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Liao Y, Qi W, Li S, Shi X, Wu X, Chi F, Xia R, Qin L, Cao L, Ren L. Analysis of onset-to-door time and its influencing factors in Chinese patients with acute ischemic stroke during the 2020 COVID-19 epidemic: a preliminary, prospective, multicenter study. BMC Health Serv Res 2024; 24:615. [PMID: 38730381 PMCID: PMC11084012 DOI: 10.1186/s12913-024-11088-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 05/08/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Pre-hospital delay in China is a serious issue with unclear relevant reasons, seriously impeding the adoption of appropriate measures. Herein, we analyzed the onset-to-door time (ODT) in Chinese patients with acute ischemic stroke (AIS) and its influencing factors. METHODS We prospectively recruited 3,459 patients with AIS from nine representative tertiary general hospitals in China between January and June 2022. Patients were divided into ODT ≤ 3 h and ODT > 3 h groups. Following single-factor analysis, binary logistic regression analysis was performed to evaluate the risk factors leading to pre-hospital delay. RESULTS In total, 763 (21.83%) patients arrived at the hospital within 3 h of onset. After adjusting for confounding factors, the risk factors for ODT were residence in rural areas (odds ratio [OR]: 1.478, 95% credibility interval [CI]: 1.024-2.146) and hospital transfer (OR: 7.479, 95% CI: 2.548-32.337). The protective factors for ODT were location of onset ≤ 20 km from the first-visit hospital (OR: 0.355, 95% CI: 0.236-0.530), transportation by emergency medical services (OR: 0.346, 95% CI: 0.216-0.555), history of atrial fibrillation (OR: 0.375, 95% CI: 0.207-0.679), moderate stroke (OR: 0.644, 95% CI: 0.462-0.901), and severe stroke (OR: 0.506, 95% CI: 0.285-0.908). CONCLUSIONS Most patients with AIS fail to reach a hospital within the critical 3-h window. The following measures are recommended to reduce pre-hospital delays: reasonable distribution of hospitals accessible to nearby residents, minimizing interhospital transfer, paying attention to patients with mild stroke, and encouraging patients to use ambulance services. Pre-hospital delays for patients can be reduced by implementing these measures, ultimately improving the timeliness of treatment and enhancing patient prognosis. This study was carried out amid the COVID-19 pandemic, which presented challenges and constraints.
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Affiliation(s)
- Yuqi Liao
- School of Medicine, Shenzhen University, Shenzhen, China
| | - Wenwei Qi
- National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuting Li
- School of Statistics, Shandong Technology and Business University, Yantai, China
| | - Xin Shi
- School of Statistics, Shandong Technology and Business University, Yantai, China
- School of Health Management, China Medical University, Shenyang, China
| | - Xiaohong Wu
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Feng Chi
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Runyu Xia
- School of Medicine, Shenzhen University, Shenzhen, China
| | - Limin Qin
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Liming Cao
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China.
- Hunan Provincial Key Laboratory of the Research and Development of Novel Pharmaceutical Preparations, Changsha Medical University, Changsha, China.
| | - Lijie Ren
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
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Rose SD, Lubner MG, Heil J, Greenwood GM, Szczykutowicz TP. Electrocardiographic Gating and Cerebral Perfusion Computed Tomography Option-Set Prevalence and Utilization Data From 62 Institutions in the United States. J Comput Assist Tomogr 2023; 47:315-321. [PMID: 36728742 DOI: 10.1097/rct.0000000000001412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To provide the radiology community with data to address the question: "Compared with peer institutions, is my institution efficiently using its electrocardiographic (ECG) gating and cerebral perfusion-capable computed tomography (CT) scanners?" METHODS In this retrospective study, we analyze 6 months of scanner utilization data from 62 institutions (299 locations, 507 scanners) to identify scanners capable of performing ECG gating and perfusion CT studies. We report the number of ECG gating/perfusion-capable scanners and locations as a function of the total number of locations and scanners in each institution. We additionally regress the number of ECG-gated and perfusion examinations on (1) the number of locations/scanners capable of performing these examinations and (2) the fraction of the institution's CT examination volume that requires ECG gating or perfusion. We provide look-up tables so an institution can compare its ECG-gated/perfusion examination volume to other institutions with similar ECG-gated/perfusion examination fractions and capable scanners. RESULTS We detected an effect of both ECG-gating examination fraction and the number of ECG gating-capable scanners on ECG-gated examination volume ( χ21 = 77.5 [ P < 0.001] and χ21 = 64.2 [ P < 0.001], respectively). Similar results were obtained for perfusion examination fraction and perfusion-capable scanners as they relate to perfusion examination volume ( χ21 = 51.6 [ P < 0.001] and χ21 = 45.2 [ P < 0.001], respectively). The number of ECG gating/perfusion-capable scanners and locations within an institution were found to positively correlate with both the total number of locations and scanners within an institution ( P < 0.001 for all hypothesis tests). CONCLUSIONS The study provides multi-institutional data on ECG gating and perfusion examination volumes that can be used to inform CT purchasing decisions.
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Affiliation(s)
- Sean D Rose
- From the Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX
| | - Meghan G Lubner
- Department of Radiology, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI
| | - John Heil
- Imalogix Research Institute, Bryn Mawr, PA
| | - Gina M Greenwood
- Department of Radiology, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI
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Li G, Hao Y, Wang C, Wang S, Xiong Y, Zhao X. Association Between Neutrophil-to-Lymphocyte Ratio/Lymphocyte-to-Monocyte Ratio and In-Hospital Clinical Outcomes in Ischemic Stroke Treated with Intravenous Thrombolysis. J Inflamm Res 2022; 15:5567-5578. [PMID: 36185640 PMCID: PMC9518842 DOI: 10.2147/jir.s382876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/07/2022] [Indexed: 11/25/2022] Open
Abstract
Objective Investigations on neutrophil-to-lymphocyte ratio (NLR) and lymphocyte-to-monocyte ratio (LMR) in patients with ischemic stroke are insufficient. We aimed to investigate the relationship of NLR and LMR with in-hospital clinical outcomes at different time points in ischemic stroke patients treated with intravenous tissues plasminogen activator (IV tPA). Methods We retrospectively enrolled patients who received IV tPA therapy within 4.5 hours from symptoms onset. Demographics, clinical characteristics, imaging measures, and the in-hospital clinical outcomes including early neurological improvement (ENI, defined as NIHSS score reduction within 24 hours ≥4 points or decreased to the baseline) and favorable functional outcome (defined as modified Rankin scale 0–1) were collected. Multivariable logistic regression analyses were performed to test whether NLR or LMR was an independent predictor for the in-hospital clinical outcomes. Results One hundred and two patients treated with IV tPA were included. NLR at 24 hours proved to be an independent predictor of ENI (adjusted OR=0.85, 95% CI=0.75–0.95, P=0.04). NLR at 48 hours and LMR at 48 hours proved to be independent predictors of mRS 0–1 at discharge (NLR at 48 hours: adjusted OR=0.64, 95% CI=0.49–0.83, P=0.01; LMR at 48 hours: adjusted OR=1.50, 95% CI=1.08–2.09, P=0.02). The AUC of NLR at 48 hours to predict favorable functional outcome at discharge was 0.79 (95% CI=0.70–0.88, P<0.001) and the optimal cut-off was 5.69 (sensitivity=0.52, specificity=0.63). Conclusion In our study, NLR at 24 hours was correlated with ENI. Both NLR and LMR at 48 hours were closely associated with favorable functional outcomes at discharge.
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Affiliation(s)
- Guangshuo Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yahui Hao
- China National Clinical Research Center for Neurological Diseases, Beijing, People’s Republic of China
| | - Chuanying Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Shang Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing, People’s Republic of China
| | - Yunyun Xiong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing, People’s Republic of China
- Chinese Institute of Brain Research, Beijing, People’s Republic of China
- Correspondence: Yunyun Xiong, China National Clinical Research Center for Neurological Diseases, Beijing, People’s Republic of China, Email
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Xingquan Zhao, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No. 119 Nansihuanxilu, Fengtai District, Beijing, 100070, People’s Republic of China, Email
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Walter S, Audebert HJ, Katsanos AH, Larsen K, Sacco S, Steiner T, Turc G, Tsivgoulis G. European Stroke Organisation (ESO) guidelines on mobile stroke units for prehospital stroke management. Eur Stroke J 2022; 7:XXVII-LIX. [PMID: 35300251 PMCID: PMC8921783 DOI: 10.1177/23969873221079413] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/23/2022] [Indexed: 08/03/2023] Open
Abstract
The safety and efficacy of mobile stroke units (MSUs) in prehospital stroke management has recently been investigated in different clinical studies. MSUs are ambulances equipped with a CT scanner, point-of-care lab, telemedicine and are staffed with a stroke specialised medical team. This European Stroke Organisation (ESO) guideline provides an up-to-date evidence-based recommendation to assist decision-makers in their choice on using MSUs for prehospital management of suspected stroke, which includes patients with acute ischaemic stroke (AIS), intracranial haemorrhage (ICH) and stroke mimics. The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and aggregated data meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements are provided where sufficient evidence was not available to provide recommendations based on the GRADE approach. We found moderate evidence for suggesting MSU management for patients with suspected stroke. The patient group diagnosed with AIS shows an improvement of functional outcomes at 90 days, reduced onset to treatment times and increased proportion receiving IVT within 60 min from onset. MSU management might be beneficial for patients with ICH as MSU management was associated with a higher proportion of ICH patients being primarily transported to tertiary care stroke centres. No safety concerns (all-cause mortality, proportion of stroke mimics treated with IVT, symptomatic intracranial bleeding and major extracranial bleeding) could be identified for all patients managed with a MSU compared to conventional care. We suggest MSU management to improve prehospital management of suspected stroke patients.
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Affiliation(s)
- Silke Walter
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Heinrich J Audebert
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Aristeidis H Katsanos
- Division of Neurology, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Simona Sacco
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université de Paris, Paris, France
- INSERM U1266, Paris, France
- FHU Neurovasc, Paris, France
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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5
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Soheili A, Askari-Majdabadi H, Basereh Z, Powers K, Soleimani M, Mirmohammdkhani M, Saleh T. Current status of acute ischemic stroke management in Iran: Findings from a single-center study. Turk J Emerg Med 2022; 22:213-220. [DOI: 10.4103/2452-2473.357344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 07/15/2022] [Accepted: 07/16/2022] [Indexed: 11/04/2022] Open
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Bohmann FO, Gruber K, Kurka N, Willems LM, Herrmann E, du Mesnil de Rochemont R, Scholz P, Rai H, Zickler P, Ertl M, Berlis A, Poli S, Mengel A, Ringleb P, Nagel S, Pfaff J, Wollenweber FA, Kellert L, Herzberg M, Koehler L, Haeusler KG, Alegiani A, Schubert C, Brekenfeld C, Doppler CEJ, Onur ÖA, Kabbasch C, Manser T, Steinmetz H, Pfeilschifter W. Simulation-based training improves process times in acute stroke care (STREAM). Eur J Neurol 2021; 29:138-148. [PMID: 34478596 DOI: 10.1111/ene.15093] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The objective of the STREAM Trial was to evaluate the effect of simulation training on process times in acute stroke care. METHODS The multicenter prospective interventional STREAM Trial was conducted between 10/2017 and 04/2019 at seven tertiary care neurocenters in Germany with a pre- and post-interventional observation phase. We recorded patient characteristics, acute stroke care process times, stroke team composition and simulation experience for consecutive direct-to-center patients receiving intravenous thrombolysis (IVT) and/or endovascular therapy (EVT). The intervention consisted of a composite intervention centered around stroke-specific in situ simulation training. Primary outcome measure was the 'door-to-needle' time (DTN) for IVT. Secondary outcome measures included process times of EVT and measures taken to streamline the pre-existing treatment algorithm. RESULTS The effect of the STREAM intervention on the process times of all acute stroke operations was neutral. However, secondary analyses showed a DTN reduction of 5 min from 38 min pre-intervention (interquartile range [IQR] 25-43 min) to 33 min (IQR 23-39 min, p = 0.03) post-intervention achieved by simulation-experienced stroke teams. Concerning EVT, we found significantly shorter door-to-groin times in patients who were treated by teams with simulation experience as compared to simulation-naive teams in the post-interventional phase (-21 min, simulation-naive: 95 min, IQR 69-111 vs. simulation-experienced: 74 min, IQR 51-92, p = 0.04). CONCLUSION An intervention combining workflow refinement and simulation-based stroke team training has the potential to improve process times in acute stroke care.
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Affiliation(s)
- Ferdinand O Bohmann
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Katharina Gruber
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Natalia Kurka
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Laurent M Willems
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Eva Herrmann
- Faculty of Medicine, Institute of Biostatistics and Mathematical Modelling, Goethe University, Frankfurt am Main, Germany
| | | | - Peter Scholz
- NICU Nursing Staff, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Heike Rai
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Philipp Zickler
- Department of Neurology and Clinical Neurophysiology, University Hospital Augsburg, Augsburg, Germany
| | - Michael Ertl
- Department of Neurology and Clinical Neurophysiology, University Hospital Augsburg, Augsburg, Germany
| | - Ansgar Berlis
- Department for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Sven Poli
- Department of Neurology and Stroke, University Hospital Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Annerose Mengel
- Department of Neurology and Stroke, University Hospital Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Peter Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Johannes Pfaff
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Frank A Wollenweber
- Department of Neurology, Ludwig Maximilians-University Munich, Munich, Germany.,Department of Neurology, Helios-HSK Wiesbaden, Wiesbaden, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilians-University Munich, Munich, Germany
| | - Moriz Herzberg
- Department for Diagnostic and Interventional Neuroradiology, Ludwig Maximilians-University Munich, Munich, Germany.,Department of Diagnostic and Interventional Radiology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Luzie Koehler
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, University Hospital Leipzig, Leipzig, Germany
| | | | - Anna Alegiani
- Department of Neurology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Charlotte Schubert
- Department of Neurology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Christopher E J Doppler
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
| | - Özgür A Onur
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
| | - Christoph Kabbasch
- Department of Neuroradiology, Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
| | - Tanja Manser
- School of Applied Psychology, FHNW University of Applied Sciences and Arts Northwestern Switzerland, Olten, Switzerland
| | - Helmuth Steinmetz
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Waltraud Pfeilschifter
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany.,Department of Neurology and Clinical Neurophysiology, Städtisches Klinikum Lüneburg, Lüneburg, Germany
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Holodinsky JK, Onaemo VN, Whelan R, Hunter G, Graham BR, Hamilton J, Schwartz L, Latta L, Peeling L, Kelly ME. Implementation of a provincial acute stroke pathway and its impact on access to advanced stroke care in Saskatchewan. BMJ Open Qual 2021; 10:bmjoq-2020-001214. [PMID: 34385186 PMCID: PMC8362703 DOI: 10.1136/bmjoq-2020-001214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 07/27/2021] [Indexed: 11/04/2022] Open
Abstract
Background For ischaemic stroke, outcome severity is heavily time dependent. Systems of care need to be in place to ensure that patients with stroke are treated quickly and appropriately across entire health regions. Prior to this study, the province of Saskatchewan, Canada did not have a provincial stroke strategy in place. Methods A quality improvement project was undertaken to create and evaluate a provincial stroke strategy. The Saskatchewan Acute Stroke Pathway was created using a multidisciplinary team of experts, piloted at five stroke centres and then implemented provincially. The number of stroke alerts, door-to-imaging, door-to-needle, door-to-groin puncture times and treatment rates were collected at all centres. Improvements over time were analysed using run charts and individuals control charts. Results The number of stroke alerts province-wide trended upwards in the last 6 months of the study. There were no clear trends or shifts in the proportion of stroke alerts treated with alteplase or endovascular therapy. Across the province, the weighted mean door-to-imaging time decreased from 21 to 15 min, the weighted mean door-to-needle time decreased from 62 to 47 min and the mean door-to-groin puncture time decreased from 83 to 70 min. There was high variability in the degree of improvement from centre to centre. Conclusions The implementation of a province wide acute stroke pathway has led to improvement in stroke care on a provincial basis. Further work addressing intercentre variability is ongoing.
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Affiliation(s)
- Jessalyn K Holodinsky
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Vivian N Onaemo
- Ministry of Health, Government of Saskatchewan, Regina, Saskatchewan, Canada
| | - Ruth Whelan
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Gary Hunter
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Brett R Graham
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jessica Hamilton
- Saskatchewan Health Quality Council, Saskatoon, Saskatchewan, Canada
| | - Laura Schwartz
- Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Lori Latta
- Ministry of Health, Government of Saskatchewan, Regina, Saskatchewan, Canada
| | - Lissa Peeling
- Division of Neurosurgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Michael E Kelly
- Division of Neurosurgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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8
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Decrease in intravenous thrombolysis and poor short-term functional prognosis for acute ischemic stroke during the COVID-19 pandemic. J Neurol 2021; 269:597-602. [PMID: 34379199 PMCID: PMC8355571 DOI: 10.1007/s00415-021-10740-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 08/01/2021] [Accepted: 08/02/2021] [Indexed: 01/17/2023]
Abstract
Background and purpose Since the outbreak of the coronavirus pandemic in 2019 (COVID-19), healthcare systems around the world have been hit to varying degrees. As a neurologist team, for patients with acute ischemic stroke (AIS), we compared the situations of intravenous thrombolysis (IVT) treatment from 2019 to 2020 to investigate the influence of COVID-19 pandemic on the attendance and prognosis of the IVT patients. Methods We collected the messages of objects who had received IVT (Bridging surgery was ruled out) during 2019–2020. We analyzed differences in age, gender, time from onset to start IVT, door to needle time (DNT), pretreatment NIHSS score, postoperative NIHSS score, and so on. Statistical tests were also performed to respectively compare the discharged modified Rankin score (mRS) and discharged NIHSS score between two years. Results Since the onset of COVID-19 restrictions in Wenzhou, we observed a significant reduction of 24.7% (p = 0.023) from 267(2019) to 201(2020) of received IVT on hospital admission. We compared the DNT between two years and it reflected that the DNT (min) in 2020 was obviously longer than in 2019 (51.60 ± 23.80 vs 46.80 ± 21.90, p = 0.026). We also compared the discharged mRS, which reflected much more IVT patients in 2020 during the COVID-19 pandemic had a poor short-term functional prognosis (38.2% vs 29.2%, p = 0.043). Conclusions The COVID-19 pandemic caused the decrease of admissions and prolonged the time of the green channel for stroke, which led to the worse short-term prognosis of AIS patients during the pandemic. It’s necessary to ensure an effective green channel and provide adequate medical resources during the pandemic period to reduce the damage caused by COVID-19.
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Kashida YT, Garcia-Esperon C, Lillicrap T, Miteff F, Garcia-Bermejo P, Gangadharan S, Chew BLA, O'Brien W, Evans J, Alanati K, Bivard A, Parsons M, Majersik JJ, Spratt NJ, Levi C. The Need for Structured Strategies to Improve Stroke Care in a Rural Telestroke Network in Northern New South Wales, Australia: An Observational Study. Front Neurol 2021; 12:645088. [PMID: 33897601 PMCID: PMC8064411 DOI: 10.3389/fneur.2021.645088] [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: 12/22/2020] [Accepted: 03/11/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: A telestroke network in Northern New South Wales, Australia has been developed since 2017. We theorized that the telestroke network development would drive a progressive improvement in stroke care metrics over time. Aim: This study aimed to describe changes in acute stroke workflow metrics over time to determine whether they improved with network experience. Methods: We prospectively collected data of patients assessed by telestroke who received multimodal computed tomography (mCT) and were diagnosed with ischemic stroke or transient ischemic attack from January 2017 to July 2019. The period was divided into two phases (phase 1: January 2017 – October 2018 and phase 2: November 2018 – July 2019). We compared median door-to-call, door-to-image, and door-to-decision time between the two phases. Results: We included 433 patients (243 in phase 1 and 190 in phase 2). Each spoke site treated 1.5–5.2 patients per month. There were Door-to-call time (median 39 in phase 1, 35 min in phase 2, p = 0.18), and door-to-decision time (median 81.5 vs. 83 min, p = 0.31) were not improved significantly. Similarly, in the reperfusion therapy subgroup, door-to-call time (median 29 vs. 24.5 min, p = 0.12) and door-to-decision time (median 70.5 vs. 67.5 min, p = 0.75) remained substantially unchanged. Regression analysis showed no association between time in the network and door-to-decision time (coefficient 1.5, p = 0.32). Conclusion: In our telestroke network, acute stroke timing metrics did not improve over time. There is the need for targeted education and training focusing on both stroke reperfusion competencies and the technical aspects of telestroke in areas with limited workforce and high turnover.
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Affiliation(s)
- Yumi Tomari Kashida
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
| | | | - Thomas Lillicrap
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
| | - Ferdinand Miteff
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | | | - Shyam Gangadharan
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | | | - William O'Brien
- Department of Neuroscience, Gosford Hospital, Gosford, NSW, Australia
| | - James Evans
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Khaled Alanati
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Andrew Bivard
- Department of Neurology, Melbourne Brain Center at Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Mark Parsons
- Department of Neurology, Liverpool hospital, Liverpool, NSW, Australia
| | | | - Neil James Spratt
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
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10
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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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11
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Garcia BL, Bekker R, van der Mei RD, Chavannes NH, Kruyt ND. Optimal patient protocols in regional acute stroke care. Health Care Manag Sci 2021; 24:515-530. [PMID: 33620631 PMCID: PMC8354911 DOI: 10.1007/s10729-020-09524-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 10/04/2020] [Indexed: 01/19/2023]
Abstract
In acute stroke care two proven reperfusion treatments exist: (1) a blood thinner and (2) an interventional procedure. The interventional procedure can only be given in a stroke centre with specialized facilities. Rapid initiation of either is key to improving the functional outcome (often emphasized by the common phrase in acute stroke care "time=brain"). Delays between the moment the ambulance is called and the initiation of one or both reperfusion treatment(s) should therefore be as short as possible. The speed of the process strongly depends on five factors: patient location, regional patient allocation by emergency medical services (EMS), travel times of EMS, treatment locations, and in-hospital delays. Regional patient allocation by EMS and treatment locations are sub-optimally configured in daily practice. Our aim is to construct a mathematical model for the joint decision of treatment locations and allocation of acute stroke patients in a region, such that the time until treatment is minimized. We describe acute stroke care as a multi-flow two-level hierarchical facility location problem and the model is formulated as a mixed integer linear program. The objective of the model is the minimization of the total time until treatment in a region and it incorporates volume-dependent in-hospital delays. The resulting model is used to gain insight in the performance of practically oriented patient allocation protocols, used by EMS. We observe that the protocol of directly driving to the nearest stroke centre with special facilities (i.e., the mothership protocol) performs closest to optimal, with an average total time delay that is 3.9% above optimal. Driving to the nearest regional stroke centre (i.e., the drip-and-ship protocol) is on average 8.6% worse than optimal. However, drip-and-ship performs better than the mothership protocol in rural areas and when a small fraction of the population (at most 30%) requires the second procedure, assuming sufficient patient volumes per stroke centre. In the experiments, the time until treatment using the optimal model is reduced by at most 18.9 minutes per treated patient. In economical terms, assuming 150 interventional procedures per year, the value of medical intervention in acute stroke can be improved upon up to € 1,800,000 per year.
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Affiliation(s)
- B L Garcia
- Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands.
| | - R Bekker
- Department of Mathematics, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - N H Chavannes
- Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | - N D Kruyt
- Neurology Department, Leiden University Medical Center, Leiden, Netherlands
- University NeuroVascular Center (UNVC), Leiden-The Hague, The Netherlands
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12
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Maas WJ, Lahr MMH, Buskens E, van der Zee DJ, Uyttenboogaart M. Pathway Design for Acute Stroke Care in the Era of Endovascular Thrombectomy: A Critical Overview of Optimization Efforts. Stroke 2020; 51:3452-3460. [PMID: 33070713 DOI: 10.1161/strokeaha.120.030392] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The efficacy of intravenous thrombolysis and endovascular thrombectomy (EVT) for acute ischemic stroke is highly time dependent. Optimal organization of acute stroke care is therefore important to reduce treatment delays but has become more complex after the introduction of EVT as regular treatment for large vessel occlusions. There is no singular optimal organizational model that can be generalized to different geographic regions worldwide. Current dominant organizational models for EVT include the drip-and-ship- and mothership model. Guidelines recommend routing of suspected patients with stroke to the nearest intravenous thrombolysis capable facility; however, the choice of routing to a certain model should depend on regional stroke service organization and individual patient characteristics. In general, design approaches for organizing stroke care are required, in which 2 key strategies could be considered. The first entails the identification of interventions within existing organizational models for optimizing timely delivery of intravenous thrombolysis and/or EVT. This includes adaptive patient routing toward a comprehensive stroke center, which focuses particularly on prehospital triage tools; bringing intravenous thrombolysis or EVT to the location of the patient; and expediting services and processes along the stroke pathway. The second strategy is to develop analytical or simulation model-based approaches enabling the design and evaluation of organizational models before their implementation. Organizational models for acute stroke care need to take regional and patient characteristics into account and can most efficiently be assessed and optimized through the application of model-based approaches.
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Affiliation(s)
- Willemijn J Maas
- Department of Neurology (W.J.M., M.U.), University of Groningen, University Medical Center Groningen, the Netherlands.,Department of Epidemiology, Health Technology Assessment unit (W.J.M., M.M.H.L., E.B.), University of Groningen, University Medical Center Groningen, the Netherlands
| | - Maarten M H Lahr
- Department of Epidemiology, Health Technology Assessment unit (W.J.M., M.M.H.L., E.B.), University of Groningen, University Medical Center Groningen, the Netherlands
| | - Erik Buskens
- Department of Epidemiology, Health Technology Assessment unit (W.J.M., M.M.H.L., E.B.), University of Groningen, University Medical Center Groningen, the Netherlands.,Department of Operations, Faculty of Economics and Business, University of Groningen, the Netherlands (E.B., D.-J.v.d.Z.)
| | - Durk-Jouke van der Zee
- Department of Operations, Faculty of Economics and Business, University of Groningen, the Netherlands (E.B., D.-J.v.d.Z.)
| | - Maarten Uyttenboogaart
- Department of Neurology (W.J.M., M.U.), University of Groningen, University Medical Center Groningen, the Netherlands.,Department of Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands
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13
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Aoki M, Abe T, Saitoh D, Hagiwara S, Oshima K. Severe trauma patient volume was associated with decreased mortality. Eur J Trauma Emerg Surg 2020; 47:1957-1964. [PMID: 32222789 DOI: 10.1007/s00068-020-01352-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 03/16/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The relationship between the severe trauma patient volume and outcomes is still being debated. The aim of this study was to evaluate the relationship between severe trauma patient volume, hospital mortality, and door-to-definitive treatment time. METHODS This was a retrospective cohort study that used recorded data from the Japan Trauma Data Bank. We included severe trauma patients who had an Injury Severity Score greater than 16. Hospitals were categorized according to their annual severe trauma patient volume: low volume, 1-49 (reference), medium volume, 50-99, and high volume, ≥ 100]. The association of volume categories with in-hospital mortality was evaluated by use of a mixed-effects model adjusted for patient demographics and trauma severity. Additionally, the association of volume categories with in-hospital mortality among subgroups and with door-to-definitive treatment time were also evaluated. RESULTS A total of 74,957 severe trauma patients from 213 hospitals were analyzed. In-hospital mortality was 15.7%, 15.2%, and 12.8% in the low volume, medium volume, and high volume groups, respectively. High volume was associated with reduced in-hospital mortality compared to low volume (odds ratio = 0.757, 95% confidence interval = 0.626-0.916). However, medium volume was not associated with reduced in-hospital mortality. Among subgroups, high volume was associated with reduced in-hospital mortality only in the probability of survival ≥ 0.5. Door-to-definitive treatment time was decreased in high volume, however, high volume was not associated with reduced in-hospital mortality among the patients who underwent definitive treatment and the patients whose ps < 0.5. CONCLUSIONS Severe trauma patient volume was associated with decreased mortality by decreasing preventable trauma death.
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Affiliation(s)
- Makoto Aoki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan.
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo, Japan
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Daizoh Saitoh
- Department of Traumatology and Emergency Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Shuichi Hagiwara
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Kiyohiro Oshima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
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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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Tong X, Wiltz JL, George MG, Odom EC, Coleman King SM, Chang T, Yin X, Merritt RK. A Decade of Improvement in Door-to-Needle Time Among Acute Ischemic Stroke Patients, 2008 to 2017. Circ Cardiovasc Qual Outcomes 2019; 11:e004981. [PMID: 30557047 DOI: 10.1161/circoutcomes.118.004981] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The clinical benefit of intravenous (IV) alteplase in acute ischemic stroke is time dependent. We assessed the overall temporal changes in door-to-needle (DTN) time and examine the factors associated with DTN time ≤60 and ≤45 minutes. METHODS AND RESULTS A total of 496 336 acute ischemic stroke admissions were identified in the Paul Coverdell National Acute Stroke Program from 2008 to 2017. We used generalized estimating equations models to examine the factors associated with DTN time ≤60 and ≤45 minutes, and calculated adjusted odds ratios and 95% CI. Between 2008 and 2017, the percentage of acute ischemic stroke patients who received IV alteplase including those transferred, increased from 6.4% to 15.3%. After excluding those who received IV alteplase at an outside hospital, a total of 39 737 (8%) acute ischemic stroke patients received IV alteplase within 4.5 hours of the time the patient last known to be well. Significant increases were seen in DTN time ≤60 minutes (26.4% in 2008 to 66.2% in 2017, P<0.001), as well as DTN time ≤45 minutes (10.7% in 2008 to 40.5% in 2017, P<0.001). Patients aged 55 to 84 years were more likely to receive IV alteplase within 60 minutes, while those aged 55 to 74 years were more likely to receive IV alteplase within 45 minutes, as compared with those aged 18 to 54 years. Arrival by emergency medical service, and patients with severe stroke were more likely to receive IV alteplase within 60 and 45 minutes. Conversely, women, black patients as compared with white, and patients with a medical history of diseases associated with stroke were less likely to receive DTN time ≤60 or 45 minutes. CONCLUSIONS Rapid improvements in DTN time were observed in the Paul Coverdell National Acute Stroke Program; however, opportunities to reduce disparities remain.
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Affiliation(s)
- Xin Tong
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (X.T., J.L.W., M.G.G., E.C.O., S.M.C.K., T.C., X.Y., R.K.M.)
| | - Jennifer L Wiltz
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (X.T., J.L.W., M.G.G., E.C.O., S.M.C.K., T.C., X.Y., R.K.M.).,United States Public Health Service, Atlanta, GA (J.L.W., E.C.O., S.M.C.K.)
| | - Mary G George
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (X.T., J.L.W., M.G.G., E.C.O., S.M.C.K., T.C., X.Y., R.K.M.)
| | - Erika C Odom
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (X.T., J.L.W., M.G.G., E.C.O., S.M.C.K., T.C., X.Y., R.K.M.).,United States Public Health Service, Atlanta, GA (J.L.W., E.C.O., S.M.C.K.)
| | - Sallyann M Coleman King
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (X.T., J.L.W., M.G.G., E.C.O., S.M.C.K., T.C., X.Y., R.K.M.).,United States Public Health Service, Atlanta, GA (J.L.W., E.C.O., S.M.C.K.)
| | - Tiffany Chang
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (X.T., J.L.W., M.G.G., E.C.O., S.M.C.K., T.C., X.Y., R.K.M.).,IHRC, Inc., Atlanta, GA (T.C., X.Y.)
| | - Xiaoping Yin
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (X.T., J.L.W., M.G.G., E.C.O., S.M.C.K., T.C., X.Y., R.K.M.).,IHRC, Inc., Atlanta, GA (T.C., X.Y.)
| | | | - Robert K Merritt
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (X.T., J.L.W., M.G.G., E.C.O., S.M.C.K., T.C., X.Y., R.K.M.)
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16
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Bohmann FO, Kurka N, du Mesnil de Rochemont R, Gruber K, Guenther J, Rostek P, Rai H, Zickler P, Ertl M, Berlis A, Poli S, Mengel A, Ringleb P, Nagel S, Pfaff J, Wollenweber FA, Kellert L, Herzberg M, Koehler L, Haeusler KG, Alegiani A, Schubert C, Brekenfeld C, Doppler CEJ, Onur OA, Kabbasch C, Manser T, Pfeilschifter W. Simulation-Based Training of the Rapid Evaluation and Management of Acute Stroke (STREAM)-A Prospective Single-Arm Multicenter Trial. Front Neurol 2019; 10:969. [PMID: 31572288 PMCID: PMC6749045 DOI: 10.3389/fneur.2019.00969] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 08/23/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction: Acute stroke care delivered by interdisciplinary teams is time-sensitive. Simulation-based team training is a promising tool to improve team performance in medical operations. It has the potential to improve process times, team communication, patient safety, and staff satisfaction. We aim to assess whether a multi-level approach consisting of a stringent workflow revision based on peer-to-peer review and 2–3 one-day in situ simulation trainings can improve acute stroke care processing times in high volume neurocenters within a 6 months period. Methods and Analysis: The trial is being carried out in a pre-test-post-test design at 7 tertiary care university hospital neurocenters in Germany. The intervention is directed at the interdisciplinary multiprofessional stroke teams. Before and after the intervention, process times of all direct-to-center stroke patients receiving IV thrombolysis (IVT) and/or endovascular therapy (EVT) will be recorded. The primary outcome measure will be the “door-to-needle” time of all consecutive stroke patients directly admitted to the neurocenters who receive IVT. Secondary outcome measures will be intervention-related process times of the fraction of patients undergoing EVT and effects on team communication, perceived patient safety, and staff satisfaction via a staff questionnaire. Interventions: We are applying a multi-level intervention in cooperation with three “STREAM multipliers” from each center. First step is a central meeting of the multipliers at the sponsor's institution with the purposes of algorithm review in a peer-to-peer process that is recorded in a protocol and an introduction to the principles of simulation training and debriefing as well as crew resource management and team communication. Thereafter, the multipliers cooperate with the stroke team trainers from the sponsor's institution to plan and execute 2–3 one-day simulation courses in situ in the emergency department and CT room of the trial centers whereupon they receive teaching materials to perpetuate the trainings. Clinical Trial Registration: STREAM is a registered trial at https://clinicaltrials.gov/ct2/show/NCT03228251.
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Affiliation(s)
| | - Natalia Kurka
- Department of Neurology, University Hospital Frankfurt, Frankfurt, Germany
| | | | - Katharina Gruber
- Department of Neurology, University Hospital Frankfurt, Frankfurt, Germany
| | | | - Peter Rostek
- NICU Nursing Staff, University Hospital Frankfurt, Frankfurt, Germany
| | - Heike Rai
- Department of Neurology, University Hospital Frankfurt, Frankfurt, Germany
| | - Philipp Zickler
- Department of Neurology and Clinical Neurophysiology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Michael Ertl
- Department of Neurology and Clinical Neurophysiology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Ansgar Berlis
- Department for Diagnostic and Interventional Radiology and Neuroradiology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Sven Poli
- Department of Neurology With Focus on Neurovascular Diseases and Neurooncology, University Hospital Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Annerose Mengel
- Department of Neurology With Focus on Neurovascular Diseases and Neurooncology, University Hospital Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Peter Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Johannes Pfaff
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Lars Kellert
- Department of Neurology, Ludwig Maximilians-University, Munich, Germany
| | - Moriz Herzberg
- Department for Diagnostic and Interventional Neuroradiology, Ludwig Maximilians-University, Munich, Germany
| | - Luzie Koehler
- Department of Neurology, University Hospital Leipzig, Leipzig, Germany
| | - Karl Georg Haeusler
- Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Anna Alegiani
- Department of Neurology, University Medical Centre Hamburg Eppendorf, Hamburg, Germany
| | - Charlotte Schubert
- Department of Neurology, University Medical Centre Hamburg Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Centre Hamburg Eppendorf, Hamburg, Germany
| | | | - Oezguer A Onur
- Department of Neurology, University Hospital Cologne, Cologne, Germany
| | - Christoph Kabbasch
- Department of Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Tanja Manser
- School of Applied Psychology, FHNW University of Applied Sciences and Arts Northwestern Switzerland, Olten, Switzerland
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17
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Itabashi R, Shigehatake Y, Yazawa Y, Endo K, Saito T, Fukuma K, Furui E, Mori E. Phased changes in strategies can reduce delay of intravenous thrombolysis administration to 15 min. J Neurol Sci 2019; 403:59-64. [PMID: 31226551 DOI: 10.1016/j.jns.2019.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 06/10/2019] [Accepted: 06/12/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The present study aimed to determine whether phased changes in strategies including the Helsinki model affect the delay of intravenous thrombolysis (IVT) using tissue plasminogen activator (tPA) to treat acute ischemic stroke. METHOD We retrospectively studied 516 consecutive patients treated with IVT in our department between October 2005 and December 2018. We implemented a system of hospital pre-notification in 2005, when IVT was initially implemented at our center. We then improved the IVT strategy by simplifying brain imaging (July 2011), premixing tPA (April 2014), locating a blood cell counter in the emergency room (June 2015), manually administering a tPA bolus before preparing a continuous infusion (January 2016), awarding a prize to members of the acute stroke team (November 2016), and completing registration before arrival and sending patients directly to computed tomography (February 2017). We analyzed the effects of these strategic changes on annual median door-to-needle times (DTN). RESULTS The DTN was annually reduced, from a median of 90 [interquartile range, 55-98] minutes in 2006 to 15 [12-24.25] minutes in 2017. By 2017, 94% of patients were treated within 60 min of arrival. Multivariate logistic regression analysis revealed that initial NIHSS score ≤ 4 (OR 2.67, 95% CI 1.3-5.7) and anticoagulation before onset (OR 6.00, 95% CI 2.47-14.58) were independently associated with 20 min or more of DTN in 186 patients treated from 2016 to 2018. CONCLUSIONS Phased strategic change to reduce the delay in delivering IVT reduced median DTN to 15 min at a single Japanese stroke center.
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Affiliation(s)
- Ryo Itabashi
- Departments of Stroke Neurology, Kohnan Hospital, Sendai, Japan; Department of Behavioral Neurology and Neuropsychiatry, Osaka University United Graduate School of Child Development, Suita, Japan.
| | | | - Yukako Yazawa
- Departments of Stroke Neurology, Kohnan Hospital, Sendai, Japan
| | - Kaoru Endo
- Departments of Stroke Neurology, Kohnan Hospital, Sendai, Japan
| | - Takuya Saito
- Departments of Stroke Neurology, Kohnan Hospital, Sendai, Japan
| | - Kazuki Fukuma
- Departments of Stroke Neurology, Kohnan Hospital, Sendai, Japan
| | - Eisuke Furui
- Departments of Stroke Neurology, Kohnan Hospital, Sendai, Japan
| | - Etsuro Mori
- Department of Behavioral Neurology and Neuropsychiatry, Osaka University United Graduate School of Child Development, Suita, Japan
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Tanaka K, Matsumoto S, Yamada T, Nagano S, Takase KI, Hatano T, Yamasaki R, Kira JI. Temporal Trends in Clinical Characteristics and Door-to-Needle Time in Patients Receiving Intravenous Tissue Plasminogen Activator: A Retrospective Study of 4 Hospitals in Japan. J Stroke Cerebrovasc Dis 2019; 28:104305. [PMID: 31405791 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/03/2019] [Accepted: 07/21/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Intravenous recombinant tissue plasminogen activator (rt-PA) has become a common treatment for acute ischemic stroke and has highly time-dependent benefits. We aimed to clarify temporal trends regarding the frequency and characteristics of patients receiving rt-PA and explore factors associated with door-to-needle time (DNT) in Japanese emergency hospitals. METHODS Consecutive patients who received intravenous rt-PA for acute ischemic stroke from October 2005 to December 2015 were retrospectively registered from 4 hospitals. Temporal trends in the frequency and characteristics of patients receiving rt-PA and factors associated with DNT were investigated. RESULTS A total of 750 patients, including 688 (420 men, median 75 years old) with out-of-hospital stroke, were registered. The frequency of patients receiving intravenous rt-PA for acute ischemic stroke continuously increased from 1.8% in 2005 to 9.5% in 2015. The proportion of patients who were elderly or had prestroke disability increased over time, while pretreatment stroke severity declined. The DNT gradually decreased (median 105 minutes in 2005, 61 minutes in 2015). According to multivariate regression analysis with correction for multiple comparisons, activation of a code stroke system (standardized partial regression coefficient (β) -.50, P < .001, q < .001), onset-to-door time (β -.15, P < .001, q < .001), pretreatment with antithrombotic agents (β .12, P < .001, q = .001), and year of treatment (β .11, P = .007, q = .011) were associated with DNT. CONCLUSIONS Intravenous rt-PA was widely adopted in Japanese emergency hospitals. Characteristics of patients receiving intravenous rt-PA have changed over the past decade. Several factors, including the year of treatment, were associated with DNT, which has shortened over time.
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Affiliation(s)
- Koji Tanaka
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Shoji Matsumoto
- Departments of Neurology, Kokura Memorial Hospital, Kitakyushu, Japan; Department of Comprehensive Strokology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Takeshi Yamada
- Department of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Sukehisa Nagano
- Department of Neurology, Fukuoka City Hospital, Fukuoka, Japan
| | | | - Taketo Hatano
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Ryo Yamasaki
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jun-Ichi Kira
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Liu TY, Wang CH, Chiang WC, Tang SC, Tsai LK, Lee CW, Jeng JS, Ma MHM, Hsieh MJ, Lee YC. Redistributing medical resources for a bypass strategy for large vessel occlusion: a community-based study. J Neurointerv Surg 2019; 12:98-103. [PMID: 31197027 DOI: 10.1136/neurintsurg-2019-014851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/21/2019] [Accepted: 05/22/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND A bypass strategy for large vessel occlusion (LVO) benefits patients receiving endovascular thrombectomy (EVT), but may delay some patients from receiving IV thrombolysis. However, patient centralization has been shown to improve outcomes. OBJECTIVE To understand the current coverage of medical services for patients with stroke, and to identify the best coverage under different medical resource redistribution to help balance medical equality and patient centralization. METHODS This 6-year geographic study of 7679 on-scene patients with suspected stroke with a positive Cincinnati Prehospital Stroke Scale (CPSS) score identified 4037 patients with all three CPSS items who were suspected as having an LVO. Geographic, population, and patient coverage rates for hospitals providing IV thrombolysis and those providing EVT were identified according to hospital service areas, defined as geographic districts with access to a hospital within a ≤15 min off-peak driving time estimated using Google Maps. Moreover, we estimated the effects on resource redistribution when implementing a bypass strategy. RESULTS Geographic coverage rates for hospitals providing IV thrombolysis and those providing EVT were 64.75% and 56.62%, respectively, and population coverage rates were 97.30% and 92.72%, respectively. The service areas of hospitals providing IV thrombolysis covered 93.77% of patients with suspected stroke, and those of hospitals providing EVT covered 87.89% of patients with suspected LVO. The number of hospitals providing IV thrombolysis and those providing EVT could be reduced to six and two hospitals, respectively, without affecting hospital arrival time when implementing a bypass strategy. CONCLUSION Hospitals providing IV thrombolysis and EVT could be reduced without reducing medical equality.
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Affiliation(s)
- Ting-Yu Liu
- Department of Industrial Engineering and Engineering Management, National Tsing Hua University, Hsinchu, Taiwan
| | - Chun-Han Wang
- Department of Industrial Engineering and Engineering Management, National Tsing Hua University, Hsinchu, Taiwan
| | - Wen-Chu Chiang
- Departmentof Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin county, 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
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Matthew Huei-Ming Ma
- Departmentof Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin county, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Ching Lee
- Department of Industrial Engineering and Engineering Management, National Tsing Hua University, Hsinchu, Taiwan
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20
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Truc My Nguyen T, van de Stadt SI, Groot AE, Wermer MJ, den Hertog HM, Droste HM, van Zwet EW, van Schaik SM, Coutinho JM, Kruyt ND. Thrombolysis related symptomatic intracranial hemorrhage in estimated versus measured body weight. Int J Stroke 2019; 15:159-166. [PMID: 31092150 PMCID: PMC7045279 DOI: 10.1177/1747493019851285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM In acute ischemic stroke, under- or overestimation of body weight can lead to dosing errors of recombinant tissue plasminogen activator with consequent reduced efficacy or increased risk of hemorrhagic complications. Measurement of body weight is more accurate than estimation of body weight but potentially leads to longer door-to-needle times. Our aim was to assess if weight modality (estimation of body weight versus measurement of body weight) is associated with (i) symptomatic intracranial hemorrhage rate, (ii) clinical outcome, and (iii) door-to-needle times. METHODS Consecutive patients treated with intravenous thrombolysis between 2009 and 2016 from 14 hospitals were included. Baseline characteristics and outcome parameters were retrieved from medical records. We defined symptomatic intracranial hemorrhage according to the European Cooperative Acute Stroke Study (ECASS)-III definition and clinical outcome was assessed with the modified Rankin Scale. The association of weight modality and outcome parameters was estimated with regression analyses. RESULTS A total of 4801 patients were included. Five hospitals used measurement of body weight (n = 1753), six hospitals used estimation of body weight (n = 2325), and three hospitals (n = 723) changed from estimation of body weight to measurement of body weight during the study period. In 2048 of the patients (43%), measurement of body weight was used and in 2753 (57%), estimation of body weight. In the measurement of body weight group, an inbuilt weighing bed was used in 1094 patients (53%) and a patient lift scale in 954 patients (47%). In the estimation of body weight group, policy regarding estimation was similar. Estimation of body weight was not associated with increased symptomatic intracranial hemorrhage risk (adjusted odds ratio = 1.16; 95% confidence interval 0.83-1.62) or favorable outcome (adjusted odds ratio = 0.99; 95% confidence interval 0.82-1.21), but it was significantly associated with longer door-to-needle times compared to measurement of body weight using an inbuilt weighing bed (adjusted B = 3.57; 95% confidence interval 1.33-5.80) and shorter door-to-needle times compared to measurement of body weight using a patient lift scale (-3.96; 95% confidence interval -6.38 to -1.53). CONCLUSION We did not find evidence that weight modality (estimation of body weight versus measurement of body weight) to determine recombinant tissue plasminogen activator dose in intravenous thrombolysis eligible patients is associated with symptomatic intracranial hemorrhage or clinical outcome. We did find that estimation of body weight leads to longer door-to-needle times compared to measurement of body weight using an inbuilt weighing bed and to shorter door-to-needle times compared to measurement of body weight using a patient lift scale.
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Affiliation(s)
- T Truc My Nguyen
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Stephanie Iw van de Stadt
- Department of Neurology, University Medical Centre Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Adrien E Groot
- Department of Neurology, University Medical Centre Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Marieke Jh Wermer
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Hanneke M Droste
- Department of Neurology, Isala hospital, Zwolle, the Netherlands
| | - Erik W van Zwet
- Department of Medical Statistics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Sander M van Schaik
- Department of Neurology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands.,Zaans Medical Centre, Zaandam, the Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, University Medical Centre Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
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Reducing Door-to-Needle Times for Ischaemic Stroke to a Median of 30 Minutes at a Community Hospital. Can J Neurol Sci 2018; 46:51-56. [PMID: 30516454 DOI: 10.1017/cjn.2018.368] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Alteplase is an effective treatment for ischaemic stroke patients, and it is widely available at all primary stroke centres. The effectiveness of alteplase is highly time-dependent. Large tertiary centres have reported significant improvements in their door-to-needle (DTN) times. However, these same improvements have not been reported at community hospitals. METHODS Red Deer Regional Hospital Centre (RDRHC) is a community hospital of 370 beds that serves approximately 150,000 people in their acute stroke catchment area. The RDRHC participated in a provincial DTN improvement initiative, and implemented a streamlined algorithm for the treatment of stroke patients. During this intervention period, they implemented the following changes: early alert of an incoming acute stroke patient to the neurologist and care team, meeting the patient immediately upon arrival, parallel work processes, keeping the patient on the Emergency Medical Service stretcher to the CT scanner, and administering alteplase in the imaging area. Door-to-needle data were collected from July 2007 to December 2017. RESULTS A total of 289 patients were treated from July 2007 to December 2017. In the pre-intervention period, 165 patients received alteplase and the median DTN time was 77 minutes [interquartile range (IQR): 60-103 minutes]; in the post-intervention period, 104 patients received alteplase and the median DTN time was 30 minutes (IQR: 22-42 minutes) (p < 0.001). The annual number of patients that received alteplase increased from 9 to 29 in the pre-intervention period to annual numbers of 41 to 63 patients in the post-intervention period. CONCLUSION Community hospitals staffed with community neurologists can achieve median DTN times of 30 minutes or less.
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Hassankhani H, Soheili A, Vahdati SS, Mozaffari FA, Fraser JF, Gilani N. Treatment Delays for Patients With Acute Ischemic Stroke in an Iranian Emergency Department: A Retrospective Chart Review. Ann Emerg Med 2018; 73:118-129. [PMID: 30318375 DOI: 10.1016/j.annemergmed.2018.08.435] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 08/11/2018] [Accepted: 08/16/2018] [Indexed: 10/28/2022]
Abstract
STUDY OBJECTIVE We evaluate the extent and nature of treatment delays and the contributing factors influencing them for patients with acute ischemic stroke, as well as main barriers to stroke care in an Iranian emergency department (ED). METHODS A retrospective chart review was conducted on 394 patients with acute ischemic stroke who were referred to the ED of a tertiary academic medical center in northwest Iran from March 21 to June 21, 2017. The steps of this review process included instrument development, medical records retrieval, data extraction, and data verification. Primary outcomes were identified treatment delays and causes of loss of eligibility for intravenous recombinant tissue plasminogen activator (r-tPA). RESULTS Of patients with acute ischemic stroke, 80.2% did not meet intravenous r-tPA eligibility; the most common cause was delayed (>4.5 hours) ED arrival after symptom onset (71.82%; n=283). Of 19.8% of subjects for whom the stroke code was activated, intravenous r-tPA was administered in only 5.3%. The average time from patients' arrival to first emergency medicine resident visit, notification of acute stroke team, presence of neurology resident, and computed tomography scan interpretation was lower for patients who met criteria of intravenous r-tPA than for those who lost eligibility for fibrinolytic therapy. The average door-to-needle time was 69 minutes (interquartile range 46 to 91 minutes). CONCLUSION Our ED and acute stroke team had a favorable clinical performance meeting established critical time goals of inhospital care for potentially eligible patients, but a poor clinical performance for the majority of patients who were not candidates for fibrinolytic therapy.
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Affiliation(s)
- Hadi Hassankhani
- Research Center for Evidence-Based Medicine, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amin Soheili
- Student Research Committee, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Samad S Vahdati
- Neurosciences Research Center, Department of Emergency Medicine, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farough A Mozaffari
- Department of Social Sciences, School of Law and Social Sciences, University of Tabriz, Tabriz, Iran
| | - Justin F Fraser
- Department of Neurological Surgery, Neurology, Radiology, and Neuroscience, University of Kentucky, Lexington, KY
| | - Neda Gilani
- Road Traffic Injury Research Center, Department of Statistics and Epidemiology, School of Health, Tabriz University of Medical Sciences, Tabriz, Iran
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23
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Ciccone A, Berge E, Fischer U. Systematic review of organizational models for intra-arterial treatment of acute ischemic stroke. Int J Stroke 2018; 14:12-22. [DOI: 10.1177/1747493018806157] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background Intra-arterial treatment of acute ischemic stroke requires changes to acute stroke services since most hospitals do not have on-site intra-arterial treatment facilities. Aim To identify models for delivery of intra-arterial treatment and to compare process performance and clinical and radiological outcomes of the different models. Methods We systematically searched the literature and contacted experts in the field. We performed a qualitative synthesis to identify models, and a quantitative review and meta-analysis of clinical and radiological outcomes under different organizational models. Summary of review The searches retrieved 148 publications, of which 27 were used for the identification and description of models, and 9 for the comparison of the different models. We identified four main models: the mother-ship, drip-and ship, mobile interventionist, and mobile stroke unit models. There were no randomized-controlled trials of the different models, but non-randomized comparisons were possible using data from 8 observational studies and 1 randomized-controlled trial of intra-arterial therapy, of a total of 4127 patients. Comparison between the mother-ship and drip-and-ship models showed no difference in survival (OR 0.81; 95% CI 0.63–1.03), favorable functional outcome (OR 0.96; 95% CI 0.73–1.25), or arterial patency (OR 0.89; 95% CI 0.73–1.08). Conclusions Different organizational models exist for intra-arterial treatment of acute ischemic stroke, but there is insufficient evidence to recommend a particular, universal model. Until one model can be shown to be superior, the choice of model should depend on local factors and patient characteristics.
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Affiliation(s)
- Alfonso Ciccone
- Department of Neurology, Azienda Socio Sanitaria Territoriale di Mantova, Mantova, Italy
| | - Eivind Berge
- Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - Urs Fischer
- Department of Neurology, University Hospital Bern and University of Bern, Bern, Switzerland
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24
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Pihlasviita S, Mattila OS, Ritvonen J, Sibolt G, Curtze S, Strbian D, Harve H, Pystynen M, Kuisma M, Tatlisumak T, Lindsberg PJ. Diagnosing cerebral ischemia with door-to-thrombolysis times below 20 minutes. Neurology 2018; 91:e498-e508. [DOI: 10.1212/wnl.0000000000005954] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 04/24/2018] [Indexed: 11/15/2022] Open
Abstract
ObjectivesTo clarify diagnostic accuracy and consequences of misdiagnosis in the admission evaluation of stroke-code patients in a neurologic emergency department with less than 20-minute door-to-thrombolysis times.MethodsAccuracy of admission diagnostics was studied in an observational cohort of 1,015 stroke-code patients arriving by ambulance as candidates for recanalization therapy between May 2013 and November 2015. Immediate admission evaluation was performed by a stroke neurologist or a neurology resident with dedicated stroke training, primarily utilizing CT-based imaging.ResultsThe rate of correct admission diagnosis was 91.1% (604/663) for acute cerebral ischemia (ischemic stroke/TIA), 99.2% (117/118) for hemorrhagic stroke, and 61.5% (144/234) for stroke mimics. Of the 150 (14.8%) misdiagnosed patients, 135 (90.0%) had no acute findings on initial imaging and 100 (67.6%) presented with NIH Stroke Scale score 0 to 2. Misdiagnosis altered medical management in 70 cases, including administration of unnecessary treatments (thrombolysis n = 13, other n = 24), omission of thrombolysis (n = 5), delays to specific treatments of stroke mimics (n = 13, median 56 [31–93] hours), and delays to antiplatelet medication (n = 14, median 1 [1–2] day). Misdiagnosis extended emergency department stay (median 6.6 [4.7–10.4] vs 5.8 [3.7–9.2] hours; p = 0.001) and led to unnecessary stroke unit stay (n = 10). Detailed review revealed 8 cases (0.8%) in which misdiagnosis was possible or likely to have worsened outcomes, but no death occurred as a result of misdiagnosis.ConclusionsOur findings support the safety of highly optimized door-to-needle times, built on thorough training in a large-volume, centralized stroke service with long-standing experience. Augmented imaging and front-loaded specialist engagement are warranted to further improve rapid stroke diagnostics.
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25
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Holodinsky JK, Patel AB, Thornton J, Kamal N, Jewett LR, Kelly PJ, Murphy S, Collins R, Walsh T, Cronin S, Power S, Brennan P, O’hare A, McCabe DJH, Moynihan B, Looby S, Wyse G, McCormack J, Marsden P, Harbison J, Hill MD, Williams D. Drip and ship versus direct to endovascular thrombectomy: The impact of treatment times on transport decision-making. Eur Stroke J 2018; 3:126-135. [PMID: 31008345 PMCID: PMC6460407 DOI: 10.1177/2396987318759362] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 01/23/2018] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION In ischaemic stroke care, fast reperfusion is essential for disability free survival. It is unknown if bypassing thrombolysis centres in favour of endovascular thrombectomy (mothership) outweighs transport to the nearest thrombolysis centre for alteplase and then transfer for endovascular thrombectomy (drip-and-ship). We use conditional probability modelling to determine the impact of treatment times on transport decision-making for acute ischaemic stroke. MATERIALS AND METHODS Probability of good outcome was modelled using a previously published framework, data from the Irish National Stroke Register, and an endovascular thrombectomy registry at a tertiary referral centre in Ireland. Ireland was divided into 139 regions, transport times between each region and hospital were estimated using Google's Distance Matrix Application Program Interface. Results were mapped using ArcGIS 10.3. RESULTS Using current treatment times, drip-and-ship rarely predicts best outcomes. However, if door to needle times are reduced to 30 min, drip-and-ship becomes more favourable; even more so if turnaround time (time from thrombolysis to departure for the endovascular thrombectomy centre) is also reduced. Reducing door to groin puncture times predicts better outcomes with the mothership model. DISCUSSION This is the first case study modelling pre-hospital transport for ischaemic stroke utilising real treatment times in a defined geographic area. A moderate improvement in treatment times results in significant predicted changes to the optimisation of a national acute stroke patient transport strategy. CONCLUSIONS Modelling patient transport for system-level planning is sensitive to treatment times at both thrombolysis and thrombectomy centres and has important implications for the future planning of thrombectomy services.
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Affiliation(s)
- Jessalyn K Holodinsky
- Department of Community Health Sciences, University of Calgary,
Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary,
Alberta, Canada
| | - Alka B Patel
- Department of Community Health Sciences, University of Calgary,
Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary,
Calgary, Alberta, Canada
| | - John Thornton
- Department of Neuroradiology, Royal College of Surgeons in
Ireland, Dublin, Ireland
- Beaumont Hospital, Dublin, Ireland
| | - Noreen Kamal
- Department of Clinical Neurosciences, University of Calgary,
Calgary, Alberta, Canada
| | - Lauren R Jewett
- Department of Geography, University of Calgary, Calgary,
Alberta, Canada
| | - Peter J Kelly
- Neurovascular Unit for Translational and Therapeutics Research,
Mater Misericordiae University Hospital/University College Dublin, Dublin,
Ireland
| | - Sean Murphy
- Department of Geriatric and Stroke Medicine, Royal College of
Surgeons in Ireland, Dublin, Ireland
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Ronan Collins
- Department of Geriatric and Stroke Medicine, Tallaght Hospital,
Dublin, Ireland
| | - Thomas Walsh
- Department of Stroke and Geriatric Medicine, Galway University
Hospital, Galway, Ireland
| | - Simon Cronin
- Cork NeuroScience Centre, University College Cork, Cork,
Ireland
- Department of Neurology, Cork University Hospital, Cork,
Ireland
| | - Sarah Power
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Paul Brennan
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Alan O’hare
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Dominick JH McCabe
- Department of Neurology, Stroke Service, and Vascular Neurology
Research Foundation, The Adelaide and Meath
Hospital (incorporating the National Children’s Hospital), Dublin,
Ireland
- Department of Clinical Neurosciences, UCL Institute of
Neurology, London, UK
- Academic Unit of Neurology, School of Medicine, Trinity College
Dublin, Dublin, Ireland
| | - Barry Moynihan
- Department of Geriatric and Stroke Medicine, Beaumont Hospital, Dublin, Ireland
| | - Seamus Looby
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Gerald Wyse
- Department of Neuroradiology, Cork University Hospital, Cork,
Ireland
| | - Joan McCormack
- Faculty of Science and Health, Dublin City University, Dublin,
Ireland
| | - Paul Marsden
- Department of Public Health, Health Services Executive,
Tulamore, Ireland
| | - Joseph Harbison
- Department of Medical Gerontology, Trinity College Dublin,
Dublin, Ireland
| | - Michael D Hill
- Department of Community Health Sciences, University of Calgary,
Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary,
Alberta, Canada
- Department of Clinical Neurosciences, University of Calgary,
Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary,
Alberta, Canada
- Department of Medicine, University of Calgary, Calgary,
Alberta, Canada
- Calgary Stroke Program, University of Calgary, Calgary,
Alberta, Canada
| | - David Williams
- Beaumont Hospital, Dublin, Ireland
- Department of Geriatric and Stroke Medicine, Royal College of
Surgeons in Ireland, Dublin, Ireland
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Chen Z, Churilov L, Chen Z, Naylor J, Koome M, Yan B, Kwan P. Association between implementation of a code stroke system and poststroke epilepsy. Neurology 2018; 90:e1126-e1133. [DOI: 10.1212/wnl.0000000000005212] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 01/02/2018] [Indexed: 02/02/2023] Open
Abstract
ObjectiveWe aimed to investigate the effect of a code stroke system on the development of poststroke epilepsy.MethodsWe retrospectively analyzed consecutive patients treated with IV thrombolysis under or outside the code stroke system between 2003 and 2012. Patients were followed up for at least 2 years or until death. Factors with p < 0.1 in univariate comparisons were selected for multivariable logistic and Cox regression.ResultsA total of 409 patients met the eligibility criteria. Their median age at stroke onset was 75 years (interquartile range 64–83 years); 220 (53.8%) were male. The median follow-up duration was 1,074 days (interquartile range 119–1,671 days). Thirty-two patients (7.8%) had poststroke seizures during follow-up, comprising 7 (1.7%) with acute symptomatic seizures and 25 (6.1%) with late-onset seizures. Twenty-six patients (6.4%) fulfilled the definition of poststroke epilepsy. Three hundred eighteen patients (77.8%) were treated with the code stroke system while 91 (22.2%) were not. After adjustment for age and stroke etiology, use of the code stroke system was associated with decreased odds of poststroke epilepsy (odds ratio = 0.36, 95% confidence interval 0.14–0.87, p = 0.024). Cox regression showed lower adjusted hazard rates for poststroke epilepsy within 5 years for patients managed under the code stroke system (hazard ratio = 0.60, 95% confidence interval 0.47–0.79, p < 0.001).ConclusionThe code stroke system was associated with reduced odds and instantaneous risk of poststroke epilepsy. Further studies are required to identify the contribution of the individual components and mechanisms against epileptogenesis after stroke.Classification of evidenceThis study provides Class III evidence that for people with acute ischemic stroke, implementation of a code stroke system reduces the risk of poststroke epilepsy.
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Allen M, Pearn K, Villeneuve E, Monks T, Stein K, James M. Feasibility of a hyper-acute stroke unit model of care across England: a modelling analysis. BMJ Open 2017; 7:e018143. [PMID: 29247093 PMCID: PMC5736033 DOI: 10.1136/bmjopen-2017-018143] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The policy of centralising hyperacute stroke units (HASUs) in England aims to provide stroke care in units that are both large enough to sustain expertise (>600 admissions/year) and dispersed enough to rapidly deliver time-critical treatments (<30 min maximum travel time). Currently, just over half (56%) of patients with stroke access care in such a unit. We sought to model national configurations of HASUs that would optimise both institutional size and geographical access to stroke care, to maximise the population benefit from the centralisation of stroke care. DESIGN Modelling of the effect of the national reconfiguration of stroke services. Optimal solutions were identified using a heuristic genetic algorithm. SETTING 127 acute stroke services in England, serving a population of 54 million people. PARTICIPANTS 238 887 emergency admissions with acute stroke over a 3-year period (2013-2015). INTERVENTION Modelled reconfigurations of HASUs optimised for institutional size and geographical access. MAIN OUTCOME MEASURE Travel distances and times to HASUs, proportion of patients attending a HASU with at least 600 admissions per year, and minimum and maximum HASU admissions. RESULTS Solutions were identified with 75-85 HASUs with annual stroke admissions in the range of 600-2000, which achieve up to 82% of patients attending a stroke unit within 30 min estimated travel time (with at least 95% and 98% of the patients being within 45 and 60 min travel time, respectively). CONCLUSIONS The reconfiguration of hyperacute stroke services in England could lead to all patients being treated in a HASU with between 600 and 2000 admissions per year. However, the proportion of patients within 30 min of a HASU would fall from over 90% to 80%-82%.
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Affiliation(s)
- Michael Allen
- Institute of Health Research, University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Kerry Pearn
- Institute of Health Research, University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Emma Villeneuve
- Institute of Health Research, University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Thomas Monks
- NIHR CLAHRC Wessex Data Science Hub, Southampton General Hospital, Southampton, UK
| | - Ken Stein
- Institute of Health Research, University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Martin James
- Stroke Services, Royal Devon & Exeter NHS trust, Exeter, UK
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Tahtali D, Bohmann F, Kurka N, Rostek P, Todorova-Rudolph A, Buchkremer M, Abruscato M, Hartmetz AK, Kuhlmann A, Henke C, Stegemann A, Menon S, Misselwitz B, Reihs A, Weidauer S, Thonke S, Meyding-Lamadé U, Singer O, Steinmetz H, Pfeilschifter W. Implementation of stroke teams and simulation training shortened process times in a regional stroke network-A network-wide prospective trial. PLoS One 2017; 12:e0188231. [PMID: 29206838 PMCID: PMC5716597 DOI: 10.1371/journal.pone.0188231] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 11/02/2017] [Indexed: 11/22/2022] Open
Abstract
Background To meet the requirements imposed by the time-dependency of acute stroke therapies, it is necessary 1) to initiate structural and cultural changes in the breadth of stroke-ready hospitals and 2) to find new ways to train the personnel treating patients with acute stroke. We aimed to implement and validate a composite intervention of a stroke team algorithm and simulation-based stroke team training as an effective quality initiative in our regional interdisciplinary neurovascular network consisting of 7 stroke units. Methods We recorded door-to-needle times of all consecutive stroke patients receiving thrombolysis at seven stroke units for 3 months before and after a 2 month intervention which included setting up a team-based stroke workflow at each stroke unit, a train-the-trainer seminar for stroke team simulation training and a stroke team simulation training session at each hospital as well as a recommendation to take up regular stroke team trainings. Results The intervention reduced the network-wide median door-to-needle time by 12 minutes from 43,0 (IQR 29,8–60,0, n = 122) to 31,0 (IQR 24,0–42,0, n = 112) minutes (p < 0.001) and substantially increased the share of patients receiving thrombolysis within 30 minutes of hospital arrival from 41.5% to 59.6% (p < 0.001). Stroke team training participants stated a significant increase in knowledge on the topic of acute stroke care and in the perception of patient safety. The overall course concept was regarded as highly useful by most participants from different professional backgrounds. Conclusions The composite intervention of a binding team-based algorithm and stroke team simulation training showed to be well-transferable in our regional stroke network. We provide suggestions and materials for similar campaigns in other stroke networks.
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Affiliation(s)
- Damla Tahtali
- Department of Neurology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Ferdinand Bohmann
- Department of Neurology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Natalia Kurka
- Department of Neurology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Peter Rostek
- NICU Nursing Staff, University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | | | | | | | - Andrea Kuhlmann
- Department of Neurology, Krankenhaus Nordwest, Frankfurt am Main, Germany
| | - Christian Henke
- Department of Neurology, Helios HSK Wiesbaden, Wiesbaden, Germany
| | - André Stegemann
- Department of Neurology, Sankt Katharinen-Krankenhaus, Frankfurt am Main, Germany
| | - Sanjay Menon
- Department of Neurology, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Germany
| | - Björn Misselwitz
- Geschäftsstelle Qualitätssicherung Hessen (GQH), Eschborn, Frankfurt, Germany
| | - Anke Reihs
- Geschäftsstelle Qualitätssicherung Hessen (GQH), Eschborn, Frankfurt, Germany
| | - Stefan Weidauer
- Department of Neurology, Sankt Katharinen-Krankenhaus, Frankfurt am Main, Germany
| | - Sven Thonke
- Department of Neurology, Klinikum Hanau, Hanau, Germany
| | - Uta Meyding-Lamadé
- Department of Neurology, Krankenhaus Nordwest, Frankfurt am Main, Germany
| | - Oliver Singer
- Department of Neurology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Helmuth Steinmetz
- Department of Neurology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Waltraud Pfeilschifter
- Department of Neurology, University Hospital Frankfurt, Frankfurt am Main, Germany
- * E-mail:
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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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Tsai MT, Yen YL, Su CM, Hung CW, Kung CT, Wu KH, Cheng HH. The influence of emergency department crowding on the efficiency of care for acute stroke patients. Int J Qual Health Care 2017; 28:774-778. [PMID: 27678127 DOI: 10.1093/intqhc/mzw109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 08/04/2016] [Indexed: 12/18/2022] Open
Abstract
Objective To investigate the impact of emergency department (ED) crowding (number of ED patients) and number of ED staff on the efficiency of the ED care process for acute stroke patients. Design Retrospective cohort study conducted from 1 May 2008 to 31 December 2013. Setting Largest primary stroke center (3000-bed tertiary academic hospital) in southern Taiwan. Participants Patients aged 18-80 years presenting to the ED with acute stroke symptoms ≤3 h from symptom onset (n = 1142). Main Outcome Measures Door-to-assessment time (DTA), door-to-computed tomography completion time (DTCT) and door-to-needle time (DTN). Results Of the 785 patients with ischemic stroke, 90 (11.46%) received thrombolysis. In the multivariate regression analysis, the number of ED patients and the number of attending physicians were significantly associated with delayed DTA and DTCT but not DTN. Initial assessment by a resident was also associated with delayed DTA and DTCT. The number of nurses was associated with delayed DTCT and DTN. Conclusions Although ED crowding was not associated with delayed DTN, it predicted delayed DTA and DTCT in thrombolysis-eligible stroke patients. The number of attending physicians affected initial assessment and DTCTs, whereas the number of nurses impacted thrombolytic administration times.
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Affiliation(s)
- Ming-Ta Tsai
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No.123, Dapi Rd., Niaosong Dist., Kaohsiung 83301, Taiwan
| | - Yung-Lin Yen
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No.123, Dapi Rd., Niaosong Dist., Kaohsiung 83301, Taiwan
| | - Chih-Min Su
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No.123, Dapi Rd., Niaosong Dist., Kaohsiung 83301, Taiwan
| | - Chih-Wei Hung
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No.123, Dapi Rd., Niaosong Dist., Kaohsiung 83301, Taiwan
| | - Chia-Te Kung
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No.123, Dapi Rd., Niaosong Dist., Kaohsiung 83301, Taiwan
| | - Kuan-Han Wu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No.123, Dapi Rd., Niaosong Dist., Kaohsiung 83301, Taiwan
| | - Hsien-Hung Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No.123, Dapi Rd., Niaosong Dist., Kaohsiung 83301, Taiwan
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Oluwole SA, Wang K, Dong C, Ciliberti-Vargas MA, Gutierrez CM, Yi L, Romano JG, Perez E, Tyson BA, Ayodele M, Asdaghi N, Gardener H, Rose DZ, Garcia EJ, Zevallos JC, Foster D, Robichaux M, Waddy SP, Sacco RL, Rundek T. Disparities and Trends in Door-to-Needle Time: The FL-PR CReSD Study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities). Stroke 2017; 48:2192-2197. [PMID: 28706119 PMCID: PMC5639478 DOI: 10.1161/strokeaha.116.016183] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 05/16/2017] [Accepted: 05/25/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In the United States, about half of acute ischemic stroke patients treated with tPA (tissue-type plasminogen activator) receive treatment within 60 minutes of hospital arrival. We aimed to determine the proportion of patients receiving tPA within 60 minutes (door-to-needle time [DTNT] ≤60) and 45 minutes (DTNT ≤45) of hospital arrival by race/ethnicity and sex and to identify temporal trends in DTNT ≤60 and DTNT ≤45. METHODS Among 65 654 acute ischemic stroke admissions in the National Institute of Neurological Disorders and Stroke-funded FL-PR CReSD study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities) from 2010 to 2015, we included 6181 intravenous tPA-treated cases (9.4%). Generalized estimating equations were used to determine predictors of DTNT ≤60 and DTNT ≤45. RESULTS DTNT ≤60 was achieved in 42% and DTNT ≤45 in 18% of cases. After adjustment, women less likely received DTNT ≤60 (odds ratio, 0.81; 95% confidence interval, 0.72-0.92) and DTNT ≤45 (odds ratio, 0.73; 95% confidence interval, 0.57-0.93). Compared with Whites, Blacks less likely had DTNT ≤45 during off hours (odds ratio, 0.68; 95% confidence interval, 0.47-0.98). Achievement of DTNT ≤60 and DTNT ≤45 was highest in South Florida (50%, 23%) and lowest in West Central Florida (28%, 11%). CONCLUSIONS In the FL-PR CReSD, achievement of DTNT ≤60 and DTNT ≤45 remains low. Compared with Whites, Blacks less likely receive tPA treatment within 45 minutes during off hours. Treatment within 60 and 45 minutes is lower in women compared with men and lowest in West Central Florida compared with other Florida regions and Puerto Rico. Further research is needed to identify reasons for delayed thrombolytic treatment in women and Blacks and factors contributing to regional disparities in DTNT.
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Affiliation(s)
- Sofia A Oluwole
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.)
| | - Kefeng Wang
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.)
| | - Chuanhui Dong
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.)
| | - Maria A Ciliberti-Vargas
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.)
| | - Carolina M Gutierrez
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.)
| | - Li Yi
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.)
| | - Jose G Romano
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.)
| | - Enmanuel Perez
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.)
| | - Brittany Ann Tyson
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.)
| | - Maranatha Ayodele
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.)
| | - Negar Asdaghi
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.)
| | - Hannah Gardener
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.)
| | - David Z Rose
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.)
| | - Enid J Garcia
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.)
| | - Juan Carlos Zevallos
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.)
| | - Dianne Foster
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.)
| | - Mary Robichaux
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.)
| | - Salina P Waddy
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.)
| | - Ralph L Sacco
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.)
| | - Tatjana Rundek
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (S.A.O., K.W., C.D., M.A.C.-V., C.M.G., L.Y., J.G.R., E.P., B.A.T., M.A., N.A., H.G., R.L.S., T.R.); Department of Neurology, University of South Florida Morsani College of Medicine, Tampa (D.Z.R.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (S.P.W.); The American Heart Association, Greater Southeast Affiliate, Marietta, GA (D.F., M.R.); and Florida International University Herbert Wertheim College of Medicine, Miami (J.C.Z) and University of Puerto Rico School of Medicine Endowed Health Services Research Center, San Juan (E.J.G.).
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Reuter B, Sauer T, Gumbinger C, Bruder I, Preussler S, Hacke W, Hennerici MG, Ringleb PA, Kern R, Stock C. Diurnal Variation of Intravenous Thrombolysis Rates for Acute Ischemic Stroke and Associated Quality Performance Parameters. Front Neurol 2017; 8:341. [PMID: 28785239 PMCID: PMC5519519 DOI: 10.3389/fneur.2017.00341] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 06/29/2017] [Indexed: 11/13/2022] Open
Abstract
Introduction Based on data from the Baden-Wuerttemberg stroke registry, we aimed to explore the diurnal variation of acute ischemic stroke (IS) care delivery. Materials and methods 92,530 IS patients were included, of whom 37,471 (40%) presented within an onset-to-door time ≤4.5 h. Daytime was stratified in 3-h time intervals and working vs. non-working hours. Stroke onset and hospital admission time, rate of door-to-neurological examination time ≤30 min, onset-/door-to-imaging time IV thrombolysis (IVT) rates, and onset-/door-to-needle time were determined. Multivariable regression models were used stratified by stroke onset and hospital admission time to assess the relationship between IVT rates, quality performance parameters, and daytime. The time interval 0:00 h to 3:00 h and working hours, respectively, were taken as reference. Results The IVT rate of the whole study population was strongly associated with the sleep–wake cycle. In patients presenting within the 4.5-h time window and potentially eligible for IVT stratification by hospital admission time identified two time intervals with lower IVT rates. First, between 3:01 h and 6:00 h (IVT rate 18%) and likely attributed to in-hospital delays with the lowest diurnal rate of door-to-neurological examination time ≤30 min and the longest door-to-needle time Second, between 6:01 h and 15:00 h (IVT rate 23–25%) compared to the late afternoon and evening hours (IVT rate 27–29%) due to a longer onset-to-imaging time and door-to-imaging time. No evidence for a compromised stroke service during non-working hours was observed. Conclusion The analysis provides evidence that acute IS care is subject to diurnal variation which may affect stroke outcome. An optimization of IS care aiming at constantly high IVT rates over the course of the day therefore appears desirable.
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Affiliation(s)
- Björn Reuter
- Department of Neurology and Geriatrics, Helios Klinik Müllheim, Müllheim, Germany.,Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Freiburg, Germany
| | - Tamara Sauer
- Department of Neurology, Universitätsmedizin Mannheim, Heidelberg University, Heidelberg, Germany
| | | | - Ingo Bruder
- Office for Quality Assurance in Hospitals (GeQiK), Baden-Wuerttembergische Hospital Association, Stuttgart, Germany
| | - Stella Preussler
- Institute of Medical Biometry and Informatics, Heidelberg University, Heidelberg, Germany
| | - Werner Hacke
- Department of Neurology, Heidelberg University, Heidelberg, Germany
| | - Michael G Hennerici
- Department of Neurology, Universitätsmedizin Mannheim, Heidelberg University, Heidelberg, Germany
| | - Peter A Ringleb
- Department of Neurology, Heidelberg University, Heidelberg, Germany
| | - Rolf Kern
- Department of Neurology, Klinikum Kempten, Kempten, Germany
| | - Christian Stock
- Institute of Medical Biometry and Informatics, Heidelberg University, Heidelberg, Germany.,Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
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Kamal N, Sheng S, Xian Y, Matsouaka R, Hill MD, Bhatt DL, Saver JL, Reeves MJ, Fonarow GC, Schwamm LH, Smith EE. Delays in Door-to-Needle Times and Their Impact on Treatment Time and Outcomes in Get With The Guidelines-Stroke. Stroke 2017; 48:946-954. [DOI: 10.1161/strokeaha.116.015712] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/22/2016] [Accepted: 01/13/2017] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Despite quality improvement programs such as the American Heart Association/American Stroke Association Target Stroke initiative, a substantial portion of acute ischemic stroke patients are still treated with tissue-type plasminogen activator (alteplase) later than 60 minutes from arrival. This study aims to describe the documented reasons for delays and the associations between reasons for delays and patient outcomes.
Methods—
We analyzed the characteristics of 55 296 patients who received intravenous alteplase in 1422 hospitals participating in Get With The Guidelines-Stroke from October 2012 to April 2015, excluding transferred patients and inpatient strokes. We assessed eligibility, medical, and hospital reasons for delays in door-to-needle time.
Results—
There were 27 778 patients (50.2%) treated within 60 minutes, 10 086 patients (18.2%) treated >60 minutes without documented delays, and 17 432 patients (31.5%) treated >60 minutes with one or more documented reasons for delay. Delayed door-to-needle times were associated with delayed diagnosis (36 minutes longer than those without delay in diagnosis) and hypoglycemia or seizure (34 minutes longer than without those conditions). The presence of documented delays was associated with higher odds of in-hospital mortality (odds ratio, 1.2; 95% confidence interval, 1.1–1.3) and symptomatic intracranial hemorrhage (odds ratio, 1.2; 95% confidence interval, 1.1–1.3) and lower odds of independent ambulation at discharge (odds ratio, 0.92; 95% confidence interval, 0.9–1.0) after adjusting for patient and hospital characteristics.
Conclusions—
Hospital and eligibility delays such as delay diagnosis and inability to determine eligibility were associated with longer door-to-needle times. Improved stroke recognition and management of acute comorbidities may help to reduce door-to-needle times.
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Affiliation(s)
- Noreen Kamal
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Shubin Sheng
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Ying Xian
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Roland Matsouaka
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Michael D. Hill
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Deepak L. Bhatt
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Jeffrey L. Saver
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Mathew J. Reeves
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Gregg C. Fonarow
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Lee H. Schwamm
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Eric E. Smith
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
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Miller JB, Merck LH, Wira CR, Meurer WJ, Schrock JW, Nomura JT, Siket MS, Madsen TE, Wright DW, Panagos PD, Lewandowski C. The Advanced Reperfusion Era: Implications for Emergency Systems of Ischemic Stroke Care. Ann Emerg Med 2017; 69:192-201. [DOI: 10.1016/j.annemergmed.2016.06.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 06/16/2016] [Accepted: 06/24/2016] [Indexed: 11/30/2022]
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Puy L, Lamy C, Canaple S, Arnoux A, Laine N, Iacob E, Constans JM, Godefroy O. Creation of an intensive care unit and organizational changes in an adult emergency department: Impact on acute stroke management. Am J Emerg Med 2017; 35:716-719. [PMID: 28096032 DOI: 10.1016/j.ajem.2017.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 12/26/2016] [Accepted: 01/07/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND PURPOSE Following the reorganization of a University Medical Center onto a single campus, an Intensive Care Unit was created within the adult Emergency Department (ED ICU). We assessed the effects of these organizational changes on acute stroke management and the intravenous administration of recombinant tissue plasminogen activator (IV rtPA), as characterized by the thrombolysis rate, door-to-needle time (DNT) and outcome at 3months. METHODS Between October 2013 and September 2015, we performed a retrospective, observational, single-center, comparative study of patients admitted for ischemic stroke and treated with IV rtPA during two 321-day periods (before and after the creation of the ED ICU). All patients with ischemic stroke were included. Multivariable logistic regression models were performed. The DNT was stratified according to a threshold of 60min. A favorable long-term outcome was defined as a modified Rankin score≤2 at 3months. RESULTS A total of 1334 ischemic stroke patients were included. Among them, 101 patients received IV rtPA. The frequency of IV rtPA administration was 5.8% (39 out of 676) before the creation of the ED ICU, and 9.3% (62 out of 668) afterwards (odds ratio (OR) [95% confidence interval (CI)]: 1.67 [1.08-2.60]; p=0.02). Additionally, the DNT was shorter (OR [95%CI]: 4.30 [1.17-20.90]; p=0.04) and there was an improvement in the outcome (OR [95%CI]=1.30 [1.01-2.10]; p=0.045). CONCLUSION Our results highlight the benefits of a separate ED ICU within conventional ED for acute stroke management, with a higher thrombolysis rate, reduced intrahospital delays and better safety.
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Affiliation(s)
- Laurent Puy
- Department of Neurology and Functional Neuroscience Laboratory EA 4559, Amiens University Medical Center, Amiens, France.
| | - Chantal Lamy
- Department of Neurology and Functional Neuroscience Laboratory EA 4559, Amiens University Medical Center, Amiens, France
| | - Sandrine Canaple
- Department of Neurology and Functional Neuroscience Laboratory EA 4559, Amiens University Medical Center, Amiens, France
| | - Audrey Arnoux
- Department of Neurology and Functional Neuroscience Laboratory EA 4559, Amiens University Medical Center, Amiens, France
| | - Nicolas Laine
- Department of Emergency Medicine, Amiens University Medical Center, Amiens, France
| | - Ella Iacob
- Department of Emergency Medicine, Amiens University Medical Center, Amiens, France
| | - Jean-Marc Constans
- Department of Neuroimaging, Amiens University Medical Center, Amiens, France
| | - Olivier Godefroy
- Department of Neurology and Functional Neuroscience Laboratory EA 4559, Amiens University Medical Center, Amiens, France
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Khor MX, Bown A, Barrett A, Counsell CE, MacLeod MJ, Reid JM. Pre-hospital notification is associated with improved stroke thrombolysis timing. J R Coll Physicians Edinb 2016; 45:190-5. [PMID: 26517096 DOI: 10.4997/jrcpe.2015.303] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Intravenous thrombolysis increases disability-free survival after acute ischaemic stroke in a time-dependent fashion. We aimed to determine whether pre-hospital notification, introduction of a CT scanner near to assessment site and introduction of out-of-hours thrombolysis services affect thrombolysis timing. Methods Timings related to thrombolysis were collected between May 2012 and June 2014 at a single hospital site; these included time to stroke physician assessment, time to cranial CT imaging and door to needle time. All thrombolysed ischaemic stroke patients admitted via the emergency department were included. Ambulance services were asked to pre-notify the emergency department of any suspected stroke patient during this period. Results We studied 182 patients (48% female; mean age 74 years; 59% pre-notified). Pre-hospital notification was associated with a significantly higher rate of CT scanning within 25 minutes (60% vs 24%, odds ratio [OR] 4.7, 95% confidence interval [CI] 2.4-9.0; p<0.001), earlier stroke physician assessment (median 6 vs 32 minutes; p<0.001) and receiving thrombolysis within 60 minutes (89% vs 49%, OR 8.0, 95% CI 3.8-16.9; p<0.001). Being treated outside normal working hours did not alter thrombolysis timing. Logistic regression identified the introduction of a near-site CT scanner (OR 4.6 [95% CI 1.7-12.5]) and pre-hospital notification (OR 4.7, [95% CI 2.3-9.6]) as independent predictors of door to CT time less than or equal to 25 minutes, and pre-hospital notification (OR 11.6, [95% CI 4.9-30.3]) and stroke severity (OR 1.15 per point of NIHSS scale, [95% CI 1.08-1.23]) as predictors of door to thrombolysis time less than or equal to 60 minutes. The most common perceived timing delays were radiology-related (33%), the need to acutely lower blood pressure (15%) and obtaining consent (12%). Conclusion Pre-hospital notification is associated with earlier stroke physician review, CT imaging and delivery of thrombolysis. Referral to an out of hours thrombolysis service was not associated with additional delay.
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Affiliation(s)
- M X Khor
- MX Khor, Acute Stroke Unit, Ward 204, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK. Email
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Nascimento KGD, Chavaglia SRR, Pires PDS, Ribeiro SBF, Barbosa MH. Desfechos clínicos de pacientes com acidente vascular cerebral isquêmico após terapia trombolítica. ACTA PAUL ENFERM 2016. [DOI: 10.1590/1982-0194201600091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Resumo Objetivo Analisar desfechos e fatores associados em pacientes com acidente vascular cerebral isquêmico após terapia trombolítica. Métodos Estudo do tipo coorte retrospectivo de pacientes com acidente vascular cerebral isquêmico submetidos à terapia trombolítica. Foram descritas as comorbidades; os défices neurológicos e os tempos de atendimento. Utilizou-se o teste qui quadrado para associação entre comorbidades, tempos de atendimento e ocorrência de transformação hemorrágica. Resultados Houve elevada frequência de comorbidades. Défices neurológicos pontuaram média de 15 pontos. A janela de tempo obteve média de 98 minutos e o tempo porta-agulha, 89,8 minutos. Observou-se transformação hemorrágica em 20 pacientes. Na análise bivariada, a ocorrência de transformação hemorrágica esteve associada com maior défice neurológico, fibrilação atrial e cardiopatia. Houve redução dos défices neurológicos de 51% para 12,5 entre a admissão e alta. Conclusão A terapia trombolítica apresentou resultados positivos, apesar de tempos de atendimento elevados e pacientes com défices neurológicos com elevada pontuação.
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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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Rudd AG. Can emergency stroke care be delivered in an ambulance? Lancet Neurol 2016; 15:998-1000. [DOI: 10.1016/s1474-4422(16)30162-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 06/27/2016] [Indexed: 11/15/2022]
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Mokin M, Snyder KV, Siddiqui AH, Levy EI, Hopkins LN. Recent Endovascular Stroke Trials and Their Impact on Stroke Systems of Care. J Am Coll Cardiol 2016; 67:2645-55. [DOI: 10.1016/j.jacc.2015.12.077] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 11/30/2015] [Accepted: 12/01/2015] [Indexed: 11/16/2022]
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Hsieh MJ, Tang SC, Chiang WC, Tsai LK, Jeng JS, Ma MHM. Effect of prehospital notification on acute stroke care: a multicenter study. Scand J Trauma Resusc Emerg Med 2016; 24:57. [PMID: 27121501 PMCID: PMC4847216 DOI: 10.1186/s13049-016-0251-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 04/20/2016] [Indexed: 11/24/2022] Open
Abstract
Background The sooner thrombolytic therapy is given to acute ischemic stroke patients, the better the outcome. Prehospital notification may shorten the time between hospital arrival and brain computed tomography (door-to-CT) and the door-to-needle (DTN) time. This study investigated the effect of prehospital notification on acute stroke care in an urban city in Taiwan. Methods This retrospective observational study utilized a prospectively collected dataset from patients treated at 9 hospitals and the emergency medical service (EMS) system in Taipei City from September 1, 2012 to December 31, 2014. During the study period, prehospital notification was performed by emergency medical technicians if the patient met the following criteria: (1) positive Cincinnati Prehospital Stroke Scale (CPSS), (2) symptom onset within 3 h, and (3) a sugar pinprick test result ≥ 60 mg/dL. The demographics, final diagnoses, and data associated with stroke for all patients in the prenotification group and for patients diagnosed with acute stroke within 3 h of symptoms onset were prospectively recorded in the stroke registry. The primary outcome was door-to-CT time and the secondary outcome was DTN time. The sensitivity and positive predictive value (PPV) of prehospital notifications and the association between the volume of patients receiving thrombolytic therapy at individual hospitals and DTN time were also evaluated. Results There were 928 patients who presented ≤ 3 h from stroke onset. Among them, 727 (78.3 %) patients were in the prenotification group; of these, more were male, smokers, and presented with severe symptoms, and fewer had a history of prior stroke or cardiac diseases compared to patients in the non-prenotification group. The median door-to-CT time was significantly shorter in the prenotification group than among the non-prenotification group (13 versus 19 min, p < 0.001). Prenotification was associated with shorter DTN time (63 versus 68 min, p = 0.138). The sensitivity and PPV of prenotification of stroke were 78.3 % and 78.2 %, respectively. The DTN time demonstrated a significant and highly negative association with the volume of patients receiving thrombolytic therapy (Spearman’s correlation coefficient -0.90, p < 0.001). Discussion In our study, we found prehospital notification was associated with faster door-to-CT scan and shorter DTN time in patients presenting within 3 hours of symptom onset. Such a close collaboration between hospitals and the EMS system gives citizens an in-time emergency care network. Our study revealed that, like in other countries, prehospital notification for stroke patients improved in-hospital stroke care in Taiwan. Our study showed that the sensitivity and PPV of prenotification decisions according to our CPSS-based criteria was comparable with those in other studies. Our study also found that DTN time was shorter in the hospital that treated a greater volume of patients with thrombolytic therapy. A multicenter collaboration program is needed to help those hospitals with relatively lower stroke patient volume to set up interventions that have been proven to improve stroke care. Conclusions Prehospital notification of stroke can significantly shorten door-to-CT time and improve acute stroke care in Taiwan.
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Affiliation(s)
- Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan.,Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan
| | - Wen-Chu Chiang
- Department of Emergency Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan
| | - Li-Kai Tsai
- Department of Neurology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan.
| | - Matthew Huei-Ming Ma
- Department of Emergency Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan.
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Groot AE, van Schaik IN, Visser MC, Nederkoorn PJ, Limburg M, Aramideh M, de Beer F, Zwetsloot CP, Halkes P, de Kruijk J, Kruyt ND, van der Meulen W, Spaander F, van der Ree T, Kwa VIH, Van den Berg-Vos RM, Roos YB, Coutinho JM. Association between i.v. thrombolysis volume and door-to-needle times in acute ischemic stroke. J Neurol 2016; 263:807-13. [PMID: 26946499 PMCID: PMC4826653 DOI: 10.1007/s00415-016-8076-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 02/16/2016] [Accepted: 02/16/2016] [Indexed: 11/30/2022]
Abstract
Centralization of intravenous thrombolysis (IVT) for acute ischemic stroke in high-volume centers is believed to improve the door-to-needle times (DNT), but limited data support this assumption. We examined the association between DNT and IVT volume in a large Dutch province. We identified consecutive patients treated with IVT between January 2009 and 2013. Based on annualized IVT volume, hospitals were categorized as low-volume (≤ 24), medium-volume (25-49) or high-volume (≥ 50). In logistic regression analysis, low-volume hospitals were used as reference category. Of 17,332 stroke patients from 11 participating hospitals, 1962 received IVT (11.3 %). We excluded 140 patients because of unknown DNT (n = 86) or in-hospital stroke (n = 54). There were two low-volume (total 101 patients), five medium-volume (747 patients) and four high-volume hospitals (974 patients). Median DNT was shorter in high-volume hospitals (30 min) than in medium-volume (42 min, p < 0.001) and low-volume hospitals (38 min, p < 0.001). Patients admitted to high-volume hospitals had a higher chance of DNT < 30 min (adjusted OR 3.13, 95 % CI 1.70-5.75), lower risk of symptomatic intracerebral hemorrhage (adjusted OR 0.39, 95 % CI 0.16-0.92), and a lower mortality risk (adjusted OR 0.45, 95 % CI 0.21-1.01), compared to low-volume centers. There was no difference in DNT between low- and medium-volume hospitals. Onset-to-needle times (ONT) did not differ between the groups. Hospitals in this Dutch province generally achieved short DNTs. Despite this overall good performance, higher IVT volumes were associated with shorter DNTs and lower complication risks. The ONT was not associated with IVT volume.
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Affiliation(s)
- Adrien E Groot
- Department of Neurology, Academic Medical Center, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Ivo N van Schaik
- Department of Neurology, Academic Medical Center, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Marieke C Visser
- Department of Neurology, VU Medical Center, De Boelelaan 1118, 1081, HZ, Amsterdam, The Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Academic Medical Center, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Martien Limburg
- Department of Neurology, Flevoziekenhuis, Hospitaalweg 1, 1315, RA, Almere, The Netherlands
| | - Majid Aramideh
- Department of Neurology, Medical Centre Alkmaar, Wilhelminalaan 12, 1815, JD, Alkmaar, The Netherlands
| | - Frank de Beer
- Department of Neurology, Kennemer Gasthuis, Boerhaavelaan 22, 2035, RC, Haarlem, The Netherlands
| | - Caspar P Zwetsloot
- Department of Neurology, Waterland, Waterlandlaan 250, 1441, RN, Purmerend, The Netherlands
| | - Patricia Halkes
- Department of Neurology, Medical Centre Alkmaar, Wilhelminalaan 12, 1815, JD, Alkmaar, The Netherlands
| | - Jelle de Kruijk
- Department of Neurology, Tergooi Ziekenhuis, Rijksstraat 1, 1261, AN, Blaricum, The Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Slotervaart, Louwesweg 6, 1066, EC, Amsterdam, The Netherlands
- Department of Neurology, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Willem van der Meulen
- Department of Neurology, Rode Kruis Ziekenhuis, Vondellaan 13, 1942, LE, Beverwijk, The Netherlands
| | - Fianne Spaander
- Department of Neurology, Slotervaart, Louwesweg 6, 1066, EC, Amsterdam, The Netherlands
| | - Taco van der Ree
- Department of Neurology, Westfries Gasthuis, Maelsonstraat 3, 1624, NP, Hoorn, The Netherlands
| | - Vincent I H Kwa
- Department of Neurology, Onze Lieve Vrouw Gasthuis, Oosterpark 9, 1091, AC, Amsterdam, The Netherlands
| | - Renske M Van den Berg-Vos
- Department of Neurology, Sint Lucas Andreas Ziekenhuis, Jan Tooropstraat 164, 1061, AE, Amsterdam, The Netherlands
| | - Yvo B Roos
- Department of Neurology, Academic Medical Center, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Academic Medical Center, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
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Sanders KA, Patel R, Kiely JM, Gwynn MW, Johnston LH. Improving Telestroke Treatment Times in an Expanding Network of Hospitals. J Stroke Cerebrovasc Dis 2015; 25:288-91. [PMID: 26654667 DOI: 10.1016/j.jstrokecerebrovasdis.2015.09.030] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 09/25/2015] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Like all medical innovations, telestroke must demonstrate successful outcomes to achieve sustained growth and acceptance. Asserting that telemedicine is faster, employs the latest technology, or promotes a better use of limited resources is laudable but insufficient. An analysis of stroke treatment within a telemedicine network in 2013 showed that tissue-type plasminogen activator (tPA) could be safely and reliably administered within a practice-based model of telestroke care. Since then, hospital volume and tPA administration within this network have tripled. We hypothesize that a practice-based model of telestroke can maintain positive outcomes in the face of rapid growth. METHODS Data on tPA treatment times and outcomes after thrombolysis were gathered for 165 patients treated with alteplase between November 2012 and November 2014. Comparisons were made to a previous published study of 54 patients seen between October 2010 and October 2012 in the same network. Primary outcome measures were average door-to-needle (DTN) time for TPA administration and average call-to-needle (CTN) time. RESULTS Significant reductions were observed in median DTN (93 versus 75 minutes, P < .01) and median CTN (56 versus 41 minutes, P < .01). Quality outcome measures such as post-tPA symptomatic hemorrhage (2 [4%] versus 9 [5%], P = .23), length of stay (4 versus 4 days, P = .45), mortality (8 [15%] versus 16 [10%]; P = .32), and percentage of stroke patients treated remained stable. CONCLUSIONS This study shows that a practice-based telemedicine system can produce meaningful improvement in markers of telestroke efficiency in the face of rapid growth of a telestroke network.
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Affiliation(s)
| | - Rahul Patel
- AcuteCare Telemedicine, LLC, Atlanta, Georgia
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Härtig F, Purrucker J, Hametner C, Poli S. [From stroke to reperfusion : How can we be faster?]. Med Klin Intensivmed Notfmed 2015; 111:703-707. [PMID: 26459456 DOI: 10.1007/s00063-015-0092-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/01/2015] [Accepted: 08/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND During the last two decades major efforts in clinical research have led to the establishment of intravenous thrombolysis as the first line acute therapy for ischemic stroke. More recently, data from successful phase III trials have provided proof of the efficiency of mechanical recanalization in acute stroke. The fact that the efficiency of the available therapies can be increased through faster delivery is well documented; however, many institutions dealing with the emergency care of stroke patients lack organizational or infrastructural arrangements to optimize time efficiency in the diagnostic and therapeutic workup. CONCLUSION Many of these arrangements have been well evaluated, can be implemented at reasonable costs and have been proven to increase the beneficial effects of thrombolytic therapy.
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Affiliation(s)
- F Härtig
- Abteilung Neurologie mit Schwerpunkt neurovaskuläre Erkrankungen, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72070, Tübingen, Deutschland
| | - J Purrucker
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
| | - C Hametner
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
| | - S Poli
- Abteilung Neurologie mit Schwerpunkt neurovaskuläre Erkrankungen, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72070, Tübingen, Deutschland.
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Affiliation(s)
- Eric E. Smith
- From the Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, AB
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