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Kang J, Song H, Kim SE, Kim JY, Park HK, Cho YJ, Lee KB, Lee J, Lee JS, Choi AR, Kang MY, Gorelick PB, Bae HJ. Network analysis of stroke systems of care in Korea. BMJ Neurol Open 2024; 6:e000578. [PMID: 38618152 PMCID: PMC11015290 DOI: 10.1136/bmjno-2023-000578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/03/2024] [Indexed: 04/16/2024] Open
Abstract
Background The landscape of stroke care has shifted from stand-alone hospitals to cooperative networks among hospitals. Despite the importance of these networks, limited information exists on their characteristics and functional attributes. Methods We extracted patient-level data on acute stroke care and hospital connectivity by integrating national stroke audit data with reimbursement claims data. We then used this information to transform interhospital transfers into a network framework, where hospitals were designated as nodes and transfers as edges. Using the Louvain algorithm, we grouped densely connected hospitals into distinct stroke care communities. The quality and characteristics in given stroke communities were analysed, and their distinct types were derived using network parameters. The clinical implications of this network model were also explored. Results Over 6 months, 19 113 patients with acute ischaemic stroke initially presented to 1009 hospitals, with 3114 (16.3%) transferred to 246 stroke care hospitals. These connected hospitals formed 93 communities, with a median of 9 hospitals treating a median of 201 patients. Derived communities demonstrated a modularity of 0.904 , indicating a strong community structure, highly centralised around one or two hubs. Three distinct types of structures were identified: single-hub (n=60), double-hub (n=22) and hubless systems (n=11). The endovascular treatment rate was highest in double-hub systems, followed by single-hub systems, and was almost zero in hubless systems. The hubless communities were characterised by lower patient volumes, fewer hospitals, no hub hospital and no stroke unit. Conclusions This network analysis could quantify the national stroke care system and point out areas where the organisation and functionality of acute stroke care could be improved.
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Affiliation(s)
- Jihoon Kang
- Neurology, Seoul National University Bundang Hospital, Seongnam, Korea (the Republic of)
| | - Hyunjoo Song
- School of Computer Science and Engineering, Soongsil University, Seoul, Korea (the Republic of)
| | - Seong Eun Kim
- Neurology, Seoul National University Bundang Hospital, Seongnam, Korea (the Republic of)
| | - Jun Yup Kim
- Neurology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea (the Republic of)
| | - Hong-Kyun Park
- Neurology, Inje University Ilsan Paik Hospital, Goyang, Korea (the Republic of), Korea (the Republic of)
| | - Yong-Jin Cho
- Neurology, Inje University Ilsan Paik Hospital, Goyang, Korea (the Republic of)
| | - Kyung Bok Lee
- Neurology, Soonchunhyang University Hospital, Yongsan-gu, Seoul, Korea (the Republic of)
| | - Juneyoung Lee
- Biostatistics, Korea University School of Medicine, Seoul, Korea (the Republic of)
| | - Ji Sung Lee
- Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea (the Republic of)
| | - Ah Rum Choi
- Health Insurance Review & Assessment Service, Wonju, Korea (the Republic of)
| | - Mi Yeon Kang
- Health Insurance Review & Assessment Service, Wonju, Korea (the Republic of)
| | - Philip B Gorelick
- Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Hee-Joon Bae
- Neurology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea (the Republic of)
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Raychev R, Sun JL, Schwamm L, Smith EE, Fonarow GC, Messé SR, Xian Y, Chiswell K, Blanco R, Mac Grory B, Saver JL. Performance of Thrombectomy-Capable, Comprehensive, and Primary Stroke Centers in Reperfusion Therapies for Acute Ischemic Stroke: Report From the Get With The Guidelines-Stroke Registry. Circulation 2023; 148:2019-2028. [PMID: 37855118 DOI: 10.1161/circulationaha.123.066114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/18/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND The thrombectomy-capable stroke center (TSC) is a recently introduced intermediate tier of accreditation for hospitals at which patients with acute ischemic stroke receive care. The comparative quality and clinical outcomes of reperfusion therapies at TSCs, primary stroke centers (PSCs), and comprehensive stroke centers (CSCs) have not been well delineated. METHODS We conducted a retrospective, observational, cohort study from 2018 to 2020 that included patients with acute ischemic stroke who received endovascular thrombectomy (EVT) and intravenous thrombolysis reperfusion therapies at CSCs, TSCs, or PSCs. Participants were recruited from Get With The Guidelines-Stroke registry. Study end points included timeliness of intravenous thrombolysis and EVT, successful reperfusion, discharge destination, discharge mortality, and functional independence at discharge. RESULTS Among 84 903 patients, 48 682 received EVT, of whom 73% were treated at CSCs, 22% at PSCs, and 4% at TSCs. The median annual EVT volume was 76 for CSCs, 55 for TSCs, and 32 for PSCs. Patient differences by center status included higher National Institutes of Health Stroke Scale score, longer onset-to-arrival time, and higher transfer-in rates for CSCs, TSCs, and PSCs, respectively. In adjusted analyses, the likelihood of achieving the goal door-to-needle time was higher in CSCs compared with PSCs (odds ratio [OR], 1.39 [95% CI, 1.17-1.66]) and in TSCs compared with PSCs (OR, 1.45 [95% CI, 1.08-1.96]). Likewise, the odds of achieving the goal door-to-puncture time were higher in CSCs compared with PSCs (OR, 1.58 [95% CI, 1.13-2.21]). CSCs and TSCs also demonstrated better clinical efficacy outcomes compared with PSCs. The odds of discharge to home or rehabilitation were higher in CSCs compared with PSCs (OR, 1.18 [95% CI, 1.06-1.31]), whereas the odds of in-hospital mortality or discharge to hospice were lower in both CSCs compared with PSCs (OR, 0.87 [95% CI, 0.81-0.94]) and TSCs compared with PSCs (OR, 0.86 [95% CI, 0.75-0.98]). There were no significant differences in any of the quality-of-care metrics and clinical outcomes between TSCs and CSCs. CONCLUSIONS In this study representing national US practice, CSCs and TSCs exceeded PSCs in key quality-of-care reperfusion metrics and outcomes, whereas TSCs and CSCs demonstrated a similar performance. With more than one-fifth of all EVT procedures during the study period conducted at PSCs, it may be desirable to explore national initiatives aimed at facilitating the elevation of eligible PSCs to a higher certification status.
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Affiliation(s)
- Radoslav Raychev
- Duke Clinical Research Institute, Durham, NC (J.-L.S., K.C., R.R.)
- Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA (R.R., J.S., G.C.F.)
| | - Jie-Lena Sun
- Duke Clinical Research Institute, Durham, NC (J.-L.S., K.C., R.R.)
- Duke University School of Medicine, Durham, NC (J.-L.S.)
| | - Lee Schwamm
- Yale School of Medicine, New Haven, CT (L.S.)
| | | | - Gregg C Fonarow
- Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA (R.R., J.S., G.C.F.)
| | | | - Ying Xian
- University of Texas, Southwestern Medical Center, Dallas (Y.X.)
| | - Karen Chiswell
- Duke Clinical Research Institute, Durham, NC (J.-L.S., K.C., R.R.)
| | | | | | - Jeffrey L Saver
- Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA (R.R., J.S., G.C.F.)
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Raychev R, Sun JL, Schwamm L, Smith EE, Fonarow GC, Messé SR, Xian Y, Chiswell K, Blanco R, Grory BM, Saver JL. Performance of Thrombectomy-Capable, Comprehensive, and Primary Stroke Centers in Reperfusion Therapies for Acute Ischemic Stroke: Report from the Get With The Guidelines Stroke Registry: Stroke Outcomes Per Hospital Certification Status. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.05.23292270. [PMID: 37461517 PMCID: PMC10350146 DOI: 10.1101/2023.07.05.23292270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Background The thrombectomy-capable stroke center (TSC) is a recently introduced intermediate tier of accreditation for hospitals caring for patients with acute ischemic stroke (AIS). The comparative quality and clinical outcomes of reperfusion therapies at TSCs, primary stroke centers (PSCs), and comprehensive stroke centers (CSCs) has not been well delineated. Methods We conducted a retrospective, observational, cohort study from 2018-2020 that included patients with AIS who received endovascular (EVT) and/or intravenous (IVT) reperfusion therapies at CSC, TSC, or PSC. Participants were recruited from Get With The Guidelines-Stroke registry. Study endpoints included timeliness of IVT and EVT, successful reperfusion, discharge destination, discharge mortality, and functional independence at discharge. Results Among 84,903 included patients, 48,682 received EVT, of whom 73% were treated at CSCs, 22% at PSCs, and 4% at TSCs. The median annual EVT volume was 76 for CSCs, 55 for TSCs, and 32 for PSCs. Patient differences by center status included higher NIHSS, longer onset-to-arrival time, and higher transfer-in rates for CSC/TSC/PSC, respectively. In adjusted analyses, the likelihood of achieving the goal door-to-needle time was higher in CSCs compared to PSCs (OR 1.39; 95% CI 1.17-1.66) and in TSCs compared to PSCs (OR 1.45; 95% CI 1.08-1.96). Similarly, the odds of achieving the goal door-to-puncture time were higher in CSCs compared to PSCs (OR 1.58; 95% CI 1.13-2.21). CSCs and TSCs also demonstrated better clinical efficacy outcomes compared to PSCs. The odds of discharge to home or rehabilitation were higher in CSCs compared to PSCs (OR 1.18; 95% CI 1.06-1.31), while the odds of in-hospital mortality/discharge to hospice were lower in both CSCs compared to PSCs (OR 0.87; 95% CI 0.81-0.94) and TSCs compared to PSCs (OR 0.86; 95% CI 0.75-0.98). There were no significant differences in any of the quality-of-care metrics and clinical outcomes between TSCs and CSCs. Conclusions In this study representing national US practice, CSCs and TSCs exceeded PSCs in key quality-of-care reperfusion metrics and outcomes, whereas TSCs and CSCs demonstrated similar performance. Considering that over one-fifth of all EVT procedures during the study period were conducted at PSCs, it may be desirable to explore national initiatives aimed at facilitating the elevation of eligible PSCs to a higher certification status.
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Zhang Y, Yang Y, Xiao J, Sun Y, Yang S, Fu X. Effect of multidimensional comprehensive intervention on medication compliance, social function and incidence of MACE in patients undergoing PCI. Am J Transl Res 2021; 13:8058-8066. [PMID: 34377288 PMCID: PMC8340263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/29/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To analyze the effect of multidimensional comprehensive intervention on medication compliance, social function and incidence of major adverse cardiovascular events (MACE) in patients undergoing percutaneous coronary intervention (PCI). METHODS Ninety-eight patients with coronary heart disease (CHD) who underwent PCI in our hospital were selected and divided into the regular group (n=46, receiving regular nursing intervention) and the comprehensive group (n=52, receiving multidimensional comprehensive nursing intervention) according to the different nursing intervention methods. The medication compliance, social function, quality of life, and incidence of MACE were compared between the two groups. RESULTS The comprehensive group showed significantly higher rates of taking medication on time, taking medication according to the proper amount, taking medication at the recomended times, no increase or decrease in the amount of medication, and taking medication without interruption than the regular group (P < 0.05). The comprehensive group exhibited significantly higher scores of medication compliance than the regular group (P < 0.05). The Social Disability Screening Schedule (SDSS) scores of both groups during intervention for 8 weeks were lower than those before intervention and after intervention for 2 and 4 weeks (P < 0.05). The SDSS scores of intervention for 2, 4, and 8 weeks in the comprehensive group were significantly lower than that in the regular group (P < 0.05). After intervention, the comprehensive group showed significantly higher scores of physiological function, psychological function, cognitive function, emotional function, role function, and total quality of life than the regular group (P < 0.05). The incidence of MACE in the comprehensive group was significantly lower than that in the regular group (P < 0.05). CONCLUSION The use of multidimensional comprehensive intervention for patients undergoing PCI can effectively improve patients' medication compliance, social function and quality of life, and reduce the incidence of MACE.
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Affiliation(s)
- Yan Zhang
- Department of Cardiovascular Medicine, Jinan People’s Hospital Affiliated to Shandong First Medical UniversityJinan, Shandong, China
| | - Yuhua Yang
- Department of Drug Dispensing, Zibo Central HospitalZibo, Shandong, China
| | - Jinggang Xiao
- The Second Department of Cardiovascular Medicine, Linqing People’s HospitalLinqing, Shandong, China
| | - Yao Sun
- Department of General Practice, Zibo Central HospitalZibo, Shandong, China
| | - Suping Yang
- Department of Geriatrics, Binzhou Hospital of Traditional Chinese MedicineBinzhou, Shandong, China
| | - Xintao Fu
- Department of Cardiac Surgery, Zibo Municipal HospitalZibo, Shandong, China
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Huang L, Lu C, Pang M, Li L, Zhang Y, Su A, Ding L. Effect of PDCA-based nursing intervention on activities of daily living, neurological function and self-management in acute cerebral stroke. Am J Transl Res 2021; 13:5315-5321. [PMID: 34150124 PMCID: PMC8205731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 02/02/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE This study explored and analyzed the effects of PDCA-based nursing intervention on the activities of daily living, neurological function and self-management of patients with acute cerebral stroke. METHODS A total of 137 patients with acute cerebral stroke who were hospitalized from March 2018 to March 2020 were enrolled and divided into the observation-group (n = 70) and the control-group (n = 67). The control-group was given routine care, while those subjects in the observation group were provided with nursing intervention under the optimization of PDCA cycling. The activities of daily living (ADL), NIHSS score, self-management ability and life quality were compared between these two groups. RESULTS ADL scores of the two groups after intervention were much higher than those without intervention (P<0.05), and the observation-group had apparently higher scores than the control-group (P<0.05). After intervention, the NIHSS scores of the two groups were much lower than before intervention (P<0.05), and the score of the observation-group was remarkably lower than the control-group (P<0.05). After intervention, the scores of each dimension of self-management behavior in both groups increased substantially compared to prior-intervention, and the score was higher in observation-group than in control-group (P<0.05). In addition, the two groups had increased scores in each dimension of life quality in post-intervention (P<0.05), and the observation-group had evidently higher scores than the control-group (P<0.05). CONCLUSION PDCA-based nursing intervention can substantially enhance the daily living ability, neurological function, and self-management ability of patients, thus contributing to improve the clinical prognosis of patients and as such is worth popularizing.
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Affiliation(s)
- Li Huang
- Department of Neurology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical UniversityHaikou 570311, Hainan, China
| | - Chunwan Lu
- Department of Neurosurgery, The Second Affiliated Hospital of Hainan Medical CollegeHaikou 570311, Hainan, China
| | - Min Pang
- Department of Neurology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical UniversityHaikou 570311, Hainan, China
| | - Li Li
- Department of Pediatrics, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical UniversityHaikou 570311, Hainan, China
| | - Yi Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Hainan Medical CollegeHaikou 570311, Hainan, China
| | - Aikang Su
- Department of Emergency, The Second Affiliated Hospital of Hainan Medical CollegeHaikou 570311, Hainan, China
| | - Lili Ding
- Department of Pulmonary and Critical Care Medicine, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical UniversityHaikou 570311, Hainan, China
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Yu AT, Regenhardt RW, Whitney C, Schwamm LH, Patel AB, Stapleton CJ, Viswanathan A, Hirsch JA, Lev M, Leslie-Mazwi TM. CTA Protocols in a Telestroke Network Improve Efficiency for Both Spoke and Hub Hospitals. AJNR Am J Neuroradiol 2021; 42:435-440. [PMID: 33541900 DOI: 10.3174/ajnr.a6950] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/03/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE Telestroke networks support screening for patients with emergent large-vessel occlusions who are eligible for endovascular thrombectomy. Ideal triage processes within telestroke networks remain uncertain. We characterize the impact of implementing a routine spoke hospital CTA protocol in our integrated telestroke network on transfer and thrombectomy patterns. MATERIALS AND METHODS A protocol-driven CTA process was introduced at 22 spoke hospitals in November 2017. We retrospectively identified prospectively collected patients who presented to a spoke hospital with National Institutes of Health Stroke Scale scores ≥6 between March 1, 2016 and March 1, 2017 (pre-CTA), and March 1, 2018 and March 1, 2019 (post-CTA). We describe the demographics, CTA utilization, spoke hospital retention rates, emergent large-vessel occlusion identification, and rates of endovascular thrombectomy. RESULTS There were 167 patients pre-CTA and 207 post-CTA. The rate of CTA at spoke hospitals increased from 15% to 70% (P < .001). Despite increased endovascular thrombectomy screening in the extended window, the overall rates of transfer out of spoke hospitals remained similar (56% versus 54%; P = .83). There was a nonsignificant increase in transfers to our hub hospital for endovascular thrombectomy (26% versus 35%; P = .12), but patients transferred >4.5 hours from last known well increased nearly 5-fold (7% versus 34%; P < .001). The rate of endovascular thrombectomy performed on patients transferred for possible endovascular thrombectomy more than doubled (22% versus 47%; P = .011). CONCLUSIONS Implementation of CTA at spoke hospitals in our telestroke network was feasible and improved the efficiency of stroke triage. Rates of patients retained at spoke hospitals remained stable despite higher numbers of patients screened. Emergent large-vessel occlusion confirmation at the spoke hospital lead to a more than 2-fold increase in thrombectomy rates among transferred patients at the hub.
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Affiliation(s)
- A T Yu
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - R W Regenhardt
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - C Whitney
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - L H Schwamm
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - A B Patel
- Neurosurgery (R.W.R., A.B.P., C.J.S., T.M.L.-M.)
| | | | - A Viswanathan
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - J A Hirsch
- Department of Radiology (J.A.H., M.L.), Massachusetts General Hospital, Boston, Massachusetts
| | - M Lev
- Department of Radiology (J.A.H., M.L.), Massachusetts General Hospital, Boston, Massachusetts
| | - T M Leslie-Mazwi
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.).,Neurosurgery (R.W.R., A.B.P., C.J.S., T.M.L.-M.)
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Abstract
PURPOSE OF REVIEW This article describes restorative therapies to improve patient outcomes after stroke. These therapies contrast with acute stroke treatments such as recombinant tissue plasminogen activator (rtPA) and thrombectomy that target clots, aim to salvage threatened brain tissue to limit injury, and have a time window measured in hours. Restorative therapies target the brain, aim to promote plasticity within surviving brain tissue, and have a time window measured in days to weeks or longer. RECENT FINDINGS A number of drugs are under study. Preclinical studies are providing attractive therapeutic candidates for translation, such as the C-C chemokine receptor 5 inhibitor maraviroc. Some drug studies have used a pragmatic approach, which is premature for the nascent field of neural repair. Substantial data support the utility of activity-dependent therapies, including constraint-induced movement therapy, with recent studies supporting the need for very high doses to generate the best functional gains. While stem cell therapies are at an early stage, mounting preclinical evidence supports the efficacy of mesenchymal stem cells; some initial human studies are supportive. Several types of brain stimulation have been examined, and in some cases initial studies are promising. SUMMARY Improved insights into stroke recovery and its treatment have the potential to reduce disability in a large segment of stroke survivors.
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Kang J, Kim SE, Park HK, Cho YJ, Kim JY, Lee KJ, Park JM, Park KY, Lee KB, Lee SJ, Lee JS, Lee J, Yang KH, Choi AR, Kang MY, Choi NC, Gorelick PB, Bae HJ. Routing to Endovascular Treatment of Ischemic Stroke in Korea: Recognition of Need for Process Improvement. J Korean Med Sci 2020; 35:e347. [PMID: 33107228 PMCID: PMC7590651 DOI: 10.3346/jkms.2020.35.e347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/19/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND To track triage, routing, and treatment status regarding access to endovascular treatment (EVT) after acute ischemic stroke (AIS) at a national level. METHODS From national stroke audit data, potential candidates for EVT arriving within 6 hours with National Institute of Health Stroke Scale score of ≥ 7 were identified. Acute care hospitals were classified as thrombectomy-capable hospitals (TCHs, ≥ 15 EVT cases/year) or primary stroke hospital (PSH, < 15 cases/year), and patients' initial routes and subsequent inter-hospital transfer were described. Impact of initial routing to TCHs vs. PSHs on EVT and clinical outcomes were analyzed using multilevel generalized mixed effect models. RESULTS Out of 14,902 AIS patients, 2,180 (14.6%) were EVT candidates. Eighty-one percent of EVT candidates were transported by ambulance, but only one-third were taken initially to TCHs. Initial routing to TCHs was associated with greater chances of receiving EVT compared to initial routing to PSHs (33.3% vs 12.1%, P < 0.001; adjusted odds ratio [aOR], 2.21; 95% confidence interval [CI], 1.59-2.92) and favorable outcome (38.5% vs. 28.2%, P < 0.001; aOR, 1.52; 95% CI, 1.16-2.00). Inter-hospital transfers to TCHs occurred in 17.4% of those initially routed to a PSH and was associated with the greater chance of EVT compared to remaining at PSHs (34.8% vs. 7.5%, P < 0.001), but not with better outcomes. CONCLUSION Two-thirds of EVT candidates were initially routed to PSHs despite greater chance of receiving EVT and having favorable outcomes if routed to a TCH in Korea. Process improvement is needed to direct appropriate patients to TCHs.
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Affiliation(s)
- Jihoon Kang
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of Medicine, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Seong Eun Kim
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hong Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Ilsan, Korea
| | - Yong Jin Cho
- Department of Neurology, Inje University Ilsan Paik Hospital, Ilsan, Korea
| | - Jun Yup Kim
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Keon Joo Lee
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jong Moo Park
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Kwang Yeol Park
- Department of Neurology, Chung-Ang University Hospital, Seoul, Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Seoul, Korea
| | - Soo Joo Lee
- Department of Neurology, Daejeon Eulji Medical Center, Eulji University, Daejeon, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Ki Hwa Yang
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Ah Rum Choi
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Mi Yeon Kang
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Nack Cheon Choi
- Department of Neurology, Gyeongsang National University College of Medicine, Jinju, Korea.
| | - Philip B Gorelick
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hee Joon Bae
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.
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Pichardo O, Alan P, Jorge C, Castillon O, Zuñiga J. Endovascular Treatment for Stroke in a Single Center in a Developing Country: Permanent Training is the Key. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 15:86-93. [PMID: 37502807 PMCID: PMC10370811 DOI: 10.5797/jnet.oa.2020-0088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/17/2020] [Indexed: 07/29/2023]
Abstract
Objective In Mexico, the systematic implementation of mechanical thrombectomy has been delayed due to several factors, such as the conditions of the healthcare system. The objective of this report is to explain the experience in our center going through these circumstances, how we have overcome them, our results, and our pending challenges. Methods This is a single-center, independent, and retrospective study of prospectively collected data destined to record consecutive patients treated with endovascular techniques at a Mexican hospital that implemented a mechanical thrombectomy program for large vessel occlusion (LVO). Patient selection began in February 2017 and ended in January 2020. Patients selected were between the ages of 18 and 80, and could be treated within 8 hours after onset of symptoms. The timeline of the analysis was divided in half (i.e., 18 months). We prognosticate that our concept of permanent training could have an impact on clinical outcomes. Results In all, 73 patients gathered, of which 60.3% were women and 39.7% were men, with an average patient age of 62 years old. The average Onset-Door time was 248 minutes, and mean Door-Recanalization time was 91.7 minutes, where 29.6% (27.2 min) were used in the endovascular procedure per se. The results obtained were as follows: five (6%) patients with a thrombolysis in cerebral infarction (TICI) <2B and nine patients (12.3%) with a TICI 2B. TICI 2C and 3 were considered optimal results and found in 59 (80.8%) patients. It was found that 17 (23%) patients treated in the first 18 months had favorable outcomes (modified Ranking Scale [mRS] <3), and in the last 18 months, 45 (33%) patients had favorable outcomes (p = 0.0001). Conclusion Developing countries such as Mexico usually present particular conditions that are not part of the algorithms generated in developed countries. Nevertheless, with logistic adaptation, creativity, and above all, permanent training, similar results to those in other parts of the world can be achieved.
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Affiliation(s)
- Omar Pichardo
- Neurosurgery Department, Hospital Regional 1o de Octubre, ISSSTE, Ciudad de, Mexico
- Neurosurgery Department, Centro Médico ABC, Ciudad de, Mexico
| | - Picazo Alan
- Neurosurgery Department, Hospital Regional 1o de Octubre, ISSSTE, Ciudad de, Mexico
| | - Chudyk Jorge
- Neuroradiology Department, Hospital Faro del Mayab, Mérida, Yuc., Mexico
| | - Omar Castillon
- Neurosurgery Department, Centro Médico ABC, Ciudad de, Mexico
| | - Jonathan Zuñiga
- Neurosurgery Department, Hospital Regional 1o de Octubre, ISSSTE, Ciudad de, Mexico
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Tran D, Zhu Z, Shafie M, Abcede H, Stradling D, Yu W. Three easily-implementable changes reduce median door-to-needle time for intravenous thrombolysis by 23 minutes. BMC Neurol 2019; 19:300. [PMID: 31771530 PMCID: PMC6878675 DOI: 10.1186/s12883-019-1527-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 11/13/2019] [Indexed: 01/01/2023] Open
Abstract
Background The benefit of intravenous thrombolysis (IVT) for acute ischemic stroke is time dependent. Despite great effort, the median door-to-needle time (DNT) was 60 min at the United States stroke centers. We investigated the effect of a simple quality improvement initiative on DNT for IVT. Methods This is a single-center study of patients treated with IVT between 2013 and 2017. A simple quality improvement initiative was implemented in January 2015 to allow the Stroke team to manage hypertension in the emergency room, to make decision for IVT before getting blood test results unless patients were taking oral anticoagulants, and to give IVT in the CT suite. Baseline characteristics, DNT and outcomes at hospital discharge were compared between pre- and post-intervention groups. Results Ninety and 136 patients were treated with IVT in pre- and post-intervention groups, respectively. The rate of IVT was significantly higher in the post-intervention group (20% vs. 14.4%, p = 0.007). The median DNT with interquartile range (IQR) was reduced significantly by 23 min (63[53–81] vs. 40[29–53], p < 0.001) with more patients in the post-intervention group receiving IVT within 60 min (81.6% vs. 46.7%) and 45 min (64.0% vs.17.8%). There was no significant difference in symptomatic intracerebral hemorrhage rate (1.5% vs. 1.1%), modified Rankin Scale 0–1 (29.4% vs. 23.3%), and hospital mortality (7.4% vs. 6.7%) between the 2 groups. Conclusions Three easily-implementable quality improvement initiative increases IVT rate and reduces DNT significantly without increasing the rate of IVT-related complications in our comprehensive stroke center.
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Affiliation(s)
- Demi Tran
- Department of Neurology, University of California, Irvine, CA, USA
| | - Zhu Zhu
- Department of Neurology, University of California, Irvine, CA, USA.,Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Mohammad Shafie
- Department of Neurology, University of California, Irvine, CA, USA
| | | | - Dana Stradling
- Department of Neurology, University of California, Irvine, CA, USA
| | - Wengui Yu
- Department of Neurology, University of California, Irvine, CA, USA. .,, Orange, USA.
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Shreve L, Kaur A, Vo C, Wu J, Cassidy JM, Nguyen A, Zhou RJ, Tran TB, Yang DZ, Medizade AI, Chakravarthy B, Hoonpongsimanont W, Barton E, Yu W, Srinivasan R, Cramer SC. Electroencephalography Measures are Useful for Identifying Large Acute Ischemic Stroke in the Emergency Department. J Stroke Cerebrovasc Dis 2019; 28:2280-2286. [PMID: 31174955 DOI: 10.1016/j.jstrokecerebrovasdis.2019.05.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 04/03/2019] [Accepted: 05/17/2019] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Early diagnosis of stroke optimizes reperfusion therapies, but behavioral measures have incomplete accuracy. Electroencephalogram (EEG) has high sensitivity for immediately detecting brain ischemia. This pilot study aimed to evaluate feasibility and utility of EEG for identifying patients with a large acute ischemic stroke during Emergency Department (ED) evaluation, as these data might be useful in the prehospital setting. METHODS A 3-minute resting EEG was recorded using a dense-array (256-lead) system in patients with suspected acute stroke arriving at the ED of a US Comprehensive Stroke Center. RESULTS An EEG was recorded in 24 subjects, 14 with acute cerebral ischemia (including 5 with large acute ischemic stroke) and 10 without acute cerebral ischemia. Median time from stroke onset to EEG was 6.6 hours; and from ED arrival to EEG, 1.9 hours. Delta band power (P = .004) and the alpha/delta frequency band ratio (P = .0006) each significantly distinguished patients with large acute ischemic stroke (n = 5) from all other patients with suspected stroke (n = 19), with the best diagnostic utility coming from contralesional hemisphere signals. Larger infarct volume correlated with higher EEG power in the alpha/delta frequency band ratio within both the ipsilesional (r = -0.64, P = .013) and the contralesional (r = -0.78, P = .001) hemispheres. CONCLUSIONS Within hours of stroke onset, EEG measures (1) identify patients with large acute ischemic stroke and (2) correlate with infarct volume. These results suggest that EEG measures of brain function may be useful to improve diagnosis of large acute ischemic stroke in the ED, findings that might be useful to pre-hospital applications.
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Affiliation(s)
- Lauren Shreve
- Department of Neurology, University of California, Irvine, Irvine, California
| | - Arshdeep Kaur
- Department of Neurology, University of California, Irvine, Irvine, California
| | - Christopher Vo
- Department of Neurology, University of California, Irvine, Irvine, California
| | - Jennifer Wu
- Department of Neurology, University of California, Irvine, Irvine, California; Department of Anatomy & Neurobiology, University of California, Irvine, Irvine, California
| | - Jessica M Cassidy
- Department of Neurology, University of California, Irvine, Irvine, California
| | - Andrew Nguyen
- Department of Neurology, University of California, Irvine, Irvine, California
| | - Robert J Zhou
- Department of Neurology, University of California, Irvine, Irvine, California
| | - Thuong B Tran
- Department of Neurology, University of California, Irvine, Irvine, California
| | - Derek Z Yang
- Department of Neurology, University of California, Irvine, Irvine, California
| | - Ariana I Medizade
- Department of Neurology, University of California, Irvine, Irvine, California
| | - Bharath Chakravarthy
- Department of Emergency Medicine, University of California, Irvine, Irvine, California
| | | | - Erik Barton
- Department of Emergency Medicine, University of California, Irvine, Irvine, California
| | - Wengui Yu
- Department of Neurology, University of California, Irvine, Irvine, California
| | - Ramesh Srinivasan
- Department of Cognitive Sciences, University of California, Irvine, Irvine, California; Department of Biomedical Engineering, University of California, Irvine, Irvine, California
| | - Steven C Cramer
- Department of Neurology, University of California, Irvine, Irvine, California; Department of Anatomy & Neurobiology, University of California, Irvine, Irvine, California.
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