Mobile Stroke Units: Current and Future Impact on Stroke Care

2021 ◽  
Vol 41 (01) ◽  
pp. 009-015
Author(s):  
Ritvij Bowry ◽  
James C. Grotta
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcomes ◽  
Stroke Care ◽  
The United States ◽  
Hospital Treatment ◽  
Additional Time ◽  
Stroke Units ◽  
Require Time ◽  
Intravenous Tissue Plasminogen Activator ◽  
Telemedicine Technology

AbstractIschemic stroke is a leading cause of death and major disability that impacts societies across the world. Earlier thrombolysis of blocked arteries with intravenous tissue plasminogen activator (tPA) and/or endovascular clot extraction is associated with better clinical outcomes. Mobile stroke units (MSU) can deliver faster tPA treatment and rapidly transport stroke patients to centers with endovascular capabilities. Initial MSU trials in Germany indicated more rapid tPA treatment times using MSUs compared with standard emergency room treatment, a higher proportion of patients treated within 60 minutes of stroke onset, and a trend toward better 3-month clinical outcomes with MSU care. In the United States, the first multicenter, randomized clinical trial comparing standard versus MSU treatment began in 2014 in Houston, TX, and has demonstrated feasibility and safety of MSU operations, reliability of telemedicine technology to assess patients for tPA eligibility without additional time delays, and faster door-to-groin puncture times of MSU patients needing endovascular thrombectomy in interim analysis. Scheduled for completion in 2021, this trial will determine the cost-effectiveness and benefit of MSU treatment on clinical outcomes compared with standard ambulance and hospital treatment. Beyond ischemic stroke, MSUs have additional clinical and research applications that can profoundly impact other cohorts of patients who require time-sensitive neurological care.

Abstract 1122‐000121: Integrated Geomapping Tool of Certified Stroke Centers in United States: A SVIN MT2020+ Committee Collaboration

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Evan Kolesnick ◽  
Evan Kolesnick ◽  
Alfredo Munoz ◽  
Kaiz Asif ◽  
Santiago Ortega‐Gutierrez ◽  
...  
Keyword(s):  
United States ◽  
Acute Stroke ◽  
Clinical Outcomes ◽  
Healthcare Disparities ◽  
Systems Of Care ◽  
Stroke Care ◽  
The United States ◽  
Time Dependent ◽  
Stroke Systems Of Care ◽  
Stroke Center

Introduction : Stroke is a leading cause of morbidity, mortality and healthcare spending in the United States. Acute management of ischemic stroke is time‐dependent and evidence suggests improved clinical outcomes for patients treated at designated certified stroke centers. There is an increasing trend among hospitals to obtain certification as designated stroke centers. A common source or integrated tool providing both information and location of all available stroke centers in the US irrespective of the certifying organization is not readily available. The objective of our research is to generate a comprehensive and interactive electronic resource with combined data on all geographically‐coded certified stroke centers to assist in pre‐hospital triage and study healthcare disparities in stroke including availability and access to acute stroke care by location and population. Methods : Data on stroke center certification was primarily obtained from each of the three main certifying organizations: The Joint Commission (TJC), Det Norske Veritas (DNV) and Healthcare Facilities Accreditation Program (HFAP). Geographic mapping of all stroke center locations was performed using the ArcGIS Pro application. The most current data on stroke centers is presented in an interactive electronic format and the information is frequently updated to represent newly certified centers. Utility of the tool and its analytics are shown. Role of the tool in improving pre‐hospital triage in the stroke systems of care, studying healthcare disparities and implications for public health policy are discussed. Results : Aggregate data analysis at the time of submission revealed 1,806 total certified stroke centers. TJC‐certified stroke centers represent the majority with 106 Acute Stroke Ready (ASR), 1,040 Primary Stroke Centers (PSCs), 49 Thrombectomy Capable Centers (TSCs) and 197 Comprehensive Stroke Centers (CSCs). A total of 341 DNV‐certified programs including 36 ASRs, 162 PSCs, 16 PSC Plus (thrombectomy capable) and 127 CSCs were identified. HFAP‐certified centers (75) include 16 ASRs, 49 PSCs, 2 TSCs and 8 CSCs. A preliminary map of all TJC‐certified CSCs and TSCs is shown in the figure (1). Geospatial analysis reveals distinct areas with currently limited access to certified stroke centers and currently, access to certified stroke centers is extremely limited to non‐existent in fe States (for example: Idaho, Montana, Wyoming, New Mexico and South Dakota). Conclusions : Stroke treatment and clinical outcomes are time‐dependent and prompt assessment and triage by EMS directly to appropriate designated stroke centers is therefore critical. A readily available electronic platform providing location and treatment capability for all nearby certified centers will enhance regional stroke systems of care, including enabling more rapid inter‐hospital transfers for advanced intervention. Identifying geographic areas of limited access to treatment can also help improve policy and prioritize the creation of a more equitable and well‐distributed network of stroke care in the United States.

Abstract WP280: Use of Strategies to Improve Door-to-Needle Times with Tissue Plasminogen Activator in Acute Ischemic Stroke by US Hospitals: Findings from the Target: Stroke Survey

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Gregg C Fonarow ◽  
Eric E Smith ◽  
Xin Zhao ◽  
Eric D Peterson ◽  
Ying Xian ◽  
...  
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Stroke Care ◽  
Ct Scanner ◽  
Critical Pathways ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen

Background: The benefits of intravenous tissue-plasminogen activator (tPA) in acute ischemic stroke are time-dependent and several strategies have been reported to be associated with more rapid door-to-needle (DTN) times. However, the extent to which hospitals are utilizing these strategies has not been well studied. Methods: We surveyed 304 hospitals joining Target: Stroke regarding their baseline use of strategies to reduce door-to-needle times in the 1/2008-2/2010 timeframe (prior to the initiation of Target: Stroke). The survey was developed based on literature review and expert consensus for strategies identified as being associated with shorter DTN times and further refined after pilot testing. Categorical responses are reported as frequencies. Results: Hospitals participating in the survey were 50% academic, median 163 (IQR 106-247) ischemic stroke admissions per year, median 10 (IQR 6-17) tPA treated patients per year, and had median 79 minute (IQR 71-89) DTN times. By survey, 214 of 304 hospitals (70%) reported initiating or revising strategies to reduce DTN times in the prior 2 years. Reported use of the different strategies varied in frequency, with use of ischemic stroke critical pathways, CT scanner located in the Emergency Department, and tPA being stored in the Emergency Department being the strategies least frequently employed (Table). As part of Target: Stroke participation, 279 of 304 hospitals (91.5%) indicated they planned to have a dedicated team focused on reducing DTN times. Conclusions: While most US hospitals participating in this survey report use of the strategies to improve the timeliness of tPA administration for acute ischemic stroke, significant variation exists. Further research is needed to understand which of these strategies are most effective in improving acute ischemic stroke care.

Abstract 20: Acute Stroke Care and Thrombolysis at Critical Access Hospitals in Illinois

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Shyam Prabhakaran ◽  
Robin Hamann ◽  
Kathleen O’Neill ◽  
Michelle Gardner ◽  
Peggy Jones
Keyword(s):  
Quality Improvement ◽  
Acute Stroke ◽  
Stroke Care ◽  
The United States ◽  
Critical Access Hospitals ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
Improvement Program ◽  
Discharge Disposition ◽  
Intravenous Tissue Plasminogen Activator

Background: Critical access hospitals (CAH) are the first point of stroke care in many rural regions of the United States (US). The Illinois Critical Access Hospital Network (ICAHN), a network of 51 CAH in Illinois, began a quality improvement program to address acute stroke care in 2009. We evaluated the performance on several metrics in acute stroke care at CAH between 2009 and 2011. Methods: Currently, 28 of 51 CAHs in Illinois currently participate in the American Heart Association’s Get With The Guidelines - Stroke (GWTG-S) registry for quality improvement. The GWTG-S registry captured elements including demographics, diagnosis, times of arrival, imaging completion, and intravenous tissue plasminogen activator (IV tPA) administration, and final discharge disposition. We analyzed the change in percent of stroke patients receiving tPA, door-to-needle (DTN) time, and proportion of total stroke patients admitted versus transferred to another facility over the 3 years. Fisher’s exact and Mann-Whitney tests were used as appropriate. Results: In the baseline assessment (2009), there were 111 strokes from 8 sites which grew to 12 sites and 305 strokes in year 1 (2010) and 14 sites and 328 strokes in year 3 (2011). The rate of tPA use for ischemic stroke was 2.2% in 2009, 4.0% in 2010, and 6.2% in 2011 (P=0.20). EMS arrival (41.1%), EMS pre-notification (82.6%), door-to-CT times (median 35 minutes; 34.6% < 25 minutes), and DTN times (average 93 minutes; 13.3% DTN time < 60 minutes) were not different over time. The rate of transfer from CAH to another hospital (51.3%) was constant. Every patient that received tPA except 1 (96.9%) was transferred (drip-ship) for post-tPA care. Conclusions: Improving acute stroke care at CAHs is feasible and represents a significant opportunity to increase tPA utilization in rural areas. As stroke systems develop, it is vital that CAHs be included in quality improvement efforts. The ICAHN stroke collaborative provided the opportunity to coordinate resources, share best practices, participate in targeted educational programming, and utilize data for performance improvement through the funded GWTG-S registry.

Abstract 116: Relationship of Stroke Unit Status With Quality of Care and Outcome for Acute Stroke Patients: Results From China National Stroke Registry II

2017 ◽  
Vol 10 (suppl_3) ◽  
Author(s):  
Xinmiao Zhang ◽  
Zixiao Li ◽  
Chunjuan Wang ◽  
Caiyun Wang ◽  
Xin Yang ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Cox Model ◽  
Frailty Model ◽  
Stroke Care ◽  
Estimating Equation ◽  
Composite Score ◽  
Stroke Recurrence ◽  
Stroke Units ◽  
Stroke Registry ◽  
Processes Of Care

Introduction: A key element in modern stroke care is dedicated stroke units. However, it is unclear whether processes of acute ischemic stroke (AIS) care and outcomes are different between hospitals with and without stroke units in China. Methods: We analyzed the China National Stroke Registry II data from June 2012 to January 2013. Processes of care were examined by 13 individual national guideline-recommended indicators and composite score. Patients’ outcomes included all caused death, stroke recurrence, and disability (modified Rankin Score ≥3) at 3, 6 and 12month after discharge. Propensity score matching was used to balance the baseline characteristics. We used cox model with shared frailty model and logistic regression with generalized estimating equation to analysis the relationship between stroke units and clinical outcomes. Results: Among 19 604 AIS patients, there were 11050 (56.4%) patients in 121 hospitals with stroke units, and 8554 (43.6%) patients in 96 hospitals without stroke units. After matching, 8125 pairs of patients were analyzed. Totally, the composite score of processes was higher in hospitals with stroke units than that without(77% versus 74%, p<0.05). Hospitals with stroke units were more likely to conduct anticoagulation for atrial fibrillation, early antithrombotic treatment, smoking cessation, and stroke education (Figure 1). However, there are no differences between patients in hospitals with and without stroke units in clinical outcomes(Table 1). Conclusions: Our study showed that processes of care of AIS were better in patients in hospitals with stroke units. However, patients in hospitals with stroke units didn’t performance differences in clinical outcomes after discharge.

Abstract MP25: Inequities in Interhospital Transfer for Acute Ischemic Stroke in the United States: Lower Odds for Women and the Underinsured

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Daniel M Oh ◽  
Daniela Markovic ◽  
Amytis Towfighi
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Multinomial Logistic Regression ◽  
Private Insurance ◽  
Stroke Care ◽  
The United States ◽  
Primary Diagnosis ◽  
Multinomial Logistic Model ◽  
Lower Odds ◽  
Interhospital Transfer

Background: Patients with acute ischemic stroke (AIS) may undergo interhospital transfer (IHT) for higher level of care. Although the Emergency Medical Treatment and Active Labor Act stipulates that patients should be transferred to and accepted by referral hospitals if indicated, it offers few concrete guidelines, making it vulnerable to bias. We hypothesized that (1) IHT for AIS has increased over recent years and (2) minorities, women, and those without insurance had lower odds of IHT. Methods: Using the National Inpatient Sample, adults (>18 yrs) with a primary diagnosis of AIS from 2010 to 2017 (n=770,970) were identified, corresponding to a weighted sample size of 3,798,440. Those transferred to another acute hospital were labeled IHT. Yearly rates of IHT were assessed. Adjusted odds ratio (AOR) of IHT (vs. not transferred) were compared in 2014-2017 vs. 2010-2013 using a multinomial logistic model, adjusting for socioeconomic, medical, and hospital characteristics. Multinomial logistic regression was used to determine odds of IHT by race/ethnicity, sex, and insurance status, adjusting for the above characteristics. Results: From 2010 to 2017, the proportion of IHT declined from 3.2% (SE 0.2) to 2.9% (SE 0.1). Comparing IHT in 2014-2017 to 2010-2013 showed lower odds of IHT (OR 0.93, 95% CI 0.88-0.99), but this difference did not remain significant in the fully adjusted model. Fully adjusted OR showed that black patients were more likely than white patients to undergo IHT (AOR 1.13, 1.07-1.20). Women were less likely than men to be transferred (AOR 0.89, 0.86-0.92). Compared to those with private insurance, those with Medicaid (AOR 0.86, 0.80-0.91), self-pay (0.64, 0.59-0.70), and no charge (0.64, 0.46-0.88) were less likely to undergo IHT. Conclusions: Adjusted odds of IHT for AIS did not change significantly. Blacks were more likely than whites to be transferred; however, women and the uninsured/underinsured were less likely to be transferred. Further studies are needed to further understand these inequities and develop interventions and policies to ensure that all individuals have equitable access to stroke care, regardless of their race, sex, or ability to pay.

Abstract TP383: Ischemic Stroke Patients With Diabetes Looking for Practices in Need of Improvement

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Cynthia Bautista ◽  
Sally Gerard
Keyword(s):  
Ischemic Stroke ◽  
Cause Of Death ◽  
Demographic Data ◽  
Stroke Care ◽  
The United States ◽  
Stroke Patients ◽  
Co Morbidity ◽  
Patients With Diabetes ◽  
Care Outcomes ◽  
Stroke Center

Background/Purpose: Stroke is the fifth leading cause of death and Diabetes is the seventh leading cause of death in the United States. Diabetes is an independent risk factor for stroke. Diabetes is a common co-morbidity in stroke patients and is associated with poor outcomes after stroke. Get with the Guidelines - Stroke (GWTG-S) Registry database provides a rich opportunity to look at disease-specific data and find opportunities for improving care. The purpose of this study was to examine specific elements of acute ischemic stroke care in patients with diabetes using the GWTG-S at Comprehensive and Primary Stroke Centers in Northeast of America. Methods: A retrospective, descriptive study at both a Comprehensive and Primary Stroke Center. The analysis focused on patients with ischemic stroke and diabetes entered in the GWTG-S from January 1, 2015, to December 31, 2017. Data were analyzed looking at measures specific to stroke and the presence of diabetes. General demographic data were examined to compare populations and quality outcome measures. Results: The sample of patients with ischemic stroke and diabetes was over 1,000 patient’s at the two sites (Comprehensive site N = 804, Primary site N = 203) Incidence of ischemic stroke with diabetes at the two sites were 32% and 26%, respectively. Demographic data were similar in most categories including age, race, and gender. Significant differences were found in regard to the type of insurance. Stroke care outcomes indicated thrombolytic administration rates were the same at 8%. Diabetes care outcomes indicated patients discharged on insulin occurred in 18% to 26% of the sample. Conclusion/Implications for Practice: Ischemic stroke patients with diabetes were shown to receive similar care at both a comprehensive and primary care stroke center. There were no differences between centers in thrombolysis treatment for ischemic stroke patients with diabetes. Several opportunities for improvement in diabetes-related care need to be addressed.

scholarly journals Racial Differences in Mechanical Thrombectomy Utilization for Ischemic Stroke in the United States

2020 ◽  
Vol 30 (1) ◽  
pp. 91-96 ◽  
Author(s):  
Charles Esenwa ◽  
Alain Lekoubou ◽  
Kinfe G. Bishu ◽  
Kemar Small ◽  
Ava Liberman ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Racial Differences ◽  
Population Sample ◽  
Standard Of Care ◽  
Stroke Care ◽  
The United States ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Nationally Representative ◽  
Adjusted Model

Background: Compared with non-Hispanic Whites (NHW), racial-ethnic minorities bear a disproportionate burden of stroke and receive fewer evidence-based stroke care processes and treatments. Since 2015, me­chanical thrombectomy (MT) has become standard of care for acute ischemic stroke (AIS) patients with proximal anterior circula­tion large vessel occlusion (LVO).Objectives: Our objectives were to: assess recent trends in nationwide MT utilization among patients with AIS; determine if there were racial differences; and identify what factors were associated with such differ­ences.Methods: We performed a retrospective cohort study using nationally representative data of a non-institutionalized population sample from 2006 to 2014 obtained from the Nationwide Inpatient Sample (NIS). We identified a total of 889,309 observations of AIS, of which there were 5,256 MT observa­tions.Results: In the fully adjusted model, rate of thrombectomy utilization was significantly lower in African Americans (AA) (OR .67, CI .58-.76, P<.001) compared with NHW and Hispanics (OR .94, CI .78-1.13, P=.5).Conclusion: We found a significant dispar­ity in MT utilization for AA compared with NHW and Hispanics. More work is needed to understand the drivers of this racial disparity in stroke treatment. Ethn Dis. 2020;30(1):91-96; doi:10.18865/ed.30.1.91

scholarly journals GP.1 Changes in ischemic stroke presentations and associated workflow during the first wave of the COVID-19 pandemic: A population study

2021 ◽  
Vol 48 (s3) ◽  
pp. S12-S12
Author(s):  
A Ganesh ◽  
JM Stang ◽  
FA McAlister ◽  
O Shlakhter ◽  
JK Holodinsky ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Population Level ◽  
Stroke Care ◽  
Hospital Treatment ◽  
Stroke Severity ◽  
Care Needs ◽  
Acute Therapy ◽  
Treatment Delays ◽  
Related Data ◽  
Adjusted Incidence Rate

Background: Pandemics may promote hospital avoidance among patients with emergencies, and added precautions may exacerbate treatment delays. Methods: We used linked administrative data and data from the Quality Improvement and Clinical Research Alberta Stroke Program – a registry capturing stroke-related data on the entire Albertan population(4.3 million) – to identify all patients hospitalized with stroke in the pre-pandemic(01/01/2016-27/02/2020) and COVID-19 pandemic(28/02/2020-30/08/2020) periods. We examined changes in stroke presentation rates and use of thrombolysis and endovascular therapy(EVT), adjusted for age, sex, comorbidities, and pre-admission care needs; and in workflow, stroke severity(National Institutes of Health Stroke Scale/NIHSS), and in-hospital outcomes. Results: We analyzed 19,531 patients with ischemic stroke pre-pandemic versus 2,255 during the pandemic. Hospitalizations/presentations dropped(weekly adjusted-incidence-rate-ratio[aIRR]:0.48,95%CI:0.46-0.50), as did population-level incidence of thrombolysis(aIRR:0.49,0.44-0.56) or EVT(aIRR:0.59,0.49-0.69). However, proportions of presenting patients receiving thrombolysis/EVT did not decline (thrombolysis:11.7% pre-pandemic vs 13.1% during-pandemic, aOR:1.02,0.75-1.38). For out-of-hospital strokes, onset-to-door times were prolonged(adjusted-coefficient:37.0-minutes, 95%CI:16.5-57.5), and EVT recipients experienced greater door-to-reperfusion delays(adjusted-coefficient:18.7-minutes,1.45-36.0). NIHSS scores and in-hospital mortality did not differ. Conclusions: The first COVID-19 wave was associated with a halving of presentations and acute therapy utilization for ischemic stroke at a population level, and greater pre-/in-hospital treatment delays. Our data can inform public health messaging and stroke care in future pandemic waves.

scholarly journals Access to Mechanical Thrombectomy for Ischemic Stroke in the United States

Stroke ◽  
2021 ◽  
Author(s):  
Hooman Kamel ◽  
Neal S. Parikh ◽  
Abhinaba Chatterjee ◽  
Luke K. Kim ◽  
Jeffrey L. Saver ◽  
...  
Keyword(s):  
United States ◽  
Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
The United States ◽  
Sensitivity Analyses ◽  
Stroke Severity ◽  
Discharge Data ◽  
Cerebral Vessel

Background and Purpose: Mechanical thrombectomy helps prevent disability in patients with acute ischemic stroke involving occlusion of a large cerebral vessel. Thrombectomy requires procedural expertise and not all hospitals have the staff to perform this intervention. Few population-wide data exist regarding access to mechanical thrombectomy. Methods: We examined access to thrombectomy for ischemic stroke using discharge data from calendar years 2016 to 2018 from all nonfederal emergency departments and acute care hospitals across 11 US states encompassing 80 million residents. Facilities were classified as hubs if they performed mechanical thrombectomy, gateways if they transferred patients who ultimately underwent mechanical thrombectomy, and gaps otherwise. We used standard descriptive statistics and unadjusted logistic regression models in our primary analyses. Results: Among 205 681 patients with ischemic stroke, 100 139 (48.7% [95% CI, 48.5%–48.9%]) initially received care at a thrombectomy hub, 72 534 (35.3% [95% CI, 35.1%–35.5%]) at a thrombectomy gateway, and 33 008 (16.0% [95% CI, 15.9%–16.2%]) at a thrombectomy gap. Patients who initially received care at thrombectomy gateways were substantially less likely to ultimately undergo thrombectomy than patients who initially received care at thrombectomy hubs (odds ratio, 0.27 [95% CI, 0.25–0.28]). Rural patients had particularly limited access: 27.7% (95% CI, 26.9%–28.6%) of such patients initially received care at hubs versus 69.5% (95% CI, 69.1%–69.9%) of urban patients. For 93.8% (95% CI, 93.6%–94.0%) of patients with stroke at gateways, their initial facility was capable of delivering intravenous thrombolysis, compared with 76.3% (95% CI, 75.8%–76.7%) of patients at gaps. Our findings were unchanged in models adjusted for demographics and comorbidities and persisted across multiple sensitivity analyses, including analyses adjusting for estimated stroke severity. Conclusions: We found that a substantial proportion of patients with ischemic stroke across the United States lacked access to thrombectomy even after accounting for interhospital transfers. US systems of stroke care require further development to optimize thrombectomy access.

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