Therapeutic yield and outcomes of a community teaching hospital code stroke protocol

Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

Imbalanced Regional Development of Acute Ischemic Stroke Care in Emergency Departments in China

Objective

Most patients of acute ischemic stroke (AIS) receive treatments in the department of emergency in China. We aimed to examine the status of AIS diagnosis and treatment and the impact of green pathway operation in different regions of China.

Methods

In this nationwide survey, information regarding the emergency care of AIS was collected from 451 hospitals in different regions of China, by interviewing 484 physicians from these hospitals. Structured questionnaire was used to explore the status of AIS care and impact of the green pathway.

Results

445 hospitals from 18 provinces, 4 municipalities, and 3 ethnic autonomous regions in China were included in the present study. Overall, the proportion of door-to-needle time (DNT) less than 60 min was 66.08% in the enrolled hospitals (n = 298). Stratified by regions, the results suggested that hospitals located in East regions had shorter DNT time (P=0.036), and more proportion of rtPA (P < 0.001) than those in West regions. Further analysis suggested that hospitals with a green channel were more likely to shorten DNT and improve the proportion of rtPA (P < 0.01).

Conclusion

Considerable regional differences were observed in terms of DNT time and thrombolysis rates in the departments of emergency in China. Further studies are required to confirm the regional differences in AIS care in China.

2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations for clinicians caring for adult patients with acute arterial ischemic stroke in a single document. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 guidelines and subsequent updates.

METHODS

Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. The members of the writing group unanimously approved all recommendations except when relations with industry precluded members voting. Prerelease review of the draft guideline was performed by 4 expert peer reviewers and by the members of the Stroke Council's Scientific Statements Oversight Committee and Stroke Council Leadership Committee. These guidelines use the American College of Cardiology/American Heart Association 2015 Class of Recommendations and Levels of Evidence and the new American Heart Association guidelines format.

RESULTS

These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings.

CONCLUSIONS

These guidelines are based on the best evidence currently available. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

The Emergency Care of Patients With Cancer: Setting the Research Agenda

To identify research priorities and appropriate resources and to establish the infrastructure required to address the emergency care of patients with cancer, the National Institutes of Health's National Cancer Institute and the Office of Emergency Care Research sponsored a one-day workshop, "Cancer and Emergency Medicine: Setting the Research Agenda," in March 2015 in Bethesda, MD. Participants included leading researchers and clinicians in the fields of oncology, emergency medicine, and palliative care, and representatives from the National Institutes of Health. Attendees were charged with identifying research opportunities and priorities to advance the understanding of the emergency care of cancer patients. Recommendations were made in 4 areas: the collection of epidemiologic data, care of the patient with febrile neutropenia, acute events such as dyspnea, and palliative care in the emergency department setting.

A comparison of rt-PA thrombolysis guidelines between China and the USA: are changes needed?

BACKGROUND AND PURPOSE

Thrombolytic treatment criteria vary significantly between China and the USA. We reviewed current intravenous (IV) thrombolytic therapy practices in China and the USA to determine the most appropriate.

METHODS

We conducted a systematic review of studies that used IV recombinant tissue plasminogen activator (rt-PA) therapy in China and the USA published between January 1950 and April 2012.

RESULTS

Literature search identified 17 American and 9 Chinese studies with a total of 2545 subjects. We found a significantly lower mortality rate in the US data compared with China (8% versus 13%; Chi-square  =  24.412, P < 0.001). Our meta-regression analysis uncovered significant factors influencing mortality including male sex, hypertension, high cholesterol, smoking, and onset to treatment time (all P < 0.05). There were significantly more favorable outcomes in China than in the USA (61% versus 49%, Chi-square  =  19.159, P < 0.001). No prior history of stroke and shorter onset to IV time were also significantly associated with a favorable outcome (P < 0.05).

CONCLUSIONS

Onset to IV time is critical for reducing mortality and improving favorable outcomes. We suggest Chinese acute ischemic stroke treatment guidelines be revised to include an increase in the age limit of 80 years, removing contraindications such as a history of previous sever heart, liver, and kidney dysfunction, and placing more emphasis on physician expertise.

Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates.

METHODS

Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm.

RESULTS

The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation.

CONCLUSIONS

Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.

The ABCD and ABCD2 Scores and the Risk of Stroke following a TIA: A Narrative Review

The California, ABCD, and ABCD2 risk scores (ABCD system) were developed to help stratify short-term stroke risk in patients with TIA (transient ischemic attack). Beyond this scope, the ABCD system has been extensively used to study other prognostic information such as DWI (diffusion-weighted imaging) abnormalities, large artery stenosis, atrial fibrillation and its diagnostic accuracy in TIA patients, which are independent predictors of subsequent stroke in TIA patients. Our comprehensive paper suggested that all scores have and equivalent prognostic value in predicting short-term risk of stroke; however, the ABCD2 score is being predominantly used at most centers. The majority of studies have shown that more than half of the strokes in the first 90 days, occur in the first 7 days. The majority of patients studied were predominantly classified to have a higher ABCD/ABCD2 > 3 scores and were particularly at a higher short-term risk of stroke or TIA and other vascular events. However, patients with low risk ABCD2 score < 4 may have high-risk prognostic indicators, such as diffusion weighted imaging (DWI) abnormalities, large artery atherosclerosis (LAA), and atrial fibrillation (AF). The prognostic value of these scores improved if used in conjunction with clinical information, vascular imaging data, and brain imaging data. Before more data become available, the diagnostic value of these scores, its applicability in triaging patients, and its use in evaluating long-term prognosis are rather secondary; thus, indicating that the primary significance of these scores is for short-term prognostic purposes.

Multimodal strategy in the successful implementation of a stroke unit in a community hospital

OBJECTIVES

Thrombolysis in stroke remains underutilized in daily practice. We analyzed the impact of a multimodal strategy on the rate of thrombolysis and specific procedure times during the implementation of a community hospital stroke unit.

MATERIAL AND METHODS

During a period of 2 years before and after implementation of a stroke unit, we prospectively recorded all patients with thrombolysis and specific procedure times. Calculated door-to-needle time (DNT), door-to-CT time (DCT) and CT-to-needle time (CNT) were analyzed. All structural changes before and after the implementation were analyzed.

RESULTS

The number of patients with thrombolysis increased from 24 in 2005-2006 (4.8% of all admitted patients with ischemic stroke) to 95 in 2007-2008 (12.8%). DNT was significantly reduced from 62.2±36.1 to 38.5±22.2 min (P<0.001). DCT remained unchanged at 10.3±9.5 to 10.4±13.9 min (P=0.974), whereas CNT improved from 45.7±23.1 to 28.3±20.3 min (P=0.001). Several structural changes concerning staff, logistics, procedures and laboratory were identified which contributed to decreasing DNT.

CONCLUSIONS

A multimodal strategy including several structural changes enables the successful implementation of a community hospital stroke unit offering rapid access to thrombolysis with a very short DNT.

Safety of intravenous thrombolytic use in four emergency departments without acute stroke teams

OBJECTIVES

The objective was to evaluate safety of intravenous (IV) tissue plasminogen activator (tPA) delivered without dedicated thrombolytic stroke teams.

METHODS

This was a retrospective, observational study of patients treated between 1996 and 2005 at four southeastern Michigan hospital emergency departments (EDs) with a prospectively defined comparison to the National Institute of Neurological Disorders and Stroke (NINDS) tPA stroke study cohort. Main outcome measures were mortality, intracerebral hemorrhage (ICH), systemic hemorrhage, neurologic recovery, and guideline violations.

RESULTS

A total of 273 consecutive stroke patients were treated by 95 emergency physicians (EPs) using guidelines and local neurology resources. One-year mortality was 27.8%. Unadjusted Cox model relative risk (RR) of mortality compared to the NINDS tPA treatment and placebo groups was 1.20 (95% confidence interval [CI] = 0.87 to 1.64) and 1.04 (95% CI = 0.76 to 1.41), respectively. The rate of significant ICH by computed tomography (CT) criteria was 6.6% (odds ratio [OR] = 1.03, 95% CI = 0.56 to 1.90 compared to the NINDS tPA treatment group). The proportions of symptomatic ICH by two other prespecified sets of clinical criteria were 4.8 and 7.0%. The rate of any ICH within 36 hours of treatment was 9.9% (RR = 0.94, 95% CI = 0.58 to 1.51 compared to the NINDS tPA group). The occurrence of major systemic hemorrhage (requiring transfusion) was 1.1%. Functional recovery by the modified Rankin Scale score (mRS = 0 to 2) at discharge occurred in 38% of patients with a premorbid disability mRS < 2. Guideline deviations occurred in the ED in 26% of patients and in 25% of patients following admission.

CONCLUSIONS

In these EDs there was no evidence of increased risk with respect to mortality, ICH, systemic hemorrhage, or worsened functional outcome when tPA was administered without dedicated thrombolytic stroke teams. Additional effort is needed to improve guideline compliance.

In-hospital stroke treated with intravenous tissue plasminogen activator

BACKGROUND AND PURPOSE

In-hospital strokes (IHSs) are potential candidates for thrombolysis. We analyzed the treatment procedures, safety, and efficacy of intravenous tissue plasminogen activator (IV-tPA) in IHSs compared with out-of-hospital strokes (OHSs).

METHODS

This study was based on a multicenter prospective registry of patients treated with IV-tPA divided into IHSs and OHSs. We recorded intrahospital delays and stroke outcomes.

RESULTS

Among 367 patients treated with IV-tPA, 30 were IHSs. Baseline characteristics were similar except for a greater proportion of diabetes (36.7% vs 17.5%, P=0.01), cardiac failure (16.7% vs 5.3%, P=0.014), and atrial fibrillation (33.3% vs 17.5%, P=0.034) in IHSs than OHSs. In-hospital delays were significantly longer in IHSs for door-to-computed tomography time (39.5+/-18.7 vs 22.6+/-19.7 minutes, P<0.0001) and computed tomography-to-treatment time (92.0+/-26.1 vs 65.4+/-25.8 minutes, P<0.0001). No differences were observed in safety or efficacy.

CONCLUSIONS

In-hospital procedures for thrombolysis proceed more slowly in IHSs than in OHSs. Thrombolysis is safe and efficient in IHS.

Identification of nonischemic stroke mimics among 411 code strokes at the University of California, San Diego, Stroke Center

BACKGROUND

Code Stroke systems are widely used to expedite emergency treatment of patients with stroke. Code Stroke for mimic patients-those without a stroke cause-wastes resources. We investigated how many times a Code Stroke was initiated for patients who did not have a stroke appropriate for thrombolysis.

METHODS

We conducted a retrospective review of the discharge diagnoses of all patients who presented to our emergency department as a Code Stroke. A patient was considered a stroke mimic if a stroke code was activated, but none of the first 3 International Classification of Diseases, Ninth Revision codes on discharge were transient ischemic attack-related or ischemic stroke-related.

RESULTS

A total of 411 patients presented to the emergency department as Code Stroke. In all, 104 (25.3%) were discharged without a diagnosis of stroke or transient ischemic attack. The diagnoses in this group were intracranial hemorrhage in 19 patients, subarachnoid hemorrhage 6, subdural hematoma 3, old deficit 11, hypotension 11, seizure 10, intoxication 8, hypoglycemia 7, mass lesion 6, migraine 5, and other 18. In all, 33 of 307 eligible patients (10.7%) were treated with tissue-type plasminogen activator. None of the patients with a stroke mimic received tissue-type plasminogen activator. In 44 of 104 stroke mimics (42.3%), the acute disease was caused by a severe neurologic condition other than ischemic cerebrovascular disease. Only 60 of 411 stroke codes (14.6%) were initiated for patients without a severe and acute neurologic condition.

CONCLUSIONS

In our community, 25.5% of all Code Strokes were initiated for stroke mimics. Most mimic patients had an illness likely to benefit from urgent neurologic evaluation.

Determining intravenous rt-PA eligibility in the Emergency Department

INTRODUCTION

The purpose of this study was to assess the agreement of Emergency Department (ED) attendings, ED residents, and neurology residents compared with stroke neurologists in the assessment of intravenous rt-PA eligibility.

METHODS

A convenience sample of patients presenting with possible stroke symptoms to the University of Michigan Hospital ED from June 2003 to July 2004 was identified. A physician from each of four groups: ED attending, ED resident, neurology resident, and stroke neurology attending independently evaluated each patient for eligibility for intravenous (i.v.) rt-PA. Accuracy, sensitivity, and positive predictive value (PPV) with 95% confidence intervals (CI) were calculated by physician type, compared with the stroke neurologist, for eligibility for i.v. rt-PA.

RESULTS

Exactly 36 (49%) out of the 73 evaluated patients were diagnosed with acute ischemic stroke and 11 were deemed eligible for treatment with i.v. tPA by the stroke neurologist. Agreement with the stroke neurologist for rt-PA eligibility was 93% [95% CI: 84%, 98%] (sensitivity = 82% [48%, 98%], PPV = 82% [48%, 99%]) for the ED attendings, 79% [65%, 90%] (sensitivity = 75% [35%, 97%], PPV = 43% [18% 71%]) for the ED residents, and 84% [73%, 92%] (sensitivity = 100% [74%, 100%], PPV = 52% [31%, 73%]) for the neurology residents. There were two false positive cases identified by ED attendings, eight, by ED residents, and 11 by neurology residents.

CONCLUSIONS

This study suggests that the agreement between ED attendings and stroke neurologists for determination of rt-PA eligibility is good. There is room for improvement, however, in the determination of acute stroke therapy eligibility in the ED setting especially among trainees.

Guidelines for the Early Management of Adults With Ischemic Stroke

Purpose— Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included.

Methods— Members of the panel were appointed by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council’s Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years.

Results— Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.

Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists

PURPOSE

Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included.

METHODS

Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council's Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years.

RESULTS

Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.

Geriatric neurologic emergencies

Geriatrics is an important subspecialty within the field of emergency medicine and represents a burgeoning area of practice. The special vulnerability of elderly patients to neurologic disease and injury and the comparative subtlety of clinical presentation mean that physicians should have a lower threshold for laboratory studies, radiologic imaging, consultation, and admission. Transferring appropriate patients to tertiary centers that offer specialized trauma and neurologic and neurosurgical care greatly enhances survival and functional outcomes.

Improved Quality of Stroke Care for Hospitalized Medicare Beneficiaries in Michigan

Background and Purpose— We reported previously that acute ischemic stroke patients encountered delays in obtaining neuroimaging and receiving thrombolysis, and that deep venous thrombosis prophylaxis was used only in a minority of eligible patients. We investigated whether these and other measures improved after a quality improvement initiative.

Methods— Medicare fee-for-service ischemic stroke and transient ischemic attack discharges in 136 acute care hospitals in Michigan were identified by International Classification of Diseases , 9th Revision, Clinical Modification codes. Only patients with stroke symptoms persisting for >1 hour and present on arrival were included in the analysis. Seven quality indicators were abstracted from chart review at baseline (discharges between July 1, 1998, and June 30, 1999) and at remeasurement (discharges between January 1, 2001, and June 30, 2001) after an intensive quality improvement initiative throughout Michigan hospitals. Quality indicators were compared at baseline and remeasurement.

Results— Indicators of care were determined in 5146 patients at baseline and 4980 patients on remeasurement. Four quality-of-care indicators showed significant improvement on remeasurement: antithrombotic prescribed at discharge (81.9 baseline versus 83.7% remeasurement; P =0.026), avoidance of sublingual nifedipine in patients with acute ischemic stroke (97.1 versus 99.7%; P <0.0001), documentation of a computed tomography (CT)/MRI during hospitalization (98.0 versus 99.1%; P =0.024), and appropriate deep venous thrombosis prophylaxis (13.8 versus 26.9%; P <0.0001). Time to CT/MRI did not significantly change, but time to thrombolysis improved (113 versus 88.5 minutes; P =0.045).

Conclusions— Improvement occurred in several indicators of quality of care in Michigan Medicare beneficiaries presenting with acute stroke symptoms.