Ten Years of Improving Acute Stroke Management in a Metropolitan Area: A Population-Based Quantification of Quality Indicators

BACKGROUND AND PURPOSE

Rapid access to acute stroke treatment improves clinical outcomes in patients with ischemic stroke. We aimed to shorten the time to admission and to acute stroke treatment for patients with acute stroke in the Hamburg metropolitan area by collaborative multilevel measures involving all hospitals with stroke units, the Emergency Medical Services (EMS), and health-care authorities.

METHODS

In 2007, an area-wide stroke care quality project was initiated. The project included mandatory admission of all stroke patients in Hamburg exclusively to hospitals with stroke units, harmonized acute treatment algorithms among all hospitals, repeated training of the EMS staff, a multimedia educational campaign, and a mandatory stroke care quality monitoring system based on structured data assessment and quality indicators for procedural measures. We analyzed data of all patients with acute stroke who received inhospital treatment in the city of Hamburg during the evaluation period from the quality assurance database data and evaluated trends of key quality indicators over time.

RESULTS

From 2007 to 2016, a total of 83,395 patients with acute stroke were registered. During this period, the proportion of patients admitted within ≤3 h from symptom onset increased over time from 27.8% in 2007 to 35.2% in 2016 (p < 0.001). The proportion of patients who received rapid thrombolysis (within ≤30 min after admission) increased from 7.7 to 54.1% (p < 0.001).

CONCLUSIONS

Collaborative stroke care quality projects are suitable and effective to improve acute stroke care.

Association Between Adherence to Quality Indicators and 7-Day In-Hospital Mortality After Acute Ischemic Stroke

Background and Purpose:

Quality indicators (QI) are an accepted tool to measure performance of hospitals in routine care. We investigated the association between quality of acute stroke care defined by overall adherence to evidence-based QI and early outcome in German acute care hospitals.

Methods:

Patients with ischemic stroke admitted to one of the hospitals cooperating within the ADSR (German Stroke Register Study Group) were analyzed. The ADSR is a voluntary network of 9 regional stroke registers monitoring quality of acute stroke care across 736 hospitals in Germany. Quality of stroke care was defined by adherence to 11 evidence-based indicators of early processes of stroke care. The correlation between overall adherence to QI with outcome was investigated by assessing the association between 7-day in-hospital mortality with the proportion of QI fulfilled from the total number of QI the individual patient was eligible for. Generalized linear mixed model analysis was performed adjusted for the variables age, sex, National Institutes of Health Stroke Scale and living will and as random effect for the variable hospital.

Results:

Between 2015 and 2016, 388 012 patients with ischemic stroke were reported (median age 76 years, 52.4% male). Adherence to distinct QI ranged between 41.0% (thrombolysis in eligible patients) and 95.2% (early physiotherapy). Seven-day in-hospital mortality was 3.4%. The overall proportion of QI fulfilled was median 90% (interquartile range, 75%–100%). In multivariable analysis, a linear association between overall adherence to QI and 7-day in-hospital-mortality was observed (odds ratio adherence <50% versus 100%, 12.7 [95% CI, 11.8–13.7]; P <0.001).

Conclusions:

Higher quality of care measured by adherence to a set of evidence-based process QI for the early phase of stroke treatment was associated with lower in-hospital mortality.

Unterschiede im Verlauf der neurologischen Frührehabilitation bei Patienten nach Hirninfarkt, intrazerebraler Blutung und nicht-traumatischer Subarachnoidalblutung

Patienten mit schweren neurologischen Krankheitsbildern werden nach Abschluss der Akutbehandlung in einer neurologisch-neurochirurgischen Frührehabilitation der Phase B behandelt. Über die Hälfte dieser Patienten hat einen Schlaganfall. In dieser Arbeit erfolgt eine Beschreibung des rehabilitativen Verlaufes von Patienten, differenziert nach dem jeweils vorliegenden Schlaganfallsubtyp Hirninfarkt, intrazerebrale Blutung oder nicht-traumatische Subarachnoidalblutung.

Mit dem Erhebungsinstrument der Hamburger Asklepios Kliniken für die Schlaganfallfrührehabilitation wurde zwischen 07/12 und 12/16 der frührehabilitative Verlauf sowie der Aufnahme- und Entlassungsstatus von insgesamt 1327 Schlaganfallpatienten mit Hirninfarkt (921 Patienten), intrazerebraler Blutung (324 Patienten) und nicht-traumatischer Subarachnoidalblutung (82 Patienten) dokumentiert. Es erfolgte eine deskriptive und analytische Auswertung der Daten.

Es zeigte sich ein positiver Effekt der Frührehabilitation auf die Erholung aller Schlaganfallsubtypen mit einer Verbesserung des Frühreha-Barthel-Index, einer Reduktion der vorhandenen Kathetersysteme und der Verlegung der Mehrheit der Patienten in eine weiterführende Rehabilitationseinrichtung. Auch veranschaulichten die Daten den teilweise komplexen Verlauf der Frührehabilitation, hervorgerufen durch häufige medizinische Komplikationen, den hohen Anteil an Begleiterkrankungen und der großen Anzahl an Kathetersystemen bei Aufnahme als Hinweis auf Störung verschiedener Organfunktionen. Die einzelnen Schlaganfallsubtypen unterschieden sich wesentlich in den Patientencharakteristika (Alter, Geschlechtsverteilung) und im rehabilitativen Verlauf (Latenz bis zum Einschluss in die Phase B, Dauer der rehabilitativen Behandlung, Frühreha-Barthel-Index bei Aufnahme, Häufigkeit von bestimmten Kathetersystemen, Begleiterkrankungen und Komplikationen). Aufgrund dieser Unterschiede im rehabilitativen Verlauf sollte eine Betrachtung von Daten aus der neurologisch-neurochirurgischen Frührehabilitation differenziert nach dem jeweiligen Schlaganfallsubtyp erfolgen.

Sonothrombolysis is effective with recombinant tissue-type plasminogen activator, but not with Abciximab

Transcranial “diagnostic” ultrasound (US) has been shown to accelerate thrombolysis related to recombinant tissue-type plasminogen activator (rt-PA). In this in vitro study, we evaluated the potential of US to increase clot dissolution mediated by Abciximab (Abc) compared to rt-PA. The effect of 1.8-MHz pulsed wave (PW) Doppler US on dissolution of whole venous blood clots (WBC) and platelet-rich clots (PRC) treated with Abc and rt-PA was investigated in an in vitro model. Clot dissolution was measured by weight loss. Abc-related WBC dissolution was enhanced by additional US, but the effect was not any more detectable when the US was attenuated by a human temporal bone (US-tb). In PRC there was no additional effect of US on the Abc-related clot lysis. Rt-PA-related clot dissolution was increased by US in WBC and PRC as well, however, US-tb was only effective in WBC. The effect of insonation on WBC dissolution treated with the combination of Abc plus rt-PA was lower compared with those treated with rt-PA. In this in vitro experiment, the additional effect of “diagnostic” US in combination with Abc was only present in WBC and less strong than with rt-PA. The results do not support the use of Abc for sonothrombolysis targeting both, fibrin-rich and platelet-rich clots. In contrast, US when combined with rt-PA increases dissolution in both, WBC and PRC as well.

Stroke unit care in germany: the german stroke registers study group (ADSR)

BACKGROUND

Factors influencing access to stroke unit (SU) care and data on quality of SU care in Germany are scarce. We investigated characteristics of patients directly admitted to a SU as well as patient-related and structural factors influencing adherence to predefined indicators of quality of acute stroke care across hospitals providing SU care.

METHODS

Data were derived from the German Stroke Registers Study Group (ADSR), a voluntary network of 9 regional registers for monitoring quality of acute stroke care in Germany. Multivariable logistic regression analyses were performed to investigate characteristics influencing direct admission to SU. Generalized Linear Mixed Models (GLMM) were used to estimate the influence of structural hospital characteristics (percentage of patients admitted to SU, year of SU-certification, and number of stroke and TIA patients treated per year) on adherence to predefined quality indicators.

RESULTS

In 2012 180,887 patients were treated in 255 hospitals providing certified SU care participating within the ADSR were included in the analysis; of those 82.4% were directly admitted to a SU. Ischemic stroke patients without disturbances of consciousness (p < .0001), an interval onset to admission time ≤3 h (p < .0001), and weekend admission (p < .0001) were more likely to be directly admitted to a SU. A higher proportion of quality indicators within predefined target ranges were achieved in hospitals with a higher proportion of SU admission (p = 0.0002). Quality of stroke care could be maintained even if certification was several years ago.

CONCLUSIONS

Differences in demographical and clinical characteristics regarding the probability of SU admission were observed. The influence of structural characteristics on adherence to evidence-based quality indicators was low.

The quality of acute stroke care- an analysis of evidence-based indicators in 260 000 patients

BACKGROUND

Stroke patients should be cared for in accordance with evidence-based guidelines. The extent of implementation of guidelines for the acute care of stroke patients in Germany has been unclear to date.

METHODS

The regional quality assurance projects that cooperate in the framework of the German Stroke Registers Study Group (Arbeitsgemeinschaft Deutscher Schlaganfall-Register, ADSR) collected data on the care of stroke patients in 627 hospitals in 2012. The quality of the acute hospital care of patients with stroke or transient ischemic attack (TIA) was assessed on the basis of 15 standardized, evidence-based quality indicators and compared across the nine participating regional quality assurance projects.

RESULTS

Data were obtained on more than 260 000 patients nationwide. Intravenous thrombolysis was performed in 59.7% of eligible ischemic stroke patients patients (range among participating projects, 49.7-63.6%). Dysphagia screening was documented in 86.2% (range, 74.8-93.1%). For the following indicators, the defined targets were not reached for all of Germany: anti-aggregation within 48 hours, 93.4% (range, 86.6-96.4%); anticoagulation for atrial fibrillation, 77.6% (range, 72.4-80.1%); standardized dysphagia screening, 86.2% (range, 74.8-93.1%); oral and written information of the patients or their relatives, 86.1% (range, 75.4-91.5%). The rate of patients examined or treated by a speech therapist was in the target range.

CONCLUSION

The defined targets were reached for most of the quality indicators. Some indicators, however, varied widely across regional quality assurance projects. This implies that the standardization of care for stroke patients in Germany has not yet been fully achieved.

Ein tricyclisches Tetraboradisiladodecan aus Dimethyl-di-1-propinylsilan und Ethyldiboranen(6) / A Tricyclic Tetraboradisiladodecane from Dimethyl-di-1-propynylsilane and Ethyldiboranes(6)

The exhaustive hydroboration of the (C ≡ C )-groups in Me2Si(C ≡ CMe)2 (A ) by adding ethyldiboranes(6) at room temperature is presumed to lead initially to the formation of a mixture of the threo- and erythro-3,3,5,6-tetrakis(diethylboryl)-4,4-dimethyl-4-silaheptanes (1a , b). The threo-1a reacts further by borane catalysed intermolecular condensation to the substituted disilatetraboratricyclo[6.2.1.16.9]dodecane 2 with the formula , whose crystal structure [space group C2/c, a = 19.696(2), b = 10.371(1), c = 16.580(2) Å; β = 125.90(1)°; at 122 K] has been established by X -ray diffraction. In contrast, the erythro-1b undergoes intramolecular, thermal elimination of Et3B to give the 1,2-diethyl-2,4-bis(diethylboryl)- 3,3,5-trim ethyl-3-silaborolane (4). If A is added to an excess of undiluted B (“hydridebath”), then the two substituted diastereomers of the 1-carba-arachno-pentaboranes(10) (endo/exo-Et,SiH Me2) (3a, b), are formed preferentially as the result of an initial Si-C ≡-c le a v e d hydroboration.

Organosubstituierte 1,6,2,5-Azoniathiasilaboratabicyclo[3.3.0]oct-3-ene - Herstellung und Kristallstruktur / Organosubstituted 1,6,2,5-A zoniathiasilaboratabicyclo[3.3.0]oct-3-enes - Preparation and Crystal Structure

The heterocycles Et [R3 = Me: A; R3 = C(Me)=CH2: B] react with 2-aminoethanethiol (1) by elimination of MeNH2 to give the monocyclic [R = Me: 3a; R = C(Me)=CH2: 3b] and the thermically more stable bicyclic compounds [R = Me: 4a; R = C(Me)=CH2: 4b], 4a crystallizes in the monoclinic space group P21/c [lattice constants (at 120 K) a = 9.3239(10), b = 8.9225(11), c = 17.3958(23) Å; β = 92.207(9)°] with a folded bicyclic ring system. cis-ClB(Et)C=C(Me)Si(Me2)Cl (C) and Na2-1BEt3 (prepared from 1 and NaHBEt3) form by elimination of MeNH2 preferentially 3a and minor amounts of 4a. A reacts with o-aminothiophenol (2) via (5) to (6) and the products 7-10.

Borverbindungen, LXXXI. Neue Organobor-Sulfide — Herstellung und Anwendung / Boron Compounds, LXXXI. New Organoboron Sulfides — Preparation and Uses

Bis(9-borabicyclo[3.3.1]nonane) reacts with sulfur to give the bis(1,5-cyclooctanediylboryl)- monosulfide (1) in high yield. The (9-BBN)2 disulfide 2 is easily prepared from 1 with sulfur. 2, which can also be obtained from 9-Iodo-9-BBN with sulfur, reacts with (9-BBN)2 to form 1.1 is an excellent sulfidation reagent for preparing thio compounds by S/O-exchange.

Dimere 9-Hydrochalkogeno-9-BBN-Verbindungen - Bildung und Kristallstruktur [1] / Dimeric Hydrochalcogeno-9-BBN Compounds - Formation and Crystal Structure [1]

The trans-dimer of (9-HS-9-BBN)2 (1)2, obtained from H2S with (9H-9-BBN)2 or with (9-BBN)2S, crystallizes in the monoclinic space group C2/m [lattice constants (at 120 K): a = 15.279(2), b = 15.909(3), c = 6.822(4) Å; β = 91.05(4)°] with a planar B2S2ring. The cis-dimer of (9-HSe-9-BBN)2 (2)2, obtained from (9-BBN)2Se with aniline, crystallizes in the monoclinic space group P21/n [lattice constants (at 225 K): a = 6.892(1), b= 20.623(3), c = 12.226(2) Å; β = 97.28°] with an folded B2Se2ring.

Notizen: Tricarbonyliron Complexes - Observation of 13C(CO) NMR Signals via Polarization Transfer

Improvements in the detection of 13C(CO) resonances by using polarization transfer techniques, based on long-range coupling constants nJ(13C(CO)1H) = 1 ±0.1 Hz (n > 3), are reported. Coupling constants between 13C(CO) and other rare spin-1/2 nuclei have been observed, and longrange 13C(CO)-1H coupling have been traced by two-dimensional (2D ) 13C/1H heteronuclear shift correlations (HETCOR). Seven tricarbonyliron complexes 1 to 5 serve as examples in which the [Fe(CO)3] fragment is linked to cyclic dienes (siloles: 1a, b; 1,1′-spirobisilole: 2), and to cyclic heterodienes derived from substituted 2,5-dihydro- 2,5-silaboroles [1-aza (3a, b); 1-thia (4); 1-selena (5)]. In the case of complex 5, it was possible to resolve the 77Se satellites with 2J( 77Se13C(CO )) = 4.4 Hz. In 2D 13C (CO )/1H HETCOR experiments it was shown that polarization transfer originates mainly from C-methyl groups [4J( 13C(CO)/1H (M ))], adjacent to the “terminal” carbon atom(s) of the cyclic diene or heterodiene system which are linked to the [Fe(CO)3] fragment.

Das THF-9-Natriumoxy-9-borabicyclo[3.3.1]nonan-Tetramer [1] / The THF-9-Sodiooxy-9-borabicyclo[3.3.1]nonane Tetramer [1]

The thermolysis of Na[C8H14B(Et)OH] (2), prepared from 9-Et-9-BBN (1) and NaOH, leads at about 100 °C in the presence of NaHBEt3 as catalyst to ethane and the solid NaOBC8H14 (3), which crystallizes with one mole THF as the tetrameric heterocubane 4 in the triclinic space group P1̄. The lattice constants of 4 (at 120 K) are: a = 1127.7(2), b = 1179.5(2), c = 2055.9(4) pm; α = 87.06(2), β = 87.83(2), γ = 75.37(2)°. 4 contains a slightly distorted central Na4O4 cube with C8H14B and THF substituents at the oxygen and the sodium atoms respectively. 3 can also be prepared by heating an equimolar mixture of Na[H2BC8H14] (5) and Na[(HO)2BC8H14] (6), or from (9H-9-BBN)2 and NaOH and from 9-HO-9-BBN and NaH in THF.

Structure of a reactive gold carbenoid

A formal gold-for-chromium transmetalation allowed the gold carbenoid species [Cy3 PAuCAr2 ]NTf2 (11) (Ar=pMeOC6 H4 -) to be obtained in crystalline form. The structure in the solid state suggests that there is only little back donation of electron density from gold to the carbene center of 11 and hence very modest AuC double-bond character; rather, it is the organic ligand framework that is responsible for stabilizing this species by resonance delocalization of the accumulated positive charge. Because 11 is capable of cyclopropanating p-methoxystyrene even at low temperature, the discussion of its structure is deemed relevant for a better understanding of the mechanisms of π-acid catalysis in general.

[Leaflets and websites on colorectal cancer screening and their quality assessment from experts' views]

In Germany, individuals who have statutory health insurance have free access to colorectal cancer (CRC) screening tests, and can choose between a fecal occult blood test and a screening colonoscopy. Evidence-based health information may support informed choices regarding whether or not to undergo CRC screening. The aim of this study was to assess whether the available German information materials on CRC screening meet evidence-based health information standards. A systematic search was made for print media and websites on CRC screening addressed to German people with average CRC risk (search period for print media August 2010, for websites January-March 2012). The identified information was assessed with a newly developed comprehensive list of criteria. In all, 41 print media, including 28 flyers and 13 brochures, and 36 websites were identified and assessed. These materials reported more often the benefits than the risks of CRC screening, and quantified presentations of benefits and risks were less frequently given. Most of the materials called for participation and did not indicate the option to decide whether or not to attend CRC screening. This bias in favor of screening was increased by fear-provoking or downplayed wording. Most materials included false and misleading information. The requirements for evidence-based patient information were currently not met by most of the leaflets and websites in Germany. Feedback was given to the producers of the leaflets including a discussion of the findings. The results may be used to revise existing leaflets or to develop new health information on CRC screening.

[Secondary prophylaxis of stroke from a neurological perspective]

Patients who have suffered ischemic stroke or transient ischemic attack (TIA) are at high risk of recurrent stroke, myocardial infarction or vascular death. Early pathophysiological based diagnostics and resulting secondary prevention are critical for reduction of stroke risk. Optimization of lifestyle factors, treatment of hypertension, cholesterol reduction with statins and use of antiplatelet agents in non-cardiogenic or anticoagulation in cardiogenic ischemia as well as internal carotid revascularization, in cases of more than 50% diameter stenosis of the internal carotid artery, are proven strategies for reduction of ischemic stroke risk.

Microvascular imaging in acute ischemic stroke

BACKGROUND

Microvascular imaging (MVI), a new ultrasound technology, is used to analyze brain perfusion at the patient's bedside. This study aims to evaluate the diagnostic and prognostic value of MVI in patients with acute ischemic stroke (AIS).

METHODS

Nineteen patients suffering from AIS (mean age, 70.9 ± 12.2 years; 47% female; mean NIHSS-score, 12 ± 8) were investigated within the first 12 hours after symptom onset. We used the iU22 (Philips) system (S5-1 probe; low-mechanical index; depth, 13 cm), and 2 bolus injections of an ultrasound contrast agent (2.4 mL SonoVue per injection). The area of maximal perfusion deficit (AMPD) was compared with infarction on follow-up cranial computed tomography (CT) and NIHSS score 24 hours after stroke onset.

RESULTS

Of 19 patients, 15 patients (79%) had sufficient insonation conditions. Of these patients, 12 had infarctions. The sensitivity and specificity of detecting infarctions with ultrasound perfusion imaging were 91% and 67%, respectively. A significant correlation existed between the AMPD and NIHSS score at 24 hours after symptom onset (P= .023), and with occlusion of the internal carotid artery (P= .005).

CONCLUSION

Performing bedside MVI in the early phase of AIS provides information on brain parenchyma perfusion and prognosis of AIS.