Metrics for Measuring Quality of Care in Comprehensive Stroke Centers: Detailed Follow-Up to Brain Attack Coalition Comprehensive Stroke Center Recommendations

"Picture to puncture": a novel time metric to enhance outcomes in patients transferred for endovascular reperfusion in acute ischemic stroke

BACKGROUND

Comprehensive stroke centers allow for regionalization of subspecialty stroke care. Efficacy of endovascular treatments, however, may be limited by delays in patient transfer. Our goal was to identify where these delays occurred and to assess the impact of such delays on patient outcome.

METHODS AND RESULTS

This was a retrospective study evaluating patients treated with endovascular therapy from November 2010 to July 2012 at our institution. We compared patients transferred from outside hospitals with locally treated patients with respect to demographics, imaging, and treatment times. Good outcomes, as defined by 90-day modified Rankin Scale scores of 0 to 2, were analyzed by transfer status as well as time from initial computed tomography to groin puncture ("picture-to-puncture" time). A total of 193 patients were analyzed, with a mean age of 65.8 ± 14.5 years and median National Institutes of Health Stroke Scale score of 19 (interquartile range, 15-23). More than two thirds of the patients (132 [68%]) were treated from referring facilities. Outside transfers were noted to have longer picture-to-puncture times (205 minutes [interquartile range, 162-274] versus 89 minutes [interquartile range, 70-119]; P<0.001), which was attributable to the delays in transfer. This corresponded to fewer patients with favorable Alberta Stroke Program Early CT Scores on preprocedural computed tomographic imaging (Alberta Stroke Program Early CT Scores >7: 50% versus 76%; P<0.001) and significantly worse clinical outcomes (29% versus 51%; P=0.003). In a logistic regression model, picture-to-puncture times were independently associated with good outcomes (odds ratio, 0.994; 95% confidence interval, 0.990-0.999; P=0.009).

CONCLUSIONS

Delays in picture-to-puncture times for interhospital transfers reduce the probability of good outcomes among treated patients. Strategies to reduce such delays herald an opportunity for hospitals to improve patient outcomes.

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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Changes in Interhospital Transfer Patterns of Acute Ischemic Stroke Patients in the Regional Stroke Care System After Designation of a Cerebrovascular-specified Center

The Ministry of Health and Welfare of Korea recently designated cerebrovascularspecified centers (CSCs) to improve the regional stroke care system for acute ischemic stroke (AIS) patients. This study was performed to evaluate the changes in the flow of AIS patients between hospitals and to describe the role of the Emergency Medical Information Center (EMIC) after the designation of the CSCs. Data for coordination of interhospital transfers by the EMIC were reviewed for 6 months before and after designation of the CSCs. The data included the success or failure rate, the time used for coordination of interhospital transfer, and the changes in the interhospital transfer pattern between transfer-requesting and transfer-accepting hospitals. The total number of requests for interhospital transfer increased from 198 to 244 after designation of the CSCs. The median time used for coordination decreased from 8.0 minutes to 4.0 minutes (p<0.001). The success rate of coordination increased from 88.9% to 96.7% (p<0.001). The proportion of requests by CSCs decreased from 3.5% to 0.4% (p=0.017). However, the proportion of acceptance by non-CSC hospitals increased from 15.9% to 25.8% (p=0.015). With the designation of CSCs, the EMIC could coordinate interhospital transfers more quickly. However, AIS patients are more dispersed to CSC and non-CSC hospitals, which might be because the CSCs still do not have sufficient resources to cover the increasing volume of AIS patients and non-CSC hospitals have changed their policies. Further studies based on patients' outcome are needed to determine the adequate type of interhospital transfer for AIS patients.

Advanced modality imaging evaluation in acute ischemic stroke may lead to delayed endovascular reperfusion therapy without improvement in clinical outcomes

PURPOSE

Advanced neuroimaging techniques may improve patient selection for endovascular stroke treatment but may also delay time to reperfusion. We studied the effect of advanced modality imaging with CT perfusion (CTP) or MRI compared with non-contrast CT (NCT) in a multicenter cohort.

MATERIALS AND METHODS

This is a retrospective study of 10 stroke centers who select patients for endovascular treatment using institutional protocols. Approval was obtained from each institution's review board as only de-identified information was used. We collected demographic and radiographic data, selected time intervals, and outcome data. ANOVA was used to compare the groups (NCT vs CTP vs MRI). Binary logistic regression analysis was performed to determine factors associated with a good clinical outcome.

RESULTS

556 patients were analyzed. Mean age was 66 ± 15 years and median National Institutes of Health Stroke Scale score was 18 (IQR 14-22). NCT was used in 286 (51%) patients, CTP in 190 (34%) patients, and MRI in 80 (14%) patients. NCT patients had significantly lower median times to groin puncture (61 min, IQR (40-117)) compared with CTP (114 min, IQR (81-152)) or MRI (124 min, IQR (87-165)). There were no differences in clinical outcomes, hemorrhage rates, or final infarct volumes among the groups.

CONCLUSIONS

The current retrospective study shows that multimodal imaging may be associated with delays in treatment without reducing hemorrhage rates or improving clinical outcomes. This exploratory analysis suggests that prospective randomised studies are warranted to support the hypothesis that advanced modality imaging is superior to NCT in improving clinical outcomes.

"Stroke Nav": a wireless data collection and review system to support stroke care delivery

"Stroke Nav" is a novel system to support the care of stroke patients. The system contains purpose-built web-based software to facilitate accurate near-real time data collection by clinicians throughout the complex care settings traversed by patients. Tools are included to facilitate pre-defined and bespoke data review with graphical dashboards showing performance metrics and other aggregate data. The software was designed collaboratively by health care professionals and engineers, and is accessible via the hospital intranet using desktop or laptop computers and wireless mobile devices. Stroke Nav is being routinely used in two hospitals, with over 1400 patients registered, and is now being introduced in other hospitals. The system is delivering benefits in relation to multidisciplinary communication, knowledge management, patient safety, clinical audit and service performance.

Mechanical thrombectomy in acute stroke: utilization variances and impact of procedural volume on inpatient mortality

BACKGROUND

An increasing number of endovascular mechanical thrombectomy procedures are being performed for the treatment of acute ischemic stroke. This study examines variances in the allocation of these procedures in the United States at the hospital level. We investigate operative volume across centers performing mechanical revascularization and establish that procedural volume is independently associated with inpatient mortality.

METHODS

Data was collected using the Nationwide Inpatient Sample database in the United States for 2008. Medical centers performing mechanical thrombectomy were identified using International Classification of Diseases, 9th revision codes, and procedural volumes were evaluated according to hospital size, location, control/ownership, geographic characteristics, and teaching status. Inpatient mortality was compared for hospitals performing ≥10 mechanical thrombectomy procedures versus those performing<10 procedures annually. After univariate analysis identified the factors that were significantly related to mortality, multivariable logistic regression was performed to compare mortality outcome by hospital procedure volume independent of covariates.

RESULTS

Significant allocation differences existed for mechanical thrombectomy procedures according to hospital size (P<.001), location (P<.0001), control/ownership (P<.0001), geography (P<.05), and teaching status (P<.0001). Substantial procedural volume was independently associated with decreased mortality (P=.0002; odds ratio 0.49) when adjusting for demographic covariates.

CONCLUSIONS

The number of mechanical thrombectomy procedures performed nationally remains relatively low, with a disproportionate distribution of neurointerventional centers in high-volume, urban teaching hospitals. Procedural volume is associated with mortality in facilities performing mechanical thrombectomy for acute ischemic stroke patients. These results suggest a potential benefit for treatment centralization to facilities with substantial operative volume.

Developing practice recommendations for endovascular revascularization for acute ischemic stroke

Guidelines have been established for the management of acute ischemic stroke; however, specific recommendations for endovascular revascularization therapy are lacking. Burgeoning investigation of endovascular revascularization therapies for acute ischemic stroke, rapid device development, and a diverse training background of the providers performing the procedures underscore the need for practice recommendations. This review provides a concise summary of the Society of Vascular and Interventional Neurology endovascular acute ischemic stroke roundtable meeting. This document was developed to review current clinical efficacy of pharmacologic and mechanical revascularization therapy, selection criteria, periprocedure management, and endovascular time metrics and to highlight current practice patterns. It therefore provides an outline for the future development of multisociety guidelines and recommendations to improve patient selection, procedural management, and organizational strategies for revascularization therapies in acute ischemic stroke.

The chain of care enabling tPA treatment in acute ischemic stroke: a comprehensive review of organisational models

Protracted and partial implementation of treatment with intravenous tissue plasminogen activator (tPA) within 4.5 h after acute stroke onset results in potentially eligible patients not receiving optimal treatment. The goal of this study was to review the performance of various organisational models of acute stroke care delivery, and subsequent attempts to improve implementation of tPA treatment. Publications comprehensively reporting on organisational models to improve implementation of i.v. tPA treatment of acute ischemic stroke patients were selected. The efficacy of organisational models was assessed using process outcome measures: thrombolysis rates, time-dependent operational endpoints (time delays), functional outcomes: safety (rate of symptomatic intracranial hemorrhage, mortality rates) and clinical outcome at 90 days (modified Rankin Scale). Fifty-eight published studies assessing organisational models were identified. Four dominant models of acute stroke care delivery were discerned, i.e., primary and comprehensive stroke centres, telemedicine, and the mobile stroke unit. Performance reported for these models suggest a large variation in administration of thrombolytic therapy (0.7-30 %). Time delays and functional outcomes found varied considerably, just like safety and mortality (0.0-11.5 %, and 3.4-31.9 %, respectively). These findings suggest that improving organisational models for tPA treatment may improve acute stroke care. However, implementation may be hampered by regional variation in acute stroke care capacity, expertise, and a fragmented approach towards organising stroke care.

Population-based estimates of neuroendovascular procedures: results of a state-wide study

BACKGROUND

The Brain Attack Coalition identified the availability of neuroendovascular procedures as an essential component of a comprehensive stroke center.

OBJECTIVE

To provide population-based estimates of neuroendovascular procedures.

METHODS

State-wide estimates of cervicocerebral angiograms, endovascular ischemic stroke treatments, carotid angioplasty and stent placements, intracranial angioplasty and stent placements, endovascular treatment of intracranial aneurysms, and endovascular treatment of intracranial arteriovenous malformations (AVMs) were obtained. We calculated the annual incidence rates of various neuroendovascular and neurosurgical procedures (per 100,000 persons). For the denominator, total persons in each year were categorized in 10-year age intervals.

RESULTS

The incidence of carotid endarterectomy (387.6 per 100,000 persons) and carotid stent placement (34.7 per 100,000 persons) peaked at 75-84 years. The incidence of aneurysm embolization also peaked in that population bracket (67.9 per 100,000 persons), yet there was a dramatic reduction in the incidence of surgical aneurysm treatment (3.6 per 100,000 persons) in those aged 75-84 years. There was a prominent reduction in the incidence of all procedures in the population aged ≥85 years, except for intravenous/intra-arterial thrombolytic use in ischemic stroke. The incidence of ischemic stroke increased almost by 50% in the population aged ≥85 years compared to those aged 75-84 years. However, the incidence of endovascular procedures for acute ischemic stroke decreased from 22.8 per 100,000 persons in the population aged 75-84 years to 13.2 per 100,000 persons in the population aged ≥85 years.

CONCLUSIONS

A marked disproportion of neuroendovascular procedures performed and disease prevalence was noted in persons aged ≥85 years, an increasing segment of the population according to recent Census.

Elements of a stroke center

The past decade has ushered in a refined understanding of--and commitment to--objective evidence-based practice of stroke management. Responding to the need for universal protocol-driven guidelines for stroke care, the Brain Attack Coalition published consensus statements with recommendations for primary stroke centers (Alberts MJ, et al, JAMA 283:3102-3109, 2000) and comprehensive stroke centers (Alberts MJ, et al, Stroke 36:1597-1616, 2005) in 2000 and 2005, respectively. These benchmark publications helped to define a new "standard of care" for stroke patients and laid the groundwork to establish formal certification for stroke centers. Although large randomized controlled trials evaluating the efficacy of these guidelines are currently underway, several recent reports suggest that stroke center certification may improve outcomes in patients with acute ischemic stroke. In this article, the authors briefly discuss the status of stroke center certification and the evolution of stroke systems of care.

Microcatheter to recanalization (procedure time) predicts outcomes in endovascular treatment in patients with acute ischemic stroke: when do we stop?

BACKGROUND AND PURPOSE

Endovascular treatment for acute ischemic stroke consists of various mechanical and pharmacologic modalities used for recanalization of arterial occlusions. We performed this study to determine the relationship among procedure time, recanalization, and clinical outcomes in patients with acute ischemic stroke undergoing endovascular treatment.

MATERIALS AND METHODS

We analyzed data from consecutive patients with acute ischemic stroke who underwent endovascular treatment during a 6-year period. Demographic characteristics, NIHSS score before and 24 hours after the procedure, and discharge mRS score were ascertained. Procedure time was defined by the time interval between microcatheter placement and recanalization or completion of the procedure. We estimated the procedure time after which favorable clinical outcome was unlikely, even after adjustment for age, time from symptom onset, and admission NIHSS scores.

RESULTS

We analyzed 209 patients undergoing endovascular treatment (mean age, 65 ± 16 years; 109 [52%] men; mean admission/preprocedural NIHSS score, 15.3 ± 6.8). Complete or partial recanalization was observed in 176 (84.2%) patients, while unfavorable outcome (mRS 3-6) was observed in 138 (66%) patients at discharge. In univariate analysis, patients with procedure time ≤30 minutes had lower rates of unfavorable outcome at discharge compared with patients with procedure time ≥30 minutes (52.3% versus 72.2%, P = .0049). In our analysis, the rates of favorable outcomes in endovascularly treated patients after 60 minutes were lower than rates observed with placebo treatment in the Prourokinase for Acute Ischemic Stroke Trial. In logistic regression analysis, unfavorable outcome was positively associated with age (P = .0012), admission NIHSS strata (P = .0017), and longer procedure times (P = .0379).

CONCLUSIONS

Procedure time in patients with acute ischemic stroke appears to be a critical determinant of outcomes following endovascular treatment. This highlights the need for procedure time guidelines for patients being considered for endovascular treatment in acute ischemic stroke.

Higher volume endovascular stroke centers have faster times to treatment, higher reperfusion rates and higher rates of good clinical outcomes

BACKGROUND AND PURPOSE

Technological advances have helped to improve the efficiency of treating patients with large vessel occlusion in acute ischemic stroke. Unfortunately, the sequence of events prior to reperfusion may lead to significant treatment delays. This study sought to determine if high-volume (HV) centers were efficient at delivery of endovascular treatment approaches.

METHODS

A retrospective review was performed of nine centers to assess a series of time points from obtaining a CT scan to the end of the endovascular procedure. Demographic, radiographic and angiographic variables were assessed by multivariate analysis to determine if HV centers were more efficient at delivery of care.

RESULTS

A total of 442 consecutive patients of mean age 66 ± 14 years and median NIH Stroke Scale score of 18 were studied. HV centers were more likely to treat patients after intravenous administration of tissue plasminogen activator and those transferred from outside hospitals. After adjusting for appropriate variables, HV centers had significantly lower times from CT acquisition to groin puncture (OR 0.991, 95% CI 0.989 to 0.997, p=0.001) and total procedure times (OR 0.991, 95% CI 0.986 to 0.996, p=0.001). Additionally, patients treated at HV centers were more likely to have a good clinical outcome (OR 1.86, 95% CI 1.11 to 3.10, p<0.018) and successful reperfusion (OR 1.82, 95% CI 1.16 to 2.86, p<0.008).

CONCLUSIONS

Significant delays occur in treating patients with endovascular therapy in acute ischemic stroke, offering opportunities for improvements in systems of care. Ongoing prospective clinical trials can help to assess if HV centers are achieving better clinical outcomes and higher reperfusion rates.

Neurointerventional procedural volume per hospital in United States: implications for comprehensive stroke center designation

BACKGROUND AND PURPOSE

Availability of neurointerventional procedures is recommended as a necessary component of a comprehensive stroke center by various regulatory guidelines that also emphasize adequate procedural volumes. We studied the volumes of neurointerventional procedures performed in various hospitals across the United States with subsequent comparisons with rates of minimum procedural volumes recommended by various professional bodies or used in clinical trials to ensure adequate operator experience.

METHODS

We reviewed the Nationwide Inpatient Sample database in the United States for the years 2005 to 2008. Using International Classification of Disease-Clinical Modification, 9th revision, and Medicare severity diagnosis-related group codes, we identified among hospitals that admit stroke patients those that met the minimum criteria for overall and individual procedural volumes specified in various guidelines. We then compared the characteristics between the high-volume hospitals that performed at least 100 cervicocerebral angiograms and met ≥1 other procedural criterion (n=79) and low-volume hospitals (n=958).

RESULTS

Proportions of hospitals that met individual procedural volume criteria over the 4-year period according to procedure were: cervicocerebral angiography (7.0%-7.8%); endovascular acute ischemic stroke treatments (0.4%-2.6%); carotid angioplasty/stent placement (3.0%-5.3%); intracranial angioplasty/stent placement (0.3%-1.3%); and aneurysm embolization (1.3%-2.6%). There were significant trends for increasing numbers of all the endovascular procedures except intracranial angioplasty/stent placement over the course of 4 years. The high-volume hospitals were more likely to be urban teaching hospitals (70.9% versus 13.1%; P<0.001), had larger bed size (79.7% versus 26.9%; P<0.001), and had significantly higher rates of hemorrhagic stroke admissions and lower rates of transient ischemic attack admissions. Urban teaching location/status (OR, 8.92; CI, 4.3-18.2; P<0.001) and large bed size (OR, 4.40; CI, 2.0-9.5; P<0.001) remained as independent predictors of a high-volume hospital when adjusted for age, gender, risk factors, and stroke subtype.

CONCLUSIONS

There are very few hospitals in the United States that meet all the neurointerventional procedural volume criteria for all endovascular procedures recommended to ensure adequate operator experience. Our results support the creation of specialized regional centers for ensuring adequate procedural volume within treating hospitals.

Organization of a United States county system for comprehensive acute stroke care

BACKGROUND AND PURPOSE

Organized systems of care have the potential to improve acute stroke care delivery. The current report describes the experience of implementing a county-wide system of spoke-and-hub stroke neurology receiving centers (SNRC) that incorporated several comprehensive stroke center recommendations.

METHODS

Observational study of patients with suspected stroke of <5 hours duration transported by emergency medical system personnel to an SNRC during the first year of this system.

RESULTS

A total of 1360 patients with suspected stroke were evaluated at 9 hub SNRC, of which 553 (40.7%) had a discharge diagnosis of ischemic stroke. Of these 553, intravenous tissue-type plasminogen activator was administered to 110 patients (19.9% of ischemic strokes). Care at the 6 neurointerventional-ready SNRC was a major focus in which 25.1% (99/395) of the patients with ischemic stroke received acute intravenous or intra-arterial reperfusion therapy, and in which provision of such therapies was less common with milder stroke, older age, and Hispanic origin. The door-to-needle time for intravenous tissue-type plasminogen activator met the <60-minute target in only 25% of patients and was 37% longer (P=0.0001) when SNRC were neurointerventional-ready.

CONCLUSIONS

A stroke system that incorporates features of comprehensive stroke centers can be effectively implemented with substantial rates of acute reperfusion therapy administration. Experiences potentially useful to broader implementation of comprehensive stroke centers are considered.

Adjunctive and alternative approaches to current reperfusion therapy

BACKGROUND AND PURPOSE

Current ischemic stroke reperfusion therapy consists of intravenous thrombolysis given in eligible patients after review of a noncontrast CT scan and a time-based window of opportunity. Rapid clot lysis has a strong association with clinical improvement but remains incomplete in many patients. This review appraises novel adjunctive or alternative approaches to current reperfusion strategies being tested in all trial phases. Summary of Review- Alternative approaches to current reperfusion therapy can be separated into 4 main categories: (1) combinatory approaches with other drugs or devices; (2) novel systemic thrombolytic agents; (3) endovascular medical or mechanical reperfusion treatments; and (4) noninvasive or minimally invasive methods to augment cerebral blood flow and alleviate intracranial blood flow steal.

CONCLUSIONS

Reperfusion treatments must be provided as fast as possible in patients most likely to benefit. Patients who fail to rapidly reperfuse may benefit from other strategies that maintain collateral flow or protect tissue at risk.

Does primary stroke center certification change ED diagnosis, utilization, and disposition of patients with acute stroke?

BACKGROUND AND PURPOSE

We examined the impact of primary stroke center (PSC) certification on emergency department (ED) use and outcomes within an integrated delivery system in which EDs underwent staggered certification.

METHODS

A retrospective cohort study of 30,461 patients seen in 17 integrated delivery system EDs with a primary diagnosis of transient ischemic attack (TIA), intracranial hemorrhage, or ischemic stroke between 2005 and 2008 was conducted. We compared ED stroke patient visits across hospitals for (1) temporal trends and (2) pre- and post-PSC certification-using logistic and linear regression models to adjust for comorbidities, patient characteristics, and calendar time, to examine major outcomes (ED throughput time, hospital admission, radiographic imaging utilization and throughput, and mortality) across certification stages.

RESULTS

There were 15,687 precertification ED visits and 11,040 postcertification visits. Primary stroke center certification was associated with significant changes in care processes associated with PSC certification process, including (1) ED throughput for patients with intracranial hemorrhage (55 minutes faster), (2) increased utilization of cranial magnetic resonance imaging for patients with ischemic stroke (odds ratio, 1.88; 95% confidence interval, 1.36-2.60), and (3) decrease in time to radiographic imaging for most modalities, including cranial computed tomography done within 6 hours of ED arrival (TIA: 12 minutes faster, ischemic stroke: 11 minutes faster), magnetic resonance imaging for patients with ischemic stroke (197 minutes faster), and carotid Doppler sonography for TIA patients (138 minutes faster). There were no significant changes in survival.

CONCLUSIONS

Stroke center certification was associated with significant changes in ED admission and radiographic utilization patterns, without measurable improvements in survival.