Interaction between stroke severity and quality indicators of acute stroke care: a single-center retrospective analysis

Introduction: The COVID-19 pandemic resulted in significant healthcare reorganizations, potentially striking standard medical care. We investigated the impact of the COVID-19 pandemic on acute stroke care quality and clinical outcomes to detect healthcare system’s bottlenecks from a territorial point of view. Methods: Crossed-data analysis between a prospective nation-based mandatory registry of acute stroke, Emergency Medical System (EMS) records, and daily incidence of COVID-19 in Catalonia (Spain). We included all stroke code activations during the pandemic (March 15–May 2, 2020) and an immediate prepandemic period (January 26–March 14, 2020). Primary outcomes were stroke code activations and reperfusion therapies in both periods. Secondary outcomes included clinical characteristics, workflow metrics, differences across types of stroke centers, correlation analysis between weekly EMS alerts, COVID-19 cases, and workflow metrics, and impact on mortality and clinical outcome at 90 days. Results: Stroke code activations decreased by 22% and reperfusion therapies dropped by 29% during the pandemic period, with no differences in age, stroke severity, or large vessel occlusion. Calls to EMS were handled 42 min later, and time from onset to hospital arrival increased by 53 min, with significant correlations between weekly COVID-19 cases and more EMS calls (rho = 0.81), less stroke code activations (rho = −0.37), and longer prehospital delays (rho = 0.25). Telestroke centers were afflicted with higher reductions in stroke code activations, reperfusion treatments, referrals to endovascular centers, and increased delays to thrombolytics. The independent odds of death increased (OR 1.6 [1.05–2.4], p 0.03) and good functional outcome decreased (mRS ≤2 at 90 days: OR 0.6 [0.4–0.9], p 0.015) during the pandemic period. Conclusion: During the COVID-19 pandemic, Catalonia’s stroke system’s weakest points were the delay to EMS alert and a decline of stroke code activations, reperfusion treatments, and interhospital transfers, mostly at local centers. Patients suffering an acute stroke during the pandemic period had higher odds of poor functional outcome and death. The complete stroke care system’s analysis is crucial to allocate resources appropriately.

Download Full-text

Abstract P855: Importance of Compliance in Dysphagia Screening in Acute Stroke Care

Stroke ◽

10.1161/str.52.suppl_1.p855 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Patty Noah ◽

Melanie Henderson ◽

Rebekah Heintz ◽

Russell Cerejo ◽

Christopher T Hackett ◽

...

Keyword(s):

Acute Stroke ◽

Aspiration Pneumonia ◽

Hemorrhagic Stroke ◽

Oral Intake ◽

Stroke Care ◽

Stroke Severity ◽

Stroke Patients ◽

Acute Stroke Care ◽

Chi Square ◽

Stroke Center

Introduction: Dysphagia occurs in up to two thirds of stroke patients and can lead to serious complications such as aspiration pneumonia, which is also linked to increased morbidity and mortality. Evidence-based guidelines recommend a bedside dysphagia assessment before oral intake in stroke patients regardless of initial stroke severity. Several studies have described registered nurses’ competency in terms of knowledge and skills regarding dysphagia screening. We aimed to examine the rate of aspiration pneumonia compared to the rate of dysphagia screening. Methods: A retrospective analysis of prospectively collected data at a single tertiary stroke center was carried out between January 2017 and June 2020. Data comparison was completed utilizing ICD-10 diagnosis codes to identify aspiration pneumonia in ischemic and hemorrhagic stroke patients. The data was reviewed to compare the compliance of a completed dysphagia screen prior to any oral intake to rate of aspiration pneumonia. Chi square tests were used to assess proportion differences in completed dysphagia screen and proportion of aspiration pneumonia diagnosis in the ischemic and hemorrhagic stroke patients. Results: We identified 3320 patient that met inclusion criteria. 67% were ischemic strokes, 22% were intracerebral hemorrhages and 11% were subarachnoid hemorrhages. Compliance with dysphagia screening decreased from 94.2% (n=1555/1650) in 2017-2018 to 74.0% (n=1236/1670) in 2019-2020, OR=0.17 (95%CI 0.14 - 0.22), p < 0.0001. Aspiration pneumonias increased from 58 (3.5%) in 2017-2018 to 77 (4.6%) in 2019-2020, but this difference was not statistically significant, OR=0.75 (95%CI 0.53 - 1.07), p = 0.11. Conclusion: We noted that the decrease in compliance with completing a dysphagia screen in patients with acute stroke prior to any oral intake was associated with a higher trend of aspiration pneumonia.

Download Full-text

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

European Neurology ◽

10.1159/000518428 ◽

2021 ◽

pp. 1-11

Author(s):

Anna Alegiani ◽

Michael Rosenkranz ◽

Leonie Schmitz ◽

Susanne Lezius ◽

Günter Seidel ◽

...

Keyword(s):

Acute Stroke ◽

Quality Indicators ◽

Metropolitan Area ◽

Stroke Care ◽

Care Quality ◽

Acute Stroke Care ◽

Stroke Units ◽

Stroke Treatment ◽

Acute Stroke Treatment ◽

Over Time

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.

Download Full-text

Abstract 352: Early Data From an Implementation Science Study Suggests the Need for Identification and Adoption of Best Practices to Improve the Timeliness of Stroke Treatment

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/hcq.13.suppl_1.352 ◽

2020 ◽

Vol 13 (Suppl_1) ◽

Author(s):

Lisa M Monk

Keyword(s):

Best Practices ◽

Acute Stroke ◽

Care Delivery ◽

Stroke Care ◽

Early Data ◽

Screening Tools ◽

Stroke Severity ◽

Ct Scanner ◽

Acute Stroke Care ◽

Stroke Treatment

There is a disconnect from discovery of best treatment options and application into clinical practice in a timely manner. The I M plementation of best Pr actices f O r acute stroke care-de v eloping and optimizing regional systems of Stroke Care (IMPROVE Stroke Care) goal is to develop a regional integrated stroke system that identifies, classifies, and treats patients with acute ischemic stroke more rapidly and effectively with reperfusion therapy. These improvements in acute stroke care delivery are expected to result in lower mortality, fewer recurrent strokes, and improved long term functional outcomes. Recent discoveries in stroke care and advancement in technology extends the window for both TPA administration and mechanical thombectomy. The challenge of implementing these latest advances are difficult considering the ability of hospitals to implement the original American Heart Association (AHA) Systems of Stroke Care recommendations. Early data from this project shows that the challenges continue to exist in recommendations that have been in place as early as 2005. EMS is not utilizing pre-hospital stroke screening tools, only 5% of the time, stroke severity tools, only 7% of the time, lytic checklists, 0% of the time, destination decision changed due to severity score, 0% of the time, and pre-notifying emergency rooms, only 63% of the time. Emergency departments door to CT <45 minutes, only 55% of the time, Lytic given in CT scanner, only 35% of the time, Door to lytic therapy< 45 minutes, 77% of the time, Door to Groin puncture, 81% of the time, and Door to TICI Flow 2c/3 flow <90 minutes, 39% of the time. The Systems of Stroke Care have recommendations that will improve time to treatment and outcomes for patients. This project is working to provide tools, guidance, data, and feedback to improve application of these recommendations and identify best practices and solutions to barriers.

Download Full-text

Variations in Quality Indicators of Acute Stroke Care in 6 European Countries

Stroke ◽

10.1161/strokeaha.111.628396 ◽

2012 ◽

Vol 43 (2) ◽

pp. 458-463 ◽

Cited By ~ 26

Author(s):

Silke Wiedmann ◽

Bo Norrving ◽

Tim Nowe ◽

Sònia Abilleira ◽

Kjell Asplund ◽

...

Keyword(s):

Acute Stroke ◽

Quality Indicators ◽

Stroke Care ◽

European Countries ◽

Acute Stroke Care

Download Full-text

Critical factors determining access to acute stroke care

Neurology ◽

10.1212/wnl.51.2.427 ◽

1998 ◽

Vol 51 (2) ◽

pp. 427-432 ◽

Cited By ~ 116

Author(s):

Sindhu C. Menon ◽

Dilip K. Pandey ◽

Lewis B. Morgenstern

Keyword(s):

Access To Care ◽

Acute Stroke ◽

Symptom Onset ◽

Multivariate Regression ◽

Stroke Care ◽

Care Physician ◽

Stroke Severity ◽

Acute Stroke Care ◽

Hospital Arrival ◽

Ambulance Transport

Objective: Our objective was to assess gender, ethnic, and access-to-care factors critical in delay time (DT) for presentation to the hospital for acute stroke.Background: Little information is available on the effect of gender, ethnicity, and access issues on DT.Design: Demographic, access-to-care, and DT information was obtained from emergency department (ED) documentation of stroke patients admitted from July 1995 through June 1997 at Hermann Hospital, Houston, TX. Univariate and multivariate regression analyses were performed.Results: Of the 241 eligible patients, 126 were African American (AA), 82 were non-Hispanic white (NHW), and 33 were Hispanic American (HA). Median DT from symptom onset to presentation to the ED was 222 minutes for AAs, 280 minutes for HAs, and 230 minutes for NHWs. A multivariate regression model estimated DT to ED arrival decreased with ambulance transport (p= 0.003) and increased in patients with a primary care physician(p = 0.145) and in women (p = 0.052). DT to see an ED physician after hospital arrival decreased with ambulance transport (p < 0.001), hemorrhage patients (p = 0.006), and worse stroke severity (p = 0.038), and increased in women (p = 0.041). DT to see a neurologist decreased with hemorrhage (p = 0.002) and ambulance arrival (p = 0.010). Neurologists saw patients within 3 hours of symptom onset in 34% of NHWs, 28% of AAs, and 18% of HAs.Conclusion: Gender and access-to-care issues may be important determinants of delay in acute stroke care. Less than 20% of HAs presented to the ED within 3 hours of symptom onset.

Download Full-text

Abstract 90: Nursing Education: A Critical Need in the Delivery of High Quality Stroke Care

Stroke ◽

10.1161/str.45.suppl_1.90 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Virginia Daggett ◽

Linda Williams ◽

Nicholas Burrus ◽

Jennifer Myers ◽

Laura Plue ◽

...

Keyword(s):

Acute Stroke ◽

Quality Indicators ◽

Stroke Care ◽

Training Needs ◽

Release Time ◽

Multidisciplinary Teams ◽

Care Providers ◽

Acute Stroke Care ◽

High Quality ◽

And Training

Objectives: High quality stroke care is complex, and requires strong multidisciplinary teams, including nurses, to ensure care processes are timely and appropriate. The purpose of this study was to identify training needs of nurses who deliver care to patients who present with acute stroke and are admitted to inpatient units. Methodology: Using semi-structured interviews, we conducted a qualitative study for a formative evaluation in 12 Department of Veterans Affairs Medical Centers (VAMCs) that had ≥ 50 acute ischemic stroke admissions a year and were diverse in the structure of stroke care. The interviews focused on current context and structure of stroke care, including educational practices and training needs. Secondary analyses were conducted, targeting frontline nurse and physician respondents (N = 113) in emergency, acute care and rehabilitation units. Results: Respondents across the sites reported insufficient nurse education and training for acute stroke care as an overarching theme. Moreover, themes related to the acute stroke care quality indicators emerged as areas of competencies that nurses needed training on a continuum: a) timely recognition of acute stroke and transient ischemic attacks, b) NIH Stroke Scale and neurological exams, c) dysphagia screening, d) administration of tissue plasminogen activator and management post treatment, and e) deep vein thrombosis prophylaxis. Themes that were related to structure of stroke care and/or context also emerged and attributed to training challenges across the sites, listed in order of prevalence: a) centralized care versus decentralized care, b) low volume of acute strokes, c) nurse engagement, d) structured acute stroke care education, and e) release time. Conclusions: VA stroke care providers identify educational needs around specific stroke quality indicators, but also describe key barriers including lower volume, time for training and engagement of nursing staff in acute stroke care. Future programs to improve VA stroke care need to address these barriers to optimally support high quality multidisciplinary stroke care.

Download Full-text

Abstract MP22: Sex Differences in the Delivery of Acute Telestroke Care

Stroke ◽

10.1161/str.52.suppl_1.mp22 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Johanna L Morton ◽

Suraj Didwania ◽

Eric Anderson ◽

Jason Hallock

Keyword(s):

Sex Differences ◽

Ischemic Stroke ◽

Acute Stroke ◽

Patient Population ◽

Functional Outcomes ◽

Stroke Care ◽

Stroke Severity ◽

Acute Stroke Care ◽

Presenting Symptoms ◽

Suspected Stroke

Background: Sex differences are encountered in many aspects of ischemic stroke, including risk factors, presenting symptoms, stroke mechanism, acute interventions and functional outcomes. As telestroke services continue to expand, many patients utilize telestroke for the evaluation and treatment of suspected stroke symptoms. To date, the existence of such differences between sexes has not been identified in the patient population having utilized telestroke for acute stroke care. Methods: A retrospective observational study of the experience of a single teleneurology practice serving 340 hospitals from April 2018 to June 2020 was performed. Patients seen in the emergency department (ED) with a diagnosis of suspected stroke were included. Data from the acute stroke encounter was reported through the current medical record platform. Results: Within the queried period, there were 11,454 male and 11,794 female patients identified as having received ED telestroke evaluation for suspected acute stroke. Males were younger than females (67 vs 70, P <0.01). Males had higher rates of prior stroke, hypertension, diabetes, hyperlipidemia, and coronary disease than females ( P <0.01), while females had higher rates of atrial fibrillation ( P =0.03) and TIA ( P <0.01). Rates of antiplatelet and anticoagulants were higher in males ( P <0.01) than females. There were no differences in time to ED presentation, time to request consult or make a thrombolysis decision, or length of consult. Females had higher stroke severity ( P <0.01) and door-to-needle times ( P <0.01), but lower alteplase rates ( P =0.02) compared to males. Conclusion: This review of a national heterogeneous telestroke patient population is indicative of sex differences in multiple aspects of acute ischemic stroke, most notably in thrombolysis delivered via telestroke. Further investigation into the etiology of such differences is warranted, as well as a survey of functional outcomes. As telemedicine continues to expand in the era of the COVID-19 pandemic, it is imperative that the reasons behind this disparity are investigated.

Download Full-text

Three-month functional outcomes following endovascular thrombectomy during the first wave of the COVID-19 pandemic: a Canadian single-center cohort study

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017664 ◽

2021 ◽

pp. neurintsurg-2021-017664

Author(s):

Joel Neves Briard ◽

Gabrielle Dufort ◽

Grégory Jacquin ◽

Walid Alesefir ◽

Olena Bereznyakova ◽

...

Keyword(s):

Cohort Study ◽

Acute Stroke ◽

Functional Status ◽

Functional Outcomes ◽

High Volume ◽

Stroke Care ◽

Single Center ◽

Acute Stroke Care ◽

Baseline Characteristics ◽

The Impact

BackgroundThe COVID-19 pandemic has disrupted acute stroke care logistics, including delays in hyperacute management and decreased monitoring following endovascular therapy (EVT). We aimed to assess the impact of the pandemic on 90-day functional outcome among patients treated with EVT.MethodsThis is an observational cohort study including all patients evaluated for an acute stroke between March 30, 2020 and September 30, 2020 (pandemic cohort) and 2019 (reference cohort) in a high-volume Canadian academic stroke center. We collected baseline characteristics, acute reperfusion treatment and management metrics. For EVT-treated patients, we assessed the modified Rankin score (mRS) at 90 days. We evaluated the impact of the pandemic on a 90-day favourable functional status (defined as mRS 0–2) and death using multivariable logistic regressions.ResultsAmong 383 and 339 patients included in the pandemic and reference cohorts, baseline characteristics were similar. Delays from symptom onset to evaluation and in-house treatment were longer during the early first wave, but returned to reference values in the subsequent months. Among the 127 and 136 EVT-treated patients in each respective cohort, favourable 90-day outcome occurred in 53/99 (53%) vs 52/109 (48%, p=0.40), whereas 22/99 (22%) and 28/109 (26%, p=0.56) patients died. In multivariable regressions, the pandemic period was not associated with 90-day favourable functional status (aOR 1.27, 95% CI 0.60 to 2.56) or death (aOR 0.74, 95% CI 0.33 to 1.63).ConclusionIn this single-center cohort study conducted in a Canadian pandemic epicenter, the first 6 months of the COVID-19 pandemic did not impact 90-day functional outcomes or death among EVT-treated patients.

Download Full-text