1
|
Freitas TE, Costa AI, Neves L, Barros C, Martins M, Freitas P, Noronha D, Freitas P, Faria T, Borges S, Freitas S, Henriques E, Sousa AC. Neuron-specific enolase as a prognostic biomarker in acute ischemic stroke patients treated with reperfusion therapies. Front Neurol 2024; 15:1408111. [PMID: 39091979 PMCID: PMC11291469 DOI: 10.3389/fneur.2024.1408111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024] Open
Abstract
Introduction Ischemic stroke is a significant global health concern, with reperfusion therapies playing a vital role in patient management. Neuron-specific enolase (NSE) has been suggested as a potential biomarker for assessing stroke severity and prognosis, however, the role of NSE in predicting long-term outcomes in patients undergoing reperfusion therapies is still scarce. Aim To investigate the association between serum NSE levels at admission and 48 h after reperfusion therapies, and functional outcomes at 90 days in ischemic stroke patients. Methods This study conducted a prospective cross-sectional analysis on consecutive acute ischemic stroke patients undergoing intravenous fibrinolysis and/or endovascular thrombectomy. Functional outcomes were assessed using the modified Rankin Scale (mRS) at 90 days post-stroke and two groups were defined according to having unfavorable (mRS3-6) or favorable (mRS0-2) outcome. Demographic, clinical, radiological, and laboratory data were collected, including NSE levels at admission and 48 h. Spearman's coefficient evaluated the correlation between analyzed variables. Logistic regression analysis was performed to verify which variables were independently associated with unfavorable outcome. Two ROC curves determined the cut-off points for NSE at admission and 48 h, being compared by Delong test. Results Analysis of 79 patients undergoing reperfusion treatment following acute stroke revealed that patients with mRS 3-6 had higher NIHSS at admission (p < 0.0001), higher NIHSS at 24 h (p < 0.0001), and higher NSE levels at 48 h (p = 0.008) when compared to those with mRS 0-2. Optimal cut-off values for NSE0 (>14.2 ng/mL) and NSE48h (>26.3 ng/mL) were identified, showing associations with worse clinical outcomes. Adjusted analyses demonstrated that patients with NSE48h > 26.3 ng/mL had a 13.5 times higher risk of unfavorable outcome, while each unit increase in NIHSS24h score was associated with a 22% increase in unfavorable outcome. Receiver operating characteristic analysis indicated similar predictive abilities of NSE levels at admission and 48 h (p = 0.298). Additionally, a strong positive correlation was observed between NSE48h levels and mRS at 90 days (r = 0.400 and p < 0.0001), suggesting that higher NSE levels indicate worse neurological disability post-stroke. Conclusion Serum NSE levels at 48 h post-reperfusion therapies are associated with functional outcomes in ischemic stroke patients, serving as potential tool for patient long-term prognosis.
Collapse
Affiliation(s)
| | - Ana Isabel Costa
- Internal Medicine Department, Hospital Dr. Nélio Mendonça, Funchal, Portugal
| | - Leonor Neves
- Internal Medicine Department II, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Carolina Barros
- Stroke Centre, Hospital Dr. Nélio Mendonça, Funchal, Portugal
| | - Mariana Martins
- Stroke Centre, Hospital Dr. Nélio Mendonça, Funchal, Portugal
| | - Pedro Freitas
- Stroke Centre, Hospital Dr. Nélio Mendonça, Funchal, Portugal
| | - Duarte Noronha
- Neurology Department, Hospital Dr. Nélio Mendonça, Funchal, Portugal
| | | | - Teresa Faria
- Internal Medicine Department, Hospital Dr. Nélio Mendonça, Funchal, Portugal
| | - Sofia Borges
- Centro de Investigação Clínica Dra. Maria Isabel Mendonça, Funchal, Portugal
| | - Sónia Freitas
- Centro de Investigação Clínica Dra. Maria Isabel Mendonça, Funchal, Portugal
| | - Eva Henriques
- Centro de Investigação Clínica Dra. Maria Isabel Mendonça, Funchal, Portugal
| | - Ana Célia Sousa
- Centro de Investigação Clínica Dra. Maria Isabel Mendonça, Funchal, Portugal
| |
Collapse
|
2
|
Reeves MJ, Fonarow GC, Smith EE, Sheth KN, Messe SR, Schwamm LH. Twenty Years of Get With The Guidelines-Stroke: Celebrating Past Successes, Lessons Learned, and Future Challenges. Stroke 2024; 55:1689-1698. [PMID: 38738376 PMCID: PMC11208062 DOI: 10.1161/strokeaha.124.046527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
The Get With The Guidelines-Stroke program which, began 20 years ago, is one of the largest and most important nationally representative disease registries in the United States. Its importance to the stroke community can be gauged by its sustained growth and widespread dissemination of findings that demonstrate sustained increases in both the quality of care and patient outcomes over time. The objectives of this narrative review are to provide a brief history of Get With The Guidelines-Stroke, summarize its major successes and impact, and highlight lessons learned. Looking to the next 20 years, we discuss potential challenges and opportunities for the program.
Collapse
Affiliation(s)
- Mathew J. Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
| | - Gregg C. Fonarow
- Division of Cardiology, Geffen School of Medicine, University of California Los Angeles (G.C.F.)
| | - Eric E. Smith
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada (E.E.S.)
| | - Kevin N. Sheth
- Center for Brain & Mind Health, Departments of Neurology & Neurosurgery (K.N.S.), Yale School of Medicine, New Haven, CT
| | - Steven R. Messe
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia (S.R.M.)
| | - Lee H. Schwamm
- Department of Neurology and Bioinformatics and Data Sciences (L.H.S.), Yale School of Medicine, New Haven, CT
| |
Collapse
|
3
|
Gordon Perue GL, Southerland AM. Law and Disorder in the Wild West of Stroke Certification: Is It Time to Standardize the Designation Processes? Stroke 2024; 55:1059-1061. [PMID: 38469727 DOI: 10.1161/strokeaha.124.046275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Affiliation(s)
| | - Andrew M Southerland
- Departments of Neurology and Public Health Sciences, University of Virginia, Charlottesville (A.M.S.)
| |
Collapse
|
4
|
Fernandes M, Westover MB, Singhal AB, Zafar SF. Automated Extraction of Stroke Severity from Unstructured Electronic Health Records using Natural Language Processing. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.08.24304011. [PMID: 38559062 PMCID: PMC10980121 DOI: 10.1101/2024.03.08.24304011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Multi-center electronic health records (EHR) can support quality improvement initiatives and comparative effectiveness research in stroke care. However, limitations of EHR-based research include challenges in abstracting key clinical variables from non-structured data at scale. This is further compounded by missing data. Here we develop a natural language processing (NLP) model that automatically reads EHR notes to determine the NIH stroke scale (NIHSS) score of patients with acute stroke. METHODS The study included notes from acute stroke patients (>= 18 years) admitted to the Massachusetts General Hospital (MGH) (2015-2022). The MGH data were divided into training (70%) and hold-out test (30%) sets. A two-stage model was developed to predict the admission NIHSS. A linear model with the least absolute shrinkage and selection operator (LASSO) was trained within the training set. For notes in the test set where the NIHSS was documented, the scores were extracted using regular expressions (stage 1), for notes where NIHSS was not documented, LASSO was used for prediction (stage 2). The reference standard for NIHSS was obtained from Get With The Guidelines Stroke Registry. The two-stage model was tested on the hold-out test set and validated in the MIMIC-III dataset (Medical Information Mart for Intensive Care-MIMIC III 2001-2012) v1.4, using root mean squared error (RMSE) and Spearman correlation (SC). RESULTS We included 4,163 patients (MGH = 3,876; MIMIC = 287); average age of 69 [SD 15] years; 53% male, and 72% white. 90% patients had ischemic stroke and 10% hemorrhagic stroke. The two-stage model achieved a RMSE [95% CI] of 3.13 [2.86-3.41] (SC = 0.90 [0.88-0. 91]) in the MGH hold-out test set and 2.01 [1.58-2.38] (SC = 0.96 [0.94-0.97]) in the MIMIC validation set. CONCLUSIONS The automatic NLP-based model can enable large-scale stroke severity phenotyping from EHR and therefore support real-world quality improvement and comparative effectiveness studies in stroke.
Collapse
Affiliation(s)
- Marta Fernandes
- Department of Neurology, Massachusetts General Hospital (MGH), Boston, Massachusetts, United States
| | - M. Brandon Westover
- Department of Neurology, Beth Israel Deaconess Medical Center (BIDMC), Boston, Massachusetts, United States
| | - Aneesh B. Singhal
- Department of Neurology, Massachusetts General Hospital (MGH), Boston, Massachusetts, United States
| | - Sahar F. Zafar
- Department of Neurology, Massachusetts General Hospital (MGH), Boston, Massachusetts, United States
| |
Collapse
|
5
|
Li H, Meng X, Mao K, Liu L, Xu L, Chen L, Xu C, Wang W, Li C. The short-term outcome of intracranial stenosis with distal thrombosis treated with balloon-assisted tracking. Front Neurol 2024; 15:1308152. [PMID: 38434206 PMCID: PMC10904488 DOI: 10.3389/fneur.2024.1308152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/26/2024] [Indexed: 03/05/2024] Open
Abstract
Background and purposes Treating intracranial stenosis with distal thrombosis (IS&DT) using traditional mechanical thrombectomy (MT) techniques has proven challenging. This study aimed to summarize the experience of utilizing the balloon-assisted tracking (BAT) technique for IS&DT. Methods Demographic and morphologic characteristics of patients with IS&DT were collected for this study. The BAT technique, involving a half-deflated balloon outside the intermediate catheter tip, was used in all patients to navigate through the proximal stenosis. Various parameters were recorded, including the sequence of vascular reperfusion, the puncture-to-reperfusion time (PRT), the residual stenosis rate, and the occurrence of re-occlusion. The thrombolysis in cerebral infarction (TICI) scale was used to assess the reperfusion of intracranial vessels, with a TICI score of ≥2b considered as successful perfusion. The clinical status of patients was evaluated at three time points: pre-procedure, post-procedure, and at discharge using the modified Rankin score (mRS). Results In this study, a total of 10 patients were diagnosed with IS&DT, consisting of 9 male patients (90.0%) and 1 female patient (10.0%). The patients' mean age was 63.10 years (ranging from 29 to 79 years). The mean National Institute of Health Stroke Scale (NIHSS) score before treatment was 24.3 (ranging from 12 to 40), indicating the severity of their condition. Following the procedure, all patients achieved successful reperfusion with a thrombolysis in cerebral infarction (TICI) score of ≥2b. The average puncture-to-reperfusion time (PRT) was 51.8 min (ranging from 25 to 100 min), indicating the time taken for the procedure. During the perioperative period, three patients (30.0%) experienced complications. One patient had hemorrhage, while two patients had contrast extravasation. Among these cases, only the patient with hemorrhage (10%) suffered from a permanent neurological function deficit. At discharge, the patient's condition showed improvement. The mean NIHSS score decreased to 13.2 (ranging from 1 to 34), indicating a positive response to treatment. The mean mRS score at discharge was 3.2 (ranging from 1 to 5), showing some level of functional improvement. Conclusion In conclusion, the use of the balloon-assisted tracking (BAT) technique for treating intracranial stenosis with distal thrombosis (IS&DT) showed promising results. However, a moderate rate of perioperative complications was observed, warranting further investigation and refinement of the procedure.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Conghui Li
- The First Hospital of Hebei Medical University, Shijiazhuang, China
| |
Collapse
|
6
|
Ospel JM, Dmytriw AA, Regenhardt RW, Patel AB, Hirsch JA, Kurz M, Goyal M, Ganesh A. Recent developments in pre-hospital and in-hospital triage for endovascular stroke treatment. J Neurointerv Surg 2023; 15:1065-1071. [PMID: 36241225 DOI: 10.1136/jnis-2021-018547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 10/05/2022] [Indexed: 11/04/2022]
Abstract
Triage describes the assignment of resources based on where they can be best used, are most needed, or are most likely to achieve success. Triage is of particular importance in time-critical conditions such as acute ischemic stroke. In this setting, one of the goals of triage is to minimize the delay to endovascular thrombectomy (EVT), without delaying intravenous thrombolysis or other time-critical treatments including patients who cannot benefit from EVT. EVT triage is highly context-specific, and depends on availability of financial resources, staff resources, local infrastructure, and geography. Furthermore, the EVT triage landscape is constantly changing, as EVT indications evolve and new neuroimaging methods, EVT technologies, and adjunctive medical treatments are developed and refined. This review provides an overview of recent developments in EVT triage at both the pre-hospital and in-hospital stages. We discuss pre-hospital large vessel occlusion detection tools, transport paradigms, in-hospital workflows, acute stroke neuroimaging protocols, and angiography suite workflows. The most important factor in EVT triage, however, is teamwork. Irrespective of any new technology, EVT triage will only reach optimal performance if all team members, including paramedics, nurses, technologists, emergency physicians, neurologists, radiologists, neurosurgeons, and anesthesiologists, are involved and engaged. Thus, building sustainable relationships through continuous efforts and hands-on training forms an integral part in ensuring rapid and efficient EVT triage.
Collapse
Affiliation(s)
- Johanna M Ospel
- Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Neurointerventional Program, Departments of Medical Imaging & Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
| | | | - Aman B Patel
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Martin Kurz
- Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Mayank Goyal
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Aravind Ganesh
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| |
Collapse
|
7
|
Li Z, Ma H, Li B, Zhang L, Zhang Y, Xing P, Zhang Y, Zhang X, Zhou Y, Huang Q, Li Q, Zuo Q, Ye X, Liu J, Qureshi AI, Chen W, Yang P. Impact of anesthesia modalities on functional outcome of mechanical thrombectomy in patients with acute ischemic stroke: a subgroup analysis of DIRECT-MT trial. Eur J Med Res 2023; 28:228. [PMID: 37430361 DOI: 10.1186/s40001-023-01171-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 06/14/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND This subgroup analysis of Direct Intraarterial Thrombectomy in Order to Revascularize Acute Ischemic Stroke Patients with Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals Multicenter Randomized Clinical Trial (DIRECT-MT) aimed to investigate the influence of anesthesia modalities on the outcomes of endovascular treatment. METHODS Patients were divided into two groups by receiving general anesthesia (GA) or non-general anesthesia (non-GA). The primary outcome was assessed by the between-group difference in the distribution of the modified Rankin Scale (mRS) at 90 days, estimated using the adjusted common odds ratio (acOR) by multivariable ordinal regression. Differences in workflow efficiency, procedural complication, and safety outcomes were analyzed. RESULTS Totally 636 patients were enrolled (207 for GA and 429 for non-GA groups). There was no significant shift in the mRS distribution at 90 days between the two groups (acOR, 1.093). The median time from randomization to reperfusion was significantly longer in GA group (116 vs. 93 min, P < 0.0001). Patients in non-GA group were associated with a significantly lower NIHSS score at early stages (24 h, 11 vs 15; 5-7 days or discharge, 6.5 vs 10). The rate of severe manipulation-related complication did not differ significantly between GA and non-GA groups (0.97% vs 3.26%; P = 0.08). There are no differences in the rate of mortality and intracranial hemorrhage. CONCLUSIONS In the subgroup analysis of DIRECT-MT, we found no significant difference in the functional outcome at 90 days between general anesthesia and non-general anesthesia, despite the workflow time being significantly delayed for patients with general anesthesia. Clinical trail registration clinicaltrials.gov Identifier: NCT03469206.
Collapse
Affiliation(s)
- Zifu Li
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Hongyu Ma
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Binben Li
- Department of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lei Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yongwei Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Pengfei Xing
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yongxin Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaoxi Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yu Zhou
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qinghai Huang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qiang Li
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qiao Zuo
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaofei Ye
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jianmin Liu
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Wenhuo Chen
- Department of Neurology, Municipal Hospital of Zhangzhou, Zhangzhou, Fujian Province, China.
| | - Pengfei Yang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China.
| |
Collapse
|
8
|
Kurogi R, Kada A, Ogasawara K, Nishimura K, Kitazono T, Iwama T, Matsumaru Y, Sakai N, Shiokawa Y, Miyachi S, Kuroda S, Shimizu H, Yoshimura S, Osato T, Horie N, Nagata I, Nozaki K, Date I, Hashimoto Y, Hoshino H, Nakase H, Kataoka H, Ohta T, Fukuda H, Tamiya N, Kurogi AI, Ren N, Nishimura A, Arimura K, Shimogawa T, Yoshimoto K, Onozuka D, Ogata S, Hagihara A, Saito N, Arai H, Miyamoto S, Tominaga T, Iihara K. National trends in the outcomes of subarachnoid haemorrhage and the prognostic influence of stroke centre capability in Japan: retrospective cohort study. BMJ Open 2023; 13:e068642. [PMID: 37037619 PMCID: PMC10111904 DOI: 10.1136/bmjopen-2022-068642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
OBJECTIVES To examine the national, 6-year trends in in-hospital clinical outcomes of patients with subarachnoid haemorrhage (SAH) who underwent clipping or coiling and the prognostic influence of temporal trends in the Comprehensive Stroke Center (CSC) capabilities on patient outcomes in Japan. DESIGN Retrospective study. SETTING Six hundred and thirty-one primary care institutions in Japan. PARTICIPANTS Forty-five thousand and eleven patients with SAH who were urgently hospitalised, identified using the J-ASPECT Diagnosis Procedure Combination database. PRIMARY AND SECONDARY OUTCOME MEASURES Annual number of patients with SAH who remained untreated, or who received clipping or coiling, in-hospital mortality and poor functional outcomes (modified Rankin Scale: 3-6) at discharge. Each CSC was assessed using a validated scoring system (CSC score: 1-25 points). RESULTS In the overall cohort, in-hospital mortality decreased (year for trend, OR (95% CI): 0.97 (0.96 to 0.99)), while the proportion of poor functional outcomes remained unchanged (1.00 (0.98 to 1.02)). The proportion of patients who underwent clipping gradually decreased from 46.6% to 38.5%, while that of those who received coiling and those left untreated gradually increased from 16.9% to 22.6% and 35.4% to 38%, respectively. In-hospital mortality of coiled (0.94 (0.89 to 0.98)) and untreated (0.93 (0.90 to 0.96)) patients decreased, whereas that of clipped patients remained stable. CSC score improvement was associated with increased use of coiling (per 1-point increase, 1.14 (1.08 to 1.20)) but not with short-term patient outcomes regardless of treatment modality. CONCLUSIONS The 6-year trends indicated lower in-hospital mortality for patients with SAH (attributable to better outcomes), increased use of coiling and multidisciplinary care for untreated patients. Further increasing CSC capabilities may improve overall outcomes, mainly by increasing the use of coiling. Additional studies are necessary to determine the effect of confounders such as aneurysm complexity on outcomes of clipped patients in the modern endovascular era.
Collapse
Affiliation(s)
- Ryota Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akiko Kada
- Department of Clinical Research Management, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Science, Kyushu University, Fukuoka, Japan
| | - Toru Iwama
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Yanagido, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, University of Tsukuba, Tsukuba, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City General Hospital, Kobe, Japan
| | | | - Shigeru Miyachi
- Department of Neurosurgery, Neuroendovascular Therapy Center, Aichi Medical University, Nagakute, Japan
| | - Satoshi Kuroda
- Department of Neurosurgery, Toyama University, Toyama, Japan
| | - Hiroaki Shimizu
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Toshiaki Osato
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Izumi Nagata
- Department of Neurosurgery, Kokura Memorial Hospital, Kita-kyushu, Japan
| | - Kazuhiko Nozaki
- Department of Neurosurgery, Shiga University of Medical Science, Otsu, Japan
| | - Isao Date
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Okayama, Japan
| | | | - Haruhiko Hoshino
- Department of Neurology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tsuyoshi Ohta
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hitoshi Fukuda
- Department of Neurosurgery, Kochi Medical School, Nankoku, Japan
| | - Nanako Tamiya
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - A I Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nice Ren
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ataru Nishimura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koichi Arimura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takafumi Shimogawa
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Yoshimoto
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Daisuke Onozuka
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Soshiro Ogata
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akihito Hagihara
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Koji Iihara
- Director General, National Cerebral and Cardiovascular Center Hospital, Suita, Japan
| |
Collapse
|
9
|
Cummock JS, Wong KK, Volpi JJ, Wong ST. Reliability of the National Institutes of Health (NIH) Stroke Scale Between Emergency Room and Neurology Physicians for Initial Stroke Severity Scoring. Cureus 2023; 15:e37595. [PMID: 37197099 PMCID: PMC10183481 DOI: 10.7759/cureus.37595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 05/19/2023] Open
Abstract
INTRODUCTION In patients with acute ischemic stroke (AIS), the National Institutes of Health Stroke Scale (NIHSS) is essential to establishing a patient's initial stroke severity. While previous research has validated NIHSS scoring reliability between neurologists and other clinicians, it has not specifically evaluated NIHSS scoring reliability between emergency room (ER) and neurology physicians within the same clinical scenario and timeframe in a large cohort of patients. This study specifically addresses the key question: does an ER physician's NIHSS score agree with the neurologist's NIHSS score in the same patient at the same time in a real-world context? METHODS Data was retrospectively collected from 1,946 patients being evaluated for AIS at Houston Methodist Hospital from 05/2016 - 04/2018. Triage NIHSS scores assessed by both the ER and neurology providers within one hour of each other under the same clinical context were evaluated for comparison. Ultimately, 129 patients were included in the analysis. All providers in this study were NIHSS rater-certified. RESULTS The distribution of the NIHSS score differences (ER score - neurology score) had a mean of -0.46 and a standard deviation of 2.11. The score difference between provider teams ranged ±5 points. The intraclass correlation coefficient (ICC) for the NIHSS scores between the ER and neurology teams was 0.95 (95% CI, 0.93 - 0.97) with an F-test of 42.41 and a p-value of 4.43E-69. Overall reliability was excellent between the ER and neurology teams. CONCLUSION We evaluated triage NIHSS scores performed by ER and neurology providers under matching time and treatment conditions and found excellent interrater reliability. The excellent score agreement has important implications for treatment decision-making during patient handoff and further in stroke modeling, prediction, and clinical trial registries where missing NIHSS scores may be equivalently substituted from either provider team.
Collapse
Affiliation(s)
- Jonathon S Cummock
- Systems Medicine and Bioengineering, Houston Methodist Hospital, Houston, USA
- Department of Translational Medical Sciences, Texas A&M University School of Medicine, Bryan, USA
| | - Kelvin K Wong
- Systems Medicine and Bioengineering, Houston Methodist Hospital, Houston, USA
- Department of Radiology, Weill Cornell Medicine, Houston, USA
- The Ting Tsung and Wei Fong Chao Center for BRAIN, Houston Methodist Hospital, Houston, USA
- Department of Radiology, Houston Methodist Academic Institute, Houston, USA
| | - John J Volpi
- Department of Neurology, Houston Methodist Neurological Institute, Houston, USA
| | - Stephen T Wong
- Systems Medicine and Bioengineering, Houston Methodist Hospital, Houston, USA
- Department of Radiology, Weill Cornell Medicine, Houston, USA
- The Ting Tsung and Wei Fong Chao Center for BRAIN, Houston Methodist Hospital, Houston, USA
- Department of Radiology, Houston Methodist Academic Institute, Houston, USA
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, USA
| |
Collapse
|
10
|
Muacevic A, Adler JR, Wahlster S, Keen J, Walters AM, Fong CT, Dhulipala VB, Athiraman U, Moore A, Vavilala MS, Kim LJ, Levitt MR. Associations Between Transcranial Doppler Vasospasm and Clinical Outcomes After Aneurysmal Subarachnoid Hemorrhage: A Retrospective Observational Study. Cureus 2022; 14:e31789. [PMID: 36569681 PMCID: PMC9777349 DOI: 10.7759/cureus.31789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The objective is to examine the relationship between transcranial Doppler cerebral vasospasm (TCD-vasospasm), and clinical outcomes in aneurysmal subarachnoid hemorrhage (aSAH). METHODS In a retrospective cohort study, using univariate and multivariate analysis, we examined the association between TCD-vasospasm (defined as Lindegaard ratio >3) and patient's ability to ambulate without assistance, the need for tracheostomy and gastrostomy tube placement, and the likelihood of being discharged home from the hospital. RESULTS We studied 346 patients with aSAH; median age 55 years (Interquartile range IQR 46,64), median Hunt and Hess 3 [IQR 1-5]. Overall, 68.6% (n=238) had TCD-vasospasm, and 28% (n=97) had delayed cerebral ischemia. At hospital discharge, 54.3% (n=188) were able to walk without assistance, 5.8% (n=20) had received a tracheostomy, and 12% (n=42) had received a gastrostomy tube. Fifty-three percent (n=183) were discharged directly from the hospital to their home. TCD-vasospasm was not associated with ambulation without assistance at discharge (adjusted odds ratio, aOR 0.54, 95% 0.19,1.45), tracheostomy placement (aOR 2.04, 95% 0.23,18.43), gastrostomy tube placement (aOR 0.95, 95% CI 0.28,3.26), discharge to home (aOR 0.36, 95% CI 0.11,1.23). CONCLUSION This single-center retrospective study finds that TCD-vasospasm is not associated with clinical outcomes such as ambulation without assistance, discharge to home from the hospital, tracheostomy, and gastrostomy feeding tube placement. Routine screening for cerebral vasospasm and its impact on vasospasm diagnostic and therapeutic interventions and their associations with improved clinical outcomes warrant an evaluation in large, prospective, case-controlled, multi-center studies.
Collapse
|
11
|
Quality Improvement in Neurocritical Care: a Review of the Current Landscape and Best Practices. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00734-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Purpose of Review
The field of neurocritical care (NCC) has grown such that there is now a substantial body of literature on quality improvement specific to NCC. This review will discuss the development of this literature over time and highlight current best practices with practical tips for providers.
Recent Findings
There is tremendous variability in patient care models for NCC patients, despite evidence showing that certain structural elements are associated with better outcomes. There now also exist evidence-based recommendations for neurocritical care unit (NCCU) structure and processes, as well as NCC-specific performance measure (PM) sets; however, awareness of these is variable among care providers. The evidence-based literature on NCC structure, staffing, training, standardized order sets and bundles, transitions of care including handoff, prevention of bounce backs, bed flow optimization, and inter-hospital transfers is growing and offers many examples of successful performance improvement initiatives in NCCUs.
Summary
NCC providers care for patients with life-threatening conditions like intracerebral and subarachnoid hemorrhages, ischemic stroke, and traumatic brain injury, which are associated with high morbidity, complexity of treatment, and cost. Quality improvement initiatives have been successful in improving many aspects of NCC patient care, and NCC providers should continue to update and standardize their practices with consideration of this data. More research is needed to continue to identify high-risk and high-cost NCCU structures and processes and strategies to optimize them, validate current NCC PMs, and encourage clinical adoption of those that prove to be associated with improved outcomes.
Collapse
|
12
|
Yang S, Yao W, Siegler JE, Mofatteh M, Wellington J, Wu J, Liang W, Chen G, Huang Z, Yang R, Chen J, Yang Y, Hu Z, Chen Y. Shortening door-to-puncture time and improving patient outcome with workflow optimization in patients with acute ischemic stroke associated with large vessel occlusion. BMC Emerg Med 2022; 22:136. [PMID: 35883030 PMCID: PMC9315077 DOI: 10.1186/s12873-022-00692-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/15/2022] [Indexed: 11/10/2022] Open
Abstract
Objective We aimed to evaluate door-to-puncture time (DPT) and door-to-recanalization time (DRT) without directing healthcare by neuro-interventionalist support in the emergency department (ED) by workflow optimization and improving patients’ outcomes. Methods Records of 98 consecutive ischemic stroke patients who had undergone endovascular therapy (EVT) between 2018 to 2021 were retrospectively reviewed in a single-center study. Patients were divided into three groups: pre-intervention (2018–2019), interim-intervention (2020), and post-intervention (January 1st 2021 to August 16th, 2021). We compared door-to-puncture time, door-to-recanalization time (DRT), puncture-to-recanalization time (PRT), last known normal time to-puncture time (LKNPT), and patient outcomes (measured by 3 months modified Rankin Scale) between three groups using descriptive statistics. Results Our findings indicate that process optimization measures could shorten DPT, DRT, PRT, and LKNPT. Median LKNPT was shortened by 70 min from 325 to 255 min(P < 0.05), and DPT was shortened by 119 min from 237 to 118 min. DRT shortened by 132 min from 338 to 206 min, and PRT shortened by 33 min from 92 to 59 min from the pre-intervention to post-intervention groups (all P < 0.05). Only 21.4% of patients had a favorable outcome in the pre-intervention group as compared to 55.6% in the interventional group (P= 0.026). Conclusion This study demonstrated that multidisciplinary cooperation was associated with shortened DPT, DRT, PRT, and LKNPT despite challenges posed to the healthcare system such as the COVID-19 pandemic. These practice paradigms may be transported to other stroke centers and healthcare providers to improve endovascular time metrics and patient outcomes.
Collapse
Affiliation(s)
- Shuiquan Yang
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People's Hospital, No. 16, Guanghaidadaoxi, Sanshui District, Foshan, 528100, Guangdong Province, China
| | - Weiping Yao
- Dean Office and Advanced National Stroke Center, Foshan Sanshui District People's Hospital, Foshan, Guangdong Province, China
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Mohammad Mofatteh
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | | | - Jiale Wu
- Foshan Sanshui District People's Hospital, Foshan, Guangdong Province, China.,School of Medicine, Shaoguan University, Shaoguan, Guangdong Province, China
| | - Wenjun Liang
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People's Hospital, No. 16, Guanghaidadaoxi, Sanshui District, Foshan, 528100, Guangdong Province, China
| | - Gan Chen
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People's Hospital, No. 16, Guanghaidadaoxi, Sanshui District, Foshan, 528100, Guangdong Province, China
| | - Zhou Huang
- Department of Radiology, Foshan Sanshui District People's Hospital, Foshan, Guangdong Province, China
| | - Rongshen Yang
- Foshan Sanshui District People's Hospital, Foshan, Guangdong Province, China.,School of Medicine, Shaoguan University, Shaoguan, Guangdong Province, China
| | - Juanmei Chen
- The Second Clinical College, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Yajie Yang
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Zhaohui Hu
- Medical Department and Advanced National Stroke Center, Foshan Sanshui District People's Hospital, Foshan, Guangdong Province, China.
| | - Yimin Chen
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People's Hospital, No. 16, Guanghaidadaoxi, Sanshui District, Foshan, 528100, Guangdong Province, China.
| |
Collapse
|
13
|
Rogers H, Madathil KC, Joseph A, Holmstedt C, Qanungo S, McNeese N, Morris T, Holden RJ, McElligott JT. An exploratory study investigating the barriers, facilitators, and demands affecting caregivers in a telemedicine integrated ambulance-based setting for stroke care. APPLIED ERGONOMICS 2021; 97:103537. [PMID: 34371321 DOI: 10.1016/j.apergo.2021.103537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 07/14/2021] [Accepted: 07/17/2021] [Indexed: 06/13/2023]
Abstract
Telemedicine implementation in ambulances can reduce time to treatment for stroke patients, which is important as "time is brain" for these patients. Limited research has explored the demands placed on acute stroke caregivers in a telemedicine-integrated ambulance system. This study investigates the impact of telemedicine on workload, teamwork, workflow, and communication of geographically distributed caregivers delivering stroke care in ambulance-based telemedicine and usability of the system. Simulated stroke sessions were conducted with 27 caregivers, who subsequently completed a survey measuring workload, usability, and teamwork. Follow-up interviews with each caregiver ascertained how telemedicine affected workflow and demands which were analyzed for barriers and facilitators to using telemedicine. Caregivers experienced moderate workload and rated team effectiveness and usability high. Barriers included frustration with equipment and with the training of caregivers increasing demands, the loss of personal connection of the neurologists with the patients, and physical constraints in the ambulance. Facilitators were more common with live visual communication increasing teamwork and efficiency, the ease of access to neurologist, increased flexibility, and high overall satisfaction and usability. Future research should focus on eliminating these barriers and supporting the distributed cognition of caregivers.
Collapse
|
14
|
Kim SC, Lee CY, Kim CH, Sohn SI, Hong JH, Park H. The effectiveness of systemic and endovascular intra-arterial thrombectomy protocol for decreasing door-to-recanalization time duration. J Cerebrovasc Endovasc Neurosurg 2021; 24:24-35. [PMID: 34696551 PMCID: PMC8984638 DOI: 10.7461/jcen.2021.e2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/21/2021] [Indexed: 11/29/2022] Open
Abstract
Objective Variable treatment strategies and protocols have been applied to reduce time durations in the process of acute stroke management. The aim of this study is to investigate the effectiveness of our intra-arterial thrombectomy (IAT) protocol for decreasing door-to-recanalization time duration and improve successful recanalization. Methods A systemic and endovascular protocol included door-to-image, image-to-puncture and puncture-to-recanalization. We retrospectively analyzed the patients of pre- (Sep 2012–Apr 2014) and post-IAT protocol (May 2014–Jul 2018). Univariate analysis was used for the statistical significance according to variable factors (age, gender, the location of occluded vessel, successful recanalization TICI 2b-3). Independent t-test was used to compare the time duration. Results Among all 267 patients with acute stroke of anterior circulation, there were 50 and 217 patients with pre- and post-IAT protocol. Age, gender, and the location of occluded vessel have no statistical significance (p>0.05). In pre- and post-IAT group, successful recanalization was 39 of 50 (78.0%) and 185/217 (85.3%), respectively (p<0.05). Post-IAT (48.8%, 106/217) group had a higher tendency of good outcome than pre-IAT group (36.0%, 18/50) (p>0.05). Pre- and post-IAT group showed 61.7±21.4 vs. 25±16.0 (p<0.05), 102.0±29.8 vs. 82.7±30.4 (min) (p<0.05), and 79.1±47.5 vs. 58.4±75.3 (p<0.05) in three steps, respectively. Conclusions We suggest that the application of systemic and endovascular IAT protocols showed a significant time reduction for faster recanalization in patients with LVO. To build-up the well-designed IAT protocol through puncture-to-recanalization can be needed to decrease time duration and improve clinical outcome in recanalization therapy in acute stroke patients.
Collapse
Affiliation(s)
- Su Chel Kim
- Department of Neurosurgery, Keimyung University, Dong-San Medical Center, Daegu, Korea
| | - Chang-Young Lee
- Department of Neurosurgery, Keimyung University, Dong-San Medical Center, Daegu, Korea
| | - Chang-Hyun Kim
- Department of Neurosurgery, Keimyung University, Dong-San Medical Center, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University, Dong-San Medical Center, Daegu, Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University, Dong-San Medical Center, Daegu, Korea
| | - Hyungjong Park
- Department of Neurology, Keimyung University, Dong-San Medical Center, Daegu, Korea
| |
Collapse
|
15
|
Establishing a Baseline: Evidence-Supported State Laws to Advance Stroke Care. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2021; 26 Suppl 2, Advancing Legal Epidemiology:S19-S28. [PMID: 32004219 DOI: 10.1097/phh.0000000000001126] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Approximately 800 000 strokes occur annually in the United States. Stroke systems of care policies addressing prehospital and in-hospital care have been proposed to improve access to time-sensitive, lifesaving treatments for stroke. Policy surveillance of stroke systems of care laws supported by best available evidence could reveal potential strengths and weaknesses in how stroke care delivery is regulated across the nation. DESIGN This study linked the results of an early evidence assessment of 15 stroke systems of care policy interventions supported by best available evidence to a legal data set of the body of law in effect on January 1, 2018, for the 50 states and Washington, District of Columbia. RESULTS As of January 1, 2018, 39 states addressed 1 or more aspects of prehospital or in-hospital stroke care in law; 36 recognized at least 1 type of stroke center. Thirty states recognizing stroke centers also had evidence-supported prehospital policy interventions authorized in law. Four states authorized 10 or more of 15 evidence-supported policy interventions. Some combinations of prehospital and in-hospital policy interventions were more prevalent than other combinations. CONCLUSION The analysis revealed that many states had a stroke regulatory infrastructure for in-hospital care that is supported by best available evidence. However, there are gaps in how state law integrates evidence-supported prehospital and in-hospital care that warrant further study. This study provides a baseline for ongoing policy surveillance and serves as a basis for subsequent stroke systems of care policy implementation and policy impact studies.
Collapse
|
16
|
Jauch EC, Schwamm LH, Panagos PD, Barbazzeni J, Dickson R, Dunne R, Foley J, Fraser JF, Lassers G, Martin-Gill C, O'Brien S, Pinchalk M, Prabhakaran S, Richards CT, Taillac P, Tsai AW, Yallapragada A. Recommendations for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities From the Prehospital Stroke System of Care Consensus Conference: A Consensus Statement From the American Academy of Neurology, American Heart Association/American Stroke Association, American Society of Neuroradiology, National Association of EMS Physicians, National Association of State EMS Officials, Society of NeuroInterventional Surgery, and Society of Vascular and Interventional Neurology: Endorsed by the Neurocritical Care Society. Stroke 2021; 52:e133-e152. [PMID: 33691507 DOI: 10.1161/strokeaha.120.033228] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | - Robert Dunne
- Detroit East Medical Control Authority, MI (R. Dunne).,National Association of EMS Physicians (R. Dunne, C.M.-G.)
| | | | - Justin F Fraser
- University of Kentucky, Lexington (J.F.F.).,American Association of Neurological Surgeons, Society of NeuroInterventional Surgery (J.F.F.)
| | | | | | | | - Mark Pinchalk
- City of Pittsburgh Emergency Medical Services, PA (M.P.)
| | - Shyam Prabhakaran
- University of Chicago, IL (S.P.).,American Academy of Neurology (S.P.)
| | | | - Peter Taillac
- University of Utah, Salt Lake City (P.T.).,National Association of State EMS Officials (P.T.)
| | | | | | | |
Collapse
|
17
|
A Review of the Complex Landscape of Stroke in Left Ventricular Assist Device Trials. Ann Thorac Surg 2020; 110:1762-1773. [DOI: 10.1016/j.athoracsur.2020.03.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/02/2020] [Accepted: 03/04/2020] [Indexed: 11/18/2022]
|
18
|
Silva GS, Maldonado NJ, Mejia-Mantilla JH, Ortega-Gutierrez S, Claassen J, Varelas P, Suarez JI. Neuroemergencies in South America: How to Fill in the Gaps? Neurocrit Care 2020; 31:573-582. [PMID: 31342447 DOI: 10.1007/s12028-019-00775-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
South America is a subcontinent with 393 million inhabitants with widely distinct countries and diverse ethnicities, cultures, political and societal organizations. The epidemiological transition that accompanied the technological and demographic evolution is happening in South America and leading to a rise in the incidence of neurodegenerative and cardiovascular diseases that now coexist with the still high burden of infectious diseases. South America is also quite heterogeneous regarding the existence of systems of care for the various neurological emergencies, with some countries having well-organized systems for some diseases, while others have no plan of action for the care of patients with acute neurological symptoms. In this article, we discuss the existing systems of care in different countries of South America for the treatment of neurological emergencies, mainly stroke, status epilepticus, and traumatic brain injury. We also will address existing gaps between the current systems and recommendations from the literature to improve the management of such emergencies, as well as strategies on how to solve these disparities.
Collapse
Affiliation(s)
- Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP) and Albert Einstein Hospital, Albert Einstein Street, 627, Suite 218, São Paulo, SP, 05652-900, Brazil.
| | | | | | | | | | | | - Jose I Suarez
- Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | |
Collapse
|
19
|
Yaeger KA, Shoirah H, Kellner CP, Fifi J, Mocco J. Emerging Technologies in Optimizing Pre-Intervention Workflow for Acute Stroke. Neurosurgery 2020; 85:S9-S17. [PMID: 31197335 DOI: 10.1093/neuros/nyz058] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 02/20/2019] [Indexed: 01/08/2023] Open
Abstract
Over the last several years, thrombectomy for large vessel occlusions (LVOs) has emerged as a standard of care for acute stroke patients. Furthermore, the time to reperfusion has been identified as a predictor of overall patient outcomes, and much effort has been made to identify potential areas to target in enhancing preintervention workflow. As medical technology and stroke devices improve, nearly all time points can be affected, from field stroke triage to automated imaging interpretation to mass mobile stroke code communications. In this article, we review the preintervention stroke workflow with specific regard to emerging technologies in improving time to reperfusion and overall patient outcomes.
Collapse
Affiliation(s)
- Kurt A Yaeger
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, New York
| | - Hazem Shoirah
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, New York
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, New York
| | - Johanna Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, New York
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, New York
| |
Collapse
|
20
|
Livesay S, Fried H, Gagnon D, Karanja N, Lele A, Moheet A, Olm-Shipman C, Taccone F, Tirschwell D, Wright W, Claude Hemphill Iii J. Clinical Performance Measures for Neurocritical Care: A Statement for Healthcare Professionals from the Neurocritical Care Society. Neurocrit Care 2020; 32:5-79. [PMID: 31758427 DOI: 10.1007/s12028-019-00846-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Performance measures are tools to measure the quality of clinical care. To date, there is no organized set of performance measures for neurocritical care. METHODS The Neurocritical Care Society convened a multidisciplinary writing committee to develop performance measures relevant to neurocritical care delivery in the inpatient setting. A formal methodology was used that included systematic review of the medical literature for 13 major neurocritical care conditions, extraction of high-level recommendations from clinical practice guidelines, and development of a measurement specification form. RESULTS A total of 50,257 citations were reviewed of which 150 contained strong recommendations deemed suitable for consideration as neurocritical care performance measures. Twenty-one measures were developed across nine different conditions and two neurocritical care processes of care. CONCLUSIONS This is the first organized Neurocritical Care Performance Measure Set. Next steps should focus on field testing to refine measure criteria and assess implementation.
Collapse
Affiliation(s)
- Sarah Livesay
- College of Nursing, Rush University, Chicago, IL, USA.
| | | | - David Gagnon
- Maine Medical Center Department of Pharmacy, Portland, ME, USA
| | - Navaz Karanja
- Departments of Neurosciences and Anesthesiology, University of California-San Diego, San Diego, CA, USA
| | - Abhijit Lele
- Department of Anesthesiology and Pain Medicine, Neurocritical Care Service, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Asma Moheet
- OhioHealth Riverside Methodist Hospital, Columbus, OH, USA
| | - Casey Olm-Shipman
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Fabio Taccone
- Department of Intensive Care of Hospital Erasme, Brussels, Belgium
| | - David Tirschwell
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Wendy Wright
- Departments of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | | |
Collapse
|
21
|
Colton K, Richards CT, Pruitt PB, Mendelson SJ, Holl JL, Naidech AM, Prabhakaran S, Maas MB. Early Stroke Recognition and Time-based Emergency Care Performance Metrics for Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2019; 29:104552. [PMID: 31839545 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104552] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/21/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND AIM Performance measures have been extensively studied for acute ischemic stroke, leading to guideline-established benchmarks. Factors influencing care efficiency for intracerebral hemorrhage (ICH) are not well delineated. We sought to identify factors associated with early recognition of ICH and to assess the association between early recognition and completion of emergency care tasks. METHODS Consecutive patients with spontaneous ICH were enrolled in an observational cohort study conducted from 2009 to 2017 at an urban comprehensive stroke center, excluding patient transferred from other hospitals. We used stroke team activation as the indicator of early recognition and measured completion times for multiple ICH-relevant performance metrics including door to computed tomography (CT) acquisition and door to hemostatic medication initiation. RESULTS We studied 204 cases. All stroke-related performance times were faster in patients managed with stroke team activation compared to no activation, including quicker door to CT acquisition (median 24 versus 48 minutes, P < .001) and door to hemostatic medication initiation (63 versus 99 minutes, P = .005). These associations were confirmed in adjusted models. Stroke codes were activated in 43% of cases and were more likely in patients with shorter onset-to-arrival times, higher National Institutes of Health Stroke Scale scores, and higher Glasgow Coma Scale scores. CONCLUSIONS Stroke team activation was associated with more rapid diagnostic and therapeutic interventions for patients with ICH, but activation did not occur in the majority of cases, implying absence of early recognition. A stroke team activation process improves care performance, but leveraging the advantages of existing systems will require improved triage tools to identify ICH in the acute setting.
Collapse
Affiliation(s)
- Katharine Colton
- Department of Emergency Medicine, Northwestern University, Chicago, Illinois; Department of Neurology, Northwestern University, Chicago, Illinois
| | - Christopher T Richards
- Department of Emergency Medicine, Northwestern University, Chicago, Illinois; Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois
| | - Peter B Pruitt
- Department of Emergency Medicine, Northwestern University, Chicago, Illinois; Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois
| | | | - Jane L Holl
- Department of Neurology, University of Chicago, Chicago, Illinois
| | - Andrew M Naidech
- Department of Neurology, Northwestern University, Chicago, Illinois; Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois
| | | | - Matthew B Maas
- Department of Neurology, Northwestern University, Chicago, Illinois; Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois.
| |
Collapse
|
22
|
Sweid A, Hammoud B, Ramesh S, Wong D, Alexander TD, Weinberg JH, Deprince M, Dougherty J, Maamari DJM, Tjoumakaris S, Zarzour H, Gooch MR, Herial N, Romo V, Hasan DM, Rosenwasser RH, Jabbour P. Acute ischaemic stroke interventions: large vessel occlusion and beyond. Stroke Vasc Neurol 2019; 5:80-85. [PMID: 32411412 PMCID: PMC7213503 DOI: 10.1136/svn-2019-000262] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/29/2019] [Accepted: 11/13/2019] [Indexed: 12/24/2022] Open
Abstract
Care for acute ischaemic stroke is one of the most rapidly evolving fields due to the robust outcomes achieved by mechanical thrombectomy. Large vessel occlusion (LVO) accounts for up to 38% of acute ischaemic stroke and comes with devastating outcomes for patients, families and society in the pre-intervention era. A paradigm shift and a breakthrough brought mechanical thrombectomy back into the spotlight for acute ischaemic stroke; this was because five randomised controlled trials from several countries concluded that mechanical thrombectomy for acute stroke offered overwhelming benefits. This review article will present a comprehensive overview of LVO management, techniques and devices used, and the future of stroke therapy. In addition, we review our institution experience of mechanical thrombectomy for posterior and distal circulation occlusion.
Collapse
Affiliation(s)
- Ahmad Sweid
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Batoul Hammoud
- Endocrinology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sunidhi Ramesh
- Sydney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Daniella Wong
- Sydney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Tyler D Alexander
- Sydney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Maureen Deprince
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jaime Dougherty
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | | | - Hekmat Zarzour
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael R Gooch
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel Herial
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Victor Romo
- Anesthesia, Thomas Jefferson University-Center City Campus, Philadelphia, Pennsylvania, USA
| | - David M Hasan
- Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Robert H Rosenwasser
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| |
Collapse
|
23
|
Nishimura A, Nishimura K, Onozuka D, Matsuo R, Kada A, Kamitani S, Higashi T, Ogasawara K, Shimodozono M, Harada M, Hashimoto Y, Hirano T, Hoshino H, Itabashi R, Itoh Y, Iwama T, Kohriyama T, Matsumaru Y, Osato T, Sasaki M, Shiokawa Y, Shimizu H, Takekawa H, Nishi T, Uno M, Yagita Y, Ido K, Kurogi A, Kurogi R, Arimura K, Ren N, Hagihara A, Takizawa S, Arai H, Kitazono T, Miyamoto S, Minematsu K, Iihara K. Development of Quality Indicators of Stroke Centers and Feasibility of Their Measurement Using a Nationwide Insurance Claims Database in Japan ― J-ASPECT Study ―. Circ J 2019; 83:2292-2302. [PMID: 31554766 DOI: 10.1253/circj.cj-19-0089] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
BACKGROUND We aimed to develop quality indicators (QIs) related to primary and comprehensive stroke care and examine the feasibility of their measurement using the existing Diagnosis Procedure Combination (DPC) database. METHODS AND RESULTS: We conducted a systematic review of domestic and international studies using the modified Delphi method. Feasibility of measuring the QI adherence rates was examined using a DPC-based nationwide stroke database (396,350 patients admitted during 2013-2015 to 558 hospitals participating in the J-ASPECT study). Associations between adherence rates of these QIs and hospital characteristics were analyzed using hierarchical logistic regression analysis. We developed 17 and 12 measures as QIs for primary and comprehensive stroke care, respectively. We found that measurement of the adherence rates of the developed QIs using the existing DPC database was feasible for the 6 QIs (primary stroke care: early and discharge antithrombotic drugs, mean 54.6% and 58.7%; discharge anticoagulation for atrial fibrillation, 64.4%; discharge antihypertensive agents, 51.7%; comprehensive stroke care: fasudil hydrochloride or ozagrel sodium for vasospasm prevention, 86.9%; death complications of diagnostic neuroangiography, 0.4%). We found wide inter-hospital variation in QI adherence rates based on hospital characteristics. CONCLUSIONS We developed QIs for primary and comprehensive stroke care. The DPC database may allow efficient data collection at low cost and decreased burden to evaluate the developed QIs.
Collapse
Affiliation(s)
- Ataru Nishimura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University
| | - Kunihiro Nishimura
- Statistics and Data Analysis, National Cerebral and Cardiovascular Center
| | - Daisuke Onozuka
- Department of Health Communication, Kyushu University Graduate School of Medical Sciences
| | - Ryu Matsuo
- Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University
| | - Akiko Kada
- Department of Clinical Research Management, National Hospital Organization Nagoya Medical Center
| | - Satoru Kamitani
- Division of Health Services Research, Center for Cancer Control and Information Services, National Cancer Center
| | - Takahiro Higashi
- Division of Health Services Research, Center for Cancer Control and Information Services, National Cancer Center
| | | | - Megumi Shimodozono
- Department of Rehabilitation and Physical Medicine, Kagoshima University Graduate School of Medical and Dental Sciences
| | - Masafumi Harada
- Department of Radiology, Tokushima University Graduate School of Medical Sciences
| | | | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University School of Medicine
| | | | | | - Yoshiaki Itoh
- Department of Neurology, Graduate School of Medicine, Osaka City University
| | - Toru Iwama
- Department of Neurosurgery, Gifu University Graduate School of Medicine
| | | | - Yuji Matsumaru
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba
| | | | - Makoto Sasaki
- Division of Ultrahigh Field MRI, Institute for Biomedical Sciences, Iwate Medical University
| | | | - Hiroaki Shimizu
- Department of Neurosurgery, Akita University Graduate School of Medicine
| | | | - Toru Nishi
- Division of Neurosurgery, Saiseikai Kumamoto Hospital
| | - Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School
| | | | - Keisuke Ido
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University
| | - Ai Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University
| | - Ryota Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University
| | - Koichi Arimura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University
| | - Nice Ren
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University
| | - Akihito Hagihara
- Department of Health Communication, Kyushu University Graduate School of Medical Sciences
| | - Shunya Takizawa
- Department of Neurology, Department of Internal Medicine, Tokai University School of Medicine
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University School of Medicine
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
| | | | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University
| |
Collapse
|
24
|
Heiberger CJ, Kazi S, Mehta TI, Busch C, Wolf J, Sandhu D. Effects on Stroke Metrics and Outcomes of a Nurse-led Stroke Triage Team in Acute Stroke Management. Cureus 2019; 11:e5590. [PMID: 31696008 PMCID: PMC6820891 DOI: 10.7759/cureus.5590] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 09/07/2019] [Indexed: 01/01/2023] Open
Abstract
Background Timely administration of healthcare in acute stroke, congruent with national stroke metrics, relates to better patient outcomes. A nurse-led stroke triage team instituted at our facility was hypothesized to improve metrics and outcomes. To evaluate the effect of the nurse-led stroke triage team we compared specific stroke metrics and patient outcomes before and after the program initiation. Methods In retrospective review, we analyzed stroke metrics one year prior to the start of the triage program (controls) and one year after the start of the program (cases), including the following metrics: patient arrival, emergency department assessment, neurology contact, head computed tomography (CT) scan, and delivery of tissue plasminogen activator (tPA) or puncture for mechanical thrombectomy. Primary outcome measures were improved metric times. Results Ninety-five acute stroke events were analyzed: 26 controls and 69 cases. Cohort demographics included means of age 72.82 years, National Institutes of Health Stroke Scale (NIHSS) 15.96, discharge and 90-day mRS 3.71 and 3.55 respectively, and length of stay 5.98 days. There were significantly different improvements in metrics between arrival time to CT start, emergency room physician evaluation to CT start, neurology contact to CT start, and neurology contact to tPA initiation for cases post-triage team institution. No significant differences during this period were seen for other metrics. Multivariate analysis controlling for age, sex and NIHSS found no significant difference for discharge or 90-day mRS scores. Conclusions An interdisciplinary approach to acute stroke management can impact stroke metrics. These data support the integration of specially trained stroke nurses in acute stroke triage for quality improvement efforts.
Collapse
Affiliation(s)
- Caleb J Heiberger
- Radiology, University of South Dakota Sanford School of Medicine, Sioux Falls, USA
| | - Stephanie Kazi
- Neurology, University of South Dakota Sanford School of Medicine, Sioux Falls, USA
| | - Tej I Mehta
- Radiology, University of South Dakota Sanford School of Medicine, Sioux Falls, USA
| | - Clayton Busch
- Neurology, University of South Dakota Sanford School of Medicine, Sioux Falls, USA
| | | | | |
Collapse
|
25
|
Adeoye O, Nyström KV, Yavagal DR, Luciano J, Nogueira RG, Zorowitz RD, Khalessi AA, Bushnell C, Barsan WG, Panagos P, Alberts MJ, Tiner AC, Schwamm LH, Jauch EC. Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update. Stroke 2019; 50:e187-e210. [PMID: 31104615 DOI: 10.1161/str.0000000000000173] [Citation(s) in RCA: 222] [Impact Index Per Article: 44.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In 2005, the American Stroke Association published recommendations for the establishment of stroke systems of care and in 2013 expanded on them with a statement on interactions within stroke systems of care. The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating stroke systems of care to date and to update the American Stroke Association recommendations on the basis of improvements in stroke systems of care. Over the past decade, stroke systems of care have seen vast improvements in endovascular therapy, neurocritical care, and stroke center certification, in addition to the advent of innovations, such as telestroke and mobile stroke units, in the context of significant changes in the organization of healthcare policy in the United States. This statement provides an update to prior publications to help guide policymakers and public healthcare agencies in continually updating their stroke systems of care in light of these changes. This statement and its recommendations span primordial and primary prevention, acute stroke recognition and activation of emergency medical services, triage to appropriate facilities, designation of and treatment at stroke centers, secondary prevention at hospital discharge, and rehabilitation and recovery.
Collapse
|
26
|
Kansagra AP, Wallace AN, Curfman DR, McEachern JD, Moran CJ, Cross DT, Lee JM, Ford AL, Manu SG, Panagos PD, Derdeyn CP. Streamlined triage and transfer protocols improve door-to-puncture time for endovascular thrombectomy in acute ischemic stroke. Clin Neurol Neurosurg 2019; 166:71-75. [PMID: 29408777 DOI: 10.1016/j.clineuro.2018.01.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/10/2018] [Accepted: 01/22/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Shorter time from symptom onset to treatment is associated with improved outcomes in patients who undergo mechanical thrombectomy for treatment of acute ischemic stroke due to emergent large vessel occlusion. In this work, we detail pre-thrombectomy process improvements in a multi-hospital network and report the effect on door-to-puncture time in patients undergoing mechanical thrombectomy. PATIENTS AND METHODS A streamlined workflow was adopted to minimize door-to-puncture time. Key features of this workflow included rapid and concurrent clinical and radiological evaluation with point-of-care image interpretation, pre-transfer IV thrombolysis and CTA for transferred patients, immediate transport to the angiography suite potentially before neurointerventional radiology team arrival, and minimalist room setup. Door-to-puncture time was measured prospectively and analyzed retrospectively for 78 consecutive patients treated between January 2015 and December 2015. Statistical analysis was performed using the F-test on individual coefficients of a linear regression model. RESULTS From quarter 1 to quarter 4, the number of thrombectomies performed increased by 173% (11 patients to 30 patients, p = 0.002), and there was a significant increase in the proportion of transferred patients that underwent pre-transfer CTA (p = 0.04). During this interval, overall median door-to-puncture time decreased by 74% (147 min to 39 min, p < 0.001); this decrease was greatest in transferred patients with pre-transfer CTA (81% decrease, 129 min to 25 min, p < 0.001) and smallest in patients presenting directly to the emergency department (52% decrease, 167 min to 87 min, p < 0.001). CONCLUSION Simple workflow improvements to streamline in-hospital triage and perform critical workup at transferring hospitals can produce reductions in door-to-puncture time.
Collapse
Affiliation(s)
- Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, United States; Department of Neurosurgery, Washington University School of Medicine, United States; Department of Neurology, Washington University School of Medicine, United States.
| | - Adam N Wallace
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, United States
| | - David R Curfman
- Department of Neurology, Washington University School of Medicine, United States
| | - James D McEachern
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, United States
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, United States; Department of Neurosurgery, Washington University School of Medicine, United States
| | - DeWitte T Cross
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, United States; Department of Neurosurgery, Washington University School of Medicine, United States
| | - Jin-Moo Lee
- Department of Neurology, Washington University School of Medicine, United States
| | - Andria L Ford
- Department of Neurology, Washington University School of Medicine, United States
| | - S Goyal Manu
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, United States
| | - Peter D Panagos
- Department of Neurology, Washington University School of Medicine, United States; Department of Emergency Medicine, Washington University School of Medicine, United States
| | - Colin P Derdeyn
- Department of Radiology, University of Iowa Hospitals and Clinics, United States
| |
Collapse
|
27
|
Direct-Acting Oral Anticoagulants and Warfarin-Associated Intracerebral Hemorrhage Protocol Reduces Timing of Door to Correction Interventions. J Neurosci Nurs 2019; 51:89-94. [PMID: 30801446 DOI: 10.1097/jnn.0000000000000430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is a life-threatening complication of oral anticoagulant therapy that sometimes results in hematoma expansion after onset. Our facility did not have a standardized process for treating oral anticoagulant-associated ICH; this resulted in lag times from order to reversal agent administration. PURPOSE The aim of this study was to examine the impact of a rapid anticoagulant reversal protocol, combined with warfarin and direct-acting oral anticoagulant therapy, in decreasing door to first intervention times. METHODS This study used a retrospective quality assessment research approach in examining an oral anticoagulant reversal protocol to compare the control and intervention groups. Phytonadione was the first intervention treatment for most study participants diagnosed with warfarin-associated ICH with an international normalized ratio greater than 1.4. Factor IX was the first intervention treatment for all but one study participant with DOAC-associated ICH. RESULTS Findings were statistically significant (P < .05) for door to first intervention treatments. Door to phytonadione in minutes decreased from 232.7 (SD, 199.4) to posttest findings of 111.4 (SD, 64.6). Door to factor IX in minutes decreased from 183.9 (SD, 230.2) to posttest findings of 116.6 (SD, 69.1). CONCLUSION Study findings support the hypothesis that the new protocol was associated with lower door-to-treatment times for eligible patients.
Collapse
|
28
|
Milligan TA. Diagnosis in Neurologic Disease. Med Clin North Am 2019; 103:173-190. [PMID: 30704675 DOI: 10.1016/j.mcna.2018.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The diagnosis of neurologic disease is relevant to the non-neurologist because neurologic symptoms are a common reason patients present to their health care provider and most of these patients are never referred to a neurologist. The diagnosis of a neurologic disease is a rewarding endeavor because it requires intellectual rigor, skill, and is of paramount importance to patient care. A tailored history and examination lead to localization and differential diagnosis. Diagnostic testing often involves neuroimaging and serum testing and also may involve lumbar puncture, electroencephalogram, nerve conduction studies, and electromyography. In the modern era, all neurologic diagnoses lead to treatments.
Collapse
Affiliation(s)
- Tracey A Milligan
- Department of Neurology, Harvard Medical School, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, USA.
| |
Collapse
|
29
|
Cruz-Flores S. Does Endovascular Thrombectomy for Ischemic Stroke Impact 30-Day Readmissions? JACC Cardiovasc Interv 2018; 11:2425-2426. [PMID: 30522673 DOI: 10.1016/j.jcin.2018.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 10/09/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Salvador Cruz-Flores
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas.
| |
Collapse
|
30
|
Hextrum S, Biller J. Clinical Distinction of Cerebral Ischemia and Triaging of Patients in the Emergency Department. Neuroimaging Clin N Am 2018; 28:537-549. [DOI: 10.1016/j.nic.2018.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|
31
|
Hacein-Bey L, Heit JJ, Konstas AA. Neuro-Interventional Management of Acute Ischemic Stroke. Neuroimaging Clin N Am 2018; 28:625-638. [PMID: 30322598 DOI: 10.1016/j.nic.2018.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Restoration of cerebral blood flow is the most important step in preventing irreversible damage to hypoperfused brain cells after ischemic stroke from large-vessel occlusion. For those patients who do not respond to (or are not eligible for) intravenous thrombolysis, endovascular therapy has become standard of care. A shift is currently taking place from rigid time windows for intervention (time is brain) to physiology-driven paradigms that rely heavily on neuroimaging. At this time, one can reasonably anticipate that more patients will be treated, and that outcomes will keep improving. This article discusses in detail recent advances in endovascular stroke therapy.
Collapse
Affiliation(s)
- Lotfi Hacein-Bey
- Interventional Neuroradiology and Neuroradiology, Department of Medical Imaging, Sutter Health, Sacramento, CA 95815, USA; Radiology Department, University of California Davis Medical School of Medicine, 4860 Y Street, Sacramento, CA 95817, USA.
| | - Jeremy J Heit
- Division of Neuroimaging and Neurointervention, Stanford Healthcare, 300 Pasteur Drive, Grant S047, Stanford, CA 94305, USA
| | - Angelos A Konstas
- Interventional Neuroradiology and Neuroradiology, Department of Radiology, Huntington Memorial Hospital, 100 West California Boulevard, Pasadena, CA 91105, USA
| |
Collapse
|
32
|
Khurana D, Padma MV, Bhatia R, Kaul S, Pandian J, Sylaja PN, Arjundas D, Uppal A, Pradeep VG, Suri V, Nagaraja D, Alurkar A, Narayan S. Recommendations for the Early Management of Acute Ischemic Stroke: A Consensus Statement for Healthcare Professionals from the Indian Stroke Association. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/2516608518777935] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dheeraj Khurana
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | - Rohit Bhatia
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Subhash Kaul
- Nizam’s Institute of Medical Sciences (NIMS), Hyderabad, India
| | | | - P. N. Sylaja
- Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum, India
| | | | | | | | - Vinit Suri
- Indraprastha Apollo Hospital, New Delhi, India
| | - D. Nagaraja
- National Institute of Mental Health & Neuro Sciences (NIMHANS), Hyderabad, India
| | | | - Sunil Narayan
- Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | | | | |
Collapse
|
33
|
Kim DH, Kim B, Jung C, Nam HS, Lee JS, Kim JW, Lee WJ, Seo WK, Heo JH, Baik SK, Kim BM, Rha JH. Consensus Statements by Korean Society of Interventional Neuroradiology and Korean Stroke Society: Hyperacute Endovascular Treatment Workflow to Reduce Door-to-Reperfusion Time. Korean J Radiol 2018; 19:838-848. [PMID: 30174472 PMCID: PMC6082772 DOI: 10.3348/kjr.2018.19.5.838] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 06/06/2018] [Indexed: 02/01/2023] Open
Abstract
Recent clinical trials demonstrated the clinical benefit of endovascular treatment (EVT) in patients with acute ischemic stroke due to large vessel occlusion. These trials confirmed that good outcome after EVT depends on the time interval from symptom onset to reperfusion and that in-hospital delay leads to poor clinical outcome. However, there has been no universally accepted in-hospital workflow and performance benchmark for rapid reperfusion. Additionally, wide variety in workflow for EVT is present between each stroke centers. In this consensus statement, Korean Society of Interventional Neuroradiology and Korean Stroke Society Joint Task Force Team propose a standard workflow to reduce door-to-reperfusion time for stroke patients eligible for EVT. This includes early stroke identification and pre-hospital notification to stroke team of receiving hospital in pre-hospital phase, the transfer of stroke patients from door of the emergency department to computed tomography (CT) room, warming call to neurointervention (NI) team for EVT candidate prior to imaging, NI team preparation in parallel with thrombolysis, direct transportation from CT room to angiography suite following immediate decision of EVT and standardized procedure for rapid reperfusion. Implementation of optimized workflow will improve stroke time process metrics and clinical outcome of the patient treated with EVT.
Collapse
Affiliation(s)
- Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan 49201, Korea
| | - Byungjun Kim
- Department of Radiology, Korea University Anam Hospital, Seoul 02841, Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam 13620, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University Severance Hospital, Seoul 03722, Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, Suwon 16499, Korea
| | - Jin Woo Kim
- Department of Radiology, Inje Univeristy Ilsan Paik Hospital, Goyang 10380, Korea
| | - Woong Jae Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul 06973, Korea
| | - Woo-Keun Seo
- Department of Neurology, Sungkyunkwan University, Samsung Medical Center, Seoul 06351, Korea
| | - Ji-Hoe Heo
- Department of Neurology, Yonsei University Severance Hospital, Seoul 03722, Korea
| | - Seung Kug Baik
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan 50612, Korea
| | - Byung Moon Kim
- Department of Radiology, Yonsei University Severance Hospital, Seoul 03722, Korea
| | - Joung-Ho Rha
- Department of Neurology, Inha University Hospital, Incheon 22332, Korea
| |
Collapse
|
34
|
Sacks D, Baxter B, Campbell BCV, Carpenter JS, Cognard C, Dippel D, Eesa M, Fischer U, Hausegger K, Hirsch JA, Hussain MS, Jansen O, Jayaraman MV, Khalessi AA, Kluck BW, Lavine S, Meyers PM, Ramee S, Rüfenacht DA, Schirmer CM, Vorwerk D. Multisociety Consensus Quality Improvement Revised Consensus Statement for Endovascular Therapy of Acute Ischemic Stroke. AJNR Am J Neuroradiol 2018; 39:E61-E76. [PMID: 29773566 PMCID: PMC7410632 DOI: 10.3174/ajnr.a5638] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- D Sacks
- From the Department of Interventional Radiology (D.S.), The Reading Hospital and Medical Center, West Reading, Pennsylvania
| | - B Baxter
- Department of Radiology (B.B.), Erlanger Medical Center, Chattanooga, Tennessee
| | - B C V Campbell
- Departments of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - J S Carpenter
- Department of Radiology (J.S.C.), West Virginia University, Morgantown, West Virginia
| | - C Cognard
- Department of Diagnostic and Therapeutic Neuroradiology (C.C.), Centre Hospitalier Universitaire de Toulouse, Hôpital Purpan, Toulouse, France
| | - D Dippel
- Department of Neurology (D.D.), Erasmus University Medical Center, Rotterdam, the Netherlands
| | - M Eesa
- Department of Radiology (M.E.), University of Calgary, Calgary, Alberta, Canada
| | - U Fischer
- Department of Neurology (U.F.), Inselspital-Universitätsspital Bern, Bern, Switzerland
| | - K Hausegger
- Department of Radiology (K.H.), Klagenfurt State Hospital, Klagenfurt am Wörthersee, Austria
| | - J A Hirsch
- Neuroendovascular Program, Department of Radiology (J.A.H.), Massachusetts General Hospital, Boston, Massachusetts
| | - M S Hussain
- Cerebrovascular Center, Neurological Institute (M.S.H.), Cleveland Clinic, Cleveland, Ohio
| | - O Jansen
- Department of Radiology and Neuroradiology (O.J.), Klinik für Radiologie und Neuroradiologie, Kiel, Germany
| | - M V Jayaraman
- Departments of Diagnostic Imaging, Neurology, and Neurosurgery (M.V.J.), Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - A A Khalessi
- Department of Surgery (A.A.K.), University of California San Diego Health, San Diego, California
| | - B W Kluck
- Interventional Cardiology (B.W.K.), Heart Care Group, Allentown, Pennsylvania
| | - S Lavine
- Departments of Neurological Surgery and Radiology (S.L.), Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York
| | - P M Meyers
- Departments of Radiology and Neurological Surgery (P.M.M.), Columbia University College of Physicians and Surgeons, New York, New York
| | - S Ramee
- Interventional Cardiology, Heart and Vascular Institute (S.R.), Ochsner Medical Center, New Orleans, Louisiana
| | - D A Rüfenacht
- Neuroradiology Division (D.A.R.), Swiss Neuro Institute-Clinic Hirslanden, Zürich, Switzerland
| | - C M Schirmer
- Department of Neurosurgery and Neuroscience Center (C.M.S.), Geisinger Health System, Wilkes-Barre, Pennsylvania
| | - D Vorwerk
- Diagnostic and Interventional Radiology Institutes (D.V.), Klinikum Ingolstadt, Ingolstadt, Germany
| |
Collapse
|
35
|
Hemphill JC, Adeoye OM, Alexander DN, Alexandrov AW, Amin-Hanjani S, Cushman M, George MG, LeRoux PD, Mayer SA, Qureshi AI, Saver JL, Schwamm LH, Sheth KN, Tirschwell D. Clinical Performance Measures for Adults Hospitalized With Intracerebral Hemorrhage: Performance Measures for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2018; 49:e243-e261. [PMID: 29786566 DOI: 10.1161/str.0000000000000171] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
36
|
Kim DH, Kim B, Jung C, Nam HS, Lee JS, Kim JW, Lee WJ, Seo WK, Heo JH, Baik SK, Kim BM, Rha JH. Consensus Statements by Korean Society of Interventional Neuroradiology and Korean Stroke Society: Hyperacute Endovascular Treatment Workflow to Reduce Door-to-Reperfusion Time. J Korean Med Sci 2018; 33:e143. [PMID: 29736159 PMCID: PMC5934519 DOI: 10.3346/jkms.2018.33.e143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/20/2018] [Indexed: 11/20/2022] Open
Abstract
Recent clinical trials demonstrated the clinical benefit of endovascular treatment (EVT) in patients with acute ischemic stroke due to large vessel occlusion. These trials confirmed that good outcome after EVT depends on the time interval from symptom onset to reperfusion and that in-hospital delay leads to poor clinical outcome. However, there has been no universally accepted in-hospital workflow and performance benchmark for rapid reperfusion. Additionally, wide variety in workflow for EVT is present between each stroke centers. In this consensus statement, Korean Society of Interventional Neuroradiology and Korean Stroke Society Joint Task Force Team propose a standard workflow to reduce door-to-reperfusion time for stroke patients eligible for EVT. This includes early stroke identification and pre-hospital notification to stroke team of receiving hospital in pre-hospital phase, the transfer of stroke patients from door of the emergency department to computed tomography (CT) room, warming call to neurointervention team for EVT candidate prior to imaging, neurointervention team preparation in parallel with thrombolysis, direct transportation from CT room to angiography suite following immediate decision of EVT and standardized procedure for rapid reperfusion. Implementation of optimized workflow will improve stroke time process metrics and clinical outcome of the patient treated with EVT.
Collapse
Affiliation(s)
- Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, Korea
| | - Byungjun Kim
- Department of Radiology, Korea University Anam Hospital, Seoul, Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University Severance Hospital, Seoul, Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea
| | - Jin Woo Kim
- Department of Radiology, Inje Univeristy Ilsan Paik Hospital, Goyang, Korea
| | - Woong Jae Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul, Korea
| | - Woo-Keun Seo
- Department of Neurology, Sungkyunkwan University, Samsung Medical Center, Seoul, Korea
| | - Ji-Hoe Heo
- Department of Neurology, Yonsei University Severance Hospital, Seoul, Korea
| | - Seung Kug Baik
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Byung Moon Kim
- Department of Radiology, Yonsei University Severance Hospital, Seoul, Korea
| | - Joung-Ho Rha
- Department of Neurology, Inha University Hospital, Incheon, Korea
| | | |
Collapse
|
37
|
Yu W, Kavi T, Majic T, Alva K, Moheet A, Lyden P, Schievink W, Lekovic G, Alexander M. Treatment Modality and Quality Benchmarks of Aneurysmal Subarachnoid Hemorrhage at a Comprehensive Stroke Center. Front Neurol 2018; 9:152. [PMID: 29599745 PMCID: PMC5862861 DOI: 10.3389/fneur.2018.00152] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 03/01/2018] [Indexed: 01/23/2023] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage (aSAH) is the most severe type of stroke. In 2012, the Joint Commission, in collaboration with the American Heart Association/American Stroke Association (AHA/ASA), launched the Advanced Certification for Comprehensive Stroke Centers (CSCs). This new level of certification was designed to promote higher standard of care for patients with complex stroke. Objective The goal of this study was to examine the treatment modality and quality benchmarks of aSAH at one of the first five certified CSCs in the United States. Methods Consecutive patients with aSAH at Cedars-Sinai Medical Center between April 1, 2012 and May 30, 2014 were included for this retrospective study. The ruptured aneurysm was treated with coiling or clipping within 24 h. All patients were managed per AHA guidelines. Discharge outcomes were assessed using modified Rankin Scale (mRS). The rate of aneurysm treatment, door-to-treatment time, rate of posttreatment rebleed, hospital length of stay (LOS), discharge outcome, and mortality rates were evaluated as quality indicators. Results The median age (interquartile range) of the 118 patients with aSAH was 55 (19). Among them, 84 (71.2%) were females, 94 (79.7%) were transfers from outside hospitals, and 74 (62.7%) had Hunt and Hess grades 1-3. Sixty patients (50.8%) were treated with coiling, 52 (44.1%) with clipping, and 6 (5.1%) untreated due to ictal cardiac arrest or severe comorbidities. The rate of aneurysm treatment was 95% (112/118) with median door-to-treatment time at 12.5 (8.5) h and 0.9% (1/112) posttreatment rebleed. The median ICU and hospital LOS were 12.5 (7) and 17.0 (14.5) days, respectively. Coiling was associated with significantly shorter LOS than clipping. There were 59 patients (50%) with favorable outcome and 19 deaths (16.1%) at hospital discharge. There was no significant difference in discharge outcome between coiling and clipping. Conclusion Care of aSAH at one of the early CSCs in the United States was associated with high rate of aneurysm treatment, fast door-to-treatment time, low posttreatment rebleed, excellent outcome, and low mortality rate. Coiling was associated with significant shorter LOS than clipping. There was no significant difference in discharge outcomes between treatment modalities.
Collapse
Affiliation(s)
- Wengui Yu
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Department of Neurology, University of California Irvine Medical Center, Orange, CA, United States
| | - Tapan Kavi
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Department of Neurology and Neurosurgery, Cooper University Hospital, Camden, NJ, United States
| | - Tamara Majic
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Kimberly Alva
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Asma Moheet
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Patrick Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Wouter Schievink
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Gregory Lekovic
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Division of Neurosurgery, House Clinic, Los Angeles, CA, United States
| | - Michael Alexander
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| |
Collapse
|
38
|
Harris DG, Olson SB, Rosen CB, Kalsi R, Taylor BS, Diaz JJ, Flohr TR, Crawford RS. Early Treatment at a Referral Center Improves Outcomes for Patients with Acute Vascular Disease. Ann Vasc Surg 2018. [PMID: 29518507 DOI: 10.1016/j.avsg.2018.01.088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with acute vascular disease frequently need specialized management that may require transfer to a vascular referral center. Although transfer may be medically necessary, it can delay definitive care and is an indicator of incorrect triage to the initial hospital. Regionalization of acute vascular care could improve patient triage and subsequent outcomes. To evaluate the potential benefit from regionalization, we analyzed outcomes of patients treated for acute vascular disease at vascular referral centers. METHODS Using a statewide database capturing all inpatient admissions in Maryland during 2013-2015, patients undergoing noncardiac vascular procedures on an acute basis were identified. Patients admitted to a vascular referral center were stratified by admission status as direct or transfer. The primary outcome was inpatient mortality, and the secondary outcome was resource use. Patient groups were compared by univariable analyses, and the effect of admission status on mortality was assessed by multivariable logistic regression. RESULTS Of 4,873 patients with acute vascular disease managed at vascular referral centers, 2,713 (56%) were admitted directly, whereas 2,160 (44%) were transferred. Transfers to referral centers accounted for 71% of all interhospital transfers. The transfer-group patients were older, had more comorbidities, and higher illness severities. Patients who were transferred had higher mortality (14% vs. 9%, P < 0.0001), longer hospital lengths of stay, greater critical care-resource utilization, and higher costs. After adjusting for demographics, comorbidities, and illness severity, transfer status was independently associated with higher inpatient mortality. CONCLUSIONS Primary treatment at a referral center is independently associated with improved outcomes for patients with acute vascular disease. Direct admission or earlier triage to a specialty center may improve patient and system outcomes and could be facilitated by standardization and regionalization of complex acute vascular care.
Collapse
Affiliation(s)
- Donald G Harris
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD.
| | - Sarah B Olson
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Claire B Rosen
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Richa Kalsi
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Bradley S Taylor
- Department of Surgery, Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD; Center for Aortic Disease, University of Maryland Medical Center, Baltimore, MD
| | - Jose J Diaz
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Tanya R Flohr
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Center for Aortic Disease, University of Maryland Medical Center, Baltimore, MD
| | - Robert S Crawford
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Center for Aortic Disease, University of Maryland Medical Center, Baltimore, MD
| |
Collapse
|
39
|
Multisociety Consensus Quality Improvement Revised Consensus Statement for Endovascular Therapy of Acute Ischemic Stroke: From the American Association of Neurological Surgeons (AANS), American Society of Neuroradiology (ASNR), Cardiovascular and Interventional Radiology Society of Europe (CIRSE), Canadian Interventional Radiology Association (CIRA), Congress of Neurological Surgeons (CNS), European Society of Minimally Invasive Neurological Therapy (ESMINT), European Society of Neuroradiology (ESNR), European Stroke Organization (ESO), Society for Cardiovascular Angiography and Interventions (SCAI), Society of Interventional Radiology (SIR), Society of NeuroInterventional Surgery (SNIS), and World Stroke Organization (WSO). J Vasc Interv Radiol 2018; 29:441-453. [PMID: 29478797 DOI: 10.1016/j.jvir.2017.11.026] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 11/23/2017] [Accepted: 11/23/2017] [Indexed: 01/19/2023] Open
|
40
|
Zuckerman SL, Bhatia R, Tsujiara C, Baker CB, Szafran A, Cushing D, Aiken J, Tracy M, Mocco J, Ecker RD. Prospective series of two hours supine rest after 4fr sheath-based diagnostic cerebral angiography: Outcomes, productivity and cost. Interv Neuroradiol 2018; 21:114-9. [PMID: 25934785 DOI: 10.15274/inr-2014-10102] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
There is no standard of care for catheter size or post-procedure supine time in cerebral angiography. Catheter sizes range from 4-Fr to 6-Fr with supine times ranging from two to over six hours. The objective of our study was to establish the efficacy, safety, and cost savings of two-hour supine time after 4-Fr elective cerebral angiography. A prospective, single arm study was performed on 107 patients undergoing elective cerebral angiography. All cerebral angiograms were performed with a 4-Fr sheath-based system without closure devices. Ten minutes of manual compression was applied to the femoral access site, with further compression held as clinically indicated. Patients were then monitored in a nursing unit for two hours supine and subsequently mobilized. Nursing discretion was allowed for earlier mobilization. Patients were called the next day to assess delayed hematoma and bleeding. Estimates of cost savings and productivity increases are provided. All patients ambulated in two hours or less. There were no strokes or vessel dissections. Five patients (4.7%) experienced a palpable hematoma, three patients (2.8%) experienced bleeding immediately following the procedure requiring further compression, and one patient (0.9%) experienced minor groin oozing at home. No patient required transfusion, thrombin injection, or endovascular/surgical management of a groin complication. A two-hour post-procedure supine time resulted in cost savings of $952 per angiogram and a total of $101,864. 4-Fr sheath based cerebral angiography with two-hour post-procedure supine time is safe and effective, and allows for a considerable increase in patient satisfaction, cost savings and productivity.
Collapse
Affiliation(s)
- Scott L Zuckerman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ritwik Bhatia
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Crystiana Tsujiara
- Department of Radiology, Maine Medical Center, Neuroscience Institute, Portland, Maine, USA
| | | | - Alex Szafran
- Surgery, Maine Medical Center, Neuroscience Institute, Portland, Maine, USA
| | - Deborah Cushing
- Department of Radiology, Maine Medical Center, Neuroscience Institute, Portland, Maine, USA Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
| | - Judy Aiken
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
| | - Marilyn Tracy
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
| | - J Mocco
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert D Ecker
- Department of Radiology, Maine Medical Center, Neuroscience Institute, Portland, Maine, USA Nursing, Maine Medical Center, Neuroscience Institute, Portland, Maine, USA
| |
Collapse
|
41
|
Ribo M, Boned S, Rubiera M, Tomasello A, Coscojuela P, Hernández D, Pagola J, Juega J, Rodriguez N, Muchada M, Rodriguez-Luna D, Molina CA. Direct transfer to angiosuite to reduce door-to-puncture time in thrombectomy for acute stroke. J Neurointerv Surg 2017; 10:221-224. [PMID: 28446535 DOI: 10.1136/neurintsurg-2017-013038] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 03/20/2017] [Accepted: 03/21/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate direct transfer to the angiosuite protocol of patients with acute stroke, candidates for endovascular treatment (EVT). METHODS We studied workflow metrics of all patients with stroke who had undergone EVT in the past 12 months. Patients followed three protocols: direct transfer to emergency room (DTER), CT room (DTCT) or angiosuite (DTAS, only last 6 months if admission National Institute of Health Stroke Scale (NIHSS) score >9 and time from onset <4.5 hours) according to staff/suite availability. DTAS patients underwent cone-beam CT before femoral puncture. Dramatic clinical improvement was defined as 10 NIHSS points drop at 24 hours. RESULTS 201 patients were included: 87 DTER (43.3%), 74 DTCT (36.8%), 40 DTAS (19.9%).Ten DTAS patients (25%) did not receive EVT: 3 (7.5%) showed intracranial hemorrhage on cone-beam CT and 7 (17.5%) did not show an occlusion on angiography. Mean door-to-puncture (D2P) time was shorter in DTAS (17±8 min) than DTCT (60±29 min; p<0.01). D2P was longer in DTER (90±53 min) than in the other protocols (p<0.01). For outcome analyses only patients who received EVT were compared; no significant differences in baseline characteristics, including time from symptom-onset to admission, puncture-to-recanalization, or recanalization rate, were seen. However, time from symptom-to-puncture (DTAS: 197±72 min, DTER: 279±156, DTCT: 224±142 min; p=0.01) and symptom-to-recanalization (DTAS: 257±74, DTER: 355±158, DTCT: 279±146 min; p<0.01) were longer in the DTER group. At 24 hours, there were no differences in NIHSS score (p=0.81); however, the rate of dramatic clinical improvement was significantly higher in DTAS: 48.6% (DTER 24.1%, DTCT 27.4%); p=0.01). An adjusted model pointed to shorter onset-to-puncture time as an independent predictor of dramatic improvement (OR=1.23, 95% CI 1.13 to 133; p<0.01) CONCLUSION: In a subgroup of patients direct transfer and triage in the angiosuite seems feasible, safe, and achieves significant reduction in hospital workflow times.
Collapse
Affiliation(s)
- Marc Ribo
- The Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.,Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Sandra Boned
- The Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.,Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Marta Rubiera
- The Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.,Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Alejandro Tomasello
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Pilar Coscojuela
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - David Hernández
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Jorge Pagola
- The Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.,Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Jesús Juega
- The Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.,Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Noelia Rodriguez
- The Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.,Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Marian Muchada
- The Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.,Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - David Rodriguez-Luna
- The Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.,Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Carlos A Molina
- The Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.,Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
| |
Collapse
|
42
|
Kada A, Nishimura K, Nakagawara J, Ogasawara K, Ono J, Shiokawa Y, Aruga T, Miyachi S, Nagata I, Toyoda K, Matsuda S, Suzuki A, Kataoka H, Nakamura F, Kamitani S, Iihara K. Development and validation of a score for evaluating comprehensive stroke care capabilities: J-ASPECT Study. BMC Neurol 2017; 17:46. [PMID: 28241749 PMCID: PMC5330137 DOI: 10.1186/s12883-017-0815-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 02/08/2017] [Indexed: 11/10/2022] Open
Abstract
Background Although the Brain Attack Coalition recommended establishing centers of comprehensive care for stroke and cerebrovascular disease patients, a scoring system for such centers was lacking. We created and validated a comprehensive stroke center (CSC) score, adapted to Japanese circumstances. Methods Of the selected 1369 certified training institutions in Japan, 749 completed an acute stroke care capabilities survey. Hospital performance was determined using a 25-item score, evaluating 5 subcategories: personnel, diagnostic techniques, specific expertise, infrastructure, and education. Consistency and validity were examined using correlation coefficients and factorial analysis. Results The CSC score (median, 14; interquartile range, 11–18) varied according to hospital volume. The five subcategories showed moderate consistency (Cronbach’s α = 0.765). A strong correlation existed between types of available personnel and specific expertise. Using the 2011 Japanese Diagnosis Procedure Combination database for patients hospitalized with stroke, four constructs were identified by factorial analysis (neurovascular surgery and intervention, vascular neurology, diagnostic neuroradiology, and neurocritical care and rehabilitation) that affected in-hospital mortality from ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. The total CSC score was related to in-hospital mortality from ischemic stroke (odds ratio [OR], 0.973; 95% confidence interval [CI], 0.958–0.989), intracerebral hemorrhage (OR, 0.970; 95% CI, 0.950–0.990), and subarachnoid hemorrhage (OR, 0.951; 95% CI, 0.925–0.977), with varying contributions from the four constructs. Conclusions The CSC score is a valid measure for assessing CSC capabilities, based on the availability of neurovascular surgery and intervention, vascular neurology, diagnostic neuroradiology, and critical care and rehabilitation services.
Collapse
Affiliation(s)
- Akiko Kada
- Department of Clinical Trials and Research, Clinical Research Center, National Hospital Organization Nagoya Medical Center, 4-1-1 Sannomaru, Naka-ku, Nagoya, Aichi, 460-0001, Japan.
| | - Kunihiro Nishimura
- Center for Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Jyoji Nakagawara
- Integrative Stroke Imaging Center, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan
| | - Junichi Ono
- Chiba Cardiovascular Center, Ichihara, Japan
| | | | | | - Shigeru Miyachi
- Department of Neurosurgery, Osaka Medical College, Takatsuki, Japan
| | | | - Kazunori Toyoda
- Departments of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, Kita-Kyushu, Japan
| | - Akifumi Suzuki
- Akita Prefectural Hospital Organization Research Institute for Brain and Blood Vessels, Akita, Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Fumiaki Nakamura
- Center for Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoru Kamitani
- Department of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | |
Collapse
|
43
|
Lyden P. Using the National Institutes of Health Stroke Scale: A Cautionary Tale. Stroke 2017; 48:513-519. [PMID: 28077454 DOI: 10.1161/strokeaha.116.015434] [Citation(s) in RCA: 229] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 11/17/2016] [Accepted: 12/12/2016] [Indexed: 01/21/2023]
Affiliation(s)
- Patrick Lyden
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA.
| |
Collapse
|
44
|
Bettger JP, Thomas L, Liang L, Xian Y, Bushnell CD, Saver JL, Fonarow GC, Peterson ED. Hospital Variation in Functional Recovery After Stroke. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.115.002391. [DOI: 10.1161/circoutcomes.115.002391] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 11/30/2016] [Indexed: 11/16/2022]
Abstract
Background—
Functional status is a key patient-centric outcome, but there are little data on whether functional recovery post-stroke varies among hospitals. This study examined the distribution of functional status 3 months after stroke, determined whether these outcomes vary among hospitals, and identified hospital characteristics associated with better (or worse) functional outcomes.
Methods and Results—
Observational analysis of the AVAIL study (Adherence Evaluation After Ischemic Stroke-Longitudinal) included 2083 ischemic stroke patients enrolled from 82 US hospitals participating in Get With The Guidelines-Stroke and AVAIL. The primary outcome was dependence or death at 3 months (modified Rankin Scale [mRS] score of 3–6). Secondary outcomes included functional dependence (mRS score of 3–5), disabled (mRS score of 2–5), and mRS evaluated as a continuous score. By 3 months post-discharge, 36.5% of patients were functionally dependent or dead. Rates of dependence or death varied widely by discharging hospitals (range: 0%–67%). After risk adjustment, patients had lower rates of 3-month dependence or death when treated at teaching hospitals (odds ratio, 0.72; 95% confidence interval, 0.54–0.96) and certified primary stroke centers (odds ratio, 0.69; 95% confidence interval, 0.53–0.91). In contrast, a composite measure of hospital-level adherence to acute stroke care performance metrics, stroke volume, and bed size was not associated with downstream patient functional status. Findings were robust across mRS end points and sensitivity analyses.
Conclusions—
One third of acute ischemic stroke patients were functionally dependent or dead 3 months postacute stroke; functional recovery rates varied considerably among hospitals, supporting the need to better determine which care processes can maximize functional outcomes.
Collapse
Affiliation(s)
- Janet Prvu Bettger
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.P.B., L.T., L.L., Y.X., E.D.P.); Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.B.); and University of California at Los Angeles (J.L.S., G.C.F.)
| | - Laine Thomas
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.P.B., L.T., L.L., Y.X., E.D.P.); Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.B.); and University of California at Los Angeles (J.L.S., G.C.F.)
| | - Li Liang
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.P.B., L.T., L.L., Y.X., E.D.P.); Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.B.); and University of California at Los Angeles (J.L.S., G.C.F.)
| | - Ying Xian
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.P.B., L.T., L.L., Y.X., E.D.P.); Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.B.); and University of California at Los Angeles (J.L.S., G.C.F.)
| | - Cheryl D. Bushnell
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.P.B., L.T., L.L., Y.X., E.D.P.); Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.B.); and University of California at Los Angeles (J.L.S., G.C.F.)
| | - Jeffrey L. Saver
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.P.B., L.T., L.L., Y.X., E.D.P.); Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.B.); and University of California at Los Angeles (J.L.S., G.C.F.)
| | - Gregg C. Fonarow
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.P.B., L.T., L.L., Y.X., E.D.P.); Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.B.); and University of California at Los Angeles (J.L.S., G.C.F.)
| | - Eric D. Peterson
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.P.B., L.T., L.L., Y.X., E.D.P.); Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.B.); and University of California at Los Angeles (J.L.S., G.C.F.)
| |
Collapse
|
45
|
Frei D, McGraw C, McCarthy K, Whaley M, Bellon RJ, Loy D, Wagner J, Orlando A, Bar-Or D. A standardized neurointerventional thrombectomy protocol leads to faster recanalization times. J Neurointerv Surg 2016; 9:1035-1040. [DOI: 10.1136/neurintsurg-2016-012716] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 10/05/2016] [Accepted: 10/10/2016] [Indexed: 11/04/2022]
|
46
|
Broderick JP, Abir M. Transitions of Care for Stroke Patients: Opportunities to Improve Outcomes. CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES 2016; 8:S190-2. [PMID: 26515208 DOI: 10.1161/circoutcomes.115.002288] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Joseph P Broderick
- From the Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B.); Department of Emergency Medicine, University of Michigan, Ann Arbor (M.A.); and RAND Corporation, Santa Monica, CA (M.A.).
| | - Mahshid Abir
- From the Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B.); Department of Emergency Medicine, University of Michigan, Ann Arbor (M.A.); and RAND Corporation, Santa Monica, CA (M.A.)
| |
Collapse
|
47
|
Hsieh FI, Jeng JS, Chern CM, Lee TH, Tang SC, Tsai LK, Liao HH, Chang H, LaBresh KA, Lin HJ, Chiou HY, Chiu HC, Lien LM. Quality Improvement in Acute Ischemic Stroke Care in Taiwan: The Breakthrough Collaborative in Stroke. PLoS One 2016; 11:e0160426. [PMID: 27487190 PMCID: PMC4972387 DOI: 10.1371/journal.pone.0160426] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 07/19/2016] [Indexed: 11/22/2022] Open
Abstract
In the management of acute ischemic stroke, guideline adherence is often suboptimal, particularly for intravenous thrombolysis or anticoagulation for atrial fibrillation. We sought to improve stroke care quality via a collaborative model, the Breakthrough Series (BTS)-Stroke activity, in a nationwide, multi-center activity in Taiwan. A BTS Collaborative, a short-term learning system for a large number of multidisciplinary teams from hospitals, was applied to enhance acute ischemic stroke care quality. Twenty-four hospitals participated in and submitted data for this stroke quality improvement campaign in 2010–2011. Totally, 14 stroke quality measures, adopted from the Get With The Guideline (GWTG)-Stroke program, were used to evaluate the performance and outcome of the ischemic stroke patients. Data for a one-year period from 24 hospitals with 13,181 acute ischemic stroke patients were analyzed. In 14 hospitals, most stroke quality measures improved significantly during the BTS-activity compared with a pre-BTS-Stroke activity period (2006–08). The rate of intravenous thrombolysis increased from 1.2% to 4.6%, door-to-needle time ≤60 minutes improved from 7.1% to 50.8%, symptomatic hemorrhage after intravenous thrombolysis decreased from 11.0% to 5.6%, and anticoagulation therapy for atrial fibrillation increased from 32.1% to 64.1%. The yearly composite measures of five stroke quality measures revealed significant improvements from 2006 to 2011 (75% to 86.3%, p<0.001). The quarterly composite measures also improved significantly during the BTS-Stroke activity. In conclusion, a BTS collaborative model is associated with improved guideline adherence for patients with acute ischemic stroke. GWTG-Stroke recommendations can be successfully applied in countries besides the United States.
Collapse
Affiliation(s)
- Fang-I Hsieh
- School of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chang-Ming Chern
- Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tsong-Hai Lee
- Department of Neurology, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Linkou, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsun-Hsiang Liao
- Taiwan Joint Commission on Hospital Accreditation, Taipei, Taiwan
| | - Hang Chang
- Taiwan Joint Commission on Hospital Accreditation, Taipei, Taiwan
| | | | - Hung-Jung Lin
- Taiwan Joint Commission on Hospital Accreditation, Taipei, Taiwan
- Department of Emergency Medicine, Chi-Mei Medical Center, Tainan, Taiwan
- Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Hung-Yi Chiou
- School of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Hou-Chang Chiu
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
- College of Medicine, Fu Jen Catholic University, Taipei, Taiwan
| | - Li-Ming Lien
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| |
Collapse
|
48
|
Mokin M, Snyder KV, Siddiqui AH, Levy EI, Hopkins LN. Recent Endovascular Stroke Trials and Their Impact on Stroke Systems of Care. J Am Coll Cardiol 2016; 67:2645-55. [DOI: 10.1016/j.jacc.2015.12.077] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 11/30/2015] [Accepted: 12/01/2015] [Indexed: 11/16/2022]
|
49
|
Shams T, Zaidat O, Yavagal D, Xavier A, Jovin T, Janardhan V. 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. INTERVENTIONAL NEUROLOGY 2016; 5:1-28. [PMID: 27610118 PMCID: PMC4934489 DOI: 10.1159/000443617] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- Tanzila Shams
- Texas Stroke Institute, HCA North Texas Division, Dallas-Fort Worth, Tex., USA
| | - Osama Zaidat
- Mercy Neuroscience and Stroke Center, Toledo, Ohio, USA
| | - Dileep Yavagal
- Jackson Memorial Hospital, University of Miami Health System, Miami, Fla., USA
| | - Andrew Xavier
- Detroit Medical Center, Wayne State University, Detroit, Mich., USA
| | - Tudor Jovin
- UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburg, Pa., USA
| | - Vallabh Janardhan
- Texas Stroke Institute, HCA North Texas Division, Dallas-Fort Worth, Tex., USA
| |
Collapse
|
50
|
Schwamm LH, Jaff MR, Dyer KS, Gonzalez RG, Huck AE. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 13-2016. A 49-Year-Old Woman with Sudden Hemiplegia and Aphasia during a Transatlantic Flight. N Engl J Med 2016; 374:1671-80. [PMID: 27119240 DOI: 10.1056/nejmcpc1501151] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Lee H Schwamm
- From the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Massachusetts General Hospital, the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Harvard Medical School, and the Department of Emergency Medicine, Boston Medical Center, and the Department of Emergency Medicine, Boston University School of Medicine (K.S.D.) - all in Boston
| | - Michael R Jaff
- From the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Massachusetts General Hospital, the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Harvard Medical School, and the Department of Emergency Medicine, Boston Medical Center, and the Department of Emergency Medicine, Boston University School of Medicine (K.S.D.) - all in Boston
| | - K Sophia Dyer
- From the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Massachusetts General Hospital, the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Harvard Medical School, and the Department of Emergency Medicine, Boston Medical Center, and the Department of Emergency Medicine, Boston University School of Medicine (K.S.D.) - all in Boston
| | - R Gilberto Gonzalez
- From the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Massachusetts General Hospital, the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Harvard Medical School, and the Department of Emergency Medicine, Boston Medical Center, and the Department of Emergency Medicine, Boston University School of Medicine (K.S.D.) - all in Boston
| | - Amelia E Huck
- From the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Massachusetts General Hospital, the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Harvard Medical School, and the Department of Emergency Medicine, Boston Medical Center, and the Department of Emergency Medicine, Boston University School of Medicine (K.S.D.) - all in Boston
| |
Collapse
|