A System-Based Intervention to Improve Access to Hyperacute Stroke Care

AbstractBackground:Hyperacute stroke is a time-sensitive emergency for which outcomes improve with faster treatment. When stroke systems are accessed via emergency medical services (EMS), patients are routed to hyperacute stroke centres and are treated faster. But over a third of patients with strokes do not come to the hospital by EMS, and may inadvertently arrive at centres that do not provide acute stroke services. We developed and studied the impact of protocols to quickly identify and move “walk-in” patients from non-hyperacute hospitals to regional stroke centres (RSCs).Methods and Results:Protocols were developed by a multi-disciplinary and multi-institutional working group and implemented across 14 acute hospital sites within the Greater Toronto Area in December of 2012. Key metrics were recorded 18 months pre- and post-implementation. The teams regularly reviewed incident reports of protocol non-adherence and patient flow data. Transports increased by 80% from 103 to 185. The number of patients receiving tissue plasminogen activator (tPA) increased by 68% from 34 to 57. Total EMS transport time decreased 17 minutes (mean time of 54.46 to 37.86 minutes,p<0.0001). Calls responded to within 9 minutes increased from 34 to 59%.Conclusions:A systems-based approach that included a multi-organizational collaboration and consensus-based protocols to move patients from non-hyperacute hospitals to RSCs resulted in more patients receiving hyperacute stroke interventions and improvements in EMS response and transport times. As hyperacute stroke care becomes more centralized and endovascular therapy becomes more broadly implemented, the protocols developed here can be employed by other regions organizing patient flow across systems of stroke care.

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Development of the Madrid Stroke Programme: Milestones and Changes in Stroke Trends and Mortality from 1997 to 2017

Neuroepidemiology ◽

10.1159/000514077 ◽

2021 ◽

pp. 1-6

Author(s):

Silvia Pastor ◽

Elena de Celis ◽

Itsaso Losantos García ◽

María Alonso de Leciñana ◽

Blanca Fuentes ◽

...

Keyword(s):

Hospital Mortality ◽

Hospital Admissions ◽

Temporal Trends ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Care Organization ◽

Stroke Units ◽

Health Region ◽

Number Of Patients ◽

The Impact

Introduction: Stroke is a serious health problem, given it is the second leading cause of death and a major cause of disability in the European Union. Our study aimed to assess the impact of stroke care organization measures (such as the development of stroke units, implementation of a regional stroke code, and treatment with intravenous thrombolysis and mechanical thrombectomy) implemented from 1997 to 2017 on hospital admissions due to stroke and mortality attributed to stroke in the Madrid health region. Methods: Epidemiological data were obtained from the National Statistics Institute public website. We collected data on the number of patients discharged with a diagnosis of stroke, in-hospital mortality due to stroke and the number of inhabitants in the Madrid health region each year. We calculated rates of discharges and mortality due to stroke and the number of inhabitants per SU bed, and we analysed temporal trends in in-hospital mortality due to stroke using the Daniels test in 2 separate time periods (before and after 2011). Figures representing annual changes in these data from 1997 to 2017 were elaborated, marking stroke care organizational measures in the year they were implemented to visualize their temporal relation with changes in stroke statistics. Results: Hospital discharges with a diagnosis of stroke have increased from 170.3/100,000 inhabitants in 1997 to 230.23/100,000 inhabitants in 2017. However, the in-hospital mortality rate due to stroke has decreased (from 33.3 to 15.2%). A statistically significant temporal trend towards a decrease in the mortality percentage and rate was found from 1997 to 2011. Conclusions: Our study illustrates how measures such as the development of stroke units, implementation of a regional stroke code and treatment with intravenous thrombolysis coincide in time with a reduction in in-hospital mortality due to stroke.

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Impact of COVID-19 Pandemic on the Incidence, Prehospital Evaluation, and Presentation of Ischemic Stroke at a Nonurban Comprehensive Stroke Center

Stroke Research and Treatment ◽

10.1155/2021/6624231 ◽

2021 ◽

Vol 2021 ◽

pp. 1-5

Author(s):

Cesar Velasco ◽

Brandon Wattai ◽

Scott Buchle ◽

Alicia Richardson ◽

Varun Padmanaban ◽

...

Keyword(s):

Urban Areas ◽

Stroke Care ◽

Final Diagnosis ◽

Medical Attention ◽

Presenting Symptoms ◽

Number Of Patients ◽

Community Transmission ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

The Impact

Introduction. Many reports have described a decrease in the numbers of patients seeking medical attention for typical emergencies during the COVID-19 pandemic. These reports primarily relate to urban areas with widespread community transmission. The impact of COVID-19 on nonurban areas with minimal community transmission is less well understood. Methods. Using a prospectively maintained prehospital quality improvement database, we reviewed our hospital EMS transports with a diagnosis of stroke from January to April 2019 (baseline) and January to April 2020 (pandemic). We compared the volume of patients, transport/presentation times, severity of presenting symptoms, and final diagnosis. Results. In January, February, March, and April 2019, 10, 11, 17, and 19 patients, respectively, were transported in comparison to 19, 14, 10, and 8 during the same months in 2020. From January through April 2019, there was a 53% increase in transports, compared to a 42% decrease during the same months in 2020, constituting significantly different trend-line slopes (3.30; 95% CI 0.48–6.12 versus -3.70; 95% CI -5.76–-1.64, p = 0.001 ). Patient demographics, comorbidities, and symptom severity were mostly similar over the two time periods, and the number of patients with a final diagnosis of stroke was also similar. However, the median interval from EMS dispatch to ED arrival for patients with a final diagnosis of stroke was significantly longer in January to April 2020 ( 50 ± 11.7 min ) compared to the same time period in 2019 ( 42 ± 8.2 min , p = 0.01 ). Discussion/Conclusion. Our data indicate a decrease in patient transport volumes and longer intervals to EMS activation for suspected stroke care. These results suggest that even in a nonurban location without widespread community transmission, patients may be delaying or avoiding care for severe illnesses such as stroke. Clinicians and public health officials should not ignore the potential impact of pandemic-like illnesses even in areas of relatively low disease prevalence.

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Robust capacity planning for accident and emergency services

RAIRO - Operations Research ◽

10.1051/ro/2019112 ◽

2020 ◽

Vol 54 (6) ◽

pp. 1757-1773

Author(s):

Elvan Gökalp

Keyword(s):

Capacity Planning ◽

Emergency Services ◽

Simulation Optimization ◽

Patient Flow ◽

Waiting Times ◽

Model Parameters ◽

Planning Problem ◽

Accident And Emergency ◽

Number Of Patients ◽

The Impact

Accident and emergency departments (A&E) are the first place of contact for urgent and complex patients. These departments are subject to uncertainties due to the unplanned patient arrivals. After arrival to an A&E, patients are categorized by a triage nurse based on the urgency. The performance of an A&E is measured based on the number of patients waiting for more than a certain time to be treated. Due to the uncertainties affecting the patient flow, finding the optimum staff capacities while ensuring the performance targets is a complex problem. This paper proposes a robust-optimization based approximation for the patient waiting times in an A&E. We also develop a simulation optimization heuristic to solve this capacity planning problem. The performance of the approximation approach is then compared with that of the simulation optimization heuristic. Finally, the impact of model parameters on the performances of two approaches is investigated. The experiments show that the proposed approximation results in good enough solutions.

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Epidemiological Surveillance of the Impact of the COVID-19 Pandemic on Stroke Care Using Artificial Intelligence

Stroke ◽

10.1161/strokeaha.120.031960 ◽

2021 ◽

Author(s):

Raul G. Nogueira ◽

Jason M. Davies ◽

Rishi Gupta ◽

Ameer E. Hassan ◽

Thomas Devlin ◽

...

Keyword(s):

Artificial Intelligence ◽

Acute Stroke ◽

Systems Of Care ◽

Ct Perfusion ◽

Stroke Care ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Number Of Patients ◽

The Impact

Background and Purpose: The degree to which the coronavirus disease 2019 (COVID-19) pandemic has affected systems of care, in particular, those for time-sensitive conditions such as stroke, remains poorly quantified. We sought to evaluate the impact of COVID-19 in the overall screening for acute stroke utilizing a commercial clinical artificial intelligence platform. Methods: Data were derived from the Viz Platform, an artificial intelligence application designed to optimize the workflow of patients with acute stroke. Neuroimaging data on suspected patients with stroke across 97 hospitals in 20 US states were collected in real time and retrospectively analyzed with the number of patients undergoing imaging screening serving as a surrogate for the amount of stroke care. The main outcome measures were the number of computed tomography (CT) angiography, CT perfusion, large vessel occlusions (defined according to the automated software detection), and severe strokes on CT perfusion (defined as those with hypoperfusion volumes >70 mL) normalized as number of patients per day per hospital. Data from the prepandemic (November 4, 2019 to February 29, 2020) and pandemic (March 1 to May 10, 2020) periods were compared at national and state levels. Correlations were made between the inter-period changes in imaging screening, stroke hospitalizations, and thrombectomy procedures using state-specific sampling. Results: A total of 23 223 patients were included. The incidence of large vessel occlusion on CT angiography and severe strokes on CT perfusion were 11.2% (n=2602) and 14.7% (n=1229/8328), respectively. There were significant declines in the overall number of CT angiographies (−22.8%; 1.39–1.07 patients/day per hospital, P <0.001) and CT perfusion (−26.1%; 0.50–0.37 patients/day per hospital, P <0.001) as well as in the incidence of large vessel occlusion (−17.1%; 0.15–0.13 patients/day per hospital, P <0.001) and severe strokes on CT perfusion (−16.7%; 0.12–0.10 patients/day per hospital, P <0.005). The sampled cohort showed similar declines in the rates of large vessel occlusions versus thrombectomy (18.8% versus 19.5%, P =0.9) and comprehensive stroke center hospitalizations (18.8% versus 11.0%, P =0.4). Conclusions: A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This analysis underscores the broader application of artificial intelligence neuroimaging platforms for the real-time monitoring of stroke systems of care.

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Severe hemiparesis as a prehospital tool to triage stroke severity: a pilot study to assess diagnostic accuracy and treatment times

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-011940 ◽

2015 ◽

Vol 8 (8) ◽

pp. 775-777 ◽

Cited By ~ 9

Author(s):

Rishi Gupta ◽

Marissa Manuel ◽

Kumiko Owada ◽

Samish Dhungana ◽

Leslie Busby ◽

...

Keyword(s):

Pilot Study ◽

Endovascular Therapy ◽

Acute Treatment ◽

Mechanical Thrombectomy ◽

Stroke Severity ◽

Intravenous Tissue Plasminogen Activator ◽

Number Of Patients ◽

Tissue Plasminogen ◽

The Times ◽

The Impact

IntroductionWith the publication of the recent trials showing the tremendous benefits of mechanical thrombectomy, opportunities exist to refine prehospital processes to identify patients with larger stroke syndromes.Materials and methodsWe retrospectively reviewed consecutive patients who were brought via scene flight from rural parts of the region to our institution, from December 1, 2014 to June 5, 2015, with severe hemiparesis or hemiplegia. We assessed the accuracy of the diagnosis of stroke and the number of patients requiring endovascular therapy. Moreover, we reviewed the times along the pathway of patients who were treated with endovascular therapy.Results45 patients were brought via helicopter from the field to our institution. 27 (60%) patients were diagnosed with an ischemic stroke. Of these, 12 (26.7%) were treated with mechanical thrombectomy and 6 (13.3%) with intravenous tissue plasminogen activator alone. An additional three patients required embolization procedures for either a dural arteriovenous fistula or cerebral aneurysm. Thus a total of 15 (33%) patients received an endovascular procedure and 21/45 (46.7%) received an acute treatment. For patients treated with thrombectomy, the median time from first medical contact to groin puncture was 101 min, with 8 of the 12 patients (66.7%) being discharged to home.ConclusionsWe have presented a pilot study showing that severe hemiparesis or hemiplegia may be a reasonable prehospital tool in recognizing patients requiring endovascular treatment. Patients being identified earlier may be treated faster and potentially improve outcomes. Further prospective controlled studies are required to assess the impact on outcomes and cost effectiveness using this methodology.

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Abstract TP303: Institutional Stroke Quality Improvement and Impact on Vascular Neurology Fellows Practice Patterns

Stroke ◽

10.1161/str.48.suppl_1.tp303 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

John Lynch ◽

Richard Benson ◽

Amie Hsia ◽

Richard Leigh ◽

Zurab Nadareishvili ◽

...

Keyword(s):

Quality Improvement ◽

Practice Patterns ◽

Clinical Care ◽

Heart Association ◽

Stroke Care ◽

Number Of Patients ◽

Yearly Average ◽

Case Logs ◽

The Impact ◽

Iv Tpa

Background and objectives: The American Heart Association quality improvement (QI) program Target Stroke is focused on reducing door-to-needle (DTN) time for IV tissue plasminogen activator (tPA) therapy to ≤60 minutes. Multidisciplinary QI procedures similar to the Target Stroke best practices have been shown to improve DTN times at an MRI based program. Whether these strategies improve the performance of trainees is unclear. The objective of this study was to determine the impact of a multidisciplinary QI program on the practice patterns of vascular neurology (VN) fellows at an MRI based stroke program. Methods: Case logs from the NIH Stroke Program VN fellows (N=22) were reviewed from July 2008-July 2015. Data was collected for the following: total patients screened, patients triaged, stroke code proceeds, tPA treated cases, and door to needle time (DTN) for each patient treated including DTN ≤60 minutes. QI processes that included stroke team education and process changes were initiated in 2013 to improve stroke care at two hospitals where VN fellows provide clinical care. We compared VN fellow practice patterns before (2008-12) and after (2013-15) QI implementation. Results: A total of 5093 cases were reviewed for the study. From 2008-15, fellows screened a yearly average of 232 patients, triaged 54% (125) to acute imaging, and treated 7.8% (18) patients each year with IV tPA. VN fellow practice patterns after QI implementation (2013-15) improved for percent treated with IV tPA (5.8% vs. 9.9%, p<0.05), median DTN (83 vs. 71 min.; p<0.05), and percentage treated ≤60 minutes (11% vs. 40%; p<0.05). The mean number of patients screened was slightly higher before 2013 (238 vs. 225), and triage rates were similar (52.4% vs. 55%, p=0.58). Conclusion: The results of this study suggest that an institutional multidisciplinary QI stroke program can improve the practice patterns of VN fellows at an MRI based stroke program.

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Impact of National Lockdown on the Hyperacute Stroke Care and Rapid Transient Ischaemic Attack Outpatient Service in a Comprehensive Tertiary Stroke Centre During the COVID-19 Pandemic

Frontiers in Neurology ◽

10.3389/fneur.2021.627493 ◽

2021 ◽

Vol 12 ◽

Author(s):

Lucio D'Anna ◽

Maddison Brown ◽

Sikdar Oishi ◽

Natalya Ellis ◽

Zoe Brown ◽

...

Keyword(s):

Acute Stroke ◽

Outpatient Service ◽

Stroke Care ◽

Reperfusion Therapy ◽

Long Term Effects ◽

Number Of Patients ◽

Stroke Center ◽

Ischemic Attack ◽

The Uk ◽

The Impact

Background: The COVID-19 pandemic is having major implications for stroke services worldwide. We aimed to study the impact of the national lockdown period during the COVID-19 outbreak on stroke and transient ischemic attack (TIA) care in London, UK.Methods: We retrospectively analyzed data from a quality improvement registry of consecutive patients presenting with acute ischemic stroke and TIA to the Stroke Department, Imperial College Health Care Trust London during the national lockdown period (between March 23rd and 30th June 2020). As controls, we evaluated the clinical reports and stroke quality metrics of patients presenting with stroke or TIA in the same period of 2019.Results: Between March 23rd and 30th June 2020, we documented a fall in the number of stroke admissions by 31.33% and of TIA outpatient referrals by 24.44% compared to the same period in 2019. During the lockdown, we observed a significant increase in symptom onset-to-door time in patients presenting with stroke (median = 240 vs. 160 min, p = 0.020) and TIA (median = 3 vs. 0 days, p = 0.002) and a significant reduction in the total number of patients thrombolysed [27 (11.49%) vs. 46 (16.25%, p = 0.030)]. Patients in the 2020 cohort presented with a lower median pre-stroke mRS (p = 0.015), but an increased NIHSS (p = 0.002). We registered a marked decrease in mimic diagnoses compared to the same period of 2019. Statistically significant differences were found between the COVID and pre-COVID cohorts in the time from onset to door (median 99 vs. 88 min, p = 0.026) and from onset to needle (median 148 vs. 126 min, p = 0.036) for thrombolysis whilst we did not observe any significant delay to reperfusion therapies (door-to-needle and door-to-groin puncture time).Conclusions: National lockdown in the UK due to the COVID-19 pandemic was associated with a significant decrease in acute stroke admission and TIA evaluations at our stroke center. Moreover, a lower proportion of acute stroke patients in the pandemic cohort benefited from reperfusion therapy. Further research is needed to evaluate the long-term effects of the pandemic on stroke care.

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Abstract 3670: Lean Manufacturing Process Improvement Methods Accelerate and Simplify Transfer of Patients to a Comprehensive Stroke Center

Stroke ◽

10.1161/str.43.suppl_1.a3670 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Mary Spencer ◽

Renee B Van Stavern ◽

Peter Panagos ◽

Adrienne Ford ◽

Brian Hoff ◽

...

Keyword(s):

Performance Management ◽

Process Improvement ◽

Manufacturing Process ◽

Lean Manufacturing ◽

Stroke Care ◽

Protocol Implementation ◽

Future State ◽

Number Of Patients ◽

New Process ◽

Mean Time

Background and Purpose: Acute therapies offered at comprehensive stroke centers require the rapid transfer of stroke patients from outlying hospitals. Here, we describe the application of Lean manufacturing process improvement methods to stroke care in order to accelerate the transfer of patients from outlying hospitals. Methods: A multidisciplinary team of Stroke Neurologists, Vascular Neurosurgeons, ED Physician, Call Center staff and Lean Performance Management Engineers critically evaluated the chain of events required to accept a patient for transfer from outlying hospitals. Barriers and inefficiencies were identified in a “current state” Value Stream Map (VSM). A “future state” VSM created a new process for stroke patient transfer by overcoming the identified barriers and was implemented in March, 2011. Metrics were prospectively collected for a 4-month period prior to (7/1/10-10/30/10) and after implementation of the “future state” VSM (3/1/11-6/30/11), and included: mean time from call start to physician acceptance, percent of calls resulting in acceptance of patients within 15 minutes, total number of patients accepted within 15 minutes over 4 months, and total number of calls. Student’s T-test was used to compare means, while Chi-square test was used to compare ratios. Results: Identified barriers to rapid acceptance of patients included: 1) inefficient distribution of cases between services (neurology vs. neurosurgery); 2) calls frequently transferred from one physician to another on other services; and 3) lack of available beds resulting in acceptance delays. To overcome these inefficiencies, a new process was created with the following changes: 1) alternating call coverage shared between neurology and neurosurgery; 2) immediate acceptance of the patient with behind the scenes patient allocation to appropriate service; 3) direct involvement of patient placement services in transfer process. Mean time to acceptance decreased significantly from 14 min prior to new protocol implementation to 9 minutes (p< 0.03). The total number patients accepted within 15 minutes increased from 186 to 307 during this 4-month period. Percent accepted within 15 minutes also increased from 73% to 92% (p<0.0002). In addition, the rate of patient calls (#calls/month) increased after new protocol implementation (see table ). Conclusions: Lean manufacturing process improvement tools are effective in designing hospital and physician work flow to help improve stroke care. Such practices require a collaborative approach including all parties involved in the process.

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P124: The Ottawa Chest Pain Rule would increase stretcher capacity if implemented for cardiac chest pain patients

CJEM ◽

10.1017/cem.2016.299 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S119-S119 ◽

Cited By ~ 1

Author(s):

M. Sonntag ◽

E. Lang

Keyword(s):

Emergency Department ◽

Chest Pain ◽

Patient Flow ◽

System Capacity ◽

Cardiac Monitoring ◽

Convenience Sample ◽

Heart Score ◽

Number Of Patients ◽

The Impact ◽

Pain Patients

Introduction: Reducing the number of patients requiring cardiac monitoring would increase system capacity and improve emergency department (ED) patient flow. The Ottawa Chest Pain Rule helps physicians identify chest pain patients who do not require cardiac monitoring and is based on a ‘normal or non-specific’ ECG and being pain-free on initial physician assessment. Our objective was to measure the impact that the implementation of this decision rule would have on cardiac monitoring bed utilization in adult EDs in Calgary. Methods: A convenience sample of patients was prospectively obtained at each of the four Calgary adult emergency sites. All patients presenting with the Canadian Triage Acuity Scale chief complaint of “cardiac pain”, or “chest pain with cardiac features” were captured for inclusion in the study. Real time interviews and survey assessments were conducted with the primary nurse and physician involved in each patient’s care. Results: A total of 61 patients were captured by the study. Physicians identified cardiac as the primary rule-out pathology in 51% of these patients. The average Heart Score of all study patients was 4.2, and 30% of patients were ultimately admitted. Physicians believed that 39% of the 61 patients needed cardiac monitoring, while primary nurses believed that 59% needed monitoring. Of the 61 patients, 59% were triaged to areas providing cardiac monitoring. The application of the Ottawa Rule would have allowed 47% of patients triaged to cardiac monitoring to be taken off cardiac monitoring. This would translate to a total of greater than 74 hours saved or a reduction of 30% of the total cardiac monitored patient time. Conclusion: The Ottawa rule appears to be a low-risk emergency department flow intervention that has the potential to help reduce resource utilization in emergency departments. This change may result in increased emergency department capacity and improved overall patient flow. This simple rule based only on ECG findings and absence of chest pain can easily be applied and implemented without increasing physician workload or increasing risk to patients.

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WED 260 Time to scan: barriers to imaging outside normal working hours

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2018-abn.129 ◽

2018 ◽

Vol 89 (10) ◽

pp. A37.2-A37

Author(s):

Hosty Jennifer ◽

Bunn Jonathan ◽

Bainbridge Rachel ◽

Dunn Geoffrey ◽

Endean Keith ◽

...

Keyword(s):

Nurse Practitioners ◽

Working Hours ◽

Standard Operating Procedure ◽

Stroke Care ◽

Out Of Hours ◽

Scanning Time ◽

Number Of Patients ◽

Ct Head ◽

The Mean ◽

Mean Time

SSNAP measures quality and organisation of stroke care. Domain 1.1 looks at the number of patients scanned within 1 hour of arrival at hospital; local trust performance is 57.4% (national average 51.3%), with the specialist stroke unit at 79.2%. This is in part related to ‘direct to scan protocols’ in extended working hours, but we currently lack equivalent medical staffing and radiographer support during this time. We aimed to explore which factors impacted on scanning time out of hours. An initial consecutive 14 day sample identified delays in approval of scan request by the duty radiologist. A new Standard Operating Procedure allowed specialist stroke nurse practitioners (SNPs) to request CT head scans directly with the duty radiographer, eliminating need for liaison with the radiologist. A repeat 14 day analysis identified additional factors resulting in delays, including delays in scan request and in-hospital competing emergency clinical scanning requirements, meaning no significant improvement in percentage of patients scanned within 1 hour was observed. The mean time from arrival to scan performance was 52 min, but 21.8% of patients did not undergo a CT head within 1 hour of arrival. Further strategies are required to maximise patients meeting this target.

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