Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association's Task Force on the Development of Stroke Systems

Knowledge and Awareness of Stroke among the Elderly Population: Analysis of Data from a Sample of Older Adults in a Developing Country

Background and Objectives: Stroke prevention has traditionally concentrated on research to improve knowledge and awareness of the disease in the general population. Since stroke incidents increase with age, there is a need to focus on the elderly, a high-risk group for developing the disease. This study aimed to examine the level of stroke awareness and knowledge, their predictors, and their source of information. Materials and Methods: A prospective cross-sectional study targeted Lebanese senior citizens aged 65 years and above. A total of 513 participants enrolled in the study through a self-administered survey distributed using a snowball sampling technique. Results: Most participants had appropriate baseline knowledge (more than 75% correct answers) of stroke, including risk factors, alarming signs, and preventive measures. Better knowledge of disease risks was significantly associated with having a university degree (ORa = 1.609; p = 0.029). Participants who had previous ischemic attacks showed significantly lower knowledge of the alarming signs (ORa = 0.467; p = 0.036) and prevention measures (ORa = 0.427; p = 0.029). Those suffering from depression had better knowledge of stroke alarming signs (ORa = 2.060.; p = 0.050). Seeking information from pharmacists, physicians, or the internet was not significantly associated with better knowledge of stroke risks, alarming signs, and preventive measures. Conclusions: The present study showed that seniors had fair knowledge of stroke, despite gaps in stroke prevention measures. Healthcare providers could play a leading role in improving public health by educating seniors to enhance awareness about prevention measures, detecting alarming signs, and acting fast to save a life.

A Conceptual Framework for Optimizing the Equity of Hospital-Based Emergency Care: The Structure of Hospital Transfer Networks

Policy Points Current pay-for-performance and other payment policies ignore hospital transfers for emergency conditions, which may exacerbate disparities. No conceptual framework currently exists that offers a patient-centered, population-based perspective for the structure of hospital transfer networks. The hospital transfer network equity-quality framework highlights the external and internal factors that determine the structure of hospital transfer networks, including structural inequity and racism.

CONTEXT

Emergency care includes two key components: initial stabilization and transfer to a higher level of care. Significant work has focused on ensuring that local facilities can stabilize patients. However, less is understood about transfers for definitive care. To better understand how transfer network structure impacts population health and equity in emergency care, we proposea conceptual framework, the hospital transfer network equity-quality model (NET-EQUITY). NET-EQUITY can help optimize population outcomes, decrease disparities, and enhance planning by supporting a framework for understanding emergency department transfers.

METHODS

To develop the NET-EQUITY framework, we synthesized work on health systems and quality of health care (Donabedian, the Institute of Medicine, Ferlie, and Shortell) and the research framework of the National Institute on Minority Health and Health Disparities with legal and empirical research.

FINDINGS

The central thesis of our framework is that the structure of hospital transfer networks influences patient outcomes, as defined by the Institute of Medicine, which includes equity. The structure of hospital transfer networks is shaped by internal and external factors. The four main external factors are the regulatory, economic environment, provider, and sociocultural and physical/built environment. These environments all implicate issues of equity that are important to understand to foster an equitable population-based system of emergency care. The framework highlights external and internal factors that determine the structure of hospital transfer networks, including structural racism and inequity.

CONCLUSIONS

The NET-EQUITY framework provides a patient-centered, equity-focused framework for understanding the health of populations and how the structure of hospital transfer networks can influence the quality of care that patients receive.

Barriers to Gait Training among Stroke Survivors: An Integrative Review

Gait recovery is vital for stroke survivors' ability to perform their activities associated with daily living. Consequently, a gait impairment is a significant target for stroke survivors' physical rehabilitation. This review aims to identify barriers to gait training among stroke survivors. An integrative review was conducted following Whittemore and Knafl's methodology. The research was carried out on the electronic databases Scopus, PubMed, and B-on, applying a time span of 2006 to 2022. A total of 4189 articles were initially identified. After selecting and analyzing the articles, twelve studies were included in the sample. This review allowed for the identification of several barriers to gait training among stroke survivors, which can be grouped into three categories: individual, environmental, and rehabilitation workforce-related barriers. These findings highlight that participation in gait training is not solely dependent on the stroke survivor. Instead, the uptake of rehabilitation programs may also depend on environmental and rehabilitation workforce-related factors.

Exploring the Need for Mobile Application in Stroke Management by Informal Caregivers: A Qualitative Study

BACKGROUND

Mobile health (mHealth) has been considered as a prominent concept in digital health and is widely used and easily accessible. Periodic follow-up visits, previously planned procedures, and rehabilitation services for stroke survivors have been cut down during the recent COVID-19 pandemic. Therefore, in this qualitative study we aimed to explore the need for a mobile application in stroke management by informal caregivers.

METHODS

A phenomenological qualitative study was conducted from November 2020 to June 2021. Thirteen respondents were recruited from two public rehabilitation centers in Kota Bharu, Kelantan, Malaysia. In-depth interviews were conducted. A comprehensive representation of perspectives from the respondents was achieved through purposive sampling. The interviews were conducted in the Kelantanese dialect, recorded, transcribed, and analyzed by using thematic analysis.

RESULTS

Thirteen participants were involved in the interviews. All of them agreed with the need for a mobile application in stroke management. They believed the future stroke application will help them to seek information, continuous stroke home care, and help in the welfare of caregivers and stroke patients.

CONCLUSIONS

The current study revealed two themes with respective subthemes that were identified, namely, self-seeking for information and reasons for using a stroke mobile application in the future. This application helps in reducing healthcare costs, enhancing the rehabilitation process, facilitating patient engagement in decision making, and the continuous monitoring of patient health.

Implementation of the Helsinki Model at West Tallinn Central Hospital

Ischemic stroke is defined as neurological deficit caused by brain infarction. The intravenous tissue plasminogen activator, alteplase, is an effective treatment. However, efficacy of this method is time dependent. An important step in improving outcome and increasing the number of patients receiving alteplase is the shortening of waiting times at the hospital, the so-called door-to-needle time (DNT). The comprehensive Helsinki model was proposed in 2012, which enabled the shortening of the DNT to less than 20 min. Background and Objectives: The aim of this study was to analyze the transferability of the suggested model to the West Tallinn Central Hospital (WTCH). Materials and Methods: Since the first thrombolysis in 2005, all patients are registered in the WTCH thrombolysis registry. Several steps following the Helsinki model have been implemented over the years. Results: The results demonstrate that the number and also the percent of thrombolysed stroke patients increased during the years, from a few thrombolysis annually, to 260 in 2021. The mean DNT dropped significantly to 33 min after the implementation of several steps, from the emergency medical services (EMS) prenotification with a phone call to the neurologists, to the setting-up of a thrombolysis team based in the stroke unit. Also, the immediate start of treatment using a computed tomography table was introduced. Conclusions: In conclusion, several implemented steps enabled the shortening of the DNT from 30 to 25.2 min. Short DNTs were achieved and maintained only with EMS prenotification.

Emergency Medical Services Prenotification is Associated with Reduced Odds of In-Hospital Mortality in Stroke Patients

Objective: Arrival by emergency medical services (EMS) and prenotification among ischemic stroke patients is well-established to improve the timeliness and quality of stroke care, yet the association of prenotification with in-hospital mortality has not been previously described. Our cross-sectional study aimed to assess the association between EMS prenotification and in-hospital mortality for patients with acute ischemic stroke or transient ischemic attack.Methods: We analyzed data from the Massachusetts Paul Coverdell National Acute Stroke Program registry. Our study population included adult patients presenting by EMS with transient ischemic attack or acute ischemic stroke from non-health care settings between 2016 and 2020. We excluded patients who were comfort measures only on arrival or day after arrival. We used generalized estimating equations to assess the association between prenotification and in-hospital stroke mortality.Results: In the adjusted model, prenotification was associated with lower odds of in-hospital mortality (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.76-0.98). Other variables associated with in-hospital mortality were longer door-to-imaging interval (OR 1.03, 95% CI 1.03-1.04) and year of presentation (OR 0.91 for each year, 95% CI 0.88-0.93). Odds of in-hospital mortality also varied by insurance, race, and ethnicity.Conclusions: Prenotification by EMS was associated with reduced in-hospital mortality for patients with ischemic stroke and transient ischemic attack. These findings add to the large body of literature demonstrating the key role of EMS in the stroke systems of care. Our study underscores the importance of standardizing prehospital screening and triage, increasing rates of prenotification via feedback and education, and encouraging active collaborations between prehospital personnel and stroke-capable hospitals to increase in-hospital survival among patients with stroke and transient ischemic attack.

Current State of Stroke Care in the Philippines

Stroke remains the leading cause of disability and death in the Philippines. Evaluating the current state of stroke care, the needed resources, and the gaps in health policies and programs is crucial to decrease stroke-related mortality and morbidity effectively. This paper aims to characterize the Philippines' stroke system of care and network using the World Health Organization health system building blocks framework. To integrate existing national laws and policies governing stroke and its risk factors dispersed across many general policies, the Philippine Department of Health (DOH) institutionalized a national policy framework for preventing and managing stroke. Despite policy reforms, government financing coverage remains limited. In terms of access to medicines, the government launched its stroke medicine access program (MAP) in 2016, providing more than 1,000 vials of recombinant tissue plasminogen activator (rTPA) or alteplase subsidized to selected government hospitals across the country. However, DOH discontinued the program due to the lack of neuroimaging machines and organized system of care to support the provision of the said medicine. Despite limited resources, stroke diagnostics and treatment facilities are more concentrated in urban settings, mostly in private hospitals, where out-of-pocket expenditures prevail. These barriers to access are also reflective of the current state of human resource on stroke where medical specialists (e.g., neurologists) serve in the few tertiary and training hospitals situated in urban settings. Meanwhile, there is no established unified national stroke registry thus, determining the local burden of stroke remains a challenge. The lack of centralization and fragmentation of the stroke cases reporting system leads to reliance on data from hospital records or community-based stroke surveys, which may inaccurately depict the country's actual stroke incidence and prevalence. Based on these gaps, specific recommendations geared toward systems approach - governance, financing, information system, human resources for health, and medicines were identified.

Delta Sleep-Inducing Peptide Recovers Motor Function in SD Rats after Focal Stroke

Background and Objectives: Mutual effect of the preliminary and therapeutic intranasal treatment of SD rats with DSIP (8 days) on the outcome of focal stroke, induced with intraluminal middle cerebral occlusion (MCAO), was investigated. Materials and Methods: The groups were the following: MCAO + vehicle, MCAO + DSIP, and SHAM-operated. DSIP or vehicle was applied nasally 60 (±15) minutes prior to the occlusion and for 7 days after reperfusion at dose 120 µg/kg. The battery of behavioral tests was performed on 1, 3, 7, 14, and 21 days after MCAO. Motor coordination and balance and bilateral asymmetry were tested. At the end of the study, animals were euthanized, and their brains were perfused, serial cryoslices were made, and infarction volume in them was calculated. Results: Although brain infarction in DSIP-treated animals was smaller than in vehicle-treated animals, the difference was not significant. However, motor performance in the rotarod test significantly recovered in DSIP-treated animals. Conclusions: Intranasal administration of DSIP in the course of 8 days leads to accelerated recovery of motor functions.

Stroke follow-up in primary care: a discourse study on the discharge summary as a tool for knowledge transfer and collaboration

Background

The acute treatment for stroke takes place in hospitals and in Norway follow-up of stroke survivors residing in the communities largely takes place in general practice. In order to provide continuous post stroke care, these two levels of care must collaborate, and information and knowledge must be transferred between them. The discharge summary, a written report from the hospital, is central to this communication. Norwegian national guidelines for treatment of stroke, issued in 2010, therefore give recommendations on the content of the discharge summaries. One ambition is to achieve collaboration and knowledge transfer, contributing to integration of the health care services. However, studies suggest that adherence to guidelines in general practice is weak, that collaboration within the health care services does not work the way the authorities intend, and that health care services are fragmented.

This study aims to assess to what degree the discharge summaries adhere to the guideline recommendations on content and to what degree they are used as tools for knowledge transfer and collaboration between secondary and primary care.

Methods

The study was an analysis of 54 discharge summaries for home-dwelling stroke patients. The patients had been discharged from two Norwegian local hospitals in 2011 and 2012 and followed up in primary care. We examined whether content was according to guidelines’ recommendations and performed a descriptive and interpretative discourse analysis, using tools adapted from an established integrated approach to discourse analysis. 

Results

We found a varying degree of adherence to the different advice for the contents of the discharge summaries. One tendency was clear: topics relevant here and now, i.e. at the hospital, were included, while topics most relevant for the later follow-up in primary care were to a larger degree omitted. In most discharge summaries, we did not find anything indicating that the doctors at the hospital made themselves available for collaboration with primary care after dischargeof the patient.

Conclusions

The discharge summaries did not fulfill their potential to serve as tools for collaboration, knowledge transfer, and guideline implementation. Instead, they may contribute to sustain the gap between hospital medicine and general practice.

Quantifying the Impact of Acute Stroke System of Care Transfer Protocols on Patient Outcomes

BACKGROUND

We quantify the impact of implementing a stroke system of care requiring transport of individuals believed to have stroke to a primary stroke center, in rural and urban settings, based on time from symptom recognition to treatment, probability of receiving treatment within 3 hours of stroke onset, and probability of overcrowding. We use Indiana as an example.

METHODS

We used discrete-event simulation to estimate outcomes for 2 scenarios: stroke system of care with enabling technology (mobile stroke unit, stroke team expansion) and stroke system of care with no enabling technology, as compared with the status quo. We considered patient flow from symptom recognition to treatment. Patient locations and stroke events were generated for the 92 Indiana counties in Indiana, subdivided into 1009 locations. We considered time from emergency medical service (EMS) arrival at onset to treatment, probability of tissue plasminogen activator administered within 3 h of onset, and percentage of patients admitted beyond the occupancy level at the comprehensive stroke center.

RESULTS

Results varied by urbanicity. Under no enabling technology, having a stroke system of care improved outcomes for individuals in urban and suburban settings. However, in rural settings, the implementation of stroke system of care guidelines decreased the average rate of treatment within 3 h of stroke onset and increased the EMS arrival to treatment times compared with sending the individual to the closest provider. Enabling technologies improved outcomes regardless of setting.

DISCUSSION

Geographic disparities tend to increase the number of transfers, decrease the rate of treatment within 3 h of onset, and increase transit time. This could be overcome through federal and state initiatives to reduce quality gaps in stroke care in rural settings and promote care with dedicated stroke wards.

Vascular Teams in Peripheral Vascular Disease

Peripheral vascular disease affects millions of individuals worldwide, and results in significant morbidity and mortality. The complex nature of the disease, the presence of multiple comorbidities, and the existence of a wide variety of therapeutic options suggests that a multidisciplinary approach to treatment has the potential to improve care of these patients. The success of the heart team for complex coronary artery and structural heart disease could serve as a model for the efficient and effective management of patients with peripheral vascular disease. In this paper, the authors propose a multidisciplinary vascular team approach for the treatment of critical limb ischemia, pulmonary embolism, acute ischemic stroke, and acute aortic syndromes. The successful implementation of such vascular teams has the potential to significantly enhance quality of care, improve clinical outcomes, and reduce costs. Prospective evaluation is warranted to determine how to best integrate this approach into routine clinical care.

Comprehensive Stroke Center Certification Series: Setting the Vision

The road to Comprehensive Stroke Center (CSC) certification is challenging and requires full integration of neurological, neurosurgical, neurointerventional, and neurocritical care and rehabilitation services across the entire continuum of care. To successfully achieve this level of certification, centers must coordinate significant resources and services into an organized program. This paper is the first in a three-part series outlining common pitfalls facing many organizations during their journey to initial CSC certification and re-certification and offers a roadmap and pearls for success on this journey. Setting the vision for certification is a key first step in the certification process. This includes fully understanding the certification standards, requirements, and supporting documents. Program leadership must then conduct a thorough gap analysis and build a business plan to support the program as it transitions to a CSC. These key steps should inform the timeline for certification application.

What Is Stroke Certification and Does It Matter?

Many academic and community hospitals have obtained, or are considering obtaining, stroke center certification. Participation in structured quality improvement programs that also incorporate an objective assessment has been shown to improve outcomes and foster team building. Although obtaining certification can be challenging and costly, it can provide a framework to ensure hospitals deliver high- level, evidence-based stroke care. For the intensive care unit nurse, awareness and participation in the certification programs process is an important part of professional nursing practice.

The Association between Presentation by EMS and EMS Prenotification with Receipt of Intravenous Tissue-Type Plasminogen Activator in a State Implementing Stroke Systems of Care

Introduction: Collaboration between emergency medical services (EMS) and hospitals receiving stroke patients is critical to ensure prompt, effective treatment, and is a key component of the stroke systems of care (SSoC). The goal of our study was to evaluate the association between presentation by EMS and EMS prenotification with odds of receiving Tissue-type Plasminogen Activator (IV-tPA) in a state implementing SSoC while rigorously accounting for missing data. Methods: We utilized data from the Massachusetts Paul Coverdell Stroke Registry for this study, and analyzed adult patients presenting with ischemic stroke to Massachusetts Coverdell hospitals between 2016 and 2018. Patients with contraindications to IV-tPA were excluded. We used generalized estimating equations to assess associations between presentation by EMS, EMS prenotification, and receipt of IV-tPA. We also performed a sensitivity analysis using multiple imputation to assess the sensitivity of our findings to missing data. Results: We identified 9,230 eligible patients with ischemic stroke during the study period. In multivariate complete case regressions, presentation by EMS and EMS prenotification were associated with statistically significant increased odds of receiving IV-tPA (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.28-1.80, p-value < 0.01; OR 1.75, 95% CI 1.36-2.24, p-value < 0.01, respectively). Analysis of imputed data indicated level or stronger associations. Conlcusion: Our analysis indicates that presentation by EMS and EMS prenotification are associated with increased odds of receiving IV-tPA in a state implementing the SSoC. Our results lend importance to the critical role of EMS in the SSoC. Future interventions should work to increase rates of prenotification by EMS and assess inequities in receipt of IV-tPA.

Rates, Characteristics, and Outcomes of Patients Transferred to Specialized Stroke Centers for Advanced Care

Background While many patients are transferred to specialized stroke centers for advanced acute ischemic stroke (AIS) care, few studies have characterized these patients. We sought to determine variation in the rates and differences in the baseline characteristics and clinical outcomes between AIS cases presenting directly to stroke centers' front door versus Transfer-Ins from another hospital. Methods and Results We analyzed 970 390 AIS cases in the Get With The Guidelines-Stroke registry from January 2010 to March 2014 to compare hospitals with high Transfer-In rates (≥15%) versus those with low Transfer-In rates (<5%) and to compare the front-door versus Transfer-In patients admitted to those hospitals with high Transfer-In rates (high Transfer-In hospitals). Of 970 390 patients discharged from 1646 hospitals, 87% initially presented via the emergency department versus 13% were a Transfer-In from another hospital. High Transfer-In hospitals had a median 31% Transfer-In rate among all stroke discharges, were larger, had higher annual AIS volume and intravenous tPA (tissue-type plasminogen activator) rates, and were more often Midwest teaching hospitals and stroke centers. Compared with front-door, Transfer-In patients were younger, more often white, had higher median National Institutes of Health Stroke Scale scores, less often hypertension and previous stroke/transient ischemic attack, and higher in-hospital mortality (7.9% versus 4.9%; standardized difference, 12.4%). After multivariable adjustment, Transfer-In patients had higher in-hospital mortality and discharge modified Rankin scale. Conclusions There is significant regional variability in the transfer of patients with AIS. Because Transfer-In patients seem to have worse short-term outcomes, these patients have the potential to negatively influence institutional mortality rates and should be accounted for explicitly in hospital risk-profiling measures.

Quality Through Coopetition: An Empiric Approach to Measure Population Outcomes for Emergency Care-Sensitive Conditions

STUDY OBJECTIVE

We develop a novel approach for measuring regional outcomes for emergency care-sensitive conditions.

METHODS

We used statewide inpatient hospital discharge data from the Pennsylvania Healthcare Cost Containment Council. This cross-sectional, retrospective, population-based analysis used International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes to identify admissions for emergency care-sensitive conditions (ischemic stroke, ST-segment elevation myocardial infarction, out-of-hospital cardiac arrest, severe sepsis, and trauma). We analyzed the origin and destination patterns of patients, grouped hospitals with a hierarchical cluster analysis, and defined boundary shapefiles for emergency care service regions.

RESULTS

Optimal clustering configurations determined 10 emergency care service regions for Pennsylvania.

CONCLUSION

We used cluster analysis to empirically identify regional use patterns for emergency conditions requiring a communitywide system response. This method of attribution allows regional performance to be benchmarked and could be used to develop population-based outcome measures after life-threatening illness and injury.

Telemedicine in Rehabilitation

Telerehabilitation refers to the virtual delivery of rehabilitation services into the patient's home. This methodology has shown to be advantageous when used to enhance or replace conventional therapy to overcome geographic, physical, and cognitive barriers. The exponential growth of technology has led to the development of new applications that enable health care providers to monitor, educate, treat, and support patients in their own environment. Best practices and well-designed Telerehabilitation studies are needed to build and sustain a strong Telerehabilitation system that is integrated in the current health care structure and is cost-effective.

The results of implementation of specialized stroke units and educational programs aimed at the secondary prevention of stroke in Tyumen district

Aim. To evaluate the main results of work of specialized stroke units and departments and implementation of educational campaigns on secondary stroke prevention in Tyumen district in 2011-2017.

Material and methods. Work efficacy of specialized stroke units and departments in Tyumen district was evaluated according to standard measures (length of hospital stay, compliance with patient routing rules, timely diagnostic measures, frequency and efficacy of thrombolysis). The results of work of schools for stroke patients and their caregivers were evaluated using questionnaires distributed after the end of each educational program.

Results. We demonstrated an improvement of main efficacy measures of stroke units and departments, with most of them reaching target values for Russian Federation. There was a high attendance of educational programs on secondary stroke prevention (8254 persons during the study period). A total of 2200 distributed questionnaires demonstrated a high level of satisfaction with the results of educational programs and the quality of education organization.

Conclusion. Implementation of specialized stroke units in Tyumen district enabled an increase of the number of patients receiving systemic thrombolytic therapy, a decrease of mortality and an improvement of functional outcomes. Educational programs for stroke patients and their relatives increased the level of stroke awareness in the target population.

Risk-Appropriate Care to Improve Practice and Birth Outcomes

Identification and referral of women with high-risk pregnancies to hospitals better equipped and staffed to provide care for them have been important steps to improve birth outcomes. Based on recent recommendations from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine to provide regionalized maternal care for pregnant women at high risk and reduce rates of maternal morbidity and mortality, health care organizations and providers have refocused their attention to women's well-being rather than solely on the well-being of the fetus or newborn. Opportunities to improve practice and birth outcomes exist through the implementation of a more standardized and integrated system of risk-appropriate care.

Long-Term Outcomes of Out-of-Hospital Cardiac Arrest Care at Regionalized Centers

STUDY OBJECTIVE

It is unknown whether regionalization of postarrest care by interfacility transfer to cardiac arrest receiving centers reduces mortality. We seek to evaluate whether treatment at a cardiac arrest receiving center, whether by direct transport or early interfacility transfer, is independently associated with long-term outcome.

METHODS

We performed a retrospective cohort study including adults resuscitated from out-of-hospital cardiac arrest in southwestern Pennsylvania and neighboring Ohio, West Virginia, and Maryland, which includes approximately 5.7 million residents in urban, suburban, and rural counties. Patients were treated by 1 of 78 ground emergency medical services agencies or 2 air medical transport agencies between January 1, 2010, and November 30, 2014. Our primary exposures of interest were interfacility transfer to a cardiac arrest receiving center within 24 hours of arrest or any treatment at a cardiac arrest receiving center regardless of transfer status. Our primary outcome was vital status, assessed through December 31, 2014, with National Death Index records. We used unadjusted and adjusted survival analyses to test the independent association of cardiac arrest receiving center care, whether through direct or interfacility transport, on mortality.

RESULTS

Overall, 5,217 cases were observed for 3,629 person-years, with 3,865 total deaths. Most patients (82%) were treated at 42 non-cardiac arrest receiving centers with median annual volume of 17 cases (interquartile range 1 to 53 cases per center annually), whereas 18% were cared for at cardiac arrest receiving centers receiving at least 1 interfacility transfer per month. In adjusted models, treatment at a cardiac arrest receiving center was independently associated with reduced hazard of death compared with treatment at a non-cardiac arrest receiving center (adjusted hazard ratio 0.84; 95% confidence interval 0.74 to 0.94). These effects were unchanged when analysis was restricted to patients brought from the scene to the treating hospital. No other hospital characteristic, including total out-of-hospital cardiac arrest patient volume and cardiac catheterization capabilities, independently predicted outcome.

CONCLUSION

Both early interfacility transfer to a cardiac arrest receiving center and direct transport to a cardiac arrest receiving center from the scene are independently associated with reduced mortality.

Community-based stroke system of care improves patient outcomes in Chinese rural areas

BACKGROUND

Building effective and efficient stroke care systems is a key step in improving prevention, treatment and rehabilitation of stroke. The aim of this study was to evaluate the effectiveness of this stroke system of care on stroke management during a 2-year follow-up.

METHODS

A stroke system of care was developed from November 2009 to November 2010 in three townships in Ganyu County. Additional three matched townships were invited as controls. We first investigated the stroke incidence of these populations. Subsequently, this stroke system of care and an educational campaign in the three intervention townships were implemented and the effectiveness of the system was evaluated in the next 2 years.

RESULTS

At postintervention, more patients in the intervention communities obtained stroke knowledge and then the proportion of patients with stroke who were admitted within 3 hours of onset markedly increased in 2012 (12.0% vs 8.1%, p=0.044) and in 2013 (15.2% vs 9.7%, p=0.008) compared with those in the control communities. In the intervention communities, this proportion of patients with acute ischaemic stroke who received thrombolytic treatment was markedly raised from 2.1% in 2012 to 3.0% in 2013. More importantly, the fatality rate substantially decreased in 2013 in the intervention communities compared with that in the control communities (6.1% vs 9.7%, p=0.032). Similarly, the disability rate significantly decreased in 2013 (45.3% vs 51.5%, p=0.045).

CONCLUSIONS

The community-based stroke system of care was effective and practical for optimising stroke treatments and improving patient outcomes.

TRIAL REGISTRATION NUMBER

ChiCTR-RCH-13003408, Post-results.

The American Heart Association's Get With the Guidelines (GWTG)-Stroke development and impact on stroke care

The American Heart Association’s Get With the Guidelines (GWTG)-Stroke programme has changed stroke care delivery in the USA since its establishment in 2003. GWTG is a voluntary registry and continuous quality improvement initiative that collects data on patient characteristics, hospital adherence to guidelines and inpatient outcomes. Implementation of the programme saw increased provision of evidence-based care and improved patient outcomes. This review will describe the development of the programme and discuss the impact on stroke outcomes and transformation of stroke care delivery that followed its implementation.

Stroke and Helicopter Emergency Medical Service Transports: An Analysis of 25,332 Patients

OBJECTIVE

Helicopter emergency medical services (HEMS) are effective in time-sensitive illnesses, including stroke. Intravenous tissue plasminogen activator is beneficial for ischemic stroke within 4.5 hours of onset. This study analyzed the largest repository of US HEMS electronic medical record data characterizing demographic and logistical trends during stroke center accreditation. This study developed a methodology to aggregate, analyze, and report data from multiple providers.

METHODS

This is a descriptive study of aggregate, deidentified data from 67 US providers from 2004 to 2011. Retrospective data including age, ethnicity, total transport time, mission type, and locality were analyzed. The effect of primary stroke center (PSC) designation was assessed for 2011.

RESULTS

A total of 25,332 patients were transported for "stroke." Stroke increased from 1.4% to 3.9% during the study. Ninety-six percent of transports arrived at definitive care within 2 hours. Seventy-two percent of transports were "interfacility," and 58% were from "rural" or "super-rural" localities. Seventy-nine percent of 2011 transports were to PSCs. Ethnicity and age were significant barriers to transport to PSCs (P < .001).

CONCLUSIONS

HEMS has increased access to stroke care for super-rural, rural, and urban communities offering timely transport within the treatment window if symptoms are recognized within 2.5 hours of onset. This study created a methodology for future multicenter aggregate data studies.

Telemedicine Quality and Outcomes in Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

Telestroke is one of the most frequently used and rapidly expanding applications of telemedicine, delivering much-needed stroke expertise to hospitals and patients. This document reviews the current status of telestroke and suggests measures for ongoing quality and outcome monitoring to improve performance and to enhance delivery of care.

METHODS

A literature search was undertaken to examine the current status of telestroke and relevant quality indicators. The members of the writing committee contributed to the review of specific quality and outcome measures with specific suggestions for metrics in telestroke networks. The drafts were circulated and revised by all committee members, and suggestions were discussed for consensus.

RESULTS

Models of telestroke and the role of telestroke in stroke systems of care are reviewed. A brief description of the science of quality monitoring and prior experience in quality measures for stroke is provided. Process measures, outcomes, tissue-type plasminogen activator use, patient and provider satisfaction, and telestroke technology are reviewed, and suggestions are provided for quality metrics. Additional topics include licensing, credentialing, training, and documentation.

Society of Vascular and Interventional Neurology (SVIN) Stroke Interventional Laboratory Consensus (SILC) Criteria: A 7M Management Approach to Developing a Stroke Interventional Laboratory in the Era of Stroke Thrombectomy for Large Vessel Occlusions

Brain attack care is rapidly evolving with cutting-edge stroke interventions similar to the growth of heart attack care with cardiac interventions in the last two decades. As the field of stroke intervention is growing exponentially globally, there is clearly an unmet need to standardize stroke interventional laboratories for safe, effective, and timely stroke care. Towards this goal, the Society of Vascular and Interventional Neurology (SVIN) Writing Committee has developed the Stroke Interventional Laboratory Consensus (SILC) criteria using a 7M management approach for the development and standardization of each stroke interventional laboratory within stroke centers. The SILC criteria include: (1) manpower: personnel including roles of medical and administrative directors, attending physicians, fellows, physician extenders, and all the key stakeholders in the stroke chain of survival; (2) machines: resources needed in terms of physical facilities, and angiography equipment; (3) materials: medical device inventory, medications, and angiography supplies; (4) methods: standardized protocols for stroke workflow optimization; (5) metrics (volume): existing credentialing criteria for facilities and stroke interventionalists; (6) metrics (quality): benchmarks for quality assurance; (7) metrics (safety): radiation and procedural safety practices.

The Relationships Among Regionalization, Processes, and Outcomes for Stroke Care: A Nationwide Population-based Study

Regionalization for stroke care, including stroke center designation, is being implemented in the United States, Canada, or other countries. Limited information is available, however, concerning the relationships among regionalization, processes, and outcomes for stroke care. We examined the association of regionalization with processes and outcomes, and the mediating effect of processes of care on the association between regionalization and mortality for acute stroke in Taiwan. We analyzed all 229,568 admissions with acute ischemic stroke from January 2004 to September 2012 through Taiwan's National Health Insurance Research Database. Regionalized care for acute stroke has been implemented since July 2009 in Taiwan. Rates of thrombolytic therapy within 3 hours after onset of ischemic stroke, average numbers of processes of care, and 30-day mortality rates at monthly intervals for baseline (66 months) and 39 months after the implementation of regionalization. After accounting for secular trends and other confounders, changes in rates of thrombolytic therapy (level change 0.269% per month, P = 0.017 and trend change 0.010% per month, P = 0.048), average numbers of processes of care (trend change 0.001 per month, P = 0.030), and 30-day mortality rates (level change -0.442% per month, P = 0.007 and trend change -0.021% per month, P = 0.015) were attributable to regionalization. The processes of care were mediators of the association between regionalization and 30-day mortality after stroke. Regionalization for stroke care may improve timeliness and processes of stroke care, including access to timely thrombolytic therapy from emergency medical services to hospital care, which may in turn enhance stroke outcomes.

Changing Management of Acute Ischaemic Stroke: the New Treatments and Emerging Role of Endovascular Therapy

OPINION STATEMENT

Urgent reperfusion of the ischaemic brain is the aim of stroke treatment, and the last two decades have seen a rapid advancement in the medical and endovascular treatment of acute ischaemic stroke. Intravenous tissue plasminogen activator (tPA) was first introduced as a safe and effective thrombolytic agent followed by the introduction of newer thrombolytic agents as well as anticoagulant and antiplatelet agents, proposed as potentially safer drugs with more favourable interaction profiles. In addition to chemo-thrombolysis, other techniques including transcranial sonothrombolysis and microbubble cavitation have been introduced which are showing promising results, but await large-scale clinical trials. These developments in medical therapies which are undoubtedly of great importance due to their potential widespread and immediate availability are paralleled with gradual but steady improvements in endovascular recanalisation techniques which were initiated by the introduction of the MERCI (Mechanical Embolus Removal in Cerebral Ischemia) and Penumbra systems. The introduction of the Solitaire device was a significant achievement in reliable and safe endovascular recanalisation and was followed by further innovative stent retrievers. Initial trials failed to show a solid benefit in endovascular intervention compared with IV-tPA alone. These counterintuitive results did not last long, however, when a series of very well-designed randomised controlled trials, pioneered by MR-CLEAN, EXTEND-IA and ESCAPE, emerged, confirming the well-believed daily anecdotal evidence. There have now been seven positive trials of endovascular treatment for acute ischaemic stroke. Now that level I evidence regarding the superiority of endovascular recanalisation is abundantly available, the clinical challenge is how to select patients suitable for intervention and to familiarise and educate stroke care providers with this recent development in stroke care. It is important for the interventional services to be provided only in comprehensive stroke centres and endovascular interventions attempted by experienced well-trained operators, at this stage as an adjunct to the established medical treatment of IV-tPA, if there are no contraindications.

Using Puppets to Teach Schoolchildren to Detect Stroke and Call 911

To overcome barriers to improved outcomes, we undertook an intervention to teach schoolchildren how to detect a stroke and call emergency medical services (EMS). We obtained permission from parents and guardians to use an 8-min puppet show to instruct the fourth, fifth, and sixth graders about stroke detection, symptomatology, and calling EMS. A pretest and three posttests-one immediately following the presentation, one at 3 months, and a third at 6 months-were administered. Responses from 282 students were evaluable. Significant improvements (p < .001) in knowledge were found through all posttests in identifying what parts of the body stroke affected and through the first two posttests in recognizing symptoms stroke victims experienced. Students demonstrated at pretest a high awareness of EMS and 911 (97.5%) and showed slight, but not significant, improvement over time.

Development of regional stroke programs

The organization of stroke care has undergone a dramatic evolution in the USA over the last two decades. Beginning with the recommendation for Primary Stroke Centers (PSCs) in 1994, there has been a concerted effort by physicians, the American Heart Association/American Stroke Association (AHA/ASA), National Institutes of Health (NIH), and state legislatures to advance an evidence-based system of care with several tiers of stroke centers. At the apex of this structure are Regional Stroke Centers (RSCs), which do not have official recognition like PSCs and Comprehensive Stroke Centers (CSCs), but their existence as a hub for the many disparate spokes of stroke care in their region is increasingly necessary. Observational evidence suggests that this approach is improving the delivery of stroke care and reducing costs in the USA. Similar efforts are being made in Europe and Asia with encouraging results. The RSC model has the potential to lead to more uniform evidence-based stroke medicine, but many challenges exist.

Diastolic myocardial dysfunction by tissue Doppler imaging predicts mortality in patients with cerebral infarction

Several clinical prediction score models have been investigated for predicting mortality in patients with cerebral infarction. However, none of these include echocardiographic measures. Our objective was to evaluate the prognostic value of tissue Doppler imaging (TDI) of the myocardium in patients with cerebral infarction. Two hundred forty-four patients with cerebral infarction and subsequent echocardiographic examination in sinus rhythm were identified. Using TDI in three apical projections, longitudinal mitral annular velocities were obtained in six segments. Cox regression models, C-statistics and reclassification analysis were performed for global and segmental e'. During a median follow-up of 3 years 42 patients died. Patients who died had significantly impaired systolic and diastolic function (determined by LVEF and E/e'). The risk of dying increased with decreasing global e', being approximately 13 times higher for patients in the lowest tertile compared to patients in the highest tertile (HR 13.4 [3.2;56.3], p < 0.001). Patients with significantly impaired global e' showed increased mortality after multivariable adjustment for: LVEF, E/e', age, gender, heart failure, chronic obstructive pulmonary disease, prior cerebral infarction, ischemic heart disease, cancer, hypertension, hypercholesterolemia, carotid stenosis, mitral regurgitation, liver disease and thromboembolisms (HR 1.9 [1.1;3.2]), per 1 cm/s decrease, p < 0.05). Similar pattern was seen in segmental analyses of the e'. In contrast to e', no conventional echocardiographic parameters remained independent predictors of mortality after multivariable adjustment. Diastolic myocardial dysfunction determined as e' by TDI is a significant predictor of mortality in patients with cerebral infarction. Applying this parameter can aid the prognostic assessment after cerebral infarction.

An Analysis of Spatial Clustering of Stroke Types, In-hospital Mortality, and Reported Risk Factors in Alberta, Canada, Using Geographic Information Systems

BACKGROUND

Despite advances in the quality and delivery of stroke care, regional disparities in stroke incidence and outcome persist. Spatial analysis using geographic information systems (GIS) can assist in identifying high-risk populations and regional differences in efficacy of stroke care. The aim of this study was to identify and locate geographic clusters of high or low rates of stroke, risk factors, and in-hospital mortality across a provincial health care network in Alberta, Canada.

METHODS

This study employed a spatial epidemiological approach using population-based hospital administrative data. Getis-Ord Gi* and Spatial Scan statistics were used to identify and locate statistically significant "hot" and "cold" spots of stroke occurrence by type, risk factors, and in-hospital mortality.

RESULTS

Marked regional variations were found. East central Alberta was a significant hot spot for ischemic stroke (relative risk [RR] 1.43, p<0.001), transient ischemic attack (RR 2.25, p<0.05), and in-hospital mortality (RR 1.50, p<0.05). Hot spots of intracerebral hemorrhage (RR 1.80, p<0.05) and subarachnoid hemorrhage (RR 1.64, p<0.05) were identified in a major urban centre. Unexpectedly, stroke risk factor hot spots (RR 2.58, p<0.001) were not spatially associated (did not overlap) with hot spots of ischemic stroke, transient ischemic attack, or in-hospital mortality.

CONCLUSIONS

Integration of health care administrative data sets with geographic information systems contributes valuable information by identifying the existence and location of regional disparities in the spatial distribution of stroke occurrence and outcomes. Findings from this study raise important questions regarding why regional differences exist and how disparities might be mitigated.

Optimization modeling to maximize population access to comprehensive stroke centers

OBJECTIVE

The location of comprehensive stroke centers (CSCs) is critical to ensuring rapid access to acute stroke therapies; we conducted a population-level virtual trial simulating change in access to CSCs using optimization modeling to selectively convert primary stroke centers (PSCs) to CSCs.

METHODS

Up to 20 certified PSCs per state were selected for conversion to maximize the population with 60-minute CSC access by ground and air. Access was compared across states based on region and the presence of state-level emergency medical service policies preferentially routing patients to stroke centers.

RESULTS

In 2010, there were 811 Joint Commission PSCs and 0 CSCs in the United States. Of the US population, 65.8% had 60-minute ground access to PSCs. After adding up to 20 optimally located CSCs per state, 63.1% of the US population had 60-minute ground access and 86.0% had 60-minute ground/air access to a CSC. Across states, median CSC access was 55.7% by ground (interquartile range 35.7%-71.5%) and 85.3% by ground/air (interquartile range 59.8%-92.1%). Ground access was lower in Stroke Belt states compared with non-Stroke Belt states (32.0% vs 58.6%, p = 0.02) and lower in states without emergency medical service routing policies (52.7% vs 68.3%, p = 0.04).

CONCLUSION

Optimal system simulation can be used to develop efficient care systems that maximize accessibility. Under optimal conditions, a large proportion of the US population will be unable to access a CSC within 60 minutes.

Disparities in accessibility of certified primary stroke centers

BACKGROUND AND PURPOSE

We examine whether the proportion of the US population with ≤60 minute access to Primary Stroke Centers (PSCs) varies based on geographic and demographic factors.

METHODS

Population level access to PSCs within 60 minutes was estimated using validated models of prehospital time accounting for critical prehospital time intervals and existing road networks. We examined the association between geographic factors, demographic factors, and access to care. Multivariable models quantified the association between demographics and PSC access for the entire United States and then stratified by urbanicity.

RESULTS

Of the 309 million people in the United States, 65.8% had ≤60 minute PSC access by ground ambulance (87% major cities, 59% minor cities, 9% suburbs, and 1% rural). PSC access was lower in stroke belt states (44% versus 69%). Non-whites were more likely to have access than whites (77% versus 62%), and Hispanics were more likely to have access than non-Hispanics (78% versus 64%). Demographics were not meaningfully associated with access in major cities or suburbs. In smaller cities, there was less access in areas with lower income, less education, more uninsured, more Medicare and Medicaid eligibles, lower healthcare utilization, and healthcare resources.

CONCLUSIONS

There are significant geographic disparities in access to PSCs. Access is limited in nonurban areas. Despite the higher burden of cerebrovascular disease in stroke belt states, access to care is lower in these areas. Selecting demographic and healthcare factors is strongly associated with access to care in smaller cities, but not in other areas, including major cities.

Mechanisms of action of hyperbaric oxygenation in stroke: a review

This article outlines the therapeutic mechanisms of hyperbaric oxygenation in acute stroke, based on information obtained from peer-reviewed medical literature. Hyperbaric oxygen is an approved treatment modality for ischemia-reperfusion injury in several conditions. It maintains the viability of the marginal tissue, reduces the mitochondrial dysfunction, metabolic penumbra, and blocks inflammatory cascades observed in acute stroke. Basic and clinical data suggest that hyperbaric oxygen could be a safe and effective treatment option in the management of acute stroke. Further work is needed to clarify its clinical utility when applied within the treatment window of "gold standard" treatments (<3-5 hours).

Compliance with acute stroke care quality measures in hospitals with and without primary stroke center certification: the North Carolina Stroke Care Collaborative

Background

Organized stroke care is associated with improved outcomes. Data are limited on differences in changes in the quality of acute stroke care at The Joint Commission–certified Primary Stroke Centers (PSCs) versus non‐PSCs over time.

Methods and Results

We compared compliance with the Joint Commission's 10 acute stroke care performance measures and defect‐free care in PSCs and non‐PSCs participating in the Registry of the North Carolina Stroke Care Collaborative from January 2005 through February 2010. We included 29 654 cases presenting at 47 hospitals—10 PSCs, 8 preparing for certification, and 29 non‐PSCs—representing 43% of North Carolina's non–Veterans Affairs, acute care hospitals. Using a non‐PSC referent, odds ratios and 95% CIs were calculated using logistic regression and generalized estimating equations accounting for clustering of cases within hospitals. Time trends were presented graphically using simple linear regression. Performance measure compliance increased for all measures for all 3 groups in 2005–2010, with the exception of discharge on antithrombotics, which remained consistently high. PSCs and hospitals preparing for certification had better compliance with all but 2 performance measures compared with non‐PSCs (each P<0.01). Defect‐free care was delivered most consistently at hospitals preparing for certification (52.8%), followed by PSCs (45.0%) and non‐PSCs (21.9%). Between 2005 and 2010, PSCs and hospitals preparing for certification had a higher average annual percent increase in the provision of defect‐free care (P=0.01 and 0.04, respectively) compared with non‐PSCs.

Conclusions

PSC certification is associated with an overall improvement in the quality of stroke care in North Carolina; however, room for improvement remains.

Modern medical management of acute ischemic stroke

The modern management of patients with ischemic stroke begins by having a system in place that organizes the provision of preventive, acute treatment, and rehabilitative services. In the acute setting, initial evaluation is aimed at rapidly establishing a diagnosis by excluding stroke mimics, distinguishing between ischemic and hemorrhagic strokes, and determining if the patient is a candidate for treatment with intravenous tissue plasminogen activator (IV-tPA, alteplase). In some centers, select patients who do not qualify for administration of IV-tPA may be considered for endovascular intervention. General measures include the use of platelet antiaggregants, treatment of fever, blood pressure management, and continuation of statins if the patient has already been taking them. Post-acute evaluation and management is aimed at secondary prevention and optimizing recovery, including recognition and treatment of post-stroke depression.

Prenotification and other factors involved in rapid tPA administration

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.

Prehospital factors determining regional variation in thrombolytic therapy in acute ischemic stroke

BACKGROUND

Treatment rates with intravenous tissue plasminogen activator vary by region, which can be partially explained by organizational models of stroke care. A recent study demonstrated that prehospital factors determine a higher thrombolysis rate in a centralized vs. decentralized model in the north of the Netherlands.

AIM

To investigate prehospital factors that may explain variation in thrombolytic therapy between a centralized and a decentralized model.

METHODS

A consecutive case observational study was conducted in the north of the Netherlands comparing patients arriving within 4·5 h in a centralized vs. decentralized stroke care model. Factors investigated were transportation mode, prehospital diagnostic accuracy, and preferential referral of thrombolysis candidates. Potential confounders were adjusted using logistic regression analysis.

RESULTS

A total of 172 and 299 arriving within 4·5 h were enrolled in centralized and decentralized settings, respectively. The rate of transportation by emergency medical services was greater in the centralized model (adjusted odds ratio 3·11; 95% confidence interval, 1·59-6·06). Also, more misdiagnoses of stroke occurred in the central model (P = 0·05). In postal code areas with and without potential preferential referral of thrombolysis candidates due to overlapping catchment areas, the odds of hospital arrival within 4·5 h in the central vs. decentral model were 2·15 (95% confidence interval, 1·39-3·32) and 1·44 (95% confidence interval, 1·04-2·00), respectively.

CONCLUSIONS

These results suggest that the larger proportion of patients arriving within 4·5 h in the centralized model might be related to a lower threshold to use emergency services to transport stroke patients and partly to preferential referral of thrombolysis candidates.