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Qureshi AI, Lodhi A, Maqsood H, Ma X, Hubert GJ, Gomez CR, Kwok CS, Ford DE, Hanley DF, Mehr DR, Shah QA, Suri MFK. Physician Transfer Versus Patient Transfer for Mechanical Thrombectomy in Patients With Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2024; 13:e031906. [PMID: 38899767 DOI: 10.1161/jaha.123.031906] [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: 07/26/2023] [Accepted: 03/01/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Physician transfer is an alternate option to patient transfer for expedient performance of mechanical thrombectomy in patients with acute ischemic stroke. METHODS AND RESULTS We conducted a systematic review to identify studies that evaluate the effect of physician transfer in patients with acute ischemic stroke who undergo mechanical thrombectomy. A search of PubMed, Scopus, and Web of Science was undertaken, and data were extracted. A statistical pooling with random-effects meta-analysis was performed to examine the odds of reduced time interval between stroke onset and recanalization, functional independence, death, and angiographic recanalization. A total of 12 studies (11 nonrandomized observational studies and 1 nonrandomized controlled trial) were included, with a total of 1894 patients. Physician transfer was associated with a significantly shorter time interval between stroke onset and recanalization with a pooled mean difference estimate of -62.08 (95% CI, -112.56 to -11.61]; P=0.016; 8 studies involving 1419 patients) with high between-study heterogeneity in the estimates (I2=90.6%). The odds for functional independence at 90 days were significantly higher (odds ratio, 1.29 [95% CI, 1.00-1.66]; P=0.046; 7 studies with 1222 patients) with physician transfer with low between-study heterogeneity (I2=0%). Physician transfer was not associated with higher odds of near-complete or complete angiographic recanalization (odds ratio, 1.18 [95% CI, 0.89-1.57; P=0.25; I2=2.8%; 11 studies with 1856 subjects). CONCLUSIONS Physician transfer was associated with a significant reduction in the mean of time interval between symptom onset and recanalization and increased odds for functional independence at 90 days with physician transfer compared with patient transfer among patients who undergo mechanical thrombectomy.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institutes St Cloud MN USA
- Department of Neurology University of Missouri Columbia MO USA
| | | | | | - Xiaoyu Ma
- Zeenat Qureshi Stroke Institutes St Cloud MN USA
| | - Gordian J Hubert
- Department of Neurology, TEMPiS Telestroke Center München Klinik gGmbH Munich Germany
| | - Camilo R Gomez
- Department of Neurology University of Missouri Columbia MO USA
| | - Chun S Kwok
- Department of Cardiology, Queen Elizabeth Hospital Birmingham University Hospitals of Birmingham NHS Trust Stoke-on-Trent UK
| | - Daniel E Ford
- Department of Medicine Johns Hopkins University Baltimore MD USA
| | - Daniel F Hanley
- Department of Neurology Johns Hopkins University Baltimore MD USA
| | - David R Mehr
- Department of Geriatric Medicine University of Missouri Columbia MO USA
| | - Qaisar A Shah
- Department of Neurology Winchester Medical Center Winchester VA USA
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Farcas AM, Crowe RP, Kennel J, Little N, Haamid A, Camacho MA, Pleasant T, Owusu-Ansah S, Joiner AP, Tripp R, Kimbrell J, Grover JM, Ashford S, Burton B, Uribe J, Innes JC, Page DI, Taigman M, Dorsett M. Achieving Equity in EMS Care and Patient Outcomes Through Quality Management Systems: A Position Statement. PREHOSP EMERG CARE 2024:1-11. [PMID: 38727731 DOI: 10.1080/10903127.2024.2352582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024]
Abstract
Improving health and safety in our communities requires deliberate focus and commitment to equity. Inequities are differences in access, treatment, and outcomes between individuals and across populations that are systemic, avoidable, and unjust. Within health care in general, and Emergency Medical Services (EMS) in particular, there are demonstrated inequities in the quality of care provided to patients based on a number of characteristics linked to discrimination, exclusion, or bias. Given the critical role that EMS plays within the health care system, it is imperative that EMS systems reduce inequities by delivering evidence-based, high-quality care for the communities and patients we serve. To achieve equity in EMS care delivery and patient outcomes, the National Association of EMS Physicians recommends that EMS systems and agencies: make health equity a strategic priority and commit to improving equity at all levels.assess and monitor clinical and safety quality measures through the lens of inequities as an integrated part of the quality management process.ensure that data elements are structured to enable equity analysis at every level and routinely evaluate data for limitations hindering equity analysis and improvement.involve patients and community stakeholders in determining data ownership and stewardship to ensure its ongoing evolution and fitness for use for measuring care inequities.address biases as they translate into the quality of care and standards of respect for patients.pursue equity through a framework rooted in the principles of improvement science.
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Affiliation(s)
- Andra M Farcas
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, Colorado
| | | | - Jamie Kennel
- Oregon Health & Science University and Oregon Institute of Technology, Portland, Oregon
| | | | - Ameera Haamid
- Section of Emergency Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Mario Andres Camacho
- Department of Emergency Medicine, Denver Health Medical Center, School of Medicine, University of Colorado, Denver, Colorado
| | | | - Sylvia Owusu-Ansah
- Division of Pediatric Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anjni P Joiner
- Department of Emergency Medicine, School of Medicine, Duke University, Durham, North Carolina
| | - Rickquel Tripp
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joshua Kimbrell
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center, Jamaica, New York
| | - Joseph M Grover
- UNC Department of Emergency Medicine, Chapel Hill, North Carolina
| | | | - Brooke Burton
- Unified Fire Authority in Salt Lake County, Salt Lake City, Utah
| | - Jeffrey Uribe
- Department of Emergency Medicine, Medstar Health, Columbia, Maryland
| | - Johanna C Innes
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - David I Page
- Center for Prehospital Care, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | | | - Maia Dorsett
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York
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Wolcott ZC, English SW. Artificial intelligence to enhance prehospital stroke diagnosis and triage: a perspective. Front Neurol 2024; 15:1389056. [PMID: 38756217 PMCID: PMC11096539 DOI: 10.3389/fneur.2024.1389056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/22/2024] [Indexed: 05/18/2024] Open
Abstract
As health systems organize to deliver the highest quality stroke care to their patients, there is increasing emphasis being placed on prehospital stroke recognition, accurate diagnosis, and efficient triage to improve outcomes after stroke. Emergency medical services (EMS) personnel currently rely heavily on dispatch accuracy, stroke screening tools, bypass protocols and prehospital notification to care for patients with suspected stroke, but novel tools including mobile stroke units and telemedicine-enabled ambulances are already changing the landscape of prehospital stroke care. Herein, the authors provide our perspective on the current state of prehospital stroke diagnosis and triage including several of these emerging trends. Then, we provide commentary to highlight potential artificial intelligence (AI) applications to improve stroke detection, improve accurate and timely dispatch, enhance EMS training and performance, and develop novel stroke diagnostic tools for prehospital use.
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Kwok CS, Gillani SA, Bains NK, Gomez CR, Hanley DF, Ford DE, Hassan AE, Nguyen TN, Siddiq F, Spiotta AM, Qureshi AI. Mechanical thrombectomy in patients with acute ischemic stroke in the USA before and after time window expansion. J Neurointerv Surg 2024; 16:447-452. [PMID: 37438102 DOI: 10.1136/jnis-2023-020286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/22/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND In 2018, the time window for mechanical thrombectomy eligibility in patients with acute ischemic stroke increased from within 6 hours to within 24 hours of symptom onset. The purpose of this study was to evaluate the effect of window expansion on procedural and hospital volumes and patient outcomes at a national level. METHODS We conducted a retrospective cohort study of patients with acute ischemic stroke undergoing mechanical thrombectomy using data from the National Inpatient Sample. We compared the numbers of mechanical thrombectomy procedures and performing hospitals between 2017 and 2019 in the USA, and the proportion of patients discharged home/self-care, those with in-hospital mortality and post-procedural intracranial hemorrhage (2019 vs 2017) after adjustment for potential confounders. RESULTS The number of patients with ischemic stroke who underwent mechanical thrombectomy increased from 16 960 in 2017 to 28 120 in 2019. There was an increase in the number of hospitals performing mechanical thrombectomy (501 in 2017, 585 in 2019) and those performing ≥50 procedures/year (97 in 2017, 199 in 2019; P<0.001). The odds of in-hospital mortality decreased (OR 0.79, 95% CI 0.66 to 0.94, P=0.008) and the odds of intracranial hemorrhage increased (OR 1.18, 95% CI 1.06 to 1.31, P=0.003) in 2019 compared with 2017, with no change in odds of discharge to home. CONCLUSIONS The window expansion for mechanical thrombectomy for patients with acute ischemic stroke was associated with an increase in the numbers of mechanical thrombectomy procedures and performing hospitals with a reduction of in-hospital mortality in the USA.
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Affiliation(s)
- Chun Shing Kwok
- Department of Post Qualifying Healthcare Practice, Birmingham City University, Birmingham, UK
- Department of Cardiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Syed A Gillani
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Navpreet K Bains
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Camilo R Gomez
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Daniel F Hanley
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Daniel E Ford
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Thanh N Nguyen
- Neurology, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Farhan Siddiq
- Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
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Paxton JH, Keenan KJ, Wilburn JM, Wise SL, Klausner HA, Ball MT, Dunne RB, Kreitel KD, Morgan LF, Fales WD, Madhok D, Barazangi N, McLean ST, Cross K, Distenfield L, Sykes J, Lovoi P, Johnson B, Smith WS. Headpulse measurement can reliably identify large-vessel occlusion stroke in prehospital suspected stroke patients: Results from the EPISODE-PS-COVID study. Acad Emerg Med 2024. [PMID: 38643419 DOI: 10.1111/acem.14919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/26/2024] [Accepted: 03/12/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Large-vessel occlusion (LVO) stroke represents one-third of acute ischemic stroke (AIS) in the United States but causes two-thirds of poststroke dependence and >90% of poststroke mortality. Prehospital LVO stroke detection permits efficient emergency medical systems (EMS) transport to an endovascular thrombectomy (EVT)-capable center. Our primary objective was to determine the feasibility of using a cranial accelerometry (CA) headset device for prehospital LVO stroke detection. Our secondary objective was development of an algorithm capable of distinguishing LVO stroke from other conditions. METHODS We prospectively enrolled consecutive adult patients suspected of acute stroke from 11 study hospitals in four different U.S. geographical regions over a 21-month period. Patients received device placement by prehospital EMS personnel. Headset data were matched with clinical data following informed consent. LVO stroke diagnosis was determined by medical chart review. The device was trained using device data and Los Angeles Motor Scale (LAMS) examination components. A binary threshold was selected for comparison of device performance to LAMS scores. RESULTS A total of 594 subjects were enrolled, including 183 subjects who received the second-generation device. Usable data were captured in 158 patients (86.3%). Study subjects were 53% female and 56% Black/African American, with median age 69 years. Twenty-six (16.4%) patients had LVO and 132 (83.6%) were not LVO (not-LVO AIS, 33; intracerebral hemorrhage, nine; stroke mimics, 90). COVID-19 testing and positivity rates (10.6%) were not different between groups. We found a sensitivity of 38.5% and specificity of 82.7% for LAMS ≥ 4 in detecting LVO stroke versus a sensitivity of 84.6% (p < 0.0015 for superiority) and specificity of 82.6% (p = 0.81 for superiority) for the device algorithm (CA + LAMS). CONCLUSIONS Obtaining adequate recordings with a CA headset is highly feasible in the prehospital environment. Use of the device algorithm incorporating both CA and LAMS data for LVO detection resulted in significantly higher sensitivity without reduced specificity when compared to the use of LAMS alone.
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Affiliation(s)
- James H Paxton
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Kevin J Keenan
- Department of Neurology, University of California, Davis, Sacramento, California, USA
| | - John M Wilburn
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Stefanie L Wise
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Howard A Klausner
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Matthew T Ball
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Robert B Dunne
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - K Derek Kreitel
- Department of Radiology, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Larry F Morgan
- Department of Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - William D Fales
- Department of Emergency Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Debbie Madhok
- Department of Emergency Medicine, University of California, San Francisco, California, USA
| | - Nobl Barazangi
- Department of Neurology, California Pacific Medical Center, San Francisco, California, USA
| | - Steven T McLean
- Department of Emergency Medicine, Ascension St. Mary's Hospital, Saginaw, Michigan, USA
| | - Katherine Cross
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | | | | | - Paul Lovoi
- MindRhythm, Inc., Cupertino, California, USA
| | | | - Wade S Smith
- Department of Neurology, University of California, Davis, Sacramento, California, USA
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Herrmann ML, Franck C, Schuchardt FF, Meier S, Henningsen M, Wimmesberger N, Rau D, Busch H, Taschner CA, Farin‐Glattacker E, Brich J. The non-paretic-hand-to-opposite-ear test: A simple test to detect aphasia and neglect and an indicator of large anterior vessel occlusion in patients with suspected acute stroke. Brain Behav 2024; 14:e3450. [PMID: 38450998 PMCID: PMC10918592 DOI: 10.1002/brb3.3450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/28/2024] [Accepted: 02/04/2024] [Indexed: 03/08/2024] Open
Abstract
INTRODUCTION Aphasia and neglect in combination with hemiparesis are reliable indicators of large anterior vessel occlusion (LAVO). Prehospital identification of these symptoms is generally considered difficult by emergency medical service (EMS) personnel. Therefore, we evaluated the simple non-paretic-hand-to-opposite-ear (NPE) test to identify aphasia and neglect with a single test. As the NPE test includes a test for arm paresis, we also evaluated the diagnostic ability of the NPE test to detect LAVO in patients with suspected stroke. METHODS In this prospective observational study, we performed the NPE test in 1042 patients with suspected acute stroke between May 2021 and May 2022. We analyzed the correlation between the NPE test and the aphasia/neglect items of the National Institutes of Health Stroke Scale. Additionally, the predictive values of the NPE test for LAVO detection were calculated. RESULTS The NPE test showed a strong, significant correlation with both aphasia and neglect. A positive NPE test result predicted LAVO with a sensitivity of 0.70, a specificity of 0.88, and an accuracy of 0.85. Logistic regression analysis showed an odds ratio of 16.14 (95% confidence interval 10.82-24.44) for predicting LAVO. CONCLUSION The NPE test is a simple test for the detection of both aphasia and neglect. With its predictive values for LAVO detection being comparable to the results of LAVO scores in the prehospital setting, this simple test might be a promising test for prehospital LAVO detection by EMS personnel. Further prospective prehospital validation is needed.
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Affiliation(s)
- Matthias L. Herrmann
- Department of Neurology and Clinical Neuroscience, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Clara Franck
- Section of Health Care Research and Rehabilitation Research (SEVERA), Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Florian F. Schuchardt
- Department of Neurology and Clinical Neuroscience, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Simone Meier
- Department of Neurology and Clinical Neuroscience, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Max Henningsen
- Department of Neurology and Clinical Neuroscience, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Nicole Wimmesberger
- Section of Health Care Research and Rehabilitation Research (SEVERA), Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Diana Rau
- Section of Health Care Research and Rehabilitation Research (SEVERA), Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Hans‐Jörg Busch
- Department of Emergency Medicine, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Christian A. Taschner
- Department of Neuroradiology, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Erik Farin‐Glattacker
- Section of Health Care Research and Rehabilitation Research (SEVERA), Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Jochen Brich
- Department of Neurology and Clinical Neuroscience, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
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Wang CM, Chang YM, Tzeng RC, Chen TS, Wu ST, Lin KH, Chang CC, Huang MH, Vong SC, Wu MH, Chen CH, Lin CW, Sung PS. A simple, organized web-based system improved the transfer efficiency and patient outcomes for endovascular thrombectomy in regional stroke network. J Formos Med Assoc 2024:S0929-6646(24)00089-5. [PMID: 38360489 DOI: 10.1016/j.jfma.2024.02.002] [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: 10/09/2023] [Revised: 02/04/2024] [Accepted: 02/06/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Endovascular thrombectomy (EVT) is a time-sensitive treatment for acute ischemic stroke with large vessel occlusion. To optimize transfer efficiency, a web-based platform was introduced in the Tainan Stroke Network (TSN). We assessed its application and effectiveness in regional stroke care. METHOD This new web-based platform containing a questionnaire-style interface was introduced on October 1, 2021. To assess the transfer efficiency and patient outcomes, acute stroke patients transferred from PSCs to CSC for EVT from April 01, 2020, to December 30, 2022, were enrolled. The patients were classified into the traditional transferal pathway (TTP) group and the new transferal pathway (NTP) group depending on mode of transfer. Patient characteristics, time segments after stroke onset and outcome were compared between groups. RESULT A total of 104 patients were enrolled, with 77 in the TTP group and 27 in the NTP group. Compared to the TTP group, the NTP group had a significantly shorter onset-to-CSC door time (TTP vs. NTP: 267 vs. 198 min; p = 0.041) and a higher EVT rate (TTP vs. NTP: 18.2% vs. 48.1%, p = 0.002). Among EVT patients, those in the NTP group had a significantly shorter CSC door-to-puncture time (TTP vs. NTP: 131.5 vs. 110 min; p = 0.029). The NTP group had a higher rate of good functional outcomes at 3 months (TTP vs. NTP: 21% vs. 61.5%; p = 0.034). CONCLUSION This new web-based EVT transfer system provides notable improvements in clinical outcomes, transfer efficiency, and EVT execution for potential EVT candidates without markedly changing the regional stroke care paradigm.
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Affiliation(s)
- Chun-Min Wang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Ming Chang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ray-Chang Tzeng
- Department of Neurology, Tainan Municipal Hospital, Tainan, Taiwan
| | | | | | | | - Che-Chao Chang
- An Nan Hospital, China Medical University, Tainan, Taiwan
| | - Meng-Hua Huang
- Kaohsiung Veterans General Hospital Tainan Branch, Tainan, Taiwan
| | | | - Mu-Han Wu
- Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan
| | - Chih-Hung Chen
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Che-Wei Lin
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.
| | - Pi-Shan Sung
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Stein LK, Maillie L, Erdman J, Loebel E, Mayman N, Sharma A, Wolmer S, Tuhrim S, Fifi JT, Jette N, Mocco J, Dhamoon MS. Variation in US acute ischemic stroke treatment by hospital regions: limited endovascular access despite evidence. J Neurointerv Surg 2024; 16:151-155. [PMID: 37068938 PMCID: PMC11192062 DOI: 10.1136/jnis-2023-020128] [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: 02/28/2023] [Accepted: 04/02/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Although national organizations recognize the importance of regionalized acute ischemic stroke (AIS) care, data informing expansion are sparse. We assessed real-world regional variation in emergent AIS treatment, including growth in revascularization therapies and stroke center certification. We hypothesized that we would observe overall growth in revascularization therapy utilization, but observed differences would vary greatly regionally. METHODS A retrospective cross-sectional analysis was carried out of de-identified national inpatient Medicare Fee-for-Service datasets from 2016 to 2019. We identified AIS admissions and treatment with thrombolysis and endovascular thrombectomy (ET) with International Classification of Diseases, 10th Revision, Clinical Modification codes. We grouped hospitals in Dartmouth Atlas of Healthcare Hospital Referral Regions (HRR) and calculated hospital, demographic, and acute stroke treatment characteristics for each HRR. We calculated the percent of hospitals with stroke certification and AIS cases treated with thrombolysis or ET per HRR. RESULTS There were 957 958 AIS admissions. Relative mean (SD) growth in percent of AIS admissions receiving revascularization therapy per HRR from 2016 to 2019 was 13.4 (31.7)% (IQR -6.1-31.7%) for thrombolysis and 28.0 (72.0)% (IQR 0-56.0%) for ET. The proportion of HRRs with decreased or no difference in ET utilization was 38.9% and the proportion of HRRs with decreased or no difference in thrombolysis utilization was 32.7%. Mean (SD) stroke center certification proportion across HRRs was 45.3 (31.5)% and this varied widely (IQR 18.3-73.4%). CONCLUSIONS Overall growth in AIS treatment has been modest and, within HRRs, growth in AIS treatment and the proportion of centers with stroke certification varies dramatically.
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Affiliation(s)
- Laura K Stein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Luke Maillie
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Erdman
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Emma Loebel
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Naomi Mayman
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Akarsh Sharma
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Stanley Tuhrim
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Johanna T Fifi
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nathalie Jette
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Fiorella D, Jovin TG, Arthur AS, Nogueira R, Siddiqui AH, Hirsch JA, Albuquerque FC. Triage of Emergent Large Vessel Occlusion (ELVO) patients directly to Comprehensive Stroke Centers (CSCs) is good practice and benefits patients in Urban and Suburban population Centers - New insights from the TRIAGE-STROKE and RACECAT studies. J Neurointerv Surg 2023; 16:1-3. [PMID: 38114326 DOI: 10.1136/jnis-2023-021341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Affiliation(s)
- David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
- SUNY SB, Stony Brook, New York, USA
| | - Tudor G Jovin
- Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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Zhu D, Wang C, Ma P, Qi D, Cao W, Li S, Du M, He J, Ye S, Song T, Hu R, Li P, Zheng T, Liu J, Fang Y. Arm-only combined transarterial and transvenous access for neurointerventional procedures: a double-center retrospective study. Br J Radiol 2023; 96:20230465. [PMID: 37750839 PMCID: PMC10646665 DOI: 10.1259/bjr.20230465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/04/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023] Open
Abstract
OBJECTIVE This study aims to share our experience with the arm-only combined transarterial and transvenous access approach for neurointerventional procedures and evaluate its efficacy and safety. METHODS The arm-only combined transarterial and transvenous access approach was performed using the right/bilateral proximal radial arteries and the right forearm superficial vein system, guided by ultrasonic guidance. Arterial access closure was achieved using a transradial band radial compression device, while manual compression was utilized for venous approach closure. RESULTS Thirteen procedures were successfully performed using the arm-only combined transarterial and transvenous access approach, yielding favorable outcomes. The procedures included dural arteriovenous fistula embolization (seven cases), cerebral arteriovenous malformation embolization (four cases), venous sinus thrombosis catheter-directed thrombolysis and intravenous thrombectomy (one case), and cerebral venous sinus stenosis manometry (one case). All procedures were uneventful, allowing patients to ambulate on the same day. At discharge, all patients exhibited modified Rankin scores of 0-2, without any access site or perioperative complications. CONCLUSION This double-center study preliminarily demonstrates the feasibility and safety of arm-only combined transarterial and transvenous access applied in neurointerventional procedures for complicated cerebrovascular diseases. The proximal radial artery and forearm superficial vein are recommended as the primary access sites. Unobstructed compression is strongly recommended for radial approach closure. ADVANCES IN KNOWLEDGE This study aimed to add evidence and experience on the arm-only combined transarterial and transvenous access, as a new approach, for neurointerventional treatment that required arteriovenous approaches.
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Affiliation(s)
- Deyuan Zhu
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Chuanchuan Wang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Peipei Ma
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Dayong Qi
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Wei Cao
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Suya Li
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Meng Du
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Juanling He
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shifei Ye
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Tonghui Song
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Rongguo Hu
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Peng Li
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Tianheng Zheng
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jianmin Liu
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yibin Fang
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
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11
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Ospel JM, Dmytriw AA, Regenhardt RW, Patel AB, Hirsch JA, Kurz M, Goyal M, Ganesh A. Recent developments in pre-hospital and in-hospital triage for endovascular stroke treatment. J Neurointerv Surg 2023; 15:1065-1071. [PMID: 36241225 DOI: 10.1136/jnis-2021-018547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 10/05/2022] [Indexed: 11/04/2022]
Abstract
Triage describes the assignment of resources based on where they can be best used, are most needed, or are most likely to achieve success. Triage is of particular importance in time-critical conditions such as acute ischemic stroke. In this setting, one of the goals of triage is to minimize the delay to endovascular thrombectomy (EVT), without delaying intravenous thrombolysis or other time-critical treatments including patients who cannot benefit from EVT. EVT triage is highly context-specific, and depends on availability of financial resources, staff resources, local infrastructure, and geography. Furthermore, the EVT triage landscape is constantly changing, as EVT indications evolve and new neuroimaging methods, EVT technologies, and adjunctive medical treatments are developed and refined. This review provides an overview of recent developments in EVT triage at both the pre-hospital and in-hospital stages. We discuss pre-hospital large vessel occlusion detection tools, transport paradigms, in-hospital workflows, acute stroke neuroimaging protocols, and angiography suite workflows. The most important factor in EVT triage, however, is teamwork. Irrespective of any new technology, EVT triage will only reach optimal performance if all team members, including paramedics, nurses, technologists, emergency physicians, neurologists, radiologists, neurosurgeons, and anesthesiologists, are involved and engaged. Thus, building sustainable relationships through continuous efforts and hands-on training forms an integral part in ensuring rapid and efficient EVT triage.
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Affiliation(s)
- Johanna M Ospel
- Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Neurointerventional Program, Departments of Medical Imaging & Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
| | | | - Aman B Patel
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Martin Kurz
- Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Mayank Goyal
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Aravind Ganesh
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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12
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Zachrison KS, Beaulieu ND, Mehrotra A. Changing Health Care Markets Have the Potential to Undermine Stroke Systems of Care. JAMA Neurol 2023; 80:1131-1132. [PMID: 37695597 DOI: 10.1001/jamaneurol.2023.3103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
This Viewpoint discusses the importance of prioritizing quality of care for patients with stroke in a changing health care environment.
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Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Nancy D Beaulieu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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13
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Keenan KJ, Smith WS, Jadhav AP, Haussen DC, Budzik RF, Bonafé A, Bhuva P, Yavagal DR, Ribò M, Cognard C, Hanel RA, Hassan AE, Sila CA, Saver JL, Liebeskind DS, Jovin TG, Nogueira RG. Large vessel occlusion prediction scale thresholds that are sensitive for DAWN Trial patients. Interv Neuroradiol 2023:15910199231203266. [PMID: 37915142 DOI: 10.1177/15910199231203266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Large vessel occlusion (LVO) prediction scales are used to triage prehospital suspected stroke patients with a high probability of LVO stroke to endovascular therapy centers. The sensitivities of these scales in the 6-to-24-h time window are unknown. Higher scale score thresholds are typically less sensitive and more specific. Knowing the highest scale score thresholds that remain sensitive could inform threshold selection for clinical use. Sensitivities may also vary between left and right-sided LVOs. METHODS LVO prediction scale scores were retrospectively calculated using the National Institutes of Health Stroke Scale (NIHSS) scores of patients enrolled in the DAWN Trial. All patients had last known well times between 6 and 24 h, NIHSS scores ≥ 10, intracranial internal carotid artery or proximal middle cerebral artery occlusions, and mismatches between their clinical severities and infarct core volumes. Scale thresholds with sensitivities ≥ 85% were identified, along with scores ≥ 5% more sensitive for left or right-sided LVOs. Specificities could not be calculated because all patients had LVOs. RESULTS A total of 201 out of 206 patients had the required NIHSS subitem scores. CPSS = 3, C-STAT ≥ 2, FAST-ED ≥ 4, G-FAST ≥ 3, RACE ≥ 5, and SAVE ≥ 3 were the highest thresholds that were still 85% sensitive for DAWN Trial LVO stroke patients. RACE ≥ 5 was the only typically used score threshold more sensitive for right-sided LVOs, though similar small differences were seen for other scales at higher thresholds. CONCLUSIONS Our findings likely represent the maximum sensitivities of the LVO prediction scales tested for ideal thrombectomy candidates in the 6-to-24-h time window because NIHSS scores were documented in hospitals during a clinical trial rather than in the prehospital setting. Patients with NIHSS scores < 10 or more distal LVOs would lower sensitivities further. Selecting even higher scale thresholds for LVO triage would lead to many missed LVO strokes.
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Affiliation(s)
- Kevin J Keenan
- Department of Neurology, University of California, Davis, Sacramento, CA, USA
| | - Wade S Smith
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Ashutosh P Jadhav
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Diogo C Haussen
- Department of Neurology and Radiology, Emory University School of Medicine at Grady Memorial Hospital, Atlanta, GA, USA
| | - Ronald F Budzik
- Department of Radiology, OhioHealth/Riverside Methodist Hospital, Columbus, OH, USA
| | - Alain Bonafé
- Department of Neuroradiology, University Hospital of Montpellier, Hop Gui de Chauliac, Montpellier, France
| | - Parita Bhuva
- Texas Stroke Institute at HCA North Texas, Plano, TX, USA
| | - Dileep R Yavagal
- Department of Neurology, University of Miami School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
| | - Marc Ribò
- Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain
- Department of Neurology, Vall d'Hebron University Hospital, Stroke Unit, Barcelona, Spain
| | - Christophe Cognard
- Department of Neuroradiology, Hospital Purpan, Toulouse, Midi-Pyrénées, France
| | - Ricardo A Hanel
- Baptist Medical Center Jacksonville/Lyerly Neurosurgery, Jacksonville, FL, USA
| | - Ameer E Hassan
- Department of Neurology, Valley Baptist Medical Center - Harlingen, TX, USA
| | - Cathy A Sila
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles, CA, USA
| | | | - Tudor G Jovin
- Cooper Hospital University Medical Center, Camden, NJ, USA
| | - Raul G Nogueira
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh, Pittsburgh, PA, USA
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14
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Fulmer EB, Keener Mast D, Godoy Garraza L, Gilchrist S, Rasool A, Xu Y, Brown A, Omeaku N, Ye Z, Donald B, Shantharam S, Coleman King S, Popoola A, Cincotta K. Impact of State Stroke Systems of Care Laws on Stroke Outcomes. Healthcare (Basel) 2023; 11:2842. [PMID: 37957987 PMCID: PMC10648022 DOI: 10.3390/healthcare11212842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/24/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
Since 2003, 38 US states and Washington, DC have adopted legislation and/or regulations to strengthen stroke systems of care (SSOCs). This study estimated the impact of SSOC laws on stroke outcomes. We used a coded legal dataset of 50 states and DC SSOC laws (years 2003-2018), national stroke accreditation information (years 1997-2018), data from the Healthcare Cost and Utilization Project (years 2012-2018), and National Vital Statistics System (years 1979-2019). We applied a natural experimental design paired with longitudinal modeling to estimate the impact of having one or more SSOC policies in effect on outcomes. On average, states with one or more SSOC policies in effect achieved better access to primary stroke centers (PSCs) than expected without SSOC policies (ranging from 2.7 to 8.0 percentage points (PP) higher), lower inpatient hospital costs (USD 610-1724 less per hospital stay), lower age-adjusted stroke mortality (1.0-1.6 fewer annual deaths per 100,000), a higher proportion of stroke patients with brain imaging results within 45 min of emergency department arrival (3.6-5.0 PP higher), and, in some states, lower in-hospital stroke mortality (5 fewer deaths per 1000). Findings were mixed for some outcomes and there was limited evidence of model fit for others. No effect was observed in racial and/or rural disparities in stroke mortality.
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Affiliation(s)
- Erika B. Fulmer
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop MS-S107-1, Atlanta, GA 30341, USA; (A.R.); (Z.Y.); (S.S.); (S.C.K.); (A.P.)
| | - Dana Keener Mast
- ICF, 1902 Reston Metro Plaza, Reston, VA 20190, USA; (D.K.M.); (L.G.G.); (Y.X.); (K.C.)
| | - Lucas Godoy Garraza
- ICF, 1902 Reston Metro Plaza, Reston, VA 20190, USA; (D.K.M.); (L.G.G.); (Y.X.); (K.C.)
| | - Siobhan Gilchrist
- ASRT, Inc., 4158 Onslow Place SE, Smyrna, GA 30080, USA; (S.G.); (A.B.); (N.O.); (B.D.)
| | - Aysha Rasool
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop MS-S107-1, Atlanta, GA 30341, USA; (A.R.); (Z.Y.); (S.S.); (S.C.K.); (A.P.)
- Oak Ridge Institute for Science and Education, P.O. Box 117, Oak Ridge, TN 37831-0117, USA
| | - Ye Xu
- ICF, 1902 Reston Metro Plaza, Reston, VA 20190, USA; (D.K.M.); (L.G.G.); (Y.X.); (K.C.)
| | - Amanda Brown
- ASRT, Inc., 4158 Onslow Place SE, Smyrna, GA 30080, USA; (S.G.); (A.B.); (N.O.); (B.D.)
| | - Nina Omeaku
- ASRT, Inc., 4158 Onslow Place SE, Smyrna, GA 30080, USA; (S.G.); (A.B.); (N.O.); (B.D.)
| | - Zhiqiu Ye
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop MS-S107-1, Atlanta, GA 30341, USA; (A.R.); (Z.Y.); (S.S.); (S.C.K.); (A.P.)
| | - Bruce Donald
- ASRT, Inc., 4158 Onslow Place SE, Smyrna, GA 30080, USA; (S.G.); (A.B.); (N.O.); (B.D.)
| | - Sharada Shantharam
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop MS-S107-1, Atlanta, GA 30341, USA; (A.R.); (Z.Y.); (S.S.); (S.C.K.); (A.P.)
| | - Sallyann Coleman King
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop MS-S107-1, Atlanta, GA 30341, USA; (A.R.); (Z.Y.); (S.S.); (S.C.K.); (A.P.)
| | - Adebola Popoola
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop MS-S107-1, Atlanta, GA 30341, USA; (A.R.); (Z.Y.); (S.S.); (S.C.K.); (A.P.)
| | - Kristen Cincotta
- ICF, 1902 Reston Metro Plaza, Reston, VA 20190, USA; (D.K.M.); (L.G.G.); (Y.X.); (K.C.)
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15
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Schuler FAF, Ribó M, Dequatre‐Ponchelle N, Rémi J, Dobrocky T, Goeldlin MB, Gralla J, Kaesmacher J, Meinel TR, Mordasini P, Seiffge DJ, Fischer U, Arnold M, Kägi G, Jung S. Geographical Requirements for the Applicability of the Results of the RACECAT Study to Other Stroke Networks. J Am Heart Assoc 2023; 12:e029965. [PMID: 37830330 PMCID: PMC10757535 DOI: 10.1161/jaha.123.029965] [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: 02/23/2023] [Accepted: 08/11/2023] [Indexed: 10/14/2023]
Abstract
Background The RACECAT (Transfer to the Closest Local Stroke Center vs Direct Transfer to Endovascular Stroke Center of Acute Stroke Patients With Suspected Large Vessel Occlusion in the Catalan Territory) trial was the first randomized trial addressing the prehospital triage of acute stroke patients based on the distribution of thrombolysis centers and intervention centers in Catalonia, Spain. The study compared the drip-and-ship with the mothership paradigm in regions where a local thrombolysis center can be reached faster than the nearest intervention center (equipoise region). The present study aims to determine the population-based applicability of the results of the RACECAT study to 4 stroke networks with a different degree of clustering of the intervention centers (clustered, dispersed). Methods and Results Stroke networks were compared with regard to transport time saved for thrombolysis (under the drip-and-ship approach) and transport time saved for endovascular therapy (under the mothership approach). Population-based transport times were modeled with a local instance of an openrouteservice server using open data from OpenStreetMap.The fraction of the population in the equipoise region differed substantially between clustered networks (Catalonia, 63.4%; France North, 87.7%) and dispersed networks (Southwest Bavaria, 40.1%; Switzerland, 40.0%). Transport time savings for thrombolysis under the drip-and-ship approach were more marked in clustered networks (Catalonia, 29 minutes; France North, 27 minutes) than in dispersed networks (Southwest Bavaria and Switzerland, both 18 minutes). Conclusions Infrastructure differences between stroke networks may hamper the applicability of the results of the RACECAT study to other stroke networks with a different distribution of intervention centers. Stroke networks should assess the population densities and hospital type/distribution in the temporal domain before applying prehospital triage algorithms to their specific setting.
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Affiliation(s)
- Florian A. F. Schuler
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Marc Ribó
- Stroke Unit, Department of NeurologyVall d’Hebron University HospitalBarcelonaSpain
| | | | - Jan Rémi
- Department of NeurologyUniversity Hospital, Ludwig‐Maximilians‐UniversityMunichGermany
| | - Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Martina B. Goeldlin
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Thomas R. Meinel
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
- Network RadiologyKantonsspital St. GallenSt. GallenSwitzerland
| | - David J. Seiffge
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Urs Fischer
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
- Department of NeurologyUniversity Hospital Basel, University of BaselSwitzerland
| | - Marcel Arnold
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Georg Kägi
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
- Department of NeurologyKantonsspital St. GallenSt. GallenSwitzerland
| | - Simon Jung
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
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16
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Patel MD, Brown AB, Kebede ES. Statewide availability of acute stroke treatment, services, and programs: A survey of North Carolina Hospitals. J Stroke Cerebrovasc Dis 2023; 32:107323. [PMID: 37633205 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/14/2023] [Accepted: 08/21/2023] [Indexed: 08/28/2023] Open
Abstract
INTRODUCTION We conducted a statewide assessment of the availability of stroke treatment, services, and programs in North Carolina (NC) hospitals. We also examined differences in stroke care capabilities between urban, suburban, and rural hospitals and trends over the past 2 decades. METHODS An electronic survey was distributed to all 111 licensed hospitals in NC. Survey questions asked about stroke center certification status (i.e., standardized levels of stroke care capabilities), diagnostic testing, acute treatments and protocols, and post-acute management. Responses were collected from October 2020-April 2021. Select characteristics were compared to those from prior NC surveys in 1998, 2003, and 2008. RESULTS All 111 hospitals responded to the survey (100% response rate). Among 108 hospitals providing acute stroke care, 12 (11%) were Comprehensive Stroke Centers or Thrombectomy-Capable Stroke Centers, which were all located in urban or suburban areas. While 38% of urban/suburban hospitals were non-certified, 48% of rural hospitals were non-certified. Non-contrast computed tomography (CT), CT angiography, and alteplase treatment were widely available (100%, 95%, and 99%, respectively). Endovascular thrombectomy was solely available in urban/suburban hospitals (29%). Of non-tertiary hospitals, 81% were using telestroke for treatment and transfer decisions. Compared to prior survey results, the availability of CT angiography (76% in 2008 to 95% in 2020-2021), alteplase treatment (69% in 2008 to 99% in 2020-2021), and acute stroke clinical pathways (47% in 2008 to 90% in 2020-2021) increased. However, having an in-house neurologist on staff dropped from approximately 55% in prior surveys to 21% in the current survey. CONCLUSIONS Rural NC hospitals were less likely to have advanced diagnostic imaging and treatment capabilities for acute stroke. Temporal trends in staffing with an in-house neurologist and use of telestroke services should be further examined.
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Affiliation(s)
- Mehul D Patel
- Department of Emergency Medicine, School of Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, CB# 7594, Chapel Hill, NC 27599-7594, USA.
| | - Anna Bess Brown
- Division of Public Health, North Carolina Department of Health and Human Services, NC, USA
| | - Essete S Kebede
- Division of Public Health, North Carolina Department of Health and Human Services, NC, USA
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17
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Lin KW, Chen YJ, Hou SW, Tang SC, Chiang WC, Tsai LK, Lee CW, Lee YC, Chien YC, Hsieh MJ, Jeng JS, Huei-Ming Ma M. Effect of using G-FAST to recognize emergent large vessel occlusion: A city-wide community experience. J Formos Med Assoc 2023; 122:1069-1076. [PMID: 37120338 DOI: 10.1016/j.jfma.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 03/19/2023] [Accepted: 04/10/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND/PURPOSE A prehospital bypass strategy was suggested for large vessel occlusion. This study aimed to evaluate the effect of a bypass strategy using the gaze-face-arm-speech-time test (G-FAST) implemented in a metropolitan community. METHODS Pre-notified patients with positive Cincinnati Prehospital Stroke Scale and symptom onset <3 h from July 2016 to December 2017 (pre-intervention period) and those with positive G-FAST and symptom onset <6 h from July 2019 to December 2020 (intervention period) were included. Patients aged <20 years and those with missing in-hospital data were excluded. The primary outcomes were the rates of receiving endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT). The secondary outcomes were total prehospital time, door-to-computed tomography (CT) time, door-to-needle (DTN) time, and door-to-puncture (DTP) time. RESULTS We included 802 and 695 pre-notified patients from the pre-intervention and intervention periods, respectively. The characteristics of the patients in the two periods were similar. In the primary outcomes, pre-notified patients during the intervention period showed higher rates of receiving EVT (4.49% vs. 15.25%, p < 0.001) and IVT (15.34% vs. 21.58%, p = 0.002). In the secondary outcomes, pre-notified patients during intervention period had longer total prehospital time (mean 23.38 vs 25.23 min, p < 0.001), longer door-to-CT time (median 10 vs 11 min, p < 0.001), longer DTN time (median 53 vs 54.5 min, p < 0.001) but shorter DTP time (median 141 vs 139.5 min, p < 0.001). CONCLUSION The prehospital bypass strategy with G-FAST showed benefits for stroke patients.
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Affiliation(s)
- Kai-Wei Lin
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ying-Ju Chen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Sheng-Wen Hou
- Department of Emergency Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Chu Chiang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, 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
| | - Yu-Ching Lee
- Department of Industrial Engineering and Engineering Management, National Tsing Hua University, Hsinchu, Taiwan
| | - Yu-Chun Chien
- Emergency Medical Services Division, National Fire Agency, Ministry of the Interior, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, 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
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
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Ramos-Pachón A, Rodríguez-Luna D, Martí-Fàbregas J, Millán M, Bustamante A, Martínez-Sánchez M, Serena J, Terceño M, Vera-Cáceres C, Camps-Renom P, Prats-Sánchez L, Rodríguez-Villatoro N, Cardona-Portela P, Urra X, Solà S, del Mar Escudero M, Salvat-Plana M, Ribó M, Abilleira S, Pérez de la Ossa N, Silva Y. Effect of Bypassing the Closest Stroke Center in Patients with Intracerebral Hemorrhage: A Secondary Analysis of the RACECAT Randomized Clinical Trial. JAMA Neurol 2023; 80:1028-1036. [PMID: 37603325 PMCID: PMC10442788 DOI: 10.1001/jamaneurol.2023.2754] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/05/2023] [Indexed: 08/22/2023]
Abstract
Importance Prehospital transfer protocols are based on rapid access to reperfusion therapies for patients with ischemic stroke. The effect of different protocols among patients receiving a final diagnosis of intracerebral hemorrhage (ICH) is unknown. Objective To determine the effect of direct transport to an endovascular treatment (EVT)-capable stroke center vs transport to the nearest local stroke center. Design, Setting, and Participants This was a prespecified secondary analysis of RACECAT, a multicenter, population-based, cluster-randomized clinical trial conducted from March 2017 to June 2020 in Catalonia, Spain. Patients were evaluated by a blinded end point assessment. All consecutive patients suspected of experiencing a large vessel occlusion stroke (Rapid Arterial Occlusion Evaluation Scale [RACE] score in the field >4 on a scale of 0 to 9, with lower to higher stroke severity) with final diagnosis of ICH were included. A total of 1401 patients were enrolled in RACECAT with suspicion of large vessel occlusion stroke. The current analysis was conducted in October 2022. Intervention Direct transport to an EVT-capable stroke center (n = 137) or to the closest local stroke center (n = 165). Main Outcomes and Measures The primary outcome was tested using cumulative ordinal logistic regression to estimate the common odds ratio (OR) and 95% CI of the shift analysis of disability at 90 days as assessed by the modified Rankin Scale (mRS) score (range, 0 [no symptoms] to 6 [death]) in the intention-to-treat population. Secondary outcomes, included 90-day mortality, death or severe functional dependency, early neurological deterioration, early mortality, ICH volume and enlargement, rate of neurosurgical treatment, rate of clinical complications during initial transport, and rate of adverse events until day 5. Results Of 1401 patients enrolled, 1099 were excluded from this analysis (32 rejected informed consent, 920 had ischemic stroke, 29 had transient ischemic attack, 12 had subarachnoid hemorrhage, and 106 had stroke mimic). Thus, 302 patients were included (204 [67.5%] men; mean [SD] age 71.7 [12.8] years; and median [IQR] RACE score, 7 [6-8]). For the primary outcome, direct transfer to an EVT-capable stroke center (mean [SD] mRS score, 4.93 [1.38]) resulted in worse functional outcome at 90 days compared with transfer to the nearest local stroke center (mean [SD] mRS score, 4.66 [1.39]; adjusted common OR, 0.63; 95% CI, 0.41-0.96). Direct transfer to an EVT-capable stroke center also suggested potentially higher 90-day mortality compared with transfer to the nearest local stroke center (67 of 137 [48.9%] vs 62 of 165 [37.6%]; adjusted hazard ratio, 1.40; 95% CI, 0.99-1.99). The rates of medical complications during the initial transfer (30 of 137 [22.6%] vs 9 of 165 patients [5.6%]; adjusted OR, 5.29; 95% CI, 2.38-11.73) and in-hospital pneumonia (49 of 137 patients [35.8%] vs 29 of 165 patients [17.6%]; OR, 2.61; 95% CI, 1.53-4.44) were higher in the EVT-capable stroke center group. Conclusions and Relevance In this secondary analysis of the RACECAT randomized clinical trial, bypassing the closest stroke center resulted in reduced chances of functional independence at 90 days for patients who received a final diagnosis of ICH. Trial Registration ClinicalTrials.gov Identifier: NCT02795962.
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Affiliation(s)
- Anna Ramos-Pachón
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | | | - Joan Martí-Fàbregas
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | - Mònica Millán
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Alejandro Bustamante
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Marina Martínez-Sánchez
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Joaquín Serena
- Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain
| | - Mikel Terceño
- Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain
| | | | - Pol Camps-Renom
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | - Luis Prats-Sánchez
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | | | - Pere Cardona-Portela
- Stroke Unit, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Spain
| | - Xabier Urra
- Stroke Unit, Hospital Clínic, and August Pi i Sunyer Biomedical Research Institute Barcelona, Barcelona, Spain
| | - Silvia Solà
- Sistema d’Emergències Mèdiques, Barcelona, Spain
| | | | - Mercè Salvat-Plana
- Catalan Stroke Program, Agency for Health Quality and Assessment of Catalonia, and CIBER Epidemiology and Public Health, Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Sònia Abilleira
- Catalan Stroke Program, Agency for Health Quality and Assessment of Catalonia, and CIBER Epidemiology and Public Health, Barcelona, Spain
| | - Natalia Pérez de la Ossa
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Yolanda Silva
- Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain
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Jayaraman MV, Baird G, Oueidat K, Paolucci G, Haas RA, Torabi R, Moldovan K, Rhodes J, Potvin J, Alexander-Scott N, Yaghi S, Madsen T, Furie K, McTaggart RA. Long-term effect of field triage on times to endovascular treatment for emergent large vessel occlusion. J Neurointerv Surg 2023; 15:e86-e92. [PMID: 35896319 DOI: 10.1136/jnis-2022-019250] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/10/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Delays to endovascular therapy (EVT) for stroke may be mitigated with direct field triage to EVT centers. We sought to compare times to treatment over a 5.5 year span between two adjacent states, one with field triage and one without, served by a single comprehensive stroke center (CSC). METHODS During the study period, one of the two states implemented severity-based triage for suspected emergent large vessel occlusion, while in the other state, patients were transported to the closest hospital regardless of severity. We compared times to treatment and clinical outcomes between these two states. We also performed a matched pairs analysis, matching on date treated and distance from field to CSC. RESULTS 639 patients met the inclusion criteria, 407 in State 1 (with field triage) and 232 in State 2 (without field triage). In State 1, scene to EVT decreased 6% (or 8.13 min, p=0.0004) every year but no decrease was observed for State 2 (<1%, p=0.94). Cumulatively over 5.5 years, there was a reduction of 43 min in time to EVT in State 1, but no change in State 2. Lower rates of disability were seen in State 1, both for the entire cohort (all OR 1.22, 95% CI 1.07 to 1.40, p=0.0032) and for those independent at baseline (1.36, 95% CI 1.15 to 1.59, p=0.0003). CONCLUSIONS Comparing adjacent states over time, the implementation of severity-based field triage significantly reduced time to EVT.
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Affiliation(s)
- Mahesh V Jayaraman
- Diagnostic Imaging, Neurology and Neurosurgery, Brown University, Providence, Rhode Island, USA
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Grayson Baird
- Diagnostic Imaging, Brown University, Providence, Rhode Island, USA
| | - Karim Oueidat
- Diagnostic Imaging, Brown University, Providence, Rhode Island, USA
| | - Gino Paolucci
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Richard A Haas
- Diagnostic Imaging, Neurology and Neurosurgery, Brown University, Providence, Rhode Island, USA
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Radmehr Torabi
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
- Neurosurgery and Diagnostic Imaging, Brown University, Providence, Rhode Island, USA
| | - Krisztina Moldovan
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
- Neurosurgery, Brown University, Providence, Rhode Island, USA
| | - Jason Rhodes
- Department of Health, State of Rhode Island, Providence, Rhode Island, USA
| | - John Potvin
- Division of Emergency Medical Services, City of East Providence, East Providence, Rhode Island, USA
| | | | - Shadi Yaghi
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
- Neurology, Brown University, Providence, Rhode Island, USA
| | - Tracy Madsen
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
- Emergency Medicine, Brown University, Providence, Rhode Island, USA
| | - Karen Furie
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
- Neurology, Brown University, Providence, Rhode Island, USA
| | - Ryan A McTaggart
- Diagnostic Imaging, Neurology and Neurosurgery, Brown University, Providence, Rhode Island, USA
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
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Fladt J, Ospel JM, Singh N, Saver JL, Fisher M, Goyal M. Optimizing Patient-Centered Stroke Care and Research in the Prehospital Setting. Stroke 2023; 54:2453-2460. [PMID: 37548010 DOI: 10.1161/strokeaha.123.044169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Over the past decades, continuous technological advances and the availability of novel therapies have enabled treatment of more acute medical conditions than ever before. Many of these treatments, such as intravenous thrombolysis and mechanical thrombectomy for acute ischemic stroke, are highly time sensitive. This has raised interest in shifting advanced acute care from hospitals to the prehospital setting. Key objectives of advanced prehospital stroke care may include (1) early targeted treatments in the prehospital setting, for example, intravenous thrombolysis for acute stroke, and (2) advanced prehospital diagnostics such as prehospital large vessel occlusion and intracranial hemorrhage detection, to help inform patient triage and potentially reduce subsequent workload in emergency departments. Major challenges that may hamper a swift transition to more advanced prehospital care are related to conducting clinical trials in the prehospital setting to provide sufficient evidence for emergency interventions, as well as ambulance design, infrastructure, emergency medical service personnel training and workload, and cost barriers. Utilizing new technologies such as telemedicine, mobile stroke units and portable diagnostic devices, customized software applications, and smart storage space management may help surmount these challenges and establish efficient, targeted care strategies that are achievable in the prehospital setting. In this article, we delineate the paradigm of shifting advanced stroke care to the prehospital setting and outline future directions in providing evidence-based, patient-centered prehospital care. While we use acute stroke as an illustrative example, these principles are not limited to stroke patients and can be applied to prehospital triage for any time-critical disease.
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Affiliation(s)
- Joachim Fladt
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (J.F., J.M.O., M.G.)
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (J.F.)
| | - Johanna M Ospel
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (J.F., J.M.O., M.G.)
| | - Nishita Singh
- Department of Neurology, University of Manitoba, Winnipeg, Canada (N.S.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (M.F.)
| | - Mayank Goyal
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (J.F., J.M.O., M.G.)
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21
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Dekker L, Daems JD, Duvekot MHC, Nguyen TTM, Venema E, van Es ACGM, Rozeman AD, Moudrous W, Dorresteijn KRIS, Hensen JHJ, Bosch J, van Zwet EW, de Schryver ELLM, Kloos LMH, de Laat KF, Aerden LAM, van den Wijngaard IR, Dippel DWJ, Kerkhoff H, Wermer MJH, Roozenbeek B, Kruyt ND. Comparison of Prehospital Assessment by Paramedics and In-Hospital Assessment by Physicians in Suspected Stroke Patients: Results From 2 Prospective Cohort Studies. Stroke 2023; 54:2279-2285. [PMID: 37465998 DOI: 10.1161/strokeaha.123.042644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/22/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND It is unknown if ambulance paramedics adequately assess neurological deficits used for prehospital stroke scales to detect anterior large-vessel occlusions. We aimed to compare prehospital assessment of these stroke-related deficits by paramedics with in-hospital assessment by physicians. METHODS We used data from 2 prospective cohort studies: the LPSS (Leiden Prehospital Stroke Study) and PRESTO study (Prehospital Triage of Patients With Suspected Stroke). In both studies, paramedics scored 9 neurological deficits in stroke code patients in the field. Trained physicians scored the National Institutes of Health Stroke Scale (NIHSS) at hospital presentation. Patients with transient ischemic attack were excluded because of the transient nature of symptoms. Spearman rank correlation coefficient (rs) was used to assess correlation between the total prehospital assessment score, defined as the sum of all prehospital items, and the total NIHSS score. Correlation, sensitivity and specificity were calculated for each prehospital item with the corresponding NIHSS item as reference. RESULTS We included 2850 stroke code patients. Of these, 1528 had ischemic stroke, 243 intracranial hemorrhage, and 1079 stroke mimics. Correlation between the total prehospital assessment score and NIHSS score was strong (rs=0.70 [95% CI, 0.68-0.72]). Concerning individual items, prehospital assessment of arm (rs=0.68) and leg (rs=0.64) motor function correlated strongest with corresponding NIHSS items, and had highest sensitivity (arm 95%, leg 93%) and moderate specificity (arm 71%, leg 70%). Neglect (rs=0.31), abnormal speech (rs=0.50), and gaze deviation (rs=0.51) had weakest correlations. Neglect and gaze deviation had lowest sensitivity (52% and 66%) but high specificity (84% and 89%), while abnormal speech had high sensitivity (85%) but lowest specificity (65%). CONCLUSIONS The overall prehospital assessment of stroke code patients correlates strongly with in-hospital assessment. Prehospital assessment of neglect, abnormal speech, and gaze deviation differed most from in-hospital assessment. Focused training on these deficits may improve prehospital triage.
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Affiliation(s)
- Luuk Dekker
- Department of Neurology (L.D., T.T.M.N., I.R.v.d.W., M.J.H.W., N.D.K.), Leiden University Medical Center, the Netherlands
| | - Jasper D Daems
- Department of Neurology (J.D.D., M.H.C.D., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Public Health (J.D.D., E.V.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Martijne H C Duvekot
- Department of Neurology (J.D.D., M.H.C.D., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands (M.H.C.D., A.D.R., H.K.)
| | - T Truc My Nguyen
- Department of Neurology (L.D., T.T.M.N., I.R.v.d.W., M.J.H.W., N.D.K.), Leiden University Medical Center, the Netherlands
| | - Esmee Venema
- Department of Public Health (J.D.D., E.V.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Emergency Medicine (E.V.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan C G M van Es
- Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands
| | - Anouk D Rozeman
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands (M.H.C.D., A.D.R., H.K.)
| | - Walid Moudrous
- Department of Neurology (W.M.), Maasstad Hospital, Rotterdam, the Netherlands
| | | | - Jan-Hein J Hensen
- Department of Radiology (J.-H.J.H.), Maasstad Hospital, Rotterdam, the Netherlands
| | - Jan Bosch
- Emergency Medical Services Hollands-Midden, Leiden, the Netherlands (J.B.)
| | - Erik W van Zwet
- Department of Medical Statistics (E.W.v.Z.), Leiden University Medical Center, the Netherlands
| | - Els L L M de Schryver
- Department of Neurology, Alrijne Hospital, Leiderdorp, the Netherlands (E.L.L.M.d.S.)
| | - Loet M H Kloos
- Department of Neurology, Groene Hart Hospital, Gouda, the Netherlands (L.M.H.K.)
| | - Karlijn F de Laat
- Department of Neurology, Haga Hospital, The Hague, the Netherlands (K.F.d.L.)
| | - Leo A M Aerden
- Department of Neurology, Reinier de Graaf Gasthuis Hospital, Delft, the Netherlands (L.A.M.A.)
| | - Ido R van den Wijngaard
- Department of Neurology (L.D., T.T.M.N., I.R.v.d.W., M.J.H.W., N.D.K.), Leiden University Medical Center, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology (J.D.D., M.H.C.D., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands (M.H.C.D., A.D.R., H.K.)
| | - Marieke J H Wermer
- Department of Neurology (L.D., T.T.M.N., I.R.v.d.W., M.J.H.W., N.D.K.), Leiden University Medical Center, the Netherlands
- Department of Neurology, University Medical Center Groningen, Groningen, the Netherlands (M.J.H.W.)
| | - Bob Roozenbeek
- Department of Neurology (J.D.D., M.H.C.D., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Nyika D Kruyt
- Department of Neurology (L.D., T.T.M.N., I.R.v.d.W., M.J.H.W., N.D.K.), Leiden University Medical Center, the Netherlands
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22
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Jun-O’Connell AH, Sivakumar S, Henninger N, Silver B, Trivedi M, Ghasemi M, Lalla RR, Kobayashi KJ. Outcomes of Telestroke Inter-Hospital Transfers Among Intervention and Non-Intervention Patients. J Clin Med Res 2023; 15:292-299. [PMID: 37434777 PMCID: PMC10332878 DOI: 10.14740/jocmr4945] [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: 05/11/2023] [Accepted: 06/10/2023] [Indexed: 07/13/2023] Open
Abstract
Background Telestroke is an established telemedicine method of delivering emergency stroke care. However, not all neurological patients utilizing telestroke service require emergency interventions or transfer to a comprehensive stroke center. To develop an understanding of the appropriateness of inter-hospital neurological transfers utilizing the telemedicine, our study aimed to assess the differences in outcomes of inter-hospital transfers utilizing the service in relation to the need for neurological interventions. Methods The pragmatic, retrospective analysis included 181 consecutive patients, who were emergently transferred from telestroke-affiliated regional medical centers between October 3, 2021, and May 3, 2022. In this exploratory study investigating the outcomes of telestroke-referred patients, patients receiving interventions were compared to those that did not following transfer to our tertiary center. Neurological interventions included mechanical thrombectomy (MT) and/or tissue plasminogen activator (tPA), craniectomy, electroencephalography (EEG), or external ventricular drain (EVD). Transfer mortality rate, discharge functional status defined by modified Rankin scale (mRS), neurological status defined by National Institutes of Health Stroke Scale (NIHSS), 30-day unpreventable readmission rate, 90-day clinical major adverse cardiovascular events (MACE), and 90-day mRS, and NIHSS were studied. We used χ2 or Fisher exact tests to evaluate the association between the intervention and categorical or dichotomous variables. Continuous or ordinal measures were compared using Wilcoxon rank-sum tests. All tests of statistical significance were considered to be significant at P < 0.05. Results Among the 181 transferred patients, 114 (63%) received neuro-intervention and 67 (37%) did not. The death rate during the index admission was not statistically significant between the intervention and non-intervention groups (P = 0.196). The discharge NIHSS and mRS were worse in the intervention compared to the non-intervention (P < 0.05 each, respectively). The 90-day mortality and cardiovascular event rates were similar between intervention and non-intervention groups (P > 0.05 each, respectively). The 30-day readmission rates were also similar between the two groups (14% intervention vs. 13.4% non-intervention, P = 0.910). The 90-day mRS were not significantly different between intervention and non-intervention groups (median 3 (IQR: 1 - 6) vs. 2 (IQR: 0 - 6), P = 0.109). However, 90-day NIHSS was worse in the intervention compared to non-intervention group (median 2 (IQR: 0 - 11) vs. 0 (IQR: 0 - 3), P = 0.004). Conclusions Telestroke is a valuable resource that expedites emergent neurological care via referral to a stroke center. However, not all transferred patients benefit from the transfer process. Future multicenter studies are warranted to study the effects or appropriateness of telestroke networks, and to better understand the patient characteristics, resources allocation, and transferring institutions to improve telestroke care.
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Affiliation(s)
- Adalia H. Jun-O’Connell
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Shravan Sivakumar
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Brian Silver
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Meghna Trivedi
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Mehdi Ghasemi
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Rakhee R. Lalla
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Kimiyoshi J. Kobayashi
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
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23
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Richards CT, Oostema JA, Chapman SN, Mamer LE, Brandler ES, Alexandrov AW, Czap AL, Martinez-Gutierrez JC, Martin-Gill C, Panchal AR, McMullan JT, Zachrison KS. Prehospital Stroke Care Part 2: On-Scene Evaluation and Management by Emergency Medical Services Practitioners. Stroke 2023; 54:1416-1425. [PMID: 36866672 PMCID: PMC10133016 DOI: 10.1161/strokeaha.123.039792] [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: 01/03/2023] [Accepted: 02/02/2023] [Indexed: 03/04/2023]
Abstract
The prehospital phase is a critical component of delivering high-quality acute stroke care. This topical review discusses the current state of prehospital acute stroke screening and transport, as well as new and emerging advances in prehospital diagnosis and treatment of acute stroke. Topics include prehospital stroke screening, stroke severity screening, emerging technologies to aid in the identification and diagnosis of acute stroke in the prehospital setting, prenotification of receiving emergency departments, decision support for destination determination, and the capabilities and opportunities for prehospital stroke treatment in mobile stroke units. Further evidence-based guideline development and implementation of new technologies are critical for ongoing improvements in prehospital stroke care.
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Affiliation(s)
- Christopher T. Richards
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - J. Adam Oostema
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI
| | | | - Lauren E. Mamer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Ethan S. Brandler
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Anne W. Alexandrov
- College of Nursing, University of Tennessee Health Science Center, Memphis, TN
| | - Alexandra L. Czap
- Department of Neurology, University of Texas Houston McGovern Medical School, Houston, TX
| | | | | | - Ashish R. Panchal
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jason T. McMullan
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kori S. Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
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24
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Pariona-Vargas F, Mun KT, Lo EH, Starkman S, Sanossian N, Hosseini MB, Stratton S, Eckstein M, Conwit RA, Liebeskind DS, Sharma LK, Rao NM, Shkirkova K, Avila G, Kim-Tenser MA, Saver JL. Circadian variation in stroke onset: Differences between ischemic and hemorrhagic stroke and weekdays versus weekends. J Stroke Cerebrovasc Dis 2023; 32:107106. [PMID: 37116446 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107106] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/03/2023] [Accepted: 03/27/2023] [Indexed: 04/30/2023] Open
Abstract
OBJECTIVES To delineate diurnal variation onset distinguishing ischemic from hemorrhagic stroke, wake from sleep onset, and weekdays from weekends/holidays. MATERIALS AND METHODS We analyzed patients enrolled in the FAST-MAG trial of field-initiated neuroprotective agent in patients with hyperacute stroke within 2h of symptoms onset. Stroke onset times were analyzed in 1h, 4h, and 12h time blocks throughout the 24h day-night cycle. Patient demographic, clinical features, stroke severity, and prehospital workflow were evaluated for association with onset times. RESULTS Among 1615 acute cerebrovascular disease patients, final diagnoses were acute cerebral ischemia in 76.5% and Intracerebral hemorrhage in 23.5%. Considering all acute cerebrovascular disease patients, frequency of wake onset times showed a bimodal pattern, with peaks on onsets at 09:00-13:59 and 17:00-18:59 and early morning (00:00-05:59) onset in only 3.8%. Circadian rhythmicity differed among stroke subtypes: in acute cerebral ischemia, a single broad plateau of elevated incidences was seen from 10:00-21:59; in Intracerebral hemorrhage, bimodal peaks occurred at 09:00 and 19:00. The ratio of Intracerebral hemorrhage to acute cerebral ischemia occurrence was highest in early morning, 02:00-06:59. Marked weekday vs weekends pattern variation was noted for acute cerebral ischemia, with a broad plateau between 09:00 and 21:59 on weekdays but a unimodal peak at 14:00-15:59 on weekends. CONCLUSIONS Wake onset of acute cerebrovascular disease showed a marked circadian variation, with distinctive patterns of a broad elevated plateau among acute cerebral ischemia patients; a bimodal peak among intracerebral hemorrhage patients; and a weekend change in acute cerebral ischemia pattern to a unimodal peak.
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Affiliation(s)
- Fatima Pariona-Vargas
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, United States.
| | - Katherine T Mun
- Department of Neurology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States
| | - Eng H Lo
- Department of Neurology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States; Department of Radiology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States
| | - Sidney Starkman
- Department of Neurology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States
| | - Nerses Sanossian
- Department of Neurology, University of Southern California, Los Angeles, CA, United States
| | - Mersedeh Bahr Hosseini
- Department of Neurology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States
| | - Samuel Stratton
- Department of Neurology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States
| | - Marc Eckstein
- Department of Neurology, University of Southern California, Los Angeles, CA, United States
| | - Robin A Conwit
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States; Department of Neurology, Indiana University, United States
| | - David S Liebeskind
- Department of Neurology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States
| | - Latisha K Sharma
- Department of Neurology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States
| | - Neal M Rao
- Department of Neurology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States
| | - Kristina Shkirkova
- Department of Neurology, University of Southern California, Los Angeles, CA, United States
| | - Gilda Avila
- Department of Neurology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States
| | - May A Kim-Tenser
- Department of Neurology, University of Southern California, Los Angeles, CA, United States
| | - Jeffrey L Saver
- Department of Neurology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States
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25
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Zachrison KS, Nielsen VM, de la Ossa NP, Madsen TE, Cash RE, Crowe RP, Odom EC, Jauch EC, Adeoye OM, Richards CT. Prehospital Stroke Care Part 1: Emergency Medical Services and the Stroke Systems of Care. Stroke 2023; 54:1138-1147. [PMID: 36444720 PMCID: PMC11050637 DOI: 10.1161/strokeaha.122.039586] [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] [Indexed: 11/30/2022]
Abstract
Acute stroke care begins before hospital arrival, and several prehospital factors are critical in influencing overall patient care and poststroke outcomes. This topical review provides an overview of the state of the science on prehospital components of stroke systems of care and how emergency medical services systems may interact in the system to support acute stroke care. Topics include layperson recognition of stroke, prehospital transport strategies, networked stroke care, systems for data integration and real-time feedback, and inequities that exist within and among systems.
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Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (K.S.Z., R.E.C.)
| | | | - Natalia Perez de la Ossa
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias I Pujol, Badalona, Spain and Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain (N.P.d.l.O)
| | - Tracy E Madsen
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI (T.E.M.)
| | - Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (K.S.Z., R.E.C.)
| | | | - Erika C Odom
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (E.C.O.)
| | - Edward C Jauch
- Department of Research, University of North Carolina Health Sciences at Mountain Area Health Education Center, Asheville, NC (E.C.J.)
| | - Opeolu M Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO (O.M.A.)
| | - Christopher T Richards
- Division of EMS, Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH (C.T.R.)
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26
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Kennedy BA, Stout PJ. Telestroke Process at a Community Hospital: A Quality Improvement Project. J Emerg Nurs 2023:S0099-1767(22)00348-8. [PMID: 36710095 DOI: 10.1016/j.jen.2022.12.008] [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: 07/19/2022] [Revised: 11/23/2022] [Accepted: 12/18/2022] [Indexed: 01/30/2023]
Abstract
INTRODUCTION An updated stroke process was designed and implemented at an Acute Stroke Ready community hospital that relies on telestroke services. The objectives of the current quality improvement project were to describe the updates to the stroke process and compare pre- and postintervention data on nurse-driven elements of the process, namely telestroke notification and neurologist assessment. METHODS Our multidisciplinary team reviewed quality data over several months to identify areas of improvement in the stroke process. Delays in door to telestroke notification and neurologist assessment were identified. A new process was developed and implemented, including e-alert notification and storing the telestroke cart in the computed tomography suite. The study period was 14 months, with nonrandomized, convenience sample data collected for 7 months before and after intervention. RESULTS There was a significant reduction in door to telestroke notification and neurologist assessment after implementing the new process. Door to telestroke notification and neurologist assessment were also strongly correlated. DISCUSSION This project led to significant improvements in nurse-driven elements of the stroke process. It demonstrates effective implementation of e-alert and collaboration with telestroke services at an Acute Stroke Ready Hospital serving rural communities.
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27
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Oostema JA, Nickles A, Luo Z, Reeves MJ. Emergency Medical Services Stroke Care Performance Variability in Michigan: Analysis of a Statewide Linked Stroke Registry. J Am Heart Assoc 2022; 12:e026834. [PMID: 36537345 PMCID: PMC9973590 DOI: 10.1161/jaha.122.026834] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Emergency medical services (EMS) compliance with recommended prehospital care for patients with acute stroke is inconsistent; however, sources of variability in compliance are not well understood. The current analysis utilizes a linkage between a statewide stroke registry and EMS information system data to explore patient and EMS agency-level contributions to variability in prehospital care. Methods and Results This is a retrospective analysis of a cohort of confirmed stroke cases transported by EMS to hospitals participating in a statewide stroke registry. Using EMS information system data, the authors quantified EMS compliance with 6 performance measures derived from national guidelines for prehospital stroke care: prehospital stroke scale performance, glucose check, stroke recognition, on-scene time ≤15 minutes, time last known well documentation, and hospital prenotification. Multilevel multivariable logistic regression analysis was then used to examine associations between patient-level demographic and clinical characteristics and EMS compliance while accounting for and quantifying the variation attributable to agency of transport and recipient hospital. Over an 18-month period, EMS and stroke registry records were linked for 5707 EMS-transported stroke cases. Compliance ranged from 24% of cases for last known well documentation to 82% for documentation of a glucose check. The other measures were documented in approximately half of cases. Older age, higher National Institutes of Health Stroke Scale, and earlier presentation were associated with more compliant prehospital care. EMS agencies accounted for more than half of the variation in EMS prehospital stroke scale documentation and last known well documentation and 27% of variation in glucose check but <10% of stroke recognition and prenotification variability. Conclusions EMS stroke care remains highly variable across different performance measures and EMS agencies. EMS agency and electronic medical record type are important sources of variability in compliance with key prehospital performance metrics for stroke.
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Affiliation(s)
- J. Adam Oostema
- Department of Emergency MedicineMichigan State University College of Human Medicine, Secchia CenterGrand RapidsMI
| | - Adrienne Nickles
- Michigan Department of Health and Human Services, Lifecourse Epidemiology and Genomics DivisionLansingMI
| | - Zhehui Luo
- Department of Epidemiology and BiostatisticsMichigan State University College of Human MedicineEast LansingMI
| | - Mathew J. Reeves
- Department of Epidemiology and BiostatisticsMichigan State University College of Human MedicineEast LansingMI
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28
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Yu CY, Guilliams KP, Panagos PD, Kansagra AP. Pediatric hospital proximity to endovascular thrombectomy centers in the United States. Interv Neuroradiol 2022; 28:682-686. [PMID: 34913385 PMCID: PMC9706276 DOI: 10.1177/15910199211059334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Cathy Y Yu
- Washington University School of
Medicine, St Louis, Missouri, USA
| | - Kristin P Guilliams
- Department of Pediatrics, Washington University School of
Medicine, St Louis, Missouri, USA
- Department of Neurology, Washington University School of
Medicine, St Louis, Missouri, USA
| | - Peter D Panagos
- Department of Neurology, Washington University School of
Medicine, St Louis, Missouri, USA
- Department of Emergency Medicine, Washington University School of
Medicine, St Louis, Missouri, USA
| | - Akash P Kansagra
- Department of Neurology, Washington University School of
Medicine, St Louis, Missouri, USA
- Department of Neurological Surgery, Washington University School of
Medicine, St Louis, Missouri, USA
- Mallinckrodt Institute of Radiology, Washington University School of
Medicine, St Louis, Missouri, USA
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29
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Shownkeen H, Richards CT, Buffo K, Graham S, Iacob T, Mohajer-Esfahani M, Lindstrom A, Garg A, Gutti P, Sachdeva K, Shrivastava A, Williams J, Crumlett H, Huml J. Outcomes of Patients Receiving Thrombolysis in a Mobile Stroke Unit: a 4-Year Retrospective, Observational, Single-Center Study. PREHOSP EMERG CARE 2022:1-7. [DOI: 10.1080/10903127.2022.2142991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Harish Shownkeen
- Northwestern Medicine Central DuPage Hospital, Mobile Stroke Unit, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Christopher T. Richards
- Northwestern Medicine Central DuPage Hospital, Neuro - Interventional, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Keely Buffo
- University of Cincinnati, Emergency Medicine, 231 Albert Sabin Way, PO Box 670769, ML: 0769, Cincinnati, 45221 United States
| | - Stephen Graham
- Northwestern Medicine Central DuPage Hospital, Emergency Medicine, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Tudor Iacob
- Northwestern Medicine Central DuPage Hospital, Neurology, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Mehr Mohajer-Esfahani
- Northwestern Medicine Huntley Hospital, Cardiac Telemetry, 10400 Haligus Rd, Huntley, 60142-9553 United States
| | - Anne Lindstrom
- Marianjoy Rehabilitation Hospital, Rehabilitation, 26W171 Roosevelt Rd, Wheaton, 60189-0795 United States
| | - Anjali Garg
- Northwestern Medicine Central DuPage Hospital, Neurology, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Padmaja Gutti
- Northwestern Medicine Central DuPage Hospital, Neurology, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Kapil Sachdeva
- Northwestern Medicine Central DuPage Hospital, Neurology, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Archana Shrivastava
- Northwestern Medicine Central DuPage Hospital, Neurology, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Justin Williams
- Northwestern Medicine Central DuPage Hospital, Emergency Medical Services, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Hillary Crumlett
- Northwestern Medicine Central DuPage Hospital, Inpatient Nursing and Emergency Department, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Jeffrey Huml
- Northwestern Medicine Central DuPage Hospital, Critical Care, 25 N Winfield Rd, Winfield, 60190-1379 United States
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30
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Ohashi K, Osanai T, Fujiwara K, Tanikawa T, Tani Y, Takamiya S, Sato H, Morii Y, Bando K, Ogasawara K. Spatial-temporal analysis of cerebral infarction mortality in Hokkaido, Japan: an ecological study using a conditional autoregressive model. Int J Health Geogr 2022; 21:16. [PMID: 36316770 PMCID: PMC9623919 DOI: 10.1186/s12942-022-00316-1] [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: 06/14/2022] [Accepted: 09/19/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Accessibility to stroke treatments is a challenge that depends on the place of residence. However, recent advances in medical technology have improved health outcomes. Nevertheless, the geographic heterogeneity of medical resources may increase regional disparities. Therefore, evaluating spatial and temporal influences of the medical system on regional outcomes and advanced treatment of cerebral infarction are important from a health policy perspective. This spatial and temporal study aims to identify factors associated with mortality and to clarify regional disparities in cerebral infarction mortality at municipality level. METHODS This ecological study used public data between 2010 and 2020 from municipalities in Hokkaido, Japan. We applied spatial and temporal condition autoregression analysis in a Bayesian setting, with inference based on the Markov chain Monte Carlo simulation. The response variable was the number of deaths due to cerebral infarction (ICD-10 code: I63). The explanatory variables were healthcare accessibility and socioeconomic status. RESULTS The large number of emergency hospitals per 10,000 people (relative risk (RR) = 0.906, credible interval (Cr) = 0.861 to 0.954) was associated with low mortality. On the other hand, the large number of general hospitals per 10,000 people (RR = 1.123, Cr = 1.068 to 1.178) and longer distance to primary stroke centers (RR = 1.064, Cr = 1.014 to 1.110) were associated with high mortality. The standardized mortality ratio decreased from 2010 to 2020 in Hokkaido by approximately 44%. Regional disparity in mortality remained at the same level from 2010 to 2015, after which it narrowed by approximately 5% to 2020. After mapping, we identified municipalities with high mortality rates that emerged in Hokkaido's central and northeastern parts. CONCLUSION Cerebral infarction mortality rates and the disparity in Hokkaido improved during the study period (2010-2020). This study emphasized that healthcare accessibility through places such as emergency hospitals and primary stroke centers was important in determining cerebral infarction mortality at the municipality level. In addition, this study identified municipalities with high mortality rates that require healthcare policy changes. The impact of socioeconomic factors on stroke is a global challenge, and improving access to healthcare may reduce disparities in outcomes.
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Affiliation(s)
- Kazuki Ohashi
- grid.39158.360000 0001 2173 7691Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-ku, 060-0812 Sapporo, Japan
| | - Toshiya Osanai
- grid.39158.360000 0001 2173 7691Department of Neurosurgery, Faculty of Medicine, Graduate School of Medicine, Hokkaido University, N15-W7, Kita-ku, 060-8638 Sapporo, Japan
| | - Kensuke Fujiwara
- grid.39158.360000 0001 2173 7691Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-ku, 060-0812 Sapporo, Japan ,grid.444620.00000 0001 0666 3591Graduate School of Commerce, Otaru University of Commerce, 3-5-21, 047-8501 Midori, Otaru Japan
| | - Takumi Tanikawa
- grid.39158.360000 0001 2173 7691Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-ku, 060-0812 Sapporo, Japan ,grid.444700.30000 0001 2176 3638Faculty of Health Sciences, Hokkaido University of Science, 7-15-4-1, Maeda, Teine-ku, 006-8585 Sapporo, Japan
| | - Yuji Tani
- grid.39158.360000 0001 2173 7691Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-ku, 060-0812 Sapporo, Japan ,grid.252427.40000 0000 8638 2724Department of Medical Informatics and Hospital Management, Asahikawa Medical University, E2-1-1-1, 078-8510 Midorigaoka, Asahikawa Japan
| | - Soichiro Takamiya
- grid.39158.360000 0001 2173 7691Department of Neurosurgery, Faculty of Medicine, Graduate School of Medicine, Hokkaido University, N15-W7, Kita-ku, 060-8638 Sapporo, Japan ,Department of Neurosurgery, Otaru General Hospital, 1-1-1, 047-8550 Wakamatsu, Otaru Japan
| | - Hirotaka Sato
- Department of Neurosurgery, Kitami Red Cross Hospital, N6-E2, Kitami, 090-8666 Sapporo, Japan
| | - Yasuhiro Morii
- grid.39158.360000 0001 2173 7691Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-ku, 060-0812 Sapporo, Japan ,grid.415776.60000 0001 2037 6433Center for Outcomes Research and Economic Evaluation for Health, National Institute of Public Health, 2-3-6, 351-0197 Wako, Minami Japan
| | - Kyohei Bando
- grid.39158.360000 0001 2173 7691Graduate school of Health Sciences, Hokkaido University, N12-W5, Kita-ku, 060-0812 Sapporo, Japan
| | - Katsuhiko Ogasawara
- grid.39158.360000 0001 2173 7691Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-ku, 060-0812 Sapporo, Japan
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García‐Tornel Á, Seró L, Urra X, Cardona P, Zaragoza J, Krupinski J, Gómez‐Choco M, Mas Sala N, Catena E, Palomeras E, Serena J, Hernandez‐Perez M, Boned S, Olivé‐Gadea M, Requena M, Muchada M, Tomasello A, Molina CA, Salvat‐Plana M, Escudero M, Jimenez X, Davalos A, Jovin TG, Purroy F, Abilleira S, Ribó M, Perez de la Ossa N, Jacobi MR, Sanjuan E, Santana K, Molina C, Rubiera M, Rodríguez N, Pagola J, Rodriguez‐Luna D, Maisterra O, Santamarina E, Muchada M, Juega J, Boned S, Franco AP, García‐Tornel Á, Gadea MO, Deck M, Requena M, Sala V, de la Ossa NP, Muñoz L, Millán M, Gomis M, López‐Cancio E, Dorado L, Hernández‐Pérez M, Ciurans J, Samaniego D, Canento T, Martin L, Planas A, Broto J, Sorrentino A, Paré M, Zhu N, Garrido A, Grau L, Crespo AM, Presas S, Almendrote M, Ramos A, Lucente G, Ispierto L, Lozano M, Becerra JL, Jiménez M, Rolán DV, Guanyabens N, Sanchez‐Ojanguren J, Martínez‐Piñeiro A, Forcén S, Gea M, Álvarez M, Ramos A, Lizarbe MD, Sara, Guerra R, Bragado I, Arbex A, Rodríguez L, Bustamante A, Portela PC, García HQ, Rodríguez BL, Cayuela N, Miró J, Marzal C, Paipa A, Campoy S, Núñez A, Arroyo P, Besora S, Adell V, Campdelacreu J, Martí MA, González B, Vila LB, Crespo MF, Berbel A, Urbaneja CV, Guillen N, Vidal N, Santamaria PVV, Navarro DH, Simó M, Falip M, Matas E, Ochoa NM, Gifreu A, Muñoz A, Romero L, Portell E, Perez GH, Esteve FR, Teixidor S, Talavera AS, Gómez R, Nuin XU, Vargas M, Chamorro Á, Amaro S, Llull L, Renú A, Rudilosso S, del Valle RS, Ariño H, Solà N, la Puma D, Gil F, Gómez JB, Matos N, Falgàs N, Borrego S, Sánchez A, Balasa M, Montejo C, Guasp M, Reyes D, Cervilla PS, Contador JM, Monge VAV, Ramos O, Manzanera LSR, Rodríguez A, Campello AR, Ballester GR, Trujillano ML, Steinhauer EG, Godia EC, Santiago AJO, Conde JJ, Fábregas JM, Guisado D, Prats L, Camps P, Delgado R, Domeño AM, Marín R, Cànovas D, Estela J, Ros M, Aranceta S, Espinosa J, Rubio M, Lafuente C, Barrachina O, Anguita A, Reverter A, García C, Sansa G, Hervas M, Crosas M, Delgado T, Krupinski J, Folch DSH, Gamito GM, Alvarez JT, Subirana T, Molina J, Besora S, Romero LC, Valls GG, Jover M, Sotova JJ, Sánchez SMG, Valenzuela S, Gómez‐Choco M, Mengual JJ, Font MÀ, Ruiz MIG, Zubizarreta I, González SF, Gubieras L, Cobos CE, Romo LM, Caballol N, Cano L, Leal JS, Blas YS, Izarra MT, Trigo IB, Viturro SB, Albiñana LP, Garrido MR, Cazcarra CM, Uscamaita KE, Márquez F, Coll C, Villlas MIL, Vila BS, Perna BA, Domínguezl DL, de Lera M, Foraster AC, Monge VAV, Bojaryn U, García FP, Benabdelhak I, Capdevila GM, Montesinos JS, Vázquez D, Hervás JV, González C, Quílez A, Pascual MV, Ruiz M, Riba Y, Villar MPG, García C, Roig XU, Mora MB, Guinjoan AP, Borras J, Martínez AM, Marés R, Viñas i Gaya J, Seró L, Flores A, Rodríguez DP, Castilho G, Ortega AM, Reverté S, Zaragoza J, Baiges JJ, Zaragoza J, Ozaeta GM, Escalante S, Belloch PE, Payo I, Salvado JS, Sala NM, Soler Insa JM, Vilamala ET, Navarro JA, Tabuenca HC, Sánchez TC, Ros M, Matos N, Roldán E, Rubiol EP, Franquet E, Fuentes L, Donaire J, Martí E, Giménez L, Vázquez JG, Ambrós ENCG, Rodríguez P, Oletta JF, Mellado PP, Catena, Gómez B, Raileau V, Ruíz EC, Pardina O, Mercadal J, López‐Diéguez M, Pérez P, Gabarró L, Orriols M, Molina JC, Canet JJ, Roca M, Álvaro M, Boneu F, Giménez G, Albà J, Gibert F, Garcia J, Barragan P, Jurado G, Pascual V, Ortega JS, Solano JAM, Fernández V, Torres M, Alvaredo ABM, Parejo LR, Aragonés JM, Bullón A, Loste C, González P, Bejarano N, Sanchez F, Lucchetti G, Pla X, Gimeno J, Reynaga E, Barcons M, Celedón G, Ortiz J, Anastasovski G, Mascaró O, de los Ríos JD, Feliu M, Ribera A, Ruiz C, Corominas G, Nunes DD, Roca C, Latorre N, Yataco L, Cruz M, Blanco N, Castejón S, Calderón DC, Sunyer CP, Garcia JE, Martin RP, de Luis Sanchez A, Vivas DE, Molina JV, Palome GP, Chaume LT, Vilella AV, Bustamante M, Boltes A, Rodríguez F, Arrieta I, Molist JC, Andreu B, Soler EP, Buscà NG, López MD, Farreres JB, Ruiz VC, Batiste DM, Cartagena MPS, de Vega EC, Real JB, Roman HP, Socolich C, Camp JMA, Orgaz ATC, Felip MPF, Morón N, Bacca S, Molina M, Casarramona F, Elias L, Bukaei MZ, Gutierrez JAM, Escuin JL, Olaizola C, Vargas YL, Oyonarte JJ, Soultana R, Golpe ES, Salvador E, Vila G, Serrano M, Claverol MNL, Lamolla M, Amate M, Rodriguez A, Romero R, del Carpio M, Hernandez AI, Martín J, Rosas MC, Nogueroles A, Encarnación S, Robles A, Herrera JA, Gavilán R, Mameghani T, Araujo G, Morales MAG, Segui ERA, Climent EF, Pujol FP, Seira MJG, Pía LG, Nuñez FS, Peñalver CA, Lopes CV, Tasa ER, Vilchez CR, Zambrana MS, Ribas BS, Panés IV, Planavila MV, Lorenzo AV, Guixes MS, Medina J, Sambrano D, Zamarreño J, Pirela C, Vélez P, Cajamarca L, Pérez H, Martínez Y, Gonçalves JA, Regordosa C, Mormeneo C, Griu L, Colina MF, Farik E, Duch DC, Badenas C, Bernal O, Agramunt N, Morales S, Reynoso V, Guerrero M, Cid PR, Folqué M, Pedroza C, Hachem A, Martínez ÍS, García XV, Amorós ML, Subirós XC, Benet MC, Eendenburg CV, Osuna T, Santos DG, Pallisera DM, Oliva LG, Sanchez DG, Basurto X, Vivoda L, Van der Kleyn R, Robles DL, Barranco AC, Almendros MC, Oliveras MP, Álvarez AF, Rybyeva M, Viñas A, Barcons M, Tavera JDA, Burbano P, López C, Cruz D, Bisbe P, Fernández N, Palacio JC, Fraiz E, Aguiló O, Amorodjo R, Velázquez J, Sánchez E, Español J, de Celis JP, Coll A, Díaz G, Vergés i Sala M, Capdevila MÁC, Ferrini YY, Gorriz A, Navarro DC, Velásquez D, Soler JP, González J, Higuera JD, Cuellar L, Miniello LM, Pujol L, Cracan S, Angela MVM, Anabel LL, Molist MG, Anna D, Muñoz SS, Yolanda F, Pujalte C, Marín ET, Casas YF, Luque SH, Sendra JM, Valero FM, Olga CE, Carles GDL, Enric LD, Paramio C, Xavier, Xavier CE, Jaime EM, Jordi CM, Antonio CA, Elena CNM, Lluis CRP, Anna DF, Pere FSJ, Ana FG, Antoni FBJ, Carlos GHJ, Sergio HP, Zulma IT, Rafael MR, Albert OG, Marta OC, Soledad QGM, RodriguezJavier R, Joaquin RS, Ramon RMJ, Pere SV, Jose SAM, Angeles SGM, Francisco TE, José TGP, Isabel VCM, Jose VLJ, Angeles LCM, Isaac LG, Arnulfo MAJ, Olga MF, Teresa SGM, Miquel TM, Mercedes VLM, Manuel PRJ, Marta RF, Dominica RT, Jose SG, Meritxell SG, Sheila AR, Falip AG, Vanessa AO, Stella BP, Miriam CM, Monica CF, Estefani CM, Nuria DM, Laura DM, Margarita FP, Sylvia FC, Georgina GT, del Mar GGA, de Jesus LAD, Pilar LS, Monica LV, Jordi MC, de la Cruz Raquel M, Arantxa MB, Marcos OO, Núria PS, Sergi PM, Carlos RGJ, Virginia RP, Anna SP, Mireia SV, Rossana SL, Judit TR, Anna TC, Maria VA, Teresa AGM, Silvia BV, Maria CGR, Antonio ECJ, Agusti EM, Helena GF, Sar HL, Sonia JD, Angel MGM, Pau OS, Noemi PF, Jesus SF, Carlos SAA, Giovanna TL, Sandra VH, Marta TG, Ada AV, Sonia AA, Laura AN, Mar AB, Cristina AM, Angels AO, Jeannette AC, Miriam AP, Vanessa ACM, Remedios AGE, Silvia AS, Izaskun AS, Nuria BG, Sergio BB, Teresa BT, Roser BP, Ariadna BP, Isabel BG, Nuria BS, Laia BA, Salvador CC, Arnau CC, Iren CM, Nuria CB, Daniel CF, Marc CS, Teresa CM, Cristina CB, Sandra CC, Borrego AJLC, Orri AC, Vilanova GC, Sole AC, Torres MC, Estepa NC, de Sostoa Graell M, del Rio Lopez L, Sandra BDC, Carmen DB, Lucia DMA, Carme DPM, Javier DCP, Laura DM, Khadija EA, Pau EM, David EC, Daniel FP, Sergi FQ, Sergio FE, Anna FA, del Valle Africa F, del Valle Mª Luisa F, Maria FQS, Teresa FRM, Rut GF, Alicia GG, Laura GC, Marina GR, Gemma C, Manuela GA, Xavier GG, Beatriz GF, Marta GG, Ricardo GG, Flor GL, Maria GO, Marta GB, Susana GR, Albert GE, Gemma HS, Dolça HC, Lluis HA, Marta HR, Paula IB, Alessandro I, Marta IC, Etxetxikia JU, Jordi JG, Rajaa KA, Gustavo LG, Anna LM, de Jesus LAD, Lourdes LMM, Aida LC, Monica LB, Laura LM, Cristian LR, Pedro LR, Tania LM, Ruth LM, Jessica LC, Alexia LN, Antonio MDJ, Morales MTP, Albert MC, Natanael MCD, David MG, Paula MG, Quesada M, Marzà Fusté Mireia CM, Marta ML, Jordi MM, Pastalle MP, Silvia MV, Emma MM, Christian MP, Olga MF, Helena MC, Mireia MV, Guillem MS, Aldara MQ, Natalia NR, Asuncion NIM, Pilar NMM, Judith OM, Roger PR, Xenia PT, Ivana PB, Anna PG, Mireia PO, Alejandra PRM, Raquel PY, Anna PM, Sergi PM, Alba PC, Lourdes QB, Cristina RB, Helena RF, del Carmen RGM, Joaquim RP, Inma RF, Amalia RF, Mariola RF, Raquel RM, Yolanda RN, Alicia RI, Albert RG, Silvia RB, de Eugenio Ramon R, Priscila RBARL, Julia SL, Carolina SJA, Daniel SS, Jordi SS, Marta SS, Enriqueta SP, Maria SB, Ruth SD, Ignacio TM, Cristina TV, Ines TSE, Soledad TT, Lluis TF, Marina TR, Anna TG, Nuria TE, Florenc U, Garazi VB, De la Paz Angel V, Fernando VG, Ingrit VG, Natalia VM, Eva VC, Jose VJM, Angela VF, Carla VG, Elisabeth VV, Jose CJF, Agusti GV, Albert GG, Laura JM, Jose MC, Felix MO, Jose MBM, Manuel ML, Jesus MRM, Carles MG, Ricardo MH, Eva MO, Ramon PP, Camilo PC, Antonio PAJ, Pol QM, Jordi RM, Sonia AA, Celia AA, Lorena AF, Joan BP, Laia BA, Francisco CV, Jaume CH, Gloria CGM, Gonzalo CM, Xavier CE, Enric CG, Montserrat CS, Carlos DS, Javier ER, del Mar ECM, Joaquin FA, Carlos FG, Patricia FP, Laura FE, Cristina FG, Marta GP, Ainhoa GG, Rafael HS, Dolça HC, Marta HR, Sonia JA, Pedro JR, Angeles LCM, Alejandro LL, Aleix LO, Rosa MRM, Daniel MM, Marta MM, Noelia ME, Olga MF, Sandra MJ, Matilde MR, Jessica NR, Maria NIR, Raquel NV, Alba PTM, Montserrat PVC, Alba PC, Angels RM, Alejandro RT, Merce RO, Mariola RF, Baltasar SG, Paola SP, Enriqueta SP, Cristina SB, Angeles SGM, Meritxell TF, Gemma TB, Jose TA, Agusti EM, Purificacion FM, Luis HP, Laura JM, Pedro LF, Alfonso LG, Felix MO, Jose MBM, Carles MG, Eva MO, Ricardo PL, Ramon PP, Joan QA, Miguel VL, Consuelo AD, Jeannette AC, Miguel AM, Anna AC, Raquel BG, Antonio BC, Del Mar CGM, Montserrat CO, Daniel CF, Marc CS, Isabel CMC, Alexander CB, Gloria CGM, Gonzalo CM, Sergio CC, Alexandre CO, Lidia CP, Rita CO, Carles DE, Javier DCP, del Mar ECM, Raquel FM, Luis GLP, Marta GP, Vallve GA, Manuela GA, Xavier GG, Carlos GM, Elena HV, Dolça HC, Cristina HG, Rafael MR, Marta MM, Daniel MM, Sergi MB, Xavier MP, Isabel MD, Maria MC, Pastalle MP, de la Cruz Raquel M, Olga MF, Javier MSF, Roger PR, Alba PTM, Feliciano PB, Monica PA, Cristina RB, Obed RP, Javier RPF, Mar RT, Sandra RP, Laura SS, Yolanda SM, Sheila SM, Eduardo SC, Soledad TT, Lluis TF, José TGP, Ricard TT, Narcis VD, Olga VE, Nuria VP, Andres BG, Marc BP, Cristina BS, Victor BA, Gemma BB, Estel BC, Alejandro CG, Esther CC, Sanchez CF, Toledo EJF, Roger ER, Xavier ERF, Mireia FS, Jordi GL, Daniel GL, Jorge HL, Alicia JLS, Joel LO, Samuel LY, Marta LV, Soto LS, Nicolas MC, Jesus MCD, Arich MP, Susana MS, Raul MM, Isabel MHM, Jose OFM, Bàrbara PB, Pedro PS, Judith RC, Marc RL, Verònica RL, Silvina RL, Gerard SC, Marc SL, Manel SR, Meritxell SG, Albert SC, Noemí SD, Gabriel SMG, Miquel TM, Maria VPA, Silvia VM, Salvat‐Plana M, Roig J, Hidalgo V, Vivanco‐Hidalgo RM, Gallofré M, Cobo E. Workflow times and outcomes in patients triaged for a suspected severe stroke. Ann Neurol 2022; 92:931-942. [DOI: 10.1002/ana.26489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/21/2022] [Accepted: 08/18/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Álvaro García‐Tornel
- Stroke Unit. Department of Neurology. Hospital Universitari Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Laia Seró
- Department of Neurology Hospital Universitari Joan XXIII Tarragona Spain
| | | | - Pere Cardona
- Stroke Unit Hospital Universitari Bellvitge, L'Hospitalet de Llobregat Spain
| | - Josep Zaragoza
- Department of Neurology Hospital Verge de la Cinta Tortosa Spain
| | | | - Manuel Gómez‐Choco
- Department of Neurology Complex Hospitalari Hospital Moisés Broggi Sant Joan Despí Spain
| | - Natalia Mas Sala
- Department of Neurology Hospital Sant Joan de Déu ‐ Fundació Althaia Manresa Spain
| | - Esther Catena
- Department of Neurology Consorci Sanitari Alt Penedès‐Garraf Spain
| | | | - Joaquin Serena
- Stroke Unit Hospital Universitari Josep Trueta Girona Spain
| | | | - Sandra Boned
- Stroke Unit. Department of Neurology. Hospital Universitari Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Marta Olivé‐Gadea
- Stroke Unit. Department of Neurology. Hospital Universitari Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Manuel Requena
- Stroke Unit. Department of Neurology. Hospital Universitari Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
- Department of Interventional Neurorradiology. Hospital Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Marian Muchada
- Stroke Unit. Department of Neurology. Hospital Universitari Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Alejandro Tomasello
- Department of Interventional Neurorradiology. Hospital Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Carlos A. Molina
- Stroke Unit. Department of Neurology. Hospital Universitari Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Mercè Salvat‐Plana
- Stroke Program, Catalan Health Department, Agency for Health Quality and Assesment of Catalonia (AQuAS) CIBER Epidemiología y Salud Pública (CIBERESP) Barcelona Spain
| | | | | | - Antoni Davalos
- Stroke Unit Hospital Germans Trias i Pujol Badalona Barcelona Spain
| | - Tudor G Jovin
- Neurological Institute Cooper University Hospital Camden New Jersey
| | - Francesc Purroy
- Stroke Unit. Department of Neurology Hospital Universitari Arnau de Vilanova de Lleida Lleida Spain
| | - Sonia Abilleira
- Stroke Program, Catalan Health Department, Agency for Health Quality and Assesment of Catalonia (AQuAS) CIBER Epidemiología y Salud Pública (CIBERESP) Barcelona Spain
| | - Marc Ribó
- Stroke Unit. Department of Neurology. Hospital Universitari Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
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Richards CT. Strengthening the stroke chain of survival in community emergency departments. J Am Coll Emerg Physicians Open 2022; 3:e12763. [PMID: 35898235 PMCID: PMC9307289 DOI: 10.1002/emp2.12763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/29/2022] [Accepted: 05/19/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Christopher T. Richards
- Division of Emergency Medical Services Department of Emergency Medicine University of Cincinnati College of Medicine Cincinnati Ohio USA
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Keenan KJ, Smith WS, Cole SB, Martin C, Hemphill JC, Madhok DY. Large vessel occlusion prediction scales provide high negative but low positive predictive values in prehospital suspected stroke patients. BMJ Neurol Open 2022; 4:e000272. [PMID: 35910334 PMCID: PMC9274523 DOI: 10.1136/bmjno-2022-000272] [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: 01/19/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction We studied a registry of Emergency Medical Systems (EMS) identified prehospital suspected stroke patients brought to an academic endovascular capable hospital over 1 year to assess the prevalence of disease and externally validate large vessel occlusion (LVO) stroke prediction scales with a focus on predictive values. Methods All patients had last known well times within 6 hours and a positive prehospital Cincinnati Prehospital Stroke Scale. LVO prediction scale scores were retrospectively calculated from emergency department arrival National Institutes of Health Stroke Scale scores. Final diagnoses were determined by chart review. Prevalence and diagnostic performance statistics were calculated. We prespecified analyses to identify scale thresholds with positive predictive values (PPVs) ≥80% and negative predictive values (NPVs) ≥95%. A secondary analysis identified thresholds with PPVs ≥50%. Results Of 220 EMS transported patients, 13.6% had LVO stroke, 15.9% had intracranial haemorrhage, 20.5% had non-LVO stroke and 50% had stroke mimic diagnoses. LVO stroke prevalence was 15.8% among the 184 diagnostic performance study eligible patients. Only Field Assessment Stroke Triage for Emergency Destination (FAST-ED) ≥7 had a PPV ≥80%, but this threshold missed 83% of LVO strokes. FAST-ED ≥6, Prehospital Acute Severity Scale =3 and Rapid Arterial oCclusion Evaluation ≥7 had PPVs ≥50% but sensitivities were <50%. Several standard and lower alternative scale thresholds achieved NPVs ≥95%, but false positives were common. Conclusions Diagnostic performance tradeoffs of LVO prediction scales limited their ability to achieve high PPVs without missing most LVO strokes. Multiple scales provided high NPV thresholds, but these were associated with many false positives.
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Affiliation(s)
- Kevin J Keenan
- Department of Neurology, University of California Davis, Sacramento, California, USA
- Department of Neurology, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Wade S Smith
- Department of Neurology, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Sara B Cole
- Department of Neurology, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Christine Martin
- Department of Neurology, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - J Claude Hemphill
- Department of Neurology, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Debbie Y Madhok
- Department of Neurology, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
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Updated Trends, Disparities, and Clinical Impact of Neuroimaging Utilization in Ischemic Stroke in the Medicare Population: 2012 to 2019. J Am Coll Radiol 2022; 19:854-865. [PMID: 35483436 PMCID: PMC9308737 DOI: 10.1016/j.jacr.2022.03.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 03/12/2022] [Accepted: 03/18/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The purpose of this study was to update trends, investigate sociodemographic disparities, and evaluate the impact on mortality of stroke neuroimaging across the United States from 2012 to 2019. METHODS Retrospective cohort study using CMS Medicare 5% Research Identifiable Files, representing consecutive ischemic stroke emergency department or hospitalized patients aged ≥65 years. A total of 85,547 stroke episodes with demographic and clinical information were analyzed using Cochran-Mantel-Haenszel tests and logistic regression. Outcome measures were neuroimaging (CT angiography [CTA], CT perfusion [CTP], MRI, MR angiography [MRA]) utilization, acute treatment (endovascular thrombectomy [EVT] and intravenous thrombolysis [IVT]), and mortality while in the hospital and at 30 days and 1 year post discharge. RESULTS Significantly increasing utilization trends for CTA (250%), CTP (428%) and MRI (18%), and a decreasing trend for MRA (-33%) were observed from 2012 to 2019 (P < .0001). Controlling for covariates in the logistic regression models, CTA and CTP were significantly associated with higher EVT and IVT utilization. Although CTA, MRI, and MRA were associated with lower mortality, CTP was associated with higher mortality post discharge. Less neuroimaging was performed in rural patients; older patients (≥80 years) had lower utilization of CTA, MRI, and MRA; female patients had lower rates of CTA; and Black patients had lower utilization of CTA and CTP. CONCLUSIONS CTA and CTP utilization increased in the Medicare ischemic stroke population from 2012 to 2019 and both were associated with greater EVT and IVT use. However, disparities exist in neuroimaging utilization across all demographic groups, and further understanding of the root causes of these disparities will be crucial to achieving equity in stroke care.
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Kilic M, Wendl C, Wilfling S, Olmes D, Linker RA, Schlachetzki F. Acute Middle Cerebral Artery Occlusion Detection Using Mobile Non-Imaging Brain Perfusion Ultrasound-First Case. J Clin Med 2022; 11:jcm11123384. [PMID: 35743454 PMCID: PMC9225458 DOI: 10.3390/jcm11123384] [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: 05/13/2022] [Revised: 05/29/2022] [Accepted: 06/02/2022] [Indexed: 12/02/2022] Open
Abstract
Mobile brain perfusion ultrasound (BPU) is a novel non-imaging technique creating only hemispheric perfusion curves following ultrasound contrast injection and has been specifically designed for early prehospital large vessel occlusion (LVO) stroke identification. We report on the first patient investigated with the SONAS® system, a portable point-of-care ultrasound system for BPU. This patient was admitted into our stroke unit about 12 h following onset of a fluctuating motor aphasia, dysarthria and facial weakness resulting in an NIHSS of 3 to 8. Occlusion of the left middle cerebral artery occlusion was diagnosed by computed tomography angiography. BPU was performed in conjunction with injection of echo-contrast agent to generate hemispheric perfusion curves and in parallel, conventional color-coded sonography (TCCS) assessing MCAO. Both assessments confirmed the results of angiography. Emergency mechanical thrombectomy (MT) achieved complete recanalization (TICI 3) and post-interventional NIHSS of 2 the next day. Telephone follow-up after 2 years found the patient fully active in professional life. Point-of-care BPU is a non-invasive technique especially suitable for prehospital stroke diagnosis for LVO. BPU in conjunction with prehospital stroke scales may enable goal-directed stroke patient placement, i.e., directly to comprehensive stroke centers aiming for MT. Further results of the ongoing phase II study are needed to confirm this finding.
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Affiliation(s)
- Mustafa Kilic
- Department of Neurology, Center for Vascular Neurology and Intensive Care, University of Regensburg, University Hospital Regensburg, Medbo Bezirksklinikum Regensburg, Universitaetsstr. 84, 93053 Regensburg, Germany; (M.K.); (S.W.); (D.O.); (R.A.L.)
| | - Christina Wendl
- Center for Neuroradiology, University Hospital Regensburg, Medbo Bezirksklinikum Regensburg, Universitaetsstr. 84, 93053 Regensburg, Germany;
| | - Sibylle Wilfling
- Department of Neurology, Center for Vascular Neurology and Intensive Care, University of Regensburg, University Hospital Regensburg, Medbo Bezirksklinikum Regensburg, Universitaetsstr. 84, 93053 Regensburg, Germany; (M.K.); (S.W.); (D.O.); (R.A.L.)
| | - David Olmes
- Department of Neurology, Center for Vascular Neurology and Intensive Care, University of Regensburg, University Hospital Regensburg, Medbo Bezirksklinikum Regensburg, Universitaetsstr. 84, 93053 Regensburg, Germany; (M.K.); (S.W.); (D.O.); (R.A.L.)
| | - Ralf Andreas Linker
- Department of Neurology, Center for Vascular Neurology and Intensive Care, University of Regensburg, University Hospital Regensburg, Medbo Bezirksklinikum Regensburg, Universitaetsstr. 84, 93053 Regensburg, Germany; (M.K.); (S.W.); (D.O.); (R.A.L.)
| | - Felix Schlachetzki
- Department of Neurology, Center for Vascular Neurology and Intensive Care, University of Regensburg, University Hospital Regensburg, Medbo Bezirksklinikum Regensburg, Universitaetsstr. 84, 93053 Regensburg, Germany; (M.K.); (S.W.); (D.O.); (R.A.L.)
- Correspondence: ; Tel.: +49-941-941-3502; Fax: +49-941-941-3095
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Yu CY, Panagos PD, Kansagra AP. Travel time and distance for bypass and non-bypass routing of stroke patients in the USA. J Neurointerv Surg 2022:neurintsurg-2022-018787. [PMID: 35545427 DOI: 10.1136/neurintsurg-2022-018787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/25/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Endovascular thrombectomy is not available at all hospitals that offer intravenous thrombolysis, prompting debate regarding the preferred transport destination for acute ischemic stroke. This study aimed to quantify real-world travel time and distance of bypass and non-bypass transport models for large-vessel occlusion (LVO) and non-LVO stroke. METHODS This cross-sectional study included population data of census tracts in the contiguous USA from the 2014-2018 United States Census Bureau's American Community Survey, stroke (thrombolysis-capable) and thrombectomy-capable centers certified by a state or national body, and road network data from a mapping service. Census tracts were categorized by urbanization level. Data were retrieved from March to November 2020. Travel times and distances were calculated for each census tract to each of the following: nearest stroke center (nearest), nearest thrombectomy-capable center (bypass), and nearest stroke center then to the nearest thrombectomy-capable center (transfer). Population-weighted median and IQR were calculated nationally and by urbanization. RESULTS 72 538 census tracts, 2388 stroke hospitals, and 371 thrombectomy-capable centers were included. Nationally, population-weighted median travel time for nearest and bypass routing was 11.7 min (IQR 7.7-19.3) and 26.4 min (14.8-55.1), respectively. For transfer routing, the population-weighted median travel times with 60 min, 90 min, and 120 min door-in-door-out times were 94.1 min (78.5-127.7), 124.1 min (108.5-157.7), and 154.1 min (138.4-187.6), respectively. CONCLUSIONS Bypass routing offers modest travel time benefits for LVO patients and incurs modest penalties for non-LVO patients. Differences are greatest in rural areas. A majority of Americans live in areas for which current guidelines recommend bypass.
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Affiliation(s)
- Cathy Y Yu
- Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Peter D Panagos
- Department of Emergency Medicine, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
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Pérez de la Ossa N, Abilleira S, Jovin TG, García-Tornel Á, Jimenez X, Urra X, Cardona P, Cocho D, Purroy F, Serena J, San Román Manzanera L, Vivanco-Hidalgo RM, Salvat-Plana M, Chamorro A, Gallofré M, Molina CA, Cobo E, Davalos A, Ribo M. Effect of Direct Transportation to Thrombectomy-Capable Center vs Local Stroke Center on Neurological Outcomes in Patients With Suspected Large-Vessel Occlusion Stroke in Nonurban Areas: The RACECAT Randomized Clinical Trial. JAMA 2022; 327:1782-1794. [PMID: 35510397 PMCID: PMC9073661 DOI: 10.1001/jama.2022.4404] [Citation(s) in RCA: 68] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE In nonurban areas with limited access to thrombectomy-capable centers, optimal prehospital transport strategies in patients with suspected large-vessel occlusion stroke are unknown. OBJECTIVE To determine whether, in nonurban areas, direct transport to a thrombectomy-capable center is beneficial compared with transport to the closest local stroke center. DESIGN, SETTING, AND PARTICIPANTS Multicenter, population-based, cluster-randomized trial including 1401 patients with suspected acute large-vessel occlusion stroke attended by emergency medical services in areas where the closest local stroke center was not capable of performing thrombectomy in Catalonia, Spain, between March 2017 and June 2020. The date of final follow-up was September 2020. INTERVENTIONS Transportation to a thrombectomy-capable center (n = 688) or the closest local stroke center (n = 713). MAIN OUTCOMES AND MEASURES The primary outcome was disability at 90 days based on the modified Rankin Scale (mRS; scores range from 0 [no symptoms] to 6 [death]) in the target population of patients with ischemic stroke. There were 11 secondary outcomes, including rate of intravenous tissue plasminogen activator administration and thrombectomy in the target population and 90-day mortality in the safety population of all randomized patients. RESULTS Enrollment was halted for futility following a second interim analysis. The 1401 enrolled patients were included in the safety analysis, of whom 1369 (98%) consented to participate and were included in the as-randomized analysis (56% men; median age, 75 [IQR, 65-83] years; median National Institutes of Health Stroke Scale score, 17 [IQR, 11-21]); 949 (69%) comprised the target ischemic stroke population included in the primary analysis. For the primary outcome in the target population, median mRS score was 3 (IQR, 2-5) vs 3 (IQR, 2-5) (adjusted common odds ratio [OR], 1.03; 95% CI, 0.82-1.29). Of 11 reported secondary outcomes, 8 showed no significant difference. Compared with patients first transported to local stroke centers, patients directly transported to thrombectomy-capable centers had significantly lower odds of receiving intravenous tissue plasminogen activator (in the target population, 229/482 [47.5%] vs 282/467 [60.4%]; OR, 0.59; 95% CI, 0.45-0.76) and significantly higher odds of receiving thrombectomy (in the target population, 235/482 [48.8%] vs 184/467 [39.4%]; OR, 1.46; 95% CI, 1.13-1.89). Mortality at 90 days in the safety population was not significantly different between groups (188/688 [27.3%] vs 194/713 [27.2%]; adjusted hazard ratio, 0.97; 95% CI, 0.79-1.18). CONCLUSIONS AND RELEVANCE In nonurban areas in Catalonia, Spain, there was no significant difference in 90-day neurological outcomes between transportation to a local stroke center vs a thrombectomy-capable referral center in patients with suspected large-vessel occlusion stroke. These findings require replication in other settings. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02795962.
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Affiliation(s)
- Natalia Pérez de la Ossa
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Sònia Abilleira
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Tudor G. Jovin
- Neurological Institute, Cooper University Hospital, Camden, New Jersey
| | - Álvaro García-Tornel
- Department of Neurology, Stroke Unit, Hospital Universitari Vall d’Hebrón, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Xavier Jimenez
- Emergency Medical Services of Catalonia, Barcelona, Spain
| | - Xabier Urra
- Department of Neurology, Stroke Unit, Hospital Clínic, Barcelona, Spain
| | - Pere Cardona
- Department of Neurology, Stroke Unit, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Dolores Cocho
- Neurology Department, Hospital Granollers, Granollers, Spain
| | - Francisco Purroy
- Department of Neurology, Stroke Unit, Hospital Arnau de Vilanova, Lleida, Spain
| | - Joaquin Serena
- Department of Neurology, Stroke Unit, Hospital Josep Trueta, Girona, Spain
| | | | - Rosa Maria Vivanco-Hidalgo
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Mercè Salvat-Plana
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Angel Chamorro
- Department of Neurology, Stroke Unit, Hospital Clínic, Barcelona, Spain
| | - Miquel Gallofré
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Carlos A. Molina
- Department of Neurology, Stroke Unit, Hospital Universitari Vall d’Hebrón, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Erik Cobo
- Statistics and Operational Research, Universitat Politècnica de Catalunya, Barcelona, Spain
| | - Antoni Davalos
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Marc Ribo
- Department of Neurology, Stroke Unit, Hospital Universitari Vall d’Hebrón, Universitat Autonoma de Barcelona, Barcelona, Spain
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Zachrison KS, Schwamm LH. Strategic Opportunities to Improve Stroke Systems of Care. JAMA 2022; 327:1765-1767. [PMID: 35510400 DOI: 10.1001/jama.2022.3820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Lee H Schwamm
- Harvard Medical School, Boston, Massachusetts
- Stroke Division, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
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Seker F, Fifi JT, Morey JR, Osanai T, Oki S, Brekenfeld C, Fiehler J, Bendszus M, Möhlenbruch MA. Transferring neurointerventionalists saves time compared with interhospital transfer of stroke patients for endovascular thrombectomy: a collaborative pooled analysis of 1001 patients (EVEREST). J Neurointerv Surg 2022; 15:517-520. [PMID: 35501118 DOI: 10.1136/neurintsurg-2021-018049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 04/10/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Interhospital transfer of stroke patients (drip and ship concept) is associated with longer treatment times compared with primary admission to a comprehensive stroke center (mothership concept). In recent years, studies on a novel concept of performing endovascular thrombectomy (EVT) at external hospitals (EXT) by transferring neurointerventionalists, instead of patients, have been published. This collaborative study aimed at answering the question of whether EXT saves time in the workflow of acute stroke treatment across various geographical regions. METHODS This was a patient level pooled analysis of one prospective observational study and four retrospective cohort studies, the EVEREST collaboration (EndoVascular thrombEctomy at Referring and External STroke centers). Time from initial stroke imaging to EVT (vascular puncture) was compared in mothership, drip and ship, and EXT concepts. RESULTS In total, 1001 stroke patients from various geographical regions who underwent EVT due to large vessel occlusion were included. These were divided into mothership (n=162, 16.2%), drip and ship (n=458, 45.8%), and EXT (n=381, 38.1%) cohorts. The median time periods from onset to EVT (195 min vs 320 min, p<0.001) and from imaging to EVT (97 min vs 184 min, p<0.001) in EXT were significantly shorter than for drip and ship thrombectomy concept. CONCLUSIONS This pooled analysis of the EVEREST collaboration adds evidence that performing EVT at external hospitals can save time compared with drip and ship across various geographical regions. We encourage conducting randomized controlled trials comparing both triage concepts.
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Affiliation(s)
- Fatih Seker
- Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johanna T Fifi
- Neurosurgery, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
| | - Jacob R Morey
- Neurosurgery, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
| | - Toshiya Osanai
- Neurosurgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Sogo Oki
- Neurosurgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Caspar Brekenfeld
- Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Bendszus
- Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
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40
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Hammond G, Waken RJ, Johnson DY, Towfighi A, Joynt Maddox KE. Racial Inequities Across Rural Strata in Acute Stroke Care and In-Hospital Mortality: National Trends Over 6 Years. Stroke 2022; 53:1711-1719. [PMID: 35172607 PMCID: PMC9324215 DOI: 10.1161/strokeaha.121.035006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 11/19/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are glaring racial and rural-urban inequities in stroke outcomes. The objective of this study was to determine whether there were recent changes to trends in racial inequities in stroke treatment and in-hospital mortality, and whether racial inequities differed across rural strata. METHODS Retrospective analysis of Black and White patients >18 years old admitted to US acute care hospitals with a primary discharge diagnosis of stroke (unweighted N=652 836) from the National Inpatient Sample from 2012 to 2017. Rural residence was classified by county as urban, town, or rural. The primary outcomes were intravenous thrombolysis and endovascular therapy use among patients with acute ischemic stroke, and in-hospital mortality for all stroke patients. Logistic regression models were run for each outcome adjusting for age, comorbidities, primary payer, and ZIP code median income. RESULTS The sample was 53% female, 81% White, and 19% Black. Black patients from rural areas had the lowest odds of receiving intravenous thrombolysis (adjusted odds ratio [aOR], 0.43 [95% CI, 0.37-0.50]) and endovascular therapy (aOR, 0.60 [0.46-0.78]), compared with White urban patients. Black rural patients were the least likely to be discharged home after a stroke compared with White/urban patients (aOR, 0.79 [0.75-0.83]), this was true for Black patients across the urban-rural spectrum when compared with Whites. Black patients from urban areas had lower mortality than White patients from urban areas (aOR, 0.87 [0.84-0.91]), while White patients from rural areas (aOR, 1.14 [1.10-1.19]) had the highest mortality of all groups. CONCLUSIONS Black patients living in rural areas represent a particularly high-risk group for poor access to advanced stroke care and impaired poststroke functional status. Rural White patients have the highest in-hospital mortality. Clinical and policy interventions are needed to improve access and reduce inequities in stroke care and outcomes.
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Affiliation(s)
- Gmerice Hammond
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
| | - RJ Waken
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
| | - Daniel Y. Johnson
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
| | - Amytis Towfighi
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Karen E. Joynt Maddox
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
- Center for Health Economics and Policy, Institute for Public Health at Washington University, St. Louis, MO
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Kilic M, Scalzo F, Lyle C, Baldaranov D, Dirnbacher M, Honda T, Liebeskind DS, Schlachetzki F. A mobile battery-powered brain perfusion ultrasound (BPU) device designed for prehospital stroke diagnosis: correlation to perfusion MRI in healthy volunteers. Neurol Res Pract 2022; 4:13. [PMID: 35399083 PMCID: PMC8996400 DOI: 10.1186/s42466-022-00179-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/11/2022] [Indexed: 12/07/2022] Open
Abstract
Background Early prehospital stroke identification is crucial for goal directed hospital admission especially in rural areas. However, clinical prehospital stroke scales are designed to identify any stroke but cannot sufficiently differentiate hemorrhagic from ischemic stroke, including large vessel occlusion (LVO) amenable to mechanical thrombectomy. We report on a novel small, portable and battery driven point-of-care ultrasound system (SONAS®) specifically developed for mobile non-invasive brain perfusion ultrasound (BPU) measurement after bolus injection of an echo-enhancing agent suitable for the use in prehospital stroke diagnosis filling a current, unmet and critical need for LVO identification.
Methods In a phase I study of healthy volunteers we performed comparative perfusion-weighted magnetic resonance imaging (PWI) and BPU measurements, including safety analysis. Results Twelve volunteers (n = 7 females, n = 5 males, age ranging between 19 and 55 years) tolerated the measurement extremely well including analysis of blood–brain barrier integrity, and the correlation coefficient between the generated time kinetic curves after contrast agent bolus between PWI and BPU transducers ranged between 0.89 and 0.76. Conclusions Mobile BPU using the SONAS® device is feasible and safe with results comparable to PWI. When applied in conjunction with prehospital stroke scales this may lead to a more accurate stroke diagnosis and patients bypassing regular stroke units to comprehensive stroke centers. Further studies are needed in acute stroke patients and in the prehospital phase including assessment of immediate and long-term morbidity and mortality in stroke. Trial registration: Clinical trials.gov, registered 28.Sep.2017, Identifier: NCT03296852.
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Affiliation(s)
- Mustafa Kilic
- Department of Neurology, Center for Vascular Neurology and Intensive Care, University of Regensburg, medbo Bezirksklinikum Regensburg, Universitaetsstr.84, 93053, Regensburg, Germany
| | - Fabien Scalzo
- Department of Neurology, UCLA Stroke Center and Brain Research Institute, 635 Charles E Young Drive South, Suite 116, Los Angeles, CA, 90095, USA
| | - Chandler Lyle
- BURL Concepts, Inc., 4901 Morena Boulevard Suite 703, San Diego, CA, 92117, USA
| | - Dobri Baldaranov
- Department of Neurology, Center for Vascular Neurology and Intensive Care, University of Regensburg, medbo Bezirksklinikum Regensburg, Universitaetsstr.84, 93053, Regensburg, Germany.,Alzheimer's Therapeutic Research Institute, Keck School of Medicine, University of Southern California, 9860 Mesa Rim Road, San Diego, CA, 92121, USA
| | | | - Tristan Honda
- Department of Neurology, Neurovascular Imaging Research Core and UCLA Stroke Center, University of California Los Angeles, Ronald Reagan UCLA Medical Center, 300 Medical Plaza Driveway B200, Los Angeles, CA, 90095, USA
| | - David S Liebeskind
- Department of Neurology, Neurovascular Imaging Research Core and UCLA Stroke Center, University of California Los Angeles, Ronald Reagan UCLA Medical Center, 300 Medical Plaza Driveway B200, Los Angeles, CA, 90095, USA
| | - Felix Schlachetzki
- Department of Neurology, Center for Vascular Neurology and Intensive Care, University of Regensburg, medbo Bezirksklinikum Regensburg, Universitaetsstr.84, 93053, Regensburg, Germany.
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Wang C, Chang Y, Yang Y, Chiang W, Tang S, Tsai L, Lee C, Jeng J, Ma MH, Hsieh M, Lee Y. Prehospital‐Stroke‐Scale Parameterized Hospital Selection Protocol for Suspected Stroke Patients Considering Door‐to‐Treatment Durations. J Am Heart Assoc 2022; 11:e023760. [PMID: 35347996 PMCID: PMC9075444 DOI: 10.1161/jaha.121.023760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background To mitigate uncertainty that may arise in the judgment of emergency medical technicians when relying on a prehospital stroke scale at the scene, we propose a hospital selection protocol that considers the uncertainty of a prehospital stroke scale and the actual door‐to‐treatment durations, and we have developed a web‐based system to be used with mobile devices. Methods and Results This hospital selection protocol incorporates real‐time, estimated transport time obtained from Google Maps, historical median door‐to‐treatment duration at hospitals that only provide the standard intravenous thrombolysis treatment, and at hospitals with endovascular thrombectomy for probable large‐vessel occlusion cases. We have validated the efficiency of the proposed protocol and compared it with other strategies used by emergency medical technicians when deciding on a receiving hospital. Using the proposed protocol for the triage reduces the time from onset to receiving definitive treatment by nearly 11 minutes. We found that the nearest endovascular thrombectomy–capable hospital from the scene may not be the most ideal if the door‐to‐treatment durations are discriminative. The results show that, when the tolerable bypass transport threshold and administration time are reduced to 9 minutes and 30.5 minutes, respectively, 228 patients out of 7678 cases, whose receiving hospitals were changed to endovascular thrombectomy–capable hospitals, received definitive treatment in a shorter time. The results of our analysis give recommendations for appropriate allowable bypass transport time for regional planning. Conclusions By applying almost‐real value parameters, we have validated a web‐based model, which can be universally adapted for optimal, time‐saving hospital selection for patients with stroke.
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Affiliation(s)
- Chun‐Han Wang
- Department of Industrial Engineering and Engineering Management National Tsing Hua University Hsinchu Taiwan
| | - Yu‐Chen Chang
- Department of Industrial Engineering and Engineering Management National Tsing Hua University Hsinchu Taiwan
| | - Yung Yang
- Department of Industrial Engineering and Engineering Management National Tsing Hua University Hsinchu Taiwan
| | - Wen‐Chu Chiang
- Department of Emergency Medicine National Taiwan University Hospital Yun‐Lin Branch Yun‐Lin 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
- Department of Emergency Medicine National Taiwan University Hospital Yun‐Lin Branch Yun‐Lin 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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Zachrison KS, Samuels‐Kalow ME, Li S, Yan Z, Reeves MJ, Hsia RY, Schwamm LH, Camargo CA. The relationship between stroke system organization and disparities in access to stroke center care in California. J Am Coll Emerg Physicians Open 2022; 3:e12706. [PMID: 35316966 PMCID: PMC8921441 DOI: 10.1002/emp2.12706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 11/08/2022] Open
Abstract
Background There are significant racial and ethnic disparities in receipt of reperfusion interventions for acute ischemic stroke. Our objective was to determine whether there are disparities in access to stroke center care by race or ethnicity that help explain differences in reperfusion therapy and to understand whether interhospital patient transfer plays a role in improving access. Methods Using statewide administrating data including all emergency department and hospital discharges in California from 2010 to 2017, we identified all acute ischemic stroke patients. Primary outcomes of interest included presentation to primary or comprehensive stroke center (PSC or CSC), interhospital transfer, discharge from PSC or CSC, and discharge from CSC alone. We used hierarchical logistic regression modeling to identify the relationship between patient‐ and hospital‐level characteristics and outcomes of interest. Results Of 336,247 ischemic stroke patients, 55.4% were non‐Hispanic White, 19.6% Hispanic, 10.6% non‐Hispanic Asian/Pacific Islander, and 10.3% non‐Hispanic Black. There was no difference in initial presentation to stroke center hospitals between groups. However, adjusted odds of reperfusion intervention, interhospital transfer and discharge from CSC did vary by race and ethnicity. Adjusted odds of interhospital transfer were lower among Hispanic (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.89 to 0.98) and non‐Hispanic Asian/Pacific Islander patients (OR 0.84, 95% CI 0.79 to 0.90) and odds of discharge from a CSC were lower for Hispanic (OR 0.91, 95% CI 0.85 to 0.97) and non‐Hispanic Black patients (OR 0.74, 95% CI 0.67 to 0.81). Conclusions There are racial and ethnic disparities in reperfusion intervention receipt among stroke patients in California. Stroke system of care design, hospital resources, and transfer patterns may contribute to this disparity.
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Affiliation(s)
- Kori S. Zachrison
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | | | - Sijia Li
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | - Zhiyu Yan
- Department of Neurology Massachusetts General Hospital Boston Massachusetts USA
| | - Mathew J. Reeves
- Department of Epidemiology and Biostatistics Michigan State University East Lansing Michigan USA
| | - Renee Y. Hsia
- Department of Emergency Medicine University of California San Francisco San Francisco California USA
- Philip R. Lee Institute for Health Policy Studies University of California San Francisco San Francisco California USA
| | - Lee H. Schwamm
- Department of Neurology Massachusetts General Hospital Boston Massachusetts USA
| | - Carlos A. Camargo
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
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44
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Hill MD, Warach S, Rostanski SK. Should Primary Stroke Centers Perform Advanced Imaging? Stroke 2022; 53:1423-1430. [PMID: 35227077 DOI: 10.1161/strokeaha.121.033528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michael D Hill
- Departments of Clinical Neurosciences, Community Health Sciences, Medicine, and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (M.D.H.)
| | - Steven Warach
- Department of Neurology, Dell Medical School, University of Texas at Austin (S.W.).,Ascension Healthcare' St. Louis' MO (S.W.)
| | - Sara K Rostanski
- Department of Neurology, NYU Grossman School of Medicine, New York, NY (S.K.R.).,Bellevue Hospital' Manhattan' NY (S.K.R.)
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45
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Hariharan P, Tariq MB, Grotta JC, Czap AL. Mobile Stroke Units: Current Evidence and Impact. Curr Neurol Neurosci Rep 2022; 22:71-81. [PMID: 35129761 DOI: 10.1007/s11910-022-01170-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Several approaches have been developed to optimize prehospital systems for acute stroke given poor access and significant delays to timely treatment. Specially equipped ambulances that directly initiate treatment, known as Mobile Stroke Units (MSUs), have rapidly proliferated across the world. This review provides a comprehensive summary on the efficacy of MSUs in acute stroke, its various applications beyond thrombolysis, as well as the establishment, optimal setting and cost-effectiveness of incorporating an MSU into healthcare systems. RECENT FINDINGS MSUs speed stroke treatment into the first "golden hour" when better outcomes from thrombolysis are achieved. While evidence for the positive impact of MSUs on outcomes was previously unavailable, two recent landmark controlled trials, B_PROUD and BEST-MSU, show that MSUs result in significantly lesser disability compared to conventional ambulance care. Emerging literature prove the significant impact of MSUs. Adaptability however remains limited by significant upfront financial investment, challenges with reimbursements and pending evidence on their cost-effectiveness.
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Affiliation(s)
- Praveen Hariharan
- Department of Neurology, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin St, MSB 7.044, Houston, TX, 77030, USA
| | - Muhammad Bilal Tariq
- Department of Neurology, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin St, MSB 7.044, Houston, TX, 77030, USA
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital Texas Medical Center, Houston, TX, USA
| | - Alexandra L Czap
- Department of Neurology, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin St, MSB 7.044, Houston, TX, 77030, USA.
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Zachrison KS, Cash RE, Adeoye O, Boggs KM, Schwamm LH, Mehrotra A, Camargo CA. Estimated Population Access to Acute Stroke and Telestroke Centers in the US, 2019. JAMA Netw Open 2022; 5:e2145824. [PMID: 35138392 PMCID: PMC8829668 DOI: 10.1001/jamanetworkopen.2021.45824] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This cross-sectional study assesses US population access to emergency departments with acute stroke capabilities and telestroke capacity in 2019.
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Affiliation(s)
- Kori S. Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Rebecca E. Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Opeolu Adeoye
- Department of Emergency Medicine, Washington University, St Louis, Missouri
| | - Krislyn M. Boggs
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
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47
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Aroor SR, Asif KS, Potter-Vig J, Sharma A, Menon BK, Inoa V, Zevallos CB, Romano JG, Ortega-Gutierrez S, Goldstein LB, Yavagal DR. Mechanical Thrombectomy Access for All? Challenges in Increasing Endovascular Treatment for Acute Ischemic Stroke in the United States. J Stroke 2022; 24:41-48. [PMID: 35135058 PMCID: PMC8829477 DOI: 10.5853/jos.2021.03909] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 01/11/2022] [Indexed: 11/11/2022] Open
Abstract
Mechanical thrombectomy (MT) is the most effective treatment for selected patients with an acute ischemic stroke due to emergent large vessel occlusions (LVOs). There is an urgent need to identify and address challenges in access to MT to maximize the numbers of patients who can benefit from this treatment. Barriers in access to MT include delays in evaluation and accurate diagnosis of LVO leading to inappropriate triage, logistical delays related to availability of facilities and trained interventionalists, and financial hurdles that affect treatment reimbursement. Collection of regional data related to these barriers is critical to better understand current access gaps and a measurable access score to thrombectomy could be useful to plan local public health intervention.
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Affiliation(s)
- Sushanth Rao Aroor
- Department of Neurology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Kaiz S. Asif
- Department of Neurosurgery, University of Illinois and AMITA Health, Chicago, IL, USA
| | | | - Arun Sharma
- University of Miami, Herbert Business School, Miami, FL, USA
| | - Bijoy K. Menon
- Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Violiza Inoa
- Semmes Murphey Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Cynthia B. Zevallos
- Department of Neurology, University of Iowa Hospital and Clinics, Iowa City, IA, USA
| | - Jose G. Romano
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Larry B. Goldstein
- Department of Neurology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Dileep R. Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Correspondence: Dileep R. Yavagal Departments of Neurology and Neurosurgery, University of Miami Miller School of Medicine, 1600 NW 10th Ave 1140, Miami, FL 33136, USA Tel: +1-305-355-1103 E-mail:
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48
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Gropen TI, Ivankova NV, Beasley M, Hess EP, Mittman B, Gazi M, Minor M, Crawford W, Floyd AB, Varner GL, Lyerly MJ, Shoemaker CC, Owens J, Wilson K, Gray J, Kamal S. Trauma Communications Center Coordinated Severity-Based Stroke Triage: Protocol of a Hybrid Type 1 Effectiveness-Implementation Study. Front Neurol 2021; 12:788273. [PMID: 34938265 PMCID: PMC8686821 DOI: 10.3389/fneur.2021.788273] [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: 10/01/2021] [Accepted: 11/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Mechanical thrombectomy (MT) can improve the outcomes of patients with large vessel occlusion (LVO), but a minority of patients with LVO are treated and there are disparities in timely access to MT. In part, this is because in most regions, including Alabama, the emergency medical service (EMS) transports all patients with suspected stroke, regardless of severity, to the nearest stroke center. Consequently, patients with LVO may experience delayed arrival at stroke centers with MT capability and worse outcomes. Alabama's trauma communications center (TCC) coordinates EMS transport of trauma patients by trauma severity and regional hospital capability. Our aims are to develop a severity-based stroke triage (SBST) care model based on Alabama's trauma system, compare the effectiveness of this care pathway to current stroke triage in Alabama for improving broad, equitable, and timely access to MT, and explore stakeholder perceptions of the intervention's feasibility, appropriateness, and acceptability. Methods: This is a hybrid type 1 effectiveness-implementation study with a multi-phase mixed methods sequential design and an embedded observational stepped wedge cluster trial. We will extend TCC guided stroke severity assessment to all EMS regions in Alabama; conduct stakeholder interviews and focus groups to aid in development of region and hospital specific prehospital and inter-facility stroke triage plans for patients with suspected LVO; implement a phased rollout of TCC Coordinated SBST across Alabama's six EMS regions; and conduct stakeholder surveys and interviews to assess context-specific perceptions of the intervention. The primary outcome is the change in proportion of prehospital stroke system patients with suspected LVO who are treated with MT before and after implementation of TCC Coordinated SBST. Secondary outcomes include change in broad public health impact before and after implementation and stakeholder perceptions of the intervention's feasibility, appropriateness, and acceptability using a mixed methods approach. With 1200 to 1300 total observations over 36 months, we have 80% power to detect a 15% improvement in the primary endpoint. Discussion: This project, if successful, can demonstrate how the trauma system infrastructure can serve as the basis for a more integrated and effective system of emergency stroke care.
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Affiliation(s)
- Toby I Gropen
- Division of Cerebrovascular Disease, The University of Alabama at Birmingham, Birmingham, AL, United States
| | | | - Mark Beasley
- The University of Alabama at Birmingham, Birmingham, AL, United States
| | - Erik P Hess
- Vanderbilt University Medical Center, Nashville, TN, United States
| | - Brian Mittman
- Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Melissa Gazi
- The University of Alabama at Birmingham, Birmingham, AL, United States
| | - Michael Minor
- The University of Alabama at Birmingham, Birmingham, AL, United States
| | - William Crawford
- The Office of Emergency Medical Services, Alabama Department of Public Health, Montgomery, AL, United States
| | - Alice B Floyd
- The Office of Emergency Medical Services, Alabama Department of Public Health, Prattville, AL, United States
| | - Gary L Varner
- The Office of Emergency Medical Services, Alabama Department of Public Health, Montgomery, AL, United States
| | - Michael J Lyerly
- The University of Alabama at Birmingham, Birmingham, AL, United States
| | | | - Jackie Owens
- Mobile Infirmary Medical Center, Mobile, AL, United States
| | - Kent Wilson
- The Office of Emergency Medical Services, Alabama Department of Public Health, Prattville, AL, United States
| | - Jamie Gray
- The Office of Emergency Medical Services, Alabama Department of Public Health, Montgomery, AL, United States
| | - Shaila Kamal
- The University of Alabama at Birmingham, Birmingham, AL, United States
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49
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Allen M, Pearn K, Ford GA, White P, Rudd AG, McMeekin P, Stein K, James M. National implementation of reperfusion for acute ischaemic stroke in England: How should services be configured? A modelling study. Eur Stroke J 2021; 7:28-40. [PMID: 35300255 PMCID: PMC8921787 DOI: 10.1177/23969873211063323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 10/25/2021] [Accepted: 10/29/2021] [Indexed: 11/21/2022] Open
Abstract
Objectives To guide policy when planning thrombolysis (IVT) and thrombectomy (MT) services for acute stroke in England, focussing on the choice between ‘mothership’ (direct conveyance to an MT centre) and ‘drip-and-ship’ (secondary transfer) provision and the impact of bypassing local acute stroke centres. Design Outcome-based modelling study. Setting 107 acute stroke centres in England, 24 of which provide IVT and MT (IVT/MT centres) and 83 provide only IVT (IVT-only units). Participants 242,874 emergency admissions with acute stroke over 3 years (2015–2017). Intervention Reperfusion delivered by drip-and-ship, mothership or ‘hybrid’ models; impact of additional travel time to directly access an IVT/MT centre by bypassing a more local IVT-only unit; effect of pre-hospital selection for large artery occlusion (LAO). Main outcome measures Population benefit from reperfusion, time to IVT and MT, admission numbers to IVT-only units and IVT/MT centres. Results Without pre-hospital selection for LAO, 94% of the population of England live in areas where the greatest clinical benefit, assuming unknown patient status, accrues from direct conveyance to an IVT/MT centre. However, this policy produces unsustainable admission numbers at these centres, with 78 out of 83 IVT-only units receiving fewer than 300 admissions per year (compared to 3 with drip-and-ship). Implementing a maximum permitted additional travel time to bypass an IVT-only unit, using a pre-hospital test for LAO, and selecting patients based on stroke onset time, all help to mitigate the destabilising effect but there is still some significant disruption to admission numbers, and improved selection of patients suitable for MT selectively reduces the number of patients who would receive IVT at IVT-only centres, challenging the sustainability of IVT expertise in IVT-only centres. Conclusions Implementation of reperfusion for acute stroke based solely on achieving the maximum population benefit potentially leads to destabilisation of the emergency stroke care system. Careful planning is required to create a sustainable system, and modelling may be used to help planners maximise benefit from reperfusion while creating a sustainable emergency stroke care system.
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Affiliation(s)
- Michael Allen
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Kerry Pearn
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Gary A Ford
- Radcliffe Department of Medicine, Oxford University and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Phil White
- Translational and Clinical Research Institute, Newcastle University and Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Anthony G Rudd
- Kings College London and Guy’s and St Thomas, NHS Foundation Trust, London, UK
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle Upon Tyne, UK
| | - Ken Stein
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Martin James
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
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50
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Chuck CC, Martin TJ, Kalagara R, Madsen TE, Furie KL, Yaghi S, Reznik ME. Statewide Emergency Medical Services Protocols for Suspected Stroke and Large Vessel Occlusion. JAMA Neurol 2021; 78:1404-1406. [PMID: 34542567 DOI: 10.1001/jamaneurol.2021.3227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Carlin C Chuck
- Alpert Medical School, Brown University, Providence, Rhode Island
| | - Thomas J Martin
- Alpert Medical School, Brown University, Providence, Rhode Island
| | | | - Tracy E Madsen
- Department of Emergency Medicine, Alpert Medical School, Brown University, Providence, Rhode Island
| | - Karen L Furie
- Department of Neurology, Alpert Medical School, Brown University, Providence, Rhode Island
| | - Shadi Yaghi
- Department of Neurology, Alpert Medical School, Brown University, Providence, Rhode Island
| | - Michael E Reznik
- Department of Neurology, Alpert Medical School, Brown University, Providence, Rhode Island
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