The effect of a stroke unit: reductions in mortality, discharge rate to nursing home, length of hospital stay, and cost. A community-based study

Healthcare Professionals' Experiences with Functional Independence Measure (FIM) as a Structured Framework for Interprofessional Team Meetings in Danish Stroke Rehabilitation: A Qualitative Cross-Sectoral Collaborative Study

Purpose

An ethnographic and phenomenological mapping of the experiences of healthcare professionals with the functional independence measure (FIM) in stroke rehabilitation.

Methods

This is a cross-sectoral qualitative study with triangulation of data from two focus group interviews, 15 individual interviews, and 11 participant observations of FIM assessments performed by six different healthcare professions in interprofessional teams. FIM assessments were performed at hospital and in a community rehabilitation centre as interprofessional meetings with a local facilitator certified in FIM.

Results

Three overarching themes, learning space, improved interprofessional collaboration, and transferability, emerged from the data. The use of FIM within the provided structures established an environment that allowed the various healthcare professionals (HCP) to learn with, about, and from each other. This is perceived as promoting interprofessional collaboration and enhancing patient-specific knowledge within the interprofessional team. The established patient-specific knowledge is specific to the individual team and is difficult to transfer intraorganisationally and across sectors.

Conclusion

FIM was a catalyst for improved interprofessional knowledge transfer and interprofessional collaboration within the individual teams, but intraorganisational and cross-sectoral dissemination of patient-specific knowledge was limited.

Delivery of acute ischaemic stroke treatments in the European region in 2019 and 2020

INTRODUCTION

We assessed best available data on access and delivery of acute stroke unit (SU) care, intravenous thrombolysis (IVT) and endovascular treatment (EVT) in the European region in 2019 and 2020.

PATIENTS AND METHODS

We compared national data per number of inhabitants and per 100 annual incident first-ever ischaemic strokes (AIIS) in 46 countries. Population estimates and ischaemic stroke incidence were based on United Nations data and the Global Burden of Disease Report 2019, respectively.

RESULTS

The estimated mean number of acute SUs in 2019 was 3.68 (95% CI: 2.90-4.45) per one million inhabitants (MIH) with 7/44 countries having less than one SU per one MIH. The estimated mean annual number of IVTs was 21.03 (95% CI: 15.63-26.43) per 100,000 and 17.14% (95% CI: 12.98-21.30) of the AIIS in 2019, with highest country rates at 79.19 and 52.66%, respectively, and 15 countries delivering less than 10 IVT per 100,000. The estimated mean annual number of EVTs in 2019 was 7.87 (95% CI: 5.96-9.77) per 100,000 and 6.91% (95% CI: 5.15-8.67) of AIIS, with 11 countries delivering less than 1.5 EVT per 100,000. Rates of SUs, IVT and EVT were stable in 2020. There was an increase in mean rates of SUs, IVT and EVT compared to similar data from 2016.

CONCLUSION

Although there was an increase in reperfusion treatment rates in many countries between 2016 and 2019, this was halted in 2020. There are persistent major inequalities in acute stroke treatment in the European region. Tailored strategies directed to the most vulnerable regions should be prioritised.

The history of Danish neuroscience

The history of Danish neuroscience starts with an account of impressive contributions made at the 17th century. Thomas Bartholin was the first Danish neuroscientist, and his disciple Nicolaus Steno became internationally one of the most prominent neuroscientists in this period. From the start, Danish neuroscience was linked to clinical disciplines. This continued in the 19th and first half of the 20th centuries with new initiatives linking basic neuroscience to clinical neurology and psychiatry in the same scientific environment. Subsequently, from the middle of the 20th century, basic neuroscience was developing rapidly within the preclinical university sector. Clinical neuroscience continued and was even reinforced during this period with important translational research and a close co-operation between basic and clinical neuroscience. To distinguish 'history' from 'present time' is not easy, as many historical events continue in present time. Therefore, we decided to consider 'History' as new major scientific developments in Denmark, which were launched before the end of the 20th century. With this aim, scientists mentioned will have been born, with a few exceptions, no later than the early 1960s. However, we often refer to more recent publications in documenting the developments of initiatives launched before the end of the last century. In addition, several scientists have moved to Denmark after the beginning of the present century, and they certainly are contributing to the present status of Danish neuroscience-but, again, this is not the History of Danish neuroscience.

The Sky's the Limit: Expanding Nursing's Contribution to Acute Stroke Science

Stroke is the number one cause of preventable disability in adults in the United States. Significant advances have occurred in medications and technology supporting rapid stroke diagnosis and treatment during the past 30 years, along with blurring of the lines of what traditionally constituted nursing or medical research. Ischemic stroke is a disease of vascular insufficiency that mirrors myocardial infarction more than any other neurologic diagnosis. My primary program of research is focused on exploration of methods to improve intracranial blood flow in patients with hyperacute ischemic stroke who have viable, yet vulnerable, brain tissue to prevent worsening or enable improvement of stroke symptoms. I am also examining augmentation of recombinant tissue plasminogen activator treatment and stimulation of both arteriogenesis and angiogenesis with external counter-pulsation in patients with intracranial atherosclerosis. My secondary program of research focuses on methods to improve stroke systems of care, including improvement of advance practice providers' contributions to acute stroke care, use of innovative mobile stroke units, and improvement of quality core measure processes. Lessons learned along the way are highlighted, along with the value of interdisciplinary "team science" to build knowledge and enhance the care of highly vulnerable patients with acute stroke.

Overview of Acute Ischemic Stroke Evaluation and Management

Stroke is a major contributor to death and disability worldwide. Prior to modern therapy, post-stroke mortality was approximately 10% in the acute period, with nearly one-half of the patients developing moderate-to-severe disability. The most fundamental aspect of acute stroke management is "time is brain". In acute ischemic stroke, the primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction. Several landmark endovascular thrombectomy trials were found to be of benefit in select patients with acute stroke caused by occlusion of the proximal anterior circulation, which has led to a paradigm shift in the management of acute ischemic strokes. In this modern era of acute stroke care, more patients will survive with varying degrees of disability post-stroke. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation. In this article, we provide an overview on the evaluation and the current advances in the management of acute ischemic stroke, starting in the prehospital setting and in the emergency department, followed by post-acute stroke hospital management and rehabilitation.

The effect of transcranial direct current stimulation combined with functional task training on motor recovery in stroke patients

BACKGROUND

Motor deficits are common after stroke and are a major contributor to stroke-related disability and the potential for long-lasting neurobiological consequences of stroke remains unresolved. There are only a few treatments available for the improvement of motor function in stroke patients. However, the mechanisms underlying stroke recovery remain poorly understood, and effective neurorehabilitation interventions remain insufficiently proven for widespread implementation.

METHODS

Herein, we propose to enhance the effects of brain plasticity using a powerful noninvasive technique for brain modulation consisting of navigated transcranial magnetic stimulation (TMS) priming with transcranial direct current stimulation (tDCS) in combination with motor-training-like constraint-induced movement therapy (CIMT). Our hypothesis is that navigated low-frequency rTMS stimulus priming with precise location provided by neuronavigation on the healthy side of the brain and with anodal tDCS on the affected side combined with CIMT will induce a greater motor function improvement than that obtained with sham tDCS combined with CIMT alone. We predict that the application of this technique will result in a large reduction in cortical excitability and dis-inhibition in the affected hemisphere and lead to improvements in behavioral measures of hand function in stroke patients.

DISCUSSION

The proposed study, therefore, is important for several reasons. The results could potentially lead to improved stroke therapeutics, and the approach makes use of 2 potential pathways to modulate brain function.

TRIAL REGISTRATION

This study protocol was registered in Clinical Trials Registry (https://clinicaltrials.gov/ct2/show/NCT04646577).

ETHICS AND DISSEMINATION

The study has been reviewed and approved by the Human Research Ethics Committee of the King Fahad Specialist Hospital Dammam. The results will be actively disseminated through peer-reviewed journals, conference presentations, social media, broadcast media, print media, the internet and various community/stakeholder engagement activities.

Patients With Acute Ischemic Stroke Who Receive Brain Magnetic Resonance Imaging Demonstrate Favorable In-Hospital Outcomes

Background

Use of inpatient brain magnetic resonance imaging (MRI) in patients with acute ischemic stroke is highly institution dependent and has been associated with increased length and cost of hospital stay. We examined whether inpatient brain MRI in patients with acute ischemic stroke is associated with improved clinical outcomes to justify its resource requirements.

Methods and Results

The National Inpatient Sample database was queried retrospectively to find 94 003 patients who were admitted for acute ischemic stroke and then received inpatient brain MRI between 2012 and 2014. Multivariable regression analysis was performed with respect to a control group to assess for differences in the rates of inpatient mortality and complications, as well as the length and cost of hospital stay based on brain MRI use. Inpatient brain MRI was independently associated with lower rates of inpatient mortality (1.67% versus 3.09%; adjusted odds ratio [OR], 0.60; 95% CI, 0.53–0.68; P<0.001), gastrostomy (2.28% versus 2.89%; adjusted OR, 0.82; 95% CI, 0.73–0.93; P<0.001), and mechanical ventilation (1.97% versus 2.82%; adjusted OR, 0.68; 95% CI, 0.60–0.77; P<0.001). Brain MRI was independently associated with ≈0.32 days (8%) and $1131 (11%) increase in the total length (P<0.001) and cost (P<0.001) of hospital stay, respectively.

Conclusions

Inpatient brain MRI in patients with acute ischemic stroke is associated with substantial decrease in the rates of inpatient mortality and complications, at the expense of marginally increased length and cost of hospitalization.

Strokes occurring in the hospital: Symptom recognition and eligibility for treatment in the intensive care units versus hospital wards

BACKGROUND:

Studies have shown that 4%–17% of acute ischemic strokes (AISs) occur in patients hospitalized for another reason; scanty data are available about the care delivery and outcome of this patient population.

MATERIALS AND METHODS:

All consecutive inhospital AISs over a 10-year period at our comprehensive stroke center were included in the study. We compared the meantime from last known neurologically intact to symptom detection and also eligibility for acute treatment of patients based on their physical location in the hospital with respect to the level of care when they were found to have the stroke symptoms.

RESULTS:

Fifty-three patients suffered inhospital AIS during this period (28 in intensive care units/emergency department [ICUs/ED] vs. 25 in regular floors). Only in four patients (7.5%), initial brain imaging was done within 25 min from symptom recognition (as recommended by the American Heart Association/American Society of Anesthesiologists guidelines). Forty-two (79%) underwent brain imaging within 6 h of symptom recognition; of them, 11 (26%) received intravenous thrombolysis (IVT) within the first 4.5 h of symptom onset and 7 (17%) underwent endovascular treatment (EVT). The mean (±standard deviation) time in minutes from last known neurologically intact to symptom detection for floor patients was significantly longer compared to the ICU/ED patients (194 [±149] vs. 74 [±45], P = 0.0003). Patients admitted to the ICU/ED had more chance of being recognized earlier and being eligible for IVT or/and EVT compared to the patients admitted to the regular floors (44% vs. 25%, P = 0.14); however, the difference did not reach statistical significance.

CONCLUSIONS:

ICU/ED patients had a significantly shorter time to stroke symptom detection from last known neurologically intact when compared to the regular floor patients. Furthermore, they had a trend toward a higher likelihood of being eligible for acute treatment compared to the regular floors, although the result did not reach statistical significance.

In-Hospital Mortality From Cerebrovascular Disease

Introduction Cerebrovascular disease (CVD) is the second most common cause of death. Despite the advances made in recent years with the introduction of specific treatment units and thrombolytics, CVD remains the leading cause of neurological hospitalization and adult disability. Objective Our objective is to determine the frequency and causes of early mortality, during hospitalization, of patients with acute CVD. Methods We conducted a retrospective, descriptive study of 704 patients treated for acute CVD at the Neurology Service of the Hospital in Curitiba, Brazil, over a period of three years, to whom the CVD Program protocol was applied. We checked the conditions at hospital discharge, obtaining the mortality rate and its causes. Results We studied 463 men and 241 women, over 14 years of age with an average of 64 years; 57 patients died. Of the 614 with ischemic CVD, nine males and four females died, establishing a mortality rate of 1.9%. Of the 90 patients with hemorrhagic CVD, 44 died: 26 male and 18 female. The main causes of death were arrhythmias, pneumonia with acute respiratory failure, acute myocardial infarction, and multiple organ failure. Conclusion We found no relationship between mortality and specific risk factors, except for age over 65 years. The low rate of deaths obtained in ischemic stroke reflects the multidisciplinary work involved in caring for patients with cerebrovascular disease in our center, which allows us to obtain results as low in mortality as those described in the literature.

Neurocritical Care Outcomes, Research, and Technology: A Review

Importance

Neurocritical care has grown into an organized specialty that may have consequences for patient care, outcomes, research, and neurointensive care (neuroICU) technology.

Observations

Neurocritical care improves care and outcomes of the patients who are neurocritically ill, and neuroICUs positively affect the financial state of health care systems. The development of neurocritical care as a recognized subspecialty has fostered multidisciplinary research, neuromonitoring, and neurocritical care information technology, with advances and innovations in practice and progress.

Conclusions and Relevance

Neurocritical care has become an important part of health systems and an established subspecialty of neurology. Understanding its structure, scope of practice, consequences for care, and research are important.

Outcomes Among Patients With Ischemic Stroke Treated With Intravenous tPA (Tissue-Type Plasminogen Activator) via Telemedicine

Background and Purpose- Telemedicine is increasingly utilized for intravenous tPA (tissue-type plasminogen activator) delivery. The comparative safety of leaving tPA-treated patients at a presenting (spoke) hospital (drip-and-stay) or transferring patients to a central treating (hub) hospital (drip-and-ship) is not established. We sought to compare outcomes between drip-and-ship and drip-and-stay patients treated with tPA via telemedicine. We hypothesized that there would be no differences in short-term outcomes of in-hospital mortality, length of stay, or discharge disposition or in 90-day outcomes between groups. Methods- We retrospectively identified patients treated with tPA at 17 spoke hospitals between September 2015 and December 2016. Demographic, clinical, and outcome data were obtained from a prospective telemedicine registry. We used negative binomial, multinomial, and logistic regression analyses to evaluate length of stay, discharge disposition, and inpatient mortality, respectively. We compared the proportion of patients with 90-day modified Rankin Scale score <2 by group. Results- Among 430 tPA-treated patients, 232 (53.9%) were transferred to the hub after treatment. The median arrival National Institutes of Health Stroke Scale score was higher for drip-and-ship (10; interquartile range, 5-18) compared with drip-and-stay patients (6; interquartile range, 4-10; P<0.001). Unadjusted length of stay was longer in drip-and-stay patients (incidence rate ratio, 0.82; 95% CI, 0.71-0.95). There were no significant differences in adjusted length of stay, hospital mortality, or discharge disposition. Among the 64% of patients with complete 90-day modified Rankin Scale score, the proportion with good outcomes (modified Rankin Scale score <2) did not differ between groups. Conclusions- We found no differences in measured outcomes between drip-and-ship and drip-and-stay patients treated in our network, although our study may be underpowered to detect small differences.

Development of an EMG-Controlled Knee Exoskeleton to Assist Home Rehabilitation in a Game Context

As a leading cause of loss of functional movement, stroke often makes it difficult for patients to walk. Interventions to aid motor recovery in stroke patients should be carried out as a matter of urgency. However, muscle activity in the knee is usually too weak to generate overt movements, which poses a challenge for early post-stroke rehabilitation training. Although electromyography (EMG)-controlled exoskeletons have the potential to solve this problem, most existing robotic devices in rehabilitation centers are expensive, technologically complex, and allow only low training intensity. To address these problems, we have developed an EMG-controlled knee exoskeleton for use at home to assist stroke patients in their rehabilitation. EMG signals of the subject are acquired by an easy-to-don EMG sensor and then processed by a Kalman filter to control the exoskeleton autonomously. A newly-designed game is introduced to improve rehabilitation by encouraging patients' involvement in the training process. Six healthy subjects took part in an initial test of this new training tool. The test showed that subjects could use their EMG signals to control the exoskeleton to assist them in playing the game. Subjects found the rehabilitation process interesting, and they improved their control performance through 20-block training, with game scores increasing from 41.3 ± 15.19 to 78.5 ± 25.2. The setup process was simplified compared to traditional studies and took only 72 s according to test on one healthy subject. The time lag of EMG signal processing, which is an important aspect for real-time control, was significantly reduced to about 64 ms by employing a Kalman filter, while the delay caused by the exoskeleton was about 110 ms. This easy-to-use rehabilitation tool has a greatly simplified training process and allows patients to undergo rehabilitation in a home environment without the need for a therapist to be present. It has the potential to improve the intensity of rehabilitation and the outcomes for stroke patients in the initial phase of rehabilitation.

Long-Term Outcomes of Mechanical Thrombectomy for Stroke: A Meta-Analysis

Mechanical thrombectomy (MT) has become the standard treatment for large vessel occlusion (LVO) in acute ischemic stroke (AIS). Few studies have investigated long-term outcomes for AIS treated with MT. Therefore, a pooled meta-analysis using data from randomized clinical trials (RCT) was performed to assess for long-term clinical outcomes. A systematic literature search was conducted on 27 September 2017, by searching the English literature in the Cochrane Library, MEDLINE, and Embase for RCTs investigating long-term outcomes (greater than standard 3-month timepoint) of endovascular intervention versus medical management for patients with AIS. The study was carried out according to PRISMA guidelines and random effects analysis was carried out to account for heterogeneity. Three trials were included: IMS III, MR CLEAN, and REVASCAT, comprising a total of 1,362 patients. Long-term clinical outcomes were available for 1-year follow-up in IMS III and REVASCAT and at 2 years in MR CLEAN. Functional independence at long-term follow-up favored endovascular stroke intervention (OR 1.51; p = 0.02). When stratified by LVO inclusion criteria, greater endovascular functional independence benefits were observed (OR 1.85; p = 0.0005). There was a significant difference between the 2 arms in favor of endovascular therapy for the quality of life at long-term follow-up (mean difference 0.11; p = 0.0002). No difference in mortality at long-term follow-up was observed (OR 0.82; p = 0.12). We conclude that endovascular therapy results in favorable outcomes at long-term follow-up for patients with acute ischemic stroke compared to standard medical treatment alone and that the 90-day timepoint offers a fair representation of the long-term outcomes.

Discharge Destination from a Rehabilitation Unit After Acute Ischemic Stroke

Background: We reviewed numerous variables for ischemic stroke patients admitted to a rehabilitation unit to determine those that were statistically associated with discharge destination. Methods: A retrospective chart review of patients with ischemic stroke discharged from the rehabilitation unit between January 1, 2005 and December 31, 2015. Variables were examined for their association with discharge destination (home versus long-term care (LTC)). Univariable relationships with discharge destination were assessed, and a multivariable logistic regression model was built. Results: Univariate predictors of discharge to LTC: advanced age, decreasing admission and discharge functional independence measure (FIM) scores, increasing change in FIM score from admission to discharge, dependency, residence outside of home before the stroke, absence of a caregiver, urinary and bowel incontinence, low Berg balance score at admission and discharge, low Montreal Cognitive Assessment scores, smoking, chronic heart failure, and an inability to transfer. Multivariable logistic regression: five factors remained significant predictors with LTC disposition: advanced age, bowel incontinence, residence outside of the home prior to stroke, right hemisphere site of the stroke, and absence of a caregiver. Conclusions: Several easily measured variables were significantly associated with discharge to LTC versus home following stroke rehabilitation.

Access to and delivery of acute ischaemic stroke treatments: A survey of national scientific societies and stroke experts in 44 European countries

Introduction

Acute stroke unit care, intravenous thrombolysis and endovascular treatment significantly improve the outcome for patients with ischaemic stroke, but data on access and delivery throughout Europe are lacking. We assessed best available data on access and delivery of acute stroke unit care, intravenous thrombolysis and endovascular treatment throughout Europe.

Methods

A survey, drafted by stroke professionals (ESO, ESMINT, EAN) and a patient organisation (SAFE), was sent to national stroke societies and experts in 51 European countries (World Health Organization definition) requesting experts to provide national data on stroke unit, intravenous thrombolysis and endovascular treatment rates. We compared both pooled and individual national data per one million inhabitants and per 1000 annual incident ischaemic strokes with highest country rates. Population estimates were based on United Nations data, stroke incidences on the Global Burden of Disease Report.

Results

We obtained data from 44 European countries. The estimated mean number of stroke units was 2.9 per million inhabitants (95% CI 2.3-3.6) and 1.5 per 1000 annual incident strokes (95% CI 1.1-1.9), highest country rates were 9.2 and 5.8. Intravenous thrombolysis was provided in 42/44 countries. The estimated mean annual number of intravenous thrombolysis was 142.0 per million inhabitants (95% CI 107.4-176.7) and 72.7 per 1000 annual incident strokes (95% CI 54.2-91.2), highest country rates were 412.2 and 205.5. Endovascular treatment was provided in 40/44 countries. The estimated mean annual number of endovascular treatments was 37.1 per million inhabitants (95% CI 26.7-47.5) and 19.3 per 1000 annual incident strokes (95% CI 13.5-25.1), highest country rates were 111.5 and 55.9. Overall, 7.3% of incident ischaemic stroke patients received intravenous thrombolysis (95% CI 5.4-9.1) and 1.9% received endovascular treatment (95% CI 1.3-2.5), highest country rates were 20.6% and 5.6%.

Conclusion

We observed major inequalities in acute stroke treatment between and within 44 European countries. Our data will assist decision makers implementing tailored stroke care programmes for reducing stroke-related morbidity and mortality in Europe.

Ischemic stroke across sexes: What is the status quo?

Stroke prevalence is expected to increase in the next decades due to the aging of the Western population. Ischemic stroke (IS) shows an age- and sex-dependent distribution in which men represent the most affected population within 65 years of age, being passed by post-menopausal women in older age groups. Furthermore, a sexual dimorphism concerning risk factors, presentation and treatment of IS has been widely recognized. In order to address these phenomena, a number of issue have been raised involving both socio-economical and biological factors. The latter can be either dependent on sex hormones or due to intrinsic factors. Although women have poorer outcomes and are more likely to die after a cerebrovascular event, they are still underrepresented in clinical trials and this is mirrored by the lack of sex-tailored therapies. A greater effort is needed in the future to ensure improved treatment and quality of life to both sexes.

Nursing-Based Dysrhythmia Detection on a Dedicated Stroke Unit Using a Unit-Based Cardiac Telemetry Monitoring System

BACKGROUND

Acute stroke care includes cardiac rhythm monitoring in the first 24 hours. The method of monitoring varies, as do the reported findings. The nurses' role in this process can be intensive, including primary response and review of all data. Competency is critical as the acute stroke setting can be associated with life-threatening dysrhythmias as well as the detection of atrial fibrillation that affects therapy. Limited studies exist to evaluate the effectiveness of a unit-based cardiac monitoring system for which the bedside nurse has primary responsibility.

OBJECTIVE

The goal was to determine if a unit-based cardiac monitoring system for which the bedside nurse was responsible detected clinically significant dysrhythmias.

METHODS

Stroke unit nurses completed a mandatory education program on identifying common dysrhythmias and using the monitoring equipment along with a structured algorithm for cardiac dysrhythmia detection. The nurse was responsible for all alarms as well as review of their patients' data. Their findings were recorded and reviewed by a cardiology team after the 24-hour monitoring was completed. A total of 300 consecutive stokes, transient ischemic attack, and possible stroke patients were enrolled.

RESULTS

Nurses identified 96% of all significant dysrhythmias. Twenty-eight percent of the stroke patients had a dysrhythmia, of which 79% were atrial fibrillation/atrial flutter. The bedside nurses did identify all 8 new atrial fibrillation cases.

CONCLUSION

Stroke unit nurses who complete an educational program can identify dysrhythmias on their patients' unit-based cardiac monitoring systems and can improve patient outcomes.

Acute Ischaemic Stroke: Management, Recent Advances and Controversies

Acute ischaemic stroke is a major cause of death and disability. It may become an enormous burden to the patients themselves, their families as well as the health care systems. Patients at risk of airway, breathing and circulatory compromise should receive prompt resuscitation. Vital parameters and neurological status should be closely monitored. Attentions to blood pressure, temperature and sugar profile are important. The significance of early and correct diagnosis and subsequent treatment cannot be over-emphasised. There have been tremendous recent advances in different treatment modalities in acute stroke management. Various recanalisation modalities include intravenous and/or intra-arterial thrombolysis, acute defibrinogenation, anti-platelet treatment and anticoagulation. Carotid endarterectomy and endovascular strategies are recommended in selected patients. Advanced neuro-imaging techniques and neuroprotectants are being evaluated. Multidisciplinary stroke teams have been shown to improve patient survival and functional outcome. Pre-defined algorithms and protocols should be in place to expedite smooth and effective delivery of stroke service. Future directions should be aimed at exploring safer recanalisation modalities and extending the limit of the current 3-hour treatment window for thrombolysis.

The prognosis of stroke survivors primarily discharged to their homes

OBJECTIVES

Stroke is one of the leading causes for nursing home placement (NHP). We have studied the prognosis and risk factors regarding NHP for stroke patients initially discharged to their homes.

MATERIALS AND METHODS

All stroke patients in the municipality of Stavanger, Norway, between January 1, 1996, and March 31, 2004, were included and followed until death or May 31, 2012. Time intervals for NHP and death were compared to an age- and sex-matched, stroke-free control cohort. Logistic regression analysis was used to assess risk factors for NHP.

RESULTS

A total of 452 patients were included. A total of 48 patients (10.6%) were directly placed in a nursing home, while 401 patients (88.7%) were discharged to their homes; 180 patients (44.7%) directly and 221 patients (55.3%) after temporary rehabilitation. Of the patients discharged to their homes, 29.7% needed NHP at a later time point as compared to 19.9% of the controls (P<.001). Logistic regression analysis showed that only age (P<.001) was a risk factor for NHP. Stroke patients discharged home and stroke patients admitted directly to nursing home were significantly younger at time of NHP; stroke patients discharged home died significantly earlier than the controls.

CONCLUSIONS

Almost 90% of the stroke patients could be discharged to their homes, but they needed more often NHP in the long run than the stroke-free controls. Stroke patients discharged to their homes were younger at the time of NHP and death indicating that the stroke deficit may contribute to increased morbidity and mortality in this patient group.

Standardized Treatment of Neonatal Status Epilepticus Improves Outcome

We aimed to decrease practice variation in treatment of neonatal status epilepticus by implementing a standardized protocol. Our primary goal was to achieve 80% adherence to the algorithm within 12 months. Secondary outcome measures included serum phenobarbital concentrations, number of patients progressing from seizures to status epilepticus, and length of hospital stay. Data collection occurred for 6 months prior and 12 months following protocol implementation. Adherence of 80% within 12 months was partially achieved in patients diagnosed in our hospital; in pretreated patients, adherence was not achieved. Maximum phenobarbital concentrations were decreased (56.8 vs 41.0 µg/mL), fewer patients progressed from seizures to status epilepticus (46% vs 36%), and hospital length of stay decreased by 9.7 days in survivors. In conclusion, standardized, protocol-driven treatment of neonatal status epilepticus improves consistency and short-term outcome.

Should There Be an Age Split for Stroke DRGs? Analysing a Large Clinical Data Set of a Principal Teaching Hospital over a Five-Year Period

The aim of this study was to analyse the inpatient statistics collection relating to stroke patients admitted to a major teaching hospital, with particular reference to length of stay, and to assess the adequacy of the diagnosis related group (DRG) as a predictor of length of stay. The study subjects were selected by DRG to identify all stroke inpatients admitted and discharged between 1 July 1995 and 30 June 2000. There were 1365 stroke discharges (half of whom were over 75 years of age at discharge) over the period of the study. The median length of stay was 8 days, and 67% of the subjects experienced complications and/or comorbidities. Age was significantly associated with increased length of stay of stroke patients, independent of complications or comorbidities.

These findings raise the question of whether casemix-based funding should be based solely on DRGs for complicated conditions such as stroke, or whether additional measures such as age should be used for funding allocation. This study provides a model that health information managers and other researchers could use to analyse inpatient statistics collections at state, territory or national levels.

Telestroke-the promise and the challenge. Part one: growth and current practice

Acute ischemic stroke remains a major public health concern, with low national treatment rates for the condition, demonstrating a disconnection between the evidence of treatment benefit and delivery of this treatment. Intravenous thrombolysis and endovascular thrombectomy are both strongly evidence supported and exquisitely time sensitive therapies. The mismatch between the distribution and incidence of stroke presentations and the availability of specialist care significantly affects access to care. Telestroke, the use of telemedicine for stroke, aims to surmount this hurdle by distributing stroke expertise more effectively, through video consultation with and examination of patients in locations removed from specialist care. This is the first of a detailed two part review, and explores the growth and current practice of telestroke, including the specific role it plays in the assessment and management of patients after emergent large vessel occlusion.

Tachycardia burden in stroke unit is associated with functional outcome after ischemic stroke

BACKGROUND

Stroke unit care is associated with decrease in mortality and improvement in neurological outcome in patients with acute stroke. Heart rate is a commonly monitored variable in the stroke unit. However, little is known about tachycardia burden in the stroke unit and its association with outcome.

AIMS

To investigate the effects of tachycardia burden in the stroke unit on functional outcome in patients with acute ischemic stroke.

METHODS

We collected data from 246 patients with acute ischemic stroke admitted to our stroke unit between July 2013 and June 2014. Tachycardia burden was defined as duration of heart rate over 95 per minute divided by the total monitoring time, using the heart rate data sampled every 1 min. We divided the study population into quartiles of tachycardia burden and analyzed their association with poor three-month functional outcome (modified Rankin Scale score of ≥3).

RESULTS

Among included patients (age, 67.4 ± 12.8; male, 53.7%), tachycardia burden was 0.7% (median, interquartile range [0.1-5.7%]). The patients with higher tachycardia burdens were older, more likely to have higher stroke severity, cardioembolic etiology, atrial fibrillation, fever, pneumonia, higher initial glucose level, and higher white blood cell count. As compared with the lowest quartile (<0.1%), the highest quartile of tachycardia burden (≥6.0%) was significantly associated with poor outcome (adjusted odds ratio, 5.10; 95% confidence interval, 1.38-18.90; p = 0.01) after adjustment for covariates.

CONCLUSIONS

Patients with increased tachycardia burden during stroke unit stay have poor functional outcome. Countermeasures against worsening factors might be utilized for patients with increased tachycardia burden.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation

BACKGROUND AND PURPOSE

The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA).

METHOD

Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale.

RESULTS

The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation.

DISCUSSION AND CONCLUSION

The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke.

Prevalence of self-reported stroke and disability in the French adult population: a transversal study

In France, the prevalence of stroke and the level of disability of stroke survivors are little known. The aim of this study was to evaluate functional limitations in adults at home and in institutions, with and without self-reported stroke. A survey named “the Disability Health survey” was carried out in people's homes (DHH) and in institutions (DHI). Medical history and functional level (activities-of-daily-living, ADL and instrumented-activities-of-daily-living IADL) were collected through interviews. The modified Rankin score (mRS) and the level of dependence and disability were compared between participants with and without stroke. 33896 subjects responded. The overall prevalence of stroke was 1.6% (CI95% [1.4%–1.7%]). The mRS was over 2 for 34.4% of participants with stroke (28.7% of participants at home and 87.8% of participants in institutions) versus respectively 3.9%, 3.1% and 71.6% without stroke. Difficulty washing was the most frequently reported ADL for those with stroke (30.6% versus 3% for those without stroke). Difficulty with ADL and IADL increased with age but the relative risk was higher below the age of 60 (17 to 25) than over 85 years (1.5 to 2.2), depending on the ADL. In the overall population, 22.6% of those confined to bed or chair reported a history of stroke. These results thus demonstrate a high national prevalence of stroke. Older people are highly dependent, irrespective of stroke history and the relative risk of dependence in young subjects with a history of stroke is high compared with those without.

Health service management study for stroke: a randomized controlled trial to evaluate two models of stroke care

BACKGROUND

The most effective and efficient model for providing organized stroke care remains uncertain. This study aimed to compare the effect of two models in a randomized controlled trial.

METHODS

Patients with acute stroke were randomized on day one of admission to combined, co-located acute/rehabilitation stroke care or traditionally separated acute/rehabilitation stroke care. Outcomes measured at baseline and 90 days postdischarge included functional independence measure, length of hospital stay, and functional independence measure efficiency (change in functional independence measure score ÷ total length of hospital stay).

RESULTS

Among 41 patients randomized, 20 were allocated co-located acute/rehabilitation stroke care and 21 traditionally separated acute/rehabilitation stroke care. Baseline measurements showed no significant difference. There was no significant difference in functional independence measure scores between the two groups at discharge and again at 90 days postdischarge (co-located acute/rehabilitation stroke care: 103.6 ± 22.2 vs. traditionally separated acute/rehabilitation stroke care: 99.5 ± 27.7; P = 0.77 at discharge; co-located acute/rehabilitation stroke care: 109.5 ± 21.7 vs. traditionally separated acute/rehabilitation stroke care: 104.4 ± 27.9; P = 0.8875 at 90 days post-discharge). Total length of hospital stay was 5.28 days less in co-located acute/rehabilitation stroke care compared with traditionally separated acute/rehabilitation stroke care (24.15 ± 3.18 vs. 29.42 ± 4.5, P = 0.35). There was significant improvement in functional independence measure efficiency score among participants assigned to co-located acute/rehabilitation stroke care compared with traditionally separated acute/rehabilitation stroke care (co-located acute/rehabilitation stroke care: median 1.60, interquartile range: 0.87-2.81; traditionally separated acute/rehabilitation stroke care: median 0.82, interquartile range: 0.27-1.57, P = 0.0393). Linear regression analysis revealed a high inverse correlation (R(2) = 0.89) between functional independence measure efficiency and time spent in the acute stroke unit.

CONCLUSION

This proof-of-concept study has shown that co-located acute/rehabilitation stroke care was just as effective as traditionally separated acute/rehabilitation stroke care as reflected in functional independence measure scores, but significantly more efficient as shown in greater functional independence measure efficiency. Co-located acute/rehabilitation stroke care has potential for significantly improved hospital bed utilization with no patient disadvantage.

Task-Oriented Physical Exercise Using Postural Re-Alignment with Body Weight Support in Chronic Stroke

The recovery of functional gait is the main target for subjects who have suffered a stroke. The methods designed to improve balance and gait appear to be essential for skills and autonomy and to reduce the costs of assistance. The aim of our study was to evaluate the improvement of stroke victims in the chronic phase through the rehabilitation of gait, balance and posture using postural re-alignment with specific body weight support. The study includes 20 subjects with residual hemiparetic gait after stroke. Evaluation with international rating scales, gait analysis and stabilometric test was carried out at the beginning and after the 1st and the 3rd month of therapy; a follow-up control was made 3 months after the end of the rehabilitation program. All subjects underwent the rehabilitation protocol with Dynamic Antigravity Postural System 2 times a week for 3 months and were also treated with high efficiency focused acoustic waves (ViSS) to increase strength and muscular endurance (300Hz) or to reduce spastic hypertonia (200–120 Hz). The study shows a significant improvement in gait and balance with the persistence of results at the follow-up 3 months after the end of treatment. The subjects showed an increase in walking speed, greater stability and a consequent reduction of sedentary lifestyle with less risk of complications or recurrence. In conclusion this rehabilitation program is efficient for posture and walking quality.

Organization of acute stroke services in Poland - Polish Stroke Unit Network development

BACKGROUND AND PURPOSE

According to the recommendations of stroke organizations, every stroke patient should be treated in a specialized stroke unit (SU). We aimed to evaluate the development of the SU network in Poland during the past decade.

MATERIAL AND METHODS

In Poland, stroke is treated mainly by neurologists. A questionnaire evaluating structure and staff of neurological departments was sent to all neurological departments in 2003, 2005 and 2007. In 2010, we collected data based on information from the National Health Fund. We divided departments into categories: with a comprehensive SU, with a primary SU unit, and departments without an SU. Primary SUs were further divided into class A SUs (fulfilling criteria of the National Programme of Prevention and Treatment of Stroke Experts - eligible for thrombolysis), class B (conditionally fulfilling criteria), and class C (not fulfilling criteria).

RESULTS

Final analyses included 87.4% of departments (194/222) in 2003, 85.5% of departments (188/220) in 2005, and 83.1% of departments (182/219) in 2007. According to the above-mentioned classification there were 20 class A SUs in 2003, 58 in 2005 and 5 comprehensive and 51 class A SUs in 2007. In 2012, based on information from the National Health Fund there were 150 SUs, all fulfilling criteria for thrombolysis, 9 of them comprehensive SUs.

CONCLUSIONS

The SU network in Poland is developing dynamically but thrombolysis and endovascular procedures are done too rarely. Now it is necessary to improve quality of stroke services and to make organizational changes in the in-hospital stroke pathways as well as to organize continuous education of medical staff.

Economic evidence on integrated care for stroke patients; a systematic review

Introduction

Given the high incidence of stroke worldwide and the large costs associated with the use of health care resources, it is important to define cost-effective and evidence-based services for stroke rehabilitation. The objective of this review was to assess the evidence on the relative cost or cost-effectiveness of all integrated care arrangements for stroke patients compared to usual care. Integrated care was defined as a multidisciplinary tool to improve the quality and efficiency of evidence-based care and is used as a communication tool between professionals to manage and standardize the outcome-orientated care.

Methods

A systematic literature review of cost analyses and economic evaluations was performed. Study characteristics, study quality and results were summarized.

Results

Fifteen studies met the inclusion criteria; six on early-supported discharge services, four on home-based rehabilitation, two on stroke units and three on stroke services. The follow-up per patient was generally short; one year or less. The comparators and the scope of included costs varied between studies.

Conclusions

Six out of six studies provided evidence that the costs of early-supported discharge are less than for conventional care, at similar health outcomes. Home-based rehabilitation is unlikely to lead to cost-savings, but achieves better health outcomes. Care in stroke units is more expensive than conventional care, but leads to improved health outcomes. The cost-effectiveness studies on integrated stroke services suggest that they can reduce costs. For future research we recommend to focus on the moderate and severely affected patients, include stroke severity as variable, adopt a societal costing perspective and include long-term costs and effects.

Comprehensive Stroke Units: A Review of Comparative Evidence and Experience

Background

Stroke unit care offers significant benefits in survival and dependency when compared to general medical ward. Most stroke units are either acute or rehabilitation, but comprehensive (combined acute and rehabilitation) model (comprehensive stroke unit) is less common.

Aim

To examine different levels of evidence of comprehensive stroke unit compared to other organized inpatient stroke care and share local experience of comprehensive stroke units.

Methods

Cochrane Library and Medline (1980 to December 2010) review of English language articles comparing stroke units to alternative forms of stroke care delivery, different types of stroke unit models, and differences in processes of care within different stroke unit models. Different levels of comparative evidence of comprehensive stroke units to other models of stroke units are collected.

Results

There are no randomized controlled trials directly comparing comprehensive stroke units to other stroke unit models (either acute or rehabilitation). Comprehensive stroke units are associated with reduced length of stay and greatest reduction in combined death and dependency in a meta-analysis study when compared to other stroke unit models. Comprehensive stroke units also have better length of stay and functional outcome when compared to acute or rehabilitation stroke unit models in a cross-sectional study, and better length of stay in a ‘before-and-after’ comparative study. Components of stroke unit care that improve outcome are multifactorial and most probably include early mobilization. A comprehensive stroke unit model has been successfully implemented in metropolitan and rural hospital settings.

Conclusions

Comprehensive stroke units are associated with reductions in length of stay and combined death and dependency and improved functional outcomes compared to other stroke unit models. A comprehensive stroke unit model is worth considering as the preferred model of stroke unit care in the planning and delivery of metropolitan and rural stroke services.

Results of New Policies for Inpatient Rehabilitation Coverage in Japan

Background. A new interdisciplinary postacute rehabilitation unit, the Kaifukuki (convalescent) rehabilitation ward (KRW), has been incorporated into the Japanese medical insurance system since 2000. More than 57 000 beds (45 beds per 100 000 population) are currently available nationwide. The maximal coverage for therapy sessions increased from 2 to 3 hours per day, 7 days a week, in 2006. Objective. To investigate how changes in policy affected rehabilitation outcomes of KRWs in a retrospective cohort study of 87 917 patients over 10 years. Results. The mean (standard deviation) age of the patients was 73.0 (13.8) years, and 55.4% were women. Diagnoses included stroke (47.9%); orthopedic diseases, including hip fracture (35.2%); and traumatic brain and spinal cord injury (5.4 %). Onset–admission interval (OAI) was 31.5 (18.6) days, length of stay was 75.9 (46.1) days, and 69.1% were discharged home. Daily therapy time was 79.4 (34.5) minutes. Admission/discharge scores of the Barthel Index and the Functional Independence Measure were 49.3 (31.0)/70.4 (31.9) and 75.3 (31.2)/91.7 (31.8), respectively. Year-by-year comparison revealed that older age, greater initial disability, and shorter OAI were coupled with a higher dose of rehabilitative interventions and a higher rate of home discharge. Longitudinal data from a cohort of hospitals implied a small but significant dose-dependent effect of hours of therapy on rehabilitation outcome after stroke. Conclusions. Although the organization of KRWs is in flux as the system of hospitals grows, results over the past 8 years suggest that changes in national insurance policies are affecting the quantity and organization of rehabilitation interventions and improvement in patient outcomes.

[A descriptive study of patients seen in a stroke unit in the Community of Extremadura]

OBJECTIVES

To describe the activity in the stroke unit (SU) of the Hospital de Caceres as well as the demographic characteristics and cardiovascular risk factors in our patients. To determine the patient's functional status at discharge.

MATERIAL AND METHODS

A descriptive study of 432 patients admitted consecutively in the SU of the Hospital de Caceres from October, 2008 to May, 2010 was carried out. The different study variables (demographic, risk factors, dependence) were determined and analyzed.

RESULTS

The patient prototype was a 71-year old-man from the rural environment, with hypertension, hyperlipidemia, diabetes, who had an ischemic stroke. On medical discharge from the stroke unit (SU), the patient had a mild functional dependence, after and average stay of 2.8 days in the SU.

CONCLUSIONS

All patients who suffers a stroke should be attended by and benefit from the care provided in a SU. These units are organizational models that improve patient care in the acute phase, this resulting in lower mortality and disability in these patients.

Stroke unit care in clinical practice: an observational study in the Florence center of the European Registers of Stroke (EROS) Project

BACKGROUND

Randomized trials and meta-analyses indicate positive effects of stroke unit (SU) care on survival and dependency of patients with stroke. However, data on the advantages of SU in 'real-world' settings are limited. We prospectively assessed, in a large University Hospital, the effect of SU versus other conventional wards (OCW) care on all-cause mortality, death or dependency, death or institutionalization.

METHODS

In a prospective observational study in the European Registers of Stroke Project, patients hospitalized for first-in-a-lifetime stroke were evaluated for demographics, risk factors, clinical presentation, resource use, 3-month and 1-year survival, and functional outcome.

RESULTS

Overall, 355 patients (54.1% men, mean age 73.4 ± 14.5 years) were registered, 140 (39.4%) admitted to the SU, and 215 (60.6%) to OCW. OCW patients were older, whilst SU patients had more severe strokes according to NIHSS (P for trend = 0.025). SU patients were significantly more often treated by specialists in stroke medicine, stroke nurses, physiotherapists and speech therapists (all P < 0.001), psychologists (P = 0.025), dietitians (P < 0.001), and social workers (P = 0.003). MRI, carotid, and transcranial Doppler were significantly more often performed in SU patients (all P < 0.001). Intravenous fluids (P = 0.003) and intravenous anticoagulation (P < 0.001) were more often prescribed in SU. Controlling for case-mix, SU significantly reduced 1-year mortality (P = 0.020), death or dependency at 3 months (P = 0.006) and 1 year (P = 0.043), and death or institutionalization at 3 months (P = 0.001) and 1 year (P = 0.009).

CONCLUSIONS

We confirmed the benefits of SU care in a clinical setting. Further analyses should define the contribution of individual components of care to stroke outcome.

[Medico-economic assessment of the Pontoise Hospital stroke unit]

INTRODUCTION

Annually, approximately 120,000 people in France have a stroke. Various controlled studies have pointed out the benefits of treatment in a stroke unit (SU). The objective of this study was to evaluate, from a medical point of view, the economic impact of the Pontoise Hospital SU.

PATIENTS AND METHODS

Based on the national cost study (NCS [étude nationale des coûts: ENC]) we analyzed data of five diagnosis related groups (DRG) which have a principle diagnosis in relation with stroke. This work was limited to strokes and transient ischemic events in adults and excluded sub-arachnoid hemorrhage. Medical and economic parameters were collected over the period from January to October 2006 and compared with those of the same period in 2005, that is to say before the opening of the SU.

RESULTS

Three hundred and twenty-three hospital stays occurred between January 1st and October 31st, 2006 and 216 during the same time period before the opening of the SU, an increase of approximately 50% of all stroke-related admissions in our hospital. The number of stays carried out in the neurology unit increased by 29%. There was no significant difference between the two periods regarding age (median 69 versus 70 years) and sex- ratio. Average length of stay (ALS) was the same (9 days). There were no significant differences concerning the death rate (5.6% versus 6.2%) and that of discharge to home (44.6% versus 44.4%). The cost by stay in 2006 was 3534 euros [median; min 664-max 57,542] versus 3541 euros in 2005 [681-35,149] (p=0.57). Analysis by DRG highlighted an increase in the cost for serious strokes, cerebral infarctions and hemorrhages. For transitory ischemic events, the cost and the ALS decreased.

CONCLUSION

After the opening of the SU, there was an increase in the activity without an increase in the total cost. This could be related in part to the limited means allocated to the stroke unit at its opening (in particular medical staff). The NCS can be used to evaluate the activity of a stroke unit. This work could be completed on a larger number of units or in several units of different size.

Effectiveness of two rehabilitation strategies provided by nurses for stroke patients in Mexico

OBJECTIVE

Rehabilitation strategies have been developed to improve functional state in stroke patients. The main objective of this study was to evaluate the effectiveness of the early rehabilitation at hospital and its continuity at home provided by nurses, on the functional recovery of basic and social activities in stroke patients compared with conventional care.

DESIGN

A randomised clinical trial was carried out in three general hospitals of the Mexican Institute of Social Security (IMSS) in Mexico City between April 2003-May 2004.

PARTICIPANTS

Stroke patients.

METHODS

Two rehabilitation strategies provided by nurses for stroke patients were compared: physiotherapy plus caregiver education in rehabilitation (strategy 1, S1) vs. education alone (strategy 2, S2). The main outcome variables were the basic (Barthel index) and social (Frenchay activities index) activities of daily living, of each patient. Age, sex, morbidity, stroke symptoms, complications, neurological damage (Canadian Scale), cognitive state (mini-mental state examination questionnaire) and duration of hospitalisation were defined as the control variables. Patients were evaluated at baseline and months one, three and six thereafter.

RESULTS

One hundred and ten patients with ischaemic stroke were enrolled and randomised; 59 were assigned to S1 and 51 to S2. Comparison of the outcome variables showed that patients improved significantly over time, but no differences were observed between groups. We observed no significant difference in strategy performance with regard to the basic and instrumental activities of daily living.

RELEVANCE TO CLINICAL PRACTICE

Participants who received physiotherapy with additional caregiver education benefit no more than those whose caregivers received education alone. Those countries that do not have integral rehabilitation programmes for stroke patients should understand their importance and budget resources for them. Meanwhile, both caregiver education and nurses trained in specific care and physiotherapy are alternatives that benefit these patients.