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Klu M, de Souza AC, Carbonera LA, Secchi TL, Pille A, Rodrigues M, Brondani R, de Almeida AG, Dal Pizzol A, Camelo DMF, Mantovani GP, Oldoni C, Tessari MS, Nasi LA, Martins SCO. Improving door-to-reperfusion time in acute ischemic stroke during the COVID-19 pandemic: experience from a public comprehensive stroke center in Brazil. Front Neurol 2023; 14:1155931. [PMID: 37492852 PMCID: PMC10365273 DOI: 10.3389/fneur.2023.1155931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/13/2023] [Indexed: 07/27/2023] Open
Abstract
Background The global COVID-19 pandemic has had a devastating effect on global health, resulting in a strain on healthcare services worldwide. The faster a patient with acute ischemic stroke (AIS) receives reperfusion treatment, the greater the odds of a good functional outcome. To maintain the time-dependent processes in acute stroke care, strategies to reorganize infrastructure and optimize human and medical resources were needed. Methods Data from AIS patients who received thrombolytic therapy were prospectively assessed in the emergency department (ED) of Hospital de Clínicas de Porto Alegre from 2019 to 2021. Treatment times for each stage were measured, and the reasons for a delay in receiving thrombolytic therapy were evaluated. Results A total of 256 patients received thrombolytic therapy during this period. Patients who arrived by the emergency medical service (EMS) had a lower median door-to-needle time (DNT). In the multivariable analysis, the independent predictors of DNT >60 min were previous atrial fibrillation (OR 7) and receiving thrombolysis in the ED (OR 9). The majority of patients had more than one reason for treatment delay. The main reasons were as follows: delay in starting the CT scan, delay in the decision-making process after the CT scan, and delay in reducing blood pressure. Several actions were implemented during the study period. The most important factor that contributed to a decrease in DNT was starting the bolus and continuous infusion of tPA on the CT scan table (decreased the median DNT from 74 to 52, DNT ≤ 60 min in 67% of patients treated at radiology service vs. 24% of patients treated in the ED). The DNT decreased from 78 min to 66 min in 2020 and 57 min in 2021 (p = 0.01). Conclusion Acute stroke care continued to be a priority despite the COVID-19 pandemic. The implementation of a thrombolytic bolus and the start of continuous infusion on the CT scan table was the main factor that contributed to the reduction of DNT. Continuous monitoring of service times is essential for improving the quality of the stroke center and achieving better functional outcomes for patients.
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Affiliation(s)
- Marcelo Klu
- Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Ana Claudia de Souza
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Leonardo Augusto Carbonera
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Thais Leite Secchi
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Arthur Pille
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Marcio Rodrigues
- Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Rosane Brondani
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Andrea Garcia de Almeida
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Angélica Dal Pizzol
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Daniel Monte Freire Camelo
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Gabriel Paulo Mantovani
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Carolina Oldoni
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Marcelo Somma Tessari
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Luiz Antonio Nasi
- Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Sheila Cristina Ouriques Martins
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
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Leite KFDS, Faria MGBFD, Andrade RLDP, Sousa KDLD, Santos SRD, Ferreira KS, Rezende CEMD, Neto OMP, Monroe AA. Effect of implementing care protocols on acute ischemic stroke outcomes: a systematic review. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:173-185. [PMID: 36948202 PMCID: PMC10033200 DOI: 10.1055/s-0042-1759578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 01/13/2022] [Indexed: 03/24/2023]
Abstract
BACKGROUND Implementing stroke care protocols has intended to provide better care quality, favor early functional recovery, and achieving long-term results for the rehabilitation of the patient. OBJECTIVE To analyze the effect of implementing care protocols on the outcomes of acute ischemic stroke. METHODS Primary studies published from 2011 to 2020 and which met the following criteria were included: population should be people with acute ischemic stroke; studies should present results on the outcomes of using protocols in the therapeutic approach to acute ischemic stroke. The bibliographic search was carried out in June 2020 in 7 databases. The article selection was conducted by two independent reviewers and the results were narratively synthesized. RESULTS A total of 11,226 publications were retrieved in the databases, of which 30 were included in the study. After implementing the protocol, 70.8% of the publications found an increase in the rate of performing reperfusion therapy, such as thrombolysis and thrombectomy; 45.5% identified an improvement in the clinical prognosis of the patient; and 25.0% of the studies identified a decrease in the length of hospital stay. Out of 19 studies that addressed the rate of symptomatic intracranial hemorrhage, 2 (10.5%) identified a decrease. A decrease in mortality was mentioned in 3 (25.0%) articles out of 12 that evaluated this outcome. CONCLUSIONS We have identified the importance of implementing protocols in increasing the performance of reperfusion therapies, and a good functional outcome with improved prognosis after discharge. However, there is still a need to invest in reducing post-thrombolysis complications and mortality.
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Affiliation(s)
- Karina Fonseca de Souza Leite
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
| | - Mariana Gaspar Botelho Funari de Faria
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
| | - Rubia Laine de Paula Andrade
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
| | - Keila Diane Lima de Sousa
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
| | - Samuel Ribeiro dos Santos
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
| | - Kamila Santos Ferreira
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Hospital das Clínicas, Ribeirão Preto SP, Brazil.
| | - Carlos Eduardo Menezes de Rezende
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
- Ministério da Saúde, Agência Nacional de Saúde Suplementar, Brasília DF, Brazil.
| | - Octavio Marques Pontes Neto
- Universidade de São Paulo, Faculdade de Medicina de Ribeirao Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil.
| | - Aline Aparecida Monroe
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
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Situmeang RFV, Pangestu A, Stevano R, Tannu Y, Herlambang J, Putri C. Reasons withholding intravenous thrombolysis for acute ischemic stroke in an Indonesian Tertiary Center. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2023. [DOI: 10.1186/s41983-023-00613-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Abstract
Background
Intravenous thrombolysis is the current therapy of choice in patients with acute ischemic stroke (AIS). While highly effective, the rate at which the procedure is employed is low. Studies evaluating the causes withholding thrombolytic treatment in developing nations remain scarce. We aim to determine the factors withholding thrombolytic treatment in AIS patients.
Methods
This is a retrospective study of AIS patients at Siloam Hospitals Lippo Village, Indonesia, in a 10-month period between April 2019 to February 2020. Patient data were collected from the medical records.
Results
One hundred and forty-five cases of AIS were found within a 10-month period (April 2019 to February 2020). Thrombolysis was performed in 6.90% of all patients with AIS (21.28% when adjusted for eligible patients with onset ≤ 4.5 h). Prehospital delay exceeding 4.5 h was the most common cause of withholding thrombolytic treatment (68.28% of patients present above 4.5 h or with unknown onset). Among patients presenting ≤ 4.5 h, causes withholding thrombolysis include clinical improvement (35.14%), mild non-disabling symptoms (32.43%), patient/family refusal (18.92%), extensive infarction (5.41%), seizures at onset (2.7%), as well as history of acute bleeding diathesis (2.7%) and gastrointestinal bleeding (2.7%).
Conclusions
Prehospital delay constitutes the primary obstacle toward receiving thrombolytic therapy for AIS, especially in developing countries. Among patients with onset below 4.5 h, other notable causes include clinical improvement, mild non-disabling symptoms, and patient/family refusal. Of note, the rate of patient/family refusal in our study was much higher compared to previous findings, which may reflect possible socio-economic, communication, or educational issues.
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Leite KFDS, dos Santos SR, Andrade RLDP, de Faria MGBF, Saita NM, Arcêncio RA, Isaac ISDS, de Rezende CEM, Villa TCS, Pontes Neto OM, Monroe AA. Reducing care time after implementing protocols for acute ischemic stroke: a systematic review. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:725-740. [PMID: 36254446 PMCID: PMC9685828 DOI: 10.1055/s-0042-1755194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Abstract
Background The treatment of acute ischemic stroke with cerebral reperfusion therapy requires rapid care and recognition of symptoms.
Objective To analyze the effectiveness of implementing protocols for acute ischemic stroke in reducing care time.
Methods Systematic review, which was performed with primary studies in Portuguese, English, and Spanish published between 2011 and 2020. Inclusion criteria: study population should comprise people with acute ischemic stroke and studies should present results on the effectiveness of using urgent care protocols in reducing care time. The bibliographic search was conducted in June 2020 in the LILACS, MEDLINE, Embase, Scopus, CINAHL, Academic Search Premier, and SocINDEX databases. The articles were selected, and data were extracted by two independent reviewers; the synthesis of the results was performed narratively. The methodological quality of articles was evaluated through specific instruments proposed by the Joanna Briggs Institute.
Results A total of 11,226 publications were found, of which 35 were included in the study. Only one study reported improvement in the symptoms-onset-to-door time after protocol implementation. The effectiveness of the therapeutic approach protocols for ischemic stroke was identified in improving door-to-image, image-to-needle, door-to-needle and symptoms-onset-to-needle times. The main limitation found in the articles concerned the lack of clarity in relation to the study population.
Conclusions Several advances have been identified in in-hospital care with protocol implementation; however, it is necessary to improve the recognition time of stroke symptoms among those who have the first contact with the person affected by the stroke and among the professionals involved with the prehospital care.
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Affiliation(s)
- Karina Fonseca de Souza Leite
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Samuel Ribeiro dos Santos
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Rubia Laine de Paula Andrade
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Mariana Gaspar Botelho Funari de Faria
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Nanci Michele Saita
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Ricardo Alexandre Arcêncio
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Igor Simões da Silva Isaac
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Carlos Eduardo Menezes de Rezende
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
- Ministério da Saúde, Agência Nacional de Saúde Suplementar, Brasília DF, Brazil
| | - Tereza Cristina Scatena Villa
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Octavio Marques Pontes Neto
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil
| | - Aline Aparecida Monroe
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
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Michael SS, Church RJ, Michael SH, Clark RT, Reznek MA. Effect of resident complement on timeliness of stroke team activation in an academic emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12643. [PMID: 35079732 PMCID: PMC8769070 DOI: 10.1002/emp2.12643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 12/07/2021] [Accepted: 12/20/2021] [Indexed: 11/07/2022] Open
Abstract
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.
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Affiliation(s)
- Sean S. Michael
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
- Department of Emergency MedicineUniversity of Massachusetts Medical SchoolWorcesterMassachusettsUSA
| | - Richard J. Church
- Department of Emergency MedicineUniversity of Massachusetts Medical SchoolWorcesterMassachusettsUSA
| | - Sarah H. Michael
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
- Department of Emergency MedicineBrown UniversityProvidenceRhode IslandUSA
| | - Richard T. Clark
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Martin A. Reznek
- Department of Emergency MedicineUniversity of Massachusetts Medical SchoolWorcesterMassachusettsUSA
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Sikora J, Karczmarska-Wódzka A, Bugieda J, Sobczak P. The Importance of Platelets Response during Antiplatelet Treatment after Ischemic Stroke-Between Benefit and Risk: A Systematic Review. Int J Mol Sci 2022; 23:ijms23031043. [PMID: 35162965 PMCID: PMC8835275 DOI: 10.3390/ijms23031043] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 01/01/2023] Open
Abstract
Ischemic stroke is a disease related to abnormal blood flow that leads to brain dysfunction. The early and late phases of the disease are distinguished. A distinction is made between the early and late stages of the disease, and the best effect in treating an ischemic stroke is usually achieved within the first hours after the onset of symptoms. This review looked at studies platelet activity monitoring studies to determine the risks and benefits of various approaches including antiplatelet therapy. A study was conducted on recently published literature based on PRISMA. This review includes 32 research articles directly addressing the importance of monitoring platelet function during antiplatelet therapy (dual or monotherapy) after ischemic stroke. In patients with transient ischemic attack or ischemic stroke, antiplatelet therapy can reduce the risk of stroke by 11–15%, assuming that patients respond well. Secondary prevention results are dependent on platelet reactivity, meaning that patients do not respond equally to antiplatelet therapy. It is very important that aspirin-resistant patients can benefit from the use of dual antiplatelet therapy. The individualized approach to secondary stroke prevention is to administer the most appropriate drug at the correct dose and apply the optimal therapeutic procedure to the individual patient.
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Affiliation(s)
- Joanna Sikora
- Research and Education Unit for Experimental Biotechnology, Department of Transplantology and General Surgery, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland; (A.K.-W.); (J.B.)
- Correspondence: ; Tel.: +48-52-585-59-76; Fax: +48-52-585-43-80
| | - Aleksandra Karczmarska-Wódzka
- Research and Education Unit for Experimental Biotechnology, Department of Transplantology and General Surgery, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland; (A.K.-W.); (J.B.)
| | - Joanna Bugieda
- Research and Education Unit for Experimental Biotechnology, Department of Transplantology and General Surgery, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland; (A.K.-W.); (J.B.)
| | - Przemysław Sobczak
- Department of Laboratory Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland;
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Xian Y, Xu H, Smith EE, Saver JL, Reeves MJ, Bhatt DL, Hernandez AF, Peterson ED, Schwamm LH, Fonarow GC. Achieving More Rapid Door-to-Needle Times and Improved Outcomes in Acute Ischemic Stroke in a Nationwide Quality Improvement Intervention. Stroke 2021; 53:1328-1338. [PMID: 34802250 DOI: 10.1161/strokeaha.121.035853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Ying Xian
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX. (Y.X.)
| | - Haolin Xu
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (H.X., A.F.H.)
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (E.E.S.)
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles (J.L.S.)
| | - Mathew J Reeves
- Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (H.X., A.F.H.)
| | - Eric D Peterson
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX. (E.D.P.)
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.)
| | - Gregg C Fonarow
- Division of Cardiology, University of California at Los Angeles (G.C.F.)
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Prabhakaran S, Khorzad R, Parnianpour Z, Romo E, Richards CT, Meurer WJ, Lee J, Mendelson SJ, Holl JL. Door-In-Door-Out Process Times at Primary Stroke Centers in Chicago. Ann Emerg Med 2021; 78:674-681. [PMID: 34598828 DOI: 10.1016/j.annemergmed.2021.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/07/2021] [Accepted: 06/17/2021] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE Acute stroke patients often require interfacility transfer from primary stroke centers to comprehensive stroke centers. Given the time-sensitive benefits of endovascular reperfusion, reducing door-in-door-out time at the primary stroke center is a target for quality improvement. We sought to identify modifiable predictors of door-in-door-out times at 3 Chicago-region primary stroke centers. METHODS We performed a retrospective analysis of consecutive patients with acute stroke from February 1, 2018 to January 31, 2020 who required transfer from 1 of 3 primary stroke centers to 1 of 3 affiliated comprehensive stroke centers in the Chicago region. Stroke coordinators at each primary stroke center abstracted data on type of transport, medical interventions and treatments prior to transfer, and relevant time intervals from patient arrival to departure. We evaluated predictors of door-in-door-out time using median regression models. RESULTS Of 191 total patients, 67.9% arrived by emergency medical services and 57.4% during off-hours. Telestroke was performed in 84.2%, 30.5% received alteplase, and 48.4% underwent a computed tomography (CT) angiography at the primary stroke center. The median door-in-door-out time was 148.5 (interquartile range 106 to 207.8) minutes. The largest contributors to door-in-door-out time, in minutes, were CT to CT angiography time (22 [7 to 73.5]), transfer center contact to ambulance request time (20 [8 to 53.3]), ambulance request to arrival time (20.5 [14 to 36]), and transfer ambulance time at primary stroke center (26 [21 to 35]). Factors associated with door-in-door-out time were (adjusted median differences, in minutes [95% confidence intervals]): CT angiography performed at primary stroke center (+39 [12.3 to 65.7]), walk-in arrival mode (+53 [4.1 to 101.9]), administration of intravenous alteplase (-29 [-31.3 to -26.7]), intubation at primary stroke center (+23 [7.3 to 38.7]), and ambulance request by primary stroke center (-20 [-34.3 to -5.7]). CONCLUSION Door-in-door-out times at Chicago-area primary stroke centers average nearly 150 minutes. Reducing time to CT angiography, receipt of alteplase, and ambulance request are likely important modifiable targets for interventions to decrease door-in-door-out times at primary stroke centers.
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Affiliation(s)
| | - Rebeca Khorzad
- Patient Throughput, Northwestern Medicine, Lake Forest, IL
| | - Zahra Parnianpour
- Department of Neurology, Biological Sciences Division, The University of Chicago, Chicago, IL
| | - Elida Romo
- Department of Neurology, Biological Sciences Division, The University of Chicago, Chicago, IL
| | - Christopher T Richards
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Jungwha Lee
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Jane L Holl
- Department of Neurology, The University of Chicago, Chicago, IL
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9
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Chowdhury SZ, Baskar PS, Bhaskar S. Effect of prehospital workflow optimization on treatment delays and clinical outcomes in acute ischemic stroke: A systematic review and meta-analysis. Acad Emerg Med 2021; 28:781-801. [PMID: 33387368 DOI: 10.1111/acem.14204] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/21/2020] [Accepted: 12/24/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The prehospital phase is critical in ensuring that stroke treatment is delivered quickly and is a major source of time delay. This study sought to identify and examine prehospital stroke workflow optimizations (PSWOs) and their impact on improving health systems, reperfusion rates, treatment delays, and clinical outcomes. METHODS The authors conducted a systematic literature review and meta-analysis by extracting data from several research databases (PubMed, Cochrane, Medline, and Embase) published since 2005. We used appropriate key search terms to identify clinical studies concerning prehospital workflow optimization, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS The authors identified 27 articles that looked at the impact of prehospital workflow optimizations on time and treatment parameters; 26 were included in the meta-analysis. The PSWO were subgrouped into three categories: improved intravenous thrombolysis (IVT) triage, large-vessel occlusion (LVO) bypass, and mobile stroke unit (MSU). The salient findings are as follows: improved IVT triage led to significantly improved rates of IVT (relative risk [RR] = 1.80, 95% confidence interval [CI] = 1.18 to 2.75); however, MSU did not (RR = 1.22, 95% CI = 0.98 to 1.52). Improved IVT triage (standard mean difference [SMD] = -0.82, 95% CI = -1.32 to -0.32), LVO bypass (SMD = -0.80, 95% CI = -1.13 to -0.47), and MSU (SMD = -0.87, 95% CI = -1.57 to -0.17) were found to significantly reduce door-to-needle time for IVT. MSU was found to significantly reduce call-to-needle (SMD = -1.41, 95% CI = -1.94 to -0.88) and onset-to-needle (SMD = -1.15, 95% CI = -1.74 to -0.56) times for IVT. MSU additionally demonstrated significant reduction in door-to-perfusion (SMD = -0.72, 95% CI = -1.32 to -0.12) as well as call-to-perfusion (SMD = -0.73, 95% CI = -1.08 to -0.38) times for EVT. Finally, PSWO did not demonstrate significant improvements in rates of good functional outcome (RR = 1.04, 95% CI = 0.97 to 1.12) or mortality at 90 days (RR = 1.00, 95% CI = 0.76 to 1.31). CONCLUSIONS This systematic review and meta-analysis found that PSWO significantly improves several time metrics related to stroke treatment leading to improvement in IVT reperfusion rates. Thus, the implementation of these measures in stroke networks is a promising avenue to improve an often-neglected aspect of the stroke response. However, the limited available data suggest functional outcomes and mortality are not significantly improved by PSWO; hence, further studies and improvement strategies vis-à-vis PSWOs are warranted.
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Affiliation(s)
- Seemub Zaman Chowdhury
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical ResearchClinical Sciences Stream Sydney New South Wales Australia
- University of New South Wales (UNSWSouth Western Sydney Clinical SchoolUNSW Medicine Sydney New South Wales Australia
| | - Prithvi Santana Baskar
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical ResearchClinical Sciences Stream Sydney New South Wales Australia
- University of New South Wales (UNSWSouth Western Sydney Clinical SchoolUNSW Medicine Sydney New South Wales Australia
| | - Sonu Bhaskar
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical ResearchClinical Sciences Stream Sydney New South Wales Australia
- University of New South Wales (UNSWSouth Western Sydney Clinical SchoolUNSW Medicine Sydney New South Wales Australia
- Department of Neurology & Neurophysiology Liverpool Hospital & South West Sydney Local Health District (SWSLHD Sydney New South Wales Australia
- Stroke & Neurology Research Group Ingham Institute for Applied Medical Research Sydney New South Wales Australia
- NSW Brain Clot BankNSW Health Statewide Biobank and NSW Health Pathology Sydney New South Wales Australia
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10
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Brown CW, Elofuke P. Multiperspective simulations for implementing a change in service: stroke telethrombolysis. BMJ SIMULATION & TECHNOLOGY ENHANCED LEARNING 2021; 7:624-626. [DOI: 10.1136/bmjstel-2020-000848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/28/2021] [Indexed: 11/04/2022]
Abstract
Simulation-based training has been used in a variety of ways to demonstrate and improve process elements of patient care. One example of this is in improving door-to-needle times in hyperacute stroke care. Changes in service by one team which affect another bring difference of opinions between service providers involved and can lead to interdepartmental conflict. In this report, we use Kurt Lewin’s model for change to describe how a series of multiperspective simulation-based exercises were used in implementing a change in practice with the introduction of telethrombolysis within a large tertiary stroke referral hospital. The use of multiperspective or bidirectional simulation allowed a ‘meeting of minds’ with each service able to illustrate key themes to the other service. This was demonstrated through a series of simulation-based exercises. Following successful simulation-based exercises and subsequent interdepartmental agreement, a telethrombolysis pilot has been conducted within our centre. Ongoing audit of practice continues as this method of treatment delivery is continued. Further simulation work is planned as a national thrombectomy service is instigated.
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11
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Polineni SP, Perez EJ, Wang K, Gutierrez CM, Walker J, Foster D, Dong C, Asdaghi N, Romano JG, Sacco RL, Rundek T. Sex and Race-Ethnic Disparities in Door-to-CT Time in Acute Ischemic Stroke: The Florida Stroke Registry. J Am Heart Assoc 2021; 10:e017543. [PMID: 33787282 PMCID: PMC8174374 DOI: 10.1161/jaha.120.017543] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Less than 40% of acute stroke patients have computed tomography (CT) imaging performed within 25 minutes of hospital arrival. We aimed to examine the race‐ethnic and sex differences in door‐to‐CT (DTCT) ≤25 minutes in the FSR (Florida Stroke Registry). Methods and Results Data were collected from 2010 to 2018 for 63 265 patients with acute ischemic stroke from the FSR and secondary analysis was performed on 15 877 patients with intravenous tissue plasminogen activator‐treated ischemic stroke. Generalized estimating equation models were used to determine predictors of DTCT ≤25. DTCT ≤25 was achieved in 56% of cases of suspected acute stroke, improving from 36% in 2010 to 72% in 2018. Women (odds ratio [OR], 0.90; 95% CI, 0.87–0.93) and Black (OR, 0.88; CI, 0.84–0.94) patients who had strokes were less likely, and Hispanic patients more likely (OR, 1.07; CI, 1.01–1.14), to achieve DTCT ≤25. In a secondary analysis among intravenous tissue plasminogen activator‐treated patients, 81% of patients achieved DTCT ≤25. In this subgroup, women were less likely to receive DTCT ≤25 (0.85, 0.77–0.94) whereas no significant differences were observed by race or ethnicity. Conclusions In the FSR, there was considerable improvement in acute stroke care metric DTCT ≤25 in 2018 in comparison to 2010. However, sex and race‐ethnic disparities persist and require further efforts to improve performance and reduce these disparities.
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Affiliation(s)
- Sai P Polineni
- Department of Neurology University of Miami Miller School of Medicine Miami FL
| | | | - Kefeng Wang
- Department of Neurology University of Miami Miller School of Medicine Miami FL
| | | | | | | | - Chuanhui Dong
- Department of Neurology University of Miami Miller School of Medicine Miami FL
| | - Negar Asdaghi
- Department of Neurology University of Miami Miller School of Medicine Miami FL
| | - Jose G Romano
- Department of Neurology University of Miami Miller School of Medicine Miami FL
| | - Ralph L Sacco
- Department of Neurology University of Miami Miller School of Medicine Miami FL
| | - Tatjana Rundek
- Department of Neurology University of Miami Miller School of Medicine Miami FL
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12
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Hasnain MG, Attia JR, Akter S, Rahman T, Hall A, Hubbard IJ, Levi CR, Paul CL. Effectiveness of interventions to improve rates of intravenous thrombolysis using behaviour change wheel functions: a systematic review and meta-analysis. Implement Sci 2020; 15:98. [PMID: 33148294 PMCID: PMC7641813 DOI: 10.1186/s13012-020-01054-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 10/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite being one of the few evidence-based treatments for acute ischemic stroke, intravenous thrombolysis has low implementation rates-mainly due to a narrow therapeutic window and the health system changes required to deliver it within the recommended time. This systematic review and meta-analyses explores the differential effectiveness of intervention strategies aimed at improving the rates of intravenous thrombolysis based on the number and type of behaviour change wheel functions employed. METHOD The following databases were searched: MEDLINE, EMBASE, PsycINFO, CINAHL and SCOPUS. Multiple authors independently completed study selection and extraction of data. The review included studies that investigated the effects of intervention strategies aimed at improving the rates of intravenous thrombolysis and/or onset-to-needle, onset-to-door and door-to-needle time for thrombolysis in patients with acute ischemic stroke. Interventions were coded according to the behaviour change wheel nomenclature. Study quality was assessed using the QualSyst scoring system for quantitative research methodologies. Random effects meta-analyses were used to examine effectiveness of interventions based on the behaviour change wheel model in improving rates of thrombolysis, while meta-regression was used to examine the association between the number of behaviour change wheel intervention strategies and intervention effectiveness. RESULTS Results from 77 studies were included. Five behaviour change wheel interventions, 'Education', 'Persuasion', 'Training', 'Environmental restructuring' and 'Enablement', were found to be employed among the included studies. Effects were similar across all intervention approaches regardless of type or number of behaviour change wheel-based strategies employed. High heterogeneity (I2 > 75%) was observed for all the pooled analyses. Publication bias was also identified. CONCLUSION There was no evidence for preferring one type of behaviour change intervention strategy, nor for including multiple strategies in improving thrombolysis rates. However, the study results should be interpreted with caution, as they display high heterogeneity and publication bias.
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Affiliation(s)
- Md Golam Hasnain
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
| | - John R. Attia
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
- John Hunter Hospital, New Lambton Heights, New South Wales Australia
| | - Shahinoor Akter
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Department of Anthropology, Jagannath University, Dhaka, Bangladesh
| | - Tabassum Rahman
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Centre for Development, Economics and Sustainability, Monash University, Melbourne, Victoria Australia
| | - Alix Hall
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
| | - Isobel J. Hubbard
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
| | - Christopher R. Levi
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, New South Wales Australia
| | - Christine L. Paul
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
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13
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Jaffe TA, Goldstein JN, Yun BJ, Etherton M, Leslie-Mazwi T, Schwamm LH, Zachrison KS. Impact of Emergency Department Crowding on Delays in Acute Stroke Care. West J Emerg Med 2020; 21:892-899. [PMID: 32726261 PMCID: PMC7390586 DOI: 10.5811/westjem.2020.5.45873] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 05/05/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction Delays in identification and treatment of acute stroke contribute to significant morbidity and mortality. Multiple clinical factors have been associated with delays in acute stroke care. We aimed to determine the relationship between emergency department (ED) crowding and the delivery of timely emergency stroke care. Methods We used prospectively collected data from our institutional Get with the Guidelines-Stroke registry to identify consecutive acute ischemic stroke patients presenting to our urban academic ED from July 2016–August 2018. We used capacity logs to determine the degree of ED crowding at the time of patients’ presentation and classified them as ordinal variables (normal, high, and severe capacity constraints). Outcomes of interest were door-to-imaging time (DIT) among patients potentially eligible for alteplase or endovascular therapy on presentation, door-to-needle time (DTN) for alteplase delivery, and door-to-groin puncture (DTP) times for endovascular therapy. Bivariate comparisons were made using t-tests, chi-square, and Wilcoxon rank-sum tests as appropriate. We used regression models to examine the relationship after accounting for patient demographics, transfer status, arrival mode, and initial stroke severity by the National Institutes of Health Stroke Scale. Results Of the 1379 patients with ischemic stroke presenting during the study period, 1081 (78%) presented at times of normal capacity, 203 (15%) during high ED crowding, and 94 (7%) during severe crowding. Median DIT was 26 minutes (interquartile range [IQR] 17–52); DTN time was 43 minutes (IQR 31–59); and median DTP was 58.5 minutes (IQR 56.5–100). Treatment times were not significantly different during periods of higher ED utilization in bivariate or in multivariable testing. Conclusion In our single institution analysis, we found no significant delays in stroke care delivery associated with increased ED crowding. This finding suggests that robust processes of care may enable continued high-quality acute care delivery, even during times with an increased capacity burden.
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Affiliation(s)
- Todd A Jaffe
- Harvard Affiliated Emergency Medicine Residency at Massachusetts General Hospital and Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Joshua N Goldstein
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Brian J Yun
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Mark Etherton
- Massachusetts General Hospital, Department of Neurology, Boston, Massachusetts
| | | | - Lee H Schwamm
- Massachusetts General Hospital, Department of Neurology, Boston, Massachusetts
| | - Kori S Zachrison
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
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14
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Hasnain MG, Paul CL, Attia JR, Ryan A, Kerr E, D'Este C, Hall A, Milton AH, Hubbard IJ, Levi CR. Door-to-needle time for thrombolysis: a secondary analysis of the TIPS cluster randomised controlled trial. BMJ Open 2019; 9:e032482. [PMID: 31843839 PMCID: PMC6924711 DOI: 10.1136/bmjopen-2019-032482] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 11/18/2019] [Accepted: 11/19/2019] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE The current study aimed to evaluate the effects of a multi-component in-hospital intervention on the door-to-needle time for intravenous thrombolysis in acute ischaemic stroke. DESIGN This study was a post hoc analysis of door-to-needle time data from a cluster-randomised controlled trial testing an intervention to boost intravenous thrombolysis implementation. SETTING The study was conducted among 20 hospitals from three Australian states. PARTICIPANT Eligible hospitals had a Stroke Care Unit or staffing equivalent to a stroke physician and a nurse, and were in the early stages of implementing thrombolysis. INTERVENTION The intervention was multifaceted and developed using the behaviour change wheel and informed by breakthrough collaborative methodology using components of the health behaviour change wheel. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome for this analysis was door-to-needle time for thrombolysis and secondary outcome was the proportion of patients received thrombolysis within 60 min of hospital arrival. RESULTS The intervention versus control difference in the door-to-needle times was non-significant overall nor significant by hospital classification. To provide additional context for the findings, we also evaluated the results within intervention and control hospitals. During the active-intervention period, the intervention hospitals showed a significant decrease in the door-to-needle time of 9.25 min (95% CI: -16.93 to 1.57), but during the post-intervention period, the result was not significant. During the active intervention period, control hospitals also showed a significant decrease in the door-to-needle time of 5.26 min (95% CI: -8.37 to -2.14) and during the post-intervention period, this trend continued with a decrease of 12.13 min (95% CI: -17.44 to 6.81). CONCLUSION Across these primary stroke care centres in Australia, a secular trend towards shorter door-to-needle times across both intervention and control hospitals was evident, however the TIPS (Thrombolysis ImPlementation in Stroke) intervention showed no overall effect on door-to-needle times in the randomised comparison. TRIAL REGISTRATION NUMBER Trial Registration-URL: http://www.anzctr.org.au/ Unique Identifier: ACTRN 12613000939796.
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Affiliation(s)
- Md Golam Hasnain
- School of Medicine and Public Health (SMPH), Faculty of Health and Medicine, University of Newcastle (UoN), Callaghan, New South Wales, Australia
| | - Christine L Paul
- School of Medicine and Public Health (SMPH), Faculty of Health and Medicine, University of Newcastle (UoN), Callaghan, New South Wales, Australia
| | - John R Attia
- School of Medicine and Public Health (SMPH), Faculty of Health and Medicine, University of Newcastle (UoN), Callaghan, New South Wales, Australia
- Hunter Medical Research Institute (HMRI), Clinical Research Design and Statistical Services, New Lambton Heights, New South Wales, Australia
| | - Annika Ryan
- School of Medicine and Public Health (SMPH), Faculty of Health and Medicine, University of Newcastle (UoN), Callaghan, New South Wales, Australia
| | - Erin Kerr
- John Hunter Hospital, Department of Neurology, New Lambton Heights, New South Wales, Australia
| | - Catherine D'Este
- School of Medicine and Public Health (SMPH), Faculty of Health and Medicine, University of Newcastle (UoN), Callaghan, New South Wales, Australia
- National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University (ANU), Acton, Australian Capital Territory, Australia
| | - Alix Hall
- Hunter Medical Research Institute (HMRI), Clinical Research Design and Statistical Services, New Lambton Heights, New South Wales, Australia
| | | | - Isobel J Hubbard
- School of Medicine and Public Health (SMPH), Faculty of Health and Medicine, University of Newcastle (UoN), Callaghan, New South Wales, Australia
| | - Christopher R Levi
- School of Medicine and Public Health (SMPH), Faculty of Health and Medicine, University of Newcastle (UoN), Callaghan, New South Wales, Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Sydney, New South Wales, Australia
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15
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Kummer BR, Lerario MP, Hunter MD, Wu X, Efraim ES, Salehi Omran S, Chen ML, Diaz IL, Sacchetti D, Lekic T, Kulick ER, Pishanidar S, Mir SA, Zhang Y, Asaeda G, Navi BB, Marshall RS, Fink ME. Geographic Analysis of Mobile Stroke Unit Treatment in a Dense Urban Area: The New York City METRONOME Registry. J Am Heart Assoc 2019; 8:e013529. [PMID: 31795824 PMCID: PMC6951069 DOI: 10.1161/jaha.119.013529] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background Mobile stroke units (MSUs) reduce time to intravenous thrombolysis in acute ischemic stroke. Whether this advantage exists in densely populated urban areas with many proximate hospitals is unclear. Methods and Results We evaluated patients from the METRONOME (Metropolitan New York Mobile Stroke) registry with suspected acute ischemic stroke who were transported by a bi-institutional MSU operating in Manhattan, New York, from October 2016 to September 2017. The comparison group included patients transported to our hospitals via conventional ambulance for acute ischemic stroke during the same hours of MSU operation (Monday to Friday, 9 am to 5 pm). Our exposure was MSU care, and our primary outcome was dispatch-to-thrombolysis time. We estimated mean differences in the primary outcome between both groups, adjusting for clinical, demographic, and geographic factors, including numbers of nearby designated stroke centers and population density. We identified 66 patients treated or transported by MSU and 19 patients transported by conventional ambulance. Patients receiving MSU care had significantly shorter dispatch-to-thrombolysis time than patients receiving conventional care (mean: 61.2 versus 91.6 minutes; P=0.001). Compared with patients receiving conventional care, patients receiving MSU care were significantly more likely to be picked up closer to a higher mean number of designated stroke centers in a 2.0-mile radius (4.8 versus 2.7, P=0.002). In multivariable analysis, MSU care was associated with a mean decrease in dispatch-to-thrombolysis time of 29.7 minutes (95% CI, 6.9-52.5) compared with conventional care. Conclusions In a densely populated urban area with a high number of intermediary stroke centers, MSU care was associated with substantially quicker time to thrombolysis compared with conventional ambulance care.
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Affiliation(s)
- Benjamin R Kummer
- Department of Neurology Icahn School of Medicine at Mount Sinai New York NY
| | - Mackenzie P Lerario
- Department of Neurology NewYork-Presbyterian Queens Flushing NY.,Department of Neurology Weill Cornell Medicine New York NY.,Clinical Translational Neuroscience Unit Feil Family Brain & Mind Research Institute Weill Cornell Medicine New York NY
| | | | - Xian Wu
- Department of Healthcare Policy and Research Weill Cornell Medicine New York NY
| | | | - Setareh Salehi Omran
- Department of Neurology Weill Cornell Medicine New York NY.,Clinical Translational Neuroscience Unit Feil Family Brain & Mind Research Institute Weill Cornell Medicine New York NY
| | - Monica L Chen
- Clinical Translational Neuroscience Unit Feil Family Brain & Mind Research Institute Weill Cornell Medicine New York NY
| | - Ivan L Diaz
- Department of Healthcare Policy and Research Weill Cornell Medicine New York NY
| | - Daniel Sacchetti
- Department of Neurology Brown Alpert School of Medicine Providence RI
| | - Tim Lekic
- Desert Neurology & Sleep La Quinta CA
| | - Erin R Kulick
- School of Public Health Brown University Providence RI
| | - Sammy Pishanidar
- Department of Neurology NewYork-Presbyterian Queens Flushing NY.,Department of Neurology Weill Cornell Medicine New York NY.,Clinical Translational Neuroscience Unit Feil Family Brain & Mind Research Institute Weill Cornell Medicine New York NY
| | - Saad A Mir
- Department of Neurology Weill Cornell Medicine New York NY.,Clinical Translational Neuroscience Unit Feil Family Brain & Mind Research Institute Weill Cornell Medicine New York NY
| | - Yi Zhang
- New York University Winthrop Hospital Mineola NY
| | | | - Babak B Navi
- Department of Neurology Weill Cornell Medicine New York NY.,Clinical Translational Neuroscience Unit Feil Family Brain & Mind Research Institute Weill Cornell Medicine New York NY
| | - Randolph S Marshall
- Department of Neurology Columbia College of Physicians & Surgeons New York NY
| | - Matthew E Fink
- Department of Neurology Weill Cornell Medicine New York NY
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16
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Scheving WL, Ebersole JM, Froehler M, Moore D, Brown-Espaillat K, Closser J, Self WH, Ward MJ. Implementation of a pilot electronic stroke outcome reporting system for emergency care providers. Am J Emerg Med 2019; 38:114-117. [PMID: 31349907 DOI: 10.1016/j.ajem.2019.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 07/10/2019] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Emergency department (ED) providers and clinicians find that feedback on acute stroke patients is rewarding, valuable to professional development, and helpful for practice improvement. However, feedback is rarely provided, particularly for patients with stroke. Here we describe the implementation of an electronic stroke outcome reporting tool for providing feedback to ED providers. METHODS We sought to evaluate the implementation of an electronic stroke outcome reporting tool at 3 Nashville hospitals. ED staff and providers voluntarily enrolled to receive de-identified reports of clinical (e.g., survival) and operational (e.g., timeliness) outcomes of patients with acute ischemic stroke and were offered free continuing education (CE) credits for following up on patients. We evaluated the implementation of this system through a descriptive evaluation of the feasibility, use of the system and CE, and perceived usefulness of the reports. RESULTS We enrolled 232 ED providers, including 107 (46%) nurses and 57 (25%) attending physicians and transmitted 55 stroke outcome reports. Reports took 30-60 min to compile and were viewed by a mean of 2.6 (SD 1.5) registered providers; 97.1% found the reports useful and 36.2% reported likelihood to change practice. Continuing education credits were initiated or claimed by 22 providers. CONCLUSIONS An electronic stroke outcome reporting tool was used and liked by ED staff and providers but the time to compile the reports is the major challenge to scalability. Future research should address the effectiveness of this reporting tool as a source of provider education and its impact on clinical and operational outcomes.
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Affiliation(s)
- William L Scheving
- Vanderbilt University School of Medicine, Nashville, TN, United States of America.
| | - Joseph M Ebersole
- Vanderbilt University School of Medicine, Nashville, TN, United States of America.
| | - Michael Froehler
- Vanderbilt University Medical Center, Department of Neurology, Nashville, TN, United States of America.
| | - Donald Moore
- Vanderbilt University Medical Center, Office of Health Sciences Education, Nashville, TN, United States of America.
| | | | - James Closser
- Vanderbilt University Medical Center, Department of Neurology, United States of America.
| | - Wesley H Self
- Vanderbilt University Medical Center, Department of Emergency Medicine, United States of America.
| | - Michael J Ward
- Vanderbilt University Medical Center, Department of Emergency Medicine, United States of America.
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17
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Koster GT, Nguyen TTM, Groot AED, Coutinho JM, Bosch J, den Hertog HM, van Walderveen MAA, Algra A, Wermer MJH, Roos YB, Kruyt ND. A Reduction in Time with Electronic Monitoring In Stroke (ARTEMIS): study protocol for a randomised multicentre trial. BMJ Open 2018; 8:e020844. [PMID: 29950465 PMCID: PMC6020955 DOI: 10.1136/bmjopen-2017-020844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Time is the most crucial factor limiting efficacy of intravenous thrombolysis (IVT) and intra-arterial thrombectomy (IAT). The delay between alarming the Emergency Medical Services (EMS) dispatch office and IVT/IAT initiation, that is, the 'total system delay' (TSD), depends on logistics and team effort. A promising method to reduce TSD is real-time audio-visual feedback to caregivers involved. With 'A Reduction in Time with Electronic Monitoring in Stroke' (ARTEMIS), we aim to investigate the effect of real-time audio-visual feedback on actual TSD to IVT/IAT to caregivers. METHODS AND ANALYSIS ARTEMIS is a multiregional, multicentre, randomised open end-point trial including patients ≥18 years considered IVT/IAT-eligible by the EMS dispatch office or on-site EMS personnel. Patients are electronically tracked and randomised for real-time audio-visual feedback on TSD to caregivers via premounted handhelds and tablets throughout the TSD trajectory. Primary outcome is TSD to IVT/IAT. Secondary outcomes comprise proportion of IVT/IAT-treated patients, symptomatic intracerebral haemorrhage, IVT/IAT-treated stroke mimics, clinical outcome after three months and cost-effectiveness. Separate analyses for IAT-patients with or without prior IVT, within or out of office hours and EMS region will be performed. With 75 IAT-patients and 225 IVT-patients in each arm, we will be able to demonstrate a 20 min difference in TSD to IAT and a 10 min difference in TSD to IVT (p=0.05 and power=0.8). ETHICS AND DISSEMINATION Study findings will be disseminated through peer-reviewed journals and (inter)national conference presentations. TRIAL REGISTRATION NUMBER NCT02808806; Pre-results.
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Affiliation(s)
- Gaia T Koster
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - T Truc My Nguyen
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Adrien E D Groot
- Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jan Bosch
- Department of Research and Development, Regional Emergency Medical Services Hollands Midden, Leiden, The Netherlands
| | - Heleen M den Hertog
- Department of Neurology, Medical Spectrum Twente, Enschede, The Netherlands
- Department of Neurology, Isala Clinics, Zwolle, the Netherlands
| | | | - Ale Algra
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Yvo B Roos
- Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
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18
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Wu TY, Coleman E, Wright SL, Mason DF, Reimers J, Duncan R, Griffiths M, Hurrell M, Dixon D, Weaver J, Meretoja A, Fink JN. Helsinki Stroke Model Is Transferrable With "Real-World" Resources and Reduced Stroke Thrombolysis Delay to 34 min in Christchurch. Front Neurol 2018; 9:290. [PMID: 29760676 PMCID: PMC5937050 DOI: 10.3389/fneur.2018.00290] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/16/2018] [Indexed: 01/01/2023] Open
Abstract
Background Christchurch hospital is a tertiary hospital in New Zealand supported by five general neurologists with after-hours services provided mainly by onsite non-neurology medical residents. We assessed the transferrability and impact of the Helsinki Stroke model on stroke thrombolysis door-to-needle time (DNT) in Christchurch hospital. Methods Key components of the Helsinki Stroke model were implemented first in 2015 with introduction of patient pre-notification and thrombolysis by the computed tomography (CT) suite, followed by implementation of direct transfer to CT on ambulance stretcher in May 2017. Data from the prospective thrombolysis registry which began in 2012 were analyzed for the impact of these interventions on median DNT. Results Between May and December 2017, 46 patients were treated with alteplase, 25 (54%) patients were treated in-hours (08:00–17:00 non-public holiday weekdays) and 21 (46%) patients were treated after-hours. The in-hours, after-hours, and overall median (interquartile range) DNTs were 34 (28–43), 47 (38–60), and 40 (30–51) minutes. The corresponding times in 2012–2014 prior to interventions were 87 (68–106), 86 (72–116), and 87 (71–112) minutes, representing median DNT reduction of 53, 39, and 47 minutes, respectively (p-values <0.01). The interventions also resulted in significant reductions in the overall median door-to-CT time (from 49 to 19 min), CT-to-needle time (32 to 20 min) and onset-to-needle time (168 to 120 min). Conclusion The Helsinki stroke model is transferrable with real-world resources and reduced stroke DNT in Christchurch by over 50%.
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Affiliation(s)
- Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Erin Coleman
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Sarah L Wright
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Deborah F Mason
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Jon Reimers
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Roderick Duncan
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Mary Griffiths
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Michael Hurrell
- Department of Radiology, Christchurch Hospital, Christchurch, New Zealand
| | - David Dixon
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - James Weaver
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - John N Fink
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
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19
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Kummer BR, Lerario MP, Navi BB, Ganzman AC, Ribaudo D, Mir SA, Pishanidar S, Lekic T, Williams O, Kamel H, Marshall RS, Hripcsak G, Elkind MSV, Fink ME. Clinical Information Systems Integration in New York City's First Mobile Stroke Unit. Appl Clin Inform 2018; 9:89-98. [PMID: 29415308 DOI: 10.1055/s-0037-1621704] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Mobile stroke units (MSUs) reduce time to thrombolytic therapy in acute ischemic stroke. These units are widely used, but the clinical information systems underlying MSU operations are understudied. OBJECTIVE The first MSU on the East Coast of the United States was established at New York Presbyterian Hospital (NYP) in October 2016. We describe our program's 7-month pilot, focusing on the integration of our hospital's clinical information systems into our MSU to support patient care and research efforts. METHODS NYP's MSU was staffed by two paramedics, one radiology technologist, and a vascular neurologist. The unit was equipped with four laptop computers and networking infrastructure enabling all staff to access the hospital intranet and clinical applications during operating hours. A telephone-based registration procedure registered patients from the field into our admit/discharge/transfer system, which interfaced with the institutional electronic health record (EHR). We developed and implemented a computerized physician order entry set in our EHR with prefilled values to permit quick ordering of medications, imaging, and laboratory testing. We also developed and implemented a structured clinician note to facilitate care documentation and clinical data extraction. RESULTS Our MSU began operating on October 3, 2016. As of April 27, 2017, the MSU transported 49 patients, of whom 16 received tissue plasminogen activator (t-PA). Zero technical problems impacting patient care were reported around registration, order entry, or intranet access. Two onboard network failures occurred, resulting in computed tomography scanner malfunctions, although no patients became ineligible for time-sensitive treatment as a result. Thirteen (26.5%) clinical notes contained at least one incomplete time field. CONCLUSION The main technical challenges encountered during the integration of our hospital's clinical information systems into our MSU were onboard network failures and incomplete clinical documentation. Future studies are necessary to determine whether such integrative efforts improve MSU care quality, and which enhancements to information systems will optimize clinical care and research efforts.
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Affiliation(s)
- Benjamin R Kummer
- Department of Biomedical Informatics, Columbia University, New York, United States.,Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, United States.,Department of Neurology, Columbia College of Physicians and Surgeons, New York, United States
| | - Michael P Lerario
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, United States.,Department of Neurology, Weill Cornell Medicine, New York, United States.,Department of Neurology, New York-Presbyterian Queens, Flushing, New York, United States
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, United States.,Department of Neurology, Weill Cornell Medicine, New York, United States
| | - Adam C Ganzman
- Department of Neurology, Weill Cornell Medicine, New York, United States
| | - Daniel Ribaudo
- Department of Emergency Medical Services, New York Presbyterian Hospital, New York, United States
| | - Saad A Mir
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, United States.,Department of Neurology, Weill Cornell Medicine, New York, United States
| | - Sammy Pishanidar
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, United States.,Department of Neurology, Weill Cornell Medicine, New York, United States
| | - Tim Lekic
- Department of Neurology, Columbia College of Physicians and Surgeons, New York, United States
| | - Olajide Williams
- Department of Neurology, Columbia College of Physicians and Surgeons, New York, United States
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, United States.,Department of Neurology, Weill Cornell Medicine, New York, United States
| | - Randolph S Marshall
- Department of Neurology, Columbia College of Physicians and Surgeons, New York, United States
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, United States
| | - Mitchell S V Elkind
- Department of Neurology, Columbia College of Physicians and Surgeons, New York, United States.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, United States
| | - Matthew E Fink
- Department of Neurology, Weill Cornell Medicine, New York, United States
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20
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Kamal N, Smith EE, Jeerakathil T, Hill MD. Thrombolysis: Improving door-to-needle times for ischemic stroke treatment - A narrative review. Int J Stroke 2017; 13:268-276. [PMID: 29140185 DOI: 10.1177/1747493017743060] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The effectiveness of thrombolysis is highly time dependent. For this reason, short target times have been set to reduce time to treatment from hospital arrival, which is called door-to-needle time. Summary of review There has been considerable work done at single centers and across multiple hospitals to improve door-to-needle time. There have been reductions of 8 to 47 min when applying one or more improvement strategies at single centers, and there have been many multi-hospital initiatives. The delays to treatment have been attributed to both patient and hospital factors, and strategies to address these delays have been proven to reduce door-to-needle time. The most effective strategies include pre-notification of arrival by Emergency Medical Services (EMS), single-call activation of stroke team, rapid registration process, moving the patient to computed tomography on EMS stretcher, and administration of alteplase in the scanner. There are many exciting areas of future direction including reduction of door-to-needle time in developing countries, improving pre-hospital response times, and improving the efficiency of endovascular treatment. Conclusions There is now a broad understanding of the causes of delays to fast treatment and the strategies that can be employed to improve door-to-needle time such that most centers could achieve median door-to-needle time of 30 min.
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Affiliation(s)
- Noreen Kamal
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Eric E Smith
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,2 Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | | | - Michael D Hill
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,2 Department of Community Health Sciences, University of Calgary, Calgary, Canada.,4 Department of Medicine, University of Calgary, Calgary, Canada.,5 Department of Radiology, University of Calgary, Calgary, Canada
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21
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Positive impact of the participation in the ENCHANTED trial in reducing Door-to-Needle Time. Sci Rep 2017; 7:14168. [PMID: 29074964 PMCID: PMC5658430 DOI: 10.1038/s41598-017-14164-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/05/2017] [Indexed: 11/09/2022] Open
Abstract
Door-to-needle time (DNT) is a key performance indicator for efficient use of intravenous thrombolysis in acute ischemic stroke (AIS). We aimed to determine whether DNT improved over time in the Enhanced Control of Hypertension and Acute Stroke Study (ENCHANTED) and the clinical predictors of DNT. Temporal trends in DNT were assessed across fourths of time since activation of study centers using generalized linear model. Predictors of long DNT (>60 min) were determined in logistic regression models. Overall mean DNT (min) was 71.8 (95% confidence interval [CI] 70.4–73.2), but decreased significantly over time (fourths): 77.9 (74.9–80.9), 69.3 (66.7–72.0), 69.1 (66.5–71.8) and 71.4 (68.7–74.2) (P for trend, 0.003). The reduction in DNT was particularly marked in China (P for trend, 0.001), but was not significant across the other participating countries (P for trend, 0.065). Independent predictors of long DNT were recruitment from China, short onset-to-door time, lower numbers of patients treated per center, higher diastolic blood pressure, off-hour admission, and absence of proximal clot occlusion. DNT in ENCHANTED declined progressively during the trial, especially in China. However, DNT in China is still longer than the key performance parameter of ≤60 minutes recommended in guidelines. Effective national programs are needed to improve DNT in China.
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22
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Length of stay in emergency department and cerebral intravenous thrombolysis in community hospitals. Eur J Emerg Med 2017; 24:208-216. [DOI: 10.1097/mej.0000000000000330] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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Ruff IM, Liberman AL, Caprio FZ, Maas MB, Mendelson SJ, Sorond FA, Bergman D, Bernstein RA, Curran Y, Prabhakaran S. A resident boot camp for reducing door-to-needle times at academic medical centers. Neurol Clin Pract 2017; 7:237-245. [PMID: 28680767 DOI: 10.1212/cpj.0000000000000367] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 03/01/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND We sought to determine if a structured educational program for neurology residents can lower door-to-needle (DTN) times at an academic institution. METHODS A neurology resident educational stroke boot camp was developed and implemented in April 2013. Using a prospective database of 170 consecutive acute ischemic stroke (AIS) patients treated with IV tissue plasminogen activator (tPA) in our emergency department (ED), we evaluated the effect of the intervention on DTN times. We compared DTN times and other process measures preintervention and postintervention. p Values < 0.05 were considered significant. RESULTS The proportion of AIS patients treated with tPA within 60 minutes of arrival to our ED tripled from 18.1% preintervention to 61.2% postintervention (p < 0.001) with concomitant reduction in DTN time (median 79 minutes vs 58 minutes, p < 0.001). The resident-delegated task (stroke code to tPA) was reduced (75 minutes vs 44 minutes, p < 0.001), while there was no difference in ED-delegated tasks (door to stroke code [7 minutes vs 6 minutes, p = 0.631], door to CT [18 minutes in both groups, p = 0.547]). There was an increase in stroke mimics treated (6.9% vs 18.4%, p = 0.031), which did not lead to an increase in adverse outcomes. CONCLUSIONS DTN times were reduced after the implementation of a stroke boot camp and were driven primarily by efficient resident stroke code management. Educational programs should be developed for health care providers involved in acute stroke patient care to improve rapid access to IV tPA at academic institutions.
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Affiliation(s)
- Ilana M Ruff
- Northwestern University (IMR, FZC, MBM, SJM, FAS, DB, RAB, YC, SP), Evanston, IL; and Albert Einstein College of Medicine (ALL), Bronx, NY
| | - Ava L Liberman
- Northwestern University (IMR, FZC, MBM, SJM, FAS, DB, RAB, YC, SP), Evanston, IL; and Albert Einstein College of Medicine (ALL), Bronx, NY
| | - Fan Z Caprio
- Northwestern University (IMR, FZC, MBM, SJM, FAS, DB, RAB, YC, SP), Evanston, IL; and Albert Einstein College of Medicine (ALL), Bronx, NY
| | - Matthew B Maas
- Northwestern University (IMR, FZC, MBM, SJM, FAS, DB, RAB, YC, SP), Evanston, IL; and Albert Einstein College of Medicine (ALL), Bronx, NY
| | - Scott J Mendelson
- Northwestern University (IMR, FZC, MBM, SJM, FAS, DB, RAB, YC, SP), Evanston, IL; and Albert Einstein College of Medicine (ALL), Bronx, NY
| | - Farzaneh A Sorond
- Northwestern University (IMR, FZC, MBM, SJM, FAS, DB, RAB, YC, SP), Evanston, IL; and Albert Einstein College of Medicine (ALL), Bronx, NY
| | - Deborah Bergman
- Northwestern University (IMR, FZC, MBM, SJM, FAS, DB, RAB, YC, SP), Evanston, IL; and Albert Einstein College of Medicine (ALL), Bronx, NY
| | - Richard A Bernstein
- Northwestern University (IMR, FZC, MBM, SJM, FAS, DB, RAB, YC, SP), Evanston, IL; and Albert Einstein College of Medicine (ALL), Bronx, NY
| | - Yvonne Curran
- Northwestern University (IMR, FZC, MBM, SJM, FAS, DB, RAB, YC, SP), Evanston, IL; and Albert Einstein College of Medicine (ALL), Bronx, NY
| | - Shyam Prabhakaran
- Northwestern University (IMR, FZC, MBM, SJM, FAS, DB, RAB, YC, SP), Evanston, IL; and Albert Einstein College of Medicine (ALL), Bronx, NY
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24
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Hillen ME, He W, Al-Qudah Z, Wang W, Hidalgo A, Walia J. Long-Term Impact of Implementation of a Stroke Protocol on Door-to-Needle Time in the Administration of Intravenous Tissue Plasminogen Activator. J Stroke Cerebrovasc Dis 2017; 26:1569-1572. [PMID: 28411038 DOI: 10.1016/j.jstrokecerebrovasdis.2016.07.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 02/03/2016] [Accepted: 07/05/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND This study aims to evaluate the effectiveness of implementing a stroke protocol (SP) in improving door-to-needle time (DTNT) and door-to-computed tomography (DTCT) time from 2010 to 2014. Published data from the Get With The Guidelines-Stroke (GWTGS) participating hospitals showed that median DTNT = 75 minutes with 26.6% of the patients achieving the recommended DTNT of 60 minutes or less. Implementation of an SP, which specifies the role of nurses, physicians, and technicians during acute stroke evaluation, can improve DTNT. METHODS This longitudinal quality assurance study was designed to compare the DTNT and the DTCT time pre- and post implementation of an SP in our hospital. Patients' data before (2009-2010) and after (2010-2014) the implementation of an SP were collected each year during the same 6-month period and compared using statistical software SPSS 20.0 for Windows (SPSS Inc., Chicago, IL). RESULTS Although our DTNT did not significantly improve over the years, the median DTNT (59 minutes) was much less than the reported 75 minutes of GWTGS hospitals. Our DTCT time diminished from 20.6 minutes in 2009 to 15.9 minutes in 2014. The percentage of patients with a DTNT of 1 hour or less did not differ among all years (P = .296) and was 55.8%. CONCLUSIONS Our study suggests that our performance in evaluating acute ischemic stroke patients within the American Heart Association/American Stroke Association suggested time window is reachable for prolonged periods of time. Continuous monitoring and education of all players involved are crucial to ensure best possible outcomes in the timely administration of intravenous tissue plasminogen activator.
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Affiliation(s)
- Machteld E Hillen
- Department of Neurology, Rutgers New Jersey Medical School, Newark, NJ.
| | | | | | - Weizhen Wang
- VA New Jersey Healthcare System, East Orange, NJ
| | - Andrea Hidalgo
- Department of Neurology, Rutgers New Jersey Medical School, Newark, NJ
| | - Jessy Walia
- Department of Neurology, Rutgers New Jersey Medical School, Newark, NJ
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25
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Rostanski SK, Stillman JI, Schaff LR, Perdomo CA, Liberman AL, Miller EC, Marshall RS, Willey JZ, Williams O. E-Mail Is an Effective Tool for Rapid Feedback in Acute Stroke. Neurohospitalist 2017; 7:159-163. [PMID: 28974993 DOI: 10.1177/1941874416689358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether e-mail is a useful mechanism to provide prompt, case-specific data feedback and improve door-to-needle (DTN) time for acute ischemic stroke treated with intravenous tissue plasminogen activator (IV-tPA) in the emergency department (ED) at a high-volume academic stroke center. METHODS We instituted a quality improvement project at Columbia University Medical Center where clinical details are shared via e-mail with the entire treatment team after every case of IV-tPA administration in the ED. Door-to-needle and component times were compared between the prefeedback (January 2013 to March 2015) and postfeedback intervention (April 2015 to June 2016) periods. RESULTS A total of 273 cases were included in this analysis, 102 (37%) in the postintervention period. Median door-to-stroke code activation (2 vs 0 minutes, P < .01), door-to-CT Scan (21 vs 18 minutes, P < .01), and DTN (54 vs 49 minutes, P = .17) times were shorter in the postintervention period, although the latter did not reach statistical significance. The proportion of cases with the fastest DTN (≤45 minutes) was higher in the postintervention period (29.2% vs 42.2%, P = .03). CONCLUSION E-mail is a simple and effective tool to provide rapid feedback and promote interdisciplinary communication to improve acute stroke care in the ED.
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Affiliation(s)
- Sara K Rostanski
- Department of Neurology, Columbia University Medical Center, New York, NY, USA.,Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Joshua I Stillman
- Department of Emergency Medicine, Columbia University Medical Center, New York, NY, USA
| | - Lauren R Schaff
- Department of Neurology, Columbia University Medical Center, New York, NY, USA.,Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Crismely A Perdomo
- Department of Neurology, Columbia University Medical Center, New York, NY, USA.,Department of Neurology, New York-Presbyterian Hospital, New York, NY, USA
| | - Ava L Liberman
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eliza C Miller
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Randolph S Marshall
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Joshua Z Willey
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Olajide Williams
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
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26
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Reznek MA, Murray E, Youngren MN, Durham NT, Michael SS. Door-to-Imaging Time for Acute Stroke Patients Is Adversely Affected by Emergency Department Crowding. Stroke 2017; 48:49-54. [DOI: 10.1161/strokeaha.116.015131] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 09/25/2016] [Accepted: 10/10/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
National guidelines call for door-to-imaging time (DIT) within 25 minutes for suspected acute stroke patients. Studies examining factors that affect DIT have focused primarily on stroke-specific care processes and patient-specific factors. We hypothesized that emergency department (ED) crowding is associated with longer DIT.
Methods—
We conducted a retrospective investigation of 1 year of consecutive patients in our prospective Code Stroke registry, which included all ED stroke team activations. The registry and electronic health records were abstracted for 27 potential predictors of DIT, including patient, stroke care process, and ED operational factors. We fit a multivariate logistic regression model and calculated odds ratios and 95% confidence intervals. Second, we constructed a random forest recursive partitioning model to cross-validate our findings and explore the proportional importance of each category of predictor. Our primary outcome was the binary variable of DIT within the 25-minute goal.
Results—
A total of 463 patients met inclusion criteria. In the regression model, ED occupancy rate emerged as a predictor of DIT, with odds ratio of 0.83 (95% confidence interval, 0.75–0.91) of DIT within 25 minutes per 10% absolute increase in ED occupancy rate. The secondary analysis estimated that ED operational factors accounted for nearly 14% of the algorithm’s prediction of DIT.
Conclusions—
ED crowding is associated with reduced odds of meeting DIT goals for acute stroke. In addition to improving stroke-specific processes of care, efforts to reduce ED overcrowding should be considered central to optimizing the timeliness of acute stroke care.
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Affiliation(s)
- Martin A. Reznek
- From the Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA (M.A.R, E.M., S.S.M., M.N.Y); and CVS Health, Woonsocket, RI (N.T.D.)
| | - Evangelia Murray
- From the Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA (M.A.R, E.M., S.S.M., M.N.Y); and CVS Health, Woonsocket, RI (N.T.D.)
| | - Marguerite N. Youngren
- From the Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA (M.A.R, E.M., S.S.M., M.N.Y); and CVS Health, Woonsocket, RI (N.T.D.)
| | - Natassia T. Durham
- From the Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA (M.A.R, E.M., S.S.M., M.N.Y); and CVS Health, Woonsocket, RI (N.T.D.)
| | - Sean S. Michael
- From the Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA (M.A.R, E.M., S.S.M., M.N.Y); and CVS Health, Woonsocket, RI (N.T.D.)
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27
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Feasibility and Efficacy of Nurse-Driven Acute Stroke Care. J Stroke Cerebrovasc Dis 2016; 26:987-991. [PMID: 28012837 DOI: 10.1016/j.jstrokecerebrovasdis.2016.11.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 11/07/2016] [Accepted: 11/09/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Acute stroke care requires rapid assessment and intervention. Replacing traditional sequential algorithms in stroke care with parallel processing using telestroke consultation could be useful in the management of acute stroke patients. The purpose of this study was to assess the feasibility of a nurse-driven acute stroke protocol using a parallel processing model. METHODS This is a prospective, nonrandomized, feasibility study of a quality improvement initiative. Stroke team members had a 1-month training phase, and then the protocol was implemented for 6 months and data were collected on a "run-sheet." The primary outcome of this study was to determine if a nurse-driven acute stroke protocol is feasible and assists in decreasing door to needle (intravenous tissue plasminogen activator [IV-tPA]) times. RESULTS Of the 153 stroke patients seen during the protocol implementation phase, 57 were designated as "level 1" (symptom onset <4.5 hours) strokes requiring acute stroke management. Among these strokes, 78% were nurse-driven, and 75% of the telestroke encounters were also nurse-driven. The average door to computerized tomography time was significantly reduced in nurse-driven codes (38.9 minutes versus 24.4 minutes; P < .04). CONCLUSIONS The use of a nurse-driven protocol is feasible and effective. When used in conjunction with a telestroke specialist, it may be of value in improving patient outcomes by decreasing the time for door to decision for IV-tPA.
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28
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Thrombolysis in Stroke within 30 Minutes: Results of the Acute Brain Care Intervention Study. PLoS One 2016; 11:e0166668. [PMID: 27861540 PMCID: PMC5115772 DOI: 10.1371/journal.pone.0166668] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 11/02/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND AND PURPOSE Time is brain: benefits of intravenous thrombolysis (IVT) in ischemic stroke last for 4.5 hours but rapidly decrease as time progresses following symptom onset. The goal of the Acute Brain Care (ABC) intervention study was to reduce the door-to-needle time (DNT) to ≤30 minutes by optimizing in-hospital stroke treatment. METHODS We performed a single-centre before (pre-intervention period: 2000-2005) versus after (post-intervention period: 2006-2012) comparison in a cohort of consecutive patients treated with IVT. The intervention consisted of the implementation of a multidisciplinary stroke protocol combining simple strategies to reduce the DNT. Primary endpoint was the DNT, presented as proportion ≤30 minutes and median time. Secondary clinical endpoints were symptomatic intracranial hemorrhage (SICH), and favourable outcome defined as a modified Rankin scale (mRs) score of 0-2 at 3 months. Endpoints were additionally adjusted for baseline imbalances between the groups. RESULTS In the pre-intervention period, none (0.0%) of the 100 patients (mean age 63.8 years, median National Institutes of Health Stroke Scale [NIHSS] score 14) treated with IVT had a DNT ≤30 minutes compared to 234 (62.7%) of the 373 patients (mean age 66.7 years, median NIHSS score 10) in the post-intervention period (p<0.001). The median DNT decreased from 75 (IQR 60-105) to 28 minutes (IQR 20-37, p<0.001). SICH rate remained stable (3.0% versus 4.4%, OR 1.50, 95% CI 0.43─5.25; adjusted OR 5.47, 95% CI 0.69-42.12). The proportion of patients with a favourable outcome increased (38.9% versus 52.3%, OR 1.72, 95% CI 1.09-2.73) but lost statistical significance after adjustment (adjusted OR 1.46, 95% CI 0.82-2.61). CONCLUSIONS Important and sustained reduction of the DNT to 30 minutes or less can be safely achieved by optimizing in-hospital stroke treatment. With its simple strategies, the ABC-protocol is a pragmatic framework for increasing the therapeutic yield in time-dependent stroke treatment.
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Prabhakaran S, Lee J, O'Neill K. Regional Learning Collaboratives Produce Rapid and Sustainable Improvements in Stroke Thrombolysis Times. Circ Cardiovasc Qual Outcomes 2016; 9:585-92. [PMID: 27625405 DOI: 10.1161/circoutcomes.116.003222] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 08/17/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Reduction in door-to-needle (DTN) times in patients with acute ischemic stroke treated with tissue-type plasminogen activator is associated with improved outcomes. We hypothesized that a learning collaborative would rapidly reduce DTN times at Chicago's primary stroke centers. METHODS AND RESULTS We analyzed data from all adult patients with out-of-hospital ischemic stroke hospitalized between January 1, 2010 and March 31, 2015 and who received tissue-type plasminogen activator in the emergency department at 15 primary stroke centers in Chicago and 15 primary stroke centers in St. Louis. We implemented a structured learning collaborative in Chicago in quarter 1 of 2013 that included (1) a quality improvement leader, (2) stroke content expert, (3) multidisciplinary teams from each site, (4) a targeted goal for the program (DTN time <60 minutes in >50% of patients treated with tissue-type plasminogen activator), and (5) face-to-face meetings with on-site visits. We used interrupted time-series analysis to compare the impact of the learning collaborative on DTN times in Chicago pre- and post implementation and also concurrently versus St. Louis. We prespecified adjustment for mode of arrival, emergency medical services prenotification, and onset-to-arrival times. P values less than 0.05 were considered significant. In adjusted analysis, the reduction in DTN time within 1 quarter of implementation was 15.5 minutes (P=0.046) at Chicago sites versus 1.17 minutes at St. Louis sites (P=0.601). CONCLUSIONS Using a learning collaborative model at Chicago's 15 primary stroke centers, we observed major reductions in DTN times within 1 quarter of implementation. Regional collaboration and best practices sharing should be a model for rapid and sustainable system-wide quality improvement.
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Affiliation(s)
- Shyam Prabhakaran
- From the Departments of Neurology (S.P.) and Preventive Medicine-Biostatistics (J.L.), Northwestern University Feinberg School of Medicine, Chicago, IL; and American Heart Association/American Stroke Association Midwest Affiliate, Chicago, IL (K.O.N.).
| | - Jungwha Lee
- From the Departments of Neurology (S.P.) and Preventive Medicine-Biostatistics (J.L.), Northwestern University Feinberg School of Medicine, Chicago, IL; and American Heart Association/American Stroke Association Midwest Affiliate, Chicago, IL (K.O.N.)
| | - Kathleen O'Neill
- From the Departments of Neurology (S.P.) and Preventive Medicine-Biostatistics (J.L.), Northwestern University Feinberg School of Medicine, Chicago, IL; and American Heart Association/American Stroke Association Midwest Affiliate, Chicago, IL (K.O.N.)
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Marto JP, Borbinha C, Calado S, Viana-Baptista M. The Stroke Chronometer—A New Strategy to Reduce Door-to-Needle Time. J Stroke Cerebrovasc Dis 2016; 25:2305-7. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.05.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/08/2016] [Accepted: 05/17/2016] [Indexed: 11/29/2022] Open
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Pidaparthi L, Kotha A, Aleti VR, Kohat AK, Kandadai MR, Turaga S, Shaik JA, Alladi S, Kanikannan MA, Rupam B, Kaul S. Factors influencing nonadministration of thrombolytic therapy in early arrival strokes in a university hospital in Hyderabad, India. Ann Indian Acad Neurol 2016; 19:351-5. [PMID: 27570387 PMCID: PMC4980958 DOI: 10.4103/0972-2327.179976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND It is a well-known fact that very few patients of stroke arrive at the hospital within the window period of thrombolysis. Even among those who do, not all receive thrombolytic therapy. OBJECTIVE The objectives of this study were to determine the proportion of early arrival ischemic strokes (within 6 h of stroke onset) in our hospital and to evaluate the causes of nonadministration of intravenous and/or intraarterial thrombolysis in them. MATERIALS AND METHODS Data of all early arrival acute stroke patients between January 2010 and January 2015 were included. Factors determining nonadministration of intravenous and/or intraarterial thrombolysis in early arrival strokes were analyzed. RESULTS Out of 2,593 stroke patients, only 145 (5.6%) patients presented within 6 h of stroke onset and among them 118 (81.4%) patients had ischemic stroke and 27 (18.6%) patients had hemorrhagic stroke. A total of 89/118 (75.4%) patients were thrombolyzed. The reasons for nonadministration of thrombolysis in the remaining 29 patients were analyzed, which included unavoidable factors in 8/29 patients [massive infarct (N = 4), hemorrhagic infarct (N = 1), gastrointestinal bleed (N = 1), oral anticoagulant usage with prolonged international normalized ratio (INR) (N = 1), and recent cataract surgery (N = 1)]. Avoidable factors were found for 21/29 patients, include nonaffordability (N = 7), fear of bleed (N = 4), rapidly improving symptoms (N = 4), mild stroke (N = 2), delayed neurologist referral within the hospital (N = 2), and logistic difficulty in organizing endovascular treatment (N = 2). CONCLUSION One-fourth of early ischemic stroke patients in our study were not thrombolyzed even though they arrived within the window period. The majority of the reasons for nonadministration of thrombolysis were potentially preventable, such as nonaffordability, intrahospital delay, and nonavailability of newer endovascular interventions.
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Affiliation(s)
- Lalitha Pidaparthi
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Anitha Kotha
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Venkat Reddy Aleti
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Abhijeet Kumar Kohat
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Mridula R Kandadai
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Suryaprabha Turaga
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Jabeen A Shaik
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Suvarna Alladi
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Meena A Kanikannan
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Borgohain Rupam
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Subhash Kaul
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
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Schwamm LH, Jaff MR, Dyer KS, Gonzalez RG, Huck AE. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 13-2016. A 49-Year-Old Woman with Sudden Hemiplegia and Aphasia during a Transatlantic Flight. N Engl J Med 2016; 374:1671-80. [PMID: 27119240 DOI: 10.1056/nejmcpc1501151] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Lee H Schwamm
- From the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Massachusetts General Hospital, the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Harvard Medical School, and the Department of Emergency Medicine, Boston Medical Center, and the Department of Emergency Medicine, Boston University School of Medicine (K.S.D.) - all in Boston
| | - Michael R Jaff
- From the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Massachusetts General Hospital, the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Harvard Medical School, and the Department of Emergency Medicine, Boston Medical Center, and the Department of Emergency Medicine, Boston University School of Medicine (K.S.D.) - all in Boston
| | - K Sophia Dyer
- From the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Massachusetts General Hospital, the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Harvard Medical School, and the Department of Emergency Medicine, Boston Medical Center, and the Department of Emergency Medicine, Boston University School of Medicine (K.S.D.) - all in Boston
| | - R Gilberto Gonzalez
- From the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Massachusetts General Hospital, the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Harvard Medical School, and the Department of Emergency Medicine, Boston Medical Center, and the Department of Emergency Medicine, Boston University School of Medicine (K.S.D.) - all in Boston
| | - Amelia E Huck
- From the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Massachusetts General Hospital, the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Harvard Medical School, and the Department of Emergency Medicine, Boston Medical Center, and the Department of Emergency Medicine, Boston University School of Medicine (K.S.D.) - all in Boston
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Burton KR, Kapral MK, Li S, Fang J, Moody AR, Krahn M, Laupacis A. Predictors of diagnostic neuroimaging delays among adults presenting with symptoms suggestive of acute stroke in Ontario: a prospective cohort study. CMAJ Open 2016; 4:E331-7. [PMID: 27398382 PMCID: PMC4933639 DOI: 10.9778/cmajo.20150110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many studies have examined the timeliness of thrombolysis for acute ischemic stroke, but less is known about door-to-imaging time. We conducted a prospective cohort study to assess the timing of neuroimaging among patients with suspected acute stroke in the province of Ontario, Canada, and to examine factors associated with delays in neuroimaging. METHODS We included all patients 18 years and older with suspected acute stroke seen at hospitals with neuroimaging capacity within the Ontario Stroke Registry between Apr. 1, 2010, and Mar. 31, 2011. We used a hierarchical, multivariable Cox proportional hazards model to evaluate the association between patient and hospital factors and the likelihood of receiving timely neuroimaging (≤ 25 min) after arrival in the emergency department. RESULTS A total of 13 250 patients presented to an emergency department with stroke-like symptoms during the study period. Of the 3984 who arrived within 4 hours after symptom onset, 1087 (27.3%) had timely neuroimaging. The factors independently associated with an increased likelihood of timely neuroimaging were less time from symptom onset to presentation, more severe stroke, male sex, no history of stroke or transient ischemic attack, arrival to hospital from a setting other than home and presentation to a designated stroke centre or an urban hospital. INTERPRETATION A minority of patients with stroke-like symptoms who presented within the 4-hour thrombolytic treatment window received timely neuroimaging. Neuroimaging delays were influenced by various patient and hospital factors, some of which are modifiable.
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Affiliation(s)
- Kirsteen R Burton
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
| | - Moira K Kapral
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
| | - Shudong Li
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
| | - Jiming Fang
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
| | - Alan R Moody
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
| | - Murray Krahn
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
| | - Andreas Laupacis
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
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Moran JL, Nakagawa K, Asai SM, Koenig MA. 24/7 Neurocritical Care Nurse Practitioner Coverage Reduced Door-to-Needle Time in Stroke Patients Treated with Tissue Plasminogen Activator. J Stroke Cerebrovasc Dis 2016; 25:1148-1152. [PMID: 26907680 DOI: 10.1016/j.jstrokecerebrovasdis.2016.01.033] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 01/10/2016] [Accepted: 01/21/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Stroke centers with limited on-site neurovascular physician coverage may experience delays in acute stroke treatment. We sought to assess the impact of providing 24/7 neurocritical care acute care nurse practitioner (ACNP) "stroke code" first responder coverage on treatment delays in acute stroke patients who received tissue plasminogen activator (tPA). METHODS Consecutive acute ischemic stroke patients treated with intravenous tPA at a primary stroke center on Oahu between 2009 and 2014were retrospectively studied. 24/7 ACNP stroke code coverage (intervention) was introduced on July 1, 2011. The tPA utilization, door-to-needle (DTN) time, imaging-to-needle (ITN) time, and independent ambulation at hospital discharge were compared between the preintervention period (24 months) and the postintervention period (33 months). RESULTS We studied 166 stroke code patients who were treated with intravenous tPA, 44 of whom were treated during the preintervention period and 122 of whom were treated during the postintervention period. After the intervention, the median DTN time was reduced from 53 minutes (interquartile range [IQR] 45-73) to 45 minutes (IQR 35-58) (P = .001), and the median ITN time was reduced from 36 minutes (IQR 28-64) to 21 minutes (IQR 16-31) (P < .0001). Compliance with the 60-minute target DTN improved from 61.4% (27 of 44 patients) in the preintervention period to 81.2% (99 of 122 patients) in the postintervention period (P = .004). The tPA treatment rates were similar between the preintervention and postintervention periods (P = .60). CONCLUSIONS Addition of 24/7 on-site neurocritical care ACNP first responder coverage for acute stroke code significantly reduced the DTN time among acute stroke patients treated with tPA.
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Affiliation(s)
- Jennifer L Moran
- The Queen's Medical Center, Neuroscience Institute, Honolulu, Hawaii
| | - Kazuma Nakagawa
- The Queen's Medical Center, Neuroscience Institute, Honolulu, Hawaii; Department of Medicine, The University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii
| | - Susan M Asai
- The Queen's Medical Center, Neuroscience Institute, Honolulu, Hawaii
| | - Matthew A Koenig
- The Queen's Medical Center, Neuroscience Institute, Honolulu, Hawaii; Department of Medicine, The University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii.
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Abstract
There has been a tremendous evolution in the stroke systems of care in the USA. Public awareness, prehospital care, and in-hospital protocols have never been so effectively connected. However, given the critical role of time to effective reperfusion in the setting of acute ischemic stroke, it is vital and timely to implement strategies to further streamline emergency stroke care. This article reviews the most current standards and guidelines related to the flow of stroke care in the prehospital and emergency settings.
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Affiliation(s)
- Keith G DeSousa
- Department of Neurology, University of Miami Miller School of Medicine, 1120 NW 14th St, CRB 13th Floor, Miami, FL, 33136, USA,
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Chen CH, Tang SC, Tsai LK, Hsieh MJ, Yeh SJ, Huang KY, Jeng JS. Stroke code improves intravenous thrombolysis administration in acute ischemic stroke. PLoS One 2014; 9:e104862. [PMID: 25111200 PMCID: PMC4128738 DOI: 10.1371/journal.pone.0104862] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 07/12/2014] [Indexed: 11/18/2022] Open
Abstract
Background and Purpose Timely intravenous (IV) thrombolysis for acute ischemic stroke is associated with better clinical outcomes. Acute stroke care implemented with “Stroke Code” (SC) may increase IV tissue plasminogen activator (tPA) administration. The present study aimed to investigate the impact of SC on thrombolysis. Methods The study period was divided into the “pre-SC era” (January 2006 to July 2010) and “SC era” (August 2010 to July 2013). Demographics, critical times (stroke symptom onset, presentation to the emergency department, neuroimaging, thrombolysis), stroke severity, and clinical outcomes were recorded and compared between the two eras. Results During the study period, 5957 patients with acute ischemic stroke were admitted; of these, 1301 (21.8%) arrived at the emergency department within 3 h of stroke onset and 307 (5.2%) received IV-tPA. The number and frequency of IV-tPA treatments for patients with an onset-to-door time of <3 h increased from the pre-SC era (n = 91, 13.9%) to the SC era (n = 216, 33.3%) (P<0.001). SC also improved the efficiency of IV-tPA administration; the median door-to-needle time decreased (88 to 51 min, P<0.001) and the percentage of door-to-needle times ≤60 min increased (14.3% to 71.3%, P<0.001). The SC era group tended to have more patients with good outcome (modified Rankin Scale ≤2) at discharge (49.5 vs. 39.6%, P = 0.11), with no difference in symptomatic hemorrhage events or in-hospital mortality. Conclusion The SC protocol increases the percentage of acute ischemic stroke patients receiving IV-tPA and decreases door-to-needle time.
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Affiliation(s)
- Chih-Hao Chen
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
- Division of Neurology, Department of Internal Medicine, Far-Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Shin-Joe Yeh
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuang-Yu Huang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
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