PND21 A Tool Proposal For Measuring Costs Using Time-Driven Activity-Based Costing For The Ischemic Stroke Care Pathway

Background and purpose: In-hospital stroke-onset assessment and management present numerous challenges, especially in community hospitals. Comprehensive analysis of key stroke care metrics in community-based primary stroke centers is under-studied. Methods: Medical records were reviewed for patients admitted to a community hospital for non-cerebrovascular indications and for whom a stroke alert was activated between 2013 and 2019. Demographic, clinical, radiologic and laboratory information were collected for each incident stroke. Descriptive statistical analysis was employed. When applicable, Kruskal-Wallis and Chi-Square tests were used to compare median values and categorical data between pre-specified groups. Statistical significance was set at alpha = 0.05. Results: There were 192 patients with in-hospital stroke-alert activation; mean age (SD) was 71.0 years (15.0), 49.5% female. 51.6% (99/192) had in-hospital ischemic and hemorrhagic stroke. The most frequent mechanism of stroke was cardioembolism. Upon stroke activation, 45.8% had ischemic stroke while 40.1% had stroke mimics. Stroke team response time from activation was 26 minutes for all in-hospital activations. Intravenous thrombolysis was utilized in 8% of those with ischemic stroke; 3.4% were transferred for consideration of endovascular thrombectomy. In-hospital mortality was 17.7%, and the proportion of patients discharged to home was 34.4% for all activations. Conclusion: The in-hospital stroke mortality was high, and the proportions of patients who either received or were considered for acute intervention were low. Quality improvement targeting increased use of acute stroke intervention in eligible patients and reducing hospital mortality in this patient cohort is needed.

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Expert opinion paper on cardiac imaging after ischemic stroke

Clinical Research in Cardiology ◽

10.1007/s00392-021-01834-x ◽

2021 ◽

Author(s):

Renate B. Schnabel ◽

Stephan Camen ◽

Fabian Knebel ◽

Andreas Hagendorff ◽

Udo Bavendiek ◽

...

Keyword(s):

Ischemic Stroke ◽

Expert Opinion ◽

Cardiac Imaging ◽

Controlled Trial ◽

Case Series ◽

Stroke Care ◽

Imaging Method ◽

Cardiac Evaluation ◽

Magnetic Resonance Imaging Mri ◽

Ischemic Attack

AbstractThis expert opinion paper on cardiac imaging after acute ischemic stroke or transient ischemic attack (TIA) includes a statement of the “Heart and Brain” consortium of the German Cardiac Society and the German Stroke Society. The Stroke Unit-Commission of the German Stroke Society and the German Atrial Fibrillation NETwork (AFNET) endorsed this paper. Cardiac imaging is a key component of etiological work-up after stroke. Enhanced echocardiographic tools, constantly improving cardiac computer tomography (CT) as well as cardiac magnetic resonance imaging (MRI) offer comprehensive non- or less-invasive cardiac evaluation at the expense of increased costs and/or radiation exposure. Certain imaging findings usually lead to a change in medical secondary stroke prevention or may influence medical treatment. However, there is no proof from a randomized controlled trial (RCT) that the choice of the imaging method influences the prognosis of stroke patients. Summarizing present knowledge, the German Heart and Brain consortium proposes an interdisciplinary, staged standard diagnostic scheme for the detection of risk factors of cardio-embolic stroke. This expert opinion paper aims to give practical advice to physicians who are involved in stroke care. In line with the nature of an expert opinion paper, labeling of classes of recommendations is not provided, since many statements are based on expert opinion, reported case series, and clinical experience.

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Integrative physiological assessment of cerebral hemodynamics and metabolism in acute ischemic stroke

Journal of Cerebral Blood Flow & Metabolism ◽

10.1177/0271678x211033732 ◽

2021 ◽

pp. 0271678X2110337

Author(s):

Jui-Lin Fan ◽

Ricardo C Nogueira ◽

Patrice Brassard ◽

Caroline A Rickards ◽

Matthew Page ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Cerebral Autoregulation ◽

Cerebral Perfusion ◽

Prognostic Markers ◽

Important Determinant ◽

Stroke Care ◽

Contentious Issue ◽

Ischemic Tissue ◽

Physiological Assessment

Restoring perfusion to ischemic tissue is the primary goal of acute ischemic stroke care, yet only a small portion of patients receive reperfusion treatment. Since blood pressure (BP) is an important determinant of cerebral perfusion, effective BP management could facilitate reperfusion. But how BP should be managed in very early phase of ischemic stroke remains a contentious issue, due to the lack of clear evidence. Given the complex relationship between BP and cerebral blood flow (CBF)—termed cerebral autoregulation (CA)—bedside monitoring of cerebral perfusion and oxygenation could help guide BP management, thereby improve stroke patient outcome. The aim of INFOMATAS is to ‘ identify novel therapeutic targets for treatment and management in acute ischemic stroke’. In this review, we identify novel physiological parameters which could be used to guide BP management in acute stroke, and explore methodologies for monitoring them at the bedside. We outline the challenges in translating these potential prognostic markers into clinical use.

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Retrospective Review and Proof of Concept of Asia’s First Mobile Stroke Unit Experience in Kovai Medical Center and Hospital

Journal of Stroke Medicine ◽

10.1177/2516608520968418 ◽

2020 ◽

Vol 3 (2) ◽

pp. 116-123

Author(s):

Mathew Cherian ◽

Pankaj Mehta ◽

Shriram Varadharajan ◽

Santosh Poyyamozhi ◽

Elango Swamiappan ◽

...

Keyword(s):

Acute Stroke ◽

Retrospective Review ◽

Stroke Unit ◽

Care Pathway ◽

Clinical Care ◽

Stroke Care ◽

First Year ◽

Proof Of Concept ◽

Mobile Stroke Unit ◽

Clinical Care Pathway

Background: We review our initial experience of India’s and Asia’s first mobile stroke unit (MSU) following the completion of its first year of operation. We outline the clinical care pathway integrating the MSU services using a case example taking readers along our clinical care workflow while highlighting the challenges faced in organizing and optimizing such services in India. Methods: Retrospective review of data collected for all patients from March 2018 to February 2019 transported and treated within the MSU during the first year of its operation. Recent case example is reviewed highlighting complete comprehensive acute clinical care pathway from prehospital MSU services to advanced endovascular treatment with focus on challenges faced in developing nation for stroke care. Results: The MSU was dispatched and utilized for 14 patients with clinical symptoms of acute stroke. These patients were predominantly males (64%) with median age of 59 years. Ischemic stroke was seen in 7 patients, hemorrhagic in 6, and 1 patient was classified as stroke mimic. Intravenous tissue plasminogen activator was administered to 3 patients within MSU. Most of the patients’ treatment was initiated within 2 h of symptom onset and with the median time of patient contact (rendezvous) following stroke being 55 mins. Conclusion: Retrospective review of Asia’s first MSU reveals its proof of concept in India. Although the number of patients availing treatment in MSU is low as compared to elsewhere in the world, increased public awareness with active government support including subsidizing treatment costs could accelerate development of optimal prehospital acute stroke care policy in India.

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Race and Income Disparity in Ischemic Stroke Care: Nationwide Inpatient Sample Database, 2002 to 2008

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2012.06.004 ◽

2014 ◽

Vol 23 (1) ◽

pp. 17-24 ◽

Cited By ~ 44

Author(s):

Matthew M. Kimball ◽

Dan Neal ◽

Michael F. Waters ◽

Brian L. Hoh

Keyword(s):

Ischemic Stroke ◽

Nationwide Inpatient Sample ◽

Stroke Care ◽

Income Disparity ◽

Nationwide Inpatient Sample Database

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Abstract TP322: Additional Factors May Affect Hospital Performance Ratings on Ischemic Stroke Care in California

Stroke ◽

10.1161/str.47.suppl_1.tp322 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Limin Wang ◽

Merry Holliday-Hanson ◽

Joseph Parker

Keyword(s):

Ischemic Stroke ◽

Geographic Location ◽

Stroke Care ◽

Hospital Performance ◽

Performance Ratings ◽

Tissue Type ◽

Stroke Severity ◽

Discharge Data ◽

Insurance Type ◽

Hospital Characteristics

Objectives: A report on ischemic stroke care at California hospitals was based on risk-adjusted 30-day mortality and accounted for many important risk factors (patient demography, clinical characteristics, and stroke severity). Other studies have indicated that geographic location, hospital characteristics and insurance type may also be drivers of differences in quality of care. The effect that these and other factors may have on hospital performance ratings for ischemic stroke is not well understood. Methods: Data used were from the California patient discharge data 2011-2013, collected by the Office of Statewide Health Planning and Development (OSHPD). Hospitals were chosen according to their performance in two recent hospital “report cards” on stroke produced by OSHPD. We compared 15 hospitals rated as “Better” with 14 “Worse” hospitals (10615 patients) on patient demographics, geographic location, insurance type, hospital characteristics, tissue-type plasminogen activator (tPA) use and expected 30-day mortality rate. Results: Patients admitted to “Worse” hospitals were more likely to be younger, white or Hispanic, and reside in lower income zip codes than “Better” hospitals ( P <0.001). “Worse” hospitals served a significantly higher percentage of patients with Medi-Cal insurance than “Better” hospitals (14.4% vs 9.6%, P <0.001). There were no significant differences in hospital geography or teaching status, bed size or Get With the Guidelines-Stroke Hospitals status between “Worse” and “Better” hospitals. Patients admitted to “Worse” hospitals had similar lengths of stay as those at “Better” hospitals and the transfer rate was also similar. “Worse” hospitals coded significantly fewer secondary diagnoses compared to “Better” hospitals (40.5% vs 53.0%, P <0.005). The tPA usage rate was significantly higher in the “worse” group than the “Better” group (11.5% vs 9.2%, P <0.005). “Worse” hospitals had significantly lower expected 30-day mortality rates compared to “Better” hospitals (8.8% vs 11.6%, P <0.005). Conclusion: Hospital performance ratings on ischemic stroke outcome were significantly associated with patient geographic location, socioeconomic status, and insurance type, but were not related to hospital characteristics.

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Abstract WP399: Reduced Cost and Decreased Length of Stay Associated with Acute Ischemic Stroke Care Provided by Nurse Practitioners: A Single Primary Stroke Center Experience

Stroke ◽

10.1161/str.48.suppl_1.wp399 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Leah Roering ◽

Michelle Peterson ◽

Muhammad Shah Miran ◽

Melissa Freese ◽

Kenneth Shea ◽

...

Keyword(s):

Ischemic Stroke ◽

Length Of Stay ◽

Acute Ischemic Stroke ◽

Nurse Practitioners ◽

Acute Care Hospital ◽

Stroke Care ◽

Care Hospital ◽

Medical Provider ◽

The Mean ◽

Stroke Center

Background: Nurse practitioner (NP) have a wider role in modern stroke centers providing quality evidence based care to patients in both in and outpatient settings for acute ischemic stroke (AIS) and transient ischemic attack (TIA) patients. We studied the outcome measures, length of stay (LOS) and cost before and after implementation of nurse practitioners as the primary medical provider in a community based stroke center. Methods: St Cloud hospital is acute care hospital with dedicated stroke service responsible for workup and management of all patients admitted with AIS and TIA. From March 2014-March 2015, all patients were primarily managed by stroke neurologists with or without support of NP, representing physician driven arm. From June 2015-March 2016 all non-critical patients were managed primarily by NP, representing the NP driven arm of care. For this analysis, we excluded all patients with subarachnoid hemorrhage or intracerebral hemorrhage. Using ICD codes, we abstracted LOS and hospitalization cost for all patients, and compared between two arms. Results: A total of 822 patients were included in physician arm and 336 in NP arm. The mean age was 72±14 years for both arms, and 54.4% were male in physician arm and 57.4% were male in NP arm. The mean total LOS for the physician arm was 3.1 ±3.3 days while 2.9±3.6 for NP arm (p=0.6). The total cost for physician arm was $11,286.70 ±$10,920.90 while the NP arm was $10,277.30± $10,142.30 (p=0.1). Conclusion: There is a trend towards lower cost and length of stay with implementation of NP as primary stroke provider for patients admitted with acute ischemic stroke.

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Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018

International Journal of Stroke ◽

10.1177/1747493018786616 ◽

2018 ◽

Vol 13 (9) ◽

pp. 949-984 ◽

Cited By ~ 73

Author(s):

JM Boulanger ◽

MP Lindsay ◽

G Gubitz ◽

EE Smith ◽

G Stotts ◽

...

Keyword(s):

Emergency Department ◽

Ischemic Stroke ◽

Acute Stroke ◽

Transient Ischemic Attack ◽

Best Practice ◽

Stroke Care ◽

Stroke Management ◽

Practice Recommendations ◽

Prehospital Emergency ◽

Ischemic Attack

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider’s recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

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