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Wen R, Wang M, Bian W, Zhu H, Xiao Y, Zeng J, He Q, Wang Y, Liu X, Shi Y, Hong Z, Xu B. Effectiveness of the acute stroke care map program in reducing in-hospital delay for acute ischemic stroke in a Chinese urban area: an interrupted time series analysis. Front Neurol 2024; 15:1364952. [PMID: 38699054 PMCID: PMC11063247 DOI: 10.3389/fneur.2024.1364952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/25/2024] [Indexed: 05/05/2024] Open
Abstract
Background Timely intravenous thrombolysis (IVT) is crucial for improving outcomes in acute ischemic stroke (AIS) patients. This study evaluates the effectiveness of the Acute Stroke Care Map (ASCaM) initiative in Shenyang, aimed at reducing door-to-needle times (DNT) and thus improving the timeliness of care for AIS patients. Methods An retrospective cohort study was conducted from April 2019 to December 2021 in 30 hospitals participating in the ASCaM initiative in Shenyang. The ASCaM bundle included strategies such as EMS prenotification, rapid stroke triage, on-call stroke neurologists, immediate neuroimaging interpretation, and the innovative Pre-hospital Emergency Call and Location Identification feature. An interrupted time series analysis (ITSA) was used to assess the impact of ASCaM on DNT, comparing 9 months pre-intervention with 24 months post-intervention. Results Data from 9,680 IVT-treated ischemic stroke patients were analyzed, including 2,401 in the pre-intervention phase and 7,279 post-intervention. The ITSA revealed a significant reduction in monthly DNT by -1.12 min and a level change of -5.727 min post-ASCaM implementation. Conclusion The ASCaM initiative significantly reduced in-hospital delays for AIS patients, demonstrating its effectiveness as a comprehensive stroke care improvement strategy in urban settings. These findings highlight the potential of coordinated care interventions to enhance timely access to reperfusion therapies and overall stroke prognosis.
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Affiliation(s)
- Rui Wen
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Miaoran Wang
- Affiliated Central Hospital of Shenyang Medical College, Shenyang Medical College, Shenyang, China
| | - Wei Bian
- Shenyang First People’s Hospital, Shenyang Medical College, Shenyang, China
| | - Haoyue Zhu
- Shenyang First People’s Hospital, Shenyang Medical College, Shenyang, China
| | - Ying Xiao
- Shenyang First People’s Hospital, Shenyang Medical College, Shenyang, China
| | - Jing Zeng
- ChongQing Medical University, ChongQing, China
| | - Qian He
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Yu Wang
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Xiaoqing Liu
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Yangdi Shi
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Zhe Hong
- Shenyang First People’s Hospital, Shenyang Medical College, Shenyang, China
| | - Bing Xu
- Shenyang Tenth People’s Hospital, Shenyang, China
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Maltby S, Garcia-Esperon C, Jackson K, Butcher K, Evans JW, O'Brien W, Dixon C, Russell S, Wilson N, Kluge MG, Ryan A, Paul CL, Spratt NJ, Levi CR, Walker FR. TACTICS VR Stroke Telehealth Virtual Reality Training for Health Care Professionals Involved in Stroke Management at Telestroke Spoke Hospitals: Module Design and Implementation Study. JMIR Serious Games 2023; 11:e43416. [PMID: 38060297 PMCID: PMC10739245 DOI: 10.2196/43416] [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: 10/30/2022] [Revised: 09/06/2023] [Accepted: 10/09/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Stroke management in rural areas is more variable and there is less access to reperfusion therapies, when compared with metropolitan areas. Delays in treatment contribute to worse patient outcomes. To improve stroke management in rural areas, health districts are implementing telestroke networks. The New South Wales Telestroke Service provides neurologist-led telehealth to 23 rural spoke hospitals aiming to improve treatment delivery and patient outcomes. The training of clinical staff was identified as a critical aspect for the successful implementation of this service. Virtual reality (VR) training has not previously been used in this context. OBJECTIVE We sought to develop an evidence-based VR training module specifically tailored for stroke telehealth. During implementation, we aimed to assess the feasibility of workplace deployment and collected feedback from spoke hospital staff involved in stroke management on training acceptability and usability as well as perceived training impact. METHODS The TACTICS VR Stroke Telehealth application was developed with subject matter experts. During implementation, both quantitative and qualitative data were documented, including VR use and survey feedback. VR hardware was deployed to 23 rural hospitals, and use data were captured via automated Wi-Fi transfer. At 7 hospitals in a single local health district, staff using TACTICS VR were invited to complete surveys before and after training. RESULTS TACTICS VR Stroke Telehealth was deployed to rural New South Wales hospitals starting on April 14, 2021. Through August 20, 2023, a total of 177 VR sessions were completed. Survey respondents (n=20) indicated a high level of acceptability, usability, and perceived training impact (eg, accuracy and knowledge transfer; mean scores 3.8-4.4; 5=strongly agree). Furthermore, respondents agreed that TACTICS VR increased confidence (13/18, 72%), improved understanding (16/18, 89%), and improved awareness (17/18, 94%) regarding stroke telehealth. A comparison of matched pre- and posttraining responses revealed that training improved the understanding of telehealth workflow practices (after training: mean 4.2, SD 0.6; before training: mean 3.2, SD 0.9; P<.001), knowledge on accessing stroke telehealth (mean 4.1, SD 0.6 vs mean 3.1, SD 1.0; P=.001), the awareness of stroke telehealth (mean 4.1, SD 0.6 vs mean 3.4, SD 0.9; P=.03), ability to optimally communicate with colleagues (mean 4.2, SD 0.6 vs mean 3.7, SD 0.9; P=.02), and ability to make improvements (mean 4.0, SD 0.6 vs mean 3.5, SD 0.9; P=.03). Remote training and deployment were feasible, and limited issues were identified, although uptake varied widely (0-66 sessions/site). CONCLUSIONS TACTICS VR Stroke Telehealth is a new VR application specifically tailored for stroke telehealth workflow training at spoke hospitals. Training was considered acceptable, usable, and useful and had positive perceived training impacts in a real-world clinical implementation context. Additional work is required to optimize training uptake and integrate training into existing education pathways.
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Affiliation(s)
- Steven Maltby
- Centre for Advanced Training Systems, The University of Newcastle, Newcastle, Australia
- Hunter Medical Research Institute, New Lambton Heights, Australia
- School of Biomedical Sciences & Pharmacy, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
| | - Carlos Garcia-Esperon
- Hunter Medical Research Institute, New Lambton Heights, Australia
- John Hunter Hospital, New Lambton Heights, Australia
| | - Kate Jackson
- NSW Agency for Clinical Innovation, St Leonards, Australia
| | - Ken Butcher
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
| | - James W Evans
- Department of Neurosciences, Gosford Hospital, Gosford, Australia
| | - William O'Brien
- Department of Neurosciences, Gosford Hospital, Gosford, Australia
| | - Courtney Dixon
- NSW Agency for Clinical Innovation, St Leonards, Australia
| | - Skye Russell
- NSW Agency for Clinical Innovation, St Leonards, Australia
| | - Natalie Wilson
- NSW Agency for Clinical Innovation, St Leonards, Australia
| | - Murielle G Kluge
- Centre for Advanced Training Systems, The University of Newcastle, Newcastle, Australia
- School of Biomedical Sciences & Pharmacy, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
| | - Annika Ryan
- Hunter Medical Research Institute, New Lambton Heights, Australia
- School of Medicine and Public Health, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
| | - Christine L Paul
- Hunter Medical Research Institute, New Lambton Heights, Australia
- School of Medicine and Public Health, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
| | - Neil J Spratt
- Hunter Medical Research Institute, New Lambton Heights, Australia
- School of Biomedical Sciences & Pharmacy, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
- John Hunter Hospital, New Lambton Heights, Australia
| | - Christopher R Levi
- School of Medicine and Public Health, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
- John Hunter Health & Innovation Precinct, New Lambton Heights, Australia
| | - Frederick Rohan Walker
- Centre for Advanced Training Systems, The University of Newcastle, Newcastle, Australia
- Hunter Medical Research Institute, New Lambton Heights, Australia
- School of Biomedical Sciences & Pharmacy, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
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Radu RA, Gascou G, Machi P, Capirossi C, Costalat V, Cagnazzo F. Current and future trends in acute ischemic stroke treatment: direct-to-angiography suite, middle vessel occlusion, large core, and minor strokes. Eur J Radiol Open 2023; 11:100536. [PMID: 37964786 PMCID: PMC10641156 DOI: 10.1016/j.ejro.2023.100536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 09/18/2023] [Accepted: 10/24/2023] [Indexed: 11/16/2023] Open
Abstract
Since the publication of the landmark thrombectomy trials in 2015, the field of endovascular therapy for ischemic stroke has been rapidly growing. The very low number needed to treat to provide functional benefits shown by the initial randomized trials has led clinicians and investigators to seek to translate the benefits of endovascular therapy to other patient subgroups. Even if the treatment effect is diminished, currently available data has provided sufficient information to extend endovascular therapy to large infarct core patients. Recently, published data have also shown that sophisticated imaging is not necessary for late time- window patients. As a result, further research into patient selection and the stroke pathway now focuses on dramatically reducing door-to-groin times and improving outcomes by circumventing classical imaging paradigms altogether and employing a direct-to-angio suite approach for selected large vessel occlusion patients in the early time window. While the results of this approach mainly concern patients with severe deficits, there are further struggles to provide evidence of the efficacy and safety of endovascular treatment in minor stroke and large vessel occlusion, as well as in patients with middle vessel occlusions. The current lack of good quality data regarding these patients provides significant challenges for accurately selecting potential candidates for endovascular treatment. However, current and future randomized trials will probably elucidate the efficacy of endovascular treatment in these patient populations.
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Affiliation(s)
- Răzvan Alexandru Radu
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- Stroke Unit, Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Gregory Gascou
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Paolo Machi
- Department of Neuroradiology, University of Geneva Medical Center, Switzerland
| | - Carolina Capirossi
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- Department of Neurointerventional Radiology, Careggi Hospital, Florence, Italy
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Federico Cagnazzo
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
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Kim SJH, Wood S, Marquina C, Bell JS, Meretoja A, Kilkenny MF, Ilomäki J. Temporal and age-specific trends in incidence and 1-year case-fatality of hospitalized ischaemic stroke in Victoria, Australia. J Stroke Cerebrovasc Dis 2023; 32:107331. [PMID: 37740993 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107331] [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: 04/15/2023] [Revised: 07/31/2023] [Accepted: 08/27/2023] [Indexed: 09/25/2023] Open
Abstract
OBJECTIVES Investigate temporal and age-specific trends in the incidence of ischaemic stroke and case-fatality risk in Victoria, Australia. MATERIALS AND METHODS Patients hospitalised with first ischaemic stroke between 2012 and 2018 were included. Trends in age-standardised incidence rates of ischaemic stroke were assessed using linear regression models. Cox proportional hazard regression models were used to examine the case-fatality risk. RESULTS Overall age-standardised incidence of ischaemic stroke was stable from 2012/13 to 2017/18 (87.6 to 84.8 events per 100,000 population; Annual percentage change [APC] -0.32; 95% Confidence interval [CI] -1.13 to 0.50). The incidence declined in females (APC -1.00; 95% CI -1.49 to -0.50), people aged 75-84 years (APC -1.60; 95% CI -2.83 to -0.36) and in metropolitan areas (APC -0.74; 95% CI -1.02 to -0.45). The risk of 1-year case-fatality (HR 0.85; 95% CI 0.78 to 0.93) significantly declined in 2016/17 compared to 2012/13. CONCLUSIONS Overall ischaemic stroke incidence remained stable while decreasing trends were observed in females, elderly and metropolitan areas. 1-year case-fatality declined from 2012 to 2017.
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Affiliation(s)
- Stella Jung-Hyun Kim
- Centre for Medicine Use and Safety, Monash University, Melbourne, Victoria, Australia.
| | - Stephen Wood
- Centre for Medicine Use and Safety, Monash University, Melbourne, Victoria, Australia
| | - Clara Marquina
- Centre for Medicine Use and Safety, Monash University, Melbourne, Victoria, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Monash University, Melbourne, Victoria, Australia
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Monique F Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia; The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, VIC, Australia
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Monash University, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.
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Koca G, Kumar M, Gubitz G, Kamal N. Optimizing acute stroke treatment process: insights from sub-tasks durations in a prospective observational time and motion study. Front Neurol 2023; 14:1253065. [PMID: 37965162 PMCID: PMC10641836 DOI: 10.3389/fneur.2023.1253065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/09/2023] [Indexed: 11/16/2023] Open
Abstract
Background Rapid treatment is critical in managing acute ischemic stroke (AIS) to improve patient outcomes. Various strategies have been used to optimize this treatment process, including the Acute Stroke Protocol (ASP) activation, and minimizing the duration of key performance metrices, such as door-to-needle time (DNT), CT-to-needle time (CTNT), CT-to-groin puncture time (CTGP), and door-to-groin puncture time (DGPT). However, identifying the delay-causing sub-tasks within the ASP could yield novel insights, facilitating optimization strategies for the AIS treatment process. Methods This two-phase prospective observational time and motion study aimed to identify sub-tasks and compare their respective durations involved in the treatment process for AIS patients within ASPs. The study compared sub-task durations between "routine working hours" and "evenings and weekends" (after-hours), as well as between stroke neurologists and non-stroke neurologists. Additionally, the established performance metrices of AIS were compared among the aforementioned groups. Results Phase 1 identified and categorized 34 sub-tasks into five broad categories, while Phase 2 analyzed the ASP for 389 patients. Among the 185 patients included in the study, 57 received revascularization treatment, with 30 receiving intravenous (IV) thrombolysis only, 20 receiving endovascular thrombectomy (EVT) only, and 7 receiving both IV thrombolysis and EVT. Significant delays were observed in sub-tasks including triage, registration, patient history sharing, treatment decisions, preparation of patients, preparation of thrombolytic agents, and angiosuite preparation. The majority of these significant delays (P < 0.05) were observed when were performed by a non-stroke neurologist and during after-hours operations. Furthermore, certain sub-tasks were exclusively performed during after-hours or when the treatment was provided by a non-stroke neurologist. Consequently, DNT, CTNT, and CTGP were significantly prolonged for both non-stroke neurologists and off-hours treatment. DGPT was significantly longer only when the ASP was conducted by non-stroke neurologists. Conclusions The study identified several sub-tasks that lead to significant delays during the execution of the ASP. These findings provide a premise to design targeted quality improvement interventions to optimize the ASP for these specific delay-causing sub-tasks, particularly for non-stroke neurologists and after-hours. This approach has the potential to significantly enhance the efficiency of the AIS treatment process.
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Affiliation(s)
- Gizem Koca
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - Mukesh Kumar
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - Gord Gubitz
- Division of Neurology, QEII – Halifax Infirmary (HI) Site, Nova Scotia Health, Halifax, NS, Canada
- Division of Neurology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
- Division of Neurology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
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Gajurel BP, Nepal G, Jaiswal V, Ang SP, Nain P, Shama N, Ruchika F, Bohara S, Kharel S, Yadav JK, Medina JRT, Shrestha AB. Utilization rates of intravenous thrombolysis for acute ischemic stroke in Asian countries:: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e35560. [PMID: 37861564 PMCID: PMC10589571 DOI: 10.1097/md.0000000000035560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/18/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Despite intravenous thrombolysis (IVT) being used for the treatment of acute ischemic stroke (AIS) for over two decades, its accessibility remains limited in various regions of the world. The Asian region, which experiences the highest age-standardized incidence of AIS, currently lacks comprehensive data on the utilization of IVT. AIMS This study aimed to provide precise estimates of IVT usage for AIS in Asian countries. METHODS A literature search was conducted on PubMed and Google using appropriate search terms. English language, peer reviewed articles published after 2010 were included in the analysis. The pooled proportion was calculated utilizing the DerSimonian and Laird random-effects model. Additionally, a subgroup analysis was conducted, taking into account factors such as the study's country, the economic status of the country, specific Asian regions, publication year (before 2015 and from 2015 onwards), study location, study setting, hospital stroke protocol, and national stroke guidelines. RESULTS 67 observational studies with 778,046 patients with AIS were included in the meta-analysis. The overall utilization rate of IVT was found to be 9.1%. High-income countries had a higher rate (11.3%) compared to lower-middle-income (8.1%) and upper-middle-income countries (9%). Central and North Asia had the highest rate (17.5%) and Southeast Asia had the lowest rate (6.8%). Studies conducted after 2015 had a higher thrombolysis rate (11.3%) compared to those before 2015 (1.5%). Presence of hospital stroke protocols (10.7%) and national stroke guidelines (10.1%) were associated with higher thrombolysis rates. CONCLUSION The overall utilization rate of IVT for AIS in Asia stood at 9.1%, showcasing noteworthy disparities across countries, regions, and income brackets. To improve thrombolysis rates in the region, addressing prehospital delays, increasing public awareness, and implementing stroke protocols and national guidelines are key strategies.
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Affiliation(s)
- Bikram Prasad Gajurel
- Department of Neurology, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - Gaurav Nepal
- Department of General Medicine, Rani Primary Healthcare Centre, Biratnagar, Nepal
| | | | - Song Peng Ang
- Division of Internal Medicine, Rutgers Health/Community Medical Center, NJ
| | - Priyanshu Nain
- Department of Medicine, Maulana Azad Medical College, New Delhi, India
| | - Nishat Shama
- Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders, Dhaka, Bangladesh
| | - F.N.U. Ruchika
- Department of Surgery, JJM Medical College, Davangere, India
| | - Sujan Bohara
- Department of Internal Medicine, Nepalese Army Institute of Health Science, Kathmandu, Nepal
| | - Sanjeev Kharel
- Department of Internal Medicine, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | | | - Jillian Reeze T. Medina
- Manila Central University - Filemon D. Tanchoco Medical Foundation College of Medicine, Philippines
| | - Abhigan Babu Shrestha
- Department of Internal Medicine, M Abdur Rahim Medical College, Dinajpur, Bangladesh
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Lynch EA, Bulto LN, Cheng H, Craig L, Luker JA, Bagot KL, Thayabaranathan T, Janssen H, McInnes E, Middleton S, Cadilhac DA. Interventions for the uptake of evidence-based recommendations in acute stroke settings. Cochrane Database Syst Rev 2023; 8:CD012520. [PMID: 37565934 PMCID: PMC10416310 DOI: 10.1002/14651858.cd012520.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
BACKGROUND There is a growing body of research evidence to guide acute stroke care. Receiving care in a stroke unit improves access to recommended evidence-based therapies and patient outcomes. However, even in stroke units, evidence-based recommendations are inconsistently delivered by healthcare workers to patients with stroke. Implementation interventions are strategies designed to improve the delivery of evidence-based care. OBJECTIVES To assess the effects of implementation interventions (compared to no intervention or another implementation intervention) on adherence to evidence-based recommendations by health professionals working in acute stroke units. Secondary objectives were to assess factors that may modify the effect of these interventions, and to determine if single or multifaceted strategies are more effective in increasing adherence with evidence-based recommendations. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Joanna Briggs Institute and ProQuest databases to 13 April 2022. We searched the grey literature and trial registries and reviewed reference lists of all included studies, relevant systematic reviews and primary studies; contacted corresponding authors of relevant studies and conducted forward citation searching of the included studies. There were no restrictions on language and publication date. SELECTION CRITERIA We included randomised trials and cluster-randomised trials. Participants were health professionals providing care to patients in acute stroke units; implementation interventions (i.e. strategies to improve delivery of evidence-based care) were compared to no intervention or another implementation intervention. We included studies only if they reported on our primary outcome which was quality of care, as measured by adherence to evidence-based recommendations, in order to address the review aim. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data and assessed risk of bias and certainty of evidence using GRADE. We compared single implementation interventions to no intervention, multifaceted implementation interventions to no intervention, multifaceted implementation interventions compared to single implementation interventions and multifaceted implementation interventions to another multifaceted intervention. Our primary outcome was adherence to evidence-based recommendations. MAIN RESULTS We included seven cluster-randomised trials with 42,489 patient participants from 129 hospitals, conducted in Australia, the UK, China, and the Netherlands. Health professional participants (numbers not specified) included nursing, medical and allied health professionals. Interventions in all studies included implementation strategies targeting healthcare workers; three studies included delivery arrangements, no studies used financial arrangements or governance arrangements. Five trials compared a multifaceted implementation intervention to no intervention, two trials compared one multifaceted implementation intervention to another multifaceted implementation intervention. No included studies compared a single implementation intervention to no intervention or to a multifaceted implementation intervention. Quality of care outcomes (proportions of patients receiving evidence-based care) were included in all included studies. All studies had low risks of selection bias and reporting bias, but high risk of performance bias. Three studies had high risks of bias from non-blinding of outcome assessors or due to analyses used. We are uncertain whether a multifaceted implementation intervention leads to any change in adherence to evidence-based recommendations compared with no intervention (risk ratio (RR) 1.73; 95% confidence interval (CI) 0.83 to 3.61; 4 trials; 76 clusters; 2144 participants, I2 =92%, very low-certainty evidence). Looking at two specific processes of care, multifaceted implementation interventions compared to no intervention probably lead to little or no difference in the proportion of patients with ischaemic stroke who received thrombolysis (RR 1.14, 95% CI 0.94 to 1.37, 2 trials; 32 clusters; 1228 participants, moderate-certainty evidence), but probably do increase the proportion of patients who receive a swallow screen within 24 hours of admission (RR 6.76, 95% CI 4.44 to 10.76; 1 trial; 19 clusters; 1,804 participants; moderate-certainty evidence). Multifaceted implementation interventions probably make little or no difference in reducing the risk of death, disability or dependency compared to no intervention (RR 0.93, 95% CI 0.85 to 1.02; 3 trials; 51 clusters ; 1228 participants; moderate-certainty evidence), and probably make little or no difference to hospital length of stay compared with no intervention (difference in absolute change 1.5 days; 95% CI -0.5 to 3.5; 1 trial; 19 clusters; 1804 participants; moderate-certainty evidence). We do not know if a multifaceted implementation intervention compared to no intervention result in changes to resource use or health professionals' knowledge because no included studies collected these outcomes. AUTHORS' CONCLUSIONS We are uncertain whether a multifaceted implementation intervention compared to no intervention improves adherence to evidence-based recommendations in acute stroke settings, because the certainty of evidence is very low.
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Affiliation(s)
| | - Lemma N Bulto
- Caring Futures Institute, Flinders University, Adelaide, Australia
| | - Heilok Cheng
- Nursing Research Institute, St Vincent's Health Australia, Sydney, Australia
| | - Louise Craig
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Julie A Luker
- Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Kathleen L Bagot
- Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia
| | | | - Heidi Janssen
- School of Health Sciences, The University of Newcastle, Callaghan, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Australia, Sydney, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Australia, Sydney, Australia
- NSW School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Dominique A Cadilhac
- Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia
- Stroke and Ageing Research, School of Clinical Sciences, Monash University, Clayton, Australia
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Zhang Y, Jing Y, Zhu Y, Jiang T, Tang X, Yi W. Radio frequency identification technology reduce intravenous thrombolysis time in acute ischemic stroke. PLoS One 2023; 18:e0288207. [PMID: 37467248 DOI: 10.1371/journal.pone.0288207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/21/2023] [Indexed: 07/21/2023] Open
Abstract
PURPOSE To inspect whether time management with radio frequency identification technology (RFID) reduces symptom onset-to-intravenous thrombolysis time (OTT) in acute ischemic stroke (AIS). METHODS In the retrospective study, patients with AIS, transferred by Emergency Medical Services (EMS) to Hunan Provincial People's Hospital between September 2019 to June 2022, divided into three groups, as traditional group, in-hospital RFID group and whole process RFID group. Baseline characteristics and time metrics were compared. RESULTS After the whole emergency process applied with RFID time management, Door to intravenous thrombolysis time (DNT) was reduced from 125.00±43.16 min to 32.59±25.45 min (F = 121.857, p<0.001), and OTT was reduced from 235.53±57.27 min to 144.31±47.96 min (F = 10.377, p<0.001). CONCLUSIONS Time management with RFID is effective in reducing OTT in AIS patients with thrombolysis treatment.
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Affiliation(s)
- Yixiong Zhang
- The First People's Hospital of Huaihua, Huaihua City, China
| | - Yingxia Jing
- Poisoning Research Laboratory, Institute of Emergency Medicine, Hunan Provincial People's Hospital, The First Affiliate Hospital of Hunan Normal University, Changsha City, China
| | - Yimin Zhu
- Poisoning Research Laboratory, Institute of Emergency Medicine, Hunan Provincial People's Hospital, The First Affiliate Hospital of Hunan Normal University, Changsha City, China
| | - Tao Jiang
- The First People's Hospital of Huaihua, Huaihua City, China
| | - Xianyi Tang
- Poisoning Research Laboratory, Institute of Emergency Medicine, Hunan Provincial People's Hospital, The First Affiliate Hospital of Hunan Normal University, Changsha City, China
| | - Weichen Yi
- The First People's Hospital of Huaihua, Huaihua City, China
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Klu M, de Souza AC, Carbonera LA, Secchi TL, Pille A, Rodrigues M, Brondani R, de Almeida AG, Dal Pizzol A, Camelo DMF, Mantovani GP, Oldoni C, Tessari MS, Nasi LA, Martins SCO. Improving door-to-reperfusion time in acute ischemic stroke during the COVID-19 pandemic: experience from a public comprehensive stroke center in Brazil. Front Neurol 2023; 14:1155931. [PMID: 37492852 PMCID: PMC10365273 DOI: 10.3389/fneur.2023.1155931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/13/2023] [Indexed: 07/27/2023] Open
Abstract
Background The global COVID-19 pandemic has had a devastating effect on global health, resulting in a strain on healthcare services worldwide. The faster a patient with acute ischemic stroke (AIS) receives reperfusion treatment, the greater the odds of a good functional outcome. To maintain the time-dependent processes in acute stroke care, strategies to reorganize infrastructure and optimize human and medical resources were needed. Methods Data from AIS patients who received thrombolytic therapy were prospectively assessed in the emergency department (ED) of Hospital de Clínicas de Porto Alegre from 2019 to 2021. Treatment times for each stage were measured, and the reasons for a delay in receiving thrombolytic therapy were evaluated. Results A total of 256 patients received thrombolytic therapy during this period. Patients who arrived by the emergency medical service (EMS) had a lower median door-to-needle time (DNT). In the multivariable analysis, the independent predictors of DNT >60 min were previous atrial fibrillation (OR 7) and receiving thrombolysis in the ED (OR 9). The majority of patients had more than one reason for treatment delay. The main reasons were as follows: delay in starting the CT scan, delay in the decision-making process after the CT scan, and delay in reducing blood pressure. Several actions were implemented during the study period. The most important factor that contributed to a decrease in DNT was starting the bolus and continuous infusion of tPA on the CT scan table (decreased the median DNT from 74 to 52, DNT ≤ 60 min in 67% of patients treated at radiology service vs. 24% of patients treated in the ED). The DNT decreased from 78 min to 66 min in 2020 and 57 min in 2021 (p = 0.01). Conclusion Acute stroke care continued to be a priority despite the COVID-19 pandemic. The implementation of a thrombolytic bolus and the start of continuous infusion on the CT scan table was the main factor that contributed to the reduction of DNT. Continuous monitoring of service times is essential for improving the quality of the stroke center and achieving better functional outcomes for patients.
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Affiliation(s)
- Marcelo Klu
- Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Ana Claudia de Souza
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Leonardo Augusto Carbonera
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Thais Leite Secchi
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Arthur Pille
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Marcio Rodrigues
- Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Rosane Brondani
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Andrea Garcia de Almeida
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Angélica Dal Pizzol
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Daniel Monte Freire Camelo
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Gabriel Paulo Mantovani
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Carolina Oldoni
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Marcelo Somma Tessari
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Luiz Antonio Nasi
- Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Sheila Cristina Ouriques Martins
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
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Bösel J, Hubert GJ, Jesser J, Möhlenbruch MA, Ringleb PA. Access to and application of recanalizing therapies for severe acute ischemic stroke caused by large vessel occlusion. Neurol Res Pract 2023; 5:19. [PMID: 37198694 DOI: 10.1186/s42466-023-00245-9] [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: 03/10/2023] [Accepted: 05/02/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Groundbreaking study results since 2014 have dramatically changed the therapeutic options in acute therapy for severe ischemic stroke caused by large vessel occlusion (LVO). The scientifically proven advances in stroke imaging and thrombectomy techniques have allowed to offer the optimal version or combination of best medical and interventional therapy to the selected patient, yielding favorable or even excellent clinical outcomes within time windows unheard of before. The provision of the best possible individual therapy has become a guideline-based gold standard, but remains a great challenge. With geographic, regional, cultural, economic and resource differences worldwide, optimal local solutions have to be strived for. AIM This standard operation procedure (SOP) is aimed to give a suggestion of how to give patients access to and apply modern recanalizing therapy for acute ischemic stroke caused by LVO. METHOD The SOP was developed based on current guidelines, the evidence from the most recent trials and the experience of authors who have been involved in the above-named development at different levels. RESULTS This SOP is meant to be a comprehensive, yet not too detailed template to allow for freedom in local adaption. It comprises all relevant stages in providing care to the patient with severe ischemic stroke such as suspicion and alarm, prehospital acute measures, recognition and grading, transport, emergency room workup, selective cerebral imaging, differential treatment by recanalizing therapies (intravenous thrombolysis, endovascular stroke treatmet, or combined), complications, stroke unit and neurocritical care. CONCLUSIONS The challenge of giving patients access to and applying recanalizing therapies in severe ischemic stroke may be facilitated by a systematic, SOP-based approach adapted to local settings.
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Affiliation(s)
- Julian Bösel
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany.
| | - Gordian J Hubert
- TEMPiS Telestroke Center, Department of Neurology, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Munich, Germany
| | - Jessica Jesser
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter A Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
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11
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Tejada Meza H, Saldaña Inda I, Serrano Ponz M, Ara JR, Marta Moreno J. Impact of a series of measures for optimisation hospital code stroke care on door-to-needle times. Neurologia 2023; 38:141-149. [PMID: 37059569 DOI: 10.1016/j.nrleng.2020.07.023] [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: 04/16/2020] [Accepted: 07/07/2020] [Indexed: 04/16/2023] Open
Abstract
INTRODUCTION Time continues to be a fundamental variable in reperfusion treatments for acute ischaemic stroke. Despite the recommendations made in clinical guidelines, only around one-third of these patients receive fibrinolysis within 60minutes. In this study, we describe our experience with the implementation of a specific protocol for patients with acute ischaemic stroke and evaluate its impact on door-to-needle times in our hospital. METHODS Measures were gradually implemented in late 2015 to shorten stroke management times and optimise the care provided to patients with acute ischaemic stroke; these measures included the creation of a specific on-call neurovascular care team. We compare stroke management times before (2013-2015) and after (2017-2019) the introduction of the protocol. RESULTS The study includes 182 patients attended before implementation of the protocol and 249 attended after. Once all measures were in effect, the overall median door-to-needle time was 45minutes (vs 74 minutes before, a 39% reduction; P<.001), with 73.5% of patients treated within 60minutes (a 47% increase; P<.001). Median overall time to treatment (onset-to-needle time) was reduced by 20minutes (P<.001). CONCLUSIONS The measures included in our protocol achieved a significant, sustained reduction in door-to-needle times, although there remains room for improvement. The mechanisms established for monitoring outcomes and for continuous improvement will enable further advances in this regard.
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Affiliation(s)
- H Tejada Meza
- Sección de Neurovascular, Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, España; Sección de Neurointervencionismo, Servicio de Radiología, Hospital Universitario Miguel Servet, Zaragoza, España; Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, España.
| | - I Saldaña Inda
- Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, España
| | - M Serrano Ponz
- Sección de Neurovascular, Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, España; Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, España; Departamento de Medicina, Psiquiatría y Dermatología, Facultad de Medicina, Universidad de Zaragoza, Zaragoza, España
| | - J R Ara
- Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, España; Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, España
| | - J Marta Moreno
- Sección de Neurovascular, Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, España; Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, España
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12
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Yogendrakumar V, Churilov L, Guha P, Beharry J, Mitchell PJ, Kleinig TJ, Yassi N, Thijs V, Wu TY, Brown H, Dewey HM, Wijeratne T, Yan B, Sharma G, Desmond PM, Parsons MW, Donnan GA, Davis SM, Campbell BCV. Tenecteplase Treatment and Thrombus Characteristics Associated With Early Reperfusion: An EXTEND-IA TNK Trials Analysis. Stroke 2023; 54:706-714. [PMID: 36727510 DOI: 10.1161/strokeaha.122.041061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Intracranial occlusion site, contrast permeability, and clot burden are thrombus characteristics that influence alteplase-associated reperfusion. In this study, we assessed the reperfusion efficacy of tenecteplase and alteplase in subgroups based on these characteristics in a pooled analysis of the EXTEND-IA TNK trial (Tenecteplase Versus Alteplase Before Endovascular Therapy for Ischemic Stroke). METHODS Patients with large vessel occlusion were randomized to treatment with tenecteplase (0.25 or 0.4 mg/kg) or alteplase before thrombectomy in hospitals across Australia and New Zealand (2015-2019). The primary outcome, early reperfusion, was defined as the absence of retrievable thrombus or >50% reperfusion on first-pass angiogram. We compared the effect of tenecteplase versus alteplase overall, and in subgroups, based on the following measured with computed tomography angiography: intracranial occlusion site, contrast permeability (measured via residual flow grades), and clot burden (measured via clot burden scores). We adjusted for covariates using mixed effects logistic regression models. RESULTS Tenecteplase was associated with higher odds of early reperfusion (75/369 [20%] versus alteplase: 9/96 [9%], adjusted odds ratio [aOR], 2.18 [95% CI, 1.03-4.63]). The difference between thrombolytics was notable in occlusions with low clot burden (tenecteplase: 66/261 [25%] versus alteplase: 5/67 [7%], aOR, 3.93 [95% CI, 1.50-10.33]) when compared to high clot burden lesions (tenecteplase: 9/108 [8%] versus alteplase: 4/29 [14%], aOR, 0.58 [95% CI, 0.16-2.06]; Pinteraction=0.01). We did not observe an association between contrast permeability and tenecteplase treatment effect (permeability present: aOR, 2.83 [95% CI, 1.00-8.05] versus absent: aOR, 1.98 [95% CI, 0.65-6.03]; Pinteraction=0.62). Tenecteplase treatment effect was superior with distal M1 or M2 occlusions (53/176 [30%] versus alteplase: 4/42 [10%], aOR, 3.73 [95% CI, 1.25-11.11]), but both thrombolytics had limited efficacy with internal carotid artery occlusions (tenecteplase 1/73 [1%] versus alteplase 1/19 [5%], aOR, 0.22 [95% CI, 0.01-3.83]; Pinteraction=0.16). CONCLUSIONS Tenecteplase demonstrates superior early reperfusion versus alteplase in lesions with low clot burden. Reperfusion efficacy remains limited in internal carotid artery occlusions and lesions with high clot burden. Further innovation in thrombolytic therapies are required.
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Affiliation(s)
- Vignan Yogendrakumar
- Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (V.Y., L.C., P.G., J.B., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.)
| | - Leonid Churilov
- Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (V.Y., L.C., P.G., J.B., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.)
| | - Prodipta Guha
- Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (V.Y., L.C., P.G., J.B., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.)
| | - James Beharry
- Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (V.Y., L.C., P.G., J.B., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.).,Department of Medicine, Austin Health, Heidelberg, Australia (J.B., V.T.)
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, Parkville, Australia (P.J.M., B.Y., P.M.D.)
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Australia (T.J.K.)
| | - Nawaf Yassi
- Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (V.Y., L.C., P.G., J.B., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.).,Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia (N.Y.)
| | - Vincent Thijs
- Department of Medicine, Austin Health, Heidelberg, Australia (J.B., V.T.).,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia (V.T.)
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, New Zealand (T.Y.W.)
| | - Helen Brown
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia (H.B.)
| | - Helen M Dewey
- Department of Neurosciences, Eastern Health and Eastern Health Clinical School, Clayton, Victoria, Australia (H.M.D.)
| | - Tissa Wijeratne
- Melbourne Medical School, Department of Medicine and Neurology, University of Melbourne and Western Health, St Albans, Australia (T.W.)
| | - Bernard Yan
- Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (V.Y., L.C., P.G., J.B., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.).,Department of Radiology, Royal Melbourne Hospital, Parkville, Australia (P.J.M., B.Y., P.M.D.)
| | - Gagan Sharma
- Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (V.Y., L.C., P.G., J.B., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.)
| | - Patricia M Desmond
- Department of Radiology, Royal Melbourne Hospital, Parkville, Australia (P.J.M., B.Y., P.M.D.)
| | - Mark W Parsons
- Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (V.Y., L.C., P.G., J.B., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.).,Department of Neurology, Liverpool Hospital, Sydney, Australia (M.W.P.)
| | - Geoffrey A Donnan
- Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (V.Y., L.C., P.G., J.B., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.)
| | - Stephen M Davis
- Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (V.Y., L.C., P.G., J.B., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.)
| | - Bruce C V Campbell
- Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (V.Y., L.C., P.G., J.B., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.)
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Svobodová V, Maršálková H, Volevach E, Mikulík R. Simulation-based team training improves door-to-needle time for intravenous thrombolysis. BMJ Open Qual 2023; 12:bmjoq-2022-002107. [PMID: 36810293 PMCID: PMC9944663 DOI: 10.1136/bmjoq-2022-002107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 02/01/2023] [Indexed: 02/23/2023] Open
Abstract
PURPOSE There is a clinical need for shortened door-to-needle time (DNT) for intravenous thrombolysis, but effective training methods are missing. Simulation training improves teamwork and logistics in numerous fields. Still, it is not clear if simulation improves logistics in stroke. METHODS To evaluate the efficiency of a simulation training programme, the DNT of participating centres was compared with the rest of stroke centres in the Czech Republic. Patients' data were prospectively collected from the nationally used Safe Implementation of Treatments in Stroke Registry. The outcome was an improvement in DNT in 2018 as compared with 2015 (after and before the simulation training). Scenarios were based on real clinical cases, and simulation courses were conducted in a standardly equipped simulation centre. FINDINGS Between 2016 and 2017, 10 courses were conducted for stroke teams from 9 of all 45 stroke centres. DNT data were available both in 2015 and 2018 from 41 (91%) stroke centres. The simulation training improved the DNT in 2018 as compared with 2015 by 30 min (95% CI 25.7 to 34.7) and as compared with 20 min (95% CI 15.8 to 24.3) in stroke centres without the simulation training (p=0.01). Any parenchymal haemorrhage occurred in 5.4% and 3.5% of patients treated in centres without and with simulation training (p=0.054), respectively. CONCLUSIONS DNT was considerably shortened nationally. It was feasible to implement simulation as a nationwide training programme. The simulation was associated with improved DNT; however, other studies should confirm that such an association is causal.
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Affiliation(s)
- Veronika Svobodová
- International Clinical Research Center, St Anne's University Hospital in Brno, Brno, Czech Republic
| | - Hana Maršálková
- International Clinical Research Center, St Anne's University Hospital in Brno, Brno, Czech Republic
| | - Ekaterina Volevach
- International Clinical Research Center, St Anne's University Hospital in Brno, Brno, Czech Republic
| | - Robert Mikulík
- International Clinical Research Center, St Anne's University Hospital in Brno, Brno, Czech Republic .,Department of Neurology, Masaryk University Faculty of Medicine, Brno, Czech Republic
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14
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Horn MA, Hov MR, Heuser K, Taubøll E. Time To Control-A goal in seizure management. Seizure 2023; 106:76. [PMID: 36774777 DOI: 10.1016/j.seizure.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 02/11/2023] Open
Affiliation(s)
- Morten Andreas Horn
- Department of Neurology, Oslo University Hospital, PO Box 4956 Nydalen, N-0424 Oslo, Norway.
| | - Maren Ranhoff Hov
- Department of Neurology, Oslo University Hospital, PO Box 4956 Nydalen, N-0424 Oslo, Norway; Faculty of Health Science, Oslo Metropolitan University, PO Box 4 St Olavs Plass, N-0130 Oslo, Norway.
| | - Kjell Heuser
- Department of Neurology, Oslo University Hospital, PO Box 4956 Nydalen, N-0424 Oslo, Norway.
| | - Erik Taubøll
- Department of Neurology, Oslo University Hospital, PO Box 4956 Nydalen, N-0424 Oslo, Norway; Department of Neurology, Faculty of Medicine, University of Oslo, PO Box 1078 Blindern, N-0316 Oslo, Norway.
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Wong JZW, Park PSW, Frost T, Stephens K, Newk-Fon Hey Tow FK, Garcia PG, Senanayake C, Choi PMC. Using body cameras to quantify the duration of a Code Stroke and identify workflow issues: a continuous observation workflow time study. BMJ Open 2023; 13:e067816. [PMID: 36697041 PMCID: PMC9884893 DOI: 10.1136/bmjopen-2022-067816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE 'Code Stroke' (Code) is used in health services to streamline hyperacute assessment and treatment delivery for patients with ischaemic stroke. However, there are few studies that detail the time spent on individual components performed during a Code. We sought to quantify the time taken for each process during a Code and investigate associations with modifiable and non-modifiable factors. DESIGN Continuous observation workflow time study. SETTING AND PARTICIPANTS Recordings of 100 Codes were performed at a high-volume primary stroke centre in Melbourne, Australia, between January and June 2020 using a body camera worn by a member of the stroke team. MAIN OUTCOME MEASURES The main measures included the overall duration of Codes and the individual processes within the Code workflow. Associations between variables of interest and process times were explored using linear regression models. RESULTS 100 Codes were captured, representing 19.2% of all Codes over the 6 months. The median duration of a complete Code was 54.2 min (IQR 39.1-74.7). Administrative work performed after treatment is completed (median 21.0 min (IQR 9.8-31.4)); multimodal CT imaging (median 13.0 min (IQR 11.5-15.7)), and time between decision and thrombolysis administration (median 8.1 min (IQR 6.1-10.8)) were the longest components of a Code. Tenecteplase was able to be prepared faster than alteplase (median 1.8 vs 4.9 min, p=0.02). The presence of a second junior doctor was associated with shorter administrative work time (median 10.3 vs 25.1 min, p<0.01). No specific modifiable factors were found to be associated with shorter overall Code duration. CONCLUSIONS Codes are time intensive. Time spent on decision-making was a relatively small component of the overall Code duration. Data from body cameras can provide granular data on all aspects of Code workflow to inform potential areas for improvement at individual centres.
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Affiliation(s)
- Joseph Zhi Wen Wong
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
- Departments of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Peter Si Woo Park
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Tanya Frost
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Karen Stephens
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | | | - Pamela Gayle Garcia
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Channa Senanayake
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Philip M C Choi
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
- Eastern Health Clinical School, Monash University Faculty of Medicine, Nursing and Health Sciences, Clayton, Victoria, Australia
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16
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Zhou T, Li T, Zhu L, Li Z, Li Q, Wang Z, Wu L, He Y, Li Y, Zhou Z, Guan M, Ma Z, pei X, Meng S, Feng Y, Zhang G, Zhao W, Liu X, Wang M. One-stop stroke management platform reduces workflow times in patients receiving mechanical thrombectomy. Front Neurol 2023; 13:1044347. [PMID: 36742054 PMCID: PMC9889633 DOI: 10.3389/fneur.2022.1044347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/23/2022] [Indexed: 01/20/2023] Open
Abstract
Background and purpose Clinical outcome in patients who received thrombectomy treatment is time-dependent. The purpose of this study was to evaluate the efficacy of the one-stop stroke management (OSSM) platform in reducing in-hospital workflow times in patients receiving thrombectomy compared with the traditional model. Methods The data of patients who received thrombectomy treatment through the OSSM platform and traditional protocol transshipment pathway were retrospectively analyzed and compared. The treatment-related time interval and the clinical outcome of the two groups were also assessed and compared. The primary efficacy endpoint was the time from door to groin puncture (DPT). Results There were 196 patients in the OSSM group and 210 patients in the control group, in which they were treated by the traditional approach. The mean DPT was significantly shorter in the OSSM group than in the control group (76 vs. 122 min; P < 0.001). The percentages of good clinical outcomes at the 90-day time point of the two groups were comparable (P = 0.110). A total of 121 patients in the OSSM group and 124 patients in the control group arrived at the hospital within 360 min from symptom onset. The mean DPT and time from symptom onset to recanalization (ORT) were significantly shorter in the OSSM group than in the control group. Finally, a higher rate of good functional outcomes was achieved in the OSSM group than in the control group (53.71 vs. 40.32%; P = 0.036). Conclusion Compared to the traditional transfer model, the OSSM transfer model significantly reduced the in-hospital delay in patients with acute stroke receiving thrombectomy treatment. This novel model significantly improved the clinical outcomes of patients presenting within the first 6 h after symptom onset.
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Bonifacio-Delgadillo DM, Castellanos-Pedroza E, Martínez-Guerra BA, Sánchez-Martínez CM, Marquez-Romero JM. Delivering acute stroke care in a middle-income country. The Mexican model: "ResISSSTE Cerebro". Front Neurol 2023; 14:1103066. [PMID: 36908627 PMCID: PMC9992879 DOI: 10.3389/fneur.2023.1103066] [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: 11/19/2022] [Accepted: 02/02/2023] [Indexed: 02/24/2023] Open
Abstract
Introduction Founded in 2019, the "ResISSSTE Cerebro" program is the first and only stroke network within the Mexican public health system. One advanced stroke center (ASC) and seven essential stroke centers (ESC) provide acute stroke (AS) care through a modified hub-and-spoke model. This study describes the workflow, metrics, and outcomes in AS obtained during the program's third year of operation. Materials and methods Participants were adult beneficiaries of the ISSSTE health system in Mexico City with acute focal neurological deficit within 24 h of symptom onset. Initial evaluation could occur at any facility, but the stroke team at the ASC took all decisions regarding treatment and transfers of patients. Registered variables included demographics, stroke risk factors, AS treatment workflow time points, and clinical outcome measures. Results We analyzed data from 236 patients, 104 (44.3%) men with a median age of 71 years. Sixty percent of the patients were initially evaluated at the ESC, and 122 (85.9%) were transferred to the ASC. The median transfer time was 123 min. The most common risk factor was hypertension (73.6%). Stroke subtypes were ischemic (86.0%) and hemorrhagic (14.0%). Median times for onset-to-door, door-to-imaging, door-to-needle, and door-to-groin were: 135.5, 37.0, 76.0, and 151.5 min, respectively. The rate of intravenous thrombolysis was 35%. Large vessel occlusion was present in 63 patients, from whom 44% received endovascular therapy; 71.4% achieved early clinical improvement (median NIHSS reduction of 11 points). Treatment-associated morbimortality was 3.4%. Conclusion With the implementation of a modified hub-and-spoke model, this study shows that delivery of AS care in low- and middle-income countries is feasible and achieves good clinical outcomes.
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Affiliation(s)
- Dulce María Bonifacio-Delgadillo
- Department of Interventional Neurology, Centro Médico Nacional 20 de Noviembre Instituto de Seguridad y Servicios Sociales de Los Trabajadores del Estado (ISSSTE), Mexico City, Mexico
| | - Enrique Castellanos-Pedroza
- Department of Interventional Neurology, Centro Médico Nacional 20 de Noviembre Instituto de Seguridad y Servicios Sociales de Los Trabajadores del Estado (ISSSTE), Mexico City, Mexico
| | | | - Claudia Marisol Sánchez-Martínez
- Department of Interventional Neurology, Centro Médico Nacional 20 de Noviembre Instituto de Seguridad y Servicios Sociales de Los Trabajadores del Estado (ISSSTE), Mexico City, Mexico
| | - Juan Manuel Marquez-Romero
- Department of Neurology, Hospital General de Zona #2, Instituto Mexicano del Seguro Social (IMSS), Órganos de Operación Administrativa Desconcentrada (OOAD) Aguascalientes, Aguascalientes, Mexico
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Gdovinova Z, Kovačik M, Urbani D. How stroke care has changed in Slovakia in the last 5 years. Eur Stroke J 2023; 8:52-58. [PMID: 36793747 PMCID: PMC9923130 DOI: 10.1177/23969873221115457] [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: 05/19/2022] [Accepted: 06/24/2022] [Indexed: 02/12/2023] Open
Abstract
Introduction Although stroke patients in Slovakia had been treated according to European recommendations, no network of primary and comprehensive stroke centers had been officially established; the ESO recommended quality parameters had not been fulfilled. Therefore, the Slovak Stroke Society decided to change the stroke management concept and introduced mandatory evaluation of quality parameters. This article focuses on key success factors of the change in stroke management in Slovakia and presents the 5-year results and perspectives for the future. Material and methods We processed data from the stroke register at the National Health Information Center, which is mandatory in Slovakia for all hospitals designated as primary and secondary stroke care centers. Results Since 2016, we have started to change stroke management. New National Guideline for Stroke Care was prepared in 2017 and published in 2018 as a Recommendation of the Ministry of Health of the Slovak Republic. The recommendation included pre-hospital as well as in-hospital stroke care, a network of primary stroke centers (hospitals administering intravenous thrombolysis - 37), and secondary stroke centers (hospitals treating with intravenous thrombolysis + endovascular treatment (ET) - 6). A stroke priority was instituted, having equally high priority as myocardial infarction. More efficient in-hospital workflow and pre-hospital patient triage shortened the time to treatment. Prenotification became mandatory in all hospitals. Non-contrast CT, and CT angiography is mandatory in all hospitals. In patients with suspected proximal large-vessel occlusion the EMS stays at the CT facility in primary stroke centers until the CT angiography is finished. If LVO is confirmed, the patient is transported to an EVT secondary stroke center by the same EMS. From 2019 all secondary stroke centers offer endovascular thrombectomy in a 24/7/365 system. We consider the introduction of quality control one of the most critical steps in stroke management. The result of these activities is 25.2% of patients treated with IVT and 10.2% by endovascular treatment, and median DNT 30 min. Number of patients screened for dysphagia increased from 26.4% in 2019 to 85.9% in 2020. In the most of the hospitals the proportion of ischemic stroke patients discharged with antiplatelets and in case of AF with anticoagulants was >85%. Discussion Our results indicate that it is possible to change stroke management at a single hospital and national level. For continuous and further improvement, regular quality monitoring is necessary; therefore, the results of stroke hospital management are presented regularly once a year at national and international level. Collaboration with the "Second for Life" patient organization is very important for the "time is brain" campaign in Slovakia. Conclusion Due to the change in stroke management over the last 5 years, we have reduced the time for acute stroke treatment and improved the proportion of patients with acute treatment, and in this area, we have achieved and exceeded the goals of the Stroke Action Plan for Europe for 2018-2030. Nevertheless, we still have many insufficiencies in stroke rehabilitation and post-stroke nursing that need to be addressed.
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Affiliation(s)
- Zuzana Gdovinova
- Department of Neurology, Faculty of Medicine,
Pavol Jozef Šafárik University Kosice, Kosice, Slovakia,Zuzana Gdovinova, Department of Neurology, Faculty
of Medicine, Pavol Jozef Šafárik University Kosice, Trieda SNP 1, Kosice 04011, Slovakia.
| | - Michal Kovačik
- Ivan Stodola Liptovsky Hospital With
Polyclinics, Liptovsky Mikulas, Žilina Region, Slovakia
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Comparison of door-to-needle time of tenecteplase versus alteplase for acute ischemic stroke. Am J Emerg Med 2023; 63:158-160. [PMID: 36192247 DOI: 10.1016/j.ajem.2022.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 12/13/2022] Open
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20
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Gerschenfeld G, Liegey JS, Laborne FX, Yger M, Lyon V, Checkouri T, Tricard-Dessagne B, Marnat G, Clarençon F, Chausson N, Turc G, Sibon I, Alamowitch S, Olindo S. Treatment times, functional outcome, and hemorrhage rates after switching to tenecteplase for stroke thrombolysis: Insights from the TETRIS registry. Eur Stroke J 2022; 7:358-364. [PMID: 36478758 PMCID: PMC9720850 DOI: 10.1177/23969873221113729] [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: 05/10/2022] [Accepted: 06/27/2022] [Indexed: 02/25/2024] Open
Abstract
INTRODUCTION The encouraging efficacy and safety data on intravenous thrombolysis with tenecteplase in ischemic stroke and its practical advantages motivated our centers to switch from alteplase to tenecteplase. We report its impact on treatment times and clinical outcomes. METHODS We retrospectively analyzed clinical and procedural data of patients treated with alteplase or tenecteplase in a comprehensive (CSC) and a primary stroke center (PSC), which transitioned respectively in 2019 and 2018. Tenecteplase enabled in-imaging thrombolysis in the CSC. The main outcomes were the imaging-to-thrombolysis and thrombolysis-to-puncture times. We assessed the association of tenecteplase with 3-month functional independence and parenchymal hemorrhage (PH) with multivariable logistic models. RESULTS We included 795 patients, 387 (48.7%) received alteplase and 408 (51.3%) tenecteplase. Both groups (tenecteplase vs alteplase) were similar in terms of age (75 vs 76 years), baseline NIHSS score (7 vs 7.5) and proportion of patients treated with mechanical thrombectomy (24.1% vs 27.5%). Tenecteplase patients had shorter imaging-to-thrombolysis times (27 vs 36 min, p < 0.0001) mainly driven by patients treated in the CSC (22 vs 38 min, p < 0.001). In the PSC, tenecteplase patients had shorter thrombolysis-to-puncture times (84 vs 95 min, p = 0.02), reflecting faster interhospital transfer for MT. 3-month functional independence rate was higher in the tenecteplase group (62.8% vs 53.4%, p < 0.01). In the multivariable analysis, tenecteplase was significantly associated with functional independence (ORa 1.68, 95% CI 1.15-2.48, p < 0.01), but not with PH (ORa 0.68, 95% CI 0.41-1.12, p = 0.13). CONCLUSION Switch from alteplase to tenecteplase reduced process times and may improve functional outcome, with similar safety profile.
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Affiliation(s)
- Gaspard Gerschenfeld
- AP-HP, Service des Urgences
Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne
Université, Paris, France
- STARE Team, iCRIN, Institut du Cerveau
et de la Moelle épinière, ICM, Paris, France
| | | | | | - Marion Yger
- AP-HP, Service des Urgences
Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne
Université, Paris, France
- STARE Team, iCRIN, Institut du Cerveau
et de la Moelle épinière, ICM, Paris, France
| | - Victoire Lyon
- Service de Neurologie Vasculaire, CHU
de Bordeaux, Bordeaux, France
| | - Thomas Checkouri
- AP-HP, Service des Urgences
Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne
Université, Paris, France
- STARE Team, iCRIN, Institut du Cerveau
et de la Moelle épinière, ICM, Paris, France
| | | | - Gaultier Marnat
- Service de Neuroradiologie diagnostique
et interventionnelle, CHU de Bordeaux, Bordeaux, France
| | - Frédéric Clarençon
- AP-HP, Service de Neuroradiologie,
Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Nicolas Chausson
- Service de Neurologie, Unité
Neuro-vasculaire, Hôpital Sud Francilien, Corbeil-Essonnes, France
| | - Guillaume Turc
- Service de Neurologie, GHU Paris
Psychiatrie et Neurosciences, Université de Paris, INSERM U1266, FHU Neurovasc,
Paris, France
| | - Igor Sibon
- Service de Neurologie Vasculaire, CHU
de Bordeaux, Bordeaux, France
| | - Sonia Alamowitch
- AP-HP, Service des Urgences
Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne
Université, Paris, France
- STARE Team, iCRIN, Institut du Cerveau
et de la Moelle épinière, ICM, Paris, France
- CRSA, Sorbonne Université, INSERM, UMRS
938, Hôpital Saint-Antoine, Paris, France
| | - Stéphane Olindo
- Service de Neurologie Vasculaire, CHU
de Bordeaux, Bordeaux, France
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21
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Yuan G, Xia H, Xu J, Long C, Liu L, Huang F, Zeng J, Yuan L. Reducing intravenous thrombolysis delay in acute ischemic stroke through a quality improvement program in the emergency department. Front Neurol 2022; 13:931193. [PMID: 36226088 PMCID: PMC9548581 DOI: 10.3389/fneur.2022.931193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/26/2022] [Indexed: 11/14/2022] Open
Abstract
Objective This study aims to investigate the effectiveness of a quality improvement program for reducing intravenous thrombolysis (IVT) delay in acute ischemic stroke (AIS). Materials and methods We implement a quality improvement program consisting of 10 interventions for reducing IVT delay, including the establishment of an acute stroke team, standardized management of stroke teams, popularization of stroke and its treatment, emergency bypass route (BER), the achievement of computed tomography (CT) priority, no-delay CT interpretation, intravenous thrombolysis on the CT table, payment after treatment, whole recording, and incentive policy. We retrospectively analyzed the clinical time and outcome data of AIS patients treated with IVT in pre-intervention (108 patients) and post-intervention groups (598 patients), and further compared the differences between the non-emergency bypass route (NBER) and BER in the post-intervention group. Results The thrombolysis rate increased from ~29% in the pre-intervention group to 48% in the post-intervention group. Compared with the pre-intervention group, the median of door-to-needle time (DNT) was greatly shortened from 95 to 26 min (P < 0.001), door-to-CT time (DCT) was noticeably decreased from 20 to 18 min (P < 0.001), and onset-to-needle time (OTT) significantly declined from 206 to 133 min (P = 0.001). Under the new mode after the intervention, we further analyzed the IVT delay difference between the NBER (518 patients) and BER groups (80 patients) from the post-intervention group. The median values of DNT (18 vs. 27 min, P < 0.001), DCT (10 vs. 19 min, P < 0.001), and OTT (99 vs. 143 min, P < 0.001) showed significant reductions in the BER group. The quality improvement program under the emergency platform successfully controlled the median of DNT to within 26 min. Conclusions Collectively, the BER mode is a feasible scheme that greatly decreased DNT in AIS patients, and the secret to success was to accomplish as much as possible before the patient arrives at the emergency room.
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Affiliation(s)
- Guangxiong Yuan
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Hong Xia
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Jun Xu
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Chen Long
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Lei Liu
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Feng Huang
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Jianping Zeng
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, China
- *Correspondence: Jianping Zeng
| | - Lingqing Yuan
- National Clinical Research Center for Metabolic Diseases, Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Lingqing Yuan
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22
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Ernst J, Storch KF, Tran AT, Gabriel MM, Leotescu A, Boeck AL, Huber MK, Abu-Fares O, Bronzlik P, Götz F, Worthmann H, Schuppner R, Grosse GM, Weissenborn K. Advancement of door-to-needle times in acute stroke treatment after repetitive process analysis: never give up! Ther Adv Neurol Disord 2022; 15:17562864221122491. [PMID: 36147621 PMCID: PMC9486271 DOI: 10.1177/17562864221122491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/05/2022] [Indexed: 11/21/2022] Open
Abstract
Background: In acute ischemic stroke, timely treatment is of utmost relevance.
Identification of delaying factors and knowledge about challenges concerning
hospital structures are crucial for continuous improvement of process times
in stroke care. Objective: In this study, we report on our experience in optimizing the door-to-needle
time (DNT) at our tertiary care center by continuous quality
improvement. Methods: Five hundred forty patients with acute ischemic stroke receiving intravenous
thrombolysis (IVT) at Hannover Medical School were consecutively analyzed in
two phases. In study phase I, including 292 patients, process times and
delaying factors were collected prospectively from May 2015 until September
2017. In study phase II, process times of 248 patients were obtained from
January 2019 until February 2021. In each study phase, a new clinical
standard operation procedure (SOP) was implemented, considering previously
identified delaying factors. Pre- and post-SOP treatment times and delaying
factors were analyzed to evaluate the new protocols. Results: In study phase I, SOP I reduced the median DNT by 15 min. The probability to
receive treatment within 30 min after admission increased by factor 5.35
[95% confidence interval (CI): 2.46–11.66]. Further development of the SOP
with implementation of a mobile thrombolysis kit led to a further decrease
of DNT by 5 min in median in study phase II. The median DNT was 29
(25th–75th percentiles: 18–44) min, and the probability to undergo IVT
within 15 min after admission increased by factor 4.2 (95% CI: 1.63–10.83)
compared with study phase I. Conclusion: Continuous process analysis and subsequent development of targeted workflow
adjustments led to a substantial improvement of DNT. These results
illustrate that with appropriate vigilance, there is constantly an
opportunity for improvement in stroke care.
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Affiliation(s)
- Johanna Ernst
- Department of Neurology, Hannover Medical School, Carl-Neuberg Strasse 1, Hannover 30625, Lower Saxony, Germany
| | - Kai F Storch
- Department of Neurology, Hannover Medical School, Hannover, Germany.,Department of Anesthesiology, Hannover Medical School, Hannover, Germany
| | - Anh Thu Tran
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Maria M Gabriel
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Andrei Leotescu
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Anna-Lena Boeck
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Meret K Huber
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Omar Abu-Fares
- Department of Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Paul Bronzlik
- Department of Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Friedrich Götz
- Department of Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Hans Worthmann
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Ramona Schuppner
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Gerrit M Grosse
- Department of Neurology, Hannover Medical School, Hannover, Germany
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Implementation of the Helsinki Model at West Tallinn Central Hospital. Medicina (B Aires) 2022; 58:medicina58091173. [PMID: 36143850 PMCID: PMC9503615 DOI: 10.3390/medicina58091173] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 11/17/2022] Open
Abstract
Ischemic stroke is defined as neurological deficit caused by brain infarction. The intravenous tissue plasminogen activator, alteplase, is an effective treatment. However, efficacy of this method is time dependent. An important step in improving outcome and increasing the number of patients receiving alteplase is the shortening of waiting times at the hospital, the so-called door-to-needle time (DNT). The comprehensive Helsinki model was proposed in 2012, which enabled the shortening of the DNT to less than 20 min. Background and Objectives: The aim of this study was to analyze the transferability of the suggested model to the West Tallinn Central Hospital (WTCH). Materials and Methods: Since the first thrombolysis in 2005, all patients are registered in the WTCH thrombolysis registry. Several steps following the Helsinki model have been implemented over the years. Results: The results demonstrate that the number and also the percent of thrombolysed stroke patients increased during the years, from a few thrombolysis annually, to 260 in 2021. The mean DNT dropped significantly to 33 min after the implementation of several steps, from the emergency medical services (EMS) prenotification with a phone call to the neurologists, to the setting-up of a thrombolysis team based in the stroke unit. Also, the immediate start of treatment using a computed tomography table was introduced. Conclusions: In conclusion, several implemented steps enabled the shortening of the DNT from 30 to 25.2 min. Short DNTs were achieved and maintained only with EMS prenotification.
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Bladin CF, Bagot KL, Vu M, Kim J, Bernard S, Smith K, Hocking G, Coupland T, Pearce D, Badcock D, Budge M, Nadurata V, Pearce W, Hall H, Kelly B, Spencer A, Chapman P, Oqueli E, Sahathevan R, Kraemer T, Hair C, Stub D, Cadilhac DA. Real-world, feasibility study to investigate the use of a multidisciplinary app (Pulsara) to improve prehospital communication and timelines for acute stroke/STEMI care. BMJ Open 2022; 12:e052332. [PMID: 35851025 PMCID: PMC9297229 DOI: 10.1136/bmjopen-2021-052332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To determine if a digital communication app improves care timelines for patients with suspected acute stroke/ST-elevation myocardial infarction (STEMI). DESIGN Real-world feasibility study, quasi-experimental design. SETTING Prehospital (25 Ambulance Victoria branches) and within-hospital (2 hospitals) in regional Victoria, Australia. PARTICIPANTS Paramedics or emergency department (ED) clinicians identified patients with suspected acute stroke (onset <4.5 hours; n=604) or STEMI (n=247). INTERVENTION The Pulsara communication app provides secure, two-way, real-time communication. Assessment and treatment times were recorded for 12 months (May 2017-April 2018), with timelines compared between 'Pulsara initiated' (Pulsara) and 'not initiated' (no Pulsara). PRIMARY OUTCOME MEASURE Door-to-treatment (needle for stroke, balloon for STEMI) Secondary outcome measures: ambulance and hospital processes. RESULTS Stroke (no Pulsara n=215, Pulsara n=389) and STEMI (no Pulsara n=76, Pulsara n=171) groups were of similar age and sex (stroke: 76 vs 75 years; both groups 50% male; STEMI: 66 vs 63 years; 68% and 72% male). When Pulsara was used, patients were off ambulance stretcher faster for stroke (11(7, 17) vs 19(11, 29); p=0.0001) and STEMI (14(7, 23) vs 19(10, 32); p=0.0014). ED door-to-first medical review was faster (6(2, 14) vs 23(8, 67); p=0.0001) for stroke but only by 1 min for STEMI (3 (0, 7) vs 4 (0, 14); p=0.25). Door-to-CT times were 44 min faster (27(18, 44) vs 71(43, 147); p=0.0001) for stroke, and percutaneous intervention door-to-balloon times improved by 17 min, but non-significant (56 (34, 88) vs 73 (49, 110); p=0.41) for STEMI. There were improvements in the proportions of patients treated within 60 min for stroke (12%-26%, p=0.15) and 90 min for STEMI (50%-78%, p=0.20). CONCLUSIONS In this Australian-first study, uptake of the digital communication app was strong, patient-centred care timelines improved, although door-to-treatment times remained similar.
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Affiliation(s)
- Chris F Bladin
- Ambulance Victoria, Doncaster, Victoria, Australia
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
- Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
| | - Kathleen L Bagot
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
- Stroke and Ageing Research, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Michelle Vu
- Epworth Hospital, Richmond, Victoria, Australia
| | - Joosup Kim
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
- Stroke and Ageing Research, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | | | - Karen Smith
- Centre for Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | | | - Debra Pearce
- Ballarat Health Services, Ballarat, Victoria, Australia
| | | | - Marc Budge
- Bendigo Health, Bendigo, Victoria, Australia
| | | | - Wayne Pearce
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - Howard Hall
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - Ben Kelly
- Ballarat Health Services, Ballarat, Victoria, Australia
| | - Angie Spencer
- Ballarat Health Services, Ballarat, Victoria, Australia
| | | | - Ernesto Oqueli
- Ballarat Health Services, Ballarat, Victoria, Australia
- Department of Medicine, Deakin University, Burwood, Sydney, Australia
| | - Ramesh Sahathevan
- Ballarat Health Services, Ballarat, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Casey Hair
- Ballarat Health Services, Ballarat, Victoria, Australia
| | - Dion Stub
- Ambulance Victoria, Doncaster, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dominique A Cadilhac
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
- Stroke and Ageing Research, Department of Medicine, Monash University, Clayton, Victoria, Australia
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Allen M, James C, Frost J, Liabo K, Pearn K, Monks T, Everson R, Stein K, James M. Use of Clinical Pathway Simulation and Machine Learning to Identify Key Levers for Maximizing the Benefit of Intravenous Thrombolysis in Acute Stroke. Stroke 2022; 53:2758-2767. [PMID: 35862194 PMCID: PMC9389935 DOI: 10.1161/strokeaha.121.038454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Expert opinion is that about 20% of emergency stroke patients should receive thrombolysis. Currently, 11% to 12% of patients in England and Wales receive thrombolysis, ranging from 2% to 24% between hospitals. The aim of this study was to assess how much variation is due to differences in local patient populations, and how much is due to differences in clinical decision-making and stroke pathway performance, while estimating a realistic target thrombolysis use.
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Affiliation(s)
- Michael Allen
- Medical School, University of Exeter, St Luke’s Campus, United Kingdom (M.A., C.J., J.F., K.L., K.P., T.M., K.S.)
| | - Charlotte James
- Medical School, University of Exeter, St Luke’s Campus, United Kingdom (M.A., C.J., J.F., K.L., K.P., T.M., K.S.)
| | - Julia Frost
- Medical School, University of Exeter, St Luke’s Campus, United Kingdom (M.A., C.J., J.F., K.L., K.P., T.M., K.S.)
| | - Kristin Liabo
- Medical School, University of Exeter, St Luke’s Campus, United Kingdom (M.A., C.J., J.F., K.L., K.P., T.M., K.S.)
| | - Kerry Pearn
- Medical School, University of Exeter, St Luke’s Campus, United Kingdom (M.A., C.J., J.F., K.L., K.P., T.M., K.S.)
| | - Thomas Monks
- Medical School, University of Exeter, St Luke’s Campus, United Kingdom (M.A., C.J., J.F., K.L., K.P., T.M., K.S.)
| | - Richard Everson
- Computer Science, University of Exeter, Streatham Campus, United Kingdom (R.E.)
| | - Ken Stein
- Medical School, University of Exeter, St Luke’s Campus, United Kingdom (M.A., C.J., J.F., K.L., K.P., T.M., K.S.)
| | - Martin James
- Royal Devon and Exeter Hospital, Royal Devon and Exeter NHS Foundation Trust, United Kingdom (M.J.)
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Vicente-Pascual M, Quilez A, Gil MP, González-Mingot C, Vázquez-Justes D, Mauri-Capdevila G, Sanahuja J, García-Vázquez C, Purroy F. The influence of organisational management on door-to-needle times for fibrinolytic treatment. NEUROLOGÍA (ENGLISH EDITION) 2022:S2173-5808(22)00072-4. [PMID: 35842131 DOI: 10.1016/j.nrleng.2020.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 10/05/2020] [Indexed: 10/17/2022] Open
Abstract
INTRODUCTION Door-to-needle time (DNT) has been established as the main indicator in code stroke protocols. According to the 2018 guidelines of the American Heart Association/American Stroke Association, DNT should be less than 45minuts; therefore, effective and revised pre-admission and in-hospital protocols are required. METHOD We analysed organisational changes made between 2011 and 2019 and their influence on DNT and the clinical progression of patients treated with fibrinolysis. We collected data from our centre, stored and monitored under the Master Plan for Cerebrovascular Disease of the regional government of Catalonia. Among other measures, we analysed the differences between years and differences derived from the implementation of the Helsinki model. RESULTS The study included 447 patients, and we observed significant differences in DNT between different years. Pre-hospital code stroke activation, recorded in 315 cases (70.5%), reduced DNT by a median of 14minutes. However, the linear regression model only showed an inversely proportional relationship between the adoption of the Helsinki code stroke model and DNT (beta coefficient, -0.42; P<.001). The removal of vascular neurologists after the adoption of the Helsinki model increased DNT and the 90-day mortality rate. CONCLUSION DNT is influenced by the organisational model. In our sample, the application of the Helsinki model, the role of the lead vascular neurologist, and notification of code stroke by pre-hospital emergency services are key factors for the reduction of DNT and the clinical improvement of the patient.
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Affiliation(s)
- M Vicente-Pascual
- Servicio de Neurología, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - A Quilez
- Servicio de Neurología, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - M P Gil
- Servicio de Neurología, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - C González-Mingot
- Servicio de Neurología, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - D Vázquez-Justes
- Servicio de Neurología, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - G Mauri-Capdevila
- Servicio de Neurología, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - J Sanahuja
- Servicio de Neurología, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - C García-Vázquez
- Grupo de Neurosciencias Clínica, Institut de Recerca Biomèdica de Lleida, Lleida, Spain
| | - F Purroy
- Servicio de Neurología, Hospital Universitari Arnau de Vilanova, Lleida, Spain; Grupo de Neurosciencias Clínica, Institut de Recerca Biomèdica de Lleida, Lleida, Spain.
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Mikulík R, Bar M, Bělašková S, Černík D, Fiksa J, Herzig R, Jura R, Jurák L, Klečka L, Neumann J, Ostrý S, Šaňák D, Ševčík P, Škoda O, Šrámek M, Tomek A, Václavík D. Ultrashort Door‐to‐Needle Time for Intravenous Thrombolysis Is Safer and Improves Outcome in the Czech Republic: Nationwide Study 2004 to 2019. J Am Heart Assoc 2022; 11:e023524. [PMID: 35574953 PMCID: PMC9238542 DOI: 10.1161/jaha.121.023524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background The benefit of intravenous thrombolysis is time dependent. It remains unclear, however, whether dramatic shortening of door‐to‐needle time (DNT) among different types of hospitals nationwide does not compromise safety and still improves outcome. Methods and Results Multifaceted intervention to shorten DNT was introduced at a national level, and prospectively collected data from a registry between 2004 and 2019 were analyzed. Generalized estimating equation was used to identify the association between DNT and outcomes independently from prespecified baseline variables. The primary outcome was modified Rankin score 0 to 1 at 3 months, and secondary outcomes were parenchymal hemorrhage/intracerebral hemorrhage (ICH), any ICH, and death. Of 31 316 patients treated with intravenous thrombolysis alone, 18 861 (60%) had available data: age 70±13 years, National Institutes of Health Stroke Scale at baseline (median, 8; interquartile range, 5–14), and 45% men. DNT groups 0 to 20 minutes, 21 to 40 minutes, 41 to 60 minutes, and >60 minutes had 3536 (19%), 5333 (28%), 4856 (26%), and 5136 (27%) patients. National median DNT dropped from 74 minutes in 2004 to 22 minutes in 2019. Shorter DNT had proportional benefit: it increased the odds of achieving modified Rankin score 0 to 1 and decreased the odds of parenchymal hemorrhage/ICH, any ICH, and mortality. Patients with DNT ≤20 minutes, 21 to 40 minutes, and 41 to 60 minutes as compared with DNT >60 minutes had adjusted odds ratios for modified Rankin score 0 to 1 of the following: 1.30 (95% CI, 1.12–1.51), 1.33 (95% CI, 1.15–1.54), and 1.15 (95% CI, 1.02–1.29), and for parenchymal hemorrhage/ICH: 0.57 (95% CI, 0.45–0.71), 0.76 (95% CI, 0.61–0.94), 0.83 (95% CI, 0.70–0.99), respectively. Conclusions Ultrashort initiation of thrombolysis is feasible, improves outcome, and makes treatments safer because of fewer intracerebral hemorrhages. Stroke management should be optimized to initiate thrombolysis as soon as possible optimally within 20 minutes from arrival to a hospital.
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Affiliation(s)
- Robert Mikulík
- International Clinical Research Center and Department of Neurology St. Anne’s University Hospital in Brno Czech Republic
- Faculty of Medicine at Masaryk University Brno Czech Republic
| | - Michal Bar
- Department of Neurology University Hospital Ostrava and Faculty of Medicine at University Ostrava Ostrava Czech Republic
| | - Silvie Bělašková
- International Clinical Research Center and Department of Neurology St. Anne’s University Hospital in Brno Czech Republic
| | - David Černík
- Comprehensive Stroke Center ‐ Department of Neurology Masaryk Hospital Ustí nad Labem ‐ KZ a.s. Ustí nad Labem Czech Republic
| | - Jan Fiksa
- Department of Neurology First Faculty of Medicine and General University Hospital, Charles University Prague Czech Republic
| | - Roman Herzig
- Comprehensive Stroke Center University Hospital Hradec KrálovéCharles University Faculty of Medicine in Hradec Králové Czech Republic
| | - René Jura
- Faculty of Medicine at Masaryk University Brno Czech Republic
- Department of Neurology University Hospital Brno Brno Czech Republic
| | - Lubomír Jurák
- Neurocenter Regional Hospital Liberec Liberec Czech Republic
| | - Lukáš Klečka
- Department of Neurology Town Hospital Ostrava Ostrava Czech Republic
| | - Jiří Neumann
- Department of Neurology Chomutov Hospital, KZ a.s. Chomutov Czech Republic
| | - Svatopluk Ostrý
- Comprehensive Stroke Center Hospital České Budějovice, a.s. České Budějovice Czech Republic
- Department of Neurosurgery and Neurooncology First Faculty of Medicine Charles University in Prague Czech Republic
- Military University Hospital Prague Prague Czech Republic
| | - Daniel Šaňák
- Comprehensive Stroke Center in Department of Neurology Palacký Medical School and University Hospital Olomouc Czech Republic
| | - Petr Ševčík
- Department of Neurology Faculty of Medicine in Pilsen Charles University Pilsen Czech Republic
- Department of Neurology University Hospital Pilsen Pilsen Czech Republic
| | - Ondřej Škoda
- Department of Neurology Hospital Jihlava Jihlava Czech Republic
- Department of Neurology 3rd Medical School of Charles University and Vinohrady University Hospital Prague Czech Republic
| | - Martin Šrámek
- Department of Neurology Central Military University Hospital Prague and Motol University Hospital Prague Czech Republic
| | - Aleš Tomek
- Department of Neurology 2nd Medical School of Charles University and Motol University Hospital Prague Czech Republic
| | - Daniel Václavík
- Department of Neurology and AGEL Research and Training Institute Ostrava Vítkovice Hospital Ostrava Czech Republic
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Sapra H. "No Time to Die" - Saving the Neurons. Indian J Crit Care Med 2022; 26:539-540. [PMID: 35719449 PMCID: PMC9160637 DOI: 10.5005/jp-journals-10071-24221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
How to cite this article: Sapra H. "No Time to Die" - Saving the Neurons. Indian J Crit Care Med 2022;26(5):539-540.
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Affiliation(s)
- Harsh Sapra
- Department of Neurocritical Care, Medanta–The Medicity, Gurugram, Haryana, India,Harsh Sapra, Department of Neurocritical Care, Medanta–The Medicity, Gurugram, Haryana, India, Phone: +91 9650898677, e-mail:
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Li H, Xu D, Xu Y, Wei L. Impact of Medical Community Model on Intravenous Alteplase Door-to-Needle Times and Prognosis of Patients With Acute Ischemic Stroke. Front Surg 2022; 9:888015. [PMID: 35574548 PMCID: PMC9091958 DOI: 10.3389/fsurg.2022.888015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/23/2022] [Indexed: 11/18/2022] Open
Abstract
Objective In this study, we retrospectively analyzed 795 AIS patients who received intravenous alteplase for thrombolytic therapy in one third-class hospital or three second-class hospitals in Dongyang City and sought to evaluate the effects of the medical community model on intravenous alteplase door-to-needle time (DNT) and prognosis of patients with acute ischemic stroke. Methods According to whether the medical community model is established or not, 303 AIS patients (204 cases from the third-class hospital and 99 cases from three second-class hospitals) were assigned to control group unavailable to the medical community model and 492 AIS patients (297 cases from the third-class hospital, and 195 cases from three second-class hospitals) into observational group available to the medical community model. Results A higher thrombolysis rate, a shorter DNT, more patients with DNT ≤ 60 min and DNT ≤ 45 min, a shorter ONT, lower National Institutes of Health Stroke Scale (NIHSS) scores at 24 h, 7 d, 14 d, and modified Rankin scale (mRS) scores at 3 months after thrombolytic therapy, a shorter length of hospital stay, and less hospitalization expense were found in the observational group than the control group. Subgroup analysis based on different-class hospitals revealed that the medical community model could reduce the DNT and ONT to increase the thrombolysis rate of AIS patients, especially in low-class hospitals. After the establishment of the medical community model, the AIS patients whether from the third-class hospital or three second-class hospitals exhibited lower NIHSS scores at 24 h, 7 d, 14 d after thrombolytic therapy (p < 0.05). After a 90-day follow-up for mRS scores, a significant difference was only noted in the mRS scores of AIS patients from the third-class hospital after establishing the medical community model (p < 0.05). It was also found that the medical community model led to reduced length of hospital stay and hospitalization expenses for AIS patients, especially for the second-class hospitals. Conclusion The data suggest that the medical community model could significantly reduce intravenous alteplase DNT and improve the prognosis of patients with AIS.
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Ortega-Gutierrez S, Quispe-Orozco D, Schafer S, Farooqui M, Zevallos CB, Dandapat S, Mendez-Ruiz A, Aagaard-Kienitz B, Petersen N, Derdeyn CP. Angiography suite cone-beam CT perfusion for selection of thrombectomy patients: A pilot study. J Neuroimaging 2022; 32:493-501. [PMID: 35315169 PMCID: PMC9314685 DOI: 10.1111/jon.12988] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/07/2022] [Accepted: 02/26/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE The availability of cone-beam CT perfusion (CBCTP) in angiography suites may improve large-vessel occlusion (LVO) triage and reduce reperfusion times for patients presenting during extended time window. We aim to evaluate the perfusion maps correlation and agreement between multidetector CT perfusion (MDCTP) and CBCTP when obtained sequentially in patients undergoing endovascular therapy. METHODS This is a prospective, pilot, single-arm interventional cohort study of consecutive patients with anterior circulation LVO. All patients underwent MDCTP and CBCTP prior to endovascular therapy, generating cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time-to-maximum/time to peak contrast concentration maps. We compared the two imaging modalities using three different methods: (1) six regions of interest (ROIs) placed in the anterior circulation territory; (2) ROIs placed in all 10 Alberta Stroke Program Early CT Score regions; and (3) ROI drawn around the entire ischemic area. ROI ratios (unaffected/affected area) were compared for all sequences in each method. We used the intraclass correlation coefficient to calculate the correlation between the studies. Bland-Altman plots were also created to measure the degree of agreement. Finally, a sensitivity analysis was done comparing both modalities in patients with low infarct growth rate. RESULTS Fourteen patients were included (median age 81 years [74-87], 50% males, median National Institutes of Health Stroke Scale 19 [14-22]). Median time between studies was 42 minutes (interquartile range 29-61). Independently of the method used, we found moderate to excellent correlation in CBF, CBV, and MTT between modalities. CBF correlation further improved in patients with low infarct growth. CONCLUSION These results demonstrate promising accuracy of CBCTP in evaluating ischemic tissue in patients presenting with LVO ischemic stroke.
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Affiliation(s)
- Santiago Ortega-Gutierrez
- Department of Neurology, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA.,Department of Neurosurgery, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA.,Department of Radiology, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA
| | - Darko Quispe-Orozco
- Department of Neurology, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA
| | | | - Mudassir Farooqui
- Department of Neurology, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA
| | - Cynthia B Zevallos
- Department of Neurology, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA
| | | | - Alan Mendez-Ruiz
- Department of Neurology, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA
| | - Beverly Aagaard-Kienitz
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Nils Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Colin P Derdeyn
- Department of Neurology, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA.,Department of Neurosurgery, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA.,Department of Radiology, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, Iowa, USA
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Ryan A, Paul CL, Cox M, Whalen O, Bivard A, Attia J, Bladin C, Davis SM, Campbell BCV, Parsons M, Grimley RS, Anderson C, Donnan GA, Oldmeadow C, Kuhle S, Walker FR, Hood RJ, Maltby S, Keynes A, Delcourt C, Hatchwell L, Malavera A, Yang Q, Wong A, Muller C, Sabet A, Garcia-Esperon C, Brown H, Spratt N, Kleinig T, Butcher K, Levi CR. TACTICS - Trial of Advanced CT Imaging and Combined Education Support for Drip and Ship: evaluating the effectiveness of an 'implementation intervention' in providing better patient access to reperfusion therapies: protocol for a non-randomised controlled stepped wedge cluster trial in acute stroke. BMJ Open 2022; 12:e055461. [PMID: 35149571 PMCID: PMC8845197 DOI: 10.1136/bmjopen-2021-055461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Stroke reperfusion therapies, comprising intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT), are best practice treatments for eligible acute ischemic stroke patients. In Australia, EVT is provided at few, mainly metropolitan, comprehensive stroke centres (CSC). There are significant challenges for Australia's rural and remote populations in accessing EVT, but improved access can be facilitated by a 'drip and ship' approach. TACTICS (Trial of Advanced CT Imaging and Combined Education Support for Drip and Ship) aims to test whether a multicomponent, multidisciplinary implementation intervention can increase the proportion of stroke patients receiving EVT. METHODS AND ANALYSIS This is a non-randomised controlled, stepped wedge trial involving six clusters across three Australian states. Each cluster comprises one CSC hub and a minimum of three primary stroke centre (PSC) spokes. Hospitals will work in a hub and spoke model of care with access to a multislice CT scanner and CT perfusion image processing software (MIStar, Apollo Medical Imaging). The intervention, underpinned by behavioural theory and technical assistance, will be allocated sequentially, and clusters will move from the preintervention (control) period to the postintervention period. PRIMARY OUTCOME Proportion of all stroke patients receiving EVT, accounting for clustering. SECONDARY OUTCOMES Proportion of patients receiving IVT at PSCs, proportion of treated patients (IVT and/or EVT) with good (modified Rankin Scale (mRS) score 0-2) or poor (mRS score 5-6) functional outcomes and European Quality of Life Scale scores 3 months postintervention, proportion of EVT-treated patients with symptomatic haemorrhage, and proportion of reperfusion therapy-treated patients with good versus poor outcome who presented with large vessel occlusion at spokes. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Hunter New England Human Research Ethics Committee (18/09/19/4.13, HREC/18/HNE/241, 2019/ETH01238). Trial results will be disseminated widely through published manuscripts, conference presentations and at national and international platforms regardless of whether the trial was positive or neutral. TRIAL REGISTRATION NUMBER ACTRN12619000750189; UTNU1111-1230-4161.
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Affiliation(s)
- Annika Ryan
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Christine L Paul
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Martine Cox
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Olivia Whalen
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Andrew Bivard
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - John Attia
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Christopher Bladin
- Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Mark Parsons
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Department of Neurology, Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Liverpool, New South Wales, Australia
| | - Rohan S Grimley
- Queensland State-wide Stroke Clinical Network, Healthcare Improvement Unit, Queensland Health, Herston, Queensland, Australia
- School of Medicine, Griffith University, Southport, Queensland, Australia
| | - Craig Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Christopher Oldmeadow
- Data Sciences, Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Sarah Kuhle
- Queensland State-wide Stroke Clinical Network, Healthcare Improvement Unit, Queensland Health, Herston, Queensland, Australia
| | - Frederick R Walker
- Centre for Advanced Training Systems, School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Rebecca J Hood
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Centre for Advanced Training Systems, School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Steven Maltby
- Centre for Advanced Training Systems, School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Angela Keynes
- Centre for Advanced Training Systems, School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Candice Delcourt
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Luke Hatchwell
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Alejandra Malavera
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Qing Yang
- Apollo Medical Imaging Technology Pty Ltd, Melbourne, Victoria, Australia
| | - Andrew Wong
- Royal Brisbane and Women's Hospital, University of Queensland, Brisbane, Queensland, Australia
| | - Claire Muller
- Queensland State-wide Stroke Clinical Network, Healthcare Improvement Unit, Queensland Health, Herston, Queensland, Australia
- Royal Brisbane and Women's Hospital, University of Queensland, Brisbane, Queensland, Australia
| | - Arman Sabet
- School of Medicine, Griffith University, Southport, Queensland, Australia
- Department of Neurology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Carlos Garcia-Esperon
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Area Administration, Hunter New England Local Health District, New Lambton, New South Wales, Australia
| | - Helen Brown
- Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Neil Spratt
- Division of Medicine, Department of Neurology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
- School of Biomedical Sciences and Pharmacy, Translational Stroke Laboratory, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ken Butcher
- Department of Neurology, Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Liverpool, New South Wales, Australia
- Clinical Neuroscience, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Christopher R Levi
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Area Administration, Hunter New England Local Health District, New Lambton, New South Wales, Australia
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Bao H, Zhang S, Hao J, Zuo L, Xu X, Yang Y, Jiang H, Li G. Improving the Prehospital Identification and Acute Care of Acute Stroke Patients: A Quality Improvement Project. Emerg Med Int 2022; 2022:3456144. [PMID: 35186333 PMCID: PMC8850070 DOI: 10.1155/2022/3456144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 12/28/2021] [Accepted: 01/03/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There are a large number of stroke patients in China, and there is currently a lack of prehospital acute stroke care training programs. AIM To develop a prehospital emergency medical service (PEMS) training program to improve the prehospital identification and acute care of acute stroke. METHODS Forty prehospital emergency doctors whose service stations are located within a 10 km radius from Shanghai Pudong New Area Medical Emergency Service Center took this course on November 13, 2014. A questionnaire was designed to evaluate the PEMS personnel's knowledge in stroke and acute stroke care and was conducted before and after training as an assessment of the effectiveness of training. The patient population in this study included a baseline cohort before training and a prospective cohort after training, each composed of patients who were sent to Shanghai East Hospital South Stoke Center within one year. The transit time, final diagnosis, administration of thrombolysis, and door-to-needle time (DNT) were collected and analyzed. RESULTS After the training, 100% of the PEMS personnel were competent to identify stroke cases using the Cincinnati prehospital stroke scale (CPSS). All participants realized that intravenous thrombolysis therapy in a time-sensitive manner is the most effective way to treat acute ischemic stroke. Although there was no difference in first-aid transit time before and after training, the stroke diagnosis rate improved by 6.5% after training (P=0.03). The thrombolysis rate increased to 29.6% from 24.3% but did not reach statistical significance. Compared to 84.0 minutes (standard deviation: 23.1 minutes) before the training, the average DNT after training was 53 minutes (standard deviation: 15.0 minutes), demonstrating a remarkable reduction (P < 0.01). CONCLUSION The training program effectively improved the PEMS personnel's knowledge in stroke and stroke acute care.
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Affiliation(s)
- Huan Bao
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Sumian Zhang
- Department of ICU, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Junjie Hao
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Lian Zuo
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Xiahong Xu
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Yumei Yang
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Hua Jiang
- Department of Medical Education, Shanghai Pudong Medical Emergency Center, Shanghai 201206, China
| | - Gang Li
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
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Improving Thrombolysis for Acute Ischemic Stroke: The Implementation and Evaluation of a Theory-Based Resource Integration Project in China. Int J Integr Care 2022; 22:9. [PMID: 35221825 PMCID: PMC8833266 DOI: 10.5334/ijic.5616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 01/27/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction: Intravenous thrombolysis for acute ischemic stroke remains underused in the developing countries. In 2016, a theory-based resource integration project was initiated at a major stroke center in China. This report describes the implementation process and results of the quality improvement project. Description: Eighteen environment-tailored interventions were implemented, including stroke code activation, electronic wristband bundling, structured information sharing, etc. The project was implemented from July 2016 to June 2017. A total of 519 acute ischemic stroke patients were included. After the intervention, median DNT decreased from 62 min to 37 min (P < 0.001). The percentage of cases treated within 30, 45 or 60 minutes increased from 2.5%, 17.4% and 44.6% to 27.4%, 69.4% and 84.7% respectively (P < 0.001). The median length of inpatient stay decreased from 10 days to 8 days (P < 0.001). The proportion of patients with severe disability decreased from 25.5% to 15.8% post-intervention. Discussion: Adequate pre-intervention activities are important conditions for the smooth implementation of the complex service integration initiative. The new treatment pathway has undergone a process of destruction, remodeling and solidification before stable and effective operation. In order to realize the full effect of service integration, whole society efforts are also required. Conclusions: Introduction of the theory-based resource integration project was associated with increased thrombolysis administrations, shorter DNT, and no statistically significant change in adverse outcomes. The basic principles of this project might be applicable to various resource settings.
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Turc G, Hadziahmetovic M, Walter S, Churilov L, Larsen K, Grotta JC, Yamal JM, Bowry R, Katsanos AH, Zhao H, Donnan G, Davis SM, Hussain MS, Uchino K, Helwig SA, Johns H, Weber JE, Nolte CH, Kunz A, Steiner T, Sacco S, Ebinger M, Tsivgoulis G, Faßbender K, Audebert HJ. Comparison of Mobile Stroke Unit With Usual Care for Acute Ischemic Stroke Management: A Systematic Review and Meta-analysis. JAMA Neurol 2022; 79:281-290. [PMID: 35129584 PMCID: PMC8822443 DOI: 10.1001/jamaneurol.2021.5321] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
IMPORTANCE So far, uncertainty remains as to whether there is sufficient cumulative evidence that mobile stroke unit (MSU; specialized ambulance equipped with computed tomography scanner, point-of-care laboratory, and neurological expertise) use leads to better functional outcomes compared with usual care. OBJECTIVE To determine with a systematic review and meta-analysis of the literature whether MSU use is associated with better functional outcomes in patients with acute ischemic stroke (AIS). DATA SOURCES MEDLINE, Cochrane Library, and Embase from 1960 to 2021. STUDY SELECTION Studies comparing MSU deployment and usual care for patients with suspected stroke were eligible for analysis, excluding case series and case-control studies. DATA EXTRACTION AND SYNTHESIS Independent data extraction by 2 observers, following the PRISMA and MOOSE reporting guidelines. The risk of bias in each study was determined using the ROBINS-I and RoB2 tools. In the case of articles with partially overlapping study populations, unpublished disentangled results were obtained. Data were pooled in random-effects meta-analyses. MAIN OUTCOMES AND MEASURES The primary outcome was excellent outcome as measured with the modified Rankin Scale (mRS; score of 0 to 1 at 90 days). RESULTS Compared with usual care, MSU use was associated with excellent outcome (adjusted odds ratio [OR], 1.64; 95% CI, 1.27-2.13; P < .001; 5 studies; n = 3228), reduced disability over the full range of the mRS (adjusted common OR, 1.39; 95% CI, 1.14-1.70; P = .001; 3 studies; n = 1563), good outcome (mRS score of 0 to 2: crude OR, 1.25; 95% CI, 1.09-1.44; P = .001; 6 studies; n = 3266), shorter onset-to-intravenous thrombolysis (IVT) times (median reduction, 31 minutes [95% CI, 23-39]; P < .001; 13 studies; n = 3322), delivery of IVT (crude OR, 1.83; 95% CI, 1.58-2.12; P < .001; 7 studies; n = 4790), and IVT within 60 minutes of symptom onset (crude OR, 7.71; 95% CI, 4.17-14.25; P < .001; 8 studies; n = 3351). MSU use was not associated with an increased risk of all-cause mortality at 7 days or at 90 days or with higher proportions of symptomatic intracranial hemorrhage after IVT. CONCLUSIONS AND RELEVANCE Compared with usual care, MSU use was associated with an approximately 65% increase in the odds of excellent outcome and a 30-minute reduction in onset-to-IVT times, without safety concerns. These results should help guideline writing committees and policy makers.
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Affiliation(s)
- Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France,Université de Paris, Paris, France,INSERM U1266, Paris, France,FHU Neurovasc, Paris, France
| | | | - Silke Walter
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Leonid Churilov
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - James C. Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital–Texas Medical Center, Houston
| | - Jose-Miguel Yamal
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston, School of Public Health, Houston
| | - Ritvij Bowry
- Department of Neurology and Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | - Aristeidis H. Katsanos
- Division of Neurology, McMaster University Population Health Research Institute, Hamilton, Ontario, Canada,Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Henry Zhao
- Department of Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia,Department of Medicine, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Geoffrey Donnan
- Department of Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia,Department of Medicine, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Stephen M. Davis
- Department of Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia,Department of Medicine, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Muhammad S. Hussain
- Cerebrovascular Center, Department of Neurology, and Critical Care Transport Team, Cleveland Clinic, Cleveland, Ohio
| | - Ken Uchino
- Cerebrovascular Center, Department of Neurology, and Critical Care Transport Team, Cleveland Clinic, Cleveland, Ohio
| | - Stefan A. Helwig
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Hannah Johns
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Joachim E. Weber
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H. Nolte
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Center for Stroke Research Berlin, Berlin, Germany
| | - Alexander Kunz
- Klinik für Neurologie, Neurologische Intensivmedizin, Zentrum für Hirngefäßerkrankungen, Asklepios Fachklinikum Brandenburg, Brandenburg, Germany
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Martin Ebinger
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Center for Stroke Research Berlin, Berlin, Germany,Klinik für Neurologie Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece,Department of Neurology, University of Tennessee Health Science Center, Memphis
| | - Klaus Faßbender
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Heinrich J. Audebert
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Center for Stroke Research Berlin, Berlin, Germany
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Ebinger M, Audebert HJ. Shifting acute stroke management to the prehospital setting. Curr Opin Neurol 2022; 35:4-9. [PMID: 34799513 DOI: 10.1097/wco.0000000000001012] [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
PURPOSE OF REVIEW The earlier the treatment, the better the outcomes after acute ischemic stroke. Optimizing prehospital care bears potential to shorten treatment times. We here review the recent literature on mothership vs. drip-and-ship as well as mobile stroke unit concepts. RECENT FINDINGS Mobile stroke units result in the shortest onset-to-treatment times in mostly urban settings. SUMMARY Future research should focus on further streamlining processes around mobile stroke units, especially improving dispatch algorithms and improve referral for endovascular therapy.
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Affiliation(s)
- Martin Ebinger
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Chen Y, Nguyen TN, Wellington J, Mofatteh M, Yao W, Hu Z, Kuang Q, Wu W, Wang X, Sun Y, Ouyang K, Xu J, Huang W, Yang S. Shortening Door-to-Needle Time by Multidisciplinary Collaboration and Workflow Optimization During the COVID-19 Pandemic. J Stroke Cerebrovasc Dis 2022; 31:106179. [PMID: 34735901 PMCID: PMC8526426 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106179] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/10/2021] [Accepted: 10/12/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES This study aims to evaluate shortening door-to-needle time of intravenous recombinant tissue plasminogen activator of acute ischemic stroke patients by multidisciplinary collaboration and workflow optimization based on our hospital resources. MATERIALS AND METHODS We included patients undergoing thrombolysis with intravenous recombinant tissue plasminogen activator from January 1, 2018, to September 30, 2020. Patients were divided into pre- (January 1, 2018, to December 31, 2019) and post-intervention groups (January 1, 2020, to September 31, 2020). We conducted multi-department collaboration and process optimization by implementing 16 different measures in prehospital, in-hospital, and post-acute feedback stages for acute ischemic stroke patients treated with intravenous thrombolysis. A comparison of outcomes between both groups was analyzed. RESULTS Two hundred and sixty-three patients received intravenous recombinant tissue plasminogen activator in our hospital during the study period, with 128 and 135 patients receiving treatment in the pre-intervention and post-intervention groups, respectively. The median (interquartile range) door-to-needle time decreased significantly from 57.0 (45.3-77.8) min to 37.0 (29.0-49.0) min. Door-to-needle time was shortened to 32 min in the post-intervention period in the 3rd quarter of 2020. The door-to-needle times at the metrics of ≤ 30 min, ≤ 45 min, ≤ 60 min improved considerably, and the DNT> 60 min metric exhibited a significant reduction. CONCLUSIONS A multidisciplinary collaboration and continuous process optimization can result in overall shortened door-to-needle despite the challenges incurred by the COVID-19 pandemic.
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Affiliation(s)
- Yimin Chen
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People's Hospital, No. 16, Guanghaidadaoxi, Sanshui District, Foshan, Guangdong Province 528100, China
| | - Thanh N Nguyen
- Thanh N. Nguyen Department of Neurology, Radiology, Boston University School of Medicine, Boston, MA, United States
| | - Jack Wellington
- School of Medicine, Cardiff University, Wales, United Kingdom
| | - Mohammad Mofatteh
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, United Kingdom
| | - Weiping Yao
- Dean Office, Foshan Sanshui District People's Hospital, Foshan, Guangdong Province, China
| | - Zhaohui Hu
- Medical Department, Foshan Sanshui District People's Hospital, Foshan, Guangdong Province, China
| | - Qiuping Kuang
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People's Hospital, No. 16, Guanghaidadaoxi, Sanshui District, Foshan, Guangdong Province 528100, China
| | - Weijuan Wu
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People's Hospital, No. 16, Guanghaidadaoxi, Sanshui District, Foshan, Guangdong Province 528100, China
| | - Xuejun Wang
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People's Hospital, No. 16, Guanghaidadaoxi, Sanshui District, Foshan, Guangdong Province 528100, China
| | - Yu Sun
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People's Hospital, No. 16, Guanghaidadaoxi, Sanshui District, Foshan, Guangdong Province 528100, China
| | - Kexun Ouyang
- Department of Radiology, Foshan Sanshui District People's Hospital, Foshan, Guangdong Province, China
| | - Junmiao Xu
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People's Hospital, No. 16, Guanghaidadaoxi, Sanshui District, Foshan, Guangdong Province 528100, China
| | - Weiquan Huang
- Medical Intern, Foshan Sanshui District People's Hospital, Foshan, Guangdong Province, China,School of Medicine, Shaoguan University, Shaoguan, Guangdong Province, China
| | - Shuiquan Yang
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People's Hospital, No. 16, Guanghaidadaoxi, Sanshui District, Foshan, Guangdong Province 528100, China,Corresponding author
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Lee SH, Ryoo HW, Jin SC, Ahn JY, Sohn SI, Hwang YH, Do Y, Lee YS, Kim JH. Prehospital Notification Using a Mobile Application Can Improve Regional Stroke Care System in a Metropolitan Area. J Korean Med Sci 2021; 36:e327. [PMID: 34904406 PMCID: PMC8668497 DOI: 10.3346/jkms.2021.36.e327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Acute ischemic stroke is a time-sensitive disease. Emergency medical service (EMS) prehospital notification of potential patients with stroke could play an important role in improving the in-hospital medical response and timely treatment of patients with acute ischemic stroke. We analyzed the effects of FASTroke, a mobile app that EMS can use to notify hospitals of patients with suspected acute ischemic stroke at the prehospital stage. METHODS We conducted a retrospective observational study of patients diagnosed with acute ischemic stroke at 5 major hospitals in metropolitan Daegu City, Korea, from February 2020 to January 2021. The clinical conditions and time required for managing patients were compared according to whether the EMS employed FASTroke app and further compared the factors by dividing the patients into subgroups according to the preregistration received by the hospitals when using FASTroke app. RESULTS Of the 563 patients diagnosed with acute ischemic stroke, FASTroke was activated for 200; of these, 93 were preregistered. The FASTroke prenotification showed faster door-to-computed-tomography times (19 minutes vs. 25 minutes, P < 0.001), faster door-to-intravenous-thrombolysis times (37 minutes vs. 48 minutes, P < 0.001), and faster door-to-endovascular-thrombectomy times (82 minutes vs. 119 minutes, P < 0.001). The time was further shortened when the preregistration was conducted simultaneously by the receiving hospital. CONCLUSION The FASTroke app is an easy and useful tool for prenotification as a regional stroke care system in the metropolitan area, leading to reduced transport and acute ischemic stroke management time and more reperfusion treatment. The effect was more significant when the preregistration was performed jointly.
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Affiliation(s)
- Sang-Hun Lee
- Department of Emergency Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Hyun Wook Ryoo
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, Daegu, Korea.
| | - Sang-Chan Jin
- Department of Emergency Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Jae Yun Ahn
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Youngrok Do
- Department of Neurology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Yoon-Soo Lee
- Department of Neurosurgery, Daegu Fatima Hospital, Daegu, Korea
| | - Jung Ho Kim
- Department of Emergency Medicine, Yeungnam University College of Medicine, Daegu, Korea
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Nguyen AL, Kirkwood B, Hackett L, Buntine P. Validation of the ECHS non trauma cranial CT rule in Australia: A prospective cohort study. Am J Emerg Med 2021; 52:225-231. [PMID: 34971907 DOI: 10.1016/j.ajem.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 11/10/2021] [Accepted: 12/03/2021] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Computed tomography (CT) is a commonly used imaging modality in Emergency Departments (EDs), however its use is questionable in many low yield settings. The Emergency CT Head score (ECHS) is a recently published clinical tool that assists in stratifying the need for CT brain (CTB) for patients presenting without a history of trauma. We sought to validate this tool in an Australian ED setting. METHODS We prospectively evaluated 412 patients who received CTB without a history of trauma at a large Australian ED. We assessed them for the 4 main ECHS data points: focal neurological deficit on physical examination, new acute onset headache, transient neurological deficit, and a combination of new onset seizures with an altered conscious state. We examined their association with acute and chronic CTB findings. We then applied the ECHS to our data, calculating its sensitivity and its appropriateness at this single site via the calculation of a receiver operating curve (ROC). RESULTS 10.2% of all CTB performed were positive for an acute or chronic abnormality. Only sex (male) and focal motor deficit were independent predictors of positive CTB at univariate analysis. The ECHS did not perform as anticipated in our population, with a ROC area under the curve of 0.498. An ECHS score of >0, which has been proposed as the threshold to not require imaging, had sensitivity of only 83.3% in our population. CONCLUSIONS Further research and validation is required in order to safely implement the ECHS clinical score in the Australian ED setting.
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Affiliation(s)
| | - Bronwyn Kirkwood
- Box Hill Hospital, Emergency Department, Eastern Health, 5 Arnold ST, Box Hill, Victoria 3128, Australia
| | - Liam Hackett
- Box Hill Hospital, Emergency Department, Eastern Health, 5 Arnold ST, Box Hill, Victoria 3128, Australia.
| | - Paul Buntine
- Eastern Health Clinical School, Monash University, Melbourne, Australia; Box Hill Hospital, Emergency Department, Eastern Health, 5 Arnold ST, Box Hill, Victoria 3128, Australia
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Xian Y, Xu H, Smith EE, Saver JL, Reeves MJ, Bhatt DL, Hernandez AF, Peterson ED, Schwamm LH, Fonarow GC. Achieving More Rapid Door-to-Needle Times and Improved Outcomes in Acute Ischemic Stroke in a Nationwide Quality Improvement Intervention. Stroke 2021; 53:1328-1338. [PMID: 34802250 DOI: 10.1161/strokeaha.121.035853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The benefits of tPA (tissue-type plasminogen activator) in acute ischemic stroke are time-dependent. However, delivery of thrombolytic therapy rapidly after hospital arrival was initially occurring infrequently in hospitals in the United States, discrepant with national guidelines. METHODS We evaluated door-to-needle (DTN) times and clinical outcomes among patients with acute ischemic stroke receiving tPA before and after initiation of 2 successive nationwide quality improvement initiatives: Target: Stroke Phase I (2010-2013) and Target: Stroke Phase II (2014-2018) from 913 Get With The Guidelines-Stroke hospitals in the United States between April 2003 and September 2018. RESULTS Among 154 221 patients receiving tPA within 3 hours of stroke symptom onset (median age 72 years, 50.1% female), median DTN times decreased from 78 minutes (interquartile range, 60-98) preintervention, to 66 minutes (51-87) during Phase I, and 50 minutes (37-66) during Phase II (P<0.001). Proportions of patients with DTN ≤60 minutes increased from 26.4% to 42.7% to 68.6% (P<0.001). Proportions of patients with DTN ≤45 minutes increased from 10.1% to 17.7% to 41.4% (P<0.001). By the end of the second intervention, 75.4% and 51.7% patients achieved 60-minute and 45-minute DTN goals. Compared with the preintervention period, hospitals during the second intervention period (2014-2018) achieved higher rates of tPA use (11.7% versus 5.6%; adjusted odds ratio, 2.43 [95% CI, 2.31-2.56]), lower in-hospital mortality (6.0% versus 10.0%; adjusted odds ratio, 0.69 [0.64-0.73]), fewer bleeding complication (3.4% versus 5.5%; adjusted odds ratio, 0.68 [0.62-0.74]), and higher rates of discharge to home (49.6% versus 35.7%; adjusted odds ratio, 1.43 [1.38-1.50]). Similar findings were found in sensitivity analyses of 185 501 patients receiving tPA within 4.5 hours of symptom onset. CONCLUSIONS A nationwide quality improvement program for acute ischemic stroke was associated with substantial improvement in the timeliness of thrombolytic therapy start, increased thrombolytic treatment, and improved clinical outcomes.
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Affiliation(s)
- Ying Xian
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX. (Y.X.)
| | - Haolin Xu
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (H.X., A.F.H.)
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (E.E.S.)
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles (J.L.S.)
| | - Mathew J Reeves
- Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (H.X., A.F.H.)
| | - Eric D Peterson
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX. (E.D.P.)
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.)
| | - Gregg C Fonarow
- Division of Cardiology, University of California at Los Angeles (G.C.F.)
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Bulmer T, Volders D, Blake J, Kamal N. Discrete-Event Simulation to Model the Thrombolysis Process for Acute Ischemic Stroke Patients at Urban and Rural Hospitals. Front Neurol 2021; 12:746404. [PMID: 34777215 PMCID: PMC8586711 DOI: 10.3389/fneur.2021.746404] [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] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/30/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Effective treatment with tissue plasminogen activator (tPA) critically relies on rapid treatment. Door-to-needle time (DNT) is a key measure of hospital efficiency linked to patient outcomes. Numerous changes can reduce DNT, but they are difficult to trial and implement. Discrete-event simulation (DES) provides a way to model and determine the impact of process improvements. Methods: A conceptual framework was developed to illustrate the thrombolysis process; allowing for treatment processes to be replicated using a DES model developed in ARENA. Activity time duration distributions from three sites (one urban and two rural) were used. Five scenarios, three process changes, and two reductions in activity durations, were simulated and tested. Scenarios were tested individually and in combinations. The primary outcome measure is median DNT. The study goal is to determine the largest improvement in DNT at each site. Results: Administration of tPA in the imaging area resulted in the largest median DNT reduction for Site 1 and Site 2 for individual test scenarios (12.6%, 95% CI 12.4–12.8%, and 8.2%, 95% CI 7.5–9.0%, respectively). Ensuring that patients arriving via emergency medical services (EMS) remain on the EMS stretcher to imaging resulted in the largest median DNT improvement for Site 3 (9.2%, 95% CI 7.9–10.5%). Reducing both the treatment decision time and tPA preparation time by 35% resulted in a 11.0% (95% CI 10.0–12.0%) maximum reduction in median DNT. The lowest median and 90th percentile DNTs were achieved by combining all test scenarios, with a maximum reduction of 26.7% (95% CI 24.5–28.9%) and 17.1% (95% CI 12.5–21.7%), respectively. Conclusions: The detailed conceptual framework clarifies the intra-hospital logistics of the thrombolysis process. The most significant median DNT improvement at rural hospitals resulted from ensuring patients arriving via EMS remain on the EMS stretcher to imaging, while urban sites benefit more from administering tPA in the imaging area. Reducing the durations of activities on the critical path will provide further DNT improvements. Significant DNT improvements are achievable in urban and rural settings by combining process changes with reducing activity durations.
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Affiliation(s)
- Tessa Bulmer
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - David Volders
- Interventional and Diagnostic Neuroradiology, QEII Health Sciences Centre, Nova Scotia Health, Halifax, NS, Canada.,Department of Radiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - John Blake
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
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Haršány M, Bar M, Černík D, Herzig R, Jura R, Jurák L, Neumann J, Šaňák D, Ostrý S, Ševčík P, Škoda O, Školoudík D, Václavík D, Tomek A, Mikulík R. One-Stop Management to Initiate Thrombolytic Treatment on the Computed Tomography Table: Adoption and Results. J Stroke 2021; 23:437-439. [PMID: 34649387 PMCID: PMC8521254 DOI: 10.5853/jos.2021.00878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/21/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Michal Haršány
- Department of Neurology, St. Anne's University Hospital in Brno, Faculty of Medicine Masaryk University, Brno, Czech Republic.,International Clinical Research Centre, St. Anne's University Hospital in Brno, Brno, Czech Republic
| | - Michal Bar
- Department of Neurology, University Hospital Ostrava, Faculty of Medicine at University Ostrava, Ostrava-Poruba, Czech Republic
| | - David Černík
- Comprehensive Stroke Center, Department of Neurology, Masaryk Hospital Ústí nad Labem, KZ a.s., Ústí nad Labem, Czech Republic
| | - Roman Herzig
- Department of Neurology, Charles University Faculty of Medicine and University Hospital, Hradec Kralove, Czech Republic
| | - René Jura
- Department of Neurology, University Hospital Brno, Faculty of Medicine Masaryk University, Brno, Czech Republic
| | - Lubomír Jurák
- Neurocentre, Regional Hospital Liberec, Liberec, Czech Republic
| | - Jiří Neumann
- Department of Neurology and Stroke Centre, Krajská zdravotní-Hospital Chomutov, Chomutov, Czech Republic
| | - Daniel Šaňák
- Comprehensive Stroke Center in Department of Neurology, Palacky Medical School and University Hospital, Olomouc, Czech Republic
| | - Svatopluk Ostrý
- Comprehensive Stroke Centre, Hospital České Budějovice a.s., České Budějovice, Czech Republic
| | - Petr Ševčík
- Department of Neurology, University Hospital Pilsen, Faculty of Medicine in Pilsen, Charles University, Plzen, Czech Republic
| | - Ondřej Škoda
- Department of Neurology, Vinohrady University Hospital, 3rd Medical School of Charles University, Prague, Czech Republic
| | - David Školoudík
- Center for Science and Research, Faculty of Health Sciences, Palacký University Olomouc, Olomouc, Czech Republic
| | - Daniel Václavík
- Department of Neurology and Agel Research and Training Institute, Ostrava Vitkovice Hospital, Ostrava, Czech Republic
| | - Aleš Tomek
- Department of Neurology, Motol University Hospital, 2nd Medical School of Charles University, Prague, Czech Republic
| | - Robert Mikulík
- Department of Neurology, St. Anne's University Hospital in Brno, Faculty of Medicine Masaryk University, Brno, Czech Republic.,International Clinical Research Centre, St. Anne's University Hospital in Brno, Brno, Czech Republic
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- Department of Neurology, St. Anne's University Hospital in Brno, Faculty of Medicine Masaryk University, Brno, Czech Republic
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Prabhakaran S, Khorzad R, Parnianpour Z, Romo E, Richards CT, Meurer WJ, Lee J, Mendelson SJ, Holl JL. Door-In-Door-Out Process Times at Primary Stroke Centers in Chicago. Ann Emerg Med 2021; 78:674-681. [PMID: 34598828 DOI: 10.1016/j.annemergmed.2021.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/07/2021] [Accepted: 06/17/2021] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE Acute stroke patients often require interfacility transfer from primary stroke centers to comprehensive stroke centers. Given the time-sensitive benefits of endovascular reperfusion, reducing door-in-door-out time at the primary stroke center is a target for quality improvement. We sought to identify modifiable predictors of door-in-door-out times at 3 Chicago-region primary stroke centers. METHODS We performed a retrospective analysis of consecutive patients with acute stroke from February 1, 2018 to January 31, 2020 who required transfer from 1 of 3 primary stroke centers to 1 of 3 affiliated comprehensive stroke centers in the Chicago region. Stroke coordinators at each primary stroke center abstracted data on type of transport, medical interventions and treatments prior to transfer, and relevant time intervals from patient arrival to departure. We evaluated predictors of door-in-door-out time using median regression models. RESULTS Of 191 total patients, 67.9% arrived by emergency medical services and 57.4% during off-hours. Telestroke was performed in 84.2%, 30.5% received alteplase, and 48.4% underwent a computed tomography (CT) angiography at the primary stroke center. The median door-in-door-out time was 148.5 (interquartile range 106 to 207.8) minutes. The largest contributors to door-in-door-out time, in minutes, were CT to CT angiography time (22 [7 to 73.5]), transfer center contact to ambulance request time (20 [8 to 53.3]), ambulance request to arrival time (20.5 [14 to 36]), and transfer ambulance time at primary stroke center (26 [21 to 35]). Factors associated with door-in-door-out time were (adjusted median differences, in minutes [95% confidence intervals]): CT angiography performed at primary stroke center (+39 [12.3 to 65.7]), walk-in arrival mode (+53 [4.1 to 101.9]), administration of intravenous alteplase (-29 [-31.3 to -26.7]), intubation at primary stroke center (+23 [7.3 to 38.7]), and ambulance request by primary stroke center (-20 [-34.3 to -5.7]). CONCLUSION Door-in-door-out times at Chicago-area primary stroke centers average nearly 150 minutes. Reducing time to CT angiography, receipt of alteplase, and ambulance request are likely important modifiable targets for interventions to decrease door-in-door-out times at primary stroke centers.
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Affiliation(s)
| | - Rebeca Khorzad
- Patient Throughput, Northwestern Medicine, Lake Forest, IL
| | - Zahra Parnianpour
- Department of Neurology, Biological Sciences Division, The University of Chicago, Chicago, IL
| | - Elida Romo
- Department of Neurology, Biological Sciences Division, The University of Chicago, Chicago, IL
| | - Christopher T Richards
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Jungwha Lee
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Jane L Holl
- Department of Neurology, The University of Chicago, Chicago, IL
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Baskar PS, Chowdhury SZ, Bhaskar SMM. In-hospital systems interventions in acute stroke reperfusion therapy: a meta-analysis. Acta Neurol Scand 2021; 144:418-432. [PMID: 34101170 DOI: 10.1111/ane.13476] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/07/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The value of in-hospital systems-based interventions in streamlining treatment delays associated with reperfusion therapy delivery in acute ischaemic stroke (AIS), in the emergency department (ED), is poorly understood. This systematic review and meta-analysis aimed to assess and quantify the value of in-hospital systems-based interventions in streamlining reperfusion therapy delivery following AIS. MATERIAL & METHODS Articles from the following databases were retrieved: Medline, Embase and Cochrane Central Register of Controlled Trials. The primary endpoint was in-hospital time metrics between the intervention and control group. The secondary endpoint included the rate of good functional outcome at 90 days. RESULTS 393 Systems intervention studies published after 2015 were screened, and 231 full articles were then read. In total, 35 studies with 35,815 patients were included in the final systematic review and 26 studies with 7,089 patients were used in the meta-analysis. The greatest time reductions from in-hospital system interventions were achieved in door-to-needle (DTN) time (SMD: -2.696, 95% CI: -2.976, -2.416, z = 3.03, p = 0.002). Systems interventions were also associated with a statistically significant improvement in mortality (RR: 0.25, 95% CI: 0.18, 0.38), rate of symptomatic intracerebral haemorrhage (RR: 0.07, 95% CI: 0.04, 0.1) and ≤60-minute reperfusion rates (RR: 0.63, 95% CI: 0.51, 0.79). CONCLUSIONS The use of in-hospital workflow optimization is imperative to expedite reperfusion therapy delivery and improving patient outcomes. To reduce the morbidity and mortality of stroke globally, in-hospital workflow guidelines should be adhered to and incorporated including the optimal elements identified in this study.
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Affiliation(s)
- Prithvi Santana Baskar
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical Research Clinical Sciences Stream Sydney NSW Australia
- South Western Sydney Clinical School UNSW Medicine University of New South Wales (UNSW Sydney NSW Australia
| | - Seemub Zaman Chowdhury
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical Research Clinical Sciences Stream Sydney NSW Australia
- South Western Sydney Clinical School UNSW Medicine University of New South Wales (UNSW Sydney NSW Australia
| | - Sonu Menachem Maimonides Bhaskar
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical Research Clinical Sciences Stream Sydney NSW Australia
- Liverpool Hospital & South West Sydney Local Health District (SWSLHD) Department of Neurology & Neurophysiology Sydney NSW Australia
- Ingham Institute for Applied Medical Research Stroke & Neurology Research Group Sydney NSW Australia
- NSW Brain Clot Bank NSW Health Statewide Biobank and NSW Health Pathology Sydney NSW Australia
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A new protocol reduces median door-to-needle time to the benchmark of 30 minutes in acute stroke treatment. NEUROLOGÍA (ENGLISH EDITION) 2021; 36:487-494. [PMID: 34537162 DOI: 10.1016/j.nrleng.2018.03.009] [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: 01/23/2018] [Accepted: 04/15/2018] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Recent analyses emphasise that The Benchmark Stroke Door-to-Needle Time (DNT) should be 30min. This study aimed to determine if a new in-hospital IVT protocol is effective in reducing door-to-needle time and correcting previously identified factors associated with delays. MATERIAL AND METHODS In 2014, we gradually introduced a series of measures aimed to reduce door-to-needle time for patients receiving IVT, and compared it before (2009-2012) and after (2014-2017) the new protocol was introduced. RESULTS The sample included 239 patients before and 222 after the introduction of the protocol. Median overall door-to-needle time was 27min after the protocol was fully implemented (a 48% reduction on previous door-to-needle time [52min], P<.001)]. Median door-to-needle time was lower when pre-hospital code stroke was activated (22min). We observed a 26-min reduction in the median time from onset to treatment (P<.001). After the protocol was implemented, the "3-hour-effect" did not affect door-to-needle time (P=.98). Computed tomography angiography studies performed before IVT were associated with increased door-to-needle time (P<.001); however, the test was performed after IVT was started in most cases. CONCLUSIONS Hospital reorganisation and multidisciplinary collaboration brought median door-to-needle time below 30min and corrected previously identified delay factors. Furthermore, overall time from onset to treatment was also reduced and more stroke patients were treated within 90min of symptom onset.
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Iglesias Mohedano A, García Pastor A, Díaz Otero F, Vázquez Alen P, Martín Gómez M, Simón Campo P, Salgado Cámara P, Esteban de Antonio E, Lázaro García E, Funes Molina C, del Valle Diéguez M, Saura Lorente J, Fernández Bullido Y, Gil Nuñez A. Un nuevo protocolo intrahospitalario reduce el tiempo puerta-aguja en el ictus agudo tratado con trombolisis intravenosa a menos de 30 minutos. Neurologia 2021. [DOI: 10.1016/j.nrl.2018.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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46
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Mikulik R, Bar M, Cernik D, Herzig R, Jura R, Jurak L, Neumann J, Sanak D, Ostry S, Sevcik P, Skoda O, Skoloudik D, Vaclavik D, Tomek A. Stroke 20 20: Implementation goals for intravenous thrombolysis. Eur Stroke J 2021; 6:151-159. [PMID: 34414290 DOI: 10.1177/23969873211007684] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/16/2021] [Indexed: 01/01/2023] Open
Abstract
Introduction Knowledge of the implementation gap would facilitate the use of intravenous thrombolysis in stroke, which is still low in many countries. The study was conducted to identify national implementation targets for the utilisation and logistics of intravenous thrombolysis. Material and Method Multicomponent interventions by stakeholders in health care to optimise prehospital and hospital management with the goal of fast and accessible intravenous thrombolysis for every candidate. Implementation results were documented from prospectively collected cases in all 45 stroke centres nationally. The thrombolytic rate was calculated from the total number of all ischemic strokes in the population of the Czech Republic since 2004. Results Thrombolytic rates of 1.3 (95%CI 1.1 to 1.4), 5.4 (95%CI 5.1 to 5.7), 13.6 (95%CI 13.1 to 14.0), 23.3 (95%CI 22.8 to 23.9), and 23.5% (95%CI 23.0 to 24.1%) were achieved in 2005, 2009, 2014, 2017, and 2018, respectively. National median door-to-needle times were 60-70 minutes before 2012 and then decreased progressively every year to 25 minutes (IQR 17 to 36) in 2018. In 2018, 33% of both university and non-university hospitals achieved median door-to-needle time ≤20 minutes. In 2018, door-to-needle times ≤20, ≤45, and ≤60 minutes were achieved in 39, 85, and 93% of patients. Discussion Thrombolysis can be provided to ≥ 20% of all ischemic strokes nationwide and it is realistic to achieve median door-to-needle time 20 minutes. Conclusion Stroke 20-20 could serve as national implementation target for intravenous thrombolysis and country specific implementation policies should be applied to achieve such target.
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Affiliation(s)
- Robert Mikulik
- International Clinical Research Center and Department of Neurology, St. Anne's University Hospital Brno, Brno, Czech Republic.,Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Michal Bar
- Department of Neurology, University Faculty Hospital Ostrava and Faculty of Medicine, University Ostrava, Ostrava, Czech Republic
| | - David Cernik
- Department of Neurology, Masaryk Hospital Usti nad Labem - KZ a.s., Comprehensive Stroke Center, Usti nad Labem, Czech Republic
| | - Roman Herzig
- Comprehensive Stroke Center, University Hospital Hradec Kralove and Charles University Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Rene Jura
- Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Neurology, University Hospital Brno, Brno, Czech Republic
| | - Lubomir Jurak
- Neurocenter, Regional Hospital Liberec, Liberec, Czech Republic
| | - Jiri Neumann
- Department of Neurology, County Hospital Chomutov, Chomutov, Czech Republic
| | - Daniel Sanak
- Department of Neurology, Comprehensive Stroke Center, Palacký University Medical School and Hospital, Olomouc, Czech Republic
| | - Svatopluk Ostry
- Department of Neurology, Hospital Ceske Budejovice, a.s., Ceske Budejovice, Czech Republic.,Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University in Prague and Military University Hospital Prague, Prague, Czech Republic
| | - Petr Sevcik
- Department of Neurology, Charles University Faculty of Medicine in Pilsen, Pilsen, Czech Republic.,Department of Neurology, University Hospital Pilsen, Pilsen, Czech Republic
| | - Ondrej Skoda
- Department of Neurology, Hospital Jihlava, Jihlava, Czech Republic.,Department of Neurology, 3rd Medical School of Charles University and Vinohrady University Hospital, Prague, Czech Republic
| | - David Skoloudik
- Department of Nursing, Faculty of Health Science, Palacký University Olomouc, Olomouc, Czech Republic
| | - Daniel Vaclavik
- Department of Neurology and AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Ostrava, Czech Republic
| | - Ales Tomek
- Department of Neurology, 2nd Medical School of Charles University and Motol University Hospital, Prague, Czech Republic
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Holodinsky JK, Onaemo VN, Whelan R, Hunter G, Graham BR, Hamilton J, Schwartz L, Latta L, Peeling L, Kelly ME. Implementation of a provincial acute stroke pathway and its impact on access to advanced stroke care in Saskatchewan. BMJ Open Qual 2021; 10:bmjoq-2020-001214. [PMID: 34385186 PMCID: PMC8362703 DOI: 10.1136/bmjoq-2020-001214] [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] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 07/27/2021] [Indexed: 11/04/2022] Open
Abstract
Background For ischaemic stroke, outcome severity is heavily time dependent. Systems of care need to be in place to ensure that patients with stroke are treated quickly and appropriately across entire health regions. Prior to this study, the province of Saskatchewan, Canada did not have a provincial stroke strategy in place. Methods A quality improvement project was undertaken to create and evaluate a provincial stroke strategy. The Saskatchewan Acute Stroke Pathway was created using a multidisciplinary team of experts, piloted at five stroke centres and then implemented provincially. The number of stroke alerts, door-to-imaging, door-to-needle, door-to-groin puncture times and treatment rates were collected at all centres. Improvements over time were analysed using run charts and individuals control charts. Results The number of stroke alerts province-wide trended upwards in the last 6 months of the study. There were no clear trends or shifts in the proportion of stroke alerts treated with alteplase or endovascular therapy. Across the province, the weighted mean door-to-imaging time decreased from 21 to 15 min, the weighted mean door-to-needle time decreased from 62 to 47 min and the mean door-to-groin puncture time decreased from 83 to 70 min. There was high variability in the degree of improvement from centre to centre. Conclusions The implementation of a province wide acute stroke pathway has led to improvement in stroke care on a provincial basis. Further work addressing intercentre variability is ongoing.
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Affiliation(s)
- Jessalyn K Holodinsky
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Vivian N Onaemo
- Ministry of Health, Government of Saskatchewan, Regina, Saskatchewan, Canada
| | - Ruth Whelan
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Gary Hunter
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Brett R Graham
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jessica Hamilton
- Saskatchewan Health Quality Council, Saskatoon, Saskatchewan, Canada
| | - Laura Schwartz
- Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Lori Latta
- Ministry of Health, Government of Saskatchewan, Regina, Saskatchewan, Canada
| | - Lissa Peeling
- Division of Neurosurgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Michael E Kelly
- Division of Neurosurgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Koga M, Inoue M, Tanaka K, Satow T, Fukuda T, Ihara M, Itabashi R, Kudo K, Yamagami H, Toyoda K. [Cerebrovascular imaging to facilitate stroke reperfusion therapy in Japan]. Rinsho Shinkeigaku 2021; 61:517-521. [PMID: 34275955 DOI: 10.5692/clinicalneurol.cn-001603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Imaging diagnosis is essential to perform appropriate reperfusion therapy for acute ischemic stroke. To equally perform reperfusion therapy all over in Japan, it is important to properly facilitate acute imaging evaluation for stroke suspected patients by medical staff not only in stroke-specialized hospitals but also in non-stroke-specialized hospitals. It is unique that CT and MRI are available in most of Japanese hospitals. Even in non-stroke-specialized hospitals, inpatients may suffer from in-hospital stroke. We review statements and recommendation items for a diagnostic imaging to appropriately perform reperfusion therapy based on major clinical trials, stroke guidelines and the current status of acute stroke imaging in Japan.
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Affiliation(s)
- Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center.,Division of Stroke Care Unit, National Cerebral and Cardiovascular Center
| | - Kanta Tanaka
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center
| | - Tetsu Satow
- Department of Neurosurgery, National Cerebral and Cardiovascular Center
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center
| | - Ryo Itabashi
- Division of Neurology and Gerontology, Department of Internal Medicine, School of Medicine, Iwate Medical University
| | - Kohsuke Kudo
- Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
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Park PSW, Frost T, Tan S, Wong J, Pope A, Dewey HM, Choi PMC. The Quest to Reduce Stroke Treatment Delays at A Melbourne Metropolitan Primary Stroke Centre over the Last Two Decades. Intern Med J 2021; 52:1978-1985. [PMID: 34142750 DOI: 10.1111/imj.15429] [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: 04/14/2021] [Revised: 06/12/2021] [Accepted: 06/14/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Reducing door-to-needle time (DNT) for intravenous thrombolysis in acute ischaemic stroke can lead to improved patient outcomes. Long-term reports on DNT trends in Australia are lacking in the setting of extension of the thrombolysis time window, addition of mechanical thrombectomy and increasing presentations. AIMS To examine 17-year trends of DNT and identify factors associated with improved DNT at a high-volume, metropolitan primary stroke centre. METHOD Retrospective study between 2003 and 2019 of all thrombolysis cases using departmental stroke database. Since most strategies were implemented from 2012 onwards, intervention period has been defined as period 2012-2019. Factors associated with DNT reduction were examined by regression modelling. RESULTS 15 strategies were identified including alterations to 'Code Stroke' processes. 1250 patients were thrombolysed, with 737 (58.8%) treated during the intervention period. The proportion of DNT ≤60- minutes rose from average of 22.5% during 2003-2012 to 63% during 2015-2018 and 71% in 2019. However, median DNT has only marginally improved from 58 to 51 minutes between 2015 and 2019. Faster DNT was independently associated with two modifiable workflow factors, 'Direct-to-CT' protocol (P < 0.001) and acute stroke nurse presence (P < 0.005). Over time, treated patients were older and less independent (P < 0.001), and the number of annual stroke admissions and 'Code Stroke' activations have risen by 4- and 10-fold to 748 and 1298 by 2019, respectively. CONCLUSIONS Targeted quality improvement initiatives are key to reducing thrombolysis treatment delays in the Australian metropolitan setting. Relative stagnation in DNT improvement is concerning and needs further investigation. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Peter S W Park
- Department of Neurosciences, Box Hill Hospital, Eastern Health, Victoria, Australia.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Tanya Frost
- Department of Neurosciences, Box Hill Hospital, Eastern Health, Victoria, Australia
| | - Shuangyue Tan
- Department of Neurosciences, Box Hill Hospital, Eastern Health, Victoria, Australia
| | - Joseph Wong
- Department of Neurosciences, Box Hill Hospital, Eastern Health, Victoria, Australia
| | - Alun Pope
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Helen M Dewey
- Department of Neurosciences, Box Hill Hospital, Eastern Health, Victoria, Australia.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Philip M C Choi
- Department of Neurosciences, Box Hill Hospital, Eastern Health, Victoria, Australia.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
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Klingman JG, Alexander JG, Vinson DR, Klingman LE, Nguyen‐Huynh MN. Potential accuracy of prehospital NIHSS-based triage for selection of candidates for acute endovascular stroke therapy. J Am Coll Emerg Physicians Open 2021; 2:e12441. [PMID: 33969354 PMCID: PMC8087906 DOI: 10.1002/emp2.12441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 03/11/2021] [Accepted: 03/29/2021] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Whether patients with acute stroke and large vessel occlusion (LVO) benefit from prehospital identification and diversion by emergency medical services (EMS) to an endovascular stroke therapy (EST)-capable center is controversial. We sought to estimate the accuracy of field-based identification of potential EST candidates in a hypothetical best-of-all-worlds situation. METHODS In Kaiser Permanente Northern California, all acute stroke patients arriving at its 21 stroke centers between 7:00 am and midnight from January 2016 to December 2019 were evaluated by teleneurologists on arrival. Initial National Institutes of Health Stroke Scale (NIHSS) score, presence of LVO, and referral for EST were obtained from standardized teleneurology notes. Factors associated with LVO were evaluated using generalized estimating equations accounting for clustering by facility. RESULTS Among 13,377 patients brought in by EMS with potential stroke, 7168 (53.6%) were not candidates for acute stroke interventions. Of the remaining 6089 cases, 2,573 (42.3%) had an NIHSS score >10, the cutoff with a higher association for LVO. Only 703 patients (27.3% with NIHSS score >10) were ultimately diagnosed with LVO and referred for EST. Across all NIHSS scores, only 884 (6.6%) suspected acute stroke patients had LVO and EST referral. CONCLUSIONS Even if field-based tools were as accurate as NIHSS scoring and predictions by stroke neurologists, only about 1 in 4 acute stroke patients diverted to EST-capable centers would benefit by receiving EST. Depending on geography and stroke center performance on door-to-needle time, many systems may be better served by focusing on expediting evaluation, treatment with intravenous thrombolysis, and transfer to EST-capable centers.
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Affiliation(s)
- Jeffrey G. Klingman
- Department of NeurologyKaiser Permanente, Northern CaliforniaWalnut CreekCaliforniaUSA
| | - Janet G. Alexander
- Division of ResearchKaiser Permanente, Northern CaliforniaOaklandCaliforniaUSA
| | - David R. Vinson
- Division of ResearchKaiser Permanente, Northern CaliforniaOaklandCaliforniaUSA
- Department of Emergency MedicineKaiser Permanente, Northern CaliforniaRosevilleCaliforniaUSA
| | | | - Mai N. Nguyen‐Huynh
- Department of NeurologyKaiser Permanente, Northern CaliforniaWalnut CreekCaliforniaUSA
- Division of ResearchKaiser Permanente, Northern CaliforniaOaklandCaliforniaUSA
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