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Caso V, Martins S, Mikulik R, Middleton S, Groppa S, Pandian JD, Thang NH, Danays T, van der Merwe J, Fischer T, Hacke W. Six years of the Angels Initiative: Aims, achievements, and future directions to improve stroke care worldwide. Int J Stroke 2023; 18:898-907. [PMID: 37226325 PMCID: PMC10507995 DOI: 10.1177/17474930231180067] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/01/2023] [Indexed: 05/26/2023]
Abstract
The rate of stroke-related death and disability is four times higher in low- and middle-income countries (LMICs) than in high-income countries (HICs), yet stroke units exist in only 18% of LMICs, compared with 91% of HICs. In order to ensure universal and equitable access to timely, guideline-recommended stroke care, multidisciplinary stroke-ready hospitals with coordinated teams of healthcare professionals and appropriate facilities are essential.Established in 2016, the Angels Initiative is an international, not-for-profit, public-private partnership. It is run in collaboration with the World Stroke Organization, European Stroke Organisation, and regional and national stroke societies in over 50 countries. The Angels Initiative aims to increase the global number of stroke-ready hospitals and to optimize the quality of existing stroke units. It does this through the work of dedicated consultants, who help to standardize care procedures and build coordinated, informed communities of stroke professionals. Angels consultants also establish quality monitoring frameworks using online audit platforms such as the Registry of Stroke Care Quality (RES-Q), which forms the basis of the Angels award system (gold/platinum/diamond) for all stroke-ready hospitals across the world.The Angels Initiative has supported over 1700 hospitals (>1000 in LMICs) that did not previously treat stroke patients to become "stroke ready." Since its inception in 2016, the Angels Initiative has impacted the health outcomes of an estimated 7.46 million stroke patients globally (including an estimated 4.68 million patients in LMICs). The Angels Initiative has increased the number of stroke-ready hospitals in many countries (e.g. in South Africa: 5 stroke-ready hospitals in 2015 vs 185 in 2021), reduced "door to treatment time" (e.g. in Egypt: 50% reduction vs baseline), and increased quality monitoring substantially.The focus of the work of the Angels Initiative has now expanded from the hyperacute phase of stroke treatment to the pre-hospital setting, as well as to the early post-acute setting. A continued and coordinated global effort is needed to achieve the target of the Angels Initiative of >10,000 stroke-ready hospitals by 2030, and >7500 of these in LMICs.
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Affiliation(s)
| | - Sheila Martins
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Robert Mikulik
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czech Republic
| | - Sandy Middleton
- Australian Catholic University and St. Vincent’s Health Network Sydney, Sydney, NSW, Australia
| | - Stanislav Groppa
- State University of Medicine and Pharmacy ‘Nicolae Testemitanu,’ Chisinau, Moldova
| | | | | | | | - Jan van der Merwe
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Thomas Fischer
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Werner Hacke
- Ruprecht-Karl-University Heidelberg, Heidelberg, Germany
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Geraedts M, Ebbeler D, Timmesfeld N, Kaps M, Berger K, Misselwitz B, Günster C, Dröge P, Schneider M. Long-term outcomes of stroke unit care in older stroke patients: a retrospective cohort study. Age Ageing 2022; 51:6691374. [PMID: 36057988 DOI: 10.1093/ageing/afac197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND older patients are less frequently treated in stroke units (SUs). Clinicians do not seem convinced that older patients benefit from specialised treatment in SU similarly to younger patients. OBJECTIVE our study aimed to compare older patients' long-term outcomes with and without SU treatment. METHODS this study used routinely collected health data of 232,447 patients admitted to hospitals in Germany between 2007 and 2017 who were diagnosed with ischaemic stroke (ICD 10 I63). The sample included 29,885 patients aged ≥90 years. The outcomes analysed were 10-, 30- and 90-day, and 1-, 3- and 5-year mortality and the combinations of death or recurrence, inpatient treatment and increase in long-term care needs. Bivariate chi-square tests and multivariable logistic regression analyses were used, adjusting for the covariates age, sex, co-morbidity, long-term care needs before stroke and socioeconomic status of the patients' region of origin. RESULTS between 2007 and 2017, 57.1% of patients aged <90 years and 49.6% of those aged ≥90 years were treated in a SU. The 1-year mortality rate of ≥90-year-olds was 56.9 and 61.9% with and without SU treatment, respectively. The multivariable-adjusted risk of death in ≥90-year-olds with SU treatment was odds ratio (OR) = 0.67 (95% confidence interval [CI] = 0.62-0.73) 10 days after the initial event and OR = 0.76 (95% CI = 0.71-0.82) 3 years after stroke. CONCLUSIONS even very old patients with stroke benefit from SU treatment in the short and long term. Therefore, SU treatment should be the norm even in older patients.
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Affiliation(s)
- Max Geraedts
- Institute for Health Services Research and Clinical Epidemiology, Philipps-Universitaet Marburg, 35043 Marburg, Germany
| | - Dijana Ebbeler
- Institute for Health Services Research and Clinical Epidemiology, Philipps-Universitaet Marburg, 35043 Marburg, Germany
| | - Nina Timmesfeld
- Department of Medical Informatics, Biometry and Epidemiology, Faculty of Medicine, Ruhr-University Bochum, 44780 Bochum, Germany
| | - Manfred Kaps
- Department of Neurology, University Hospital of Giessen/Marburg, Justus-Liebig-University of Giessen, 35392 Giessen, Germany
| | - Klaus Berger
- Institute of Epidemiology and Social Medicine, Westphalian-Wilhelms-University of Muenster, 48149 Münster, Germany
| | | | - Christian Günster
- WIdO - AOK Research Institute, AOK Federal Association, 10178 Berlin, Germany
| | - Patrik Dröge
- WIdO - AOK Research Institute, AOK Federal Association, 10178 Berlin, Germany
| | - Michael Schneider
- Institute for Health Services Research and Clinical Epidemiology, Philipps-Universitaet Marburg, 35043 Marburg, Germany
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3
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Martins SCO, Lavados P, Secchi TL, Brainin M, Ameriso S, Gongora-Rivera F, Sacks C, Cantú-Brito C, Alvarez Guzman TF, Pérez-Romero GE, Muñoz Collazos M, Barboza MA, Arauz A, Abanto Argomedo C, Novarro-Escudero N, Amorin Costabile HI, Crosa R, Camejo C, Mernes R, Maldonado N, Mora Cuervo DL, Pontes Neto OM, Silva GS, Carbonera LA, de Souza AC, de Sousa EDG, Flores A, Melgarejo D, Santos Carquin IR, Hoppe A, de Carvalho JJF, Mont'Alverne F, Amaya P, Bayona H, Navia González VH, Duran JC, Urrutia VC, Araujo DV, Feigin VL, Nogueira RG. Fighting Against Stroke in Latin America: A Joint Effort of Medical Professional Societies and Governments. Front Neurol 2021; 12:743732. [PMID: 34659101 PMCID: PMC8517273 DOI: 10.3389/fneur.2021.743732] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/30/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Stroke is one of the leading causes of death in Latin America, a region with countless gaps to be addressed to decrease its burden. In 2018, at the first Latin American Stroke Ministerial Meeting, stroke physician and healthcare manager representatives from 13 countries signed the Declaration of Gramado with the priorities to improve the region, with the commitment to implement all evidence-based strategies for stroke care. The second meeting in March 2020 reviewed the achievements in 2 years and discussed new objectives. This paper will review the 2-year advances and future plans of the Latin American alliance for stroke. Method: In March 2020, a survey based on the Declaration of Gramado items was sent to the neurologists participants of the Stroke Ministerial Meetings. The results were confirmed with representatives of the Ministries of Health and leaders from the countries at the second Latin American Stroke Ministerial Meeting. Results: In 2 years, public stroke awareness initiatives increased from 25 to 75% of countries. All countries have started programs to encourage physical activity, and there has been an increase in the number of countries that implement, at least partially, strategies to identify and treat hypertension, diabetes, and lifestyle risk factors. Programs to identify and treat dyslipidemia and atrial fibrillation still remained poor. The number of stroke centers increased from 322 to 448, all of them providing intravenous thrombolysis, with an increase in countries with stroke units. All countries have mechanical thrombectomy, but mostly restricted to a few private hospitals. Pre-hospital organization remains limited. The utilization of telemedicine has increased but is restricted to a few hospitals and is not widely available throughout the country. Patients have late, if any, access to rehabilitation after hospital discharge. Conclusion: The initiative to collaborate, exchange experiences, and unite societies and governments to improve stroke care in Latin America has yielded good results. Important advances have been made in the region in terms of increasing the number of acute stroke care services, implementing reperfusion treatments and creating programs for the detection and treatment of risk factors. We hope that this approach can reduce inequalities in stroke care in Latin America and serves as a model for other under-resourced environments.
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Affiliation(s)
- Sheila Cristina Ouriques Martins
- Hospital Moinhos de Vento, Porto Alegre, Brazil.,Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Brazilian Stroke Network, Porto Alegre, Brazil.,World Stroke Organization, Geneva, Switzerland
| | - Pablo Lavados
- Clinica Alemana, Universidad del Desarollo, Santiago, Chile
| | - Thaís Leite Secchi
- Hospital Moinhos de Vento, Porto Alegre, Brazil.,Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Brazilian Stroke Network, Porto Alegre, Brazil
| | - Michael Brainin
- World Stroke Organization, Geneva, Switzerland.,Department of Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems an der Donau, Austria
| | - Sebastian Ameriso
- Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia, Buenos Aires, Argentina
| | - Fernando Gongora-Rivera
- Servicio de Neurología - Unidad Neurovascular, Hospital Universitario José Eleuterio González, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico.,Instituto de Neurología y Neurocirugía, Centro Médico Zambrano Hellion, Tec Salud, San Pedro Garza García, Mexico.,Centro de Investigación y Desarrollo en Ciencias de la Salud, Universidad Aiutónoma de Nuevo León, Monterrey, Mexico
| | - Claudio Sacks
- Department of Neurology, Universidad del Valparaiso, Valparaiso, Chile
| | - Carlos Cantú-Brito
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Mexico City, Mexico
| | - Tony Fabian Alvarez Guzman
- Hospital Regional Manuela Beltran, Socorro, Colombia.,Asociación Colombiana de Neurología, Bogotá, Colombia
| | - Germán Enrique Pérez-Romero
- Asociación Colombiana de Neurología, Bogotá, Colombia.,Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, Colombia.,Fundación Hospital San Carlos, Bogotá, Colombia
| | | | - Miguel A Barboza
- Hospital Dr. Rafael A. Calderon, Neuroscience Department, San José, Costa Rica
| | - Antonio Arauz
- Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Clínica de Enfermedad Vascular Cerebral, Ciudad de México, Mexico
| | - Carlos Abanto Argomedo
- Departamento de Enfermedades Neurovasculares, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | | | | | | | | | - Ricardo Mernes
- Hospital de Clinicas, Faculdad de Medicina, Universidad Nacional de Asuncion, San Lorenzo, Paraguay
| | - Nelson Maldonado
- Hospital Central del Instituto de Previsión Social, Asunción, Paraguay
| | | | - Octávio Marques Pontes Neto
- Brazilian Stroke Network, Porto Alegre, Brazil.,Universidad San Francisco de Quito, Hospital de los Valles, Quito, Ecuador.,Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Gisele Sampaio Silva
- Brazilian Stroke Network, Porto Alegre, Brazil.,Brazilian Stroke Society, São Paulo, Brazil.,Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil.,Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Ana Claudia de Souza
- Hospital Moinhos de Vento, Porto Alegre, Brazil.,Brazilian Stroke Network, Porto Alegre, Brazil
| | | | - Alan Flores
- Hospital de Clinicas, Faculdad de Medicina, Universidad Nacional de Asuncion, San Lorenzo, Paraguay
| | - Donoban Melgarejo
- Hospital de Clinicas, Faculdad de Medicina, Universidad Nacional de Asuncion, San Lorenzo, Paraguay.,Hospital Central del Instituto de Previsión Social, Asunción, Paraguay
| | - Irving R Santos Carquin
- Emergency Hospital Public Assistance, Santiago, Chile.,Faculty of Medicine, University of Chile, Santiago, Chile.,Ministry of Health, Santiago, Chile
| | - Arnold Hoppe
- Clinica Alemana, Universidad del Desarollo, Santiago, Chile.,Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
| | | | - Francisco Mont'Alverne
- Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile.,Sociedade Brazileira de Neurorradiologia Diagnóstica e Terapêutica, São Paulo, Brazil
| | - Pablo Amaya
- Servicio de Neurología - Unidad Neurovascular, Hospital Universitario José Eleuterio González, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico.,Asociación Colombiana de Neurología, Bogotá, Colombia.,Fundación Valle del Lili, Cali, Colombia
| | - Hernan Bayona
- Asociación Colombiana de Neurología, Bogotá, Colombia.,Fundación Santa Fé de Bogotá, Bogotá, Colombia
| | | | | | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Denizar Vianna Araujo
- Ministry of Health, Brasília, Brazil.,Faculdade de Ciências Médicas da Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Valery L Feigin
- National Institute for Stroke and Applied Neurosciences, School of Public Health and Psychosocial Studies, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Raul G Nogueira
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University, Atlanta, GA, United States
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4
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Ranta A, Thompson S, Harwood MLN, Cadilhac DAM, Barber PA, Davis AJ, Gommans JH, Fink JN, McNaughton HK, Denison H, Corbin M, Feigin V, Abernethy V, Levack W, Douwes J, Girvan J, Wilson A. Reducing Ethnic and Geographic Inequities to Optimise New Zealand Stroke Care (REGIONS Care): Protocol for a Nationwide Observational Study. JMIR Res Protoc 2021; 10:e25374. [PMID: 33433396 PMCID: PMC7838000 DOI: 10.2196/25374] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/19/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Stroke systems of care differ between larger urban and smaller rural settings and it is unclear to what extent this may impact on patient outcomes. Ethnicity influences stroke risk factors and care delivery as well as patient outcomes in nonstroke settings. Little is known about the impact of ethnicity on poststroke care, especially in Māori and Pacific populations. OBJECTIVE Our goal is to describe the protocol for the Reducing Ethnic and Geographic Inequities to Optimise New Zealand Stroke Care (REGIONS Care) study. METHODS This large, nationwide observational study assesses the impact of rurality and ethnicity on best practice stroke care access and outcomes involving all 28 New Zealand hospitals caring for stroke patients, by capturing every stroke patient admitted to hospital during the 2017-2018 study period. In addition, it explores current access barriers through consumer focus groups and consumer, carer, clinician, manager, and policy-maker surveys. It also assesses the economic impact of care provided at different types of hospitals and to patients of different ethnicities and explores the cost-efficacy of individual interventions and care bundles. Finally, it compares manual data collection to routine health administrative data and explores the feasibility of developing outcome models using only administrative data and the cost-efficacy of using additional manually collected registry data. Regarding sample size estimates, in Part 1, Study A, 2400 participants are needed to identify a 10% difference between up to four geographic subgroups at 90% power with an α value of .05 and 10% to 20% loss to follow-up. In Part 1, Study B, a sample of 7645 participants was expected to include an estimated 850 Māori and 419 Pacific patients and to provide over 90% and over 80% power, respectively. Regarding Part 2, 50% of the patient or carer surveys, 40 provider surveys, and 10 focus groups were needed to achieve saturation of themes. The main outcome is the modified Rankin Scale (mRS) score at 3 months. Secondary outcomes include mRS scores; EQ-5D-3L (5-dimension, 3-level EuroQol questionnaire) scores; stroke recurrence; vascular events; death; readmission at 3, 6, and 12 months; cost of care; and themes around access barriers. RESULTS The study is underway, with national and institutional ethics approvals in place. A total of 2379 patients have been recruited for Part 1, Study A; 6837 patients have been recruited for Part 1, Study B; 10 focus groups have been conducted and 70 surveys have been completed in Part 2. Data collection has essentially been completed, including follow-up assessment; however, primary and secondary analyses, data linkage, data validation, and health economics analysis are still underway. CONCLUSIONS The methods of this study may provide the basis for future epidemiological studies that will guide care improvements in other countries and populations. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/25374.
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Affiliation(s)
- Annemarei Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand.,Department of Neurology, Capital and Coast District Health Board, Wellington, New Zealand
| | | | - Matire Louise Ngarongoa Harwood
- Department of General Practice and Primary Health Care, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Dominique Ann-Michele Cadilhac
- Translational Public Health and Evaluation Division, Stroke and Ageing Research in the Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Peter Alan Barber
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | | | | | - John Newton Fink
- Department of Neurology, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | | | - Hayley Denison
- Centre for Public Health Research, Massey University, Wellington, New Zealand
| | - Marine Corbin
- Centre for Public Health Research, Massey University, Wellington, New Zealand
| | - Valery Feigin
- Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | | | - William Levack
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Jeroen Douwes
- Centre for Public Health Research, Massey University, Wellington, New Zealand
| | | | - Andrew Wilson
- Nelson-Malborough District Health Board, Neslon-Malborough, New Zealand
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5
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Navarrro JC, Escabillas C, Aquino A, Macrohon C, Belen A, Abbariao M, Cuasay E, Lao A, Sarfati S, Hiyadan JH, Reyes FD, Salazar G, Dadgardoust P, De Leon-Gacrama F, Reandelar M. Stroke units in the Philippines: An observational study. Int J Stroke 2021; 16:849-854. [PMID: 33407015 DOI: 10.1177/1747493020981730] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In high-income countries, the management of stroke has changed substantially over the years with the advent of thrombolysis and endovascular treatment. However, in low-income countries, such interventions may not be available, or patients may come to the hospital outside the time window no longer qualified for this therapy. Most studies on stroke units were conducted in high-income countries. Unfortunately, there has been no local multicenter data with large patient numbers showing the effectiveness of stroke units in the Southeast Asian region. AIM To compare the outcomes of patients allocated to stroke units (based on accepted criteria) to those allocated to general neurology wards in the Philippines. METHODS This is an open, prospective, parallel, observational comparative study of patients from 11 institutions in the Philippines. Patients were allocated either to the stroke unit or to the general neurology ward by the admitting physician based on the criteria suggested by the Stroke Trialist Collaboration Group. The primary outcome was to determine in-hospital mortality at three- and six months in both stroke units and general neurology wards. The secondary outcomes were determined by a dichotomized modified Rankin scale: (0-2) independent and (3-5) dependent. RESULTS A total of 1025 patients were included in the study. In the primary outcome, a higher mortality rate (8.4% vs 1.0%) in the general neurology ward (p = 0.000) was seen. The six-month mortality rate was statistically significant and higher among patients admitted to the general neurology ward (3.1% vs 0.8%) (p = 0.009). Patients admitted to the stroke unit attained an independent functional outcome (mRS 0-2) as compared to the general neurology ward (73% vs 61.5%) (p = 0.000). Analysis of functionality at six months favored patients admitted in the stroke unit (88.5% vs 81.4%) as compared to the general neurology ward. CONCLUSION Patients specifically admitted to stroke units in the Philippines based on established criteria have better outcomes than those admitted to general neurology wards.
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Affiliation(s)
- Jose C Navarrro
- Department of Neurology, Jose R Reyes Memorial Medical Center, Manila City, Philippines.,St. Luke's Medical Center, Institute of Neurosciences, Quezon City, Philippines.,Department of Neurology and Psychiatry, University of Santo Tomas, Manila, Philippines
| | - Cyrus Escabillas
- Department of Neurology, Jose R Reyes Memorial Medical Center, Manila City, Philippines.,Dr Nicanor Reyes Memorial Foundation Far Eastern University, Quezon City, Philippines
| | - Abdias Aquino
- Department of Internal Medicine, Capitol Medical Center, Quezon City, Philippines
| | - Christina Macrohon
- St. Luke's Medical Center, Institute of Neurosciences, Quezon City, Philippines
| | - Allan Belen
- Community General Hospital of San Pablo City
| | - Maritoni Abbariao
- Department of Medicine, Dr. Jose Rodriguez Memorial Medical Hospital and Sanitarium, Caloocan City, Philippines
| | - Edna Cuasay
- Daniel Mercado Medical Center, Batangas, Philippines
| | - Annabelle Lao
- Department of Internal Medicine, Davao Medical School Foundation, Davao City, Philippines
| | | | | | - Fe Delos Reyes
- Department of Neurology, Baguio General Hospital Medical Center, Baguio City, Philippines
| | | | - Pariessa Dadgardoust
- Department of Neurology and Psychiatry, University of Santo Tomas, Manila, Philippines
| | | | - Macario Reandelar
- St. Luke's Medical Center, Institute of Neurosciences, Quezon City, Philippines.,Dr Nicanor Reyes Memorial Foundation Far Eastern University, Quezon City, Philippines
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Di Maria F, Kyheng M, Consoli A, Desilles JP, Gory B, Richard S, Rodesch G, Labreuche J, Girot JB, Dargazanli C, Marnat G, Lapergue B, Bourcier R. Identifying the predictors of first-pass effect and its influence on clinical outcome in the setting of endovascular thrombectomy for acute ischemic stroke: Results from a multicentric prospective registry. Int J Stroke 2020; 16:20-28. [PMID: 32380902 DOI: 10.1177/1747493020923051] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The first-pass effect, defined as a complete or near-complete recanalization after one pass (first-pass effect) of a mechanical thrombectomy device, has been related to better clinical outcome than good recanalization after more than one pass in acute ischemic stroke. We searched for predictors of first-pass effect by analyzing the results within a large prospective multicentric registry. METHODS We included patients treated by mechanical thrombectomy for isolated anterior intracranial occlusions. A multi-variate logistic regression analysis was carried out to search for predictors of first-pass effect. We also analyzed the percentage of patients with 90-day modified Rankin Scale score 0 to 2, excellent outcome (90-day modified Rankin Scale 0 to 1), 24-h NIHSS change, and 90-day all-cause mortality. RESULTS Among the 1832 patients included, clinical outcome at 90 days was significantly better in first-pass effect patients (50.6% vs. 38.9% in patients without first-pass effect), with a center-adjusted OR associated with first-pass effect of 1.74 (95%CI, 1.24 to 1.77). Older age, a lower systolic blood pressure, an MCA-M1 occlusion, higher DWI-ASPECTS at admission, mechanical thrombectomy under local anesthesia, and combined first-line device strategy were independent predictors of first-pass effect. CONCLUSIONS In this study, a strategy combining thrombectomy and thrombo-aspiration was more effective than other strategies in achieving first-pass effect. In addition, we confirm that clinical outcome was better in patients with first-pass effect compared to non-first-pass effect patients.
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Affiliation(s)
- Federico Di Maria
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Foch Suresnes FR, University of Versailles Saint Quentin-en-Yvelines, Versailles, France
| | | | - Arturo Consoli
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Foch Suresnes FR, University of Versailles Saint Quentin-en-Yvelines, Versailles, France
| | - Jean-Philippe Desilles
- Department of Interventional Neuroradiology, Fondation Ophtalmologique A. De Rothschild, Paris France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France.,University of Lorraine, INSERM U1254, Nancy, France
| | - Sébastien Richard
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France.,University of Lorraine, INSERM U1254, Nancy, France
| | - Georges Rodesch
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Foch Suresnes FR, University of Versailles Saint Quentin-en-Yvelines, Versailles, France
| | | | | | - Cyril Dargazanli
- Department of Neuroradiology, Guy de Chauliac University Hospital, Montpellier, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Bertrand Lapergue
- Department of Neurology, Hôpital Foch Suresnes FR, University of Versailles Saint Quentin-en-Yvelines, Versailles, France
| | - Romain Bourcier
- 0Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nantes, Nantes, France
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7
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Kim J, Thayabaranathan T, Donnan GA, Howard G, Howard VJ, Rothwell PM, Feigin V, Norrving B, Owolabi M, Pandian J, Liu L, Cadilhac DA, Thrift AG. Global Stroke Statistics 2019. Int J Stroke 2020; 15:819-838. [PMID: 32146867 DOI: 10.1177/1747493020909545] [Citation(s) in RCA: 182] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Data on stroke epidemiology and availability of hospital-based stroke services around the world are important for guiding policy decisions and healthcare planning. AIMS To provide the most current incidence, mortality and case-fatality data on stroke and describe current availability of stroke units around the world by country. METHODS We searched multiple databases (based on our existing search strategy) to identify new original manuscripts and review articles published between 1 June 2016 and 31 October 2018 that met the ideal criteria for data on stroke incidence and case-fatality. For data on the availability of hospital-based stroke services, we searched PubMed for all literature published up until 31 June 2018. We further screened reference lists, citation history of manuscripts and gray literature for this information. Mortality codes for International Classification of Diseases-9 and International Classification of Diseases-10 were extracted from the World Health Organization mortality database for each country providing these data. Population denominators were obtained from the World Health Organization, and when these were unavailable within a two-year period of mortality data, population denominators within a two-year period were obtained from the United Nations. Using country-specific population denominators and the most recent years of mortality data available for each country, we calculated both the crude mortality from stroke and mortality adjusted to the World Health Organization world population. RESULTS Since our last report in 2017, there were two countries with new incidence studies, China (n = 1) and India (n = 2) that met the ideal criteria. New data on case-fatality were found for Estonia and India. The most current mortality data were available for the year 2015 (39 countries), 2016 (43 countries), and 2017 (7 countries). No new data on mortality were available for six countries. Availability of stroke units was noted for 63 countries, and the proportion of patients treated in stroke units was reported for 35/63 countries. CONCLUSION Up-to-date data on stroke incidence, case-fatality, and mortality statistics provide evidence of variation among countries and changing magnitudes of burden among high and low-middle income countries. Reporting of hospital-based stroke units remains limited and should be encouraged.
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Affiliation(s)
- Joosup Kim
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.,The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - Tharshanah Thayabaranathan
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Geoffrey A Donnan
- Melbourne Brain Centre, University of Melbourne, Parkville, Victoria, Australia
| | - George Howard
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Valery Feigin
- National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand
| | - Bo Norrving
- Department of Clinical Sciences, Section of Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Mayowa Owolabi
- Center for Genomic and Precision Medicine, University of Ibadan, Ibadan, Nigeria
| | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, India
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.,The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
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8
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Istvan M, Lecoffre C, Bayat S, Béjot Y, Le Strat Y, De Peretti C, Gao F, Olié V, Grimaud O. What is the evolution of stroke unit's accessibility in metropolitan France from 2009 to 2014? A trend analysis of over 600 000 patients using national hospital databases. BMJ Open 2018; 8:e023599. [PMID: 30269075 PMCID: PMC6169775 DOI: 10.1136/bmjopen-2018-023599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 07/10/2018] [Accepted: 08/17/2018] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES We aimed to study trends in stroke unit (SU) admission during a period of their deployment in France and to assess whether this led to better and more equitable access to this specialised care. DESIGN Analysis of records from the national hospital database. SETTING All acute care hospitals in metropolitan France for the period 2009-2014. PARTICIPANTS Over 600 000 patients admitted in acute care with a main diagnosis of stroke. MAIN OUTCOME MEASURES Admission to a SU. RESULTS Between 2009 and 2014, the number of stroke admissions rose from 93 728 to 109 456, and the proportion of SU admission from 23% to 44%. Overall, characteristics associated with higher probability of SU admission were: male gender, younger age, ischaemic stroke type, medium level of comorbidity and larger size of town of residence. Although likelihood of SU admission increased in all patients' categories during the study period, we identified steeper positive temporal trends among older patients, those with more comorbidities and those residing in medium or small towns (all p values <0.001), suggesting a 'catching up' phenomena. Temporal trends of men and women did not differ however. CONCLUSIONS Admission to SU nearly doubled in France between 2009 and 2014. Faster trends observed for patients with lower admission to SU suggest that equity in access has improved over the period.
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Affiliation(s)
- Marion Istvan
- Univ Rennes, EHESP, Recherche en pharmaco-épidémiologie et recours aux soins, Rennes, France
| | - Camille Lecoffre
- Santé publique France - The French Public Health Agency, F-94415 Saint-Maurice, France
| | - Sahar Bayat
- Univ Rennes, EHESP, Recherche en pharmaco-épidémiologie et recours aux soins, Rennes, France
| | - Yannick Béjot
- Service de Neurologie Générale, Vasculaire et Dégénérative, CHU Dijon Bourgogne, Registre Dijonnais des AVC, Dijon, France
| | - Yann Le Strat
- Santé publique France - The French Public Health Agency, F-94415 Saint-Maurice, France
| | - Christine De Peretti
- Direction de la Recherche, des Etudes, de l'Evaluation et des Statistiques, Paris, France
| | - Fei Gao
- Univ Rennes, EHESP, Recherche en pharmaco-épidémiologie et recours aux soins, Rennes, France
| | - Valérie Olié
- Santé publique France - The French Public Health Agency, F-94415 Saint-Maurice, France
| | - Olivier Grimaud
- Univ Rennes, EHESP, Recherche en pharmaco-épidémiologie et recours aux soins, Rennes, France
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9
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Clarke DJ, Burton LJ, Tyson SF, Rodgers H, Drummond A, Palmer R, Hoffman A, Prescott M, Tyrrell P, Brkic L, Grenfell K, Forster A. Why do stroke survivors not receive recommended amounts of active therapy? Findings from the ReAcT study, a mixed-methods case-study evaluation in eight stroke units. Clin Rehabil 2018; 32:1119-1132. [PMID: 29582712 PMCID: PMC6068965 DOI: 10.1177/0269215518765329] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 02/24/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To identify why the National Clinical Guideline recommendation of 45 minutes of each appropriate therapy daily is not met in many English stroke units. DESIGN Mixed-methods case-study evaluation, including modified process mapping, non-participant observations of service organisation and therapy delivery, documentary analysis and semi-structured interviews. SETTING Eight stroke units in four English regions. SUBJECTS Seventy-seven patients with stroke, 53 carers and 197 stroke unit staff were observed; 49 patients, 50 carers and 131 staff participants were interviewed. RESULTS Over 1000 hours of non-participant observations and 433 patient-specific therapy observations were undertaken. The most significant factor influencing amount and frequency of therapy provided was the time therapists routinely spent, individually and collectively, in information exchange. Patient factors, including fatigue and tolerance influenced therapists' decisions about frequency and intensity, typically resulting in adaptation of therapy rather than no provision. Limited use of individual patient therapy timetables was evident. Therapist staffing levels were associated with differences in therapy provision but were not the main determinant of intensity and frequency. Few therapists demonstrated understanding of the evidence underpinning recommendations for increased therapy frequency and intensity. Units delivering more therapy had undertaken patient-focused reorganisation of therapists' working practices, enabling them to provide therapy consistent with guideline recommendations. CONCLUSION Time spent in information exchange impacted on therapy provision in stroke units. Reorganisation of therapists' work improved alignment with guidelines.
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Affiliation(s)
- David J Clarke
- Academic Unit of Elderly Care and
Rehabilitation, Leeds Institute of Health Sciences, Bradford Royal Infirmary,
Bradford, UK
| | - Louisa-Jane Burton
- Academic Unit of Elderly Care and
Rehabilitation, Leeds Institute of Health Sciences, Bradford Royal Infirmary,
Bradford, UK
| | - Sarah F Tyson
- School of Health Sciences, Manchester
Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Helen Rodgers
- Stroke Research Group, Institute of
Neuroscience, Newcastle University, Newcastle, UK
| | - Avril Drummond
- Faculty of Medicine and Health Sciences,
University of Nottingham, Nottingham, UK
| | - Rebecca Palmer
- Health Services Research, School of
Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Alex Hoffman
- Sentinel Stroke National Audit
Programme, Royal College of Physicians, London, UK
| | - Matthew Prescott
- Physiotherapy Department, Bradford
Teaching Hospitals NHS Trust, Bradford, UK
| | - Pippa Tyrrell
- Salford Royal NHS Foundation Trust and
Manchester Academic Health Science Centre, The University of Manchester, Manchester,
UK
| | - Lianne Brkic
- Academic Unit of Elderly Care and
Rehabilitation, Leeds Institute of Health Sciences, Bradford Royal Infirmary,
Bradford, UK
- Stroke Research Group, Institute of
Neuroscience, Newcastle University, Newcastle, UK
| | - Katie Grenfell
- Academic Unit of Elderly Care and
Rehabilitation, Leeds Institute of Health Sciences, Bradford Royal Infirmary,
Bradford, UK
| | - Anne Forster
- Academic Unit of Elderly Care and
Rehabilitation, Leeds Institute of Health Sciences, Bradford Royal Infirmary,
Bradford, UK
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10
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McElwaine P, McCormack J, McCormick M, Rudd A, Brennan C, Coetzee H, Cotter PE, Doyle R, Hickey A, Horgan F, Loughnane C, Macey C, Marsden P, McCabe D, Mulcahy R, Noone I, Shelley E, Stapleton T, Williams D, Kelly P, Harbison J. A comparison of service organisation and guideline compliance between two adjacent European health services. Eur Stroke J 2017; 2:238-243. [PMID: 31008317 DOI: 10.1177/2396987317703209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 03/14/2017] [Indexed: 01/19/2023] Open
Abstract
Introduction Outcomes in stroke patients are improved by a co-ordinated organisation of stroke services and provision of evidence-based care. We studied the organisation of care and application of guidelines in two neighbouring health care systems with similar characteristics. Methods Organisational elements of the 2015 National Stroke Audit (NSA) from the Republic of Ireland (ROI) were compared with the Sentinel Stroke National Audit Programme (SSNAP) in Northern Ireland (NI) and the United Kingdom (UK). Compliance was compared with UK and European guidelines. Results Twenty-one of 28 ROI hospitals (78%) reported having a stroke unit (SU) compared with all 10 in NI. Average SU size was smaller in ROI (6 beds vs. 15 beds) and bed availability per head of population was lower (1:30,633 vs. 1:12,037 p < 0.0001 Chi Sq). Fifty-four percent of ROI patients were admitted to SU care compared with 96% of UK patients (p < 0.0001). Twenty-four-hour physiological monitoring was available in 54% of ROI SUs compared to 91% of UK units (p < 0.0001). There was no significant difference between ROI and NI in access to senior specialist physicians or nurses or in SU nurse staffing (3.9/10 beds weekday mornings) but there was a higher proportion of trained nurses in ROI units (2.9/10 beds vs. 2.3/10 beds (p = 0.02 Chi Sq). Conclusion Whilst the majority of hospitals in both jurisdictions met key criteria for organised stroke care the small size and underdevelopment of the ROI units meant a substantial proportion of patients were unable to access this specialised care.
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Affiliation(s)
- Paul McElwaine
- National Clinical Programme for Stroke, Health Service Executive, Ireland.,Trinity College, University of Dublin, Ireland
| | - Joan McCormack
- National Clinical Programme for Stroke, Health Service Executive, Ireland.,Trinity College, University of Dublin, Ireland.,Irish Heart Foundation, Ireland
| | | | - Anthony Rudd
- Sentinel Stroke National Audit Programme and Kings College London, UK
| | - Carmel Brennan
- National Clinical Programme for Stroke, Health Service Executive, Ireland.,Department of Public Health, Health Service Executive, Ireland
| | - Heather Coetzee
- Ireland East Hospitals Group and University College Dublin, Ireland
| | - Paul E Cotter
- Ireland East Hospitals Group and University College Dublin, Ireland
| | - Rachel Doyle
- Ireland East Hospitals Group and University College Dublin, Ireland
| | | | | | | | | | - Paul Marsden
- Department of Public Health, Health Service Executive, Ireland
| | - Dominick McCabe
- Trinity College, University of Dublin, Ireland.,Dublin Midlands Hospitals Group, Ireland
| | | | - Imelda Noone
- Ireland East Hospitals Group and University College Dublin, Ireland
| | - Emer Shelley
- Department of Public Health, Health Service Executive, Ireland
| | | | | | - Peter Kelly
- National Clinical Programme for Stroke, Health Service Executive, Ireland.,Ireland East Hospitals Group and University College Dublin, Ireland
| | - Joseph Harbison
- National Clinical Programme for Stroke, Health Service Executive, Ireland.,Trinity College, University of Dublin, Ireland.,Dublin Midlands Hospitals Group, Ireland
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11
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Sablot D, Gaillard N, Smadja P, Bonnec JM, Bonafe A. Thrombectomy accessibility after transfer from a primary stroke center: Analysis of a three-year prospective registry. Int J Stroke 2017; 12:519-523. [PMID: 28375045 DOI: 10.1177/1747493017701151] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background No comprehensive study exists about mechanical thrombectomy accessibility for patients admitted to a primary stroke center without onsite interventional neuroradiology service. Aims To evaluate mechanical thrombectomy accessibility within 6 h after transfer from a primary stroke center to a distant (156 km apart; 1.5 h by car) comprehensive stroke center. Methods Analysis of data collected in a three-year prospective registry on patients admitted to a primary stroke center within 4.5 h after symptom onset and selected for transfer to a comprehensive stroke center for mechanical thrombectomy. Eligible patients had confirmed proximal arterial occlusion and no large cerebral infarction on MRI images (DWI-ASPECTS ≥ 5). The rate of transfer, transfer without mechanical thrombectomy, mechanical thrombectomy, reperfusion (TICI score ≥ 2b-3), and the main relevant time measures were determined. Results Among the 385 patients selected for intravenous thrombolysis and/or potential mechanical thrombectomy, 211 were considered as transferrable for mechanical thrombectomy. The rate of transfer was 56.4% (n = 119/211), transfer without mechanical thrombectomy 56.3% (n = 67/119), mechanical thrombectomy 24.6% (n = 52/211), and reperfusion by MT (TICI score 2b/3) 18% (n = 38/211). The relevant median times (interquartile range) were: 130 min (62) for intravenous thrombolysis start to comprehensive stroke center door, 95 minutes (39) for primary stroke center door-out to comprehensive stroke center door-in, 191 min (44) for intravenous thrombolysis start to mechanical thrombectomy puncture, 354 min (107) for symptom onset to mechanical thrombectomy puncture and 417 min (124) for symptom onset to recanalization. Conclusions Our study suggests that transfer to a distant comprehensive stroke center is associated with reduced access to early mechanical thrombectomy in patients with acute ischemic stroke and large artery occlusion. These results could be translated to other high volume distant primary stroke center.
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Affiliation(s)
- Denis Sablot
- 1 Neurology Department, Centre Hospitalier de Perpignan, Perpignan, France
| | - Nicolas Gaillard
- 1 Neurology Department, Centre Hospitalier de Perpignan, Perpignan, France
| | - Philippe Smadja
- 2 Radiology Department, Centre Hospitalier de Perpignan, Perpignan, France
| | - Jean-Marie Bonnec
- 3 Emergency Department, Centre Hospitalier de Perpignan, Perpignan, France
| | - Alain Bonafe
- 4 Neuroradiology Department, Hôpital Gui-de-Chauliac, Montpellier, France
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12
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Alexandrov AW, Coleman KC, Palazzo P, Shahripour RB, Alexandrov AV. Direct stroke unit admission of intravenous tissue plasminogen activator: safety, clinical outcome, and hospital cost savings. Ther Adv Neurol Disord 2016; 9:304-9. [PMID: 27366237 DOI: 10.1177/1756285616648061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In the USA, stable intravenous tissue plasminogen activator (IV tPA) patients have traditionally been cared for in an intensive care unit (ICU). We examined the safety of using an acuity-adaptable stroke unit (SU) to manage IV tPA patients. METHODS We conducted an observational study of consecutive patients admitted to our acuity-adaptable SU over the first 3 years of operation. Safety was assessed by symptomatic intracerebral hemorrhage (sICH) rates, systemic hemorrhage (SH) rates, tPA-related deaths, and transfers from SU to ICU; cost savings and length of stay (LOS) were determined. RESULTS We admitted 333 IV tPA patients, of which 302 were admitted directly to the SU. A total of 31 (10%) patients had concurrent systemic hemodynamic or pulmonary compromise warranting direct ICU admission. There were no differences in admission National Institutes of Health Stroke Scale scores between SU and ICU patients (9.0 versus 9.5, respectively). Overall sICH rate was 3.3% (n = 10) and SH rate was 2.9 (n = 9), with no difference between SU and ICU patients. No tPA-related deaths occurred, and no SU patients required transfer to the ICU. Estimated hospital cost savings were US$362,400 for 'avoided' ICU days, and hospital LOS decreased significantly (p = 0.001) from 9.8 ± 15.6 days (median 5) in year 1, to 5.2 ± 4.8 days (median 3) by year 3. CONCLUSIONS IV tPA patients may be safely cared for in a SU when nurses undergo extensive education to ensure clinical competence. Use of the ICU solely for monitoring may constitute significant overuse of system resources at an expense that is not associated with additional safety benefit.
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Affiliation(s)
- Anne W Alexandrov
- Stroke Team and Mobile Stroke Unit, University of Tennessee Health Science Center & Australian Catholic University, Sydney, Australia. Address: UTHSC CON 920 Madison, Suite 532, Memphis, TN 38163, USA
| | | | - Paola Palazzo
- Department of Neurology, Poitiers University Hospital, Poitiers, France
| | - Reza Bavarsad Shahripour
- Stroke Team and Mobile Stroke Unit, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrei V Alexandrov
- Stroke Team and Mobile Stroke Unit, University of Tennessee Health Science Center, Memphis, TN, USA
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13
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Abstract
PURPOSE Nurses represent the largest professional group working with stroke-survivors, but there is limited evidence regarding nurses' involvement in post-stroke rehabilitation. The purpose of this study was to identify and explore the perspectives of nurses and other multidisciplinary stroke team members on nurses' practice in stroke rehabilitation. METHOD Q-methodological study with 63 multidisciplinary stroke unit team members and semi-structured interviews with 27 stroke unit team members. RESULTS Irrespective of their professional backgrounds, participants shared the view that nurses can make an active contribution to stroke rehabilitation and integrate rehabilitation principles in routine practice. Training in stroke rehabilitation skills was viewed as fundamental to effective stroke care, but nurses do not routinely receive such training. The view that integrating rehabilitation techniques can only occur when nursing staffing levels were high was rejected. There was also little support for the view that nurses are uniquely placed to co-ordinate care, or that nurses have an independent rehabilitation role. CONCLUSIONS The contribution that nurses with stroke rehabilitation skills can make to effective stroke care was understood. However, realising the potential of nurses as full partners in stroke rehabilitation is unlikely to occur without introduction of structured competency-based multidisciplinary training in rehabilitation skills. Implications for Rehabilitation Multidisciplinary rehabilitation in stroke units is a cornerstone of effective stroke care. Views of stroke unit team members on nurses' involvement in rehabilitation have not been reported previously. Nurses can routinely incorporate rehabilitation principles in their care. Specialist competency-based stroke rehabilitation training needs to be provided for nurses as well as for allied health professionals.
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Affiliation(s)
- David J Clarke
- a Academic Unit of Elderly Care and Rehabilitation, Leeds Institute for Health Sciences, University of Leeds , Bradford , UK and
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14
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Jeong HG, Ko SB, Kim CK, Kim Y, Jung S, Kim TJ, Yoon BW. Tachycardia burden in stroke unit is associated with functional outcome after ischemic stroke. Int J Stroke 2016; 11:313-20. [PMID: 26860125 DOI: 10.1177/1747493016631357] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 11/05/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Stroke unit care is associated with decrease in mortality and improvement in neurological outcome in patients with acute stroke. Heart rate is a commonly monitored variable in the stroke unit. However, little is known about tachycardia burden in the stroke unit and its association with outcome. AIMS To investigate the effects of tachycardia burden in the stroke unit on functional outcome in patients with acute ischemic stroke. METHODS We collected data from 246 patients with acute ischemic stroke admitted to our stroke unit between July 2013 and June 2014. Tachycardia burden was defined as duration of heart rate over 95 per minute divided by the total monitoring time, using the heart rate data sampled every 1 min. We divided the study population into quartiles of tachycardia burden and analyzed their association with poor three-month functional outcome (modified Rankin Scale score of ≥3). RESULTS Among included patients (age, 67.4 ± 12.8; male, 53.7%), tachycardia burden was 0.7% (median, interquartile range [0.1-5.7%]). The patients with higher tachycardia burdens were older, more likely to have higher stroke severity, cardioembolic etiology, atrial fibrillation, fever, pneumonia, higher initial glucose level, and higher white blood cell count. As compared with the lowest quartile (<0.1%), the highest quartile of tachycardia burden (≥6.0%) was significantly associated with poor outcome (adjusted odds ratio, 5.10; 95% confidence interval, 1.38-18.90; p = 0.01) after adjustment for covariates. CONCLUSIONS Patients with increased tachycardia burden during stroke unit stay have poor functional outcome. Countermeasures against worsening factors might be utilized for patients with increased tachycardia burden.
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Affiliation(s)
- Han-Gil Jeong
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of KoreaThe first two authors contributed equally to this article
| | - Sang-Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of KoreaThe first two authors contributed equally to this article
| | - Chi Kyung Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of KoreaThe first two authors contributed equally to this article
| | - Yerim Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of KoreaThe first two authors contributed equally to this article
| | - Seunguk Jung
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of KoreaThe first two authors contributed equally to this article
| | - Tae Jung Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of KoreaThe first two authors contributed equally to this article
| | - Byung-Woo Yoon
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of KoreaThe first two authors contributed equally to this article.
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15
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Serles W, Gattringer T, Mutzenbach S, Seyfang L, Trenkler J, Killer-Oberpfalzer M, Deutschmann H, Niederkorn K, Wolf F, Gruber A, Hausegger K, Weber J, Thurnher S, Gizewski E, Willeit J, Karaic R, Fertl E, Našel C, Brainin M, Erian J, Oberndorfer S, Karnel F, Grisold W, Auff E, Fazekas F, Haring HP, Lang W. Endovascular stroke therapy in Austria: a nationwide 1-year experience. Eur J Neurol 2016; 23:906-11. [PMID: 26843095 DOI: 10.1111/ene.12958] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 12/07/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE Based on a tight network of stroke units (SUs) and interventional centres, endovascular treatment of acute major intracranial vessel occlusion has been widely implemented in Austria. Documentation of all patients in the nationwide SU registry has thereby become mandatory. METHODS Demographic, clinical and interventional characteristics of patients who underwent endovascular treatment for acute ischaemic stroke in 11 Austrian interventional centres between 1 October 2013 and 30 September 2014 were analysed. RESULTS In total, 301 patients (50.5% women; median age 70.5 years; median National Institutes of Health Stroke Scale score 17) were identified.193 patients (64.1%) additionally received intravenous thrombolysis. The most frequent vessel occlusion sites were the M1 segment of the middle cerebral artery (n = 161, 53.5%), the intracranial internal carotid artery (n = 60, 19.9%) and the basilar artery (n = 40, 13.3%). Stent retrievers were used in 235 patients (78.1%) and adequate reperfusion (modified Thrombolysis in Cerebral Infarction scores 2b and 3, median onset to reperfusion time 254 min) was achieved in 242 patients (81.4%). Symptomatic intracranial haemorrhage occurred in 7%. 43.8% of patients (n = 132) had good functional outcome (modified Rankin Scale score 0-2) and the mortality rate was 20.9% (n = 63) after 3 months. Compared to the anterior circulation, vertebrobasilar stroke patients had higher mortality. Patients with secondary hospital transportation had better outcomes after 3 months than in-house treated patients. CONCLUSION Our results document nationwide favourable outcome and safety rates of endovascular stroke treatment comparable to recent randomized trials. The ability to provide such data and the need to further optimize such an approach also underscore the contribution of respective registries.
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Affiliation(s)
- W Serles
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - T Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - S Mutzenbach
- Department of Neurology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - L Seyfang
- Danube University Krems and Gesundheit Österreich GmbH/BIQG, Vienna, Austria
| | - J Trenkler
- Department of Neuroradiology, Wagner-Jauregg Hospital, Linz, Austria
| | - M Killer-Oberpfalzer
- Department of Neurology, Paracelsus Medical University Salzburg, Salzburg, Austria.,Research Institute of Neurointervention, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - H Deutschmann
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - K Niederkorn
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - F Wolf
- Department of Cardiovascular and Interventional Radiology, Medical University of Vienna, Vienna, Austria
| | - A Gruber
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - K Hausegger
- Institute of Diagnostic and Interventional Radiology, Klinikum Klagenfurt, Klagenfurt, Austria
| | - J Weber
- Department of Neurology, Klinikum Klagenfurt, Klagenfurt, Austria
| | - S Thurnher
- Department of Radiology and Nuclear Medicine, Krankenhaus Barmherzige Brüder, Vienna, Austria
| | - E Gizewski
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Willeit
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - R Karaic
- Department of Radiology, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - E Fertl
- Department of Neurology, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - C Našel
- Department of Radiology, University Clinic Tulln, Tulln, Austria
| | - M Brainin
- Department of Neurology, University Clinic Tulln, Tulln, Austria
| | - J Erian
- Institute of Medical Radiology, University Clinic St Pölten, St Pölten, Austria
| | - S Oberndorfer
- Department of Neurology, University Clinic St Pölten, St Pölten, Austria
| | - F Karnel
- Department of Radiology, Kaiser Franz Josef Hospital Vienna, Vienna, Austria
| | - W Grisold
- Department of Neurology, Kaiser Franz Josef Hospital Vienna, Vienna, Austria
| | - E Auff
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - F Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - H-P Haring
- Department of Neurology, Wagner-Jauregg Hospital, Linz, Austria
| | - W Lang
- Department of Neurology, Krankenhaus Barmherzige Brüder, Vienna, Austria
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Budincevic H, Tiu C, Bereczki D, Kõrv J, Tsiskaridze A, Niederkorn K, Czlonkowska A, Demarin V. Management of ischemic stroke in Central and Eastern Europe. Int J Stroke 2015; 10 Suppl A100:125-7. [PMID: 26179030 DOI: 10.1111/ijs.12575] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 06/04/2015] [Indexed: 10/23/2022]
Abstract
Stroke is one of the leading causes of disability in Europe. Central and Eastern European countries have the highest incidence and mortality rates through Europe. The improvements in stroke prevention and treatment in Central and Eastern European countries did not completely reach the quality parameters present in Western European countries. We present features of current management of stroke in Central and Eastern European countries.
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Affiliation(s)
- Hrvoje Budincevic
- Department of Neurology, Sveti Duh University Hospital, Zagreb, Croatia.,School of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Cristina Tiu
- Department of Neurology, University Hospital Bucharest, Bucharest, Romania
| | - Daniel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
| | - Alexander Tsiskaridze
- Department of Neurology, Ivane Javakhishvili Tbilisi State University, Tbilisi, Georgia
| | - Kurt Niederkorn
- Department of Neurology, Medical University Graz, Graz, Austria
| | - Anna Czlonkowska
- 2nd Neurological Department, Institute of Psychiatry and Neurology, Warsaw, Poland
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17
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Ramsay AIG, Morris S, Hoffman A, Hunter RM, Boaden R, McKevitt C, Perry C, Pursani N, Rudd AG, Turner SJ, Tyrrell PJ, Wolfe CDA, Fulop NJ. Effects of Centralizing Acute Stroke Services on Stroke Care Provision in Two Large Metropolitan Areas in England. Stroke 2015; 46:2244-51. [PMID: 26130092 PMCID: PMC4512749 DOI: 10.1161/strokeaha.115.009723] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 05/22/2015] [Indexed: 01/19/2023]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— In 2010, Greater Manchester and London centralized acute stroke care into hyperacute units (Greater Manchester=3, London=8), with additional units providing ongoing specialist stroke care nearer patients’ homes. Greater Manchester patients presenting within 4 hours of symptom onset were eligible for hyperacute unit admission; all London patients were eligible. Research indicates that postcentralization, only London’s stroke mortality fell significantly more than elsewhere in England. This article attempts to explain this difference by analyzing how centralization affects provision of evidence-based clinical interventions. Methods— Controlled before and after analysis was conducted, using national audit data covering Greater Manchester, London, and a noncentralized urban comparator (38 623 adult stroke patients, April 2008 to December 2012). Likelihood of receiving all interventions measured reliably in pre- and postcentralization audits (brain scan; stroke unit admission; receiving antiplatelet; physiotherapist, nutrition, and swallow assessments) was calculated, adjusting for age, sex, stroke-type, consciousness, and whether stroke occurred in-hospital. Results— Postcentralization, likelihood of receiving interventions increased in all areas. London patients were overall significantly more likely to receive interventions, for example, brain scan within 3 hours: Greater Manchester=65.2% (95% confidence interval=64.3–66.2); London=72.1% (71.4–72.8); comparator=55.5% (54.8–56.3). Hyperacute units were significantly more likely to provide interventions, but fewer Greater Manchester patients were admitted to these (Greater Manchester=39%; London=93%). Differences resulted from contrasting hyperacute unit referral criteria and how reliably they were followed. Conclusions— Centralized systems admitting all stroke patients to hyperacute units, as in London, are significantly more likely to provide evidence-based clinical interventions. This may help explain previous research showing better outcomes associated with fully centralized models.
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Affiliation(s)
- Angus I G Ramsay
- From the Department of Applied Health Research, University College London, London, UK (A.I.G.R, S.M., S.J.T., N.J.F.); Clinical Standards Department, Royal College of Physicians, London, UK (A.H., A.G.R.); Research Department of Primary Care & Population Health, University College London, Royal Free Campus, London, UK (R.M.H.); Manchester Business School, University of Manchester, Manchester, UK (R.B., C.P.); Department of Primary Care and Public Health Sciences, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., A.G.R., C.D.A.W.); King's College London Stroke Research Patients and Family Group, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., N.P., A.G.R.); National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK (C.M., A.G.R, C.D.A.W.); National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, London, UK (C.D.A.W.); Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK (A.G.R.); and Stroke & Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford, UK (P.J.T.).
| | - Stephen Morris
- From the Department of Applied Health Research, University College London, London, UK (A.I.G.R, S.M., S.J.T., N.J.F.); Clinical Standards Department, Royal College of Physicians, London, UK (A.H., A.G.R.); Research Department of Primary Care & Population Health, University College London, Royal Free Campus, London, UK (R.M.H.); Manchester Business School, University of Manchester, Manchester, UK (R.B., C.P.); Department of Primary Care and Public Health Sciences, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., A.G.R., C.D.A.W.); King's College London Stroke Research Patients and Family Group, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., N.P., A.G.R.); National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK (C.M., A.G.R, C.D.A.W.); National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, London, UK (C.D.A.W.); Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK (A.G.R.); and Stroke & Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford, UK (P.J.T.)
| | - Alex Hoffman
- From the Department of Applied Health Research, University College London, London, UK (A.I.G.R, S.M., S.J.T., N.J.F.); Clinical Standards Department, Royal College of Physicians, London, UK (A.H., A.G.R.); Research Department of Primary Care & Population Health, University College London, Royal Free Campus, London, UK (R.M.H.); Manchester Business School, University of Manchester, Manchester, UK (R.B., C.P.); Department of Primary Care and Public Health Sciences, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., A.G.R., C.D.A.W.); King's College London Stroke Research Patients and Family Group, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., N.P., A.G.R.); National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK (C.M., A.G.R, C.D.A.W.); National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, London, UK (C.D.A.W.); Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK (A.G.R.); and Stroke & Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford, UK (P.J.T.)
| | - Rachael M Hunter
- From the Department of Applied Health Research, University College London, London, UK (A.I.G.R, S.M., S.J.T., N.J.F.); Clinical Standards Department, Royal College of Physicians, London, UK (A.H., A.G.R.); Research Department of Primary Care & Population Health, University College London, Royal Free Campus, London, UK (R.M.H.); Manchester Business School, University of Manchester, Manchester, UK (R.B., C.P.); Department of Primary Care and Public Health Sciences, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., A.G.R., C.D.A.W.); King's College London Stroke Research Patients and Family Group, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., N.P., A.G.R.); National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK (C.M., A.G.R, C.D.A.W.); National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, London, UK (C.D.A.W.); Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK (A.G.R.); and Stroke & Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford, UK (P.J.T.)
| | - Ruth Boaden
- From the Department of Applied Health Research, University College London, London, UK (A.I.G.R, S.M., S.J.T., N.J.F.); Clinical Standards Department, Royal College of Physicians, London, UK (A.H., A.G.R.); Research Department of Primary Care & Population Health, University College London, Royal Free Campus, London, UK (R.M.H.); Manchester Business School, University of Manchester, Manchester, UK (R.B., C.P.); Department of Primary Care and Public Health Sciences, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., A.G.R., C.D.A.W.); King's College London Stroke Research Patients and Family Group, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., N.P., A.G.R.); National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK (C.M., A.G.R, C.D.A.W.); National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, London, UK (C.D.A.W.); Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK (A.G.R.); and Stroke & Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford, UK (P.J.T.)
| | - Christopher McKevitt
- From the Department of Applied Health Research, University College London, London, UK (A.I.G.R, S.M., S.J.T., N.J.F.); Clinical Standards Department, Royal College of Physicians, London, UK (A.H., A.G.R.); Research Department of Primary Care & Population Health, University College London, Royal Free Campus, London, UK (R.M.H.); Manchester Business School, University of Manchester, Manchester, UK (R.B., C.P.); Department of Primary Care and Public Health Sciences, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., A.G.R., C.D.A.W.); King's College London Stroke Research Patients and Family Group, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., N.P., A.G.R.); National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK (C.M., A.G.R, C.D.A.W.); National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, London, UK (C.D.A.W.); Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK (A.G.R.); and Stroke & Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford, UK (P.J.T.)
| | - Catherine Perry
- From the Department of Applied Health Research, University College London, London, UK (A.I.G.R, S.M., S.J.T., N.J.F.); Clinical Standards Department, Royal College of Physicians, London, UK (A.H., A.G.R.); Research Department of Primary Care & Population Health, University College London, Royal Free Campus, London, UK (R.M.H.); Manchester Business School, University of Manchester, Manchester, UK (R.B., C.P.); Department of Primary Care and Public Health Sciences, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., A.G.R., C.D.A.W.); King's College London Stroke Research Patients and Family Group, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., N.P., A.G.R.); National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK (C.M., A.G.R, C.D.A.W.); National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, London, UK (C.D.A.W.); Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK (A.G.R.); and Stroke & Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford, UK (P.J.T.)
| | - Nanik Pursani
- From the Department of Applied Health Research, University College London, London, UK (A.I.G.R, S.M., S.J.T., N.J.F.); Clinical Standards Department, Royal College of Physicians, London, UK (A.H., A.G.R.); Research Department of Primary Care & Population Health, University College London, Royal Free Campus, London, UK (R.M.H.); Manchester Business School, University of Manchester, Manchester, UK (R.B., C.P.); Department of Primary Care and Public Health Sciences, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., A.G.R., C.D.A.W.); King's College London Stroke Research Patients and Family Group, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., N.P., A.G.R.); National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK (C.M., A.G.R, C.D.A.W.); National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, London, UK (C.D.A.W.); Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK (A.G.R.); and Stroke & Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford, UK (P.J.T.)
| | - Anthony G Rudd
- From the Department of Applied Health Research, University College London, London, UK (A.I.G.R, S.M., S.J.T., N.J.F.); Clinical Standards Department, Royal College of Physicians, London, UK (A.H., A.G.R.); Research Department of Primary Care & Population Health, University College London, Royal Free Campus, London, UK (R.M.H.); Manchester Business School, University of Manchester, Manchester, UK (R.B., C.P.); Department of Primary Care and Public Health Sciences, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., A.G.R., C.D.A.W.); King's College London Stroke Research Patients and Family Group, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., N.P., A.G.R.); National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK (C.M., A.G.R, C.D.A.W.); National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, London, UK (C.D.A.W.); Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK (A.G.R.); and Stroke & Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford, UK (P.J.T.)
| | - Simon J Turner
- From the Department of Applied Health Research, University College London, London, UK (A.I.G.R, S.M., S.J.T., N.J.F.); Clinical Standards Department, Royal College of Physicians, London, UK (A.H., A.G.R.); Research Department of Primary Care & Population Health, University College London, Royal Free Campus, London, UK (R.M.H.); Manchester Business School, University of Manchester, Manchester, UK (R.B., C.P.); Department of Primary Care and Public Health Sciences, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., A.G.R., C.D.A.W.); King's College London Stroke Research Patients and Family Group, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., N.P., A.G.R.); National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK (C.M., A.G.R, C.D.A.W.); National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, London, UK (C.D.A.W.); Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK (A.G.R.); and Stroke & Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford, UK (P.J.T.)
| | - Pippa J Tyrrell
- From the Department of Applied Health Research, University College London, London, UK (A.I.G.R, S.M., S.J.T., N.J.F.); Clinical Standards Department, Royal College of Physicians, London, UK (A.H., A.G.R.); Research Department of Primary Care & Population Health, University College London, Royal Free Campus, London, UK (R.M.H.); Manchester Business School, University of Manchester, Manchester, UK (R.B., C.P.); Department of Primary Care and Public Health Sciences, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., A.G.R., C.D.A.W.); King's College London Stroke Research Patients and Family Group, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., N.P., A.G.R.); National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK (C.M., A.G.R, C.D.A.W.); National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, London, UK (C.D.A.W.); Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK (A.G.R.); and Stroke & Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford, UK (P.J.T.)
| | - Charles D A Wolfe
- From the Department of Applied Health Research, University College London, London, UK (A.I.G.R, S.M., S.J.T., N.J.F.); Clinical Standards Department, Royal College of Physicians, London, UK (A.H., A.G.R.); Research Department of Primary Care & Population Health, University College London, Royal Free Campus, London, UK (R.M.H.); Manchester Business School, University of Manchester, Manchester, UK (R.B., C.P.); Department of Primary Care and Public Health Sciences, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., A.G.R., C.D.A.W.); King's College London Stroke Research Patients and Family Group, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., N.P., A.G.R.); National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK (C.M., A.G.R, C.D.A.W.); National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, London, UK (C.D.A.W.); Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK (A.G.R.); and Stroke & Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford, UK (P.J.T.)
| | - Naomi J Fulop
- From the Department of Applied Health Research, University College London, London, UK (A.I.G.R, S.M., S.J.T., N.J.F.); Clinical Standards Department, Royal College of Physicians, London, UK (A.H., A.G.R.); Research Department of Primary Care & Population Health, University College London, Royal Free Campus, London, UK (R.M.H.); Manchester Business School, University of Manchester, Manchester, UK (R.B., C.P.); Department of Primary Care and Public Health Sciences, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., A.G.R., C.D.A.W.); King's College London Stroke Research Patients and Family Group, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK (C.M., N.P., A.G.R.); National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK (C.M., A.G.R, C.D.A.W.); National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, London, UK (C.D.A.W.); Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK (A.G.R.); and Stroke & Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford, UK (P.J.T.)
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Baldereschi M, Di Carlo A, Vaccaro C, Toni D, Polizzi B, Inzitari D. Stroke units in Italy: engaging the public in optimizing existing resources. Eur J Neurol 2014; 21:791-6. [PMID: 24602205 DOI: 10.1111/ene.12395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 01/28/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE The lack of a wide implementation of stroke units (SU)s in Italy appears to accompany the underuse of the operating units. Community awareness of acute stroke care options may affect stroke resource use. Our aim was to determine the level of knowledge about SUs and tissue-plasminogen activator (t-PA) treatment amongst Italian adults and investigate its relationship to local stroke services implementation. METHODS A nation-based telephone survey was carried out in a sample of 1000 residents aged >18 years in May-June 2010. The questionnaire included close-ended questions regarding knowledge of SUs and t-PA treatment. Number and location of both SUs and t-PA treatments were provided by a concurrent national hospital-based survey. The prevalence and distribution of acute stroke care awareness in the community was examined and multivariate analyses were generated. RESULTS Amongst the 1000 participants (474 men, mean age 48.8 ± 17.2), only 26.2% reported knowing about the availability of t-PA treatment and only 15% were aware of the existence of SUs. Awareness of both SUs and t-PA was significantly associated only with education. These associations remained significant in the multivariate analyses. The degree of stroke services implementation (in terms of SUs/inhabitant rates and number of t-PA treatments) was not associated with SU and t-PA awareness. CONCLUSIONS This is the first European study that explored public knowledge about t-PA treatment and SUs. Italian adults proved insufficiently educated about SUs and t-PA; there is no higher awareness in areas with a greater supply of stroke services. This might partially explain the underuse of Italian SUs.
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Affiliation(s)
- M Baldereschi
- Italian National Research Council, Institute of Neuroscience, Florence, Italy
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19
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Abstract
Stroke represents the leading cause of acquired disability in adults and poses a tremendous socioeconomic burden both on patients and the society. In this sense, prompt diagnosis and urgent treatment are needed in order to radically reduce the devastating consequences of this disease. Herein the authors present the new guidelines recently adopted by the Swiss Stroke Society concerning the establishment of stroke units. Standardized treatment and allocation protocols along with an acute rehabilitation concept seem to be the core of the Swiss stroke management system. Coordinated multidisciplinary care provided by specialized medical, nursing and therapy staff is of utmost importance for achieving a significant dependency and death reduction. It is believed that the implementation of these guidelines in the stroke care system would be beneficial not only for the stroke patients, but also for the health system.
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Affiliation(s)
- Georgios K Matis
- Department of Neurosurgery, Democritus University of Thrace Medical School, Alexandroupolis, Greece
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20
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Cadilhac DA, Purvis T, Kilkenny MF, Longworth M, Mohr K, Pollack M, Levi CR. Evaluation of rural stroke services: does implementation of coordinators and pathways improve care in rural hospitals? Stroke 2013; 44:2848-53. [PMID: 23950561 DOI: 10.1161/strokeaha.113.001258] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The quality of hospital care for stroke varies, particularly in rural areas. In 2007, funding to improve stroke care became available as part of the Rural Stroke Project (RSP) in New South Wales (Australia). The RSP included the employment of clinical coordinators to establish stroke units or pathways and protocols, and more clinical staff. We aimed to describe the effectiveness of RSP in improving stroke care and patient outcomes. METHODS A historical control cohort design was used. Clinical practice and outcomes at 8 hospitals were compared using 2 medical record reviews of 100 consecutive ischemic or intracerebral hemorrhage patients ≥12 months before RSP and 3 to 6 months after RSP was implemented. Descriptive statistics and multivariable analyses of patient outcomes are presented. RESULTS SAMPLE pre-RSP n=750; mean age 74 (SD, 13) years; women 50% and post-RSP n=730; mean age 74 (SD, 13) years; women 46%. Many improvements in stroke care were found after RSP: access to stroke units (pre 0%; post 58%, P<0.001); use of aspirin within 24 hours of ischemic stroke (pre 59%; post 71%, P<0.001); use of care plans (pre 15%; post 63%, P<0.001); and allied health assessments within 48 hours (pre 65%; post 82% P<0.001). After implementation of the RSP, patients directly admitted to an RSP hospital were 89% more likely to be discharged home (adjusted odds ratio, 1.89; 95% confidence interval, 1.34-2.66). CONCLUSIONS Investment in clinical coordinators who implemented organizational change, together with increased clinician resources, effectively improved stroke care in rural hospitals, resulting in more patients being discharged home.
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Affiliation(s)
- Dominique A Cadilhac
- From the Translational Public Health Unit, Stroke and Ageing Research Centre, Department of Medicine, Southern Clinical School, Monash University, Clayton, Australia (D.A.C., T.P., M.K.); Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia (D.A.C., T.P., M.K.); Stroke Services New South Wales, New South Wales Agency for Clinical Innovation, New South Wales, Australia (M.L.); Wagga Wagga Base Hospital, Wagga Wagga, New South Wales, Australia (K.M.); Hunter Stroke Service, Hunter New England Area Health, Rankin Park Centre, New South Wales, Australia (M.P.); Centre for Brain and Mental Health Research, University of Newcastle and Hunter Medical Research Institute, New Lambton, New South Wales, Australia (C.L.); and John Hunter Hospital, Newcastle, New South Wales, Australia (C.L.)
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21
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Andrew N, Kilkenny M, Harris D, Price C, Cadilhac DA. Outcomes for people with atrial fibrillation in an Australian national audit of stroke care. Int J Stroke 2013; 9:270-7. [PMID: 23834233 DOI: 10.1111/ijs.12087] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 11/26/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Atrial fibrillation is associated with poorer outcomes poststroke. It is unclear how the quality of stroke care in hospitals influences outcomes in these patients. AIMS The study aims to compare outcomes in stroke patients with and without atrial fibrillation and identify hospital processes of care associated with poor outcomes. METHODS Data were collected using retrospective, consecutive medical record audits from participating hospitals in the 2009 and 2011 National Stroke Foundation acute services audit program. Patient characteristics, stroke severity, and hospital management data were compared for those with and without atrial fibrillation. Multiple regression analyses for outcomes of in-hospital death, dependency at discharge (modified Rankin Score 3-5), and discharge destination were undertaken, adjusted for patient clustering by hospital. RESULTS Atrial fibrillation status was known for 5473 (80%) cases; 2049 had atrial fibrillation. Atrial fibrillation was independently associated with in-hospital mortality (aOR 1.46, 95% CI 1.06, 2.02). Management on a stroke unit (aOR 0.57, 95% CI 0.40, 0.80) and having a swallow assessment within 24 h (aOR 0.71, 95% CI 0.51, 0.98) were associated with increased survival among all stroke types, as was receiving aspirin within 48 h poststroke (aOR 0.65, 95% CI 0.44, 0.97), for patients with an ischemic stroke. Stroke patients with atrial fibrillation were less likely to receive important processes of care associated with reduced mortality. CONCLUSIONS Hospital processes of care can influence outcomes in stroke patients with atrial fibrillation. The greater in-hospital mortality experienced by stroke patients with atrial fibrillation may be attenuated by admission to a stroke unit, and for ischemic stroke, early administration of aspirin.
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Affiliation(s)
- Nadine Andrew
- Translational Public Health Unit, Stroke & Ageing Research Centre, Department of Medicine, Monash Medical Centre, Southern Clinical School, Monash University, Clayton, Victoria, Australia
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22
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Abstract
PURPOSE Continuous cardiac monitoring in a stroke unit (SU) may improve detection of atrial fibrillation (AF), and SU care may improve the rate of anticoagulation by better adherence to a standardized treatment protocol in patients with AF. We investigated the effects of the SU on the detection of AF and the rate of warfarin therapy in patients with AF. MATERIALS AND METHODS Acute stroke patients who had been admitted before or after the opening of the SU were included in our study. SU patients were monitored continuously with electrocardiography. Rates of AF and warfarin therapy were compared between patients admitted to the SU (SU group) and those admitted to the general ward (GW) prior to the opening of the SU (GW group). RESULTS Total 951 patients had been admitted to the GW prior to the opening of the SU (from January 2000 to November 2002), and 2349 patients to the SU (from January 2003 to December 2008). AF was found in 149 patients (15.7%) in the GW group and in 487 (20.7%) in the SU group. Most of AF detected during admission was paroxysmal AF (84.8%). The frequency of newly detected AF was higher in the SU group than the GW group (2.5% vs. 0.7%, p=0.001). The rate of anticoagulation consideration was also higher in the SU group. CONCLUSION SU care improved the detection of AF and the rate of anticoagulation consideration in acute stroke patients. Our findings support the benefits of continuous cardiac monitoring in the SU for stroke patients.
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Affiliation(s)
- Hye-Yeon Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Department of Neurology, Kyung Hee University College of Medicine, Kangdong Hospital, Seoul, Korea
| | - Joo Hyun Seo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hoon Yang
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Yo Han Jung
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Han Jin Cho
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
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23
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Abstract
Objectives A number of evidence-based interventions are now available for stroke patients. Good quality stroke care involves a range of health professionals located across ambulance, hospital, community and primary care services. This study examined the perspectives of healthcare workers involved in stroke care in two different English case study sites on the integration challenges stroke care presents. Methods Two qualitative case studies were carried out, including 45 semi-structured interviews with clinicians and managers associated with two different hospitals providing specialised stroke services. Findings High levels of organisational, functional, service and clinical integration amongst clinicians that deliver emergency and acute stroke care were identified. This is frequently lacking amongst professionals delivering post-acute care. These findings are linked to the prevalence or lack of normative and systemic integration in each respective stage of care. Conclusions Emphasis on the need to treat stroke as an emergency condition in England over recent years has created a context in which normative and systemic integration often occurs amongst clinicians that deliver emergency and acute stroke care, aiding the development of organisational, functional, service and clinical integration across the case study sites. In contrast, integration between hospital and community (rehabilitation and general practice) care is frequently less successful.
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24
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Maiga Y, Albakaye M, Diango D, Kanikomo D, Seybou H, Minta I, Diakité S, Traoré HA, Guillon B. [Modalities of stroke management in Mali (West Africa): a survey of practices]. Mali Med 2013; 28:30-35. [PMID: 29925218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
UNLABELLED The upsurge and the impact of stroke in terms of mortality and morbidity in Africa are well documented. But their current stroke management modalities remain to be evaluated. METHODS This study investigated the modalities of healthcare practitioners working in structures involved in stroke management in seven of the eight regions and the capital city of Bamako. A questionnaire was sent out to all potential participants identified in the designated areas, whereas the relevant medical personnel were systematically enrolled to take part. 149 practitioners (90%) including 68 general practitioners, 12 specialists, and 69 residents responded to the questionnaire. Six CT-scan, 15 echocardiographs, and 21 electrocardiographs were available. The team directly involved in patient management included six neurologists, seventeen cardiologists, six neurosurgeons, 86 physical therapists, three orthophonists, and two ergotherapists. Hemiplegia was the revealing symptom of stroke in 61.1% of cases. Almost all infrastructures and the personnel are located in a geographic area representing less than 10% of the country, where only 14 % of the population live. These findings emphasize the lack and unequal distribution of resources allocated to stroke management. CONCLUSION Problems related to stroke in Mali need a re-organization of patient management networks. An initial and continued training of health practitioners should be implemented.
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Affiliation(s)
- Youssoufa Maiga
- Service de Neurologie, CHU Gabriel Touré BP 267, Bamako, MALI
| | | | - Djibo Diango
- Service d'Anesthésie Réanimation, CHU Gabriel Touré BP 267, Bamako, MALI
| | - Drissa Kanikomo
- Service de Neurochirurgie, CHU Gabriel Touré BP 267, Bamako, MALI
| | - Hassane Seybou
- Service de Neurologie, CHU Gabriel Touré BP 267, Bamako, MALI
| | - Issiaka Minta
- Service de Cardiologie, CHU Gabriel Touré BP 267, Bamako, MALI
| | - Sara Diakité
- Service de Neurologie, CHU Gabriel Touré BP 267, Bamako, MALI
| | | | - Benoit Guillon
- Clinique neurologique, Unité de Neuro-vasculaire, CHU Nantes, Hôpital Laennec, bd Jacques-Monod, saint- Herblain, 44093 Nantes cedex 1, France
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25
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Abstract
Little research has been performed to determine how a stroke unit should be staffed and what the links are between patient dependency and staffing. For this study, 140 stroke units were randomly selected--35 from each of the four quartiles of performance in the National Sentinel Audit of Stroke. A questionnaire was sent to each of the units to collect data on patient numbers and dependency, staffing numbers and therapy, and nursing contact times on a single weekday. The response rate was 66% (92 sites) and information on 1,398 patients was provided. The median number of beds was 18 (interquartile range 12-24). Staffing levels per 10 beds were a median of 10.9 nurses, 1.7 physiotherapists, 1.3 occupational therapists and 0.4 speech and language therapists. Of the patients, 74% received physiotherapy, 46% occupational therapy and 25% speech and language therapy during the day with median contact times being 170 minutes for nursing, 40 minutes for physiotherapy, 45 minutes for occupational therapy and 30 minutes for speech therapy. There was a weak correlation between patient dependency and contact time with nurses and therapists. Stroke patients in England receive relatively little rehabilitation from therapists and there is a wide variation in the amount of nursing time each patient receives.
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Affiliation(s)
- Anthony G Rudd
- Clinical Standards Department, Royal College of Physicians, London.
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