Improving the efficiency of delivery of thrombolysis for acute stroke: a systematic review

In-Hospital Emergency Treatment Delay Among Chinese Patients with Acute Ischaemic Stroke: Relation to Hospital Arrivals and Implications for Triage Pathways

Introduction

Timely access to emergency treatment during in-hospital care phase is critical for managing the onset of acute ischaemic stroke (AIS), particularly in developing countries. We aimed to explore in-hospital emergency treatment delay and the relation of door-to-needle (DTN) time to ambulance arrivals vs walk-in arrivals.

Methods

Data were collected from 1276 Chinese AIS patients admitted to a general, tertiary-level hospital for intravenous thrombolysis. Information on patients' characteristics and time taken during in-hospital emergency treatment was retrieved from the hospital registry data and medical records. Ambulance arrival was defined as being transported by emergency ambulance services, while walk-in arrival was defined as arriving at hospital by regular vehicle. In-hospital emergency treatment delay occurred when the DTN time exceeded 60 minutes. We performed multivariable logistic regression analysis to explore the association between hospital arrivals (by ambulance vs by walk-in) and treatment delay after adjustment for age, sex, education, marital status, residence, medical insurance, number of symptoms, clinical severity and survival outcome.

Results

Over half (53.76%) of patients aged over 60 years. Around one-fifth (20.61%) of patients admitted to hospital through emergency ambulance services, while their counterparts arrived by regular vehicle. Overall, the median time taken from the hospital door to treatment initiation was 86.0 minutes. Patients arrived by ambulance (adjusted odds ratio [aOR] = 1.744, 95% confidence interval [CI] = 1.185-2.566, p = 0.005), had higher socio-economic status (aOR = 1.821, 95% CI = 1.251-2.650; p = 0.002), or paid out-of-pocket (aOR = 2.323, 95% CI = 1.764-3.060; p < 0.001) had an increased likelihood of in-hospital emergency treatment delays.

Conclusion

In-hospital emergency treatment delay is common in China, and occurs throughout the entire emergency treatment journey. Having a triage pathway involving hospital arrival by ambulance seems to be more likely to experience in-hospital emergency treatment delay. Further efforts to improve triage pathways may require qualitative evidence on provider- and institutional-level factors associated with in-hospital emergency treatment delay.

The PRESTO study: awareness of stroke symptoms and time from onset to intervention

Timely access to medical assistance is the first crucial step to improving clinical outcomes of stroke patients. Many educational campaigns have been organized with the purpose of making people aware of what a stroke is and what is necessary to do after its clinical onset. The PRESTO campaign was organized in Genoa (Italy) to spread easy messages regarding the management of the acute phase of stroke. Educational material was disseminated to educate people to call the emergency medical services as soon as symptoms appear. Data collected were analyzed in three different phases of the campaign: before the beginning, during, and after the end. We enrolled 1,132 patients with ischemic stroke admitted to hospital within 24 hours of symptoms onset. Our data showed a mild reduction in onset-to-door time (24 minutes) during the months following the end of the campaign and a slight increase in number of patients who arrived at hospitals, in particular with milder symptoms and transient ischemic attack, as opposed to the same period before the campaign. Interestingly, in the months after the end of the campaign, we observed a slight reduction of the percentage of patients who accessed hospitals after 4.5 hours from symptoms onset. In conclusion, our results may suggest that an informative campaign can be successful in making people rapidly aware of stroke onset, with the consequent rapid access to hospitals. Considering the changing of way of access to information, we think that an extensive multimedia campaign should be evaluated in the next future.

Reasons for Exclusion From Intravenous Thrombolysis in Acute Ischemic Stroke: Experience From a Moroccan Stroke Unit

Background and objective The rate of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) is still low due to several absolute and relative contraindications, including admission time delay, which remains the main reason for exclusion from thrombolysis. In this study, we aimed to identify reasons for non-thrombolysis at our stroke center. Methods This retrospective study included all patients with a final diagnosis of AIS as per our stroke prospective register from 2014 to 2019. Reasons for non-thrombolysis were analyzed for all AIS and for patients admitted within 4.5 hours from symptom onset. From 2014 to 2016, a non-contrast CT scan was the unique imaging modality used to decide on performing IVT. In 2017, CT angiography was added to the imaging protocol. Results Among 3,562 patients with AIS, 3,365 (94.4%) were excluded from thrombolysis; 2,871 (80.6%) were admitted out of the IVT time window, which represents the main reason for exclusion from thrombolysis. Thrombolysis alert (TA) was triggered for 691 (19.4%) patients, and 197 patients had IVT (which represents 28.5% of TA and 5.5% of all AIS). Minor stroke and rapidly improving symptoms of stroke were also reasons for non-thrombolysis, which explain the high-average initial National Institutes of Health Stoke Scale (NIHSS) score of more than 12 in the thrombolysis group. CT angiography allows for the analysis of the supra-aortic trunks, the circle of Willis, and the collateral status. Therefore, during the period when a CT angiography scan was used, there were more IVTs for minor strokes, rapidly improving strokes, and AIS patients admitted beyond the IVT time window. Conclusions This study highlights the common reasons for exclusion from thrombolysis. Efforts should be undertaken to avoid admission time delays. Also, based on our findings, minor stroke and improving stroke no longer represent absolute contraindications for IVT in AIS.

Automated Large Artery Occlusion Detection in Stroke: A Single-Center Validation Study of an Artificial Intelligence Algorithm

INTRODUCTION

Expediting notification of lesions in acute ischemic stroke (AIS) is critical. Limited availability of experts to assess such lesions and delays in large vessel occlusion (LVO) recognition can negatively affect outcomes. Artificial intelligence (AI) may aid LVO recognition and treatment. This study aims to evaluate the performance of an AI-based algorithm for LVO detection in AIS.

METHODS

Retrospective analysis of a database of AIS patients admitted in a single center between 2014 and 2019. Vascular neurologists graded computed tomography angiographies (CTAs) for presence and site of LVO. Studies were analyzed by the Viz-LVO Algorithm® version 1.4 - neural network programmed to detect occlusions from the internal carotid artery terminus (ICA-T) to the Sylvian fissure. Comparisons between human versus AI-based readings were done by test characteristic analysis and Cohen's kappa. Primary analysis included ICA-T and/or middle cerebral artery (MCA)-M1 LVOs versus non-LVOs/more distal occlusions. Secondary analysis included MCA-M2 occlusions.

RESULTS

610 CTAs were analyzed. The AI algorithm rejected 2.5% of the CTAs due to poor quality, which were excluded from the analysis. Viz-LVO identified ICA-T and MCA-M1 LVOs with a sensitivity of 87.6%, specificity of 88.5%, and accuracy of 87.9% (AUC 0.88, 95% CI: 0.85-0.92, p < 0.001). Cohen's kappa was 0.74. In the secondary analysis, the algorithm yielded a sensitivity of 80.3%, specificity of 88.5%, and accuracy of 82.7%. The mean run time of the algorithm was 2.78 ± 0.5 min.

CONCLUSION

Automated AI reading allows for fast and accurate identification of LVO strokes with timely notification to emergency teams, enabling quick decision-making for reperfusion therapies or transfer to specialized centers if needed.

The impact of helicopter emergency medical service on acute ischemic stroke patients: A systematic review

BACKGROUND

Helicopter emergency medical services (HEMS) is commonly elected transport for acute ischemic stroke (AIS) known as a time-critical illness.

AIM

To conduct a systematic review in order to explore the HEMS impact on healthcare status, process and outcome measures for AIS patients.

METHODS

A systematic search was conducted of PubMed, Medline, CINAHL, Cochrane Library and Google Scholar. The gray literature and reference lists of included articles were also searched. Thirty studies met inclusion criteria.

RESULTS

Using Donabedian's framework, two studies focused on the impact on healthcare structure, twenty-three explored the impact on process measures, and five focused on clinical outcomes. HEMS structure implications could not be assessed due to insufficient studies. HEMS showed no significant outcome benefit compared to ground emergency medical services (EMS) and the impact on process measures was ambiguous.

CONCLUSIONS

HEMS necessity varied considerably between studies. More robust studies are needed for detection of the most suitable use of HEMS in AIS.

Can a multicomponent multidisciplinary implementation package change physicians' and nurses' perceptions and practices regarding thrombolysis for acute ischemic stroke? An exploratory analysis of a cluster-randomized trial

BACKGROUND

The Thrombolysis ImPlementation in Stroke (TIPS) trial tested the effect of a multicomponent, multidisciplinary, collaborative intervention designed to increase the rates of intravenous thrombolysis via a cluster randomized controlled trial at 20 Australian hospitals (ten intervention, ten control). This sub-study investigated changes in self-reported perceptions and practices of physicians and nurses working in acute stroke care at the participating hospitals.

METHODS

A survey with 74 statements was administered during the pre- and post-intervention periods to staff at 19 of the 20 hospitals. An exploratory factor analysis identified the structure of the survey items and linear mixed modeling was applied to the final survey domain scores to explore the differences between groups over time.

RESULT

The response rate was 45% for both the pre- (503 out of 1127 eligible staff from 19 hospitals) and post-intervention (414 out of 919 eligible staff from 18 hospitals) period. Four survey domains were identified: (1) hospital performance indicators, feedback, and training; (2) personal perceptions about thrombolysis evidence and implementation; (3) personal stroke skills and hospital stroke care policies; and (4) emergency and ambulance procedures. There was a significant pre- to post-intervention mean increase (0.21 95% CI 0.09; 0.34; p < 0.01) in scores relating to hospital performance indicators, feedback, and training; for the intervention hospitals compared to control hospitals. There was a corresponding increase in mean scores regarding perceptions about the thrombolysis evidence and implementation (0.21, 95% CI 0.06; 0.36; p < 0.05). Sub-group analysis indicated that the improvements were restricted to nurses' responses.

CONCLUSION

TIPS resulted in changes in some aspects of nurses' perceptions relating to the evidence for intravenous thrombolysis and its implementation and hospital performance indicators, feedback, and training. However, there is a need to explore further strategies for influencing the views of physicians given limited statistical power in the physician sample.

TRIAL REGISTRATION

ACTRN12613000939796, UTN: U1111-1145-6762.

Collaborative Interventions Reduce Time-to-Thrombolysis for Acute Ischemic Stroke in a Public Safety Net Hospital

BACKGROUND AND PURPOSE

Shorter time-to-thrombolysis in acute ischemic stroke (AIS) is associated with improved functional outcome and reduced morbidity. We evaluate the effect of several interventions to reduce time-to-thrombolysis at an urban, public safety net hospital.

METHODS

All patients treated with tissue plasminogen activator for AIS at our institution between 2008 and 2015 were included in a retrospective analysis of door-to-needle (DTN) time and associated factors. Between 2011 and 2014, we implemented 11 distinct interventions to reduce DTN time. Here, we assess the relative impact of each intervention on DTN time.

RESULTS

The median DTN time pre- and postintervention decreased from 87 (interquartile range: 68-109) minutes to 49 (interquartile range: 39-63) minutes. The reduction was comprised primarily of a decrease in median time from computed tomography scan order to interpretation. The goal DTN time of 60 minutes or less was achieved in 9% (95% confidence interval: 5%-22%) of cases preintervention, compared with 70% (58%-81%) postintervention. Interventions with the greatest impact on DTN time included the implementation of a stroke group paging system, dedicated emergency department stroke pharmacists, and the development of a stroke code supply box.

CONCLUSIONS

Multidisciplinary, collaborative interventions are associated with a significant and substantial reduction in time-to-thrombolysis. Such targeted interventions are efficient and achievable in resource-limited settings, where they are most needed.

Simulation training for emergency teams to manage acute ischemic stroke by telemedicine

Telemedicine contributes to initiating early intravenous recombinant tissue plasminogen activator (rt-PA) treatment for patients with acute cerebral infarction in areas without a stroke unit. However, the experience and skills of the emergency teams in the spokes to prepare patients and administer rt-PA treatment are ill-defined. Improving these skills could vastly improve management of acute stroke by telemedicine. We developed a medical simulation training model for emergency teams to perform intravenous rt-PA treatment in a telestroke system.From February 2013 to May 2015, 225 learners from 6 emergency teams included in the telestroke system "Virtuall"-in Lorrain (northeastern France)-received a standardized medical simulation training module to perform rt-PA treatment. All learners were assessed with the same pretraining and posttraining test consisting of 52 items. The percentage of right answers was determined for every learner before and after training.Median percentages of right answers were significantly higher in the posttraining test overall (82 ± 10 vs. 59 ± 13% pretraining; P < 0.001), but also in all professional subgroups: physicians (88 ± 8 vs. 67 ± 12%; P < 0.001), paramedical staff (80 ± 9 vs. 54 ± 12%; P < 0.001), nurses (80 ± 8 vs. 54 ± 12%; P < 0.001), and auxiliary nurses (76 ± 17 vs. 37 ± 15%; P = 0.002).We describe for the first time a training model for emergency teams in a telestroke system. We demonstrate significant gain in knowledge for all groups of healthcare professionals. This simulation model could be applied in any medical simulation center and form the basis of a standardized training program of spokes in a telestroke system.

Temporal delays in trauma craniotomies

OBJECTIVE The Brain Trauma Foundation recommendation regarding the timing of surgical evacuation of epidural hematomas and subdural hematomas is to perform the procedure as soon as possible. Indeed, faster evacuation is associated with better outcome. However, to the authors' knowledge, no study has looked at where delays in intrahospital care occurred for patients suffering from traumatic intracranial mass lesions. The goals of this study were as follows: 1) to characterize the performance of a Level 1 trauma center in terms of delays for emergency trauma craniotomies, 2) to review step by step where delays occurred in patient care, and 3) to propose ways to improve performance. METHODS A retrospective review was conducted covering a 5-year period of all emergency trauma craniotomies. Demographic data, injury severity, neurological status, and functional outcome data were collected. The time elapsed between emergency department (ED) arrival and CT imaging, between CT imaging and arrival at the operating room (OR), between ED arrival and OR arrival, between OR arrival and skin incision, and between ED arrival and skin incision were calculated. Patients were also subcategorized as either having immediate life-threatening emergencies (E0) or life-threatening emergencies (E1). The operative technique was also reviewed (standard craniotomy opening vs immediate bur hole decompression followed by craniotomy). RESULTS The study included 166 patients. Of these, 58 (35%) were classified into the E0 group and 108 (64.2%) into the E1 group. The median ED-to-CT delay was 54 minutes with no significant difference between the E0 and the E1 groups. The median CT-to-OR time delay was 57 minutes. The median delay for the E0 group was 39 minutes and that for the E1 group was 70 minutes (p = 0.002). The median delay from ED to OR arrival for patients with a CT scanning done at an outside hospital was 75 minutes. The median delay from ED to OR arrival was 85 minutes for the E0 group and 127 minutes for the E1 group (p < 0.0001). The median delay from OR arrival to skin incision was 35 minutes (E0: median 27 minutes; E1: median 39 minutes; p < 0.0001). The median total time elapsed between ED arrival and skin incision was 150 minutes (E0: median 131 minutes; E1: median 180 minutes). Overall, only 17% of patients underwent immediate bur hole decompression, but the proportion climbed to 41% in the E0 group. A lower Glasgow Coma Scale score was associated with a shorter delay (p = 0.0004). CONCLUSIONS A long delay until surgery still exists for patients requiring urgent mass lesion evacuation. Many factors contribute to this delay, including performing imaging and transfer to and preparation in the OR. Strategies can be implemented to reduce delays and improve the delivery of care.

Design and validation of a prehospital scale to predict stroke severity: Cincinnati Prehospital Stroke Severity Scale

BACKGROUND AND PURPOSE

We derived and validated the Cincinnati Prehospital Stroke Severity Scale (CPSSS) to identify patients with severe strokes and large vessel occlusion (LVO).

METHODS

CPSSS was developed with regression tree analysis, objectivity, anticipated ease in administration by emergency medical services personnel and the presence of cortical signs. We derived and validated the tool using the 2 National Institute of Neurological Disorders and Stroke (NINDS) tissue-type plasminogen activator Stroke Study trials and Interventional Management of Stroke III (IMS III) Trial cohorts, respectively, to predict severe stroke (National Institutes of Health Stroke Scale [NIHSS]≥15) and LVO. Standard test characteristics were determined and receiver operator curves were generated and summarized by the area under the curve.

RESULTS

CPSSS score ranges from 0 to 4; composed and scored by individual NIHSS items: 2 points for presence of conjugate gaze (NIHSS≥1); 1 point for presence of arm weakness (NIHSS≥2); and 1 point for presence abnormal level of consciousness commands and questions (NIHSS level of consciousness≥1 each). In the derivation set, CPSSS had an area under the curve of 0.89; score≥2 was 89% sensitive and 73% specific in identifying NIHSS≥15. Validation results were similar with an area under the curve of 0.83; score≥2 was 92% sensitive, 51% specific, a positive likelihood ratio of 3.3, and a negative likelihood ratio of 0.15 in predicting severe stroke. For 222 of 303 IMS III subjects with LVO, CPSSS had an area under the curve of 0.67; a score≥2 was 83% sensitive, 40% specific, positive likelihood ratio of 1.4, and negative likelihood ratio of 0.4 in predicting LVO.

CONCLUSIONS

CPSSS can identify stroke patients with NIHSS≥15 and LVO. Prospective prehospital validation is warranted.

Acute stroke care and thrombolytic therapy use in a tertiary care center in Lebanon

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.

Time intervals from subarachnoid hemorrhage to rebleed

The most threatening early complication and predictor of poor outcome after an aneurysmal subarachnoid hemorrhage (aSAH) is a rebleed. To evaluate what proportion of rebleeds might be prevented by early treatment, we assessed the time interval from the initial hemorrhage to rebleed, and the location of the patient at the time of rebleed. Patient characteristics, World Federation of Neurological Surgeons grade on admission and modified Rankin Scale outcome scores, referring hospitals and time intervals from initial hemorrhage to treatment of 293 patients treated between 2008 and 2011 were evaluated. Time intervals to rebleeds and location of the patients at the time of rebleed were retrieved. Rebleeds were confirmed by CT in 12% of patients, and an additional 4% of patients was diagnosed as having a possible rebleed. Sixty percent of rebleeds occurred after admission to the treatment center. Almost all rebleeds occurred within 24 h, with a median time interval between initial hemorrhage and rebleed of 180 min. A significantly shorter time to treatment and a higher mortality were seen in the group of patients with a rebleed. Approximately, one in six patients with an aSAH had a rebleed, of which a majority might have been preventable because they occurred after admission to the treatment center. A reduction in the rebleed rate seems feasible by securing the aneurysm as soon as possible by improving in-hospital logistics for early aneurysm treatment. Alternative options, such as immediate administration of antifibrinolytics, are being explored in a multicenter trial.

Time intervals from aneurysmal subarachnoid hemorrhage to treatment and factors contributing to delay

In the management of aneurysmal subarachnoid hemorrhage (aSAH), aneurysm treatment as early as feasible is mandatory to minimize the risk of a rebleed and may thus improve outcome. We assessed the different time intervals from the first symptoms of aSAH to start of aneurysm treatment in an effort to identify which factors contribute mostly to a delay in time to treatment. In 278 aSAH patients, time intervals between the different steps from initial hemorrhage to aneurysm treatment were retrospectively reviewed, and delaying factors were determined. Half of the patients presented to a hospital within 115 min (IQR 60-431). The median (IQR) interval from hemorrhage to diagnosis was 169 min (96-513), and from diagnosis to treatment 1,057 min (416-1,428), or 17.6 h. Aneurysm treatment started within 24 h in 76 % of treated patients. Independent factors predicting delay to treatment were primary presentation at a referring hospital and admission to the treatment center later in the day. Delay in treatment was not independently related to poor outcome. The interval to aneurysm treatment might be improved upon by immediate and direct transport to the treatment center combined with optimization of in-hospital logistics, following the 'time-is-brain' concept so successfully adopted in the treatment of ischemic stroke.

Early and intermediate prognosis of intravenous thrombolytic therapy in acute ischemic stroke subtypes according to the causative classification of stroke system

Objectives: Intravenous thrombolytic therapy has established acceptable results in treating ischemic stroke. However, there is little information on treatment outcome especially in different subtypes. The aim of current study was to evaluate early and intermediate prognosis in intravenous thrombolytic therapy for acute ischemic stroke subtypes.

Methodology: Forty eligible patients (57.5% male with mean age of 63.18±13.49 years) with definite ischemic stroke who were admitted to emergency department of Imam Reza University Hospital, in the first 180 minutes after occurrence received recombinant tissue plasminogen activator. All investigation findings were recorded and stroke subtypes were determined according to the Causative Classification of Stroke System. Stroke severity forms including modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS) scores were recorded for all patients in first, seven and 90 days after stroke and disease outcome was evaluated.

Results: The etiology of stroke was large artery atherosclerosis in 20%, cardio-aortic embolism in 45%, small artery occlusion in 17.5% and undetermined causes in 17.5%. NIHSS and mRS scores were significantly improved during time (P < 0.001 in both cases). Three months mortality rate was 25%. Among the etiologies, patients with small artery occlusion and then cardio-aortic embolism had lower NIHSS score at arrival (P = 0.04). Caplan-meier analysis showed that age, sex and symptom to needle time could predict disease outcome.

Conclusion: Intravenous thrombolytic therapy is accompanied by good early and intermediate outcome in most patients with ischemic stroke. Small artery occlusion subtype had less disease severity and higher improvement.

Understanding the reasons behind the low utilisation of thrombolysis in stroke

BACKGROUND

Thrombolysis remains the only approved therapy for acute ischaemic stroke (AIS); however, its utilisation is reported to be low.

AIMS

This study aimed to determine the reasons for the low utilisation of thrombolysis in clinical practice.

METHOD

Five metropolitan hospitals comprising two tertiary referral centres and three district hospitals conducted a retrospective, cross-sectional study. Researchers identified patients discharged with a principal diagnosis of AIS over a 12-month time period (July 2009-July 2010), and reviewed the medical record of systematically chosen samples.

RESULTS

The research team reviewed a total of 521 records (48.8% females, mean age 74.4 ± 14 years, age range 5-102 years) from the 1261 AIS patients. Sixty-nine per cent of AIS patients failed to meet eligibility criteria to receive thrombolysis because individuals arrived at the hospital later than 4.5 hours after the onset of symptoms. The factors found to be positively associated with late arrival included confusion at onset, absence of a witness at onset and waiting for improvement of symptoms. However, factors negatively associated with late arrival encompassed facial droop, slurred speech and immediately calling an ambulance. Only 14.7% of the patients arriving within 4.5 hours received thrombolysis. The main reasons for exclusion included such factors as rapidly improving symptoms (28.2%), minor symptoms (17.2%), patient receiving therapeutic anticoagulation (6.7%) and severe stroke (5.5%).

CONCLUSION

A late patient presentation represents the most significant barrier to utilising thrombolysis in the acute stroke setting. Thrombolysis continues to be currently underutilised in potentially eligible patients, and additional research is needed to identify more precise criteria for selecting patients for thrombolysis.

Optimizing the management of acute ischaemic stroke: a review of the utilization of intravenous recombinant tissue plasminogen activator (tPA)

WHAT IS KNOWN AND OBJECTIVE

Thrombolysis using intravenous tissue plasminogen activator (tPA) is the only available evidence-based treatment for acute ischaemic stroke; however, its current utilization is very low. Therefore, the aim of this article is to review the literature regarding the use of intravenous tPA for the treatment of acute ischaemic stroke. The review will also compare utilization rates of thrombolysis in different centres across the world and identify key reasons for the underutilization of thrombolysis in stroke.

METHODS

MEDLINE, EMBASE, International Pharmaceutical Abstracts (IPA) and Google Scholar were searched for relevant original articles, review papers and other publications over the publication period 1995-2012.

RESULTS AND DISCUSSION

The National Institute of Neurological Disorders and Stroke (NINDS) (1995, N = 624 patients) and ECASS III (2008, N = 821 patients) are two pivotal randomized controlled trials providing evidence for the use of intravenous tPA within 3 h or 3-4.5 h from stroke onset, respectively. Both trials have shown that tPA administration decreases disability at 90 days from stroke. Furthermore, a recent pooled analysis of randomized controlled trials (2010, N = 3670 patients) supports these results, highlighting that early stroke treatment is associated with better outcomes, especially when treatment is started within 90 min of stroke onset (but suggesting that the benefit could be afforded within a 4.5-h time window). Three major observational trials, STARS (2000, N = 389 patients), CASES (2005, N = 1135 patients) and SITS-MOST (2007, N = 6483 patients), have reported acceptable safety and efficacy in clinical practice. However, only a small proportion of acute ischaemic stroke patients receive tPA in clinical practice, because of the limited availability of tPA-utilizing sites and suboptimal use of tPA in sites where it is available.

WHAT IS NEW AND CONCLUSION

tPA reduces disability in stroke patients. Moreover, acceptable safety has been demonstrated in routine clinical practice. However, tPA is significantly underutilized, and specific efforts are needed to encourage appropriate implementation of the stroke treatment guidelines to optimize the use of this important therapy.

Barriers to the utilization of thrombolysis for acute ischaemic stroke

WHAT IS KNOWN AND OBJECTIVE

Thrombolysis is currently the only evidence-based pharmacological treatment available for acute ischaemic stroke (AIS); however, its current utilization is suboptimal (administered to <3% of AIS patients). The aim of this article was to identify the potential barriers to the use of thrombolysis via a review of the available literature.

METHODS

Medline, Embase, International Pharmaceutical Abstracts and Google Scholar were searched to identify relevant original articles, review papers and other literature published in the period 1995-2011.

RESULTS AND DISCUSSION

Several barriers to the utilization of thrombolysis in stroke have been identified in the literature and can be broadly classified as 'preadmission' barriers and 'post-admission' barriers. Preadmission barriers include patient and paramedic-related factors leading to late patient presentation for treatment (i.e. outside the therapeutic time window for the administration of thrombolysis). Post-admission barriers include in-hospital factors, such as suboptimal triage of stroke patients and inefficient in-hospital acute stroke care systems, a lack of appropriate infrastructure and expertise to administer thrombolysis, physician uncertainty in prescribing thrombolysis and difficulty in obtaining informed consent for thrombolysis. Suggested strategies to overcome these barriers include public awareness campaigns, prehospital triage by paramedics, hospital bypass protocols and prenotification systems, urgent stroke-unit admission, on-call multidisciplinary acute stroke teams, urgent neuroimaging protocols, telestroke interventions and risk-assessment tools to aid physicians when considering thrombolysis. Additionally, greater pharmacists' engagement is warranted to help identify the people at risk of stroke and support preventative strategies, and provide the public with information regarding the recognition of stroke, as well as facilitate the access and use of thrombolysis.

WHAT IS NEW AND CONCLUSION

The most effective interventions appear to be those comprising several strategies and those that target more than one barrier simultaneously. Therefore, optimal utilization of thrombolysis requires a systematic, integrated multidisciplinary approach across the continuum of acute care.

Improvement of door-to-imaging time in acute stroke patients by implementation of an all-points alarm

In patients with acute ischemic stroke, thrombolysis offers an opportunity to effectively reduce disability and dependency. The success of this treatment is time-dependent. The crucial diagnostic step before initiation of treatment is cerebral imaging. With the aim of reducing in-hospital delays, our hospital's interdisciplinary stroke management group implemented an all-points alarm to improve in-hospital time delay (the period between arrival to the emergency department and performance of cerebral imaging). The alarm simultaneously alerted all involved staff (from the neurologist to in-hospital transport) to the arrival of a patient potentially eligible for thrombolysis. Time delay, sociodemographic, and clinical data were assessed prospectively at 4 months before and 8 months after alarm implementation. Data were examined by analysis of covariance for both the intention-to-treat and per-protocol groups. During the assessment, 689 patients with symptoms compatible with stroke arrived at our hospital. Among those, 111 patients (16%) were eligible for thrombolysis (median age, 71 years; median National Institutes of Health Stroke Scale score, 11; 44% female). Patient characteristics (ie, age, sex, insurance status, National Institutes of Health Stroke Scale score, cardiovascular risk factors, and prehospital delay) did not differ significantly before (n = 34) and after (n = 77) alarm implementation. The median "door-to-imaging time" for patients eligible for thrombolysis was significantly reduced, from 54 minutes before implementation of the alarm to 35 minutes after implementation. Adjusted analysis of covariance demonstrated a significant influence of the intervention (P = .001) on differences in time delay. The proportion of ischemic stroke patients receiving thrombolysis rose from 42% to 66% (P = .04). The per-protocol analysis confirmed these results. The implementation of an all-points alarm can result in significant reduction of the time needed for in-hospital pathways for acute stroke patients.

Do centres with well-developed protocols, training and infrastructure have higher rates of thrombolysis for acute ischaemic stroke?

BACKGROUND

The introduction of intravenous thrombolysis with recombinant tissue Plasminogen Activator (rt-PA) has greatly improved the effectiveness of acute ischaemic stroke care. However, in most hospitals only 2-10% of all admitted stroke patients are treated with thrombolysis.

AIM

The purpose of this study is to identify if available protocols, training and infrastructure influence the thrombolysis rate.

DESIGN

Cohort study of 12 hospitals in the Netherlands.

METHODS

In a cohort of patients admitted with acute stroke within 24 h from onset of symptoms, data were obtained. Stroke service characteristics of 12 hospitals were acquired through structured interviews with intra- and extramural representatives, in order to asses (i) protocols, (ii) training and (iii) complexity of infrastructure. Data were analysed with multi-level logistic regression to relate the likelihood of treatment with thrombolysis to availability and completeness of protocols, training and infrastructure both outside (extramural) and inside (intramural) each centre.

RESULTS

Overall 5515 patients were included in the study. Thrombolysis rates varied from 5.7% to 21.7%. An association was observed between thrombolysis rates and extramural training [odds ratio (OR): 1.11; 95% confidence interval (CI): 0.99-1.25] and availability of intramural protocols (OR: 1.46; 95% CI: 1.12-1.91). After adjustment for hospital size and teaching vs. nonteaching hospital, these associations became stronger; extramural training [adjusted OR (aOR): 1.14; 95% CI: 1.01-1.30] and availability of intramural protocols (aOR: 1.77; 95% CI: 1.30-2.39).

CONCLUSIONS

Extramural training and intramural protocols are important tools to increase thrombolysis rates for acute ischaemic stroke in hospitals. Intramural protocols and extramural training should be aimed at all relevant professionals.

Effective implementation of research into practice: an overview of systematic reviews of the health literature

BACKGROUND

The gap between research findings and clinical practice is well documented and a range of interventions has been developed to increase the implementation of research into clinical practice.

FINDINGS

A review of systematic reviews of the effectiveness of interventions designed to increase the use of research in clinical practice. A search for relevant systematic reviews was conducted of Medline and the Cochrane Database of Reviews 1998-2009. 13 systematic reviews containing 313 primary studies were included. Four strategy types are identified: audit and feedback; computerised decision support; opinion leaders; and multifaceted interventions. Nine of the reviews reported on multifaceted interventions. This review highlights the small effects of single interventions such as audit and feedback, computerised decision support and opinion leaders. Systematic reviews of multifaceted interventions claim an improvement in effectiveness over single interventions, with effect sizes ranging from small to moderate. This review found that a number of published systematic reviews fail to state whether the recommended practice change is based on the best available research evidence.

CONCLUSIONS

This overview of systematic reviews updates the body of knowledge relating to the effectiveness of key mechanisms for improving clinical practice and service development. Multifaceted interventions are more likely to improve practice than single interventions such as audit and feedback. This review identified a small literature focusing explicitly on getting research evidence into clinical practice. It emphasizes the importance of ensuring that primary studies and systematic reviews are precise about the extent to which the reported interventions focus on changing practice based on research evidence (as opposed to other information codified in guidelines and education materials).

Multimodal strategy in the successful implementation of a stroke unit in a community hospital

OBJECTIVES

Thrombolysis in stroke remains underutilized in daily practice. We analyzed the impact of a multimodal strategy on the rate of thrombolysis and specific procedure times during the implementation of a community hospital stroke unit.

MATERIAL AND METHODS

During a period of 2 years before and after implementation of a stroke unit, we prospectively recorded all patients with thrombolysis and specific procedure times. Calculated door-to-needle time (DNT), door-to-CT time (DCT) and CT-to-needle time (CNT) were analyzed. All structural changes before and after the implementation were analyzed.

RESULTS

The number of patients with thrombolysis increased from 24 in 2005-2006 (4.8% of all admitted patients with ischemic stroke) to 95 in 2007-2008 (12.8%). DNT was significantly reduced from 62.2±36.1 to 38.5±22.2 min (P<0.001). DCT remained unchanged at 10.3±9.5 to 10.4±13.9 min (P=0.974), whereas CNT improved from 45.7±23.1 to 28.3±20.3 min (P=0.001). Several structural changes concerning staff, logistics, procedures and laboratory were identified which contributed to decreasing DNT.

CONCLUSIONS

A multimodal strategy including several structural changes enables the successful implementation of a community hospital stroke unit offering rapid access to thrombolysis with a very short DNT.

Helicopter Transport of Stroke Patients and Its Influence on Thrombolysis Rates

Background and Purpose—

Acute stroke management requires minimization of prehospital time. This study addresses the value of helicopter transport compared with other means of transportation to a stroke unit and compares their rates of thrombolysis on a nationwide basis.

Methods—

Prospective data collection and prespecified evaluation of data from 32 stroke units between 2003 and 2009 were used. We distinguished between patients transported either directly to a stroke unit or transferred indirectly via a peripheral hospital. Thus, there were 6 transport groups: helicopter emergency service (HEMS) direct and indirect, ambulance accompanied by an emergency physician direct and indirect, and ambulance without physician direct and indirect. Demographic and clinical factors, time delays, and rates of thrombolysis of patients transported by helicopter were compared with factors of patients transported otherwise.

Results—

Of 21 712 ischemic stroke patients, 905 patients (4.1%) were transported by helicopter. Of these, 752 patients (3.4%) were transported by direct HEMS, and 153 patients (0.7%) were transported by indirect HEMS. Thrombolysis rates were highest for HEMS (24% direct, 29% indirect) transport, followed by ambulance accompanied by an emergency physician (18% direct, 15% indirect). The probability of receiving thrombolysis was highest for indirect HEMS transport (OR 3.6, 2.2–6.0), followed by indirect ambulance accompanied by an emergency physician transport (OR 1.5, 1.1–1.9). The shortest times, 90 minutes or less from stroke onset to hospital arrival, were achieved with direct AMBP and direct HEMS transport.

Conclusions—

The shortest hospital arrival times and highest thrombolysis rates were seen in ischemic stroke patients transported by helicopter.

Stroke education: discrepancies among factors influencing prehospital delay and stroke knowledge

BACKGROUND

Time is essential for the treatment of acute stroke. Much time is lost outside the hospital, either due to failure in identifying stroke symptoms or due to a delay in notification or transport. We review studies reporting factors associated with better stroke knowledge and shorter time delays. We summarise the evidences for the effect of stroke knowledge and education on people's reaction in the acute situation of stroke.

METHODS

We searched MEDLINE for studies reporting factors associated with prehospital time of stroke patients, or knowledge of stroke symptoms. Further, we searched for studies reporting educational interventions aimed at increasing stroke symptom knowledge in the population.

FINDINGS

We included a total of 182 studies. Surprisingly, those factors associated with better stroke knowledge such as education and sociodemographic variables were not related to shorter time delays. Few studies report shorter time delays or better stroke knowledge in persons having suffered a previous stroke. Factors associated with shorter time delays were more severe stroke and symptoms regarded as serious, but not better knowledge about the most frequent symptoms such as hemiparesis or disorders of speech. Only 25-56% of patients recognised their own symptoms as stroke. While stroke education increases the knowledge of warning signs, a few population studies measured the impact of education on time delays; in such studies, time delays decreased after education. This may partly be mediated by better organisation of EMS and hospitals.

INTERPRETATION

There is a discrepancy between theoretical stroke knowledge and the reaction in an acute situation. Help-seeking behaviour is more dependent on the perceived severity of symptoms than on symptom knowledge. Bystanders play an important role in the decision to call for help and should be included in stroke education. Education is effective and should be culturally adapted and presented in a social context. It is unclear which educational concept is best suited to enhance symptom recognition in the acute situation of stroke, especially in view of discrepancies between knowledge and action.

The economics of treating stroke as an acute brain attack

Currently, treatments for ischemic stroke focus on restoring or improving perfusion to the ischemic area using thrombolytics. The increased hospitalization costs related to thrombolysis are offset by a decrease in rehabilitation costs, for a net cost savings to the healthcare system. However, early treatment is essential. The benefit of thrombolysis is time-dependent but only a very small proportion of patients, 2%, are presently being treated with tPA. In the United States, if the proportion of all ischemic stroke patients that receive tPA were increased to 4, 6, 8, 10, 15, or 20%, the realized cost saving would be approximately $ 15, 22, 30, 37, 55, and 74 million, respectively. Being so, efforts should be made to educate the public and paramedics regarding early stroke signs. Furthermore, additional acute stroke therapy training programs need to be established for emergency departments. Finally, hospital systems need to be re-engineered to treat patients as quickly as possible in order to optimize thrombolytic benefit as well as maximize cost-effectiveness.

Reducing prehospital delay in acute stroke

Despite the proven benefits of thrombolysis for patients presenting with acute ischemic stroke, only a limited number of patients receive thrombolytic therapy. The reason for the low treatment rate is that thrombolysis is only effective a few hours after the onset of ischemic stroke, so delays in patients being admitted to hospital and being diagnosed mean that the therapeutic window is often missed. Major factors that lead to prehospital delay include the general public's lack of knowledge of stroke symptoms and their poor understanding of the appropriate course of action following a stroke. Indeed, the patients who arrive early in hospital tend to be those who recognize the symptoms of stroke and take them seriously. Deficiencies in the identification of stroke by emergency medical services and general practitioners also contribute to prehospital delay. Aggressive, combined educational programs aimed at the general public, general practitioners, and medical and paramedical hospital staff can lead to increased stroke treatment rates. In this Review, we explore the extent of prehospital delay in stroke, identify the factors that affect the time taken for patients to reach hospital, and describe strategies designed to reduce the delay.

Guidelines for management of ischaemic stroke and transient ischaemic attack 2008

This article represents the update of the European Stroke Initiative Recommendations for Stroke Management. These guidelines cover both ischaemic stroke and transient ischaemic attacks, which are now considered to be a single entity. The article covers referral and emergency management, Stroke Unit service, diagnostics, primary and secondary prevention, general stroke treatment, specific treatment including acute management, management of complications, and rehabilitation.

Pre-hospital delay in the use of intravenous rt-PA for acute ischemic stroke in Japan

In this study we investigated the factors associated with pre-hospital delay to treat acute ischemic stroke and transient attack with intravenous recombinant tissue-plasminogen activator (rt-PA) in Japan. In 625 patients, we investigated the pathways and times of their arrival to our hospital, and the significant and independent factors in the patients' clinical backgrounds associated with delayed arrival (>2 h after notice). In total, 287 patients arrived at our hospital directly via EMS, 113 came by themselves, and 225 transferred from other institutes. Delayed arrivals occurred in 423 patients (68%). Multivariate analyses showed that staying in another hospital at notice, a worsened course, and referral from other institutes were positively related, and evening onset, having a witness at onset, loss of consciousness, and using EMS were negatively related to delayed arrival; a worsened course was positively related, and staying in other hospital at notice, having a witness at onset, loss of consciousness, and a high NIHSS on admission were negatively related to delayed alert; hypercholesterolemia and onset in a nursing home were positively related, and staying in other hospital at notice, loss of consciousness, and a high NIHSS on admission were negatively related to not using EMS. A lack of knowledge concerning stroke emergency by medical staff as well as the general public may be responsible for some stroke patients losing the chance for rt-PA treatment.

Pre-hospital and in-hospital delays after onset of acute ischemic stroke: a hospital-based study in southern Taiwan

The biggest hurdle for early hospital presentation is the narrow therapeutic window after stroke. The aims of our study were to investigate the time lags and the factors causing pre-hospital and emergency department (ED) delay during acute ischemic stroke attack. Between June 2004 and October 2005, we prospectively studied 129 acute ischemic stroke patients who presented to the ED of the study hospital within 4 hours after symptom onset. Chi-square testing for trend, univariate and multiple logistic regression analyses was performed to evaluate the factors influencing delays in the ED presentation of acute ischemic stroke patients. The median time from symptom onset to ED arrival was 71 (mean +/- SD, 82.7 +/- 57.7) minutes. The median times from ED arrival to neurologic consultation, computed tomography scan, electrocardiogram, and laboratory data completion were 10 (11.3 +/- 9.9) minutes, 17 (9.6 +/- 11.3) minutes, 14 (23.3 +/- 55) minutes, and 39 (44.4 +/- 24.5) minutes, respectively. Univariate and multiple logistic regression models revealed that age < 65 years, illiteracy and awakening with symptoms were the most significant factors related to a delay in ED presentation. This study indicates that 2 hours of pre-hospital delay is the cutoff point for thrombolytic therapy. Organization of a stroke team and standardized stroke pathways may help to shorten in-hospital time consumption. Educational efforts should not only focus on the public, but also on the training of ED physicians and other medical personnel.

Impact of acute stroke team emergency calls on in-hospital delays in acute stroke care

INTRODUCTION

Acute stroke is a medical emergency. Therefore, early recognition and rapid activation of the medical system are important prerequisites for successful management. We sought to investigate the impact of our new Acute Stroke Team emergency call system (AST) on admission delays from the emergency department (ED) to the stroke care unit (SCU) and on the subsequent length of stay (LOS) and in-hospital mortality.

METHODS

We retrospectively analysed data obtained from the Austin Hospital stroke unit database and the electronic medical record/patient tracking system for the 5 months before (August to December 2004) and after (January to May 2005) the introduction of the AST.

RESULTS

Data for 352 patients were extracted. Of these, there were 260 (73.9%) patients with ischaemic stroke, 38 (10.8%) with intracerebral haemorrhage and 54 (15.3%) with transient ischaemic attack (TIA). One hundred and seventy-two patients were admitted before and 180 after AST introduction. There were 70 AST calls from January to May 2005. Baseline characteristics of both groups were similar. Between the two groups, the median (Q1,Q3) time from door to CT scan was significantly reduced from 104 (60,149) to 82 (40,132) minutes. The LOS was significantly reduced from 6 (3,9) to 3 (2,7) days. There was no significant impact on mortality.

CONCLUSION

The introduction of AST has reduced the time from door to brain CT scan. This is an important finding as the window period for thrombolysis is short and early diagnosis is crucial.

Patients' and bystanders' awareness of stroke and pre-hospital delay after stroke onset: perspectives for thrombolysis in West Pomerania Province, Poland

OBJECTIVE

Thrombolysis is a time-dependent therapy. It is therefore very important how fast stroke patients can reach hospital. The present study was designed to assess which proportion of patients with stroke (from the population of Szczecin, the capital of West Pomerania Province, Poland) reaches hospital within the recommended time from the thrombolytic therapy point of view. The purpose of our study was also to elucidate which factors can influence the time before the ambulance service is called.

PATIENTS AND METHODS

The study involved 1,015 patients with stroke admitted to the Emergency Department of the University Hospital, Szczecin.

RESULTS

235 patients (23.1%) were admitted to the hospital within the appropriate period for thrombolytic therapy. Hospital arrival time was significantly earlier in older patients and in patients with severer neurological deficits. We also observed a tendency for faster hospitalization of women, the highly educated, and patients regularly using antiplatelet drugs for cardiovascular disease prevention.

CONCLUSIONS

The percentage of stroke patients hospitalized within 2 h after stroke onset should be increased. The most susceptible subpopulations in our country seem to be older patients, the highly educated and patients regularly using antiplatelet drugs for cardiovascular disease prevention.

Estimated Cost Savings of Increased Use of Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke in Canada

BACKGROUND AND PURPOSE

Intravenous tissue plasminogen activator (tPA) is an economically worthwhile but underused treatment option for acute ischemic stroke. We sought to identify the extent of tPA use in Canadian medical centers and the potential savings associated with increased use nationally and by province.

METHODS

We determined the nationwide annual incidence of ischemic stroke from the Canadian Institute of Health Information. The proportion of all ischemic stroke patients who received tPA was derived from published data. Economic analyses that report the expected annual cost savings of tPA were consulted. The analysis was conducted from the perspective of a universal health care system during 1 year. We estimated cost-savings with incrementally (eg, 2%, 4%, 6%, 8%, 10%, 15%, and 20%) increased use of tPA for acute ischemic stroke nationally and provincially.

RESULTS

The current average national tPA utilization is 1.4%. For every increase of 2 percentage points in utilization, $757,204 (Canadian) could possibly be saved annually (95% CI maximum loss of $3,823,992 to a maximum savings of $2,201,252). With a 20% rate, >$7.5 million (Canadian) could be saved nationwide the first year.

CONCLUSIONS

We estimate that even small increases in the proportion of all Canadian ischemic stroke patients receiving tPA could result in substantial realized savings for Canada's health care system.

Barriers to intravenous tissue plasminogen activator for acute stroke therapy in women

BACKGROUND

Given the increased lifetime risk of stroke and worse stroke outcomes in women, it is imperative to improve access to acute stroke therapy in the female population.

OBJECTIVE

The goals of this review were to analyze data comparing IV tissue plasminogen activator (tPA) use by sex, examine the literature regarding barriers to acute stroke therapy in women, and suggest areas for future research to improve understanding of these barriers as well as access in this population.

METHODS

The authors reviewed the MEDLINE literature (using the terms: stroke, women, gender, sex, tissue plasminogen activator, barriers, knowledge, risk factors, recognition, awareness, delay, presentation, access, and symptoms in various combinations) from January 1, 1996, through February 28, 2006, identified by various search strategies and the reference lists of retrieved articles.

RESULTS

Some evidence suggests that there may be less utilization of IV tPA in women compared with men. Stroke knowledge remains low for both sexes, but little is known about the recognition and translation of stroke symptoms in women. Although sex differences in out-of-hospital delays are not widespread, there is some evidence to suggest that, due to in-hospital delays during acute stroke, access to care may be more problematic for women. Overall, barriers to acute stroke therapy in women are not well understood.

CONCLUSION

tPA utilization is poor overall and may be poorer still in women than in men. Future research is needed to understand women's response to specific stroke symptoms, to elucidate sex differences in acute stroke symptom presentation, to determine reasons for in-hospital delays in women with stroke, and to understand sex-specific differences in response to acute stroke therapy. These research results may then aid in the development of intervention strategies that target women and affect physicians' decisions regarding the use of tPA in this population.

Cost-effectiveness of intravenous thrombolysis with alteplase within a 3-hour window after acute ischemic stroke

BACKGROUND AND PURPOSE

The aim of this study was to assess the costs and cost-effectiveness of intravenous thrombolysis treatment with alteplase (Actilyse) of acute ischemic stroke with 24-hour in-house neurology coverage and use of magnetic resonance imaging.

METHODS

A health economic model was designed to calculate the marginal cost-effectiveness ratios for time spans of 1, 2, 3 and 30 years. Effect data were extracted from a meta-analysis of six large-scale randomized and placebo-controlled studies of thrombolytic therapy with alteplase. Cost data were extracted from thrombolysis treatment at Aarhus Hospital, Denmark, and from previously published literature.

RESULTS

The calculated cost-effectiveness ratio after the first year was $55,591 US per quality-adjusted life-year (base case). After the second year, computation of the cost-effectiveness ratio showed that thrombolysis was cost-effective. The long-term computations (30 years) showed that thrombolysis was a dominant strategy compared with conservative treatment given the model premises.

CONCLUSIONS

A high-quality thrombolysis treatment with 24-hour in-house neurology coverage and magnetic resonance imaging might not be cost-effective in the short term compared with conservative treatment. In the long term, there are potentially large-scale health economic cost savings.