Improving door-to-needle times in acute ischemic stroke: the design and rationale for the American Heart Association/American Stroke Association's Target: Stroke initiative

A Deep Learning Approach to Predict Recanalization First-Pass Effect following Mechanical Thrombectomy in Patients with Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Following endovascular thrombectomy in patients with large-vessel occlusion stroke, successful recanalization from 1 attempt, known as the first-pass effect, has correlated favorably with long-term outcomes. Pretreatment imaging may contain information that can be used to predict the first-pass effect. Recently, applications of machine learning models have shown promising results in predicting recanalization outcomes, albeit requiring manual segmentation. In this study, we sought to construct completely automated methods using deep learning to predict the first-pass effect from pretreatment CT and MR imaging.

MATERIALS AND METHODS

Our models were developed and evaluated using a cohort of 326 patients who underwent endovascular thrombectomy at UCLA Ronald Reagan Medical Center from 2014 to 2021. We designed a hybrid transformer model with nonlocal and cross-attention modules to predict the first-pass effect on MR imaging and CT series.

RESULTS

The proposed method achieved a mean 0.8506 (SD, 0.0712) for cross-validation receiver operating characteristic area under the curve (ROC-AUC) on MR imaging and 0.8719 (SD, 0.0831) for cross-validation ROC-AUC on CT. When evaluated on the prospective test sets, our proposed model achieved a mean ROC-AUC of 0.7967 (SD, 0.0335) with a mean sensitivity of 0.7286 (SD, 0.1849) and specificity of 0.8462 (SD, 0.1216) for MR imaging and a mean ROC-AUC of 0.8051 (SD, 0.0377) with a mean sensitivity of 0.8615 (SD, 0.1131) and specificity 0.7500 (SD, 0.1054) for CT, respectively, representing the first classification of the first-pass effect from MR imaging alone and the first automated first-pass effect classification method in CT.

CONCLUSIONS

Results illustrate that both nonperfusion MR imaging and CT from admission contain signals that can predict a successful first-pass effect following endovascular thrombectomy using our deep learning methods without requiring time-intensive manual segmentation.

2024 AHA/ASA Performance and Quality Measures for Spontaneous Intracerebral Hemorrhage: A Report From the American Heart Association/American Stroke Association

The American Heart Association/American Stroke Association released a revised spontaneous intracerebral hemorrhage guideline in 2022. A working group of stroke experts reviewed this guideline and identified a subset of recommendations that were deemed suitable for creating performance measures. These 15 performance measures encompass a wide spectrum of intracerebral hemorrhage patient care, from prehospital to posthospital settings, highlighting the importance of timely interventions. The measures also include 5 quality measures and address potential challenges in data collection, with the aim of future improvements.

Virtual versus usual in-office care for multiple sclerosis: The VIRTUAL-MS multi-site randomized clinical trial study protocol

BACKGROUND

Multiple sclerosis (MS) affects nearly 1 million people and is estimated to cost $85.4 billion in the United States annually. People with MS have significant barriers to receiving care and telemedicine could substantially improve access to specialized, comprehensive care. In cross-sectional analyses, telemedicine has been shown to be feasible, have high patient and clinician satisfaction, reduce patient costs and burden, and enable a reasonable assessment of disability. However, no studies exist evaluating the longitudinal impact of telemedicine care for MS. Here we describe the study protocol for VIRtual versus UsuAL In-office care for Multiple Sclerosis (VIRTUAL-MS). The main objective of the study is to evaluate the impact of telemedicine for MS care on: patient clinical outcomes, economic costs, patient, and clinician experience.

METHODS

This two-site randomized clinical trial will enroll 120 adults with a recent diagnosis of MS and randomize 1:1 to receive in-clinic vs. telemedicine care for 24 months. The primary outcome of the study is worsening in any one of the four Multiple Sclerosis Functional Composite 4 (MSFC4) measures at 24 months. Other study outcomes include patient and clinician satisfaction, major healthcare costs, Expanded Disability Status Scale, treatment adherence, and digital outcomes.

CONCLUSION

The results of this study will directly address the key gaps in knowledge about longitudinal telemedicine-enabled care in an MS population. It will inform clinical care implementation as well as design of trials in MS and other chronic conditions.

TRIAL REGISTRATION

NCT05660187.

Barriers to integrating portable Magnetic Resonance Imaging systems in emergency medical service ambulances for stroke care

This study examines the barriers to integrating portable Magnetic Resonance Imaging (MRI) systems into ambulance services to enable effective triaging of patients to the appropriate hospitals for timely stroke care and potentially reduce door-to-needle time for thrombolytic administration. The study employs a qualitative methodology using a digital twin of the patient handling process developed and demonstrated through semi-structured interviews with 18 participants, including 11 paramedics from an Emergency Medical Services system and seven neurologists from a tertiary stroke care centre. The interview transcripts were thematically analysed to determine the barriers based on the Systems Engineering Initiative for Patient Safety framework. Key barriers include the need for MRI operation skills, procedural complexities in patient handling, space constraints, and the need for training and policy development. Potential solutions are suggested to mitigate these barriers. The findings can facilitate implementing MRI systems in ambulances to expedite stroke treatment.

Twenty Years of Get With The Guidelines-Stroke: Celebrating Past Successes, Lessons Learned, and Future Challenges

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.

Epidemiological profile of stroke in Qatar: Insights from a seven-year observational study

OBJECTIVES

Stroke prevalence is progressively increasing in developing countries due to increased vascular risk factors. This study aims to describe the epidemiology, prevalent risk factors, and outcomes of stroke in a multi-ethnic society of Qatar.

MATERIALS AND METHODS

We conducted a retrospective analysis of all patients with suspected stroke admitted to stroke services between January 2014 and September 2020.

RESULTS

A total of 11,892 patients were admitted during this period with suspected stroke. Of these, the diagnosis was ischemic stroke (48.8 %), transient ischemic attack (10.3 %), intracerebral hemorrhage (10.9 %), cerebral venous sinus thrombosis (1.3 %), and stroke mimics (28.6 %). The median age was 52 (43-62), with a male-female ratio of 3:1. The study population was predominantly Asian (56.8 %) and Arab (36 %). The majority of the patients were hypertensive (66.8 %), diabetic (47.9 %), and dyslipidemic (45.9 %). A history of prior stroke was observed in 11.7 %, while 0.9 % had prior transient ischemic attack. Among ischemic strokes, 31.7 % arrived within 4.5 h, 12.5 % received thrombolysis, and 4.6 % underwent thrombectomy. Median Door-to-Needle time was 51 (33-72) minutes. The average length of stay was 5.2 ± 9.0 days, with 71.5 % discharged home, 13.8 % transferred to rehabilitation, 9.3 % to other specialties, 3 % to long-term care, and 2.4 % suffered in-hospital mortality.

CONCLUSION

Stroke in Qatar is characterized by a younger, expatriate-dominant cohort, with notable prevalence of ischemic and hemorrhagic stroke and a distinct risk factor profile. Further analysis of epidemiological differences among different population groups can inform targeted policies for prevention and management to reduce the burden of disease.

Impact of Local Tailoring on Acute Stroke Care in 21 Disparate Emergency Departments: A Prospective Stepped Wedge Type III Hybrid Effectiveness-Implementation Study

BACKGROUND

Faster delivery of tPA (tissue-type plasminogen activator) results in better health outcomes for eligible patients with stroke. Standardization of stroke protocols in emergency departments (EDs) has been difficult, especially in nonstroke centers. We measured the effectiveness of a centrally led implementation strategy with local site tailoring to sustain adherence to an acute stroke protocol to improve door-to-needle (DTN) times across disparate EDs in a multihospital health system.

METHODS

Prospective, type III hybrid effectiveness-implementation cohort study measuring performance at 21 EDs in Utah and Idaho (stroke centers [4]/nonstroke centers [17]) from January 2018 to February 2020 using a nonrandomized stepped-wedge design, monthly repeated site measures and multilevel hierarchical modeling. Each site received the implementation strategies in 1 of 6 steps providing control and intervention data. Co-primary outcomes were percentage of DTN times ≤60 minutes and median DTN time. Secondary outcomes included percentage of door-to-activation of neurological consult times ≤10 minutes and clinical effectiveness outcomes. Results were stratified between stroke and nonstroke centers.

RESULTS

A total of 855 474 ED patient encounters occurred with 5325 code stroke activations (median age, 69 [IQR, 56-79] years; 51.8% female patients]. Percentage of door-to-activation times ≤10 minutes increased from 47.5% to 59.9% (adjusted odds ratio, 1.93 [95% CI, 1.40-2.67]). A total of 615 patients received tPA of ≤3 hours from symptom onset (median age, 71 [IQR, 58-80] years; 49.6% female patients). The percentage of DTN times ≤60 minutes increased from 72.5% to 86.1% (adjusted odds ratio, 3.38, [95% CI, 1.47-7.78]; stroke centers (77.4%-90.0%); nonstroke centers [59.3%-72.1%]). Median DTN time declined from 46 to 38 minutes (adjusted median difference, -9.68 [95% CI, -17.17 to -2.20]; stroke centers [41-35 minutes]; nonstroke centers [55-52 minutes]). No differences were observed in clinical effectiveness outcomes.

CONCLUSIONS

A centrally led implementation strategy with local site tailoring led to faster delivery of tPA across disparate EDs in a multihospital system with no change in clinical effectiveness outcomes including rates of complication. Disparities in performance persisted between stroke and nonstroke centers.

Effectiveness of the acute stroke care map program in reducing in-hospital delay for acute ischemic stroke in a Chinese urban area: an interrupted time series analysis

Background

Timely intravenous thrombolysis (IVT) is crucial for improving outcomes in acute ischemic stroke (AIS) patients. This study evaluates the effectiveness of the Acute Stroke Care Map (ASCaM) initiative in Shenyang, aimed at reducing door-to-needle times (DNT) and thus improving the timeliness of care for AIS patients.

Methods

An retrospective cohort study was conducted from April 2019 to December 2021 in 30 hospitals participating in the ASCaM initiative in Shenyang. The ASCaM bundle included strategies such as EMS prenotification, rapid stroke triage, on-call stroke neurologists, immediate neuroimaging interpretation, and the innovative Pre-hospital Emergency Call and Location Identification feature. An interrupted time series analysis (ITSA) was used to assess the impact of ASCaM on DNT, comparing 9 months pre-intervention with 24 months post-intervention.

Results

Data from 9,680 IVT-treated ischemic stroke patients were analyzed, including 2,401 in the pre-intervention phase and 7,279 post-intervention. The ITSA revealed a significant reduction in monthly DNT by -1.12 min and a level change of -5.727 min post-ASCaM implementation.

Conclusion

The ASCaM initiative significantly reduced in-hospital delays for AIS patients, demonstrating its effectiveness as a comprehensive stroke care improvement strategy in urban settings. These findings highlight the potential of coordinated care interventions to enhance timely access to reperfusion therapies and overall stroke prognosis.

Evaluating the effects of simulation training on stroke thrombolysis: a systematic review and meta-analysis

BACKGROUND

Ischaemic strokes are medical emergencies, and reperfusion treatment, most commonly intravenous thrombolysis, is time-critical. Thrombolysis administration relies on well-organised pathways of care with highly skilled and efficient clinicians. Simulation training is a widespread teaching modality, but results from studies on the impact of this intervention have yet to be synthesised. This systematic review and meta-analysis aimed to synthesise the evidence and provide a recommendation regarding the effects of simulation training for healthcare professionals on door-to-needle time in the emergency thrombolysis of patients with ischaemic stroke.

METHODS

Seven electronic databases were systematically searched (last updated 12th July 2023) for eligible full-text articles and conference abstracts. Results were screened for relevance by two independent reviewers. The primary outcome was door-to-needle time for recombinant tissue plasminogen activator administration in emergency patients with ischaemic stroke. The secondary outcomes were learner-centred, improvements in knowledge and communication, self-perceived usefulness of training, and feeling 'safe' in thrombolysis-related decision-making. Data were extracted, risk of study bias assessed, and analysis was performed using RevMan™ software (Web version 5.6.0, The Cochrane Collaboration). The quality of the evidence was assessed using the Medical Education Research Study Quality Instrument.

RESULTS

Eleven studies were included in the meta-analysis and nineteen in the qualitative synthesis (n = 20,189 total patients). There were statistically significant effects of simulation training in reducing door-to-needle time; mean difference of 15 min [95% confidence intervals (CI) 8 to 21 min]; in improving healthcare professionals' acute stroke care knowledge; risk ratio (RR) 0.42 (95% CI 0.30 to 0.60); and in feeling 'safe' in thrombolysis-related decision-making; RR 0.46 (95% CI 0.36 to 0.59). Furthermore, simulation training improved healthcare professionals' communication and was self-perceived as useful training.

CONCLUSION

This meta-analysis showed that simulation training improves door-to-needle times for the delivery of thrombolysis in ischaemic stroke. However, results should be interpreted with caution due to the heterogeneity of the included studies.

Satisfaction of adult and pediatric neurologists and neurosurgeons using telehealth during the COVID-19 pandemic in Saudi Arabia: a cross-sectional study

Objectives

Telehealth has become increasingly important in achieving universal health coverage. It offers doctors and their patients' convenience, including providing quality care at reduced costs. During the coronavirus disease (COVID)-19 pandemic, telehealth has been a vital tool for remote healthcare services. This study aimed to assess the satisfaction of adult and pediatric neurologists and neurosurgeons using telehealth, during the COVID-19 pandemic in Saudi Arabia.

Methods

This study had 348 participants. It was conducted among adult and pediatric neurologists and neurosurgeons using telehealth technology at their clinics between February and June 2021. The self-administered questionnaire included sociodemographic data, behavior in using telehealth, and an assessment of satisfaction with telehealth; the SPSS Windows software version 26 was used to analyze the data.

Results

The most common age group was 25-34 years (42.8%), with men dominating (68.4%). The mean satisfaction score was 25.9 (SD 3.91) out of 33 points, with 90.2% of respondents satisfied with telehealth and 9.8% dissatisfied. Working in an academic center or private hospital, being a first-time telehealth user, using messages as a telehealth method, and using telehealth daily were associated with increased satisfaction with telehealth use.

Conclusion

The satisfaction of adult and pediatric neurologists and neurosurgeons with telehealth was high. Although physicians still preferred face-to-face interviews, they recognized the benefits of telehealth in strengthening the patient-provider relationship, improving productivity, and integrating into daily workflows. The satisfaction levels align with past studies, but physical examination needs should be considered. Telehealth is suitable for follow-up visits and varies across subspecialties.

Trends in Stroke Thrombolysis Care Metrics and Outcomes by Race and Ethnicity, 2003-2021

Importance

Understanding is needed of racial and ethnic-specific trends in care quality and outcomes associated with the US nationwide quality initiative Target: Stroke (TS) in targeting thrombolysis treatment for acute ischemic stroke.

Objective

To examine whether the TS quality initiative was associated with improvement in thrombolysis metrics and outcomes across racial and ethnic groups.

Design, Setting, and Participants

This retrospective cohort study included patients who presented within 4.5 hours of ischemic stroke onset at hospitals participating in the Get With The Guidelines-Stroke initiative from January 1, 2003, to December 31, 2021. The data analysis was performed between December 15, 2022, and November 27, 2023.

Exposures

TS phases I (2010-2013), II (2014-2018), and III (2019-2021).

Main Outcomes and Measures

The primary outcomes were thrombolysis rates and time metrics. Patient function and mortality were secondary outcomes.

Results

Analyses included 1 189 234 patients, of whom 1 053 539 arrived to the hospital within 4.5 hours. The cohort included 50.4% female and 49.6% male patients and 2.8% Asian [median (IQR) age, 72 (61-82) years], 15.2% Black [median (IQR) age, 64 (54-75) years], 7.3% Hispanic [median (IQR) age, 68 (56-79) years], and 74.1% White [median (IQR) age, 75 (63-84) years] patients). Unadjusted thrombolysis rates increased in both the pre-TS (2003-2009) and TS periods in all racial and ethnic groups from 10% to 15% in 2003 to 43% to 46% in 2021, but disparities were observed in adjusted analyses and persisted in TS phase III, with Asian, Black, and Hispanic patients having significantly lower odds of receiving thrombolysis than White patients (adjusted odds ratio, 0.85 [95% CI, 0.81-0.90], 0.76 [95% CI, 0.74-0.78], and 0.86 [95% CI, 0.83-0.89], respectively). Door-to-needle (DTN) times improved in all racial and ethnic groups during TS, with DTN times of 60 minutes or less increasing from 26% to 28% in 2009 to 66% to 72% in 2021. However, in adjusted analyses, racial and ethnic disparities emerged. During TS phase III, compared with White patients, Asian, Black, and Hispanic patients had significantly lower odds of receiving thrombolysis with a DTN time of 60 minutes or less compared with White patients (risk-adjusted odds ratios, 0.91 [95% CI, 0.84-0.98], 0.78 [95% CI, 0.75-0.81], and 0.87 [95% CI, 0.83-0.92], respectively). During TS, clinical outcomes improved for all racial and ethnic groups from pre-TS, with TS phase III showing higher odds of ambulation at discharge among Asian, Black, Hispanic, and White patients. Asian, Black, and Hispanic patients were less likely to present within 4.5 hours.

Conclusions and Relevance

In this cohort study of patients with ischemic stroke, the TS quality initiative was associated with improvement in thrombolysis frequency, timeliness, and outcomes for all racial and ethnic groups. However, disparities persisted, indicating a need for further interventions.

The implementation of artificial intelligence significantly reduces door-in-door-out times in a primary care center prior to transfer

INTRODUCTION

Viz LVO artificial intelligence (AI) software utilizes AI-powered large vessel occlusion (LVO) detection technology which automatically identifies suspected LVO through CT angiogram (CTA) imaging and alerts on-call stroke teams. This analysis was performed to determine whether AI software can reduce the door-in-door-out (DIDO) time interval within the primary care center (PSC) prior to transfer to the comprehensive care center (CSC).

METHODS

We compared the DIDO time interval for all LVO transfer patients from a single-spoke PSC to our CSC prior to (February 2017 to November 2018) and after (November 2018 to June 2020) incorporating AI. Using a stroke database at a CSC, demographics, DIDO time at PSC, modified Rankin Scale (mRS) at 90-days, mortality rate at discharge, length of stay (LOS), and intracranial hemorrhage rates were examined.

RESULTS

There were a total of 63 patients during the study period (average age 69.99 ± 13.72, 55.56% female). We analyzed 28 patients pre-AI (average age 71.64 ± 12.28, 46.4% female), and 35 patients post-AI (average age 68.67 ± 14.88, 62.9% female). After implementing the AI software, the mean DIDO time interval within the PSC significantly improved by 102.3 min (226.7 versus 124.4 min; p = 0.0374).

CONCLUSION

The incorporation of the AI software was associated with a significant improvement in DIDO times within the PSC as well as CTA to door-out time in the PSC. More extensive studies are warranted to expand on the ability of AI technology to improve transfer times and outcomes for LVO patients.

Optimizing acute stroke treatment process: insights from sub-tasks durations in a prospective observational time and motion study

Background

Rapid treatment is critical in managing acute ischemic stroke (AIS) to improve patient outcomes. Various strategies have been used to optimize this treatment process, including the Acute Stroke Protocol (ASP) activation, and minimizing the duration of key performance metrices, such as door-to-needle time (DNT), CT-to-needle time (CTNT), CT-to-groin puncture time (CTGP), and door-to-groin puncture time (DGPT). However, identifying the delay-causing sub-tasks within the ASP could yield novel insights, facilitating optimization strategies for the AIS treatment process.

Methods

This two-phase prospective observational time and motion study aimed to identify sub-tasks and compare their respective durations involved in the treatment process for AIS patients within ASPs. The study compared sub-task durations between "routine working hours" and "evenings and weekends" (after-hours), as well as between stroke neurologists and non-stroke neurologists. Additionally, the established performance metrices of AIS were compared among the aforementioned groups.

Results

Phase 1 identified and categorized 34 sub-tasks into five broad categories, while Phase 2 analyzed the ASP for 389 patients. Among the 185 patients included in the study, 57 received revascularization treatment, with 30 receiving intravenous (IV) thrombolysis only, 20 receiving endovascular thrombectomy (EVT) only, and 7 receiving both IV thrombolysis and EVT. Significant delays were observed in sub-tasks including triage, registration, patient history sharing, treatment decisions, preparation of patients, preparation of thrombolytic agents, and angiosuite preparation. The majority of these significant delays (P < 0.05) were observed when were performed by a non-stroke neurologist and during after-hours operations. Furthermore, certain sub-tasks were exclusively performed during after-hours or when the treatment was provided by a non-stroke neurologist. Consequently, DNT, CTNT, and CTGP were significantly prolonged for both non-stroke neurologists and off-hours treatment. DGPT was significantly longer only when the ASP was conducted by non-stroke neurologists.

Conclusions

The study identified several sub-tasks that lead to significant delays during the execution of the ASP. These findings provide a premise to design targeted quality improvement interventions to optimize the ASP for these specific delay-causing sub-tasks, particularly for non-stroke neurologists and after-hours. This approach has the potential to significantly enhance the efficiency of the AIS treatment process.

Intracarotid Infusion of Redox-Active Manganese Porphyrin, MnTnBuOE-2-PyP5+, following Reperfusion Improves Long-Term, 28-Day Post-Stroke Outcomes in Rats

Endovascular mechanical thrombectomy, combined with a tissue plasminogen activator (t-PA), is efficacious as a standard care for qualifying ischemic stroke patients. However, > 50% of thrombectomy patients still have poor outcomes. Manganese porphyrins, commonly known as mimics of superoxide dismutases, are potent redox-active catalytic compounds that decrease oxidative/nitrosative stress and in turn decrease inflammatory responses, mitigating therefore the secondary injury of the ischemic brain. This study investigates the effect of intracarotid MnTnBuOE-2-PyP5+ (BMX-001) administration on long-term, 28-day post-stroke recovery in a clinically relevant setting. The 90 min of transient middle cerebral artery occlusion was performed in young, aged, male, female, and spontaneous hypertension rats. All physiological parameters, including blood pressure, blood gas, glucose, and temperature, were well controlled during ischemia. Either BMX-001 or a vehicle solution was infused through the carotid artery immediately after the removal of filament, mimicking endovascular thrombectomy, and was followed by 7 days of subcutaneous injection. Neurologic deficits and infarct volume were assessed at 28 days in a blinded manner. The effects of BMX-001 on the carotid arterial wall and blood-brain barrier permeability and its interaction with t-PA were assessed in normal rats. There were no intra-group differences in physiological variables. BMX-001-treated stroke rats regained body weight earlier, performed better in behavioral tests, and had smaller brain infarct size compared to the vehicle-treated group. No vascular wall damage and blood-brain barrier permeability changes were detected after the BMX-001 infusion. There was no drug interaction between BMX-001 and t-PA. Intracarotid BMX-001 infusion was safe, and it significantly improved stroke outcomes in rats. These findings indicate that BMX-001 is a candidate drug as an adjunct treatment for thrombectomy procedure to further improve the neurologic outcomes of thrombectomy patients. This study warrants further clinical investigation of BMX-001 as a new stroke therapy.

In-Hospital Versus Out-of-Hospital Stroke Onset Comparison of Process Metrics in a Community Primary Stroke Center

Objective

To examine in-hospital stroke onset metrics and outcomes, quality of care, and mortality compared with out-of-hospital stroke in a single community-based primary stroke center.

Patients and Methods

Medical records of in-hospital stroke onset were compared with out-of-hospital stroke onset alert data between January 1, 2013 and December 31, 2019. Time-sensitive stroke process metric data were collected for each incident stroke alert. The primary focus of interest was the time-sensitive stroke quality metrics. Secondary focus pertained to thrombolysis treatment or complications, and mortality. Descriptive and univariable statistical analyses were applied. Kruskal-Wallis and χ2 tests were used to compare median values and categorical data between prespecified groups. The statistical significance was set at α=0.05.

Results

The out-of-hospital group reported a more favorable response to time-sensitive stroke process metrics than the in-hospital group, as measured by median stroke team response time (15.0 vs 26.0 minutes; P≤.0001) and median head computed tomography scan completion time (12.0 vs 41.0 minutes; P=.0001). There was no difference in the stroke alert time between the 2 groups (14.0 vs 8.0 minutes; P=.089). Longer hospital length of stay (4 vs 3 days; P=.004) and increased hospital mortality (19.3% vs 7.4%; P=.0032) were observed for the in-hospital group.

Conclusions

The key findings in this study were that time-sensitive stroke process metrics and stroke outcome measures were superior for the out-of-hospital groups compared with the in-hospital groups. Focusing on improving time-sensitive stroke process metrics may improve outcomes in the in-hospital stroke cohort.

Shorter Door-to-Needle Times Are Associated With Better Outcomes After Intravenous Thrombolytic Therapy and Endovascular Thrombectomy for Acute Ischemic Stroke

BACKGROUND

Existing data and clinical trials could not determine whether faster intravenous thrombolytic therapy (IVT) translates into better long-term functional outcomes after acute ischemic stroke among those treated with endovascular thrombectomy (EVT). Patient-level national data can provide the required large population to study the associations between earlier IVT, versus later, with longitudinal functional outcomes and mortality in patients receiving IVT+EVT combined treatment.

METHODS

This cohort study included older US patients (age ≥65 years) who received IVT within 4.5 hours or EVT within 7 hours after acute ischemic stroke using the linked 2015 to 2018 Get With The Guidelines-Stroke and Medicare database (38 913 treated with IVT only and 3946 with IVT+EVT). Primary outcome was home time, a patient-prioritized functional outcome. Secondary outcomes included all-cause mortality in 1 year. Multivariate logistic regression and Cox proportional hazards models were used to evaluate the associations between door-to-needle (DTN) times and outcomes.

RESULTS

Among patients treated with IVT+EVT, after adjusting for patient and hospital factors, including onset-to-EVT times, each 15-minute increase in DTN times for IVT was associated with significantly higher odds of zero home time in a year (never discharged to home) (adjusted odds ratio, 1.12 [95% CI, 1.06-1.19]), less home time among those discharged to home (adjusted odds ratio, 0.93 per 1% of 365 days [95% CI, 0.89-0.98]), and higher all-cause mortality (adjusted hazard ratio, 1.07 [95% CI, 1.02-1.11]). These associations were also statistically significant among patients treated with IVT but at a modest degree (adjusted odds ratio, 1.04 for zero home time, 0.96 per 1% home time for those discharged to home, and adjusted hazard ratio 1.03 for mortality). In the secondary analysis where the IVT+EVT group was compared with 3704 patients treated with EVT only, shorter DTN times (≤60, 45, and 30 minutes) achieved incrementally more home time in a year, and more modified Rankin Scale 0 to 2 at discharge (22.3%, 23.4%, and 25.0%, respectively) versus EVT only (16.4%, P<0.001 for each). The benefit dissipated with DTN>60 minutes.

CONCLUSIONS

Among older patients with stroke treated with either IVT only or IVT+EVT, shorter DTN times are associated with better long-term functional outcomes and lower mortality. These findings support further efforts to accelerate thrombolytic administration in all eligible patients, including EVT candidates.

Who is in the emergency room matters when we talk about door-to-needle time: a single-center experience

BACKGROUND

 The efficacy of intravenous thrombolysis (IVT) is time-dependent.

OBJECTIVE

 To compare the door-to-needle (DTN) time of stroke neurologists (SNs) versus non-stroke neurologists (NSNs) and emergency room physicians (EPs). Additionally, we aimed to determine elements associated with DTN ≤ 20 minutes.

METHODS

 Prospective study of patients with IVT treated at Clínica Alemana between June 2016 and September 2021.

RESULTS

 A total of 301 patients underwent treatment for IVT. The mean DTN time was 43.3 ± 23.6 minutes. One hundred seventy-three (57.4%) patients were evaluated by SNs, 122 (40.5%) by NSNs, and 6 (2.1%) by EPs. The mean DTN times were 40.8 ± 23, 46 ± 24.7, and 58 ± 22.5 minutes, respectively. Door-to-needle time ≤ 20 minutes occurred more frequently when patients were treated by SNs compared to NSNs and EPs: 15%, 4%, and 0%, respectively (odds ratio [OR]: 4.3, 95% confidence interval [95%CI]: 1.66-11.5, p = 0.004). In univariate analysis DTN time ≤ 20 minutes was associated with treatment by a SN (p = 0.002), coronavirus disease 2019 pandemic period (p = 0.21), time to emergency room (ER) (p = 0.21), presence of diabetes (p = 0.142), hypercholesterolemia (p = 0.007), atrial fibrillation (p < 0.09), score on the National Institutes of Health Stroke Scale (NIHSS) (p = 0.001), lower systolic (p = 0.143) and diastolic (p = 0.21) blood pressures, the Alberta Stroke Program Early CT Score (ASPECTS; p = 0.09), vessel occlusion (p = 0.05), use of tenecteplase (p = 0.18), thrombectomy (p = 0.13), and years of experience of the physician (p < 0.001). After multivariate analysis, being treated by a SN (OR: 3.95; 95%CI: 1.44-10.8; p = 0.007), NIHSS (OR: 1.07; 95%CI: 1.02-1.12; p < 0.002) and lower systolic blood pressure (OR: 0.98; 95%CI: 0.96-0.99; p < 0.003) remained significant.

CONCLUSION

 Treatment by a SN resulted in a higher probability of treating the patient in a DTN time within 20 minutes.

A Spatial Variation Analysis of In-Hospital Stroke Mortality Based on Integrated Pre-Hospital and Hospital Data in Mashhad, Iran

BACKGROUND

Despite significant advances in the quality and delivery of specialized stroke care, there still persist remarkable spatial variations in emergency medical services (EMS) transport delays, stroke incidence, and its outcomes. Therefore, it is very important to investigate the possible geographical variations of in-hospital stroke mortality and to identify its associated factors.

METHODS

This historical cohort study included suspected stroke cases transferred to Ghaem Hospital of Mashhad by the EMS from March 2018 to March 2019. Using emergency mission IDs, the pre-hospital emergency data were integrated with the patient medical records in the hospital. We used the Bayesian approach for estimating the model parameters.

RESULTS

Out of 301 patients (142 (47.2%) females vs. 159 (52.8%) males) with a final diagnosis of stroke, 61 (20.3%) cases had in-hospital mortality. Results from Bayesian spatial log-logistic proportional odds (PO) model showed that age (PO=1.07), access rate to EMS (PO=0.78), arrival time (evening shift vs. day shift, PO=0.09), and sequelae variables (PO=9.20) had a significant association with the odds of in-hospital stroke mortality (P<0.05). Furthermore, the odds of in-hospital stroke mortality were higher in central urban areas compared to suburban areas.

CONCLUSION

Marked regional variations were found in the odds of in-hospital stroke mortality in Mashhad. There was a direct association between age and odds of in-hospital stroke mortality. Hence, the prognosis of in-hospital stroke mortality could be improved by better control of hypertension, prevention of the occurrence of sequelae, increasing the access rate to EMS, and optimizing shift work schedule.

The Secretome of Mesenchymal Stromal Cells in Treating Intracerebral Hemorrhage: The First Step to Bedside

Intracerebral hemorrhage is an unmet medical need that often leads to the disability and death of a patient. The lack of effective treatments for intracerebral hemorrhage makes it necessary to look for them. Previously, in our proof-of-concept study (Karagyaur M et al. Pharmaceutics, 2021), we have shown that the secretome of multipotent mesenchymal stromal cells (MSC) provides neuroprotection of the brain in a model of intracerebral hemorrhage in rats. Here, we have conducted a systematic study of the therapeutic potential of the MSC secretome in the model of hemorrhagic stroke and provided answers to the questions that need to be addressed in order to translate the secretome-based drug into clinical practice: routes and multiplicity of administration, optimal dose and door-to-treatment time. We have found that MSC secretome reveals prominent neuroprotective activity when administered intranasally or intravenously within 1-3 h after hemorrhage modeling, even in aged rats, and its multiple injections (even within 48 h) are able to reduce the delayed negative effects of hemorrhagic stroke. To our knowledge, this study provides the first systematic investigation of the therapeutic activity of a biomedical MSC-based cell-free drug in intracerebral hemorrhage and is an integral part of its preclinical studies.

Prioritizing Quality Measures in Acute Stroke Care : A Cost-Effectiveness Analysis

BACKGROUND

The American Heart Association and American Stroke Association (AHA/ASA) endorsed 15 process measures for acute ischemic stroke (AIS) to improve the quality of care. Identifying the highest-value measures could reduce the administrative burden of quality measure adoption while retaining much of the value of quality improvement.

OBJECTIVE

To prioritize AHA/ASA-endorsed quality measures for AIS on the basis of health impact and cost-effectiveness.

DESIGN

Individual-based stroke simulation model.

DATA SOURCES

Published literature.

TARGET POPULATION

U.S. patients with incident AIS.

TIME HORIZON

Lifetime.

PERSPECTIVE

Health care sector.

INTERVENTION

Current versus complete (100%) implementation at the population level of quality measures endorsed by the AHA/ASA with sufficient clinical evidence (10 of 15).

OUTCOME MEASURES

Life-years, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios, and incremental net health benefits.

RESULTS OF BASE-CASE ANALYSIS

Discounted life-years gained from complete implementation would range from 472 (tobacco use counseling) to 34 688 (early carotid imaging) for an annual AIS patient cohort. All AIS quality measures were cost-saving or highly cost-effective by AHA standards (<$50 000 per QALY for high-value care). Early carotid imaging and intravenous tissue plasminogen activator contributed the largest fraction of the total potential value of quality improvement (measured as incremental net health benefit), accounting for 72% of the total value. The top 5 quality measures accounted for 92% of the total potential value.

RESULTS OF SENSITIVITY ANALYSIS

A web-based user interface allows for context-specific sensitivity and scenario analyses.

LIMITATION

Correlations between quality measures were not incorporated.

CONCLUSION

Substantial variation exists in the potential net benefit of quality improvement across AIS quality measures. Benefits were highly concentrated among 5 of 10 measures assessed. Our results can help providers and payers set priorities for quality improvement efforts and value-based payments in AIS care.

PRIMARY FUNDING SOURCE

National Institute of Neurological Disorders and Stroke.

Causes of Pre-hospital Delay in Acute Stroke in Punjab

Background Pre-hospital delay, which refers to the time delay between the development of symptoms in the patient and the start of treatment, is one of the major factors impacting the treatment of stroke. This study aimed to identify patient characteristics and factors causing a pre-hospital delay in acute stroke (both ischemic and hemorrhagic) cases. Methodology This prospective follow-up study included 100 patients who presented with clinical features of acute stroke within 48 hours of symptom onset. A pre-designed questionnaire was administered within 72 hours of hospital admission to every patient. Results The mean time to hospital presentation was 7.73 hours. Only 2% of patients were thrombolysed. Age group, gender, education status, occupation, and socioeconomic status were not significantly (p > 0.05) associated with the mean symptom onset time to hospital arrival. Rural area (p < 0.001), nuclear family (p = 0.004), distance from the tertiary care center (p < 0.001), being alone at the time of symptom onset (p < 0.001), lack of knowledge about symptoms of stroke in patient/attendant (p < 0.001), and mode of transport were the factors that emerged as significant predictors of pre-hospital delay on univariate analysis. Living in a nuclear family, distance from the tertiary care center, and mode of transport were the factors that emerged as independent predictors of pre-hospital delay on multiple linear regression analysis. Conclusions In this study, factors associated with delayed hospital presentation including living in a nuclear family, distance from the tertiary care center, and use of public transport to reach the hospital emerged as independent predictors of pre-hospital delay.

Impact of a series of measures for optimisation hospital code stroke care on door-to-needle times

INTRODUCTION

Time continues to be a fundamental variable in reperfusion treatments for acute ischaemic stroke. Despite the recommendations made in clinical guidelines, only around one-third of these patients receive fibrinolysis within 60minutes. In this study, we describe our experience with the implementation of a specific protocol for patients with acute ischaemic stroke and evaluate its impact on door-to-needle times in our hospital.

METHODS

Measures were gradually implemented in late 2015 to shorten stroke management times and optimise the care provided to patients with acute ischaemic stroke; these measures included the creation of a specific on-call neurovascular care team. We compare stroke management times before (2013-2015) and after (2017-2019) the introduction of the protocol.

RESULTS

The study includes 182 patients attended before implementation of the protocol and 249 attended after. Once all measures were in effect, the overall median door-to-needle time was 45minutes (vs 74 minutes before, a 39% reduction; P<.001), with 73.5% of patients treated within 60minutes (a 47% increase; P<.001). Median overall time to treatment (onset-to-needle time) was reduced by 20minutes (P<.001).

CONCLUSIONS

The measures included in our protocol achieved a significant, sustained reduction in door-to-needle times, although there remains room for improvement. The mechanisms established for monitoring outcomes and for continuous improvement will enable further advances in this regard.

Stroke Thrombolysis: Beating the Clock

Background

Recombinant tissue plasminogen activator (rtPA) has revolutionized the management of acute ischemic stroke. Shorter door-to-imaging and door-to-needle (DTN) times are crucial for improving the outcomes in thrombolysed patients. Our observational study evaluated the door-to-imaging time (DIT) and DTN times for all thrombolysed patients.

Materials and methods

The study was a cross-sectional observational study over a period of 18 months at a tertiary care teaching hospital and included 252 acute ischemic stroke patients of which 52 underwent thrombolysis with rtPA. The time intervals between arrival to neuroimaging and initiation of thrombolysis were noted.

Result

Of the total patients thrombolysed, only 10 patients underwent neuroimaging [non-contrast computed tomography (NCCT) head with MRI brain screen] within 30 minutes of their arrival in the hospital, 38 patients within 30-60 minutes and 2 each within the 61-90 and 91-120 minute time frames. The DTN time was 30-60 minutes for 3 patients, while 31 patients were thrombolysed within 61-90 minutes, 7 patients within 91-120 minutes, while 5 each took 121-150 and 151-180 minutes for the same. One patient had a DTN between 181 and 210 minutes.

Conclusion

Most patients included in the study underwent neuroimaging within 60 minutes and subsequent thrombolysis within 60-90 minutes of their arrival in the hospital. But the time frames did not meet the recommended ideal intervals, and further streamlining of stroke management is needed even at tertiary care centers in India.

How to cite this article

Shah A, Diwan A. Stroke Thrombolysis: Beating the Clock. Indian J Crit Care Med 2023;27(2):107-110.

Telestroke Process at a Community Hospital: A Quality Improvement Project

INTRODUCTION

An updated stroke process was designed and implemented at an Acute Stroke Ready community hospital that relies on telestroke services. The objectives of the current quality improvement project were to describe the updates to the stroke process and compare pre- and postintervention data on nurse-driven elements of the process, namely telestroke notification and neurologist assessment.

METHODS

Our multidisciplinary team reviewed quality data over several months to identify areas of improvement in the stroke process. Delays in door to telestroke notification and neurologist assessment were identified. A new process was developed and implemented, including e-alert notification and storing the telestroke cart in the computed tomography suite. The study period was 14 months, with nonrandomized, convenience sample data collected for 7 months before and after intervention.

RESULTS

There was a significant reduction in door to telestroke notification and neurologist assessment after implementing the new process. Door to telestroke notification and neurologist assessment were also strongly correlated.

DISCUSSION

This project led to significant improvements in nurse-driven elements of the stroke process. It demonstrates effective implementation of e-alert and collaboration with telestroke services at an Acute Stroke Ready Hospital serving rural communities.

Using body cameras to quantify the duration of a Code Stroke and identify workflow issues: a continuous observation workflow time study

OBJECTIVE

'Code Stroke' (Code) is used in health services to streamline hyperacute assessment and treatment delivery for patients with ischaemic stroke. However, there are few studies that detail the time spent on individual components performed during a Code. We sought to quantify the time taken for each process during a Code and investigate associations with modifiable and non-modifiable factors.

DESIGN

Continuous observation workflow time study.

SETTING AND PARTICIPANTS

Recordings of 100 Codes were performed at a high-volume primary stroke centre in Melbourne, Australia, between January and June 2020 using a body camera worn by a member of the stroke team.

MAIN OUTCOME MEASURES

The main measures included the overall duration of Codes and the individual processes within the Code workflow. Associations between variables of interest and process times were explored using linear regression models.

RESULTS

100 Codes were captured, representing 19.2% of all Codes over the 6 months. The median duration of a complete Code was 54.2 min (IQR 39.1-74.7). Administrative work performed after treatment is completed (median 21.0 min (IQR 9.8-31.4)); multimodal CT imaging (median 13.0 min (IQR 11.5-15.7)), and time between decision and thrombolysis administration (median 8.1 min (IQR 6.1-10.8)) were the longest components of a Code. Tenecteplase was able to be prepared faster than alteplase (median 1.8 vs 4.9 min, p=0.02). The presence of a second junior doctor was associated with shorter administrative work time (median 10.3 vs 25.1 min, p<0.01). No specific modifiable factors were found to be associated with shorter overall Code duration.

CONCLUSIONS

Codes are time intensive. Time spent on decision-making was a relatively small component of the overall Code duration. Data from body cameras can provide granular data on all aspects of Code workflow to inform potential areas for improvement at individual centres.

Time and Brain Region-Dependent Excitatory Neurochemical Alterations in Bilateral Common Carotid Artery Occlusion Global Ischemia Model

Strict metabolic regulation in discrete brain regions leads to neurochemical changes in cerebral ischemia. Accumulation of extracellular glutamate is one of the early neurochemical changes that take place during cerebral ischemia. Understanding the sequential neurochemical processes involved in cerebral ischemia-mediated excitotoxicity before the clinical intervention of revascularization and reperfusion may greatly influence future therapeutic strategies for clinical stroke recovery. This study investigated the influence of time and brain regions on excitatory neurochemical indices in the bilateral common carotid artery occlusion (BCCAO) model of global ischemia. Male Wistar rats were subjected to BCCAO for 15 and 60 min to evaluate the effect of ischemia duration on excitatory neurochemical indices (dopamine level, glutamine synthetase, glutaminase, glutamate dehydrogenase, aspartate aminotransferase, monoamine oxidase, acetylcholinesterase, and Na⁺ K⁺ ATPase activities) in the discrete brain regions (cortex, striatum, cerebellum, and hippocampus). BCCAO without reperfusion caused marked time and brain region-dependent alterations in glutamatergic, glutaminergic, dopaminergic, monoaminergic, cholinergic, and electrogenic homeostasis. Prolonged BCCAO decreased cortical, striatal, and cerebellar glutamatergic, glutaminergic, dopaminergic, cholinergic, and electrogenic activities; increased hippocampal glutamatergic, glutaminergic, dopaminergic, and cholinergic activities, increased cortical and striatal monoaminergic activity; decreased cerebellar and hippocampal monoaminergic activity; and decreased hippocampal electrogenic activity. This suggests that excitatory neurotransmitters play a major role in the tissue-specific metabolic plasticity and reprogramming that takes place between the onset of cardiac arrest-mediated global ischemia and clinical intervention of recanalization. These tissue-specific neurochemical indices may serve as diagnostic and therapeutic strategies for mitigating the progression of ischemic damage before revascularization.

Frameworks for Integrating Learning Analytics With the Electronic Health Record

The information systems designed to support clinical care have evolved separately from those that support health professions education. This has resulted in a considerable digital divide between patient care and education, one that poorly serves practitioners and organizations, even as learning becomes ever more important to both. In this perspective, we advocate for the enhancement of existing health information systems so that they intentionally facilitate learning. We describe three well-regarded frameworks for learning that can point toward how health care information systems can best evolve to support learning. The Master Adaptive Learner model suggests ways that the individual practitioner can best organize their activities to ensure continual self-improvement. The PDSA cycle similarly proposes actions for improvement but at a health care organization's workflow level. Senge's Five Disciplines of the Learning Organization, a more general framework from the business literature, serves to further inform how disparate information and knowledge flows can be managed for continual improvement. Our main thesis holds that these types of learning frameworks should inform the design and integration of information systems serving the health professions. An underutilized mediator of educational improvement is the ubiquitous electronic health record. The authors list learning analytic opportunities, including potential modifications of learning management systems and the electronic health record, that would enhance health professions education and support the shared goal of delivering high-quality evidence-based health care.

Team is brain: leveraging EHR audit log data for new insights into acute care processes

OBJECTIVE

To determine whether novel measures of contextual factors from multi-site electronic health record (EHR) audit log data can explain variation in clinical process outcomes.

MATERIALS AND METHODS

We selected one widely-used process outcome: emergency department (ED)-based team time to deliver tissue plasminogen activator (tPA) to patients with acute ischemic stroke (AIS). We evaluated Epic audit log data (that tracks EHR user-interactions) for 3052 AIS patients aged 18+ who received tPA after presenting to an ED at three Northern California health systems (Stanford Health Care, UCSF Health, and Kaiser Permanente Northern California). Our primary outcome was door-to-needle time (DNT) and we assessed bivariate and multivariate relationships with six audit log-derived measures of treatment team busyness and prior team experience.

RESULTS

Prior team experience was consistently associated with shorter DNT; teams with greater prior experience specifically on AIS cases had shorter DNT (minutes) across all sites: (Site 1: -94.73, 95% CI: -129.53 to 59.92; Site 2: -80.93, 95% CI: -130.43 to 31.43; Site 3: -42.95, 95% CI: -62.73 to 23.17). Teams with greater prior experience across all types of cases also had shorter DNT at two sites: (Site 1: -6.96, 95% CI: -14.56 to 0.65; Site 2: -19.16, 95% CI: -36.15 to 2.16; Site 3: -11.07, 95% CI: -17.39 to 4.74). Team busyness was not consistently associated with DNT across study sites.

CONCLUSIONS

EHR audit log data offers a novel, scalable approach to measure key contextual factors relevant to clinical process outcomes across multiple sites. Audit log-based measures of team experience were associated with better process outcomes for AIS care, suggesting opportunities to study underlying mechanisms and improve care through deliberate training, team-building, and scheduling to maximize team experience.

The Role of Pharmacists in Providing Pharmaceutical Care in Primary and Secondary Prevention of Stroke: A Systematic Review and Meta-Analysis

Pharmacists deliver pharmaceutical care in many different healthcare settings and are well-placed to support the prevention of stroke. However, their role and impact in this area is ill-defined. This systematic review aims to explore the pharmacists’ role in stroke prevention. Nine databases were searched for studies reporting pharmacist interventions in the management of primary and secondary ischaemic stroke prevention. Study quality was evaluated through Cochrane Risk of Bias and Joanna Briggs Institute (JBI) appraisal tools where possible. A narrative review was conducted and meta-analysis performed for studies with comparable outcomes. Of the 834 initial articles, 31 met inclusion criteria. Study designs were varied and included controlled trials, observational studies, audit reports and conference abstracts. Seven studies addressed the pharmacists’ role in primary prevention and 24 in secondary prevention. Pharmacist interventions reported were diverse and often multifactorial. Overall, 20 studies reported significant improvement in outcomes. Meta-analysis showed pharmacist interventions in emergency care significantly improved the odds of achieving thrombolytic therapy door to needle (DTN) times ≤45 min, odds ratio: 2.69 (95% confidence interval (CI): 1.95−3.72); p < 0.001. The pharmacists’ role is varied and spans the stroke treatment pathway, with the potential for a positive impact on a range of health-related outcomes.

One-year recurrence of stroke and death in Lebanese survivors of first-ever stroke: Time-to-Event analysis

BACKGROUND

To date, despite the application of secondary prevention worldwide, first-ever stroke survivors remain at imminent risk of stroke recurrence and death in the short and long term. The present study aimed to assess the cumulative risk rates and identify baseline differences and stroke characteristics of Lebanese survivors.

METHODS

A prospective longitudinal study was conducted among survivors ≥18 years old who were followed-up for 15 months through a face-to-face interview. Kaplan-Meier method was used to calculate the cumulative rates of stroke mortality and recurrence. Cox-regression univariate and multivariable analyses were performed to identify the predictors of both outcomes.

RESULTS

Among 150 subjects (mean age 74 ± 12 years; 58.7% men vs. 44.3% women; 95.3% with ischemic stroke vs. 4.3% with intracerebral hemorrhage), high cumulative risk rates of stroke recurrence (25%) and death (21%) were highlighted, especially in the acute phase. Survival rates were lesser in patients with stroke recurrence compared to those without recurrence (Log rank test p < 0.001). Older age was the main predictor for both outcomes (p < 0.02). Large artery atherosclerosis was predominant in patients with stroke recurrence and death compared to small vessel occlusion (p < 0.02). Higher mental component summary scores of quality of life were inversely associated with stroke recurrence (p < 0.01). Lebanese survivors exhibited the highest percentages of depression and anxiety; elevated Hospital Anxiety and Depression Scale (HADS) scores were seen in those with stroke recurrence and those who died (≥80% with mean HADS scores ≥8). Lower Mini-Mental State Examination scores at the acute phase increased the risk of both outcomes by 10% (p < 0.03). Three out of 13 mortalities (23.1%) were presented with early epileptic seizures (p = 0.012). High educational level was the protective factor against stroke recurrence (p = 0.019). Administration of intravenous thrombolysis decreased the risk of both outcomes by 10% (p > 0.05).

CONCLUSION

Higher rates of stroke recurrence and death were observed in the first year following a stroke in Lebanon. Various factors were identified as significant determinants. Thus, health care providers and officials in Lebanon can use these findings to implement effective preventive strategies to best address the management of these factors to reduce the stroke burden and improve the short and long-term prognosis of stroke survivors.

Highly Visible Wall-Timer to Reduce Endovascular Treatment Time for Stroke

BACKGROUND

Endovascular therapy for acute ischemic stroke has revolutionized clinical care for patients with stroke and large vessel occlusion, but treatment remains time sensitive. At our stroke center, up to half of the door-to-groin time is accounted for after the patient arrives in the angio-suite. Here, we apply the concept of a highly visible timer in the angio-suite to quantify the impact on endovascular treatment time.

METHODS

This was a single-center prospective pseudorandomized study conducted over a 32-week period. Pseudorandomization was achieved by turning the timer on and off in 2-week intervals. The primary outcome was angio-suite-to-groin time, and secondary outcomes were angio-suite-to-intubation time, groin-to-recanalization time, and 90-day modified Rankin scale. A stratified analysis was performed based on type of anesthesia (ie, endotracheal intubation versus not).

RESULTS

During the 32-week study period, 97 mechanical thrombectomies were performed. The timer was on and off for 38 and 59 cases, respectively. The timer resulted in faster angio-suite-to-groin time (28 versus 33 minutes; P=0.02). The 5-minute reduction in angio-suite-to-groin was maintained after adjusting for intubation status in a multivariate regression (P=0.02). There was no difference in the 90-day modified Rankin scale between groups. The timer impact was consistent across the 32-week study period.

CONCLUSIONS

A highly visible timer in the angio-suite achieved a meaningful, albeit modest, reduction in endovascular treatment time for patients with stroke. Given the lack of risk and low cost, it is reasonable for stroke centers to consider a highly visible timer in the angio-suite to improve treatment times.

Reducing intravenous thrombolysis delay in acute ischemic stroke through a quality improvement program in the emergency department

Objective

This study aims to investigate the effectiveness of a quality improvement program for reducing intravenous thrombolysis (IVT) delay in acute ischemic stroke (AIS).

Materials and methods

We implement a quality improvement program consisting of 10 interventions for reducing IVT delay, including the establishment of an acute stroke team, standardized management of stroke teams, popularization of stroke and its treatment, emergency bypass route (BER), the achievement of computed tomography (CT) priority, no-delay CT interpretation, intravenous thrombolysis on the CT table, payment after treatment, whole recording, and incentive policy. We retrospectively analyzed the clinical time and outcome data of AIS patients treated with IVT in pre-intervention (108 patients) and post-intervention groups (598 patients), and further compared the differences between the non-emergency bypass route (NBER) and BER in the post-intervention group.

Results

The thrombolysis rate increased from ~29% in the pre-intervention group to 48% in the post-intervention group. Compared with the pre-intervention group, the median of door-to-needle time (DNT) was greatly shortened from 95 to 26 min (P < 0.001), door-to-CT time (DCT) was noticeably decreased from 20 to 18 min (P < 0.001), and onset-to-needle time (OTT) significantly declined from 206 to 133 min (P = 0.001). Under the new mode after the intervention, we further analyzed the IVT delay difference between the NBER (518 patients) and BER groups (80 patients) from the post-intervention group. The median values of DNT (18 vs. 27 min, P < 0.001), DCT (10 vs. 19 min, P < 0.001), and OTT (99 vs. 143 min, P < 0.001) showed significant reductions in the BER group. The quality improvement program under the emergency platform successfully controlled the median of DNT to within 26 min.

Conclusions

Collectively, the BER mode is a feasible scheme that greatly decreased DNT in AIS patients, and the secret to success was to accomplish as much as possible before the patient arrives at the emergency room.

Advancement of door-to-needle times in acute stroke treatment after repetitive process analysis: never give up!

Background:

In acute ischemic stroke, timely treatment is of utmost relevance. Identification of delaying factors and knowledge about challenges concerning hospital structures are crucial for continuous improvement of process times in stroke care.

Objective:

In this study, we report on our experience in optimizing the door-to-needle time (DNT) at our tertiary care center by continuous quality improvement.

Methods:

Five hundred forty patients with acute ischemic stroke receiving intravenous thrombolysis (IVT) at Hannover Medical School were consecutively analyzed in two phases. In study phase I, including 292 patients, process times and delaying factors were collected prospectively from May 2015 until September 2017. In study phase II, process times of 248 patients were obtained from January 2019 until February 2021. In each study phase, a new clinical standard operation procedure (SOP) was implemented, considering previously identified delaying factors. Pre- and post-SOP treatment times and delaying factors were analyzed to evaluate the new protocols.

Results:

In study phase I, SOP I reduced the median DNT by 15 min. The probability to receive treatment within 30 min after admission increased by factor 5.35 [95% confidence interval (CI): 2.46–11.66]. Further development of the SOP with implementation of a mobile thrombolysis kit led to a further decrease of DNT by 5 min in median in study phase II. The median DNT was 29 (25th–75th percentiles: 18–44) min, and the probability to undergo IVT within 15 min after admission increased by factor 4.2 (95% CI: 1.63–10.83) compared with study phase I.

Conclusion:

Continuous process analysis and subsequent development of targeted workflow adjustments led to a substantial improvement of DNT. These results illustrate that with appropriate vigilance, there is constantly an opportunity for improvement in stroke care.

Implementation of the Helsinki Model at West Tallinn Central Hospital

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

Rapid Thrombolysis Protocol: Results from a Before-and-after Study

Objective

Intravenous thrombolysis within 4.5 hours from time of onset has proven benefit in stroke. Universal standard for the door-to-needle (DTN) time is within 60 minutes from the time of arrival of patients to the emergency department. Our rapid thrombolysis protocol (RTPr) was developed with an aim to reduce the DTN time to a minimum by modifying our stroke post-intervention processes.

Materials and methods

This before-and-after study was conducted at a single center on patients who received intravenous thrombolysis in the emergency department. Consecutive patients who were thrombolysed using our RTPr (post-intervention group) were compared to the pre-intervention group who were thrombolysed before the implementation of the protocol. The primary outcomes were DTN time, time to recovery, and modified ranking score (mRS) on discharge. Secondary outcomes were mortality, symptomatic intracerebral hemorrhage, and hospital and intensive care unit length of stay.

Results

Seventy-four patients were enrolled in each group. Mean DTN time in pre- and post-intervention group was 56.15 minutes (95% CI 49.98–62.31) and 34.91 minutes (95% CI 29.64–40.17) (p <0.001), respectively. In pre-intervention and post-intervention groups, 43.24% (95% CI 32.57–54.59) and 41.89% (95% CI 31.32–53.26) patients, respectively, showed neurological recovery in 24 hours. About 36.49% (95% CI 26.44–47.87) in pre-intervention group and 54.05% (95% CI 42.78–64.93) in post-intervention group had discharge mRS 0–2.

Conclusion

The RTPr can be adapted by clinicians and hospitals to bring down the DTN times and improve outcomes for stroke patients.

How to cite this article

Verma A, Sarda S, Jaiswal S, Batra A, Haldar M, Sheikh WR, et al. Rapid Thrombolysis Protocol: Results from a Before-and-after Study. Indian J Crit Care Med 2022;26(5):549–554.

Triage Nurse-Activated Emergency Evaluation Reduced Door-to-Needle Time in Acute Ischemic Stroke Patients Treated with Intravenous Thrombolysis

Methods

This was a retrospective analysis in a general hospital emergency department in Beijing, China. 212 adult AIS patients treated with thrombolysis who failed to use EMSs were included. In addition to DNT, door-to-vein open time (DVT), door-to-blood sample deliver time (DBT), and 7-day NIHSS scores were evaluated.

Results

137 (64.6%) patients were in the triage nurse-activated group and 75 (35.4%) patients were in the doctor-activated group. The DNT of the triage nurse-activated group was significantly reduced compared with the doctor-activated group (28 (26, 32.5) min vs. 30 (28, 40) min, p=0.001). DNT less than 45 min was seen in 95.6% of patients in the triage nurse-activated group and 84% of patients in the doctor-activated group (p=0.011, OR 3.972, 95% CI 1.375–11.477). In addition, DVT (7 (4, 10) min vs. 8 (5, 12) min, P=0.025) and DBT (15 (13, 21) min vs. 19 (15, 26) min, p=0.001) of the triage nurse-activated group were also shorter than those of the doctor-activated group (p < 0.05). The 7-day NIHSS scores were not statistically different between the two groups.

Conclusions

Triage nurse-activated urgent emergency evaluation could reduce the door-to-needle time, which provides a feasible opportunity to optimize the emergency department service for AIS patients who failed to use emergency medical services.

A cross-sectional analysis of 2017 stroke symptoms recognition at the US regional level

OBJECTIVES

Stroke symptom recognition is critical in reducing time to treatment, but it is not known whether the increased support for stroke education programs during the last several years has led to an improvement in regional stroke symptom recognition levels since they were last assessed in the mid-2010s.

METHODS

We used the most current estimates of recognition from the 2017 National Health Interview Survey to examine regional recognition levels for individual stroke symptoms and correct identification of all five stroke symptoms.

RESULTS

Recognition of individual stroke symptoms was ≥76% in all regions, but correct identification of all stroke symptoms was lower ranging from 68.8 to 70.2%. Recognition of sudden numbness or weakness of face, arm, or leg, especially on one side (Northeast: 94.9%, Midwest: 95.8%, South: 93.8%, West: 94.5%) was the highest and recognition of sudden headache with no known cause (Northeast: 77.6%, Midwest: 76.4%, South: 77.7%, West: 76.5%) was the lowest for all regions.

DISCUSSION

We observed similar stroke symptom recognition levels in each US region with little improvement since the mid-2010s. Additional effort should be made to increase recognition of sudden headache with no known cause in US regions with current high prevalence of stroke risk factors.

Effect of resident complement on timeliness of stroke team activation in an academic emergency department

OBJECTIVES

Investigations of the impact of residents on emergency department (ED) timeliness of care typically focus only on global ED flow metrics. We sought to describe the association between resident complement/supervisory ratios and timeliness of ED care of a specific time-sensitive condition, acute stroke.

METHODS

We matched ED stroke patient arrivals at 1 academic stroke center against resident and attending staffing and constructed a Cox proportional hazards model of door-to-activation (DTA) time (ie, ED arrival ["door"] to stroke team activation). We considered multiple predictors, including calculated ratios of residents supervised by each attending physician.

RESULTS

Among 462 stroke activation patients in 2014-2015, DTA ranged from 1 to 217 minutes, 72% within 15 minutes. The median number of emergency and off-service residents supervised per attending were 1.7 (interquartile range [IQR], 1.3-2.3) and 0.7 (IQR, 0-1), respectively. A 1-resident increase in off-service residents was associated with a 24% decrease (hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.64-0.90) in the probability of stroke team activation at any given time. An independent 1-resident increase in the number of emergency residents was associated with a 13% increase (HR, 1.13; 95% CI, 1.01-1.25) in timely activation.

CONCLUSION

Timeliness of care for acute stroke may be impacted by how academic EDs configure the complement and supervisory structures of residents. Higher supervisory demands imposed by increasing the proportion of rotating off-service residents may be associated with slower stroke recognition and DTA times, but this effect may be offset when more emergency residents are present.

Factors associated with post-acute functional status and discharge dispositions in individuals with spinal cord injury

BACKGROUND

Research has evaluated the effect of surgical timing on patient functional recovery in individuals with spinal cord injury (SCI); however, there is a critical need to assess how demographics, clinical characteristics, and process of care affect functional outcomes.

OBJECTIVE

We examined the association between demographic, clinical, and process of care factors with post-acute functional status (locomotion and transfer mobility scores) and discharge disposition (home vs. institution) in individuals with SCI.

METHODS

This study was a retrospective cohort analysis of the Pennsylvania Trauma Systems Outcomes Study (PTOS) database for individuals with traumatic SCI (N = 2223). We conducted multinomial and binomial logistic regression analyses to examine post-acute functional status and discharge disposition, respectively.

RESULTS

The results indicated that older age, longer length of stay, lower Glasgow Coma Scale (GCS), higher Injury Severity Score (ISS), and individuals with tetraplegia had significantly lower motor functional score at discharge from an acute hospital. In addition, older age, individuals with public-sponsored insurance, longer length of stay, lower GCS, and higher ISS had significantly higher odds of being discharged to an institution, as compared to home. Individuals of Hispanic ethnicity, as compared to White, had lower odds of being discharged to an institution.

CONCLUSIONS

The regression models developed in this study were able to better classify discharge destinations compared to the functional outcomes at discharge from the acute hospital. Further research is necessary to determine how these factors and their associations vary nationally across the US, which have the potential to inform trauma and acute care post-SCI.

Impact of an emergency medicine pharmacist on door to needle alteplase time and patient outcomes in acute ischemic stroke

PURPOSE

Time is a critical metric in the emergency department (ED) for acute ischemic stroke and thrombolytic therapy. National guidelines have emphasized tracking time from stroke onset to treatment and decreasing door to needle (DTN) time [1, 2]. Multidisciplinary teamwork is encouraged but, there is limited evidence demonstrating the value of the pharmacist on the stroke response team. The goal of this study is to compare DTN times in the ED with or without a pharmacist at bedside and examine the impact on subsequent patient outcomes.

METHODS

This was a single-center retrospective cohort study. Investigators identified patients who presented to the ED between August 2016 - May 2020 with signs of ischemic stroke and subsequently received intravenous alteplase. Patients were excluded if they refused alteplase or received alteplase off-campus before being transferred. Pharmacist documentation of clinical interventions was used to identify participation on the stroke response team. The primary outcome was median DTN time. Secondary outcomes included severity of deficits measured by the National Institutes of Health Stroke Scale (NIHSS), hospital length of stay (LOS), 90-day Modified Rankin Scale (mRS), incidence of intracranial hemorrhage (ICH), and inpatient all-cause mortality.

RESULTS

Of the 164 patients included, 31 had an emergency medicine pharmacist at bedside (EMP group) and 133 did not (No EMP group). The median DTN time was significantly shorter at 35 min EMP [interquartile range (IQR) 29-44] vs 42 min No EMP [IQR 34-55]; p = 0.003. The number of cases achieving a DTN time of 30 min or less was significantly higher when a pharmacist was involved (35.5% vs.16.5%; p = 0.018) as well as the number of patients receiving alteplase within 45 min (80.7% vs. 57.1%; p = 0.015). NIHSS scores at discharge were lower in the EMP group (2 [IQR 0-5] vs. 4 [IQR 0-8.25]; p = 0.049). In patients with magnetic resonance imaging (MRI) confirmed stroke, a difference was not observed in the secondary outcomes.

CONCLUSION

Patients with an emergency medicine pharmacist as part of their stroke response team had significantly lower DTN times. A higher proportion of these cases met benchmark DTN times less than 45 min and 30 min. An emergency medicine pharmacist on a stroke response team has the potential to improve patient care.

Current approaches and advances in the imaging of stroke

A stroke occurs when the blood flow to the brain is suddenly interrupted, depriving brain cells of oxygen and glucose and leading to further cell death. Neuroimaging techniques, such as computed tomography and magnetic resonance imaging, have greatly improved our ability to visualise brain structures and are routinely used to diagnose the affected vascular region of a stroke patient's brain and to inform decisions about clinical care. Currently, these multimodal imaging techniques are the backbone of the clinical management of stroke patients and have immensely improved our ability to visualise brain structures. Here, we review recent developments in the field of neuroimaging and discuss how different imaging techniques are used in the diagnosis, prognosis and treatment of stroke.

Summary: Stroke imaging has undergone seismic shifts in the past decade. Although magnetic resonance imaging (MRI) is superior to computed tomography in providing vital information, further research on MRI is still required to bring its full potential into clinical practice.

Achieving More Rapid Door-to-Needle Times and Improved Outcomes in Acute Ischemic Stroke in a Nationwide Quality Improvement Intervention

BACKGROUND AND PURPOSE

The benefits of tPA (tissue-type plasminogen activator) in acute ischemic stroke are time-dependent. However, delivery of thrombolytic therapy rapidly after hospital arrival was initially occurring infrequently in hospitals in the United States, discrepant with national guidelines.

METHODS

We evaluated door-to-needle (DTN) times and clinical outcomes among patients with acute ischemic stroke receiving tPA before and after initiation of 2 successive nationwide quality improvement initiatives: Target: Stroke Phase I (2010-2013) and Target: Stroke Phase II (2014-2018) from 913 Get With The Guidelines-Stroke hospitals in the United States between April 2003 and September 2018.

RESULTS

Among 154 221 patients receiving tPA within 3 hours of stroke symptom onset (median age 72 years, 50.1% female), median DTN times decreased from 78 minutes (interquartile range, 60-98) preintervention, to 66 minutes (51-87) during Phase I, and 50 minutes (37-66) during Phase II (P<0.001). Proportions of patients with DTN ≤60 minutes increased from 26.4% to 42.7% to 68.6% (P<0.001). Proportions of patients with DTN ≤45 minutes increased from 10.1% to 17.7% to 41.4% (P<0.001). By the end of the second intervention, 75.4% and 51.7% patients achieved 60-minute and 45-minute DTN goals. Compared with the preintervention period, hospitals during the second intervention period (2014-2018) achieved higher rates of tPA use (11.7% versus 5.6%; adjusted odds ratio, 2.43 [95% CI, 2.31-2.56]), lower in-hospital mortality (6.0% versus 10.0%; adjusted odds ratio, 0.69 [0.64-0.73]), fewer bleeding complication (3.4% versus 5.5%; adjusted odds ratio, 0.68 [0.62-0.74]), and higher rates of discharge to home (49.6% versus 35.7%; adjusted odds ratio, 1.43 [1.38-1.50]). Similar findings were found in sensitivity analyses of 185 501 patients receiving tPA within 4.5 hours of symptom onset.

CONCLUSIONS

A nationwide quality improvement program for acute ischemic stroke was associated with substantial improvement in the timeliness of thrombolytic therapy start, increased thrombolytic treatment, and improved clinical outcomes.

Reflection on the Past, Present, and Future of Thrombolytic Therapy for Acute Ischemic Stroke

More than 25 years have passed since the US Food and Drug Administration approved IV recombinant tissue plasminogen activator (alteplase) for the treatment of acute ischemic stroke. This landmark decision brought a previously untreatable disease into a new therapeutic landscape, providing inspiration for clinicians and hope to patients. Since that time, the use of alteplase in the clinical setting has become standard of care, continually improving with quality measures such as door-to-needle times and other metrics of specialized stroke unit care. The past decade has seen more widespread use of alteplase in the prehospital setting with mobile stroke units and telestroke and beyond initial time windows via the use of CT perfusion or MRI. Simultaneously, the position of alteplase is being challenged by new lytics and by the concept of its bypass altogether in the era of endovascular therapy. We provide an overview of alteplase, including its earliest trials and how they have shaped the current therapeutic landscape of ischemic stroke treatment, and touch on new frontiers for thrombolytic therapy. We highlight the critical role of thrombolytic therapy in the past, present, and future of ischemic stroke care.

Impact of Intravenous Alteplase Door-to-Needle Times on 2-Year Mortality in Patients With Acute Ischemic Stroke

Objective: We sought to determine whether administration of Intravenous Thrombolysis (IVT) to patients with Acute Ischemic Stroke (AIS) within 60 min from hospital arrival is associated with lower 2-year mortality.

Methods: This retrospective study was conducted among patients receiving IVT in hospitals participating in the Georgia Coverdell Acute Stroke Registry (GCASR) from January 1, 2008 through June 30, 2018. Two-year mortality data was obtained by linking the 2008–2018 Georgia Discharge Data System data and the 2008–2020 Georgia death records. We analyzed the study population in two groups based on the time from hospital arrival to initiation of IVT expressed as Door to Needle time (DTN) in a dichotomized (DTN ≤ 60 vs. > 60 min) fashion.

Results: The median age of patients was 68 years, 49.4% were females, and the median NIHSS was 9. DTN ≤60 min was associated with lower 30-day [odds ratio (OR), 0.62; 95% CI, 0.52–0.73; P < 0.0001], 1-year (OR, 0.71; 95% CI, 0.61–0.83; P < 0.0001) and 2-year (OR, 0.76; 95% CI, 0.65–0.88; P = 0.001) mortality as well as lower rates of sICH at 36 h (OR, 0.57; 95% CI, 0.43–0.75; P = 0.0001), higher rates of ambulation at discharge (OR, 1.38; 95% CI, 1.25–1.53; P < 0.0001) and discharge to home (OR, 1.36; 95% CI, 1.23–1.52; P < 0.0001).

Conclusion: Faster DTN in patients with AIS was associated with lower 2-year mortality across all age, gender and race subgroups. These findings reinforce the need for intensifying quality improvement measures to reduce DTN in AIS patients.

Organization and Implementation of a Stroke Center in Panamá, a Model for Implementation of Stroke Centers in Low and Middle Income Countries

Background: Stroke is the second leading cause of death and disability worldwide. Stroke centers have become a central component of modern stroke services in many high-income countries, but their feasibility and efficacy in low, middle, and emerging high-income countries are less clear. Also, despite the availability of international guidelines, many hospitals worldwide do not have organized clinical stroke care. We present a methodology to help hospitals develop stroke centers and review quality data after implementation.

Objectives: To describe and compare demographics, performance, and clinical outcomes of the Pacífica Salud, Hospital Punta Pacífica (PSHPP) stroke center during its first 3 years 2017–2019.

Methods: Pacífica Salud, Hospital Punta Pacífica was organized to implement protocols of care based on the best practices by international guidelines and a quality improvement process. The methodology for implementation adapts a model for translating evidence into practice for implementation of evidence-based practices in medicine. This is a retrospective study of prospectively collected quality data between March of 2017 to December of 2019 for patients admitted to PSHPP with primary diagnosis stroke. Data collected include demographics, clinical data organized per the Joint Commission's STK Performance Measures, door to needle, door to groin puncture, 90 day modified Rankin Score, and hemorrhagic complications from IV thrombolysis and mechanical thrombectomy (MT). Primary outcome: year over year proficiency in documenting performance measures. Secondary outcome: year over year improvement.

Results: A total of 143 patients were admitted for acute ischemic stroke, TIA, or hemorrhagic stroke. Of these, 36 were admitted in 2017, 50 in 2018, and 57 in 2019. Performance measure proficiency increased in the year-over-year analysis as did the total number of patients and the number of patients treated with IV thrombolysis and MT.

Conclusions: We present the methodology and results of a stroke program implementation in Panamá. This program is the first in the country and in Central America to achieve Joint Commission International (JCI) certification as a Primary Stroke Center (PSC). We postulate that the dissemination of management guidelines is not sufficient to encourage the development of stroke centers. The application of a methodology for translation of evidence into practice with mentorship facilitated the success of this program.

Thrombolytic DNT and fatality and disability rates in acute ischemic stroke: a study from Bigdata Observatory Platform for Stroke of China

OBJECTIVE

To evaluate whether shorter door-to-needle times (DNT) with intravenous tissue plasminogen activator (tPA) for acute ischemic stroke are associated with improved 1-year outcomes in Chinese patients.

METHODS

From August to September 2019, all first-ever ischemic stroke patients who were treated with intravenous tPA within 4.5 h of the time they were last known to be well from 232 hospitals in China were included. Patients were divided into four groups according to DNT time (≤ 45 min; 45-60 min; 60-90 min; > 90 min). All discharged patients would receive a telephone follow-up at 12-month after admission. Death and disability events were recorded.

RESULTS

Finally, 2370 patients were analyzed. The median age was 65 years, 66.6% were male, and 2.4% were of ethnic minorities. In the 1-year follow-up, 211 patients died (8.9%; 95%CI: 7.8-10.0%). The patients (53.1%) had DNT times of longer than 45 min, compared with those treated within 45 min, did not have significantly higher 1-year mortality (8.9% vs 8.9% [absolute difference, 0.03% {95% CI, - 0.05% to - 0.10%}, odd ratio {OR}, 1.00 {95% CI, 0.75 to 1.33}]). In addition, 385 patients (16.2%; 14.8-17.3%) out of those survivors had disability events. The patients had DNT times of longer than 45 min, compared with those treated within 45 min, did not have significantly higher 1-year disability rate (18.9% vs 16.7% [absolute difference, 1.9% {95% CI, 1.1% to 3.0%}, odd ratio {OR}, 1.22 {95% CI, 0.89 to 1.43}]).

CONCLUSIONS

The results did not show that shorter DNT for tPA administration was significantly associated with better 1-year outcomes.

MRI as a first-line imaging modality in acute ischemic stroke: a sustainable concept

Background:

Computed tomography (CT) scans are the first-line imaging technique in acute stroke patients based on the argument of rapid feasibility. Using magnetic resonance imaging (MRI) as the first-line imaging technique is the exception to the rule, although it provides much more diagnostic information and avoids exposure to radiation. We evaluated whether an MRI-based acute stroke concept is fast, suitable, and useful to improve recanalization rates and patient outcomes.

Methods:

We performed a retrospective observational cohort study comparing patients treated at a comprehensive stroke center (Ulm/Germany) applying an MRI-based acute stroke concept with patients recorded in a large comprehensive stroke registry in Baden-Württemberg (Germany). We analyzed the quality indicators of acute stroke treatment, patient’s outcome, and the rate of transient ischemic attack (TIA) at discharge.

Results:

A total of 2182 patients from Ulm and 82,760 patients from the Baden-Württemberg (BW) stroke registry (including 29,575 patients of comprehensive stroke centers (BWc)) were included. Intravenous thrombolysis rate was higher in Ulm than in BW or the BWc stroke centers (Ulm 27.4% versus BW 20.9% versus BWc 26.1; p < 0.01), while a door-to-needle time <30 min could be achieved more frequently (Ulm 73.6% versus BW 44.1% versus BWc 47.1%; p < 0.01). Thrombectomy rate in patients with a proximal vascular occlusion was higher (Ulm 69.2% versus BW 50.7% versus BWc 59.3; p < 0.01). The number of TIA diagnoses was lower (Ulm 16.2% versus BW 24.6% versus BWc 19.9%; p < 0.01). More patients showed a shift to a favorable outcome (Ulm 21.1% versus BW 16.9% versus BWc 15.3; p < 0.01). Complication rates were similar.

Conclusions:

The MRI-based acute stroke concept is suitable, fast and seems to be beneficial. The time-dependent quality indicators were better both in comparison to all stroke units and to the comprehensive stroke units in the area. Based on the MRI concept, high rates of recanalization procedures and fewer TIA diagnoses could be observed. In addition, there was a clear trend towards an improved clinical outcome. A clinical trial comparing the effects of CT and MRI as the primary imaging technique in otherwise identical stroke unit settings is warranted.

Radiology Education Among Emergency Medicine Residencies: A National Needs Assessment

Introduction

Radiology training is an important component of emergency medicine (EM) education, but its delivery has been variable. Program directors have reported a lack of radiology skills in incoming interns. A needs assessment is a crucial first step toward improving radiology education among EM residencies. Our objective was to explore the current state of radiology education in EM residency programs.

Methods

This was a cross-sectional survey study of all Accreditation Council for Graduate Medical Education-accredited EM programs in the United States. Program leadership completed an online survey consisting of multiple choice, Likert scale, and free-response items. We calculated and reported descriptive statistics.

Results

Of eligible EM programs, 142/252 (56%) completed the survey including 105 postgraduate year (PGY) 1–3 and 36 PGY 1–4 programs. One respondent opted out of answering demographic questions. 23/141 (16%) were from the Western region, 29/141 (21%) were from the North Central region, 14/141 (10%) were from the South-Central region, 28/141 (20%) were from the Southeast region, and 47/141 (33%) were from the Northeast region. A total of 88/142 (62%) of responding programs did not have formal radiology instruction. Of the education that is provided, 127/142 (89%) provide it via didactics/lectures and 115/142 (81%) rely on instruction during clinical shifts. Only 51/142 (36%) provide asynchronous opportunities, and 23/142 (16%) have a dedicated radiology rotation. The majority of respondents reported spending 0–2 hours per month on radiology instruction (108/142; 76%); 95/141 (67%) reported that EM faculty “often” or “always” provide radiology instruction; 134/142 (95%), felt that it was “extremely” or “very important” for ED providers to be able to independently interpret radiograph results; and 129/142 (90.84%) either “sometimes” or “always” rely on their independent radiograph interpretations to make clinical decisions. The radiology studies identified as most important to be able to independently interpret were radiographs obtained for lines/tubes, chest radiographs, and radiographs obtained for musculoskeletal-related complaints.

Conclusion

A minority of EM residency programs have formal instruction in radiology despite the majority of responding program leadership believing that these are important skills. The most important curricular areas were identified. These results may inform the development of formal radiology curricula in EM graduate medical education.