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Han JH, Jang S, Choi MO, Yoon MJ, Lim SB, Kook JR, Kang DW, Kwon SU, Kim JS, Jeon SB. Point-of-care coagulation testing for reducing in-hospital delay in thrombolysis. HONG KONG J EMERG ME 2018. [DOI: 10.1177/1024907918799938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The confirmation of prothrombin time international normalized ratio by a central laboratory often delays intravenous thrombolysis in patients with acute ischemic stroke. Objectives: We investigated the feasibility, reliability, and usefulness of point-of-care determination of prothrombin time international normalized ratio for stroke thrombolysis. Methods: Among 312 patients with ischemic stroke, 202 who arrived at the emergency room within 4.5 h of stroke onset were enrolled in the study. Patients with lost orders for point-of-care testing for the prothrombin time international normalized ratio or central laboratory testing for the prothrombin time international normalized ratio (n = 47) were excluded. We compared international normalized ratio values and the time interval from arrival to the report of test results (door-to-international normalized ratio time) between point-of-care testing for the prothrombin time international normalized ratio and central laboratory testing for the prothrombin time international normalized ratio. In patients who underwent thrombolysis, we compared the time interval from arrival to thrombolysis (door-to-needle time) between the current study population and historic cohort at our center. Results: In the 155 patients included in the study, the median door-to-international normalized ratio time was 9.0 min (interquartile range, 5.0–12.0 min) for point-of-care testing for the prothrombin time international normalized ratio and 46.0 min (interquartile range, 38.0–55.0 min) for central laboratory testing for the prothrombin time international normalized ratio (p < 0.001). The intraclass correlation coefficient between point-of-care testing for the prothrombin time international normalized ratio and central laboratory testing for the prothrombin time international normalized ratio was 0.975 (95% confidence interval: 0.966–0.982). Forty-nine of the 155 patients underwent intravenous thrombolysis. The door-to-needle time was significantly decreased after implementation of point-of-care testing for the prothrombin time international normalized ratio (median, 23.0 min; interquartile range, 16.0–29.8 vs median, 46.0 min; interquartile range, 33.5–50.5 min). Conclusion: Utilization of point-of-care testing for the prothrombin time international normalized ratio was feasible in the management of patients with acute ischemic stroke. Point-of-care testing for the prothrombin time international normalized ratio was quick and reliable and had a pivotal role in expediting thrombolysis.
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Affiliation(s)
- Jung Hee Han
- Department of Nursing, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seongsoo Jang
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi-Ok Choi
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi-Jeong Yoon
- Department of Nursing, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung-Bok Lim
- Department of Nursing, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong-Ran Kook
- Department of Nursing, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong S Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Beom Jeon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Nguyen-Huynh MN, Klingman JG, Avins AL, Rao VA, Eaton A, Bhopale S, Kim AC, Morehouse JW, Flint AC. Novel Telestroke Program Improves Thrombolysis for Acute Stroke Across 21 Hospitals of an Integrated Healthcare System. Stroke 2017; 49:133-139. [PMID: 29247142 PMCID: PMC5753819 DOI: 10.1161/strokeaha.117.018413] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 11/08/2017] [Accepted: 11/15/2017] [Indexed: 12/17/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— Faster treatment with intravenous alteplase in acute ischemic stroke is associated with better outcomes. Starting in 2015, Kaiser Permanente Northern California redesigned its acute stroke workflow across all 21 Kaiser Permanente Northern California stroke centers to (1) follow a single standardized version of a modified Helsinki model and (2) have all emergency stroke cases managed by a dedicated telestroke neurologist. We examined the effect of Kaiser Permanente Northern California’s Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke program on door-to-needle (DTN) time, alteplase use, and symptomatic intracranial hemorrhage rates. Methods— The program was introduced in a staggered fashion from September 2015 to January 2016. We compared DTN times for a seasonally adjusted 9-month period at each center before implementation to the corresponding 9-month calendar period from the start of implementation. The primary outcome was the DTN time for alteplase administration. Secondary outcomes included rate of alteplase administrations per month, symptomatic intracranial hemorrhage, and disposition at time of discharge. Results— This study included 310 patients treated with alteplase in the pre–EXpediting the PRrocess of Evaluating and Stopping Stroke period and 557 patients treated with alteplase in the EXpediting the PRrocess of Evaluating and Stopping Stroke period. After implementation, alteplase administrations increased to 62/mo from 34/mo at baseline (P<0.001). Median DTN time decreased to 34 minutes after implementation from 53.5 minutes prior (P<0.001), and DTN time of <60 minutes was achieved in 87.1% versus 61.0% (P<0.001) of patients. DTN times <30 minutes were much more common in the Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke period (40.8% versus 4.2% before implementation). There was no significant difference in symptomatic intracranial hemorrhage rates in the 2 periods (3.8% versus 2.2% before implementation; P=0.29). Conclusions— Introduction of a standardized modified Helsinki protocol across 21 hospitals using telestroke management was associated with increased alteplase administrations, significantly shorter DTN times, and no increase in adverse outcomes.
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Affiliation(s)
- Mai N Nguyen-Huynh
- From the Division of Research, Kaiser Permanente Northern California, Oakland (M.N.N.-H., A.L.A., A.C.F., A.E.); Departments of Neuroscience (A.C.F., V.A.R.) and Emergency Medicine (S.B.), Kaiser Permanente, Redwood City, CA; Departments of Neurology (M.N.N.-H., J.G.K.) and Radiology (A.C.K.), Kaiser Permanente, Walnut Creek, CA; and Department of Emergency Medicine, Kaiser Permanente, Oakland, CA (J.W.M.).
| | - Jeffrey G Klingman
- From the Division of Research, Kaiser Permanente Northern California, Oakland (M.N.N.-H., A.L.A., A.C.F., A.E.); Departments of Neuroscience (A.C.F., V.A.R.) and Emergency Medicine (S.B.), Kaiser Permanente, Redwood City, CA; Departments of Neurology (M.N.N.-H., J.G.K.) and Radiology (A.C.K.), Kaiser Permanente, Walnut Creek, CA; and Department of Emergency Medicine, Kaiser Permanente, Oakland, CA (J.W.M.)
| | - Andrew L Avins
- From the Division of Research, Kaiser Permanente Northern California, Oakland (M.N.N.-H., A.L.A., A.C.F., A.E.); Departments of Neuroscience (A.C.F., V.A.R.) and Emergency Medicine (S.B.), Kaiser Permanente, Redwood City, CA; Departments of Neurology (M.N.N.-H., J.G.K.) and Radiology (A.C.K.), Kaiser Permanente, Walnut Creek, CA; and Department of Emergency Medicine, Kaiser Permanente, Oakland, CA (J.W.M.)
| | - Vivek A Rao
- From the Division of Research, Kaiser Permanente Northern California, Oakland (M.N.N.-H., A.L.A., A.C.F., A.E.); Departments of Neuroscience (A.C.F., V.A.R.) and Emergency Medicine (S.B.), Kaiser Permanente, Redwood City, CA; Departments of Neurology (M.N.N.-H., J.G.K.) and Radiology (A.C.K.), Kaiser Permanente, Walnut Creek, CA; and Department of Emergency Medicine, Kaiser Permanente, Oakland, CA (J.W.M.)
| | - Abigail Eaton
- From the Division of Research, Kaiser Permanente Northern California, Oakland (M.N.N.-H., A.L.A., A.C.F., A.E.); Departments of Neuroscience (A.C.F., V.A.R.) and Emergency Medicine (S.B.), Kaiser Permanente, Redwood City, CA; Departments of Neurology (M.N.N.-H., J.G.K.) and Radiology (A.C.K.), Kaiser Permanente, Walnut Creek, CA; and Department of Emergency Medicine, Kaiser Permanente, Oakland, CA (J.W.M.)
| | - Sunil Bhopale
- From the Division of Research, Kaiser Permanente Northern California, Oakland (M.N.N.-H., A.L.A., A.C.F., A.E.); Departments of Neuroscience (A.C.F., V.A.R.) and Emergency Medicine (S.B.), Kaiser Permanente, Redwood City, CA; Departments of Neurology (M.N.N.-H., J.G.K.) and Radiology (A.C.K.), Kaiser Permanente, Walnut Creek, CA; and Department of Emergency Medicine, Kaiser Permanente, Oakland, CA (J.W.M.)
| | - Anne C Kim
- From the Division of Research, Kaiser Permanente Northern California, Oakland (M.N.N.-H., A.L.A., A.C.F., A.E.); Departments of Neuroscience (A.C.F., V.A.R.) and Emergency Medicine (S.B.), Kaiser Permanente, Redwood City, CA; Departments of Neurology (M.N.N.-H., J.G.K.) and Radiology (A.C.K.), Kaiser Permanente, Walnut Creek, CA; and Department of Emergency Medicine, Kaiser Permanente, Oakland, CA (J.W.M.)
| | - John W Morehouse
- From the Division of Research, Kaiser Permanente Northern California, Oakland (M.N.N.-H., A.L.A., A.C.F., A.E.); Departments of Neuroscience (A.C.F., V.A.R.) and Emergency Medicine (S.B.), Kaiser Permanente, Redwood City, CA; Departments of Neurology (M.N.N.-H., J.G.K.) and Radiology (A.C.K.), Kaiser Permanente, Walnut Creek, CA; and Department of Emergency Medicine, Kaiser Permanente, Oakland, CA (J.W.M.)
| | - Alexander C Flint
- From the Division of Research, Kaiser Permanente Northern California, Oakland (M.N.N.-H., A.L.A., A.C.F., A.E.); Departments of Neuroscience (A.C.F., V.A.R.) and Emergency Medicine (S.B.), Kaiser Permanente, Redwood City, CA; Departments of Neurology (M.N.N.-H., J.G.K.) and Radiology (A.C.K.), Kaiser Permanente, Walnut Creek, CA; and Department of Emergency Medicine, Kaiser Permanente, Oakland, CA (J.W.M.)
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3
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Kamal N, Holodinsky JK, Stephenson C, Kashayp D, Demchuk AM, Hill MD, Vilneff RL, Bugbee E, Zerna C, Newcommon N, Lang E, Knox D, Smith EE. Improving Door-to-Needle Times for Acute Ischemic Stroke: Effect of Rapid Patient Registration, Moving Directly to Computed Tomography, and Giving Alteplase at the Computed Tomography Scanner. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.116.003242. [PMID: 28096208 DOI: 10.1161/circoutcomes.116.003242] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 10/26/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The effectiveness of specific systems changes to reduce DTN (door-to-needle) time has not been fully evaluated. We analyzed the impact of 4 specific DTN time reduction strategies implemented prospectively in a staggered fashion. METHODS AND RESULTS The HASTE (Hurry Acute Stroke Treatment and Evaluation) project was implemented in 3 phases at a single academic medical center. In HASTE I (June 6, 2012 to June 5, 2013), baseline performance was analyzed. In HASTE II (June 6, 2013 to January 24, 2015), 3 changes were implemented: (1) a STAT stroke protocol to prenotify the stroke team about incoming stroke patients; (2) administering alteplase at the computed tomography (CT) scanner; and (3) registering the patient as unknown to allow immediate order entry. In HASTE III (January 25, 2015 to June 29, 2015), we implemented a process to bring the patient directly to CT on the emergency medical services stretcher. Log-transformed DTN time was modeled. Data from 350 consecutive alteplase-treated patients were analyzed. Multivariable regression showed the following factors to be significant: giving alteplase in the CT (32% decrease in DTN time, 95% confidence interval [CI] 38%-55%), stretcher to CT (30% decrease in DTN time, 95% CI 16%-42%), patient registered as unknown (12% decrease in DTN time, 95% CI 3%-20%), STAT stroke protocol (11% decrease in DTN time, 95% CI 1%-20%), and stroke severity (National Institutes of Health Stroke Scale score 6-8: 19% decrease in DTN time, 95% CI 6%-31%; National Institutes of Health Stroke Scale score >8: 27% decrease in DTN time, 95% CI 17%-37%). CONCLUSIONS Taking the patient to CT on the emergency medical services stretcher, registering the patient as unknown, STAT stroke protocol, and administering alteplase in CT are associated with lower DTN time.
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Affiliation(s)
- Noreen Kamal
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Jessalyn K Holodinsky
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Caroline Stephenson
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Devika Kashayp
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Andrew M Demchuk
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Michael D Hill
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Renee L Vilneff
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Erin Bugbee
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Charlotte Zerna
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Nancy Newcommon
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Eddy Lang
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Darren Knox
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Eric E Smith
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada.
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Ormseth CH, Sheth KN, Saver JL, Fonarow GC, Schwamm LH. The American Heart Association's Get With the Guidelines (GWTG)-Stroke development and impact on stroke care. Stroke Vasc Neurol 2017; 2:94-105. [PMID: 28959497 PMCID: PMC5600018 DOI: 10.1136/svn-2017-000092] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 04/26/2017] [Indexed: 01/06/2023] Open
Abstract
The American Heart Association’s Get With the Guidelines (GWTG)-Stroke programme has changed stroke care delivery in the USA since its establishment in 2003. GWTG is a voluntary registry and continuous quality improvement initiative that collects data on patient characteristics, hospital adherence to guidelines and inpatient outcomes. Implementation of the programme saw increased provision of evidence-based care and improved patient outcomes. This review will describe the development of the programme and discuss the impact on stroke outcomes and transformation of stroke care delivery that followed its implementation.
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Affiliation(s)
- Cora H Ormseth
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kevin N Sheth
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeffrey L Saver
- Department of Neurology, UCLA Medical Center, Los Angeles, California, USA
| | - Gregg C Fonarow
- Department of Cardiology, UCLA Medical Center, Los Angeles, California, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
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5
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Andrew BY, Stack CM, Yang JP, Dodds JA. mStroke: "Mobile Stroke"-Improving Acute Stroke Care with Smartphone Technology. J Stroke Cerebrovasc Dis 2017; 26:1449-1456. [PMID: 28434773 DOI: 10.1016/j.jstrokecerebrovasdis.2017.03.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 03/15/2017] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the effect of method and time of system activation on clinical metrics in cases utilizing the Stop Stroke (Pulsara, Inc.) mobile acute stroke care coordination application. METHODS A retrospective cohort analysis of stroke codes at 12 medical centers using Stop Stroke from March 2013 to May 2016 was performed. Comparison of metrics (door-to-needle time [DTN] and door-to-CT time [DTC], and rate of DTN ≤ 60 minutes [goal DTN]) was performed between subgroups based on method (emergency medical service [EMS] versus emergency department [ED]) and time of activation. Effects were adjusted for confounders (age, sex, National Institutes of Health Stroke Scale [NIHSS] score) using multiple linear and logistic regression. RESULTS The final dataset included 2589 cases. Cases activated by EMS were more severe (median NIHSS score 8 versus 4, P < .0001) and more likely to receive recombinant tissue plasminogen activator (20% versus 12%, P < .0001) than those with ED activation. After adjustment, cases with EMS activation had shorter DTC (6.1 minutes shorter, 95% CI [-10.3, -2]) and DTN (12.8 minutes shorter, 95% CI [-21, -4.6]) and were more likely to meet goal DTN (OR 1.83, 95% CI [1.1, 3]). Cases between 1200 and 1800 had longer DTC (7.7 minutes longer, 95% CI [2.4, 13]) and DTN (21.1 minutes longer, 95% CI [9.3, 33]), and reduced rate of goal DTN (OR .3, 95% CI [.15, .61]) compared to those between 0000 and 0600. CONCLUSIONS Incorporating real-time prehospital data obtained via smartphone technology provides unique insight into acute stroke codes. Activation of mobile electronic stroke coordination in the field appears to promote a more expedited and successful care process.
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Affiliation(s)
- Benjamin Y Andrew
- Clinical Research Training Program, Duke University School of Medicine, Durham, North Carolina
| | - Colleen M Stack
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | - Julian P Yang
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | - Jodi A Dodds
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina.
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6
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Kamal N, Sheng S, Xian Y, Matsouaka R, Hill MD, Bhatt DL, Saver JL, Reeves MJ, Fonarow GC, Schwamm LH, Smith EE. Delays in Door-to-Needle Times and Their Impact on Treatment Time and Outcomes in Get With The Guidelines-Stroke. Stroke 2017; 48:946-954. [DOI: 10.1161/strokeaha.116.015712] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/22/2016] [Accepted: 01/13/2017] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Despite quality improvement programs such as the American Heart Association/American Stroke Association Target Stroke initiative, a substantial portion of acute ischemic stroke patients are still treated with tissue-type plasminogen activator (alteplase) later than 60 minutes from arrival. This study aims to describe the documented reasons for delays and the associations between reasons for delays and patient outcomes.
Methods—
We analyzed the characteristics of 55 296 patients who received intravenous alteplase in 1422 hospitals participating in Get With The Guidelines-Stroke from October 2012 to April 2015, excluding transferred patients and inpatient strokes. We assessed eligibility, medical, and hospital reasons for delays in door-to-needle time.
Results—
There were 27 778 patients (50.2%) treated within 60 minutes, 10 086 patients (18.2%) treated >60 minutes without documented delays, and 17 432 patients (31.5%) treated >60 minutes with one or more documented reasons for delay. Delayed door-to-needle times were associated with delayed diagnosis (36 minutes longer than those without delay in diagnosis) and hypoglycemia or seizure (34 minutes longer than without those conditions). The presence of documented delays was associated with higher odds of in-hospital mortality (odds ratio, 1.2; 95% confidence interval, 1.1–1.3) and symptomatic intracranial hemorrhage (odds ratio, 1.2; 95% confidence interval, 1.1–1.3) and lower odds of independent ambulation at discharge (odds ratio, 0.92; 95% confidence interval, 0.9–1.0) after adjusting for patient and hospital characteristics.
Conclusions—
Hospital and eligibility delays such as delay diagnosis and inability to determine eligibility were associated with longer door-to-needle times. Improved stroke recognition and management of acute comorbidities may help to reduce door-to-needle times.
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Affiliation(s)
- Noreen Kamal
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Shubin Sheng
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Ying Xian
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Roland Matsouaka
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Michael D. Hill
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Deepak L. Bhatt
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Jeffrey L. Saver
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Mathew J. Reeves
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Gregg C. Fonarow
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Lee H. Schwamm
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Eric E. Smith
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
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7
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Lapchak PA, Zhang JH. The High Cost of Stroke and Stroke Cytoprotection Research. Transl Stroke Res 2016; 8:307-317. [PMID: 28039575 DOI: 10.1007/s12975-016-0518-y] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 12/18/2016] [Accepted: 12/21/2016] [Indexed: 10/20/2022]
Abstract
Acute ischemic stroke is inadequately treated in the USA and worldwide due to a lengthy history of neuroprotective drug failures in clinical trials. The majority of victims must endure life-long disabilities that not only affect their livelihood, but also have an enormous societal economic impact. The rapid development of a neuroprotective or cytoprotective compound would allow future stroke victims to receive a treatment to reduce disabilities and further promote recovery of function. This opinion article reviews in detail the enormous costs associated with developing a small molecule to treat stroke, as well as providing a timely overview of the cell-death time-course and relationship to the ischemic cascade. Distinct temporal patterns of cell-death of neurovascular unit components provide opportunities to intervene and optimize new cytoprotective strategies. However, adequate research funding is mandatory to allow stroke researchers to develop and test their novel therapeutic approach to treat stroke victims.
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Affiliation(s)
- Paul A Lapchak
- Director of Translational Research, Department of Neurology & Neurosurgery, Advanced Health Sciences Pavilion, Suite 8305, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, Los Angeles, CA, 90048, USA.
| | - John H Zhang
- Director, Center for Neuroscience Research, Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, CA, 92350, USA
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8
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Zuckerman SL, Magarik JA, Espaillat KB, Ganesh Kumar N, Bhatia R, Dewan MC, Morone PJ, Hermann LD, O'Duffy AE, Riebau DA, Kirshner HS, Mocco J. Implementation of an institution-wide acute stroke algorithm: Improving stroke quality metrics. Surg Neurol Int 2016; 7:S1041-S1048. [PMID: 28144480 PMCID: PMC5234297 DOI: 10.4103/2152-7806.196366] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 09/29/2016] [Indexed: 12/03/2022] Open
Abstract
Background: In May 2012, an updated stroke algorithm was implemented at Vanderbilt University Medical Center. The current study objectives were to: (1) describe the process of implementing a new stroke algorithm and (2) compare pre- and post-algorithm quality improvement (QI) metrics, specificaly door to computed tomography time (DTCT), door to neurology time (DTN), and door to tPA administration time (DTT). Methods: Our institutional stroke algorithm underwent extensive revision, with a focus on removing variability, streamlining care, and improving time delays. The updated stroke algorithm was implemented in May 2012. Three primary stroke QI metrics were evaluated over four separate 3-month time points, one pre- and three post-algorithm periods. Results: The following data points improved after algorithm implementation: average DTCT decreased from 39.9 to 12.8 min (P < 0.001); average DTN decreased from 34.1 to 8.2 min (P ≤ 0.001), and average DTT decreased from 62.5 to 43.5 min (P = 0.17). Conclusion: A new stroke protocol that prioritized neurointervention at our institution resulted in significant lowering in the DTCT and DTN, with a nonsignificant improvement in DTT.
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Affiliation(s)
- Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jordan A Magarik
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Kiersten B Espaillat
- Vanderbilt Comprehensive Stroke Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Nishant Ganesh Kumar
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Ritwik Bhatia
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Michael C Dewan
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Peter J Morone
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Lisa D Hermann
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Anne E O'Duffy
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Derek A Riebau
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Howard S Kirshner
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - J Mocco
- Department of Neurosurgery, Mt. Sinai School of Medicine, New York, USA
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9
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Metts EL, Bailey AM, Weant KA, Justice SB. Identification of Rate-Limiting Steps in the Provision of Thrombolytics for Acute Ischemic Stroke. J Pharm Pract 2016; 30:606-611. [DOI: 10.1177/0897190016674408] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Tissue plasminogen activator (tPA) is the only pharmacotherapy shown to improve outcomes in acute ischemic stroke. The American Heart Association (AHA) recommends a door-to-needle (DTN) time of <60 minutes in at least 50% of patients presenting with acute ischemic stroke. Objective: The purpose of this study was to analyze the possible barriers that may delay tPA administration within the emergency department (ED) of an academic medical center. Methods: A retrospective chart review was conducted from February 2011 to October 2013. Patients were included if they were admitted through the ED with a diagnosis of acute ischemic stroke and received tPA. Results: Of the 130 patients who met inclusion criteria, 43.1% received tPA in ≤60 minutes. Several factors were identified to be significantly different in those with a DTN time of >60 minutes—time to ED physician consultation, neurologist arrival, blood sample acquisition, and result time ( P < .05 for all comparisons). Correlation analysis demonstrated several independent variables associated with DTN time of ≤60 minutes—time from admission to ED physician consultation, receipt of computed tomography (CT) scan, blood sample acquisition, laboratory results, and neurology service arrival ( P < .05 for all comparisons). Conclusion: The findings from this study highlight the importance of prompt physician evaluation, direct transfer to the CT scanner, and a quick turnaround time on laboratory values. The development of protocols to ensure the rapid receipt of tPA therapy should focus on limiting any potential delay these steps may cause.
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Affiliation(s)
- Elise L. Metts
- Pharmacy Department, St Rose Dominican Hospitals, Henderson, NV, USA
| | - Abby M. Bailey
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| | - Kyle A. Weant
- Pharmacy Services, Medical University of South Carolina, Charleston, SC, USA
| | - Stephanie B. Justice
- Clinical Pharmacy Services, St Claire Regional Medical Center, Morehead, KY, USA
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10
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Choi PMC, Desai JA, Kashyap D, Stephenson C, Kamal N, Vogt S, Bohm V, Suddes M, Bugbee E, Hill MD, Demchuk AM, Smith EE. Are All Stroke Patients Eligible for Fast Alteplase Treatment? An Analysis of Unavoidable Delays. Acad Emerg Med 2016; 23:393-9. [PMID: 26824684 DOI: 10.1111/acem.12914] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 09/17/2015] [Accepted: 10/22/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The National Quality Forum recently endorsed a performance measure for time to intravenous thrombolytic therapy which allows exclusions for circumstances in which fast alteplase treatment may not be possible. However, the frequency and impact of unavoidable patient reasons for long door-to-needle time (DNT), such as need for medical stabilization, are largely unknown in clinical practice. As part of the Hurry Acute Stroke Treatment and Evaluation-2 (HASTE-2) project, we sought to identify patient and systems reasons associated with longer DNT. METHODS From June 2012 to June 2013 we collected data on DNT and potential reasons for delays from 102 consecutive patients presenting directly to the emergency department who were treated with alteplase within 4.5 hours of symptom onset. RESULTS Mean age was 71 years, 56/113 (54%) were women, median NIH Stroke Scale score was 13, and median DNT was 53 minutes. Potential delays were noted in 59/102 (58%), of which 31/102 (31%) were unavoidable patient-related or eligibility reasons. Median DNT was longer when patient-related or eligibility reasons for delay were present (60 minutes) than when absent (45 minutes, p = 0.005). Multivariable modeling showed that need for urgent medical stabilization, presentation with seizure and inability to confirm eligibility were associated with 35%-50% longer DNT times. CONCLUSIONS Up to 31% of patients have delays due to medical or eligibility-related causes that may be legitimate reasons for providing alteplase later than the benchmark time of 60 minutes.
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Affiliation(s)
- Philip M. C. Choi
- Calgary Stroke Program; Department of Clinical Neurosciences; University of Calgary and Alberta Health Services; Calgary Alberta Canada
| | - Jamsheed A. Desai
- Calgary Stroke Program; Department of Clinical Neurosciences; University of Calgary and Alberta Health Services; Calgary Alberta Canada
| | - Devika Kashyap
- Calgary Stroke Program; Department of Clinical Neurosciences; University of Calgary and Alberta Health Services; Calgary Alberta Canada
| | - Caroline Stephenson
- Calgary Stroke Program; Department of Clinical Neurosciences; University of Calgary and Alberta Health Services; Calgary Alberta Canada
| | - Noreen Kamal
- Calgary Stroke Program; Department of Clinical Neurosciences; University of Calgary and Alberta Health Services; Calgary Alberta Canada
| | - Sheldon Vogt
- Calgary Stroke Program; Department of Clinical Neurosciences; University of Calgary and Alberta Health Services; Calgary Alberta Canada
| | - Victoria Bohm
- Calgary Stroke Program; Department of Clinical Neurosciences; University of Calgary and Alberta Health Services; Calgary Alberta Canada
| | - Michael Suddes
- Calgary Stroke Program; Department of Clinical Neurosciences; University of Calgary and Alberta Health Services; Calgary Alberta Canada
| | - Erin Bugbee
- Department of Emergency Medicine; Foothills Medical Centre; Alberta Health Services; Calgary Alberta Canada
| | - Michael D. Hill
- Calgary Stroke Program; Department of Clinical Neurosciences; University of Calgary and Alberta Health Services; Calgary Alberta Canada
- Hotchkiss Brain Institute; University of Calgary; Calgary Alberta Canada
- Department of Community Health Sciences; University of Calgary; Calgary Alberta Canada
- Department of Medicine; University of Calgary; Calgary Alberta Canada
- Department of Radiology; University of Calgary; Calgary Alberta Canada
| | - Andrew M. Demchuk
- Calgary Stroke Program; Department of Clinical Neurosciences; University of Calgary and Alberta Health Services; Calgary Alberta Canada
- Hotchkiss Brain Institute; University of Calgary; Calgary Alberta Canada
- Department of Radiology; University of Calgary; Calgary Alberta Canada
| | - Eric E. Smith
- Calgary Stroke Program; Department of Clinical Neurosciences; University of Calgary and Alberta Health Services; Calgary Alberta Canada
- Hotchkiss Brain Institute; University of Calgary; Calgary Alberta Canada
- Department of Community Health Sciences; University of Calgary; Calgary Alberta Canada
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11
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Loorak MH, Perin C, Kamal N, Hill M, Carpendale S. TimeSpan: Using Visualization to Explore Temporal Multi-dimensional Data of Stroke Patients. IEEE TRANSACTIONS ON VISUALIZATION AND COMPUTER GRAPHICS 2016; 22:409-418. [PMID: 26390482 DOI: 10.1109/tvcg.2015.2467325] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
We present TimeSpan, an exploratory visualization tool designed to gain a better understanding of the temporal aspects of the stroke treatment process. Working with stroke experts, we seek to provide a tool to help improve outcomes for stroke victims. Time is of critical importance in the treatment of acute ischemic stroke patients. Every minute that the artery stays blocked, an estimated 1.9 million neurons and 12 km of myelinated axons are destroyed. Consequently, there is a critical need for efficiency of stroke treatment processes. Optimizing time to treatment requires a deep understanding of interval times. Stroke health care professionals must analyze the impact of procedures, events, and patient attributes on time-ultimately, to save lives and improve quality of life after stroke. First, we interviewed eight domain experts, and closely collaborated with two of them to inform the design of TimeSpan. We classify the analytical tasks which a visualization tool should support and extract design goals from the interviews and field observations. Based on these tasks and the understanding gained from the collaboration, we designed TimeSpan, a web-based tool for exploring multi-dimensional and temporal stroke data. We describe how TimeSpan incorporates factors from stacked bar graphs, line charts, histograms, and a matrix visualization to create an interactive hybrid view of temporal data. From feedback collected from domain experts in a focus group session, we reflect on the lessons we learned from abstracting the tasks and iteratively designing TimeSpan.
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12
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Lippman JM, Smith SNC, McMurry TL, Sutton ZG, Gunnell BS, Cote J, Perina DG, Cattell-Gordon DC, Rheuban KS, Solenski NJ, Worrall BB, Southerland AM. Mobile Telestroke During Ambulance Transport Is Feasible in a Rural EMS Setting: The iTREAT Study. Telemed J E Health 2015; 22:507-13. [PMID: 26600433 DOI: 10.1089/tmj.2015.0155] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The use of telemedicine in the diagnosis and treatment of acute stroke, or telestroke, is a well-accepted method of practice improving geographic disparities in timely access to neurological expertise. We propose that mobile telestroke assessment during ambulance transport is feasible using low-cost, widely available technology. MATERIALS AND METHODS We designed a platform including a tablet-based end point, high-speed modem with commercial wireless access, external antennae, and portable mounting apparatus. Mobile connectivity testing was performed along six primary ambulance routes in a rural network. Audiovisual (AV) quality was assessed simultaneously by both an in-vehicle and an in-hospital rater using a standardized 6-point rating scale (≥4 indicating feasibility). We sought to achieve 9 min of continuous AV connectivity presumed sufficient to perform mobile telestroke assessments. RESULTS Thirty test runs were completed: 93% achieved a minimum of 9 min of continuous video transmission with a mean mobile connectivity time of 18 min. Mean video and audio quality ratings were 4.51 (4.54 vehicle; 4.48 hospital) and 5.00 (5.13 in-vehicle; 4.87 hospital), respectively. Total initial cost of the system was $1,650 per ambulance. CONCLUSIONS In this small, single-centered study we maintained high-quality continuous video transmission along primary ambulance corridors using a low-cost mobile telemedicine platform. The system is designed to be portable and adaptable, with generalizability for rapid assessment of emergency conditions in which direct observational exam may improve prehospital diagnosis and treatment. Thus mobile telestroke assessment is feasible using low-cost components and commercial wireless connectivity. More research is needed to demonstrate clinical reliability and efficacy in a live-patient setting.
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Affiliation(s)
- Jason M Lippman
- 1 Department of Neurology, University of Virginia Health System , Charlottesville, Virginia
| | - Sherita N Chapman Smith
- 2 Department of Neurology, Virginia Commonwealth University Health System , Richmond, Virginia
| | - Timothy L McMurry
- 3 Department of Public Health Sciences, University of Virginia Health System , Charlottesville, Virginia
| | - Zachary G Sutton
- 4 The Brody School of Medicine, East Carolina University , Greenville, North Carolina
| | - Brian S Gunnell
- 5 Department of Center for Telehealth, University of Virginia Health System , Charlottesville, Virginia
| | - Jack Cote
- 1 Department of Neurology, University of Virginia Health System , Charlottesville, Virginia
| | - Debra G Perina
- 6 Department of Emergency Medicine, University of Virginia Health System , Charlottesville, Virginia
| | - David C Cattell-Gordon
- 5 Department of Center for Telehealth, University of Virginia Health System , Charlottesville, Virginia
| | - Karen S Rheuban
- 5 Department of Center for Telehealth, University of Virginia Health System , Charlottesville, Virginia
| | - Nina J Solenski
- 1 Department of Neurology, University of Virginia Health System , Charlottesville, Virginia
| | - Bradford B Worrall
- 1 Department of Neurology, University of Virginia Health System , Charlottesville, Virginia.,3 Department of Public Health Sciences, University of Virginia Health System , Charlottesville, Virginia
| | - Andrew M Southerland
- 1 Department of Neurology, University of Virginia Health System , Charlottesville, Virginia.,3 Department of Public Health Sciences, University of Virginia Health System , Charlottesville, Virginia
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13
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Lapchak PA. Critical early thrombolytic and endovascular reperfusion therapy for acute ischemic stroke victims: a call for adjunct neuroprotection. Transl Stroke Res 2015; 6:345-54. [PMID: 26314402 PMCID: PMC4568436 DOI: 10.1007/s12975-015-0419-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 08/06/2015] [Indexed: 12/28/2022]
Abstract
Today, there is an enormous amount of excitement in the field of stroke victim care due to the recent success of MR. CLEAN, SWIFT PRIME, ESCAPE, EXTEND-IA, and REVASCAT endovascular trials. Successful intravenous (IV) recombinant tissue plasminogen activator (rt-PA) clinical trials [i.e., National Institute of Neurological Disorders and Stroke (NINDS) rt-PA trial, Third European Cooperative Acute Stroke Study (ECASSIII), and Third International Stroke study (IST-3)] also need to be emphasized. In the recent endovascular and thrombolytic trials, there is statistically significant improvement using both the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Score (mRS) scale, but neither approach promotes complete recovery in patients enrolled within any particular NIHSS or mRS score tier. Absolute improvement (mRS 0-2 at 90 days) with endovascular therapy is 13.5-31 %, whereas thrombolytics alone also significantly improve patient functional independence, but to a lesser degree (NINDS rt-PA trial 13 %). This article has 3 main goals: (1) first to emphasize the utility and cost-effectiveness of rt-PA to treat stroke; (2) second to review the recent endovascular trials with respect to efficacy, safety, and cost-effectiveness as a stroke treatment; and (3) to further consider and evaluate strategies to develop novel neuroprotective drugs. A thesis will be put forth so that future stroke trials and therapy development can optimally promote recovery so that stroke victims can return to "normal" life.
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Affiliation(s)
- Paul A Lapchak
- Department of Neurology & Neurosurgery, Cedars-Sinai Medical Center Advanced Healthcare Science Pavilion, 127 S. San Vicente Blvd., Suite 8305, Los Angeles, CA, 90048, USA,
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14
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Wireklint Sundström B, Herlitz J, Hansson PO, Brink P. Comparison of the university hospital and county hospitals in western Sweden to identify potential weak links in the early chain of care for acute stroke: results of an observational study. BMJ Open 2015; 5:e008228. [PMID: 26351184 PMCID: PMC4563274 DOI: 10.1136/bmjopen-2015-008228] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE To identify weak links in the early chain of care for acute stroke. SETTING 9 emergency hospitals in western Sweden, each with a stroke unit, and the emergency medical services (EMS). PARTICIPANTS All patients hospitalised with a first and a final diagnosis of stroke-between 15 December 2010 and 15 April 2011. The university hospital in the city of Gothenburg was compared with 6 county hospitals. PRIMARY AND SECONDARY MEASURES: (1) The system delay, that is, median delay time from call to the EMS until diagnosis was designated as the primary end point. Secondary end points were: (2) the system delay time from call to the EMS until arrival in a hospital ward, (3) the use of the EMS, (4) priority at the dispatch centre and (5) suspicion of stroke by the EMS nurse. RESULTS In all, 1376 acute patients with stroke (median age 79 years; 49% women) were included. The median system delay from call to the EMS until (1) diagnosis (CT scan) and (2) arrival in a hospital ward was 3 h and 52 min and 4 h and 22 min, respectively. The system delay (1) was significantly shorter in county hospitals. (3) The study showed that 76% used the EMS (Gothenburg 71%; the county 79%; p<0.0001). (4) Priority 1 was given at the dispatch centre in 54% of cases. (5) Stroke was suspected in 65% of cases. A prenotification was sent in 32% (Gothenburg 52%; the county 20%; p<0.0001). CONCLUSIONS System delay is still long and only a small fraction of patients received thrombolysis. Three of four used the EMS (more frequent in the county). They were given the highest priority at the dispatch centre in half of the cases. Stroke was suspected in two-thirds of the cases, but a prenotification was seldom sent to the hospital.
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Affiliation(s)
- Birgitta Wireklint Sundström
- Faculty of Caring Science, Work Life and Social Welfare, Research Centre PreHospen, University of Borås, The Prehospital Research Centre of Western Sweden, Borås, Sweden
| | - Johan Herlitz
- Faculty of Caring Science, Work Life and Social Welfare, Research Centre PreHospen, University of Borås, The Prehospital Research Centre of Western Sweden, Borås, Sweden
| | - Per Olof Hansson
- Department of Molecular and Clinical Medicine/Cardiology, Sahlgrenska Academy, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Peter Brink
- Emergency Medical Service System, NU-Hospital Organisation,Trollhättan, Sweden
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15
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Fargen KM, Jauch E, Khatri P, Baxter B, Schirmer CM, Turk AS, Mocco J. Needed dialog: regionalization of stroke systems of care along the trauma model. Stroke 2015; 46:1719-26. [PMID: 25931466 DOI: 10.1161/strokeaha.114.008167] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 03/26/2015] [Indexed: 01/01/2023]
Affiliation(s)
- Kyle M Fargen
- Department of Neurosurgery, University of Florida, Gainesville (K.M.F.); Departments of Emergency Medicine (E.J.) and Radiology (A.S.T.), Medical University of South Carolina, Charleston; Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, OH (P.K.); Department of Radiology, Erlanger Health System, Chattanooga, TN (B.B.); Department of Neurosurgery, Geisinger Health System, Danville, PA (C.M.S.); and Department of Neurosurgery, Mount Sinai Medical Center, New York (J.M.).
| | - Edward Jauch
- Department of Neurosurgery, University of Florida, Gainesville (K.M.F.); Departments of Emergency Medicine (E.J.) and Radiology (A.S.T.), Medical University of South Carolina, Charleston; Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, OH (P.K.); Department of Radiology, Erlanger Health System, Chattanooga, TN (B.B.); Department of Neurosurgery, Geisinger Health System, Danville, PA (C.M.S.); and Department of Neurosurgery, Mount Sinai Medical Center, New York (J.M.)
| | - Pooja Khatri
- Department of Neurosurgery, University of Florida, Gainesville (K.M.F.); Departments of Emergency Medicine (E.J.) and Radiology (A.S.T.), Medical University of South Carolina, Charleston; Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, OH (P.K.); Department of Radiology, Erlanger Health System, Chattanooga, TN (B.B.); Department of Neurosurgery, Geisinger Health System, Danville, PA (C.M.S.); and Department of Neurosurgery, Mount Sinai Medical Center, New York (J.M.)
| | - Blaise Baxter
- Department of Neurosurgery, University of Florida, Gainesville (K.M.F.); Departments of Emergency Medicine (E.J.) and Radiology (A.S.T.), Medical University of South Carolina, Charleston; Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, OH (P.K.); Department of Radiology, Erlanger Health System, Chattanooga, TN (B.B.); Department of Neurosurgery, Geisinger Health System, Danville, PA (C.M.S.); and Department of Neurosurgery, Mount Sinai Medical Center, New York (J.M.)
| | - Clemens M Schirmer
- Department of Neurosurgery, University of Florida, Gainesville (K.M.F.); Departments of Emergency Medicine (E.J.) and Radiology (A.S.T.), Medical University of South Carolina, Charleston; Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, OH (P.K.); Department of Radiology, Erlanger Health System, Chattanooga, TN (B.B.); Department of Neurosurgery, Geisinger Health System, Danville, PA (C.M.S.); and Department of Neurosurgery, Mount Sinai Medical Center, New York (J.M.)
| | - Aquilla S Turk
- Department of Neurosurgery, University of Florida, Gainesville (K.M.F.); Departments of Emergency Medicine (E.J.) and Radiology (A.S.T.), Medical University of South Carolina, Charleston; Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, OH (P.K.); Department of Radiology, Erlanger Health System, Chattanooga, TN (B.B.); Department of Neurosurgery, Geisinger Health System, Danville, PA (C.M.S.); and Department of Neurosurgery, Mount Sinai Medical Center, New York (J.M.)
| | - J Mocco
- Department of Neurosurgery, University of Florida, Gainesville (K.M.F.); Departments of Emergency Medicine (E.J.) and Radiology (A.S.T.), Medical University of South Carolina, Charleston; Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, OH (P.K.); Department of Radiology, Erlanger Health System, Chattanooga, TN (B.B.); Department of Neurosurgery, Geisinger Health System, Danville, PA (C.M.S.); and Department of Neurosurgery, Mount Sinai Medical Center, New York (J.M.)
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16
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Dombrowski SU, White M, Mackintosh JE, Gellert P, Araujo-Soares V, Thomson RG, Rodgers H, Ford GA, Sniehotta FF. The stroke 'Act FAST' campaign: remembered but not understood? Int J Stroke 2015; 10:324-30. [PMID: 25130981 DOI: 10.1111/ijs.12353] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 06/12/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND The stroke awareness raising campaign 'Act FAST' (Face, Arms, Speech: Time to call Emergency Medical Services) has been rolled out in multiple waves in England, but impact on stroke recognition and response remains unclear. PURPOSE The purpose of this study was to test whether providing knowledge of the FAST acronym through a standard Act FAST campaign leaflet increases accurate recognition and response in stroke-based scenario measures. METHODS This is a population-based, cross-sectional survey of adults in Newcastle upon Tyne, UK, sampled using the electoral register, with individuals randomized to receive a questionnaire and Act FAST leaflet (n = 2500) or a questionnaire only (n = 2500) in 2012. Campaign message retention, stroke recognition, and response measured through 16 scenario-based vignettes were assessed. Data were analyzed in 2013. RESULTS Questionnaire return rate was 32.3% (n = 1615). No differences were found between the leaflet and no-leaflet groups in return rate or demographics. Participants who received a leaflet showed better campaign recall (75.7% vs. 68.2%, P = 0.003) and recalled more FAST mnemonic elements (66.1% vs. 45.3% elements named correctly, P < 0.001). However, there were no between-group differences for stroke recognition and response to stroke-based scenarios (P > 0.05). CONCLUSIONS Despite greater levels of recall of specific 'Act FAST' elements among those receiving the Act FAST leaflet, there was no impact on stroke recognition and response measures.
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Affiliation(s)
- Stephan U Dombrowski
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK; School of Natural Sciences, University of Stirling, Stirling, UK
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17
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Boudreau DM, Guzauskas GF, Chen E, Lalla D, Tayama D, Fagan SC, Veenstra DL. Cost-Effectiveness of Recombinant Tissue-Type Plasminogen Activator Within 3 Hours of Acute Ischemic Stroke. Stroke 2014; 45:3032-9. [DOI: 10.1161/strokeaha.114.005852] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Despite the availability of results from multiple newer clinical trials and changing healthcare costs, the cost-effectiveness of recombinant tissue-type plasminogen activator (r-tPA) for treatment of acute ischemic stroke within 0 to 3 hours of symptom onset was last evaluated in 1998 for the United States Using current evidence, we evaluate the long-term cost-effectiveness of r-tPA administered 0 to 3 hours after acute ischemic stroke onset versus no r-tPA.
Methods—
A disease-based decision model to project lifetime outcomes of patients after acute ischemic stroke by r-tPA treatment status from the US payer perspective was developed. Model inputs were derived from a recent meta-analysis of r-tPA trials, cohort studies, and health state preference studies. Cost data, inflated to 2013 dollars, were based on drug wholesale acquisition cost and the literature. To compare r-tPA to no r-tPA, we calculated incremental total direct costs, incremental quality-adjusted life years, and incremental cost-effectiveness ratios. We performed 1-way and probabilistic sensitivity analyses to evaluate uncertainty in the results.
Results—
r-tPA resulted in a gain of 0.39 quality-adjusted life years (95% confidence range, 0.16–0.66) on average per patient and a lifetime cost-saving of $25 000 (95% confidence range, −$42 500 to −$11 000) compared with no r-tPA. In probabilistic sensitivity analyses, r-tPA was dominant compared with no r-tPA in ≈100% of simulations. The model was sensitive to inputs for r-tPA efficacy, healthcare costs for disabled patients, mortality rates for disabled and nondisabled patients, and quality of life estimates.
Conclusions—
Our analysis supports earlier economic evaluations that r-tPA is a cost-effective method to treat stroke. Appropriate use of r-tPA should be prioritized nationally.
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Affiliation(s)
- Denise M. Boudreau
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Gregory F. Guzauskas
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Er Chen
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Deepa Lalla
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Darren Tayama
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Susan C. Fagan
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - David L. Veenstra
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
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18
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van Dishoeck AM, Dippel DWJ, Dirks M, Looman CWN, Mackenbach JP, Steyerberg EW. Measuring Quality Improvement in Acute Ischemic Stroke Care: Interrupted Time Series Analysis of Door-to-Needle Time. Cerebrovasc Dis Extra 2014; 4:149-55. [PMID: 25076959 PMCID: PMC4105950 DOI: 10.1159/000363535] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 05/08/2014] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND In patients with acute ischemic stroke, early treatment with recombinant tissue plasminogen activator (rtPA) improves functional outcome by effectively reducing disability and dependency. Timely thrombolysis, within 1 h, is a vital aspect of acute stroke treatment, and is reflected in the widely used performance indicator 'door-to-needle time' (DNT). DNT measures the time from the moment the patient enters the emergency department until he/she receives intravenous rtPA. The purpose of the study was to measure quality improvement from the first implementation of thrombolysis in stroke patients in a university hospital in the Netherlands. We further aimed to identify specific interventions that affect DNT. METHODS We included all patients with acute ischemic stroke consecutively admitted to a large university hospital in the Netherlands between January 2006 and December 2012, and focused on those treated with thrombolytic therapy on admission. Data were collected routinely for research purposes and internal quality measurement (the Erasmus Stroke Study). We used a retrospective interrupted time series design to study the trend in DNT, analyzed by means of segmented regression. RESULTS Between January 2006 and December 2012, 1,703 patients with ischemic stroke were admitted and 262 (17%) were treated with rtPA. Patients treated with thrombolysis were on average 63 years old at the time of the stroke and 52% were male. Mean age (p = 0.58) and sex distribution (p = 0.98) did not change over the years. The proportion treated with thrombolysis increased from 5% in 2006 to 22% in 2012. In 2006, none of the patients were treated within 1 h. In 2012, this had increased to 81%. In a logistic regression analysis, this trend was significant (OR 1.6 per year, CI 1.4-1.8). The median DNT was reduced from 75 min in 2006 to 45 min in 2012 (p < 0.001 in a linear regression model). In this period, a 12% annual decrease in DNT was achieved (CI from 16 to 8%). We could not find a significant association between any specific intervention and the trend in DNT. CONCLUSION AND IMPLICATIONS The DNT steadily improved from the first implementation of thrombolysis. Specific explanations for this improvement require further study, and may relate to the combined impact of a series of structural and logistic interventions. Our results support the use of performance measures for internal communication. Median DNT should be used on a monthly or quarterly basis to inform all professionals treating stroke patient of their achievements.
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Affiliation(s)
- Anne Margreet van Dishoeck
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Maaike Dirks
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Caspar W N Looman
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Johan P Mackenbach
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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19
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Lapchak PA. Fast neuroprotection (fast-NPRX) for acute ischemic stroke victims: the time for treatment is now. Transl Stroke Res 2013; 4:704-9. [PMID: 24323424 DOI: 10.1007/s12975-013-0303-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 10/23/2013] [Indexed: 01/25/2023]
Affiliation(s)
- Paul A Lapchak
- Department of Neurology and Neurosurgery, Cedars-Sinai Medical Center, Advanced Health Sciences Pavilion, Rm 8305, 127 S. San Vicente Blvd, Los Angeles, CA, 90048, USA,
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