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Derex L, Nighoghossian N. Thrombolysis, stroke-unit admission and early rehabilitation in elderly patients. Nat Rev Neurol 2009; 5:506-11. [DOI: 10.1038/nrneurol.2009.127] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Tyson SF, Selley A. The development of the Stroke Physiotherapy Intervention Recording Tool (SPIRIT). Disabil Rehabil 2009; 26:1184-8. [PMID: 15371018 DOI: 10.1080/09638280410001714781] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To develop a recording system that describes physiotherapy interventions for the rehabilitation of postural control post-stroke. METHODS DESIGN A draft recording tool was developed using the method described by Edwards et al, involving literature searches and collaboration with senior clinicians. It was piloted with stroke physiotherapists using a cross-sectional survey design to assess validity, utility and completeness. Participants used the recording tool to record five treatment sessions. Feedback regarding the utility and completeness of the system was obtained via short semi-structured interviews. SETTING 11 NHS Trusts. PARTICIPANTS 35 stroke physiotherapists working in acute and rehabilitation settings recorded the treatment of 120 patients in 590 treatment sessions. RESULTS A double-sided A4 form with a checklist of 79 physiotherapy interventions in 9 categories was produced: the Stroke Physiotherapy Intervention Recording Tool (SPIRIT). The participants found it quick and easy to use and reflective of clinical practice. There were a few missing interventions and some confusion regarding definition of terms. Revisions were to include the omitted interventions and to produce a user's booklet defining the categories and interventions. CONCLUSIONS SPIRIT provides a system for recording physiotherapy treatment for stroke patients which reflects current clinical practice in acute and rehabilitation settings.
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Affiliation(s)
- Sarah F Tyson
- Centre for Rehabilitation and Human Performance Research, Allerton Annexe, University of Salford, Salford, UK
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Crocco TJ, Grotta JC, Jauch EC, Kasner SE, Kothari RU, Larmon BR, Saver JL, Sayre MR, Davis SM. EMS Management of Acute Stroke—Prehospital Triage (Resource Document to NAEMSP Position Statement). PREHOSP EMERG CARE 2009; 11:313-7. [PMID: 17613906 DOI: 10.1080/10903120701347844] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- T J Crocco
- Department of Emergency Medicine, West Virginia University, Morgantown, WV 26506-9149, USA.
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105
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Bayley M, Lindsay P, Hellings C, Woodbury E, Phillips S. Balancing evidence and opinion in stroke care: the 2008 best practice recommendations. CMAJ 2009; 179:1247-9. [PMID: 19047599 DOI: 10.1503/cmaj.081536] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Villiers LD, Kalula SZ, Burch VC. Does Multidisciplinary Stroke Care Improve Outcome in A Secondary-Level Hospital in South Africa? Int J Stroke 2009; 4:89-93. [DOI: 10.1111/j.1747-4949.2009.00254.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background and Purpose The improved outcome (survival and function) of stroke patients admitted to multidisciplinary stroke units (SU) in developed countries has not been replicated in developing countries in sub-Saharan Africa. This study documents the outcome of patients admitted to the first multidisciplinary SU opened at a secondary hospital in Cape Town, South Africa. Methods Patient outcomes including in-hospital mortality, resource utilization (length of hospital stay, CT brain scans performed, and tertiary hospital referral), and access to inpatient rehabilitation were recorded for all patients admitted to the hospital for 3 months before initiating multidisciplinary stroke care and for 3 months after implementing multidisciplinary stroke care. Results One hundred and ninety-five patients were studied; 101 of these were managed in the SU. Inpatient mortality decreased from 33% to 16% after initiating multidisciplinary stroke care ( P = 0·005). The length of hospital stay increased from a mean (SD, 95% CI) of 5·1 (6·5, 3·8–6·4) days to 6·8 (4·5, 5·9–7·6) days ( P = 0·01). Referral to inpatient rehabilitation increased from 5% to 19% ( P = 0·04) for those who survived to discharge. The number of CT brain scans performed and the number of referrals to the tertiary academic hospital did not increase significantly. Conclusions Multidisciplinary stroke care was successfully implemented in a resource-constrained secondary-level hospital in South Africa and despite the limitations of the study, the significant reduction in inpatient mortality and increase in referral for inpatient rehabilitation would suggest an improvement in stroke care. Resource utilization in terms of length of hospital stay increased by a mean of 2 days but the number of CT brain scans performed and referral to a tertiary hospital did not increase significantly.
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Affiliation(s)
- Linda de Villiers
- Department of Medicine, Division of Geriatric Medicine, Walter and Albertina Sisulu Institute of Ageing in Africa, Faculty of Health Sciences, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Sebastiana Zimba Kalula
- Department of Medicine, Division of Geriatric Medicine, Walter and Albertina Sisulu Institute of Ageing in Africa, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Vanessa Celeste Burch
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Facilities available in French hospitals treating acute stroke patients: comparison with 24 other European countries. J Neurol 2009; 256:867-73. [DOI: 10.1007/s00415-009-5029-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Revised: 11/02/2008] [Accepted: 11/19/2008] [Indexed: 11/26/2022]
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Abstract
Background The development of specialized stroke units has been a landmark innovation in acute stroke care. However, the high scientific evidence level for the recommendation for stroke units to provide clinical attention for acute stroke patients does not correspond to the level of stroke unit implementation. A narrative, nonsystematic review on published studies on stroke units was conducted, with special emphasis on those demonstrating their efficacy and effectiveness. We also attempt to provide some answers to several open questions regarding practical issues of stroke units.
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Affiliation(s)
- Blanca Fuentes
- Stroke Unit, Department of Neurology, University Hospital La Paz, Autonomous University of Madrid, Madrid, Spain
| | - Exuperio Diez-Tejedor
- Stroke Unit, Department of Neurology, University Hospital La Paz, Autonomous University of Madrid, Madrid, Spain
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Rautio A, Eliasson M, Stegmayr B. Favorable Trends in the Incidence and Outcome in Stroke in Nondiabetic and Diabetic Subjects. Stroke 2008; 39:3137-44. [DOI: 10.1161/strokeaha.107.504100] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Aslak Rautio
- From the Department of Public Health and Clinical Medicine (A.R., M.E., B.S.), Umeå University, Sweden; and the Department of Medicine (M.E.), Sunderby Hospital, Luleå, Sweden
| | - Mats Eliasson
- From the Department of Public Health and Clinical Medicine (A.R., M.E., B.S.), Umeå University, Sweden; and the Department of Medicine (M.E.), Sunderby Hospital, Luleå, Sweden
| | - Birgitta Stegmayr
- From the Department of Public Health and Clinical Medicine (A.R., M.E., B.S.), Umeå University, Sweden; and the Department of Medicine (M.E.), Sunderby Hospital, Luleå, Sweden
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Albright KC, Raman R, Ernstrom K, Hallevi H, Martin-Schild S, Meyer BC, Meyer DM, Morales MM, Grotta JC, Lyden PD, Savitz SI. Can comprehensive stroke centers erase the 'weekend effect'? Cerebrovasc Dis 2008; 27:107-13. [PMID: 19039213 DOI: 10.1159/000177916] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Accepted: 07/23/2008] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Prior epidemiological work has shown higher mortality in ischemic stroke patients admitted on weekends, which has been termed the 'weekend effect'. Our aim was to assess stroke patient outcomes in order to determine the significance of the 'weekend effect' at 2 comprehensive stroke centers. METHODS Consecutive stroke patients were identified using prospective databases. Patients were categorized into 4 groups: intracerebral hemorrhage (ICH group), ischemic strokes not treated with IV t-PA (intravenous tissue plasminogen activator; IS group), acute ischemic strokes treated with IV t-PA (AIS-TPA group), and transient ischemic attack (TIA group). Weekend admission was defined as the period from Friday, 17:01, to Monday, 08:59. Patients treated beyond the 3-hour window, receiving intra-arterial therapy, or enrolled in nonobservational clinical trials were excluded. Patient demographics, NIHSS scores, and admission glucose levels were examined. Adverse events, poor functional outcome (modified Rankin scale, mRS, 3-6), and mortality were compared. RESULTS A total of 2,211 patients were included (1,407 site 1, 804 site 2). Thirty-six percent (800/2,211) arrived on a weekend. No significant differences were found in the ICH, IS, AIS-TPA, or TIA groups with respect to the rate of symptomatic ICH, mRS on discharge, discharge disposition, 90-day mRS, or 90-day mortality when comparing weekend and weekday groups. Using multivariate logistic regression to adjust for site, age, admission NIHSS, and blood glucose, weekend admission was not a significant independent predictive factor for in-hospital mortality in all strokes (OR = 1.10, 95% CI 0.74-1.63, p = 0.631). CONCLUSIONS Our results suggest that comprehensive stroke centers (CSC) may ameliorate the 'weekend effect' in stroke patients. These results may be due to 24/7 availability of stroke specialists, advanced neuroimaging, or ongoing training and surveillance of specialized nursing care available at CSC. While encouraging, these results require confirmation in prospective studies.
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Affiliation(s)
- Karen C Albright
- Department of Neurosciences, University of California-San Diego, CA, USA
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Bernhardt J, Dewey H, Collier J, Thrift A, Lindley R, Moodie M, Donnan G. A Very Early Rehabilitation Trial (AVERT). Int J Stroke 2008; 1:169-71. [PMID: 18706042 DOI: 10.1111/j.1747-4949.2006.00044.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Julie Bernhardt
- National Stroke Research Institute, Level 1, Neurosciences Building, Austin Health, Heidelberg Repatriation Hospital, 300 Waterdale Road, Heidelberg Heights, 3081 Vic., Australia.
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Sekimoto M, Kakutani C, Inoue I, Ishizaki T, Hayashida K, Imanaka Y. Management patterns and healthcare costs for hospitalized patients with cerebral infarction. Health Policy 2008; 88:100-9. [DOI: 10.1016/j.healthpol.2008.01.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Revised: 01/17/2008] [Accepted: 01/19/2008] [Indexed: 10/22/2022]
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Sanclemente Ansó C, Pedragosa Vall A, Rovira Pujol E, Vigil Martín D. El ictus en manos del internista. Factores de riesgo cardiovascular. Rev Clin Esp 2008; 208:339-46. [DOI: 10.1157/13124313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Hopkins LN, Ecker RD. CEREBRAL ENDOVASCULAR NEUROSURGERY. Neurosurgery 2008; 62:SHC1483-SHC1502. [DOI: 10.1227/01.neu.0000315304.66122.f0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2007] [Accepted: 03/05/2008] [Indexed: 11/19/2022] Open
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Abstract
Stroke is the second most common cause of death and major cause of disability worldwide. Because of the ageing population, the burden will increase greatly during the next 20 years, especially in developing countries. Advances have occurred in the prevention and treatment of stroke during the past decade. For patients with acute stroke, management in a stroke care unit, intravenous tissue plasminogen activator within 3 h or aspirin within 48 h of stroke onset, and decompressive surgery for supratentorial malignant hemispheric cerebral infarction are interventions of proven benefit; several other interventions are being assessed. Proven secondary prevention strategies are warfarin for patients with atrial fibrillation, endarterectomy for symptomatic carotid stenosis, antiplatelet agents, and cholesterol reduction. The most important intervention is the management of patients in stroke care units because these provide a framework within which further study might be undertaken. These advances have exposed a worldwide shortage of stroke health-care workers, especially in developing countries.
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Affiliation(s)
- Geoffrey A Donnan
- National Stroke Research Institute, Austin Hospital, University of Melbourne, Melbourne, Victoria, Australia.
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Srinivasan M, Roffe C. Nutritional status after acute stroke: is a stroke unit better than a general geriatric ward? J Nutr Health Aging 2008; 12:323-5. [PMID: 18443715 DOI: 10.1007/bf02982663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- M Srinivasan
- School of Medicine, Keele University, Staffordshire, UK.
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Ford GA. Clinical pharmacological issues in the development of acute stroke therapies. Br J Pharmacol 2008; 153 Suppl 1:S112-9. [PMID: 18311155 DOI: 10.1038/sj.bjp.0707654] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The demonstration of the ischaemic penumbra in animal models and the effectiveness of reperfusion therapy in humans led to considerable optimism for neuroprotection in acute stroke. Initial experience with failure of phase II and III trials led to the STAIR recommendations for pre-clinical and clinical studies. Review of pre-clinical studies suggests that selection of agents for clinical development may not have been optimal. The neuroprotective agent NXY-059 fulfilled pre-clinical and many clinical STAIR criteria but a second large phase III study failed to demonstrate any benefit. Many of the STAIR criteria have not been fulfilled in the development of recent neuroprotective agents. Other issues not addressed include the use of animal models more reflective of older stroke patients with physiological derangement, demonstration of drug distribution to the proposed site of action in humans, selection of patients with salvageable tissue, achieving very early treatment, refinement of measurement of neurological impairment and disability, and physiological optimization in proof of concept human studies. Increasing the number and quality of clinical centres undertaking acute stroke research, use of surrogate imaging markers and adaptive dose designs in phase II trials could improve the likelihood of identifying an effective neuroprotective. Neuroprotection in acute stroke remains a significant challenge but has not been clearly shown to be ineffective. Given the profound burden of stroke and limited applicability of reperfusion to currently at best 10% patients, further proof of concept studies of neuroprotection remain indicated with careful review of pre-clinical data and more rigorous phase II trial design.
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Affiliation(s)
- G A Ford
- Clinical Research Centre, Newcastle University, Newcastle upon Tyne, UK.
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122
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Fuentes B, Díez-Tejedor E. General Care in Stroke: Relevance of Glycemia and Blood Pressure Levels. Cerebrovasc Dis 2007; 24 Suppl 1:134-42. [DOI: 10.1159/000107389] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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123
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Leys D, Ringelstein EB, Kaste M, Hacke W. Facilities Available in European Hospitals Treating Stroke Patients. Stroke 2007; 38:2985-91. [PMID: 17901388 DOI: 10.1161/strokeaha.107.487967] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Stroke units decrease mortality and need for institutional care, but they are not widely available. The objective of the study was to determine, among European hospitals admitting acute stroke patients, how many are able to provide an appropriate level of care. Method- We randomly selected 886 hospitals in 25 countries. We used definitions derived from a European expert survey for comprehensive stroke centers (CSC), primary stroke centers (PSC), and minimum level required for any hospital ward (AHW) admitting stroke patients. We determined the proportion of hospitals meeting criteria for each category, and which facilities were not available. RESULTS Participating hospitals treated approximately one-third of all strokes supposed to have occurred in these countries in 2005. Forty-three (4.9%) met criteria for CSC, 32 (3.6%) for PSC, 356 (40.2%) for AHW, and 455 (51.4%) provided a lower level of care. In 2005, hospitals meeting criteria for CSC, PSC, AHW, and none of them admitted 27 644 (8.3%), 17 365 (5.2%), 146 175 (44.1%), and 140 306 (42.3%) patients. There was no 24-hour availability for brain CT scan in 25% of hospitals not meeting criteria for AHW. Of 448 hospitals admitting at least 1 stroke per day, 51 (11.4%) met criteria for PSC or CSC, and 227 (50.7%) for AHW. CONCLUSIONS Less than 10% of European hospitals admitting acute stroke patients have optimal facilities, and in 40% even the minimum level is not available. Because the availability of facilities does not grant their use, our study suggests that only few acute stroke patients are treated in appropriate centers in Europe.
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Affiliation(s)
- Didier Leys
- Department of Neurology, University Hospital of Lille, 59037 Lille, France.
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124
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Millin MG, Gullett T, Daya MR. EMS management of acute stroke--out-of-hospital treatment and stroke system development (resource document to NAEMSP position statement). PREHOSP EMERG CARE 2007; 11:318-25. [PMID: 17613907 DOI: 10.1080/10903120701347885] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The American Heart Association estimates an annual incidence of stroke in the United States at 700,000, leading to over 150,000 deaths. Of all strokes, approximately 88% are ischemic and 12% are hemorrhagic. Almost half of all stroke deaths occur in the out-of-hospital environment. Within a given region, the emergency medical services (EMS) system has an important role in the management of the acute stroke patient. Decisions made by EMS personnel can affect treatment and contribute to the immediate, short-term, and long-term outcomes of the patient. Because the patient may require emergent treatment regardless if the stroke is ischemic or hemorrhagic, EMS personnel should manage all potential stroke patients in a time-dependent nature. Proper treatment and disposition of the stroke patient begins in the out-of-hospital environment, continues in the emergency department, and then extends to the inpatient admission. This article reviews the literature on the out-of-hospital treatment of stroke patients and the role of EMS in the development of stroke systems of care.
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Affiliation(s)
- Michael G Millin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21209-3652, USA.
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125
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Abstract
BACKGROUND Organised stroke unit care is provided by multidisciplinary teams that exclusively manage stroke patients in a dedicated ward (stroke, acute, rehabilitation, comprehensive), with a mobile stroke team or within a generic disability service (mixed rehabilitation ward). OBJECTIVES To assess the effect of stroke unit care compared with alternative forms of care for patients following a stroke. SEARCH STRATEGY We searched the Cochrane Stroke Group trials register (last searched April 2006), the reference lists of relevant articles, and contacted researchers in the field. SELECTION CRITERIA Randomised and prospective controlled clinical trials comparing organised inpatient stroke unit care with an alternative service. DATA COLLECTION AND ANALYSIS Two review authors initially assessed eligibility and trial quality. Descriptive details and trial data were then checked with the co-ordinators of the original trials. MAIN RESULTS Thirty-one trials, involving 6936 participants, compared stroke unit care with an alternative service; more organised care was consistently associated with improved outcomes. Twenty-six trials (5592 participants) compared stroke unit care with general wards. Stroke unit care showed reductions in the odds of death recorded at final (median one year) follow up (odds ratio (OR) 0.86; 95% confidence interval (CI) 0.76 to 0.98; P = 0.02), the odds of death or institutionalised care (OR 0.82; 95% CI 0.73 to 0.92; P = 0.0006) and death or dependency (OR 0.82; 95% CI 0.73 to 0.92; P = 0.001). Sensitivity analyses indicated that the observed benefits remained when the analysis was restricted to trials that used formal randomisation procedures with blinded outcome assessment. Outcomes were independent of patient age, sex or stroke severity, but appeared to be better in stroke units based in a discrete ward. There was no indication that organised stroke unit care resulted in a longer hospital stay. AUTHORS' CONCLUSIONS Stroke patients who receive organised inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after the stroke. The benefits were most apparent in units based in a discrete ward. No systematic increase was observed in the length of inpatient stay.
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Sena E, van der Worp HB, Howells D, Macleod M. How can we improve the pre-clinical development of drugs for stroke? Trends Neurosci 2007; 30:433-9. [PMID: 17765332 DOI: 10.1016/j.tins.2007.06.009] [Citation(s) in RCA: 271] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2007] [Revised: 06/15/2007] [Accepted: 06/18/2007] [Indexed: 01/13/2023]
Abstract
The development of stroke drugs has been characterized by success in animal studies and subsequent failure in clinical trials. Animal studies might have overstated efficacy, or clinical trials might have understated efficacy; in either case we need to better understand the reasons for failure. Techniques borrowed from clinical trials have recently allowed the impact of publication and study-quality biases on published estimates of efficacy in animal experiments to be described. On the basis of these data, we propose minimum standards for the range and quality of pre-clinical animal data. We believe the adoption of these standards will lead to improved effectiveness and efficiency in the selection of drugs for clinical trials in stroke and in the design of those trials.
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Affiliation(s)
- Emily Sena
- Department of Clinical Neurosciences, University of Edinburgh, UK
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127
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Ustrell-Roig X, Serena-Leal J. Ictus. Diagnóstico y tratamiento de las enfermedades cerebrovasculares. Rev Esp Cardiol 2007. [DOI: 10.1157/13108281] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Insalaco D, Ozkurt E, Santiago D. The perceptions of students in the allied health professions towards stroke rehabilitation teams and the SLP's role. JOURNAL OF COMMUNICATION DISORDERS 2007; 40:196-214. [PMID: 16876816 DOI: 10.1016/j.jcomdis.2006.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2005] [Revised: 05/15/2006] [Accepted: 06/08/2006] [Indexed: 05/11/2023]
Abstract
UNLABELLED The purpose of this study was to determine the perceptions and knowledge of final-year speech-language pathology (SLP), physical and occupational therapy (PT, OT) students toward stroke rehabilitation teams and the SLPs' roles on them. The investigators adapted a survey developed by (Felsher & Ross, 1994) and administered it to 35 PT, 35 OT, and 35 SLP final year students (n=105). We found that the students preferred the transdisciplinary team approach and agreed that the advantages of teamwork were the exchange of ideas, opportunities for participatory learning, and holistic treatment. Communication problems, time-consuming meetings, and role confusion were chosen as disadvantages. The students had clear perceptions of the SLP's role in aphasia, apraxia of speech, dysarthria, dysphagia, and auditory agnosia, but fewer recognized the SLP's role in alexia and memory. Some thought SLPs had a role in dressing apraxia and proprioceptive disorders. Suggestions to maximize the advantages and minimize possible disadvantages of teamwork are provided. LEARNING OUTCOMES Learners will: (1) identify the perceived advantages and disadvantages of stroke rehabilitation teamwork; (2) discover some allied health students' perceptions of the SLP's roles in stroke rehabilitation; (3) infer methods to create positive perceptions of stroke rehabilitation team members.
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Affiliation(s)
- Deborah Insalaco
- Speech-Language Pathology Department, Buffalo State College, 1300 Elmwood Ave., Ketchum Hall, Buffalo, NY 14222, USA.
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130
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Epifanov Y, Dodel R, Haacke C, Schaeg M, Schöffski O, Hennerici M, Back T. Costs of acute stroke care on regular neurological wards: A comparison with stroke unit setting. Health Policy 2007; 81:339-49. [PMID: 16930763 DOI: 10.1016/j.healthpol.2006.07.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2006] [Revised: 07/17/2006] [Accepted: 07/18/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Stroke unit care has been shown to be beneficial but costly. In an own previous study, the resource utilization of stroke unit care has been evaluated. Since the resource utilization on regular neurological wards is widely unknown, we determined the costs for acute stroke care on regular neurological wards to compare both treatment settings. METHODS AND PATIENTS We included 253 consecutive in-patients with the diagnosis of ischemic stroke (IS), intracerebral hemorrhage (ICH) or transient ischemic attack (TIA) treated on regular wards at a German University Department of Neurology, between 1 January and 30 June 1998. The modified Rankin scale (mRS) was used to assess outcome. Costs of stroke care were calculated from the perspective of the healthcare provider (hospital) by using a bottom-up approach. Resource utilization was compared to stroke unit care as determined in a previous study. Prices of 2002 were used (in Euros). RESULTS IS was present in 78% (n=196), TIA in 13% (n=34), and ICH in 9% (n=23) of patients. Length of stay was 11.1+/-8.9 (mean+/-S.D., IS), 11.1+/-6.5 (TIA), and 16.9+/-15.5 (ICH) days (p>0.05). Mean costs of stroke care were euro 3060 (US$ 3180) for TIA, euro 3070 (US$ 3200) for IS and euro 5210 (US$ 5430) for ICH (p<0.05, ICH versus IS and TIA). The highest costs were due to non-medical care (46%) and personnel (25%). The mRS improved during hospitalization from 3.0+/-1.6 to 2.2+/-1.8 (p<0.01). Compared to care on regular neurological wards, mean costs per admission with treatment on stroke units increased by 7.0%, mean costs per day by 15.6%. CONCLUSION The comparison - considering a potential bias of patient selection - shows that acute stroke unit care is approximately 16% more costly than treatment on regular neurological wards due to higher resource use of personnel and diagnostic procedures. Stroke unit treatment tends to decrease post-acute in-patient care costs.
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Affiliation(s)
- Yaroslav Epifanov
- Department of Neurology, Klinikum Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
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Leys D, Ringelstein EB, Kaste M, Hacke W. The Main Components of Stroke Unit Care: Results of a European Expert Survey. Cerebrovasc Dis 2007; 23:344-52. [PMID: 17268165 DOI: 10.1159/000099133] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2006] [Accepted: 09/05/2006] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Stroke units decrease mortality, handicap and need for institutional care, but there are only sparse evidence-based data showing which components make the difference over general wards. The aim of this survey was to identify from expert opinions what should be the major components of stroke units. METHODS A questionnaire was sent to 83 European stroke experts, to ask their opinion on what should be the components of comprehensive stroke centres (CSC), primary stroke centres (PSC) and any hospital ward (AHW) admitting acute stroke patients routinely. It consisted of a list of 107 components (personnel, diagnostic procedures, monitoring, invasive treatments provided, infrastructures, protocols and procedures and their availability for 24 h a day for 7 days a week, 24/7) to be classified as irrelevant, useful but not necessary, desirable, important but not absolutely necessary, or absolutely necessary. RESULTS 42 questionnaires (50.6%) were returned. Four components were excluded because of a poor level of agreement between experts. Eight components were considered as absolutely necessary by more than 75% of the experts for both CSC and PSC: multidisciplinary team, stroke-trained nurses, brain CT scan 24/7, CT priority for stroke patients, extracranial Doppler sonography, automated electrocardiographic monitoring, intravenous rt-PA protocols 24/7 and in-house emergency department. Eleven other components (in the fields of vascular surgery, neurosurgery, interventional radiology and clinical research) were considered as necessary in CSC by more than 75% of the experts. Only 8 components were considered as important but not absolutely necessary by more than 50% of the experts for AHW. CONCLUSION The experts showed a high level of agreement about the essential components of organized acute stroke care, providing useful information to health authorities for the allocation of resources.
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132
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Ly JV, Arakawa S, Ma H, Donnan GA. Future advances in the treatment of acute ischemic stroke. FUTURE NEUROLOGY 2007. [DOI: 10.2217/14796708.2.1.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The main obstacles to the use of tissue plasminogen activator in acute ischemic stroke are its narrow therapeutic window of 3 h and the possibility of symptomatic intracranial hemorrhage. Hence, current research is directed towards extending the therapeutic window whilst minimizing this complication. This review summarizes different approaches and gives a brief overview of the current concepts that are important in order to overcome these limitations. The main issues discussed include the concept of ischemic penumbra and its salvage by means of improving patient selection based on penumbral imaging, reperfusion and neuroprotection. We provide a perspective into how current acute stroke research may shape future acute stroke therapy.
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Affiliation(s)
- John V Ly
- National Stroke Research Institute, Level 1, Neurosciences Building, Austin Health, University of Melbourne, 300 Waterdale Rd, Heidleberg Heights, Victoria 3081, Australia
| | - Shuji Arakawa
- National Stroke Research Institute, Level 1, Neurosciences Building, Austin Health, University of Melbourne, 300 Waterdale Rd, Heidleberg Heights, Victoria 3081, Australia
| | - Henry Ma
- National Stroke Research Institute, Level 1, Neurosciences Building, Austin Health, University of Melbourne, 300 Waterdale Rd, Heidleberg Heights, Victoria 3081, Australia
| | - Geoffrey A Donnan
- National Stroke Research Institute, Level 1, Neurosciences Building, Austin Health, University of Melbourne, 300 Waterdale Rd, Heidleberg Heights, Victoria 3081, Australia
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133
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Minematsu K, Uehara T, Yasui N, Hata T, Ueda T, Okada Y, Toyota A, Naritomi H, Toyoda Y, Hasegawa Y. Effects of stroke unit on patient outcome-A prospective multicenter study in Japan-. ACTA ACUST UNITED AC 2007. [DOI: 10.3995/jstroke.29.59] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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134
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Pereira AC. Stroke: improving outcome through better diagnosis and treatment. Br J Hosp Med (Lond) 2006; 67:583-7. [PMID: 17134091 DOI: 10.12968/hmed.2006.67.11.22226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Anthony C Pereira
- Department of Neurology, Atkinson Morley Wing, St George's Hospital, London SW17 0QT
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135
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Maeda S, Mizushima Y, Takiuti T. [Issues involved with supply of medical and hygienic materials to home care patients]. Gan To Kagaku Ryoho 2006; 33 Suppl 2:273-5. [PMID: 17469358 DOI: 10.2217/14750708.3.2.273] [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: 05/15/2023]
Abstract
Questionnaires were mailed to doctors and nurses who are involved in home care to survey their observations on medical and hygienic materials and its supply to home care patients. Some of the survey items, such as problems encountered frequently, areas where an improvement was needed most and concerns that are often raised in suppling of medical and hygienic materials for home care patients, were analyzed by the Berelson's content analysis method to observe problems in suppling adequate medical and hygienic materials. As a result, 5 categories and 17 subcategories were formed. The recognized future issues were: policies concerning support extended to medical organizations and disseminate information of the system, which medical and hygienic materials supplied to home care patients.
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Affiliation(s)
- Shuko Maeda
- Dept. of Home Care Nursing, School of Nursing, Ishikawa Prefectural Nursing University
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136
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Cook C, Goode A, Erb D, Richardson J, Pietrobon R. Validation of an Item Bank in a Sample of Community-Dwelling Survivors of a Stroke. J Geriatr Phys Ther 2006; 29:107-14. [PMID: 17381853 DOI: 10.1519/00139143-200612000-00005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
PURPOSE The purpose of this study was to validate an item bank of questions associated with activities of daily living (ADL), using graded item response theory (G-IRT), in a sample of community-dwelling survivors of a stroke. METHODS The study sample consisted of 364 community-dwelling individuals who reported a recent history of stroke. Sixteen line items from the 1999-2000 National Health and Nutrition Examination Surveys (NHANES) survey were analyzed using factor analysis, internal analyses of consistency, and G-IRT. RESULTS The 16 line items demonstrated unidimensionality and were internally reliable. Thirteen line items demonstrated good discrimination and suitable thresholds. The majority of items exhibited appropriate sensitivity across the entire spectrum of functional severity indicating that these items closely reflected the relationship of decreased function with increased severity of illness. CONCLUSION Each of the 13 items is scale independent, is valid for measurement of functional impairment, and may be applicable for use in a scale for assessment of functional change in community-dwelling stroke survivors.
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Affiliation(s)
- Chad Cook
- Division of Physical Therapy, Duke University, DUMC 3907, Durham, NC 27710, USA. chad.cook@ duke.edu
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137
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Moodie M, Cadilhac D, Pearce D, Mihalopoulos C, Carter R, Davis S, Donnan G. Economic Evaluation of Australian Stroke Services. Stroke 2006; 37:2790-5. [PMID: 17008615 DOI: 10.1161/01.str.0000245083.97460.e1] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background and Purpose—
Level I evidence from randomized controlled trials demonstrates that the model of hospital care influences stroke outcomes; however, the economic evaluation of such is limited. An economic appraisal of 3 acute stroke care models was facilitated through the Stroke Care Outcomes: Providing Effective Services (SCOPES) study in Melbourne, Australia. The aim was to describe resource use up to 28 weeks poststroke for each model and examine the cost-effectiveness of stroke care units (SCUs).
Methods—
A prospective, multicenter, cohort study design was used. Costs and outcomes of stroke patients receiving 100% treatment in 1 of 3 inpatient care models (SCUs, mobile service, conventional care) were compared. Health-sector resource use up to 28 weeks was measured in 1999. Outcomes were thorough adherence to a suite of important clinical processes and the number of severe inpatient complications.
Results—
The sample comprised 395 participants (mean age 73 [SD 14], 77% first-ever strokes, males 53%). When compared with conventional care (n=84), costs for mobile service (n=209) were significantly higher (
P
=0.024), but borderline for SCU (n=102,
P
=0.08; $AUD12 251; $AUD15 903; $AUD15 383 respectively). This was primarily explained by the greater use of specialist medical services. The incremental cost-effectiveness of SCUs over conventional care was $AUD9867 per patient achieving thorough adherence to clinical processes and $AUD16 372 per patient with severe complications avoided, based on costs to 28 weeks.
Conclusions—
Although acute SCU costs are generally higher, they are more cost-effective than either mobile service or conventional care.
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Affiliation(s)
- Marjory Moodie
- Program Evaluation Unit, School of Public Health, 4/207 Bouverie Street, The University of Melbourne, Victoria 3010, Australia.
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138
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Masjuan Vallejo J, Alonso de Leciñana Cases M, García Barragán N, Zarza Sanz B, Díaz Sánchez M, Martínez Castrillo JC, Corral Corral I. Tratamiento trombolítico del ictus isquémico agudo en un centro sin experiencia previa. Desarrollo de la organización interna y primeros resultados. Rev Clin Esp 2006; 206:485-90. [PMID: 17129516 DOI: 10.1157/13094896] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Treatment of acute ischemic stroke within three hours with intravenous tissue-type plasminogen activator (t-PA) has been recently approved by the European Drug Agency. We present the development of an internal organization system that has permitted thrombolytic treatment in our center without previous experience as well as the results of the first year. PATIENTS AND METHOD Development of the thrombolysis educational program for the staff informed, of the internal organization system, and combined care protocols among the participating services. Prospective registry of patients treated with t-PA within the period 1/2004-2/2006. We collected demographic data, stroke assessment scales score (NIHSS), time to treatment, seven day and three months mortality, symptomatic hemorrhagic transformation, systemic bleedings, functional independency at three months, early significant improvement and significant deterioration. RESULTS Fifty-three patients were treated. Mean age: 65 +/- 13 years; 56% women. Mean NIHSS pre-treatment: 14 +/- 4.7. Mean time to hospital arrival: 62 +/- 40 minutes; door-to-treatment: 68 +/- 22 minutes, and mean time from stroke onset to treatment: 130 +/- 31 minutes. Symptomatic hemorrhagic transformation: 5.8%. Systemic bleeding: 3.8%. Seven day mortality: 5.6%; three months mortality: 15.1%. Early significant improvement: 51%. Significant neurological deterioration: 7.5%. Functional independency at three months: 51%. CONCLUSIONS Treatment of acute ischemic stroke within three hours with intravenous t-PA is safe and is associated with a favourable outcome when it is applied by neurologists specifically trained in acute stroke management.
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139
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Cadilhac DA, Lalor EE, Pearce DC, Levi CR, Donnan GA. Access to stroke care units in Australian public hospitals: facts and temporal progress. Intern Med J 2006; 36:700-4. [PMID: 17040355 DOI: 10.1111/j.1445-5994.2006.01168.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is level I evidence that management of stroke patients in stroke units (SU) improves outcomes (death and institutionalization) by approximately 20%. In Australia, there is uncertainty as to the proportion of incident cases that have access to SU. Recent national and State-based policy initiatives to increase access to SU have been taken. However, objective evidence related to SU implementation progress is lacking. The aims of the study were (i) to determine the number of SU in Australian acute public hospitals in 2004, (ii) to describe hospitals according to national SU policy criteria and (iii) to compare results to the 1999 survey to track progress. METHODS The method used in the study was a cross-sectional, postal survey technique. The participants were clinical representatives considered appropriate to describe stroke care within survey hospitals. RESULTS The outcome of the study was presence of a SU according to an accepted definition. Response rate was 261/301 (87%). Sixty-one sites (23%) had either a SU and/or a dedicated stroke team. Fifty sites claimed to have a SU (19%). New South Wales with 23 had the most number of SU. Based on policy criteria, up to 64 sites could have a SU. In 1999, there were 35 public hospitals with a SU. CONCLUSION Access to SU in Australian public hospitals remains low compared with other countries (Sweden, 70%). Implementation strategies supported by appropriate health policy to improve access are needed.
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Affiliation(s)
- D A Cadilhac
- National Stroke Research Institute, Repatriation Hospital, Heidelberg Heights, Victoria, Australia.
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140
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Ly JV, Zavala JA, Donnan GA. Neuroprotection and thrombolysis: combination therapy in acute ischaemic stroke. Expert Opin Pharmacother 2006; 7:1571-81. [PMID: 16872260 DOI: 10.1517/14656566.7.12.1571] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The administration of oral aspirin within 48 h and tissue plasminogen activator within 3 h of ischaemic stroke onset remain the only treatments that have been shown to have clinical benefit. There has been much excitement about neuroprotection over the last two decades, as it may minimise the harmful effects of ischaemic neuronal damage. Although each step along the ischaemic cascade offers a potential target for therapeutic intervention, and neuroprotection has shown benefit in animal studies, this has been difficult to translate to humans. Some hope has been offered by the recent finding that the free radical scavenger NXY-059 may improve outcomes in patients presenting within 6 h of onset of ischaemic stroke. There is logic to the idea that neuroprotection may be most effective when reperfusion has occurred with thrombolysis, as the neuroprotectant will have greater access to ischaemic tissue and the opportunity is presented to minimise free radical-mediated reperfusion injury. Numerous studies in animal models support this view, but the concept has not, as yet, been rigorously tested in humans.
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Affiliation(s)
- John V Ly
- National Stroke Research Institute, Level 1, Neurosciences Building, Austin Health, University of Melbourne, 300 Waterdale Road, Heidleberg Heights, Victoria 3081, Australia
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141
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Lorenzano S, Anzini A, de Michele M, Falcou A, Fausti S, Gori C, Mancini A, Cavalletti C, Colosimo C, Fiorelli M, Sacchetti ML, Argentino C, Toni D. Which model of stroke unit is better for stroke patient management? Clin Exp Hypertens 2006; 28:377-82. [PMID: 16833049 DOI: 10.1080/10641960600549728] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The increasing prevalence of cerebrovascular diseases has made urgent the need to develop timely and effective treatment strategies to tackle this health problem. Stroke units (SUs) appear to be the ideal setting where the management of acute stroke patients, including specific treatments as thrombolysis, may be optimized. Which model of SU gives the best results is still an unsettled issue. The more intensive and timely multidisciplinary approach to the acute phase of stroke, the management of medical complications, and the earlier and more focused rehabilitation, are likely the most qualifying aspects of our Neurovascular treatment unit.
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Affiliation(s)
- Svetlana Lorenzano
- Neurovascular Treatment Unit, Department of Neurological Sciences, University of Rome, "La Sapienza," Rome, Italy.
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142
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Mold F, Wolfe C, McKevitt C. Falling through the net of stroke care. HEALTH & SOCIAL CARE IN THE COMMUNITY 2006; 14:349-56. [PMID: 16787486 DOI: 10.1111/j.1365-2524.2006.00630.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
The provision of healthcare services has been shown to differ by social characteristics such as gender, age and social status. The processes by which such differences arise are unclear. We report findings from a qualitative interview study with stroke service providers undertaken during an investigation of inequalities in stroke care. We interviewed 41 professionals from hospital and community settings in south London. Participants' accounts are used to explore how it is that patients' trajectories of care might not follow evidence-based guidelines, focusing on stroke unit admission, provision of hospital rehabilitation therapies and community health and social services. Categories of patients who might not receive best care were people who were cognitively impaired, those regarded as having 'complex problems', those with communication problems and younger people. Additionally, the local availability of services was thought to affect individuals' chances of receiving particular components of care. Although professionals spoke of certain types of patients as 'falling through the net' (of services), their accounts suggest that they channel patients through services according to an implicit template of the individual suited to the service. Those who do not fit the service as currently resourced may have reduced access to specific components of care. If inequalities in access to care are to be addressed we require a better understanding of how professionals' decision-making processes test the fit between service users and the implicit template of 'suitable' patient or client.
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Affiliation(s)
- Freda Mold
- Division of Health & Social Care Research, King's College London, UK
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143
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Leira R, Blanco M, Rodríguez-Yáñez M, Flores J, García-García J. Non-Pharmacological Neuroprotection: Role of Emergency Stroke Management. Cerebrovasc Dis 2006; 21 Suppl 2:89-98. [PMID: 16651819 DOI: 10.1159/000091708] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Acute stroke should be considered a medical emergency, where actions taken in the first hours are fundamental for achieving recovery of the damaged cerebral tissue and a better prognosis for the patient. Recanalization and neuroprotective treatment has been used with mixed results. The effectiveness observed in the first hours with thrombolytic drug treatment is only applicable to a small percentage of patients, and attempts to widen this treatment window have not yet proved fruitful. Pharmacological neuroprotective treatment has not yet demonstrated the clinical effectiveness observed in experimental models. The concept of neuroprotection in cerebral ischemia also involves a series of mechanisms that take place at the cerebral level following vascular occlusion. In this context, it should be borne in mind that a series of physiological functions usually involved in the cerebral metabolism (control of blood pressure, of temperature, of glycemia and of arterial oxygen saturation) play a key role in modulation of the ischemic process. Changes in the control of these mechanisms may aggravate the process of cerebral damage in the first hours of ischemic stroke. In this work we review the prognostic importance of the main mechanisms that may influence the acute phase of cerebral ischemic stroke, as well as their therapeutic management and control in the clinical situation.
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Affiliation(s)
- Rogelio Leira
- Department of Neurology, Division of Vascular Neurology, Stroke Unit, Hospital Clínico Universitario, Santiago de Compostela, Spain.
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144
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Abstract
Functional imaging of stroke recovery is a unique source of information that might be useful in the development of restorative treatments. Several features of brain function change spontaneously after stroke. Current studies define many of the most common events. Key challenges for the future are to develop standardized approaches to help address certain questions, determine the psychometric qualities of these measures, and define the clinical usefulness of these methods.
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Affiliation(s)
- Craig D Takahashi
- Department of Neurology, University of California at Irvine, CA 92868-4280, USA
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145
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Taylor WJ, Wong A, Siegert RJ, McNaughton HK. Effectiveness of a clinical pathway for acute stroke care in a district general hospital: an audit. BMC Health Serv Res 2006; 6:16. [PMID: 16504101 PMCID: PMC1403773 DOI: 10.1186/1472-6963-6-16] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2005] [Accepted: 02/23/2006] [Indexed: 11/24/2022] Open
Abstract
Background Organised stroke care saves lives and reduces disability. A clinical pathway might be a form of organised stroke care, but the evidence for the effectiveness of this model of care is limited. Methods This study was a retrospective audit study of consecutive stroke admissions in the setting of an acute general medical unit in a district general hospital. The case-notes of patients admitted with stroke for a 6-month period before and after introduction of the pathway, were reviewed to determine data on length of stay, outcome, functional status, (Barthel Index, BI and Modified Rankin Scale, MRS), Oxfordshire Community Stroke Project (OCSP) sub-type, use of investigations, specific management issues and secondary prevention strategies. Logistic regression was used to adjust for differences in case-mix. Results N = 77 (prior to the pathway) and 76 (following the pathway). The median (interquartile range, IQR) age was 78 years (67.75–84.25), 88% were European NZ and 37% were male. The median (IQR) BI at admission for the pre-pathway group was less than the post-pathway group: 6 (0–13.5) vs. 10 (4–15.5), p = 0.018 but other baseline variables were statistically similar. There were no significant differences between any of the outcome or process of care variables, except that echocardiograms were done less frequently after the pathway was introduced. A good outcome (MRS<4) was obtained in 66.2% prior to the pathway and 67.1% after the pathway. In-hospital mortality was 20.8% and 23.1%. However, using logistic regression to adjust for the differences in admission BI, it appeared that admission after the pathway was introduced had a significant negative effect on the probability of good outcome (OR 0.29, 95%CI 0.09-0.99). Conclusion A clinical pathway for acute stroke management appeared to have no benefit for the outcome or processes of care and may even have been associated with worse outcomes. These data support the conclusions of a recent Cochrane review.
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Affiliation(s)
- William J Taylor
- Rehabilitation Teaching & Research Unit, Wellington School of Medicine & Health Sciences, University of Otago, PO Box 7343, Wellington, New Zealand
| | - Annie Wong
- Rehabilitation Teaching & Research Unit, Wellington School of Medicine & Health Sciences, University of Otago, PO Box 7343, Wellington, New Zealand
| | - Richard J Siegert
- Rehabilitation Teaching & Research Unit, Wellington School of Medicine & Health Sciences, University of Otago, PO Box 7343, Wellington, New Zealand
| | - Harry K McNaughton
- Medical Research Institute of New Zealand, PO Box 10055, Wellington, New Zealand
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146
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Watkins C. 30th anniversary commentary on Hamrin E. (1982) Attitudes of nursing staff in general medical wards towards activation of stroke patients. Journal of Advanced Nursing 7, 33-42. J Adv Nurs 2006. [DOI: 10.1111/j.1365-2648.2006.03665.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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147
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Díez-Tejedor E, Fuentes B. Homeostasis as basis of acute stroke treatment: stroke units are the key. Cerebrovasc Dis 2005; 20 Suppl 2:129-34. [PMID: 16327263 DOI: 10.1159/000089366] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Several studies suggest that the control of blood pressure (BP), blood glucose level, body temperature, and oxygen saturation, when analyzed separately, is related with successful acute stroke outcome. However, in a biological system these parameters are interrelated and could influence the process. Recent studies highlight the importance of the appropriate maintenance of these variables that are involved in homeostasis in patients with stroke and the influence they have on outcome. METHODS A review was conducted of published studies which analyzed the influence of control of these physiological variables in acute stroke, whether in isolation or combinations, and we have contributed our own data derived from observational studies. RESULTS The maintenance of homeostasis forms the basis of acute stroke treatment, in what is termed nonpharmacological neuroprotection. Stroke units (SU) are the ideal environment for this therapeutic approach since their favorable influence on the correct management of BP, body temperature, oxygen saturation, and blood glucose in the progress of stroke patients have been proved. CONCLUSIONS The proper management of physiological variables (homeostasis) such as BP, body temperature, blood glucose, and oxygen saturation is the basis of acute stroke treatment, and SU are the key to this approach.
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Affiliation(s)
- E Díez-Tejedor
- Stroke Unit, Department of Neurology, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain.
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148
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Bae HJ, Yoon DS, Lee J, Kim BK, Koo JS, Kwon O, Park JM. In-Hospital Medical Complications and Long-Term Mortality After Ischemic Stroke. Stroke 2005; 36:2441-5. [PMID: 16224097 DOI: 10.1161/01.str.0000185721.73445.fd] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Inhospital medical complications account for a considerable portion of deaths during the early stage of stroke. However, relatively few studies have examined their long-term effects on mortality in stroke patients. METHODS We prospectively and consecutively collected data on 579 patients with acute ischemic stroke from November 1998 to February 2001. Mortality was confirmed using national death certificate data from 1999 to 2003. RESULTS During admission, one or more medical complications requiring intervention developed in 160 of these 579 patients (27.6%). For these 160 subjects, the 30-day, 90-day, 1-year, 2-year, 3-year, and 4-year mortalities were 16.3, 29.4, 46.9, 55.6, 61.3, and 70.7%, whereas the mortality figures for those without such complications (n=419) were 1.4, 3.8, 8.8, 15.0, 19.1, and 22.4 (P<0.001 with log-rank test). To eliminate the short-term effects of these complications and thus reveal their long-term effects, we investigated differences in mortality versus the presence of inhospital complications at more than 30 days, 90 days, 1 year, 2 years, and 3 years after stroke, respectively. Cox's proportional hazard regression analysis was applied at these times after stroke and showed that all hazard ratios of medical complications in terms of mortality were statistically larger than one, regardless of adjusting for effects of potential predictors on mortality. CONCLUSIONS Our study shows that stroke patient mortality is influenced by inhospital medical complications significantly up to the chronic stage. This finding suggests that the appropriate prevention and management of inhospital complications could improve short-term and long-term prognoses after stroke.
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Affiliation(s)
- Hee-Joon Bae
- Department of Neurology, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea
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149
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Minkman MMN, Schouten LMT, Huijsman R, van Splunteren PT. Integrated care for patients with a stroke in the Netherlands: results and experiences from a national Breakthrough Collaborative Improvement project. Int J Integr Care 2005; 5:e14. [PMID: 16773169 PMCID: PMC1395526 DOI: 10.5334/ijic.118] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2004] [Revised: 11/08/2004] [Accepted: 03/12/2005] [Indexed: 11/20/2022] Open
Abstract
Purpose This article considers the question if measurable improvements are achieved in the quality of care in stroke services by using a Breakthrough collaborative quality improvement model. Context of case Despite the availability of explicit criteria, evidence based guidelines, national protocols and examples of best practices; stroke care in the Netherlands did not improve substantially yet. For that reason a national collaborative started in 2002 to improve integrated stroke care in 23 self selected stroke services. Data sources Characteristics of sites, teams, aims and changes were assessed by using a questionnaire and monthly self-reports of teams. Progress in achieving significant quality improvement has been assessed on a five point Likert scale (IHI score). Case description The stroke services (n=23) formed multidisciplinary teams, which worked together in a collaborative based on the IHI Breakthrough Series Model. Teams received instruction in quality improvement, reviewed self reported performance data, identified bottlenecks and improvement goals, and implemented “potentially better practices” based on criteria from the Edisse study, evidence based guidelines, own ideas and expert opinion. Conclusion and discussion Quality of care has been improved in most participating stroke services. Eighty-seven percent of the teams have improved their care significantly on at least one topic. About 34% of the teams have achieved significant improvement on all aims within the time frame of the project. The project has contributed to the further development and spread of integrated stroke care in the Netherlands.
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Affiliation(s)
- M M N Minkman
- Dutch Institute for Healthcare Improvement CBO, Utrecht, The Netherlands
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Booth J, Hillier VF, Waters KR, Davidson I. Effects of a stroke rehabilitation education programme for nurses. J Adv Nurs 2005; 49:465-73. [PMID: 15713178 DOI: 10.1111/j.1365-2648.2004.03319.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS This paper reports a study which aimed to explore the effects of education on the practice of nurses working in stroke rehabilitation units. BACKGROUND It has been suggested that a key component of the success of stroke units in reducing mortality and disability is the contribution made by nurses, but debate continues around their specific role. Literature has concentrated on nurses' perceptions of their role rather than their actual activities with patients. In studying the effects of education on nurses' practice with stroke patients there is a need to identify what nurses actually do, rather than what they say they do. METHODS A quasi-experimental, non-equivalent control group design was used to study two stroke rehabilitation units. Non-participant observation was conducted during morning care sessions, focusing on styles of physical interaction. Base-line observations were recorded in each unit, after which the staff in the intervention unit received 7 hours' education, specifically focused on therapeutic handling in relation to morning care activities. Following this, postintervention observations were conducted and comparisons of interaction styles made between units. RESULTS Twenty-six staff and 37 patients took part in the study. Following the education, staff in the intervention unit showed a change in physical interaction style more in line with therapeutic practice, with the proportion of 'doing for' interventions reducing (45.4% vs. 33.2%; P < 0.05). The proportion of facilitatory interventions increased (3.9% vs. 6.1%) however, this difference was not statistically significant (P = 0.098). The change in styles of practice was achieved with no increased demand on nurses' time. CONCLUSION Education for nurses which aims to change styles of interaction with stroke patients can be effective. However, further research is required to identify the effect of nursing interventions on patient outcomes following stroke.
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Affiliation(s)
- Joanne Booth
- Caledonian Nursing and Midwifery Research Centre, Glasgow Caledonian University, Glasgow, UK
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