); (S.C.K.); (A.P.)
| | - Sallyann Coleman King
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop MS-S107-1, Atlanta, GA 30341, USA; (A.R.); (Z.Y.); (S.S.); (S.C.K.); (A.P.)
| | - Adebola Popoola
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop MS-S107-1, Atlanta, GA 30341, USA; (A.R.); (Z.Y.); (S.S.); (S.C.K.); (A.P.)
| | - Kristen Cincotta
- ICF, 1902 Reston Metro Plaza, Reston, VA 20190, USA; (D.K.M.); (L.G.G.); (Y.X.); (K.C.)
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Caso V, Martins S, Mikulik R, Middleton S, Groppa S, Pandian JD, Thang NH, Danays T, van der Merwe J, Fischer T, Hacke W. Six years of the Angels Initiative: Aims, achievements, and future directions to improve stroke care worldwide. Int J Stroke 2023; 18:898-907. [PMID: 37226325 PMCID: PMC10507995 DOI: 10.1177/17474930231180067] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/01/2023] [Indexed: 05/26/2023]
Abstract
The rate of stroke-related death and disability is four times higher in low- and middle-income countries (LMICs) than in high-income countries (HICs), yet stroke units exist in only 18% of LMICs, compared with 91% of HICs. In order to ensure universal and equitable access to timely, guideline-recommended stroke care, multidisciplinary stroke-ready hospitals with coordinated teams of healthcare professionals and appropriate facilities are essential.Established in 2016, the Angels Initiative is an international, not-for-profit, public-private partnership. It is run in collaboration with the World Stroke Organization, European Stroke Organisation, and regional and national stroke societies in over 50 countries. The Angels Initiative aims to increase the global number of stroke-ready hospitals and to optimize the quality of existing stroke units. It does this through the work of dedicated consultants, who help to standardize care procedures and build coordinated, informed communities of stroke professionals. Angels consultants also establish quality monitoring frameworks using online audit platforms such as the Registry of Stroke Care Quality (RES-Q), which forms the basis of the Angels award system (gold/platinum/diamond) for all stroke-ready hospitals across the world.The Angels Initiative has supported over 1700 hospitals (>1000 in LMICs) that did not previously treat stroke patients to become "stroke ready." Since its inception in 2016, the Angels Initiative has impacted the health outcomes of an estimated 7.46 million stroke patients globally (including an estimated 4.68 million patients in LMICs). The Angels Initiative has increased the number of stroke-ready hospitals in many countries (e.g. in South Africa: 5 stroke-ready hospitals in 2015 vs 185 in 2021), reduced "door to treatment time" (e.g. in Egypt: 50% reduction vs baseline), and increased quality monitoring substantially.The focus of the work of the Angels Initiative has now expanded from the hyperacute phase of stroke treatment to the pre-hospital setting, as well as to the early post-acute setting. A continued and coordinated global effort is needed to achieve the target of the Angels Initiative of >10,000 stroke-ready hospitals by 2030, and >7500 of these in LMICs.
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Affiliation(s)
| | - Sheila Martins
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Robert Mikulik
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czech Republic
| | - Sandy Middleton
- Australian Catholic University and St. Vincent’s Health Network Sydney, Sydney, NSW, Australia
| | - Stanislav Groppa
- State University of Medicine and Pharmacy ‘Nicolae Testemitanu,’ Chisinau, Moldova
| | | | | | | | - Jan van der Merwe
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Thomas Fischer
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Werner Hacke
- Ruprecht-Karl-University Heidelberg, Heidelberg, Germany
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Stamm B, Royan R, Giurcanu M, Messe SR, Jauch EC, Prabhakaran S. Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke. JAMA 2023; 330:636-649. [PMID: 37581671 PMCID: PMC10427946 DOI: 10.1001/jama.2023.12739] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 06/22/2023] [Indexed: 08/16/2023]
Abstract
Importance Treatments for time-sensitive acute stroke are not available at every hospital, often requiring interhospital transfer. Current guidelines recommend hospitals achieve a door-in-door-out time of no more than 120 minutes at the transferring emergency department (ED). Objective To evaluate door-in-door-out times for acute stroke transfers in the American Heart Association Get With The Guidelines-Stroke registry and to identify patient and hospital factors associated with door-in-door-out times. Design, Setting, and Participants US registry-based, retrospective study of patients with ischemic or hemorrhagic stroke from January 2019 through December 2021 who were transferred from the ED at registry-affiliated hospitals to other acute care hospitals. Exposure Patient- and hospital-level characteristics. Main Outcomes and Measures The primary outcome was the door-in-door-out time (time of transfer out minus time of arrival to the transferring ED) as a continuous variable and a categorical variable (≤120 minutes, >120 minutes). Generalized estimating equation (GEE) regression models were used to identify patient and hospital-level characteristics associated with door-in-door-out time overall and in subgroups of patients with hemorrhagic stroke, acute ischemic stroke eligible for endovascular therapy, and acute ischemic stroke transferred for reasons other than endovascular therapy. Results Among 108 913 patients (mean [SD] age, 66.7 [15.2] years; 71.7% non-Hispanic White; 50.6% male) transferred from 1925 hospitals, 67 235 had acute ischemic stroke and 41 678 had hemorrhagic stroke. Overall, the median door-in-door-out time was 174 minutes (IQR, 116-276 minutes): 29 741 patients (27.3%) had a door-in-door-out time of 120 minutes or less. The factors significantly associated with longer median times were age 80 years or older (vs 18-59 years; 14.9 minutes, 95% CI, 12.3 to 17.5 minutes), female sex (5.2 minutes; 95% CI, 3.6 to 6.9 minutes), non-Hispanic Black vs non-Hispanic White (8.2 minutes, 95% CI, 5.7 to 10.8 minutes), and Hispanic ethnicity vs non-Hispanic White (5.4 minutes, 95% CI, 1.8 to 9.0 minutes). The following were significantly associated with shorter median door-in-door-out time: emergency medical services prenotification (-20.1 minutes; 95% CI, -22.1 to -18.1 minutes), National Institutes of Health Stroke Scale (NIHSS) score exceeding 12 vs a score of 0 to 1 (-66.7 minutes; 95% CI, -68.7 to -64.7 minutes), and patients with acute ischemic stroke eligible for endovascular therapy vs the hemorrhagic stroke subgroup (-16.8 minutes; 95% CI, -21.0 to -12.7 minutes). Among patients with acute ischemic stroke eligible for endovascular therapy, female sex, Black race, and Hispanic ethnicity were associated with a significantly higher door-in-door-out time, whereas emergency medical services prenotification, intravenous thrombolysis, and a higher NIHSS score were associated with significantly lower door-in-door-out times. Conclusions and Relevance In this US registry-based study of interhospital transfer for acute stroke, the median door-in-door-out time was 174 minutes, which is longer than current recommendations for acute stroke transfer. Disparities and modifiable health system factors associated with longer door-in-door-out times are suitable targets for quality improvement initiatives.
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Affiliation(s)
- Brian Stamm
- Department of Neurology, University of Michigan, Ann Arbor
- Department of Neurology, Northwestern University, Chicago, Illinois
| | - Regina Royan
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Emergency Medicine, Northwestern University, Chicago, Illinois
- Assistant Editor, JAMA Network Open
| | - Mihai Giurcanu
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Steven R. Messe
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - Edward C. Jauch
- Department of Research, Mountain Area Health Education Center, Asheville, North Carolina
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Asaithambi G, Tong X, Lakshminarayan K. Trends in intravenous thrombolysis utilization for acute ischemic stroke based on hospital size: Paul Coverdell National Acute Stroke Program, 2010-2019. Am J Emerg Med 2023; 67:51-55. [PMID: 36804749 PMCID: PMC10730192 DOI: 10.1016/j.ajem.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023] Open
Abstract
INTRODUCTION The rate of intravenous thrombolysis (IVT) utilization in acute ischemic stroke (AIS) has been increasing, and this has coincided with improved door-to-needle times (DNTs). Smaller hospitals have been observed to utilize IVT less frequently or even not at all. Using a multistate stroke registry, we sought to determine the impact of hospital size on trends in IVT utilization for AIS. METHODS Utilizing data from the Paul Coverdell National Acute Stroke Program (PCNASP), we studied trends in IVT for AIS patients between 2010 and 2019 based on hospital size. Hospitals were grouped into quartiles based on size. We studied the impact of hospital size on DNTs and overall IVT utilization. RESULTS During the study period, there were 530,828 AIS patients (mean age 70.3 ± 0.02 years, 50.4% men) from 540 participating hospitals. We did not identify a significant trend in IVT utilization among hospitals within the first quartile (p = 0.1005), but there were significantly increased trends within the hospitals belonging to the second, third, and fourth quartiles (p < 0.001 for all). All quartiles were observed to have significantly increased trends in DNTs ≤60 min (p < 0.0001), but only hospitals within the second, third, and fourth quartiles experienced significantly increased trends in DNTs ≤45 min (p < 0.0001). CONCLUSION In our registry-based analysis, we observed an increased trend in IVT utilization for AIS among larger hospitals. There was an overall improvement in rates of DNTs ≤60 min, but only larger hospitals were observed to have improved DNTs ≤45 min.
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Affiliation(s)
- Ganesh Asaithambi
- Allina Health Institute of Neuroscience, Spine, and Pain, Minneapolis, MN, United States of America.
| | - Xin Tong
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Kamakshi Lakshminarayan
- Department of Neurology, University of Minnesota Medical School, Minneapolis, MN, United States of America
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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: 0] [Impact Index Per Article: 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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Palaiodimou L, Kargiotis O, Katsanos AH, Kiamili A, Bakola E, Komnos A, Zisimopoulou V, Natsis K, Papagiannopoulou G, Theodorou A, Zompola C, Safouris A, Psychogios K, Ntais E, Plomaritis P, Karamatzianni G, Mavriki A, Koutsokera M, Lykou C, Koutroulou I, Gourbali V, Skafida A, Roussopoulou A, Kourtesi G, Papamichalis P, Papagiannopoulos S, Gryllia M, Tavernarakis A, Kazis D, Karapanayiotides T, Magoufis G, Giannopoulos S, Tsivgoulis G. Quality metrics in the management of acute stroke in Greece during the first 5 years of Registry of Stroke Care Quality (RES-Q) implementation. Eur Stroke J 2023; 8:5-15. [PMID: 36793743 PMCID: PMC9923128 DOI: 10.1177/23969873221103474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 05/09/2022] [Indexed: 02/12/2023] Open
Abstract
Introduction Establishment of a prospective stroke registry may promote the documentation and improvement of acute stroke care. We present the status of stroke management in Greece using the Registry of Stroke Care Quality (RES-Q) dataset. Methods Consecutive patients with acute stroke were prospectively registered in RES-Q registry by contributing sites in Greece during the years 2017-2021. Demographic and baseline characteristics, acute management, and clinical outcomes at discharge were recorded. Stroke quality metrics, with a specific interest in the association between acute reperfusion therapies and functional recovery in ischemic stroke patients are presented. Results A total of 3590 acute stroke patients were treated in 20 Greek sites (61% men, median age 64 years; median baseline NIHSS 4; 74% ischemic stroke). Acute reperfusion therapies were administered in almost 20% of acute ischemic stroke patients, with a door to needle and door to groin puncture times of 40 and 64 min, respectively. After adjustment for contributing sites, the rates of acute reperfusion therapies were higher during the time epoch 2020-2021 compared to 2017-2019 (adjusted OR 1.31; 95% CI 1.04-1.64; p < 0.022; Cochran-Mantel-Haenszel test). After propensity-score-matching, acute reperfusion therapies administration was independently associated with higher odds of reduced disability (one point reduction across all mRS scores) at hospital discharge (common OR 1.93; 95% CI 1.45-2.58; p < 0.001). Conclusions Implementation and maintenance of a nationwide stroke registry in Greece may guide the stroke management planning, so that prompt patient transportation, acute reperfusion therapies, and stroke unit hospitalization become more widely accessible, improving the functional outcomes of stroke patients.
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Affiliation(s)
- Lina Palaiodimou
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Lina Palaiodimou, Second Department of
Neurology, “Attikon” University Hospital, School of Medicine, National and
Kapodistrian University of Athens, Rimini 1, Chaidari, Athens 12462, Greece.
| | | | - Aristeidis H Katsanos
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Department of Neurology, School of
Medicine, University of Ioannina, Ioannina, Greece
| | - Argyro Kiamili
- Department of Neurology,
Korgialenio-Benakio Greek Red Cross General Hospital of Athens, Athens, Greece
| | - Eleni Bakola
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Department of Neurology, General
Hospital Eleusina Thriassio, Eleusina, Greece
| | - Apostolos Komnos
- Intensive Care Unit, General Hospital
of Larissa, Larissa, Greece
| | - Vaso Zisimopoulou
- Stroke Unit, Athens Euroclinic, Athens,
Greece
- Department of Neurology, 251 Hellenic
Air Force & VA General Hospital, Athens, Greece
| | | | - Georgia Papagiannopoulou
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - Aikaterini Theodorou
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - Christina Zompola
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | | | | | - Evangelos Ntais
- Department of Neurology, School of
Medicine, University of Ioannina, Ioannina, Greece
| | - Panagiotis Plomaritis
- Department of Neurology,
Korgialenio-Benakio Greek Red Cross General Hospital of Athens, Athens, Greece
| | - Georgia Karamatzianni
- Department of Neurology,
Korgialenio-Benakio Greek Red Cross General Hospital of Athens, Athens, Greece
| | - Andriana Mavriki
- Department of Neurology, General
Hospital Eleusina Thriassio, Eleusina, Greece
| | - Maria Koutsokera
- Department of Neurology, General
Hospital Eleusina Thriassio, Eleusina, Greece
| | - Christina Lykou
- Department of Neurology, General
Hospital Eleusina Thriassio, Eleusina, Greece
| | - Ioanna Koutroulou
- Second Department of Neurology,
Aristotle University of Thessaloniki, School of Medicine, AHEPA University Hospital,
Thessaloniki, Greece
| | | | | | - Andromachi Roussopoulou
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Department of Neurology, Tzaneio
General Hospital, Pireaus, Greece
| | - Georgia Kourtesi
- Department of Neurology, General
Hospital of Serres, Serres, Greece
| | | | - Sotirios Papagiannopoulos
- Third Department of Neurology,
Aristotle University of Thessaloniki, Papanikolaou Hospital, Thessaloniki,
Greece
| | - Maria Gryllia
- Department of Neurology, Athens
General Hospital G. Gennimatas, Athens, Greece
| | | | - Dimitrios Kazis
- Third Department of Neurology,
Aristotle University of Thessaloniki, Papanikolaou Hospital, Thessaloniki,
Greece
| | - Theodoros Karapanayiotides
- Second Department of Neurology,
Aristotle University of Thessaloniki, School of Medicine, AHEPA University Hospital,
Thessaloniki, Greece
| | | | - Sotirios Giannopoulos
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Department of Neurology, School of
Medicine, University of Ioannina, Ioannina, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
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10
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Zachrison KS, Ganti L, Sharma D, Goyal P, Decker‐Palmer M, Adeoye O, Goldstein JN, Jauch EC, Lo BM, Madsen TE, Meurer W, Oostema JA, Mendez‐Hernandez C, Venkatesh AK. A survey of stroke-related capabilities among a sample of US community emergency departments. J Am Coll Emerg Physicians Open 2022; 3:e12762. [PMID: 35898236 PMCID: PMC9307290 DOI: 10.1002/emp2.12762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/20/2022] [Accepted: 02/09/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives Most acute stroke research is conducted at academic and larger hospitals, which may differ from many non-academic (ie, community) and smaller hospitals with respect to resources and consultant availability. We describe current emergency department (ED) and hospital-level stroke-related capabilities among a sample of community EDs participating in the Emergency Quality Network (E-QUAL) stroke collaborative. Methods Among E-QUAL-participating EDs, we conducted a survey to collect data on ED and hospital stroke-related structural and process capabilities associated with quality of stroke care delivery and patient outcomes. EDs submitted data using a web-based submission portal. We present descriptive statistics of self-reported capabilities. Results Of 154 participating EDs in 30 states, 97 (63%) completed the survey. Many were rural (33%); most (82%) were not certified stroke centers. Although most reported having stroke protocols (67%), many did not include hemorrhagic stroke or transient ischemic attack (45% and 57%, respectively). Capability to perform emergent head computed tomography and to administer thrombolysis were not universal (absent in 4% and 5%, respectively). Access to neurologic consultants varied; 18% reported no 24/7 availability onsite or remotely. Of those with access, 48% reported access through telemedicine only. Admission capabilities also varied with patient transfer commonly performed (79%). Conclusion Stroke-related capabilities vary substantially between community EDs and are different from capabilities typically found in larger stroke centers. These data may be valuable for identifying areas for future investment. Additionally, the design of stroke quality improvement interventions and metrics to evaluate emergency stroke care delivery should account for these key structural differences.
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Affiliation(s)
- Kori S. Zachrison
- Department of Emergency MedicineMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Latha Ganti
- Department of Emergency MedicineUniversity of Central FloridaOrlandoFloridaUSA
| | - Dhruv Sharma
- American College of Emergency PhysiciansIrvingTexasUSA
| | - Pawan Goyal
- American College of Emergency PhysiciansIrvingTexasUSA
| | | | - Opeolu Adeoye
- Department of Emergency MedicineWashington UniversitySt. LouisMissouriUSA
| | - Joshua N. Goldstein
- Department of Emergency MedicineMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | | | - Bruce M. Lo
- Department of Emergency MedicineEastern Virginia Medical School/Sentara Norfolk General HospitalNorfolkVirginiaUSA
| | - Tracy E. Madsen
- Department of Emergency MedicineWarren Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - William Meurer
- Department of Emergency MedicineUniversity of Michigan School of MedicineAnn ArborMichiganUSA
| | - John A. Oostema
- Department of Emergency MedicineMichigan State UniversityEast LansingMichiganUSA
| | | | - Arjun K. Venkatesh
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
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11
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Sharobeam A, Yan B. Advanced imaging in acute ischemic stroke: an updated guide to the hub-and-spoke hospitals. Curr Opin Neurol 2022; 35:24-30. [PMID: 34845146 DOI: 10.1097/wco.0000000000001020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the role of the hub-and-spoke system in acute stroke care, highlight the role of advanced imaging and discuss emerging concepts and trials relevant to the hub-and-spoke model. RECENT FINDINGS The advent of advanced stroke multimodal imaging has provided increased treatment options for patients, particularly in rural and regional areas. When used in the hub-and-spoke model, advanced imaging can help facilitate and triage transfers, appropriately select patients for acute therapy and treat patients who may otherwise be ineligible based on traditional time metrics.Recent, ongoing trials in this area may lead to an even greater range of patients being eligible for acute reperfusion therapy, including mild strokes and patients with large core infarct volumes. SUMMARY Integration of advanced imaging into a hub-and-spoke system, when complemented with other systems including telemedicine, improves access to acute stroke care for patients in regional and rural areas.
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Affiliation(s)
- Angelos Sharobeam
- Melbourne Brain Centre, The Royal Melbourne Hospital, Parkville, Australia
- School of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville
- Victorian Stroke Telemedicine Service, Ambulance Victoria, Australia
| | - Bernard Yan
- Melbourne Brain Centre, The Royal Melbourne Hospital, Parkville, Australia
- School of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville
- Neurointervention Service, The Royal Melbourne Hospital, Parkville, Australia
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12
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Zachrison KS, Cash RE, Adeoye O, Boggs KM, Schwamm LH, Mehrotra A, Camargo CA. Estimated Population Access to Acute Stroke and Telestroke Centers in the US, 2019. JAMA Netw Open 2022; 5:e2145824. [PMID: 35138392 PMCID: PMC8829668 DOI: 10.1001/jamanetworkopen.2021.45824] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This cross-sectional study assesses US population access to emergency departments with acute stroke capabilities and telestroke capacity in 2019.
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Affiliation(s)
- Kori S. Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Rebecca E. Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Opeolu Adeoye
- Department of Emergency Medicine, Washington University, St Louis, Missouri
| | - Krislyn M. Boggs
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
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13
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Osuegbu OI, Adeniji FO, Owhonda GC, Kanee RB, Aigbogun EO. Exploring the Essential Stroke Care Structures in Tertiary Healthcare Facilities in Rivers State, Nigeria. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2022; 59:469580211067939. [PMID: 35049398 PMCID: PMC8785286 DOI: 10.1177/00469580211067939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study evaluated the essential stroke care structure available in the two Tertiary Health Facilities in Rives State, Nigeria. This was a descriptive survey involving the Stroke Care Survey and Assessment Tool (checklist/questionnaire) developed by the World Stroke Organisation to obtain information about the available essential stroke care structure (facilities, equipment, personnel and management protocol) at the two tertiary health facilities (RSUTH & UPTH). The study gathered relevant information, which was summarised into tables and graphs using Microsoft Excel 2016. From the results, although facilities had A and E departments, dedicated stroke units (fixed or mobile) were unavailable, and there was no locally developed protocol to support rapid triage of stroke patients. The facilities and equipment were either unavailable or insufficient. Only one health facility (RSUTH) provided 24 hrs/7 days laboratory services. The workforces were a mix between regular clinical staff and some specialists. Tissue plasminogen activator (tPA) use was non-existent, though specialists were trained on its administration. There was no locally developed or adopted stroke-specific clinical guidelines. In conclusion, the structural services available for stroke care within the studied tertiary health facilities were poor, unavailable or grossly insufficient. The state facility (RSUTH) suffered the most in terms of unavailable national support and staff development.
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Affiliation(s)
- Osborne Ikechuckwu Osuegbu
- Department of Preventive and Social Medicine, Faculty of Clinical Sciences, College of Health Sciences, 327041University of Port Harcourt, Choba, Nigeria
| | - Foluke Olukemi Adeniji
- Department of Preventive and Social Medicine, Faculty of Clinical Sciences, College of Health Sciences, 327041University of Port Harcourt, Choba, Nigeria
| | | | - Rogers Bariture Kanee
- Institute of Geo-Science and Space Technology, 108005Rivers State University, Oroworukwo, Nigeria
| | - Eric Osamudiamwen Aigbogun
- Department of Public Health, Faculty of Sciences and Technology, 248428Cavendish University Uganda, Kampala, Uganda
- Center for Occupational Health and Safety, Institute of Petroleum Studies, 327041University of Port Harcourt, Choba, Nigeria
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14
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Flowers AM, Chan W, Meyer BI, Bruce BB, Newman NJ, Biousse V. Referral Patterns of Central Retinal Artery Occlusion to an Academic Center Affiliated With a Stroke Center. J Neuroophthalmol 2021; 41:480-487. [PMID: 34788238 PMCID: PMC9546636 DOI: 10.1097/wno.0000000000001409] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Central retinal artery occlusion (CRAO) is a medical emergency, and patients who present acutely should be immediately referred to the nearest stroke center. We evaluated practice patterns for CRAO management at one academic center over the last decade. METHODS This was a retrospective study on all adult patients diagnosed with a CRAO seen at one tertiary hospital and outpatient clinic affiliated with a comprehensive stroke center ("our institution") from 2010 to 2020. Our electronic medical records were searched for CRAO diagnoses, and patient medical records were reviewed. The exclusion criteria were incorrect diagnosis, unclear diagnosis, historical CRAO, or satellite clinic location. Demographics, distance and time to presentation to our institution, number and type of prior providers seen, diagnostic tests performed, and treatments provided were collected. Summary statistics of median, mean, and frequency were calculated and reported with measures of variance (interquartile range [IQR], ranges). F, Tukey, and Fisher exact tests were used for comparisons. RESULTS We included 181 patients with a diagnosis of CRAO (80 [44.2%] women; median age 69 years [range 20-101]). The median distance from patient's home to our institution was 27.8 miles (IQR 15.5-57.4; range 2.4-930). The median time from visual loss to presentation at our institution was 144 hours (IQR 23-442 hours, range 0.5-2,920) from 2010 to 2013, 72 hours (IQR 10.5-372 hours, range 0-13,140) from 2014 to 2016, and 48 hours (IQR 7-180 hours, range 0-8,030) from 2017 to 2020 (P = 0.07). 91/181 (50%) patients presented to an outpatient provider. 73/181 (40%) presented to an emergency department. Eighty-six percent presented within 1 week of visual loss onset, and rates of comprehensive inpatient evaluation for acute CRAO improved from 44% in 2010-2013 to 82% in 2017-2020 (P < 0.01). CONCLUSIONS Patients with CRAO often present late and only after evaluation by multiple outpatient providers. Improvement has occurred over the past decade, but delays underscore the barriers to performing clinical trials evaluating very acute treatments for CRAO. Educational interventions for healthcare providers and patients are necessary.
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Affiliation(s)
- Alexis M Flowers
- Department of Ophthalmology, Emory University, Atlanta, GA 30322
| | - Wesley Chan
- Department of Ophthalmology, Emory University, Atlanta, GA 30322
| | | | - Beau B. Bruce
- Department of Ophthalmology, Emory University, Atlanta, GA 30322
- Department of Neurology, Emory University, Atlanta, GA 30322
- Department of Epidemiology, Emory University, Atlanta, GA 30322
| | - Nancy J. Newman
- Department of Ophthalmology, Emory University, Atlanta, GA 30322
- Department of Neurology, Emory University, Atlanta, GA 30322
- Department of Neurological Surgery, Emory University, Atlanta, GA 30322
| | - Valérie Biousse
- Department of Ophthalmology, Emory University, Atlanta, GA 30322
- Department of Neurology, Emory University, Atlanta, GA 30322
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15
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Bulwa Z, Chen M. Stroke Center Designations, Neurointerventionalist Demand, and the Finances of Stroke Thrombectomy in the United States. Neurology 2021; 97:S17-S24. [PMID: 34785600 DOI: 10.1212/wnl.0000000000012780] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 11/24/2020] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW This article aims to provide an update on the designation of stroke centers, neurointerventionalist demand, and cost-effectiveness of stroke thrombectomy in the United States. RECENT FINDINGS There are now more than 1,660 stroke centers certified by national accrediting bodies in the United States, 306 of which are designated as thrombectomy-capable or comprehensive stroke centers. Considering the amount of nationally certified centers and the number of patients with acute stroke eligible for thrombectomy, each center would be responsible for 64 to 104 thrombectomies per year. As a result, there is a growing demand placed on neurointerventionalists, who have the ability to alter the trajectory of large vessel occlusive strokes. Numbers needed to achieve functional independence after stroke thrombectomy at 90 days range from 3.2 to 7.4 patients in the early time window and 2.8 to 3.6 patients in the extended time window in appropriately selected candidates. With the low number needed to treat, in a variety of valued-based calculations and cost-effectiveness analyses, stroke thrombectomy has proved to be both clinically effective and cost-effective. SUMMARY Advancements in the early recognition and treatment of stroke have been paralleled by a remodeling of health care systems to ensure best practices in a timely manner. Stroke center-accrediting bodies provide oversight to safeguard these standards. As successful trial data from high volume centers transform into real-world experience, we must continue to re-evaluate cost-effectiveness, strike a balance between sufficient case volumes to maintain clinical excellence vs the burden and burnout associated with call responsibilities, and improve access to care for all.
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Affiliation(s)
- Zachary Bulwa
- From the Departments of Neurology (Z.B.) and Neurosurgery (M.C.), Rush University Medical Center, Chicago, IL.
| | - Michael Chen
- From the Departments of Neurology (Z.B.) and Neurosurgery (M.C.), Rush University Medical Center, Chicago, IL
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16
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Espiritu AI, San Jose MCZ. A Call for a Stroke Referral Network Between Primary Care and Stroke-Ready Hospitals in the Philippines: A Narrative Review. Neurologist 2021; 26:253-260. [PMID: 34734903 DOI: 10.1097/nrl.0000000000000357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The increasing stroke burden, inequity in the distribution of local neurologists, and the recent signing of the Universal Health Care Law in the Philippines provide compelling reasons for policy-makers to devise strategies to establish networks between primary care and stroke-ready hospitals. In this review, we explored the current literature and evidence that emphasized the roles of primary care providers (PCPs) and specialists, care transition, and telemedicine/teleneurology in various stages of stroke management. REVIEW SUMMARY Clear delegation of stroke care responsibilities among PCPs and specialists is needed. Due to the limited number of specialists/neurologists, PCPs may contribute to addressing the insufficiency of community knowledge of acute stroke symptoms/risk factors, coordination with specialists and stroke-ready hospitals during acute stroke, and continuity of care during the poststroke stage. At present, the Philippines has only 49 stroke-ready hospitals; thus, an efficient and functional referral system for the care transition between the PCPs and specialists must be organized in our country. To provide remote access to expert stroke care for underserved areas and to increase thrombolysis utilization, the establishment of an effective telestroke system is indispensable. The empowerment of PCPs in teleneurology may assist in strengthening communication and networking with specialists with the ultimate goal of improving patient outcomes. CONCLUSIONS In the era of Universal Health Care in the Philippines, the roles of PCP and specialists must be delineated. Increased access to stroke care through the establishment of networks among PCPs and stroke-ready hospitals (ie, via effective transition of care/teleneurology) must be prioritized especially in resource-constrained settings.
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Affiliation(s)
- Adrian I Espiritu
- Department of Neurosciences, Philippine General Hospital and College of Medicine
- the Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Maria Cristina Z San Jose
- Department of Neurosciences, Philippine General Hospital and College of Medicine
- the Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Manila, Philippines
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17
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Holl JL, Khorzad R, Zobel R, Barnard A, Hillman M, Vargas A, Richards C, Mendelson S, Prabhakaran S. Risk Assessment of the Door-In-Door-Out Process at Primary Stroke Centers for Patients With Acute Stroke Requiring Transfer to Comprehensive Stroke Centers. J Am Heart Assoc 2021; 10:e021803. [PMID: 34533049 PMCID: PMC8649509 DOI: 10.1161/jaha.121.021803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Patients with acute stroke at non- or primary stroke centers (PSCs) are transferred to comprehensive stroke centers for advanced treatments that reduce disability but experience significant delays in treatment and increased adjusted mortality. This study reports the results of a proactive, systematic, risk assessment of the door-in-door-out process and its application to solution design. Methods and Results A learning collaborative (clinicians, patients, and caregivers) at 2 PSCs and 3 comprehensive stroke centers in Chicago, Illinois participated in a failure modes, effects, and criticality analysis to identify steps in the process; failures of each step, underlying causes; and to characterize each failure's frequency, impact, and safeguards using standardized scores to calculate risk priority and criticality numbers for ranking. Targets for solution design were selected among the highest-ranked failures. The failure modes, effects, and criticality analysis process map and risk table were completed during in-person and virtual sessions. Failure to detect severe stroke/large-vessel occlusion on arrival at the PSC is the highest-ranked failure and can lead to a 45-minute door-in-door-out delay caused by failure to obtain a head computed tomography and computed tomography angiogram together. Lower risk failures include communication problems and delays within the PSC team and across the PSC comprehensive stroke center and paramedic teams. Seven solution prototypes were iteratively designed and address 4 of the 10 highest-ranked failures. Conclusions The failure modes, effects, and criticality analysis identified and characterized previously unrecognized failures of the door-in-door-out process. Use of a risk-informed approach for solution design is novel for stroke and should mitigate or eliminate the failures.
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Affiliation(s)
- Jane L Holl
- Department of Neurology Biological Sciences Division University of Chicago Chicago IL
| | | | | | - Amy Barnard
- Northwestern Medicine Lake Forest Hospital Lake Forest IL
| | | | | | - Christopher Richards
- Department of Emergency Medicine University of Cincinnati College of Medicine Cincinnati OH
| | - Scott Mendelson
- Department of Neurology Biological Sciences Division University of Chicago Chicago IL
| | - Shyam Prabhakaran
- Department of Neurology Biological Sciences Division University of Chicago Chicago IL
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18
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Ifejika NL, Wiegand J, Harbold H, Botello AA, Babalola BA, Venkatachalam AM, Novakovic R, Cannell MB. The "Network Effect" on Interfacility Transfers Among Regional Stroke Certified Hospitals. J Stroke Cerebrovasc Dis 2021; 30:106056. [PMID: 34450478 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106056] [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: 05/04/2021] [Accepted: 08/09/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION AND PURPOSE Timely inter-facility transfer of thrombectomy-eligible patients is a mainstay of Stroke Systems of Care. We investigated transfer patterns among stroke certified hospitals in the Dallas-Fort Worth (DFW) Metroplex (19 counties, 9,286 sq mi, > 7.7 million people), by hospital network and stroke center status. METHODS We conducted a North Central Texas Trauma Regional Advisory Council (NCTTRAC) Stroke Regional Care Survey at all 44 centers involved in the treatment of MT-eligible ischemic stroke patients between June-September 2019, with a response rate of 100%. All hospitals identified network status, stroke designation - Acute Stroke Ready Hospital (ASRH), Primary Stroke Center (PSC), Comprehensive Stroke Center (CSC) - and geographic location. Stroke Assessment and Large Vessel Occlusion (LVO) screening tool use was evaluated. The distance between the sending and receiving facility was calculated using GPS coordinates. If the closest CSC was not used, the average distance between the selected and the closest CSC was geospatially mapped via R statistical analysis software (Vienna, Austria) gmapsdistance package. RESULTS Of the 44 facilities, 6 were ASRHs, 27 were PSCs, 11 were CSCs. Seventy-seven percent (n=34) belonged to one of four hospital networks. All facilities used stroke assessment tools; 57% completed LVO screening. There was significant heterogeneity in inter-facility transfer patterns with no regional standardization. Seventeen percent of ASRHs (n=1) and 56% of PSCs (n=15) conducted inter-facility transfers using ground transportation via EMS. Sixty percent of non-network facilities transferred to the closest CSC. Of the remaining 40%, the average distance between the closest and the selected CSC was 1.5 miles (min max 0.2-2.9 miles). Seventeen percent of network facilities transferred to the closest CSC. Among the remaining 83%, the average distance between the closest and the selected CSC was 4.1 miles (min-max 1-8 miles). CONCLUSIONS Non-network facility status increased the likelihood of transfer to the closest Comprehensive Stroke Center. Transfer distance variability among network facilities may contribute to delays in reperfusion therapy.
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Affiliation(s)
- Nneka L Ifejika
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9055, United States; Department of Neurology, UT Southwestern Medical Center, Dallas, TX, United States; Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, United States.
| | - Jared Wiegand
- University of Texas Health Science Center at Houston School of Public Health, Dallas, TX, United States.
| | - Hunter Harbold
- Parker County Hospital District, Weatherford, TX, United States.
| | - Adrian A Botello
- North Central Texas Trauma Regional Advisory Council, Arlington, TX, United States.
| | - Babatunde A Babalola
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9055, United States.
| | | | - Roberta Novakovic
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, United States; Department of Radiology, UT Southwestern Medical Center, Dallas, TX, United States.
| | - Michael B Cannell
- University of Texas Health Science Center at Houston School of Public Health, Dallas, TX, United States; Department of Internal Medicine, Division of Geriatric Medicine, UT Southwestern Medical Center, Dallas, TX, United States.
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19
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Holder D, Leeseberg K, Giles JA, Lee JM, Namazie S, Ford AL. Central Triage of Acute Stroke Patients Across a Distributive Stroke Network Is Safe and Reduces Transfer Denials. Stroke 2021; 52:2671-2675. [PMID: 34154389 DOI: 10.1161/strokeaha.120.033018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Derek Holder
- Department of Neurology (D.H., J.A.G., J.-M.L., A.L.F.), Washington University School of Medicine, St. Louis, MO
| | - Kevin Leeseberg
- Center for Clinical Excellence, BJC Healthcare, St. Louis, MO (K.L., S.N.)
| | - James A Giles
- Department of Neurology (D.H., J.A.G., J.-M.L., A.L.F.), Washington University School of Medicine, St. Louis, MO
| | - Jin-Moo Lee
- Department of Neurology (D.H., J.A.G., J.-M.L., A.L.F.), Washington University School of Medicine, St. Louis, MO.,Mallinckrodt Institute of Radiology (J.-M.L., A.L.F.), Washington University School of Medicine, St. Louis, MO.,Department of Biomedical Engineering, Washington University, St. Louis, MO (J.-M.L.)
| | - Sheyda Namazie
- Center for Clinical Excellence, BJC Healthcare, St. Louis, MO (K.L., S.N.)
| | - Andria L Ford
- Department of Neurology (D.H., J.A.G., J.-M.L., A.L.F.), Washington University School of Medicine, St. Louis, MO.,Mallinckrodt Institute of Radiology (J.-M.L., A.L.F.), Washington University School of Medicine, St. Louis, MO
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20
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Yu CY, Blaine T, Panagos PD, Kansagra AP. Demographic Disparities in Proximity to Certified Stroke Care in the United States. Stroke 2021; 52:2571-2579. [PMID: 34107732 DOI: 10.1161/strokeaha.121.034493] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Cathy Y Yu
- Washington University School of Medicine (C.Y.Y.)
| | - Timothy Blaine
- Mallinckrodt Institute of Radiology (T.B., A.P.K.), Washington University School of Medicine, St. Louis, MO
| | - Peter D Panagos
- Department of Emergency Medicine (P.D.P.), Washington University School of Medicine, St. Louis, MO.,Department of Neurology (P.D.P., A.P.K.), Washington University School of Medicine, St. Louis, MO
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology (T.B., A.P.K.), Washington University School of Medicine, St. Louis, MO.,Department of Neurology (P.D.P., A.P.K.), Washington University School of Medicine, St. Louis, MO.,Department of Neurological Surgery (A.P.K.), Washington University School of Medicine, St. Louis, MO
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21
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Establishing a Baseline: Evidence-Supported State Laws to Advance Stroke Care. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2021; 26 Suppl 2, Advancing Legal Epidemiology:S19-S28. [PMID: 32004219 DOI: 10.1097/phh.0000000000001126] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Approximately 800 000 strokes occur annually in the United States. Stroke systems of care policies addressing prehospital and in-hospital care have been proposed to improve access to time-sensitive, lifesaving treatments for stroke. Policy surveillance of stroke systems of care laws supported by best available evidence could reveal potential strengths and weaknesses in how stroke care delivery is regulated across the nation. DESIGN This study linked the results of an early evidence assessment of 15 stroke systems of care policy interventions supported by best available evidence to a legal data set of the body of law in effect on January 1, 2018, for the 50 states and Washington, District of Columbia. RESULTS As of January 1, 2018, 39 states addressed 1 or more aspects of prehospital or in-hospital stroke care in law; 36 recognized at least 1 type of stroke center. Thirty states recognizing stroke centers also had evidence-supported prehospital policy interventions authorized in law. Four states authorized 10 or more of 15 evidence-supported policy interventions. Some combinations of prehospital and in-hospital policy interventions were more prevalent than other combinations. CONCLUSION The analysis revealed that many states had a stroke regulatory infrastructure for in-hospital care that is supported by best available evidence. However, there are gaps in how state law integrates evidence-supported prehospital and in-hospital care that warrant further study. This study provides a baseline for ongoing policy surveillance and serves as a basis for subsequent stroke systems of care policy implementation and policy impact studies.
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22
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Kägi G, Schurter D, Niederhäuser J, De Marchis GM, Engelter S, Arni P, Nyenhuis O, Imboden P, Bonvin C, Luft A, Renaud S, Nedeltchev K, Carrera E, Cereda C, Fischer U, Arnold M, Michel P. Swiss guidelines for the prehospital phase in suspected acute stroke. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2021. [DOI: 10.1177/2514183x21999230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Acute stroke treatment has advanced substantially over the last years. Important milestones constitute intravenous thrombolysis, endovascular therapy (EVT), and treatment of stroke patients in dedicated units (stroke units). At present in Switzerland there are 13 certified stroke units and 10 certified EVT-capable stroke centers. Emerging challenges for the prehospital pathways are that (i) acute stroke treatment remains very time sensitive, (ii) the time window for acute stroke treatment has opened up to 24 h in selected cases, and (iii) EVT is only available in stroke centers. The goal of the current guideline is to standardize the prehospital phase of patients with acute stroke for them to receive the optimal treatment without unnecessary delays. Different prehospital models exist. For patients with large vessel occlusion (LVO), the Drip and Ship model is the most commonly used in Switzerland. This model is challenged by the Mothership model where stroke patients with suspected LVO are directly transferred to the stroke center. This latter model is only effective if there is an accurate triage by paramedics, hence the patient may benefit from the right treatment in the right place, without loss of time. Although the Cincinnati Prehospital Stroke Scale is a well-established scale to detect acute stroke in the prehospital setting, it neglects nonmotor symptoms like visual impairment or severe vertigo. Therefore we suggest “acute occurrence of a focal neurological deficit” as the trigger to enter the acute stroke pathway. For the triage whether a patient has a LVO (yes/no), there are a number of scores published. Accuracy of these scores is borderline. Nevertheless, applying the Rapid Arterial Occlusion Evaluation score or a comparable score to recognize patients with LVO may help to speed up and triage prehospital pathways. Ultimately, the decision of which model to use in which stroke network will depend on local (e.g. geographical) characteristics.
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Affiliation(s)
- Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - David Schurter
- Protection & Rescue Zurich, Ambulance, Zurich, Switzerland
| | | | - Gian Marco De Marchis
- Department of Neurology and Stroke Centre, University Hospital Basel, Basel, Switzerland
| | - Stefan Engelter
- Department of Neurology and Stroke Centre, University Hospital Basel, Basel, Switzerland
- Neurorehabilitation Felix Platter, University of Basel, Basel, Switzerland
| | - Patrick Arni
- Protection and Rescue Bern, Medical Police, Bern, Switzerland
| | | | - Paul Imboden
- Department of Anesthesia, Intensive Care, Emergency and Pain Medicine, Kantonsspital St. Gallen, Switzerland
| | - Christophe Bonvin
- Division of Neurology and Stroke Unit, Hôpital du Valais, Sion, Switzerland
| | - Andreas Luft
- Department of Neurology, University Hospital Zurich and Cereneo, Vitznau, Switzerland
| | - Susanne Renaud
- Division of Neurology, Neuchâtel Hospital Network, Neuchâtel, Switzerland
| | | | - Emmanuel Carrera
- Department of Neurology, University Hospitals of Geneva, Geneva, Switzerland
| | - Carlo Cereda
- Department of Neurology, Neurocentro della Svizzera Italiana, Lugano Civic Hospital, Lugano, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital Bern and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital Bern and University of Bern, Bern, Switzerland
| | - Patrik Michel
- Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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23
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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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24
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Jauch EC, Schwamm LH, Panagos PD, Barbazzeni J, Dickson R, Dunne R, Foley J, Fraser JF, Lassers G, Martin-Gill C, O'Brien S, Pinchalk M, Prabhakaran S, Richards CT, Taillac P, Tsai AW, Yallapragada A. Recommendations for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities From the Prehospital Stroke System of Care Consensus Conference: A Consensus Statement From the American Academy of Neurology, American Heart Association/American Stroke Association, American Society of Neuroradiology, National Association of EMS Physicians, National Association of State EMS Officials, Society of NeuroInterventional Surgery, and Society of Vascular and Interventional Neurology: Endorsed by the Neurocritical Care Society. Stroke 2021; 52:e133-e152. [PMID: 33691507 DOI: 10.1161/strokeaha.120.033228] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | - Robert Dunne
- Detroit East Medical Control Authority, MI (R. Dunne).,National Association of EMS Physicians (R. Dunne, C.M.-G.)
| | | | - Justin F Fraser
- University of Kentucky, Lexington (J.F.F.).,American Association of Neurological Surgeons, Society of NeuroInterventional Surgery (J.F.F.)
| | | | | | | | - Mark Pinchalk
- City of Pittsburgh Emergency Medical Services, PA (M.P.)
| | - Shyam Prabhakaran
- University of Chicago, IL (S.P.).,American Academy of Neurology (S.P.)
| | | | - Peter Taillac
- University of Utah, Salt Lake City (P.T.).,National Association of State EMS Officials (P.T.)
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25
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Brom H, Brooks Carthon JM, Sloane D, McHugh M, Aiken L. Better nurse work environments associated with fewer readmissions and shorter length of stay among adults with ischemic stroke: A cross-sectional analysis of United States hospitals. Res Nurs Health 2021; 44:525-533. [PMID: 33650707 DOI: 10.1002/nur.22121] [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: 10/20/2020] [Revised: 01/15/2021] [Accepted: 02/13/2021] [Indexed: 02/04/2023]
Abstract
Stroke is among the most common reasons for disability and death. Avoiding readmissions and long lengths of stay among ischemic stroke patients has benefits for patients and health care systems alike. Although reduced readmission rates among a variety of medical patients have been associated with better nurse work environments, it is unknown how the work environment might influence readmissions and length of stay for ischemic stroke patients. Using linked data sources, we conducted a cross-sectional analysis of 543 hospitals to evaluate the association between the nurse work environment and readmissions and length of stay for 175,467 hospitalized adult ischemic stroke patients. We utilized logistic regression models for readmission to estimate odds ratios (OR) and zero-truncated negative binomial models for length of stay to estimate the incident-rate ratio (IRR). Final models accounted for hospital and patient characteristics. Seven and 30-day readmission rates were 3.9% and 10.1% respectively and the average length of stay was 4.9 days. In hospitals with better nurse work environments ischemic stroke patients experienced lower odds of 7- and 30-day readmission (7-day OR, 0.96; 95% confidence interval [CI]: 0.93-0.99 and 30-day OR, 0.97; 95% CI: 0.94-0.99) and lower length of stay (IRR, 0.97; 95% CI: 0.95-0.99). The work environment is a modifiable feature of hospitals that should be considered when providing comprehensive stroke care and improving post-stroke outcomes.
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Affiliation(s)
- Heather Brom
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, Pennsylvania, USA
| | - J Margo Brooks Carthon
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Douglas Sloane
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mathew McHugh
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Linda Aiken
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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26
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Triage and systems of care in stroke. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:401-407. [PMID: 33272408 DOI: 10.1016/b978-0-444-64034-5.00018-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
There has been increasing adoption of endovascular stroke treatment in the United States following multiple clinical trials demonstrating superior efficacy. Next steps in enhancing this treatment include an analysis and development of stroke systems of care geared toward efficient delivery of endovascular and comprehensive stroke care. The chapter presents epidemiological data and an overview of the current state of stroke delivery and potential improvements for the future in the light of clinical data.
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27
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Overwyk KJ, Yin X, Tong X, King SMC, Wiltz JL. Defect-free care trends in the Paul Coverdell National Acute Stroke Program, 2008-2018. Am Heart J 2020; 232:177-184. [PMID: 33253677 DOI: 10.1016/j.ahj.2020.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 11/16/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND In an effort to improve stroke quality of care and patient outcomes, quality of care metrics are monitored to assess utilization of evidence-based stroke care processes as part of the Paul Coverdell National Acute Stroke Program (PCNASP). We aimed to assess temporal trends in defect-free care (DFC) received by stroke patients in the PCNASP between 2008 and 2018. METHODS Quality of care data for 10 performance measures were available for 849,793 patients aged ≥18 years who were admitted to a participating hospital with a clinical diagnosis of stroke between 2008 and 2018. A patient who receives care according to all performance measures for which they are eligible, receives "defect-free care" (DFC) (eg, appropriate medications, assessments, and education). Generalized estimating equations were used to examine the factors associated with receipt of DFC. RESULTS DFC among ischemic stroke patients increased from 38.0% in 2008 to 80.8% in 2018 (P < .0001), with the largest improvement seen in receipt of stroke education (relative percent change, RPC = 64%). Similarly, DFC for hemorrhagic stroke and transient ischemic attack patients increased from 46.7% to 82.6% (RPC = 76.9%) and 39.9% to 85.0% (RPC = 113.0%) (P < .001), respectively. Among ischemic stroke patients, the adjusted odds for receiving DFC were lower for women, patients aged 18 to 54 years, Medicaid or Medicare participants, and patients with atrial fibrillation (P < .05). CONCLUSIONS From 2008 to 2018, receipt of DFC by ischemic stroke patients significantly increased in the PCNASP; however certain subgroups were less likely to receive this level of care. Targeted quality improvement initiatives could result in even further improvements among all stroke patients and help reduce disparities in care.
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28
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Alasheev AM, Hubert GJ, Santo GC, Vanhooren GT, Zvan B, Campos ST, Abilleira S, Corea F. Recommendations on telestroke in Europe. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:33-41. [DOI: 10.17116/jnevro202012003233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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29
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Bresette LM. What Is Stroke Certification and Does It Matter? Crit Care Nurs Clin North Am 2019; 32:109-119. [PMID: 32014157 DOI: 10.1016/j.cnc.2019.11.002] [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: 11/19/2022]
Abstract
Many academic and community hospitals have obtained, or are considering obtaining, stroke center certification. Participation in structured quality improvement programs that also incorporate an objective assessment has been shown to improve outcomes and foster team building. Although obtaining certification can be challenging and costly, it can provide a framework to ensure hospitals deliver high- level, evidence-based stroke care. For the intensive care unit nurse, awareness and participation in the certification programs process is an important part of professional nursing practice.
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Affiliation(s)
- Linda M Bresette
- Comprehensive Stroke Program, Neurology, Brigham and Women's Hospital, Boston, MA, USA.
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30
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Arling G, Sico JJ, Reeves MJ, Myers L, Baye F, Bravata DM. Modelling care quality for patients after a transient ischaemic attack within the US Veterans Health Administration. BMJ Open Qual 2019; 8:e000641. [PMID: 31909209 PMCID: PMC6937041 DOI: 10.1136/bmjoq-2019-000641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 10/22/2019] [Accepted: 11/23/2019] [Indexed: 12/25/2022] Open
Abstract
Objective Timely preventive care can substantially reduce risk of recurrent vascular events or death after a transient ischaemic attack (TIA). Our objective was to understand patient and facility factors influencing preventive care quality for patients with TIA in the US Veterans Health Administration (VHA). Methods We analysed administrative data from a retrospective cohort of 3052 patients with TIA cared for in the emergency department (ED) or inpatient setting in 110 VHA facilities from October 2010 to September 2011. A composite quality indicator (QI score) pass rate was constructed from four process-related quality measures—carotid imaging, brain imaging, high or moderate potency statin and antithrombotic medication, associated with the ED visit or inpatient admission after the TIA. We tested a multilevel structural equation model where facility and patient characteristics, inpatient admission, and neurological consultation were predictors of the resident’s composite QI score. Results Presenting with a speech deficit and higher Charlson Comorbidity Index (CCI) were positively related to inpatient admission. Being admitted increased the likelihood of neurology consultation, whereas history of dementia, weekend arrival and a higher CCI score made neurological consultation less likely. Speech deficit, higher CCI, inpatient admission and neurological consultation had direct positive effects on the composite quality score. Patients in facilities with fewer full-time equivalent neurology staff were less likely to be admitted or to have a neurology consultation. Facilities having greater organisational complexity and with a VHA stroke centre designation were more likely to provide a neurology consultation. Conclusions Better TIA preventive care could be achieved through increased inpatient admissions, or through enhanced neurology and other care resources in the ED and during follow-up care.
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Affiliation(s)
- Greg Arling
- School of Nursing, Purdue University, West Lafayette, Indiana, USA.,Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Jason J Sico
- Department of Internal Medicine and Neurology, Yale School of Medicine, New Haven, Connecticut, USA.,Clinical Epidemiology Research Center, VA Connecticut Health System West Haven Campus, West Haven, Connecticut, USA
| | - Mathew J Reeves
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,Department of Epidemiology, Michigan State University, East Lansing, Michigan, USA
| | - Laura Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,Center for Health Information and Communication (CHIC), Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Indianapolis, Indiana, USA
| | - Fitsum Baye
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dawn M Bravata
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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31
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Ader J, Wu J, Fonarow GC, Smith EE, Shah S, Xian Y, Bhatt DL, Schwamm LH, Reeves MJ, Matsouaka RA, Sheth KN. Hospital distance, socioeconomic status, and timely treatment of ischemic stroke. Neurology 2019; 93:e747-e757. [PMID: 31320472 DOI: 10.1212/wnl.0000000000007963] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 03/24/2019] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To determine whether lower socioeconomic status (SES) and longer home to hospital driving time are associated with reductions in tissue plasminogen activator (tPA) administration and timeliness of the treatment. METHODS We conducted a retrospective observational study using data from the Get With The Guidelines-Stroke Registry (GWTG-Stroke) between January 2015 and March 2017. The study included 118,683 ischemic stroke patients age ≥18 who were transported by emergency medical services to one of 1,489 US hospitals. We defined each patient's SES based on zip code median household income. We calculated the driving time between each patient's home zip code and the hospital where he or she was treated using the Google Maps Directions Application Programing Interface. The primary outcomes were tPA administration and onset-to-arrival time (OTA). Outcomes were analyzed using hierarchical multivariable logistic regression models. RESULTS SES was not associated with OTA (p = 0.31) or tPA administration (p = 0.47), but was associated with the secondary outcomes of onset-to-treatment time (OTT) (p = 0.0160) and in-hospital mortality (p = 0.0037), with higher SES associated with shorter OTT and lower in-hospital mortality. Driving time was associated with tPA administration (p < 0.001) and OTA (p < 0.0001), with lower odds of tPA (0.83, 0.79-0.88) and longer OTA (1.30, 1.24-1.35) in patients with the longest vs shortest driving time quartiles. Lower SES quintiles were associated with slightly longer driving time quartiles (p = 0.0029), but there was no interaction between the SES and driving time for either OTA (p = 0.1145) or tPA (p = 0.6103). CONCLUSIONS Longer driving times were associated with lower odds of tPA administration and longer OTA; however, SES did not modify these associations.
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Affiliation(s)
- Jeremy Ader
- From the Department of Neurology (J.A.), Columbia University Medical Center, New York, NY; Duke Clinical Research Institute (J.W., S.S., Y.X., R.A.M.), Durham, NC; Division of Cardiology (G.C.F.), Ronald Reagan-UCLA Medical Center, Los Angeles, CA; Department of Clinical Neurosciences and Hotchkiss Brain Institute (E.E.S.), University of Calgary, Canada; Department of Neurology (S.S.), Duke University Hospital; Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Brigham and Women's Hospital Heart & Vascular Center (D.L.B.) and Department of Neurology, Massachusetts General Hospital (L.H.S.), Harvard Medical School, Boston; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Biostatistics and Bioinformatics (R.A.M.), Duke University, Durham, NC; and Department of Neurology (K.N.S.), Division of Neurocritical Care & Emergency Neurology, Yale University, New Haven, CT.
| | - Jingjing Wu
- From the Department of Neurology (J.A.), Columbia University Medical Center, New York, NY; Duke Clinical Research Institute (J.W., S.S., Y.X., R.A.M.), Durham, NC; Division of Cardiology (G.C.F.), Ronald Reagan-UCLA Medical Center, Los Angeles, CA; Department of Clinical Neurosciences and Hotchkiss Brain Institute (E.E.S.), University of Calgary, Canada; Department of Neurology (S.S.), Duke University Hospital; Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Brigham and Women's Hospital Heart & Vascular Center (D.L.B.) and Department of Neurology, Massachusetts General Hospital (L.H.S.), Harvard Medical School, Boston; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Biostatistics and Bioinformatics (R.A.M.), Duke University, Durham, NC; and Department of Neurology (K.N.S.), Division of Neurocritical Care & Emergency Neurology, Yale University, New Haven, CT
| | - Gregg C Fonarow
- From the Department of Neurology (J.A.), Columbia University Medical Center, New York, NY; Duke Clinical Research Institute (J.W., S.S., Y.X., R.A.M.), Durham, NC; Division of Cardiology (G.C.F.), Ronald Reagan-UCLA Medical Center, Los Angeles, CA; Department of Clinical Neurosciences and Hotchkiss Brain Institute (E.E.S.), University of Calgary, Canada; Department of Neurology (S.S.), Duke University Hospital; Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Brigham and Women's Hospital Heart & Vascular Center (D.L.B.) and Department of Neurology, Massachusetts General Hospital (L.H.S.), Harvard Medical School, Boston; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Biostatistics and Bioinformatics (R.A.M.), Duke University, Durham, NC; and Department of Neurology (K.N.S.), Division of Neurocritical Care & Emergency Neurology, Yale University, New Haven, CT
| | - Eric E Smith
- From the Department of Neurology (J.A.), Columbia University Medical Center, New York, NY; Duke Clinical Research Institute (J.W., S.S., Y.X., R.A.M.), Durham, NC; Division of Cardiology (G.C.F.), Ronald Reagan-UCLA Medical Center, Los Angeles, CA; Department of Clinical Neurosciences and Hotchkiss Brain Institute (E.E.S.), University of Calgary, Canada; Department of Neurology (S.S.), Duke University Hospital; Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Brigham and Women's Hospital Heart & Vascular Center (D.L.B.) and Department of Neurology, Massachusetts General Hospital (L.H.S.), Harvard Medical School, Boston; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Biostatistics and Bioinformatics (R.A.M.), Duke University, Durham, NC; and Department of Neurology (K.N.S.), Division of Neurocritical Care & Emergency Neurology, Yale University, New Haven, CT
| | - Shreyansh Shah
- From the Department of Neurology (J.A.), Columbia University Medical Center, New York, NY; Duke Clinical Research Institute (J.W., S.S., Y.X., R.A.M.), Durham, NC; Division of Cardiology (G.C.F.), Ronald Reagan-UCLA Medical Center, Los Angeles, CA; Department of Clinical Neurosciences and Hotchkiss Brain Institute (E.E.S.), University of Calgary, Canada; Department of Neurology (S.S.), Duke University Hospital; Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Brigham and Women's Hospital Heart & Vascular Center (D.L.B.) and Department of Neurology, Massachusetts General Hospital (L.H.S.), Harvard Medical School, Boston; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Biostatistics and Bioinformatics (R.A.M.), Duke University, Durham, NC; and Department of Neurology (K.N.S.), Division of Neurocritical Care & Emergency Neurology, Yale University, New Haven, CT
| | - Ying Xian
- From the Department of Neurology (J.A.), Columbia University Medical Center, New York, NY; Duke Clinical Research Institute (J.W., S.S., Y.X., R.A.M.), Durham, NC; Division of Cardiology (G.C.F.), Ronald Reagan-UCLA Medical Center, Los Angeles, CA; Department of Clinical Neurosciences and Hotchkiss Brain Institute (E.E.S.), University of Calgary, Canada; Department of Neurology (S.S.), Duke University Hospital; Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Brigham and Women's Hospital Heart & Vascular Center (D.L.B.) and Department of Neurology, Massachusetts General Hospital (L.H.S.), Harvard Medical School, Boston; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Biostatistics and Bioinformatics (R.A.M.), Duke University, Durham, NC; and Department of Neurology (K.N.S.), Division of Neurocritical Care & Emergency Neurology, Yale University, New Haven, CT
| | - Deepak L Bhatt
- From the Department of Neurology (J.A.), Columbia University Medical Center, New York, NY; Duke Clinical Research Institute (J.W., S.S., Y.X., R.A.M.), Durham, NC; Division of Cardiology (G.C.F.), Ronald Reagan-UCLA Medical Center, Los Angeles, CA; Department of Clinical Neurosciences and Hotchkiss Brain Institute (E.E.S.), University of Calgary, Canada; Department of Neurology (S.S.), Duke University Hospital; Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Brigham and Women's Hospital Heart & Vascular Center (D.L.B.) and Department of Neurology, Massachusetts General Hospital (L.H.S.), Harvard Medical School, Boston; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Biostatistics and Bioinformatics (R.A.M.), Duke University, Durham, NC; and Department of Neurology (K.N.S.), Division of Neurocritical Care & Emergency Neurology, Yale University, New Haven, CT
| | - Lee H Schwamm
- From the Department of Neurology (J.A.), Columbia University Medical Center, New York, NY; Duke Clinical Research Institute (J.W., S.S., Y.X., R.A.M.), Durham, NC; Division of Cardiology (G.C.F.), Ronald Reagan-UCLA Medical Center, Los Angeles, CA; Department of Clinical Neurosciences and Hotchkiss Brain Institute (E.E.S.), University of Calgary, Canada; Department of Neurology (S.S.), Duke University Hospital; Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Brigham and Women's Hospital Heart & Vascular Center (D.L.B.) and Department of Neurology, Massachusetts General Hospital (L.H.S.), Harvard Medical School, Boston; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Biostatistics and Bioinformatics (R.A.M.), Duke University, Durham, NC; and Department of Neurology (K.N.S.), Division of Neurocritical Care & Emergency Neurology, Yale University, New Haven, CT
| | - Mathew J Reeves
- From the Department of Neurology (J.A.), Columbia University Medical Center, New York, NY; Duke Clinical Research Institute (J.W., S.S., Y.X., R.A.M.), Durham, NC; Division of Cardiology (G.C.F.), Ronald Reagan-UCLA Medical Center, Los Angeles, CA; Department of Clinical Neurosciences and Hotchkiss Brain Institute (E.E.S.), University of Calgary, Canada; Department of Neurology (S.S.), Duke University Hospital; Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Brigham and Women's Hospital Heart & Vascular Center (D.L.B.) and Department of Neurology, Massachusetts General Hospital (L.H.S.), Harvard Medical School, Boston; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Biostatistics and Bioinformatics (R.A.M.), Duke University, Durham, NC; and Department of Neurology (K.N.S.), Division of Neurocritical Care & Emergency Neurology, Yale University, New Haven, CT
| | - Roland A Matsouaka
- From the Department of Neurology (J.A.), Columbia University Medical Center, New York, NY; Duke Clinical Research Institute (J.W., S.S., Y.X., R.A.M.), Durham, NC; Division of Cardiology (G.C.F.), Ronald Reagan-UCLA Medical Center, Los Angeles, CA; Department of Clinical Neurosciences and Hotchkiss Brain Institute (E.E.S.), University of Calgary, Canada; Department of Neurology (S.S.), Duke University Hospital; Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Brigham and Women's Hospital Heart & Vascular Center (D.L.B.) and Department of Neurology, Massachusetts General Hospital (L.H.S.), Harvard Medical School, Boston; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Biostatistics and Bioinformatics (R.A.M.), Duke University, Durham, NC; and Department of Neurology (K.N.S.), Division of Neurocritical Care & Emergency Neurology, Yale University, New Haven, CT
| | - Kevin N Sheth
- From the Department of Neurology (J.A.), Columbia University Medical Center, New York, NY; Duke Clinical Research Institute (J.W., S.S., Y.X., R.A.M.), Durham, NC; Division of Cardiology (G.C.F.), Ronald Reagan-UCLA Medical Center, Los Angeles, CA; Department of Clinical Neurosciences and Hotchkiss Brain Institute (E.E.S.), University of Calgary, Canada; Department of Neurology (S.S.), Duke University Hospital; Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Brigham and Women's Hospital Heart & Vascular Center (D.L.B.) and Department of Neurology, Massachusetts General Hospital (L.H.S.), Harvard Medical School, Boston; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Biostatistics and Bioinformatics (R.A.M.), Duke University, Durham, NC; and Department of Neurology (K.N.S.), Division of Neurocritical Care & Emergency Neurology, Yale University, New Haven, CT
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Giorli E, Schirinzi E, Baldi R, Mannironi A, Raggio E, Reale N, Gandolfo C, Del Sette M. Planning a campaign to fight stroke: an educational pilot project in La Spezia, Italy. Neurol Sci 2019; 40:2133-2140. [PMID: 31183674 DOI: 10.1007/s10072-019-03963-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 06/03/2019] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Best medical treatments of ischemic stroke are admission to stroke unit, intravenous thrombolysis and, in selected cases, thrombectomy. Time from symptom onset to interventions is the best predictor of clinical outcome. In order to verify the effectiveness of an active education programme of awareness on the knowledge of stroke, we performed a local campaign "on the field". SUBJECTS AND METHODS We selected 101 subjects from the general population who took part in the "stroke awareness campaign" organised by the Italian Association for the fight against stroke (A.L.I.Ce). Mean age was 59 years (50% female; 50% male); 55% of the sample reported a high level of education (> 8 years: high school or university degree). After a short multiple-choice questionnaire, we administered a face-to-face standard educational protocol (15 min). The efficacy of that educational intervention was then verified after a period of 12 months, by telephone interview. RESULTS There was improvement both in the definition of stroke (66% vs. 92%, p < .001) and in recognizing symptoms and signs (19% vs. 72%, p < .001). Knowledge of the importance of stroke unit in the acute treatment of stroke did not improve, as it was already high on baseline (92% vs. 97%, p: n.s.). The improvement was evident in particular in younger and higher educated people, without difference in gender. There was no difference based on risk factor profiles of participants. CONCLUSIONS Our results suggest that a personalised education can improve knowledge on stroke symptoms and signs, independently of gender and personal risk factors. The results should be verified in larger and less selection population.
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Affiliation(s)
- Elisa Giorli
- Unit of Neurology, St. Andrea Hospital, La Spezia, Italy.
- A.L.I.Ce. Liguria, Associazione Lotta all'Ictus Cerebrale, Genoa, Italy.
| | - E Schirinzi
- A.L.I.Ce. Liguria, Associazione Lotta all'Ictus Cerebrale, Genoa, Italy
- Unit of Neurology, E.O. Ospedali Galliera, Genoa, Italy
| | - R Baldi
- S.S.D. Epidemiology, St. Andrea Hospital, La Spezia, Italy
| | - A Mannironi
- Unit of Neurology, St. Andrea Hospital, La Spezia, Italy
- A.L.I.Ce. Liguria, Associazione Lotta all'Ictus Cerebrale, Genoa, Italy
| | - E Raggio
- S.S.D. Epidemiology, St. Andrea Hospital, La Spezia, Italy
| | - N Reale
- A.L.I.Ce. Liguria, Associazione Lotta all'Ictus Cerebrale, Genoa, Italy
| | - C Gandolfo
- A.L.I.Ce. Liguria, Associazione Lotta all'Ictus Cerebrale, Genoa, Italy
- Department of Neuroscience, Ophthalmology and Genetics, University of Genoa, Genoa, Italy
| | - M Del Sette
- A.L.I.Ce. Liguria, Associazione Lotta all'Ictus Cerebrale, Genoa, Italy
- Unit of Neurology, E.O. Ospedali Galliera, Genoa, Italy
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Nishimura RA, O’Gara PT, Bavaria JE, Brindis RG, Carroll JD, Kavinsky CJ, Lindman BR, Linderbaum JA, Little SH, Mack MJ, Mauri L, Miranda WR, Shahian DM, Sundt TM. 2019 AATS/ACC/ASE/SCAI/STS Expert Consensus Systems of Care Document: A Proposal to Optimize Care for Patients With Valvular Heart Disease. Ann Thorac Surg 2019; 107:1884-1910. [DOI: 10.1016/j.athoracsur.2019.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 03/08/2019] [Indexed: 10/27/2022]
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2019 AATS/ACC/ASE/SCAI/STS Expert Consensus Systems of Care Document: A Proposal to Optimize Care for Patients With Valvular Heart Disease. J Am Coll Cardiol 2019; 73:2609-2635. [DOI: 10.1016/j.jacc.2018.10.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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35
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Nishimura RA, O'Gara PT, Bavaria JE, Brindis RG, Carroll JD, Kavinsky CJ, Lindman BR, Linderbaum JA, Little SH, Mack MJ, Mauri L, Miranda WR, Shahian DM, Sundt TM. 2019 AATS/ACC/ASE/SCAI/STS Expert Consensus Systems of Care Document: A Proposal to Optimize Care for Patients With Valvular Heart Disease: A Joint Report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Soc Echocardiogr 2019; 32:683-707. [PMID: 31010608 DOI: 10.1016/j.echo.2019.02.016] [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: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Laura Mauri
- American College of Cardiology representative
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2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: A proposal to optimize care for patients with valvular heart disease: A joint report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Thorac Cardiovasc Surg 2019; 157:e327-e354. [PMID: 31010585 DOI: 10.1016/j.jtcvs.2019.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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37
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Nishimura RA, O'Gara PT, Bavaria JE, Brindis RG, Carroll JD, Kavinsky CJ, Lindman BR, Linderbaum JA, Little SH, Mack MJ, Mauri L, Miranda WR, Shahian DM, Sundt TM. 2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: A proposal to optimize care for patients with valvular heart disease. Catheter Cardiovasc Interv 2019; 94:3-26. [DOI: 10.1002/ccd.28196] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Laura Mauri
- American College of Cardiology Representative
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Comparisons of the surgical outcomes and medical costs between transferred and directly admitted patients diagnosed with intestinal obstruction in an American tertiary referral center. Int J Colorectal Dis 2018; 33:1617-1625. [PMID: 29679151 DOI: 10.1007/s00384-018-3052-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE Intestinal obstruction is a leading cause of patient mortality and the most common reason for emergent operation in colorectal surgery. The influence of inter-hospital transfer on patients' outcomes varies greatly in different diseases. We aimed to compare the surgical outcomes and medical costs between transferred and directly admitted patients diagnosed with intestinal obstruction in an American tertiary referral center. METHODS All intestinal obstruction patients operated in Cleveland Clinic from Jan 2012 to Dec 2016 were collected from a prospectively maintained database. Preoperative characteristics; surgical outcomes, including intraoperative complication, postoperative complication, readmission, reoperation, and postoperative 30-day mortality; and medical cost were collected. All parameters were compared between two groups before and after propensity score match. Multivariate logistic analysis was used to explore risk factors of surgical outcomes. RESULTS A total of 576 patients were included, with 75 in the transferred group and 501 in the directly admitted group. Before match, the transferred patients had longer waiting interval from admission to surgery (p < 0.001), more contaminated or infected wounds (p = 0.02), different surgical procedures (p = 0.02), and similar surgical outcomes and total medical cost (all p > 0.05), compared with the directly admitted group. Multivariate analysis showed that inter-hospital transfer was not an independent predictor of any surgical outcome. After matching to balance the preoperative characteristics between two groups, no significant differences were identified in all surgical outcomes and total medical cost between two groups (all p > 0.05). CONCLUSIONS Compared with directly admitted patients, transferred intestinal obstruction patients are associated with similar surgical outcomes and similar medical costs.
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Hubert GJ, Santo G, Vanhooren G, Zvan B, Tur Campos S, Alasheev A, Abilleira S, Corea F. Recommendations on telestroke in Europe. Eur Stroke J 2018; 4:101-109. [PMID: 31259258 DOI: 10.1177/2396987318806718] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 09/20/2018] [Indexed: 11/17/2022] Open
Abstract
Lack of stroke specialists determines that many European rural areas remain underserved. Use of telemedicine in stroke care has shown to be safe, increase use of evidence-based therapy and enable coverage of large areas of low population density. The aim of this article is to summarise the following recommendations of the Telestroke Committee of the European Stroke Organisation on the setup of telestroke networks in Europe: Hospitals participating in telestroke networks should be chosen according to criteria that include population density, transportation distance, geographic specifics and in-hospital infrastructure and professional resources. Three hospital categories are identified to be part of a hub-and-spoke network: (1) the Telemedicine Stroke Centre (an European Stroke Organisation stroke centre or equivalent with specific infrastructure and setup for network and telemedicine support), (2) the telemedicine-assisted stroke Unit (equivalent to an European Stroke Organisation stroke unit but without 24 h onsite stroke expertise) and (3) the telemedicine-assisted stroke ready hospital (only covering hyperacute treatment in the emergency department and transferring all patients for further treatment).
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Affiliation(s)
- Gordian J Hubert
- Department of Neurology, TEMPiS network, Munich Clinic, Munich, Germany
| | - Gustavo Santo
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Geert Vanhooren
- Department of Neurology, AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium
| | - Bojana Zvan
- TeleKap network, Ljubljana University Medical Center, Ljubljana, Slovenia
| | | | - Andrey Alasheev
- Sverdlovsk Regional Clinical Hospital #1, Yekaterinburg, Russia
| | - Sònia Abilleira
- Stroke Programme, Agency for Health Quality and Assessment of Catalonia, CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Francesco Corea
- Stroke and Neurology Clinic, San Giovanni Battista Hospital, Foligno, Italy
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He M, Wang J, Dong Q, Ji N, Meng P, Liu N, Geng S, Qin S, Xu W, Zhang C, Li D, Zhang H, Zhu J, Qin H, Hui R, Wang Y. Community-based stroke system of care improves patient outcomes in Chinese rural areas. J Epidemiol Community Health 2018. [PMID: 29514926 DOI: 10.1136/jech-2017-210185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Building effective and efficient stroke care systems is a key step in improving prevention, treatment and rehabilitation of stroke. The aim of this study was to evaluate the effectiveness of this stroke system of care on stroke management during a 2-year follow-up. METHODS A stroke system of care was developed from November 2009 to November 2010 in three townships in Ganyu County. Additional three matched townships were invited as controls. We first investigated the stroke incidence of these populations. Subsequently, this stroke system of care and an educational campaign in the three intervention townships were implemented and the effectiveness of the system was evaluated in the next 2 years. RESULTS At postintervention, more patients in the intervention communities obtained stroke knowledge and then the proportion of patients with stroke who were admitted within 3 hours of onset markedly increased in 2012 (12.0% vs 8.1%, p=0.044) and in 2013 (15.2% vs 9.7%, p=0.008) compared with those in the control communities. In the intervention communities, this proportion of patients with acute ischaemic stroke who received thrombolytic treatment was markedly raised from 2.1% in 2012 to 3.0% in 2013. More importantly, the fatality rate substantially decreased in 2013 in the intervention communities compared with that in the control communities (6.1% vs 9.7%, p=0.032). Similarly, the disability rate significantly decreased in 2013 (45.3% vs 51.5%, p=0.045). CONCLUSIONS The community-based stroke system of care was effective and practical for optimising stroke treatments and improving patient outcomes. TRIAL REGISTRATION NUMBER ChiCTR-RCH-13003408, Post-results.
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Affiliation(s)
- Mingli He
- The First People's Hospital of Lianyungang City, Lianyungang, China
| | - Jin'e Wang
- College of Medical Science, China Three Gorges University, Yichang, China
| | - Qing Dong
- Lianyungang City Commission of Health and Family Planning, Lianyungang, China
| | - Niu Ji
- The First People's Hospital of Lianyungang City, Lianyungang, China
| | - Pin Meng
- The First People's Hospital of Lianyungang City, Lianyungang, China
| | - Na Liu
- The First People's Hospital of Lianyungang City, Lianyungang, China
| | - Shan Geng
- The First People's Hospital of Lianyungang City, Lianyungang, China
| | - Sizhou Qin
- Ganyu County Commission of Health and Family Planning, Ganyu, China
| | - Wenyan Xu
- Ganyu County Commission of Health and Family Planning, Ganyu, China
| | - Chuantong Zhang
- Ganyu County Commission of Health and Family Planning, Ganyu, China
| | - Dabo Li
- The People's Hospital of Ganyu County, Ganyu, China
| | - Huamin Zhang
- The People's Hospital of Ganyu County, Ganyu, China
| | - Jinping Zhu
- The People's Hospital of Ganyu County, Ganyu, China
| | - Hua Qin
- The People's Hospital of Ganyu County, Ganyu, China
| | - Rutai Hui
- State Key Laboratory of Cardiovascular Disease, Sino-German Laboratory for Molecular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yibo Wang
- State Key Laboratory of Cardiovascular Disease, Sino-German Laboratory for Molecular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Mullen MT, Pajerowski W, Messé SR, Mechem CC, Jia J, Abboud M, David G, Carr BG, Band R. Geographic Modeling to Quantify the Impact of Primary and Comprehensive Stroke Center Destination Policies. Stroke 2018; 49:1021-1023. [PMID: 29491140 DOI: 10.1161/strokeaha.118.020691] [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: 10/20/2018] [Revised: 01/08/2018] [Accepted: 01/25/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We evaluated the impact of a primary stroke center (PSC) destination policy in a major metropolitan city and used geographic modeling to evaluate expected changes for a comprehensive stroke center policy. METHODS We identified suspected stroke emergency medical services encounters from 1/1/2004 to 12/31/2013 in Philadelphia, PA. Transport times were compared before and after initiation of a PSC destination policy on 10/3/2011. Geographic modeling estimated the impact of bypassing the closest hospital for the closest PSC and for the closest comprehensive stroke center. RESULTS There were 2 326 943 emergency medical services runs during the study period, of which 15 099 had a provider diagnosis of stroke. Bypassing the closest hospital for a PSC was common before the official policy and increased steadily over time. Geographic modeling suggested that bypassing the closest hospital in favor of the closest PSC adds a median of 3.1 minutes to transport time. Bypassing to the closest comprehensive stroke center would add a median of 8.3 minutes. CONCLUSIONS Within a large metropolitan area, the time cost of routing patients preferentially to PSCs and comprehensive stroke centers is low.
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Affiliation(s)
- Michael T Mullen
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.).
| | - William Pajerowski
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - Steven R Messé
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - C Crawford Mechem
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - Judy Jia
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - Michael Abboud
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - Guy David
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - Brendan G Carr
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - Roger Band
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
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Miller EC. Response by Miller to Letter Regarding Article, "Incorporating Nonphysician Stroke Specialists into the Stroke Team". Stroke 2018; 49:e33. [PMID: 29284728 PMCID: PMC5780251 DOI: 10.1161/strokeaha.117.020000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Eliza C. Miller
- Department of Neurology, Columbia University Medical Center, Address: 710 West 168 Street, 6 floor, New York, NY 10032, 212-305-8389
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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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Dozois A, Hampton L, Kingston CW, Lambert G, Porcelli TJ, Sorenson D, Templin M, VonCannon S, Asimos AW. PLUMBER Study (Prevalence of Large Vessel Occlusion Strokes in Mecklenburg County Emergency Response). Stroke 2017; 48:3397-3399. [PMID: 29070716 DOI: 10.1161/strokeaha.117.018925] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 08/17/2017] [Accepted: 08/28/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The recently proposed American Heart Association/American Stroke Association EMS triage algorithm endorses routing patients with suspected large vessel occlusion (LVO) acute ischemic strokes directly to endovascular centers based on a stroke severity score. The predictive value of this algorithm for identifying LVO is dependent on the overall prevalence of LVO acute ischemic stroke in the EMS population screened for stroke, which has not been reported. METHODS We performed a cross-sectional study of patients transported by our county's EMS agency who were dispatched as a possible stroke or had a primary impression of stroke by paramedics. We determined the prevalence of LVO by reviewing medical record imaging reports based on a priori specified criteria. RESULTS We enrolled 2402 patients, of whom 777 (32.3%) had an acute stroke-related diagnosis. Among 485 patients with acute ischemic stroke, 24.1% (n=117) had an LVO, which represented only 4.87% (95% confidence interval, 4.05%-5.81%) of the total EMS population screened for stroke. CONCLUSIONS Overall, the prevalence of LVO acute ischemic stroke in our EMS population screened for stroke was low. This is an important consideration for any EMS stroke severity-based triage protocol and should be considered in predicting the rates of overtriage to endovascular stroke centers.
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Affiliation(s)
- Adeline Dozois
- From the Department of Emergency Medicine, Carolinas Medical Center, Carolinas Health System, Charlotte, NC (A.D., A.W.A.); CHS Northeast (L.H.), CHS Pineville (G.L.), and Center for Outcomes Research and Evaluation (M.T.), Carolinas Healthcare System, Charlotte, NC; Department of Neurology, Novant Health Presbyterian Medical Center, Charlotte, NC (C.W.K., D.S., S.V.C.); and Mecklenburg Emergency Medical Services Agency, Charlotte, NC (T.J.P.).
| | - Lorrie Hampton
- From the Department of Emergency Medicine, Carolinas Medical Center, Carolinas Health System, Charlotte, NC (A.D., A.W.A.); CHS Northeast (L.H.), CHS Pineville (G.L.), and Center for Outcomes Research and Evaluation (M.T.), Carolinas Healthcare System, Charlotte, NC; Department of Neurology, Novant Health Presbyterian Medical Center, Charlotte, NC (C.W.K., D.S., S.V.C.); and Mecklenburg Emergency Medical Services Agency, Charlotte, NC (T.J.P.)
| | - Carlene W Kingston
- From the Department of Emergency Medicine, Carolinas Medical Center, Carolinas Health System, Charlotte, NC (A.D., A.W.A.); CHS Northeast (L.H.), CHS Pineville (G.L.), and Center for Outcomes Research and Evaluation (M.T.), Carolinas Healthcare System, Charlotte, NC; Department of Neurology, Novant Health Presbyterian Medical Center, Charlotte, NC (C.W.K., D.S., S.V.C.); and Mecklenburg Emergency Medical Services Agency, Charlotte, NC (T.J.P.)
| | - Gwen Lambert
- From the Department of Emergency Medicine, Carolinas Medical Center, Carolinas Health System, Charlotte, NC (A.D., A.W.A.); CHS Northeast (L.H.), CHS Pineville (G.L.), and Center for Outcomes Research and Evaluation (M.T.), Carolinas Healthcare System, Charlotte, NC; Department of Neurology, Novant Health Presbyterian Medical Center, Charlotte, NC (C.W.K., D.S., S.V.C.); and Mecklenburg Emergency Medical Services Agency, Charlotte, NC (T.J.P.)
| | - Thomas J Porcelli
- From the Department of Emergency Medicine, Carolinas Medical Center, Carolinas Health System, Charlotte, NC (A.D., A.W.A.); CHS Northeast (L.H.), CHS Pineville (G.L.), and Center for Outcomes Research and Evaluation (M.T.), Carolinas Healthcare System, Charlotte, NC; Department of Neurology, Novant Health Presbyterian Medical Center, Charlotte, NC (C.W.K., D.S., S.V.C.); and Mecklenburg Emergency Medical Services Agency, Charlotte, NC (T.J.P.)
| | - Denise Sorenson
- From the Department of Emergency Medicine, Carolinas Medical Center, Carolinas Health System, Charlotte, NC (A.D., A.W.A.); CHS Northeast (L.H.), CHS Pineville (G.L.), and Center for Outcomes Research and Evaluation (M.T.), Carolinas Healthcare System, Charlotte, NC; Department of Neurology, Novant Health Presbyterian Medical Center, Charlotte, NC (C.W.K., D.S., S.V.C.); and Mecklenburg Emergency Medical Services Agency, Charlotte, NC (T.J.P.)
| | - Megan Templin
- From the Department of Emergency Medicine, Carolinas Medical Center, Carolinas Health System, Charlotte, NC (A.D., A.W.A.); CHS Northeast (L.H.), CHS Pineville (G.L.), and Center for Outcomes Research and Evaluation (M.T.), Carolinas Healthcare System, Charlotte, NC; Department of Neurology, Novant Health Presbyterian Medical Center, Charlotte, NC (C.W.K., D.S., S.V.C.); and Mecklenburg Emergency Medical Services Agency, Charlotte, NC (T.J.P.)
| | - Shellie VonCannon
- From the Department of Emergency Medicine, Carolinas Medical Center, Carolinas Health System, Charlotte, NC (A.D., A.W.A.); CHS Northeast (L.H.), CHS Pineville (G.L.), and Center for Outcomes Research and Evaluation (M.T.), Carolinas Healthcare System, Charlotte, NC; Department of Neurology, Novant Health Presbyterian Medical Center, Charlotte, NC (C.W.K., D.S., S.V.C.); and Mecklenburg Emergency Medical Services Agency, Charlotte, NC (T.J.P.)
| | - Andrew W Asimos
- From the Department of Emergency Medicine, Carolinas Medical Center, Carolinas Health System, Charlotte, NC (A.D., A.W.A.); CHS Northeast (L.H.), CHS Pineville (G.L.), and Center for Outcomes Research and Evaluation (M.T.), Carolinas Healthcare System, Charlotte, NC; Department of Neurology, Novant Health Presbyterian Medical Center, Charlotte, NC (C.W.K., D.S., S.V.C.); and Mecklenburg Emergency Medical Services Agency, Charlotte, NC (T.J.P.)
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Slivinski A, Jones R, Whitehead H, Hooper V. Improving Access to Stroke Care in the Rural Setting: The Journey to Acute Stroke Ready Designation. J Emerg Nurs 2017; 43:24-32. [PMID: 28131346 DOI: 10.1016/j.jen.2016.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 10/08/2016] [Accepted: 10/10/2016] [Indexed: 11/25/2022]
Abstract
Stroke is the fifth highest cause of death and the leading cause of long-term disability in the United States. North Carolina has one of the highest death rates from stroke in the nation. Access to acute stroke care in rural western North Carolina is limited, with only one primary stroke center within an 18-county region. Angel Medical Center, located in rural western North Carolina, sought to pursue The Joint Commission's disease-specific certification as an Acute Stroke Ready Hospital in an effort to improve stroke care and outcomes across the region. METHODS A multidisciplinary team of ED clinicians, hospital leadership, and community participants was formed to develop a structured care algorithm and intensive process improvement initiatives to guide the Acute Stroke Ready Hospital application process. RESULTS In the 7 months since implementation, door-to-laboratory results have improved by an average of 12 minutes, door-to-computed tomography interpretation has improved by 3 minutes, time to intravenous thrombolytics has improved to less than 60 minutes, and patient transfer within 2 hours of arrival has also improved. ED provider average response time has been reduced by 5 minutes, and time to neurology via telemedicine has been reduced by almost 10 minutes. IMPLICATIONS FOR PRACTICE By driving best practices in the delivery of stroke care, Angel Medical Center enhanced stroke care in a rural community, allowing patients and families to receive evaluation and treatment in a timely and efficient manner close to home.
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Assis ZA, Menon BK, Goyal M. Imaging department organization in a stroke center and workflow processes in acute stroke. Eur J Radiol 2017; 96:120-124. [PMID: 28711339 DOI: 10.1016/j.ejrad.2017.06.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 06/18/2017] [Indexed: 01/08/2023]
Abstract
The imaging department is an integral part of the stroke management task force and plays a critical role. Accurate and timely interpretation of images obtained in the emergency department and involvement in decision-making has contributed immensely in stroke care. In fact, the treatment paradigm has changed considerably after the recent positive endovascular clinical trials; and so is the hospital workflow and treatment site. As a result, the imaging department has become the site of maximum activity during an acute stroke protocol. Time management, teamwork and standardized institutional protocols contribute to improve functional outcome. In this review article, we emphasize the critical role an Imaging department's organization plays in a stroke center and the workflow involved in management of acute stroke.
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Affiliation(s)
- Zarina Abdul Assis
- Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Alberta, T2N2T9 Canada
| | - Bijoy K Menon
- Calgary Stroke Program and the Department of Radiology, Clinical Neurosciences and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Mayank Goyal
- Department of Radiology, Seaman Family MR Research Centre, 3330 Hospital Drive NW Calgary, AB T2E 4N1, Canada.
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George MG, Fischer L, Koroshetz W, Bushnell C, Frankel M, Foltz J, Thorpe PG. CDC Grand Rounds: Public Health Strategies to Prevent and Treat Strokes. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2017; 66:479-481. [PMID: 28493856 PMCID: PMC5657990 DOI: 10.15585/mmwr.mm6618a5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Worldwide, stroke is the second leading cause of death and a leading cause of serious long-term disability. In the United States, nearly 800,000 strokes occur each year; thus stroke is the fifth leading cause of death overall and the fourth leading cause of death among women (1). Major advances in stroke prevention through treatment of known risk factors has led to stroke being considered largely preventable. For example, in the United States, stroke mortality rates have declined 70% over the past 50 years, in large part because of important reductions in hypertension, tobacco smoking, and more recently, increased use of anticoagulation for atrial fibrillation (2,3). Although the reduction in stroke mortality is recognized as one of the 10 great public health achievements of the 20th century (4), gains can still be made. Approximately 80% of strokes could be prevented by screening for and addressing known risks with measures such as improving hypertension control, smoking cessation, diabetes prevention, cholesterol management, increasing use of anticoagulation for atrial fibrillation, and eliminating excessive alcohol consumption (5,6).
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Abstract
BACKGROUND With increasing public reporting of outcomes and bundled payments, hospitals and providers are scrutinized for morbidity and mortality. The impact of patient transfer before colorectal surgery has not been well characterized in a risk-adjusted fashion. OBJECTIVE We hypothesized that hospital-to-hospital transfer would independently predict morbidity and mortality beyond traditional predictor variables. DESIGN We constructed a retrospective cohort of 158,446 patients who underwent colorectal surgery using the 2009-2013 American College of Surgeons National Surgical Quality Improvement Program database. SETTINGS The study was conducted at a tertiary care hospital. PATIENTS All of the patients who underwent colorectal surgery during the study period were included. Patients were excluded for unknown transfer status or transfer from a chronic care facility. MAIN OUTCOME MEASURES Baseline characteristics were compared by transfer status. Multivariate logistic regression was used to evaluate the impact of transfer on major complications and mortality. RESULTS A total of 7259 operations (4.6%) were performed after transfer. Transferred patients had higher rates of complications (p < 0.0001) with significant differences in unplanned endotracheal reintubation, bleeding, organ-space surgical site infection, wound dehiscence, postoperative sepsis, cardiac arrest requiring cardiopulmonary resuscitation, deep venous thrombosis, and myocardial infarction. Transferred patients also had longer hospital stays (9 vs 6 days; p < 0.0001) and a higher risk of death (13.2% vs 2.6%; p < 0.0001). On multivariate analysis, transferred patients had higher mortality rates despite risk adjustment (OR = 1.13 (95% CI, 1.02-1.25); p = 0.019) and were also more likely to have serious complications (OR = 1.12 (95% CI, 1.06-1.19); p < 0.001). LIMITATIONS We were unable to analyze outcomes beyond 30 days, and we did not have information on preoperative evaluation or the reason for patient transfer. CONCLUSIONS Hospital-to-hospital transfer independently contributed to patient morbidity and mortality in patients undergoing colorectal surgery. The impact of hospital transfer must be considered when evaluating surgeon and hospital performance, because the increased risk of serious complications or death is not fully accounted for by traditional methods.
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Rhew DC, Owens SH, Buckner JB, Kueider SS. A Rural Hospital's Journey to Becoming a Certified Acute Stroke-Ready Hospital. J Emerg Nurs 2017; 43:33-39. [PMID: 28131348 DOI: 10.1016/j.jen.2016.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/28/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022]
Abstract
PROBLEM For many stroke patients, rural emergency departments are the first point of medical care to stop brain cell death. We identified a need to meet standards to improve outcomes for stroke care. METHODS An interdisciplinary Stroke Continuous Process Improvement Committee was formed. We conducted a gap analysis to address current stroke care processes. Chart audits were performed, and strategies to meet the requirements for recognition as an Acute Stroke Ready Hospital (ASRH) were implemented. The ASRH guidelines guided our certification journey. RESULTS ASRH certification was achieved. In addition, stroke care outcomes such as door-to-computed tomography results, door-to-international normalized ratio results, door teleneurology consultation, and door-to-needle time have improved. IMPLICATIONS FOR PRACTICE Achieving certification makes a strong statement to the community about a hospital's efforts to provide the highest quality in stroke care services. Becoming a certified ASRH promotes quality of patient care by reducing variation in clinical processes.
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Feasibility and Efficacy of Nurse-Driven Acute Stroke Care. J Stroke Cerebrovasc Dis 2016; 26:987-991. [PMID: 28012837 DOI: 10.1016/j.jstrokecerebrovasdis.2016.11.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 11/07/2016] [Accepted: 11/09/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Acute stroke care requires rapid assessment and intervention. Replacing traditional sequential algorithms in stroke care with parallel processing using telestroke consultation could be useful in the management of acute stroke patients. The purpose of this study was to assess the feasibility of a nurse-driven acute stroke protocol using a parallel processing model. METHODS This is a prospective, nonrandomized, feasibility study of a quality improvement initiative. Stroke team members had a 1-month training phase, and then the protocol was implemented for 6 months and data were collected on a "run-sheet." The primary outcome of this study was to determine if a nurse-driven acute stroke protocol is feasible and assists in decreasing door to needle (intravenous tissue plasminogen activator [IV-tPA]) times. RESULTS Of the 153 stroke patients seen during the protocol implementation phase, 57 were designated as "level 1" (symptom onset <4.5 hours) strokes requiring acute stroke management. Among these strokes, 78% were nurse-driven, and 75% of the telestroke encounters were also nurse-driven. The average door to computerized tomography time was significantly reduced in nurse-driven codes (38.9 minutes versus 24.4 minutes; P < .04). CONCLUSIONS The use of a nurse-driven protocol is feasible and effective. When used in conjunction with a telestroke specialist, it may be of value in improving patient outcomes by decreasing the time for door to decision for IV-tPA.
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