1
|
Hasnain MG, Attia JR, Akter S, Rahman T, Hall A, Hubbard IJ, Levi CR, Paul CL. Effectiveness of interventions to improve rates of intravenous thrombolysis using behaviour change wheel functions: a systematic review and meta-analysis. Implement Sci 2020; 15:98. [PMID: 33148294 PMCID: PMC7641813 DOI: 10.1186/s13012-020-01054-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 10/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite being one of the few evidence-based treatments for acute ischemic stroke, intravenous thrombolysis has low implementation rates-mainly due to a narrow therapeutic window and the health system changes required to deliver it within the recommended time. This systematic review and meta-analyses explores the differential effectiveness of intervention strategies aimed at improving the rates of intravenous thrombolysis based on the number and type of behaviour change wheel functions employed. METHOD The following databases were searched: MEDLINE, EMBASE, PsycINFO, CINAHL and SCOPUS. Multiple authors independently completed study selection and extraction of data. The review included studies that investigated the effects of intervention strategies aimed at improving the rates of intravenous thrombolysis and/or onset-to-needle, onset-to-door and door-to-needle time for thrombolysis in patients with acute ischemic stroke. Interventions were coded according to the behaviour change wheel nomenclature. Study quality was assessed using the QualSyst scoring system for quantitative research methodologies. Random effects meta-analyses were used to examine effectiveness of interventions based on the behaviour change wheel model in improving rates of thrombolysis, while meta-regression was used to examine the association between the number of behaviour change wheel intervention strategies and intervention effectiveness. RESULTS Results from 77 studies were included. Five behaviour change wheel interventions, 'Education', 'Persuasion', 'Training', 'Environmental restructuring' and 'Enablement', were found to be employed among the included studies. Effects were similar across all intervention approaches regardless of type or number of behaviour change wheel-based strategies employed. High heterogeneity (I2 > 75%) was observed for all the pooled analyses. Publication bias was also identified. CONCLUSION There was no evidence for preferring one type of behaviour change intervention strategy, nor for including multiple strategies in improving thrombolysis rates. However, the study results should be interpreted with caution, as they display high heterogeneity and publication bias.
Collapse
Affiliation(s)
- Md Golam Hasnain
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
| | - John R. Attia
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
- John Hunter Hospital, New Lambton Heights, New South Wales Australia
| | - Shahinoor Akter
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Department of Anthropology, Jagannath University, Dhaka, Bangladesh
| | - Tabassum Rahman
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Centre for Development, Economics and Sustainability, Monash University, Melbourne, Victoria Australia
| | - Alix Hall
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
| | - Isobel J. Hubbard
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
| | - Christopher R. Levi
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, New South Wales Australia
| | - Christine L. Paul
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
| |
Collapse
|
2
|
Factors delaying intravenous thrombolytic therapy in acute ischaemic stroke: a systematic review of the literature. J Neurol 2020; 268:2723-2734. [PMID: 32206899 DOI: 10.1007/s00415-020-09803-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND/AIMS This review examined factors that delay thrombolysis and what management strategies are currently employed to minimise this delay, with the aim of suggesting future directions to overcome bottlenecks in treatment delivery. METHODS A systematic review was performed according to PRISMA guidelines. The search strategy included a combination of synonyms and controlled vocabularies from Medical Subject Headings (MeSH) and EmTree covering brain ischemia, cerebrovascular accident, fibrinolytic therapy and Alteplase. The search was conducted using Medline (OVID), Embase (OVID), PubMed and Cochrane Library databases using truncations and Boolean operators. The literature search excluded review articles, trial protocols, opinion pieces and case reports. Inclusion criteria were: (1) The article directly related to thrombolysis in ischaemic stroke, and (2) The article examined at least one factor contributing to delay in thrombolytic therapy. RESULTS One hundred and fifty-two studies were included. Pre-hospital factors resulted in the greatest delay to thrombolysis administration. In-hospital factors relating to assessment, imaging and thrombolysis administration also contributed. Long onset-to-needle times were more common in those with atypical, or less severe, symptoms, the elderly, patients from lower socioeconomic backgrounds, and those living alone. Various strategies currently exist to reduce delays. Processes which have achieved the greatest improvements in time to thrombolysis are those which integrate out-of-hospital and in-hospital processes, such as the Helsinki model. CONCLUSION Further integrated processes are required to maximise patient benefit from thrombolysis. Expansion of community education to incorporate less common symptoms and provision of alert pagers for patients may provide further reduction in thrombolysis times.
Collapse
|
3
|
Schlemm L, Schlemm E, Nolte CH, Endres M. Pre-hospital Triage of Acute Ischemic Stroke Patients-Importance of Considering More Than Two Transport Options. Front Neurol 2019; 10:437. [PMID: 31114538 PMCID: PMC6503645 DOI: 10.3389/fneur.2019.00437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 04/10/2019] [Indexed: 01/01/2023] Open
Abstract
Background: Patients with acute ischemic stroke (AIS) and large vessel occlusion benefit from rapid access to mechanical thrombectomy in addition to intravenous thrombolysis. Prehospital triage algorithms to determine the optimal transport destination for AIS patients with unknown vessel status have so far only considered two alternatives: the nearest comprehensive (CSC) and the nearest primary stroke center (PSC). Objective: This study explores the importance of considering a larger number of PSCs during pre-hospital triage of AIS patients. Methods: Analysis was performed in random two-dimensional abstract geographic stroke care infrastructure environments and two models based on real-world geographic scenarios. Transport times to CSCs and PSCs were calculated to define sub-regions with specific triage properties. Possible transport destinations included the nearest CSC, the nearest PSC, and any of the remaining PSCs that are not closest to the scene, but transport to which would imply a shorter total time-to-CSC-via-PSC. Results: In abstract geographic environments, the median relative size of the sub-region where a triage decision is required ranged from 34 to 92%. The median relative size of the sub-region where more than two triage options need to be considered ranged from 0 to 56%. The achievable reduction in time-to-thrombectomy ("benefit") exceeded the increase in time-to-thrombolysis ("harm") by a factor of 2 in 30.5-37.0% of the sub-region where more than two triage options need to be considered. Results were confirmed in geographic environments based on real-world urban and rural stroke care infrastructures. Conclusion: Pre-hospital triage algorithms for AIS patients that only take into account the nearest CSC and the nearest PSC as transport destinations may be unable to identify the optimal transport destination for a significant proportion of patients.
Collapse
Affiliation(s)
- Ludwig Schlemm
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Eckhard Schlemm
- Medizinische Fakultät, Universität Hamburg, Hamburg, Germany.,Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Christian H Nolte
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site, Berlin, Germany.,DZNE (German Center for Neurodegenerative Diseases), Partner Site, Berlin, Germany
| | - Matthias Endres
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site, Berlin, Germany.,DZNE (German Center for Neurodegenerative Diseases), Partner Site, Berlin, Germany
| |
Collapse
|
4
|
Bushnell C, Howard VJ, Lisabeth L, Caso V, Gall S, Kleindorfer D, Chaturvedi S, Madsen TE, Demel SL, Lee SJ, Reeves M. Sex differences in the evaluation and treatment of acute ischaemic stroke. Lancet Neurol 2019; 17:641-650. [PMID: 29914709 DOI: 10.1016/s1474-4422(18)30201-1] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 05/02/2018] [Accepted: 05/14/2018] [Indexed: 10/14/2022]
Abstract
With the greater availability of treatments for acute ischaemic stroke, including advances in endovascular therapy, personalised assessment of patients before treatment is more important than ever. Women have a higher lifetime risk of stroke; therefore, reducing potential sex differences in the acute stroke setting is crucial for the provision of equitable and fast treatment. Evidence indicates sex differences in prevalence and types of non-traditional stroke symptoms or signs, prevalence of stroke mimics, and door-to-imaging times, but no substantial differences in use of emergency medical services, stroke knowledge, eligibility for or access to thrombolysis or thrombectomy, or outcomes after either therapy. Women presenting with stroke mimics or non-traditional stroke symptoms can be misdiagnosed, which can lead to inappropriate triage, and acute treatment delays. It is essential for health-care providers to recognise possible sex differences in stroke symptoms, signs, and mimics. Future studies focused on confounders that affect treatment and outcomes, such as age and pre-stroke function, are also needed.
Collapse
Affiliation(s)
- Cheryl Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC, USA.
| | - Virginia J Howard
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lynda Lisabeth
- Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
| | - Valeria Caso
- Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Seana Gall
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Dawn Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Tracy E Madsen
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Stacie L Demel
- Department of Neurology & Ophthalmology and Pharmacology & Toxicology, Michigan State University, East Lansing, MI, USA
| | - Seung-Jae Lee
- Department of Neurology, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
| | - Mathew Reeves
- Department of Epidemiology, Michigan State University, East Lansing, MI, USA
| |
Collapse
|
5
|
Huang Q, Zhang JZ, Xu WD, Wu J. Generalization of the right acute stroke promotive strategies in reducing delays of intravenous thrombolysis for acute ischemic stroke: A meta-analysis. Medicine (Baltimore) 2018; 97:e11205. [PMID: 29924046 PMCID: PMC6024468 DOI: 10.1097/md.0000000000011205] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The generalization of successful efforts for reducing time delays in intravenous thrombolysis (IVT) could help facilitate its utility and benefits in acute ischemic stroke (AIS) patients.We searched the PubMed and Embase databases for articles reporting interventions to reduce time delays in IVT, published between January 1995 and September 2017. The IVT rate was chosen as the primary outcome, while the compliance rates of onset-to-door time (prehospital delay) and door-to-needle time (in-hospital delay) within the targeted time frame were the secondary outcomes. Interventions designed to reduce prehospital, in-hospital, or total time delays were quantitatively described in meta-analyses. The efficacy of postintervention improvement was illustrated as odds ratios (ORs) and 95% confidence intervals (95% CIs).In total, 86 papers (17 on prehospital, 56 on in-hospital, and 13 on total delay) encompassing 17,665 IVT cases were enrolled, including 28 American, 23 Asian, 30 European, and 5 Australian studies. The meta-analysis revealed statistically significant improvement in promoting IVT delivery after prehospital improvement interventions with an OR of 1.45 (95% CI, 1.23-1.71) for the new transportation protocol, 1.38 (95% CI, 1.11-1.73) for educational and training programs, and 1.83 (95% CI, 1.44-2.32) for comprehensive prehospital stroke code. The benefits of reducing in-hospital delay were much greater in developed western countries than in Asian countries, with ORs of 2.90 (95% CI, 2.51-3.34), 2.17 (95% CI, 1.95-2.41), and 1.89 (95% CI, 1.74-2.04) in American, European, and Asian countries, respectively. And telemedicine (OR, 2.26; 95% CI, 2.08-2.46) seemed to work better than pre-notification alone (OR, 1.94; 95% CI, 1.74-2.17) and in-hospital organizational improvement programs (OR, 2.10; 95% CI, 1.97-2.23). Mobile stroke treatment unit and use of a comprehensive stroke pathway in the pre- and in-hospital settings significantly increased IVT rates by reducing total time delay, with ORs of 2.01 (95% CI, 1.60-2.51) and 1.77 (95% CI, 1.55-2.03), respectively.Optimization of the work flow with organizational improvement or novel technology could dramatically reduce pre- and in-hospital time delays of IVT in AIS. This study provided detailed information on the net and quantitative benefits of various programs for reducing time delays to facilitate the generalization of appropriate AIS management.
Collapse
Affiliation(s)
- Qiang Huang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
| | - Jing-ze Zhang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
| | - Wen-deng Xu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
| | - Jian Wu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| |
Collapse
|
6
|
Braun M, Ploner CJ, Lindner T, Möckel M, Schmidt WU. [Coma in the emergency room]. DER NERVENARZT 2018; 88:607-615. [PMID: 28424823 DOI: 10.1007/s00115-017-0329-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Coma of unknown origin (CUO) is a frequent unspecific emergency symptom associated with a high mortality. A fast diagnostic work-up is essential given the wide spectrum of underlying diagnoses that are made up of approximately 50% primary central nervous system (CNS) pathologies and approximately 50% extracerebral, almost exclusively internal medical causes. Despite the high mortality associated with this symptom, there are currently no generally accepted management guidelines for adult patients presenting with CUO. We propose an interdisciplinary standard operating procedure (SOP) for patients with acute CUO as has been established in our maximum care hospital. The SOP is triggered by simple triage criteria that are sufficient to identify CUO patients before arrival in hospital. The in-hospital response team is led by a neurologist. Collaboration with nursing staff, internal medicine, anesthesiology, neurosurgery and trauma surgery is organized along structured pathways that include standardized laboratory tests, including cerebrospinal fluid (CSF), toxicology, computed tomography (CT) and CT angiography imaging (CTA). Our data suggest that neurologists and internists need to be placed at the beginning of the diagnostic work-up. Imaging should not just be carried out depending on the clinical syndrome because sensitivity, specificity and inter-rater reliability of the latter are not sufficient and because in many cases, multiple pathologies can be detected that could each explain CUO alone. Clinical examination, imaging and laboratory testing should be regarded as components of an integrative diagnostic approach and the final aetiological classification should only be made after the diagnostic work-up is complete.
Collapse
Affiliation(s)
- M Braun
- Klinik für Neurologie, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland.,Centrum für Schlaganfallforschung (CSB), Berlin, Deutschland
| | - C J Ploner
- Klinik für Neurologie, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland.
| | - T Lindner
- Arbeitsbereich Notfallmedizin/Rettungsstellen, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum und Campus Charité Mitte, Berlin, Deutschland
| | - M Möckel
- Arbeitsbereich Notfallmedizin/Rettungsstellen, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum und Campus Charité Mitte, Berlin, Deutschland
| | - W U Schmidt
- Klinik für Neurologie, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland.,Centrum für Schlaganfallforschung (CSB), Berlin, Deutschland
| |
Collapse
|
7
|
Nolte CH, Ebinger M, Scheitz JF, Kunz A, Erdur H, Geisler F, Braemswig TB, Rozanski M, Weber JE, Wendt M, Zieschang K, Fiebach JB, Villringer K, Grittner U, Kaczmarek S, Endres M, Audebert HJ. Effects of Prehospital Thrombolysis in Stroke Patients With Prestroke Dependency. Stroke 2018; 49:646-651. [DOI: 10.1161/strokeaha.117.019060] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 12/13/2017] [Accepted: 01/03/2018] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Data on effects of intravenous thrombolysis on outcome of patients with ischemic stroke who are dependent on assistance in activities of daily living prestroke are scarce. Recent registry based analyses in activities of daily –independent patients suggest that earlier start of intravenous thrombolysis in the prehospital setting leads to better outcomes when compared with the treatment start in hospital. We evaluated whether these observations can be corroborated in patients with prestroke dependency.
Methods—
This observational, retrospective analysis included all patients with acute ischemic stroke depending on assistance before stroke who received intravenous thrombolysis either on the Stroke Emergency Mobile (STEMO) or through conventional in-hospital care (CC) in a tertiary stroke center (Charité, Campus Benjamin Franklin, Berlin) during routine care. Prespecified outcomes were modified Rankin Scale scores of 0 to 3 and survival at 3 months, as well as symptomatic intracranial hemorrhage. Outcomes were adjusted in multivariable logistic regression.
Results—
Between February 2011 and March 2015, 122 of 427 patients (28%) treated on STEMO and 142 of 505 patients (28%) treated via CC needed assistance before stroke. Median onset-to-treatment times were 97 (interquartile range, 69–159; STEMO) and 135 (interquartile range, 98–184; CC;
P
<0.001) minutes. After 3 months, modified Rankin Scale scores of 0 to 3 was observed in 48 STEMO patients (39%) versus 35 CC patients (25%;
P
=0.01) and 86 (70%, STEMO) versus 85 (60%, CC) patients were alive (
P
=0.07). After adjustment, STEMO care was favorable with respect to modified Rankin Scale scores of 0 to 3 (odds ratio, 1.99; 95% confidence interval, 1.02–3.87;
P
=0.042) with a nonsignificant result for survival (odds ratio, 1.73; 95% confidence interval, 0.95–3.16;
P
=0.07). Symptomatic intracranial hemorrhage occurred in 5 STEMO versus 12 CC patients (4.2% versus 8.5%;
P
=0.167).
Conclusions—
The results of this study suggest that earlier, prehospital (as compared with in-hospital) start of intravenous thrombolysis in acute ischemic stroke may translate into better clinical outcome in patients with prestroke dependency.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT02358772.
Collapse
Affiliation(s)
- Christian H. Nolte
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Martin Ebinger
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Jan F. Scheitz
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Alexander Kunz
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Hebun Erdur
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Frederik Geisler
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Tim Bastian Braemswig
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Michal Rozanski
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Joachim E. Weber
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Matthias Wendt
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Katja Zieschang
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Jochen B. Fiebach
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Kersten Villringer
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Ulrike Grittner
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Sabina Kaczmarek
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Matthias Endres
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Heinrich J. Audebert
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| |
Collapse
|
8
|
Weber JE, Audebert HJ. [Appropriate treatment of acute stroke at all times and in all places : Organizational concepts and new approaches]. Internist (Berl) 2017; 58:1213-1219. [PMID: 28840255 DOI: 10.1007/s00108-017-0305-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Stroke is one of the most common neurological diseases in acute care. The introduction of new organizational concepts in the rescue chain and in acute inpatient services can significantly reduce time to treatment and patients can receive specific therapeutic options that have been shown to improve acute stroke prognosis. This review provides an overview of organizational structures that lead to improved medical care and outlines the evidence-based therapeutic options. This is intended to give the reader a decision support on provision of specific treatment in acute ischemic stroke. The almost simultaneous proof of effectiveness of mechanical thrombectomy for targeted patient populations in five randomized trials has challenged the organization of stroke care. This provides a good example of how an optimized interplay within the rescue chain from emergency services via community hospitals to referral centers with intervention facilities can ensure access to this novel treatment for as many patients as possible. For the limited time span between onset of symptoms and start of treatment, creative but nevertheless well-standardized concepts have emerged that lead to measurable therapeutic success. It has become an urgent challenge to create sustainable regional infrastructures that allow access to appropriate treatment for all patients.
Collapse
Affiliation(s)
- J E Weber
- Klinik für Neurologie mit experimenteller Neurologie, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Deutschland.
| | - H J Audebert
- Klinik für Neurologie mit experimenteller Neurologie, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Deutschland.,Centrum für Schlaganfallforschung Berlin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| |
Collapse
|
9
|
Pikija S, Mutzenbach JS, Kunz AB, Nardone R, Leis S, Deak I, McCoy MR, Trinka E, Sellner J. Delayed Hospital Presentation and Neuroimaging in Non-surgical Spinal Cord Infarction. Front Neurol 2017; 8:143. [PMID: 28446898 PMCID: PMC5388752 DOI: 10.3389/fneur.2017.00143] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 03/29/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Lack of timely recognition and neuroimaging may be a barrier to reperfusion efforts in acute spinal cord infarction. METHODS We performed a retrospective study of patients diagnosed with acute non-surgical spinal cord infarction at our tertiary academic center from 2001 to 2015. We studied parameters associated with time from symptom onset to initial hospital presentation and magnetic resonance imaging (MRI) of the spinal cord. RESULTS We identified 39 patients among whom anterior spinal artery syndrome was the most frequent presentation (87.2%) and atherosclerosis the most common etiology (56.4%). Nearly, half of the patients presented to the emergency department on the same day of symptom onset (48.7%) but only nine (23.1%) within the first 6 h. Average time from symptom onset to spinal cord MRI was 3.2 days. We could not identify clinical, radiological, or outcome patterns associated with early vs. delayed presentation and imaging. DISCUSSION Our study found a time lag from symptom onset to hospital presentation and spinal cord MRI in patients with acute spinal cord infarction. These findings point at low clinical suspicion of spinal cord syndromes and limited recognition as a potentially treatable medical emergency.
Collapse
Affiliation(s)
- Slaven Pikija
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | | | - Alexander B Kunz
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Raffaele Nardone
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy.,Spinal Cord Injury and Tissue Regeneration Center, Paracelsus Medical University, Salzburg, Austria
| | - Stefan Leis
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Ildiko Deak
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Mark R McCoy
- Division of Neuroradiology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Spinal Cord Injury and Tissue Regeneration Center, Paracelsus Medical University, Salzburg, Austria
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Daffue K, Joubert G, Otto S. Computed tomography stroke findings and population demographics at Pelonomi Hospital, Bloemfontein. SA J Radiol 2016. [DOI: 10.4102/sajr.v20i1.993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background: Stroke remains the highest cause of death in patients more than 50 years old in South Africa, and the fourth highest cause of death overall. There is a paucity of information regarding this disease in the Free State Province.Objectives: To assess the stroke profile of patients referred for computed tomography (CT) imaging to our institution along with evaluating factors that could improve stroke management.Method: The demographic information, stroke risk factors, stroke types and time to imaging were evaluated for all patients who presented for CT stroke imaging from July 2014 until July 2015. Information was gathered prospectively from the hospital and radiology information systems.Results: The study included 174 patients (53.5% female, 46.5% male). Their mean age was 59 years (standard deviation (SD) 14.6). The most prevalent risk factors were hypertension (83.7%), smoking (20.5%) and diabetes (15.0%). The population group consisted of 67.8% ischaemic (n = 118) and 32.2% (n = 56) haemorrhagic strokes. The majority of patients with a known time of symptom onset (n = 102) presented after 8 hours (82.4%). The median order to report time (ORT) was 61 min (range 18 min–1361 min). The median arrival to report time (ART) was 32 min (range 4 min–893 min).Conclusion: Our stroke population did not differ significantly from others in South Africa and Africa overall. Pre- and in-hospital delays significantly influenced patient numbers qualifying for thrombolysis.
Collapse
|
12
|
Kunz A, Ebinger M, Geisler F, Rozanski M, Waldschmidt C, Weber JE, Wendt M, Winter B, Zieschang K, Fiebach JB, Villringer K, Erdur H, Scheitz JF, Tütüncü S, Bollweg K, Grittner U, Kaczmarek S, Endres M, Nolte CH, Audebert HJ. Functional outcomes of pre-hospital thrombolysis in a mobile stroke treatment unit compared with conventional care: an observational registry study. Lancet Neurol 2016; 15:1035-43. [DOI: 10.1016/s1474-4422(16)30129-6] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 05/02/2016] [Accepted: 06/08/2016] [Indexed: 11/30/2022]
|
13
|
Choi HY, Kim EH, Yoo J, Lee K, Song D, Kim YD, Cho HJ, Nam HS, Lee KY, Lee HS, Heo JH. Decision-Making Support Using a Standardized Script and Visual Decision Aid to Reduce Door-to-Needle Time in Stroke. J Stroke 2016; 18:239-41. [PMID: 27283284 PMCID: PMC4901956 DOI: 10.5853/jos.2016.00374] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 04/29/2016] [Accepted: 05/02/2016] [Indexed: 11/11/2022] Open
Affiliation(s)
- Hye-Yeon Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Kyung Hee University Hospital at Kangdong, Kyung Hee University College of Medicine, Seoul, Korea
| | - Eun Hye Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Joonsang Yoo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Kijeong Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Dongbeom Song
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Han-Jin Cho
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Yul Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Department of Biostatistics, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
14
|
Huang Q, Song HQ, Ji XM, Cheng WY, Feng J, Wu J, Ma QF. Generalization of the Right Acute Stroke Prevention Strategies in Reducing in-Hospital Delays. PLoS One 2016; 11:e0154972. [PMID: 27152854 PMCID: PMC4859531 DOI: 10.1371/journal.pone.0154972] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 04/21/2016] [Indexed: 11/19/2022] Open
Abstract
The aim of this study was to reduce the door-to-needle (DTN) time of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) through a comprehensive, hospital-based implementation strategy. The intervention involved a systemic literature review, identifying barriers to rapid IVT treatment at our hospital, setting target DTN time intervals, and building an evolving model for IVT candidate selection. The rate of non-in-hospital delay (DTN time ≤ 60 min) was set as the primary endpoint. A total of 348 IVT cases were enrolled in the study (202 and 146 in the pre- and post-intervention group, respectively). The median age was 61 years in both groups; 25.2% and 26.7% of patients in the pre- and post-intervention groups, respectively, were female. The post-intervention group had higher rates of dyslipidemia and minor stroke [defined as National Institutes of Health Stroke Scale (NIHSS) ≤ 3]; less frequent atrial fibrillation; higher numbers of current smokers, heavy drinkers, referrals, and multi-model head imaging cases; and lower NIHSS scores and blood sugar level (all P < 0.05). All parameters including DTN, door-to-examination, door-to-imaging, door-to-laboratory, and final-test-to-needle times were improved post-intervention (all P < 0.05), with net reductions of 63, 2, 4, 28, and 23 min, respectively. The rates of DTN time ≤ 60 min and onset-to-needle time ≤ 180 min were significantly improved by the intervention (pre: 9.9% vs. post: 60.3%; P < 0.001 and pre: 23.3% vs. post: 53.4%; P < 0.001, respectively), which was accompanied by an increase in the rate of neurological improvement (pre: 45.5% vs. post: 59.6%; P = 0.010), while there was no change in incidence of mortality or systemic intracranial hemorrhage at discharge (both P > 0.05). These findings indicate that it is possible to achieve a DTN time ≤ 60 min for up to 60% of hospitals in the current Chinese system, and that this logistical change can yield a notable improvement in the outcome of IVT patients.
Collapse
Affiliation(s)
- Qiang Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hai-qing Song
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xun-ming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wei-yang Cheng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Juan Feng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jian Wu
- Department of neurology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Beijing, China
- * E-mail: (QM); (JW)
| | - Qing-feng Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- * E-mail: (QM); (JW)
| |
Collapse
|
15
|
Braun M, Schmidt WU, Möckel M, Römer M, Ploner CJ, Lindner T. Coma of unknown origin in the emergency department: implementation of an in-house management routine. Scand J Trauma Resusc Emerg Med 2016; 24:61. [PMID: 27121376 PMCID: PMC4848793 DOI: 10.1186/s13049-016-0250-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 04/20/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Coma of unknown origin is an emergency caused by a variety of possibly life-threatening pathologies. Although lethality is high, there are currently no generally accepted management guidelines. METHODS We implemented a new interdisciplinary standard operating procedure (SOP) for patients presenting with non-traumatic coma of unknown origin. It includes a new in-house triage process, a new alert call, a new composition of the clinical response team and a new management algorithm (altogether termed "coma alarm"). It is triggered by two simple criteria to be checked with out-of-hospital emergency response teams before the patient arrives. A neurologist in collaboration with an internal specialist leads the in-hospital team. Collaboration with anaesthesiology, trauma surgery and neurosurgery is organised along structured pathways that include standardised laboratory tests and imaging. Patients were prospectively enrolled. We calculated response times as well as sensitivity and false positive rates, thus proportions of over- and undertriaged patients, as quality measures for the implementation in the SOP. RESULTS During 24 months after implementation, we identified 325 eligible patients. Sensitivity was 60 % initially (months 1-4), then fluctuated between 84 and 94 % (months 5-24). Overtriage never exceeded 15 % and undertriage could be kept low at a maximum of 11 % after a learning period. We achieved a median door-to-CT time of 20 minutes. 85 % of patients needed subsequent ICU treatment, 40 % of which required specialised neuro-ICUs. DISCUSSION Our results indicate that our new simple in-house triage criteria may be sufficient to identify eligible patients before arrival. We aimed at ensuring the fastest possible proceedings given high portions of underlying time-sensitive neurological and medical pathologies while using all available resources as purposefully as possible. CONCLUSIONS Our SOP may provide an appropriate tool for efficient management of patients with non-traumatic coma. Our results justify the assignment of the initial diagnostic workup to neurologists and internal specialists in collaboration with anaesthesiologists.
Collapse
Affiliation(s)
- Mischa Braun
- Department of Neurology, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.,Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Wolf Ulrich Schmidt
- Department of Neurology, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany. .,Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - Martin Möckel
- Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Michael Römer
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Christoph J Ploner
- Department of Neurology, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Tobias Lindner
- Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| |
Collapse
|
16
|
Weber J, Ebinger M, Audebert HJ. Prehospital stroke care: telemedicine, thrombolysis and neuroprotection. Expert Rev Neurother 2016; 15:753-61. [PMID: 26109228 DOI: 10.1586/14737175.2015.1051967] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over the last 15 years, new approaches regarding neuroprotective and thrombolytic strategies in stroke management have been evaluated in the prehospital setting. These efforts have provided exciting new potentials of hyperacute stroke care. Trials have shown that the use of specialized stroke ambulances increases the proportion of patients receiving intravenous thrombolysis and shortens alarm-to-treatment time by approximately half an hour compared to standard care. Intravenous thrombolysis within the ultra-early time window of the 'golden hour' has become a realistic scenario. However, direct effects of prehospital stroke care on functional outcome have yet to be shown and other approaches such as neuroprotective treatments could not demonstrate clinical benefit so far. There is a clear need for systematic research in the prehospital field to test the clinical effectiveness and cost-effectiveness of new therapeutic strategies. It will be necessary to test various components of prehospital stroke care alone and in combination.
Collapse
Affiliation(s)
- Joachim Weber
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | | |
Collapse
|
17
|
Huang Q, Ma QF, Feng J, Cheng WY, Jia JP, Song HQ, Chang H, Wu J. Factors Associated with In-Hospital Delay in Intravenous Thrombolysis for Acute Ischemic Stroke: Lessons from China. PLoS One 2015; 10:e0143145. [PMID: 26575839 PMCID: PMC4648585 DOI: 10.1371/journal.pone.0143145] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 10/30/2015] [Indexed: 11/19/2022] Open
Abstract
In-hospital delay reduces the benefit of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS), while factors affecting in-hospital delay are less well known in Chinese. We are aiming at determining the specific factors associated with in-hospital delay through a hospital based cohort. In-hospital delay was defined as door-to-needle time (DTN) ≥60min (standard delay criteria) or ≥75% percentile of all DTNs (severe delay criteria). Demographic data, time intervals [onset-to-door time (OTD), DTN, door-to-examination time (DTE), door-to-imaging time (DTI), door-to-laboratory time (DTL) and final-test-to-needle time (FTN, the time interval between the time obtaining the result of the last screening test and the needle time)], medical history and additional variables were calculated using Mann-Whitney U or Pearson Chi-Square tests for group comparison, and multivariate linear regression analysis was performed to identify independent variables of in-hospital delay. A total of 202 IVT cases were enrolled. The median age was 61 years and 25.2% were female. The cutoff points for the upper quartile of DTN (severe delay criteria) was 135min.When compared with the reference group without in-hospital delay, older age, shorter OTD and less referral were found in the standard delay group and male sex, presence with transient ischemic attacks or rapidly improving symptom, and with multi-model CT imaging were more frequent in the severe delay group. In the multivariate linear regression analysis, FTN (P<0.001) and DTL (P = 0.002) were significantly associated with standard delay; while DTE (P = 0.005), DTI (P = 0.033), DTL (P<0.001), and FTN (P<0.001) were positively associated with severe delay. There was not a significant change in the trend of DTNs during the study period (P = 0.054). In-hospital delay was due to multifactors in China, in which time delays of decision-making process and laboratory tests contributed the most. Efforts aiming at reducing the delay should be focused on the optimization for the items of screening tests and improvement of the pathway organization.
Collapse
Affiliation(s)
- Qiang Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qing-feng Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Juan Feng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wei-yang Cheng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jian-ping Jia
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hai-qing Song
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hong Chang
- Department of Nursing, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jian Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- * E-mail:
| |
Collapse
|
18
|
Multidisciplinary protocol for rapid head computed tomography turnaround time in acute stroke patients. J Stroke Cerebrovasc Dis 2015; 24:1256-61. [PMID: 25920753 DOI: 10.1016/j.jstrokecerebrovasdis.2015.01.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 01/28/2015] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The door-to-computed tomography (CT) head reporting time is an essential step to determining eligibility for thrombolysis in acute stroke patients, but the specific components of the process have not been reported in detail. METHODS We performed a retrospective cross-sectional analysis of the prospectively collected Get-With-The-Guidelines database in our comprehensive stroke center to evaluate the effect of a structured multidisciplinary protocol on head CT times in acute stroke patients under consideration for thrombolysis. RESULTS The median CT turnaround time in the first 6-month period was 27 (interquartile range [IQR], 27) and decreased in all subsequent periods after implementation of a formal protocol to 18 (IQR, 12; range, 17-20 minutes; P < .0001 for all pairwise comparisons). The median CT turnaround time was 18 (IQR, 12) versus 20 (IQR, 14) minutes for patients with admission diagnosis of stroke (n = 1123) versus nonstroke (n = 685; P < .0001), respectively. CONCLUSIONS A structured multidisciplinary protocol for obtaining acute stroke protocol head CT scan was associated with reduced CT turnaround time over the study period. Prospective studies should be done to determine if implementation in other stroke centers confirms the effectiveness of our protocol.
Collapse
|
19
|
Cho HJ, Lee KY, Nam HS, Kim YD, Song TJ, Jung YH, Choi HY, Heo JH. Process improvement to enhance existing stroke team activity toward more timely thrombolytic treatment. J Clin Neurol 2014; 10:328-33. [PMID: 25324882 PMCID: PMC4198714 DOI: 10.3988/jcn.2014.10.4.328] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 03/11/2014] [Accepted: 03/13/2014] [Indexed: 12/04/2022] Open
Abstract
Background and Purpose Process improvement (PI) is an approach for enhancing the existing quality improvement process by making changes while keeping the existing process. We have shown that implementation of a stroke code program using a computerized physician order entry system is effective in reducing the in-hospital time delay to thrombolysis in acute stroke patients. We investigated whether implementation of this PI could further reduce the time delays by continuous improvement of the existing process. Methods After determining a key indicator [time interval from emergency department (ED) arrival to intravenous (IV) thrombolysis] and conducting data analysis, the target time from ED arrival to IV thrombolysis in acute stroke patients was set at 40 min. The key indicator was monitored continuously at a weekly stroke conference. The possible reasons for the delay were determined in cases for which IV thrombolysis was not administered within the target time and, where possible, the problems were corrected. The time intervals from ED arrival to the various evaluation steps and treatment before and after implementation of the PI were compared. Results The median time interval from ED arrival to IV thrombolysis in acute stroke patients was significantly reduced after implementation of the PI (from 63.5 to 45 min, p=0.001). The variation in the time interval was also reduced. A reduction in the evaluation time intervals was achieved after the PI [from 23 to 17 min for computed tomography scanning (p=0.003) and from 35 to 29 min for complete blood counts (p=0.006)]. Conclusions PI is effective for continuous improvement of the existing process by reducing the time delays between ED arrival and IV thrombolysis in acute stroke patients.
Collapse
Affiliation(s)
- Han-Jin Cho
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea. ; Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Kyung Yul Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae-Jin Song
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea. ; Department of Neurology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Yo Han Jung
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea. ; Department of Neurology, Changwon Fatima Hospital, Changwon, Korea
| | - Hye-Yeon Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea. ; Department of Neurology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
20
|
Acute stroke care and thrombolytic therapy use in a tertiary care center in Lebanon. Emerg Med Int 2014; 2014:438737. [PMID: 25140255 PMCID: PMC4124754 DOI: 10.1155/2014/438737] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 07/06/2014] [Indexed: 11/17/2022] Open
Abstract
Background. Thrombolytic therapy (rt-PA) is approved for ischemic stroke presenting within 4.5 hours of symptoms onset. The rate of utilization of rt-PA is not well described in developing countries. Objectives. Our study examined patient characteristics and outcomes in addition to barriers to rt-PA utilization in a tertiary care center in Beirut, Lebanon. Methods. A retrospective chart review of all adult patients admitted to the emergency department during a one-year period (June 1st, 2009, to June 1st, 2010) with a final discharge diagnosis of ischemic stroke was completed. Descriptive analysis was done followed by a comparison of two groups (IV rt-PA and no IV rt-PA). Results. During the study period, 87 patients met the inclusion criteria and thus were included in the study. The mean age was found to be 71.9 years (SD = 11.8). Most patients arrived by private transport (85.1%). Weakness and loss of speech were the most common presenting signs (56.3%). Thirty-three patients (37.9%) presented within 4.5 hours of symptom onset. Nine patients (10.3%, 95% CI (5.5–18.5)) received rt-PA. The two groups (rt-PA versus non rt-PA) had similar outcomes (mortality, symptomatic intracerebral hemorrhage, modified Rankin scale scores, and residual deficit at hospital discharge). Conclusion. In our setting, rt-PA utilization was higher than expected. Delayed presentation was the main barrier to rt-PA administration. Public education regarding stroke is needed to decrease time from symptoms onset to ED presentation and potentially improve outcomes further.
Collapse
|
21
|
Abstract
In acute ischemic stroke, time is brain. Current guidelines recommend that the time from arrival at hospital to initiation of administration of tissue plasminogen activator, also known as the door-to-needle (DTN) time, should be 60 min or less. However, DTN times in practice usually exceed this recommended time. The median DTN times from the American Heart Association/American Stroke Association Get With The Guidelines-Stroke program and the multinational Safe Implementation of Treatment in Stroke International Stroke Thrombolysis Register are 75 min and 65 min, respectively. Prehospital factors associated with delays include patient-related factors such as poor recognition of stroke symptoms, poor use of emergency medical services, and complex psychosocial factors. Accurate recognition of stroke symptoms at a dispatcher and paramedic level is associated with shorter onset-to-arrival times. Prenotification of regional stroke centers by paramedics is strongly associated with shorter DTN times. In-hospital delays resulting in prolonged DTN times can be attenuated by having well-defined rapid triage pathways, defined stroke teams, single-call stroke team activation, established code stroke protocols, rapid access to diagnostic imaging, and laboratory services. In this review we summarize factors associated with prolonged DTN times and processes that allow faster onset-to-treatment times. Recent developments in the field are highlighted.
Collapse
|
22
|
Abstract
The management of acute ischemic stroke aims to verify the clinical diagnosis, to start general supportive care and to enable decision-making about specific forms of therapy.The risk-benefit ratio is time-dependent for many therapeutic options; therefore time delays are a disadvantage within the rescue chain. The trained and multidisciplinary team of the stroke unit forms the backbone of acute management. In addition, technical infrastructure influences therapeutic options and cerebral imaging is the cornerstone.The following four therapies are evidence-based: treatment on a stroke unit, thrombolysis, early administration of acetylsalicylic acid (ASS) and hemicraniectomy in patients younger than 60 years with a so-called malignant infarction.This article describes the necessary diagnostic steps and the general and specific therapeutic options that comprise acute management within the first 48 h.
Collapse
|