049AN AUDIT OF KNOWLEDGE OF ACUTE STROKE GUIDELINES AMONGST GENERAL AND EMERGENCY PHYSICIANS IN A COMPREHENSIVE STROKE CENTRE

Abstract Background Translating clinical guidelines into routine clinical practice is mandatory to achieve population level improvement of health. Emergence of specific therapy for acute stroke yielded the ‘time is brain’ concept introducing the need for emergency treatment, pointing to the need for increasing stroke awareness of the general population. General practitioners (GPs) manage chronic diseases and could hence catalyse stroke awareness. In our study, the knowledge of general practitioners toward accurate identification of acute stroke candidacy was investigated. Methods GPs and residents in training for family medicine participated in a survey on a voluntary basis using supervised self-administration between the 1st of February 2018 and 31st July 2018. Two clinical cases of acute stroke that differed only regarding the patient’s eligibility for intravenous thrombolysis were presented. Participants answered two open-ended questions. Text analysis was performed using NVIVO software. Results Of the 127 respondents, 69 (54.3%) were female. The median age was 49 (34–62) years. The median time spent working after graduation was 14.5 (2–22.5) years. Board-certified GPs made up 77.2% of the sample. Qualitative analysis revealed stroke as the most frequent diagnosis for both cases. Territorial localization and possible aetiology were also established. Respondents properly identified eligibility for thrombolysis. Quantitative assessment showed that having the practice closer to the stroke centre increases the likelihood of adequate diagnosis for acute stroke. Conclusions Our results show that GPs properly diagnose acute stroke and identify intravenous thrombolysis candidates. Moreover, we found that a vigorous acute stroke triage system facilitates the translation of theory into practice.

Download Full-text

tPA for Acute Ischemic Stroke and Its Controversies: A Review

The Neurohospitalist ◽

10.1177/1941874419838961 ◽

2019 ◽

Vol 10 (1) ◽

pp. 5-10 ◽

Cited By ~ 1

Author(s):

Brian Dewar ◽

Michel Shamy

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Historical Context ◽

Building Blocks ◽

Medical Community ◽

Emergency Physicians ◽

Historical Sources ◽

Historical Building ◽

Intravenous Tissue Plasminogen Activator

Background and Purpose:Although neurologists consider intravenous tissue plasminogen activator (tPA) to be standard of care in the treatment of patients with acute ischemic stroke, its use remains contentious within the broader medical community, and particularly among emergency physicians. Why might this be? We provide a historical context to this ongoing controversy by reviewing how neurologists have conceptualized the acute stroke and its treatment, with the aim of bridging this gap.Methods:Based on historical sources in the Mackie Family History of Neuroscience Collection at the University of Calgary, as well as online resources, we trace the evolution of the concept of the “acute stroke,” which has come to mean a stroke that is potentially treatable with tPA. We frame this conceptualization in relation to historical “building blocks” in anatomy, pathology, and physiology. We then use these building blocks to explain why neurologists understand tPA to be effective and why emergency physicians often do not.Results and Conclusions:Arguments against the use of tPA reiterate 20-year-old concerns about its efficacy and safety. We believe these persistent concerns can be framed as a lack of understanding of the “building blocks” upon which neurologists’ conception of tPA is built. Our view suggests that the way forward to bridge the gap between neurology and other disciplines is not to conduct more trials but to offer a shared conceptualization of the trials already completed and of the intellectual tradition from which they emerged.

Download Full-text

Knowledge and Attitudes of Saudi Emergency Physicians toward t-PA Use in Stroke

Neurology Research International ◽

10.1155/2018/3050278 ◽

2018 ◽

Vol 2018 ◽

pp. 1-7

Author(s):

Ali M. Al Khathaami ◽

Haya Aloraini ◽

S. Almudlej ◽

Haifa Al Issa ◽

Nourhan Elshammaa ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Controlled Trial ◽

Negative Attitude ◽

Stroke Care ◽

Emergency Physicians ◽

Web Based ◽

Inadequate Knowledge ◽

Proven Efficacy ◽

Knowledge And Attitude

Background and Objectives. Tissue plasminogen activator (t-PA) within 4.5 hours from onset improves outcome in patients with ischemic stroke and has been recommended by several international guidelines. Since its approval in 1996, the debate among emergency physicians continues particularly around the result interpretation of the first positive randomized controlled trial, the National Institute of Neurological Disorders and Stroke (NINDS) clinical trial. This lack of consensus might negatively affect the delivery of effective stroke care. Here we aimed to assess the knowledge and attitude of Saudi emergency physicians toward t-PA use within 4.5 hours of onset in acute ischemic stroke. Methods. A web-based, self-administered, locally designed questionnaire was sent to all emergency physicians practicing in the city of Riyadh from January to September 2017. Results. Out of 450 emergency physicians, 122 from ten hospitals in Riyadh participated in the survey, with a 27% response rate. The majority of participants were men (78%), and their mean age was 40 ± 8 years. Half of the participants were board certified, and 36% were consultants. Half of the participants consider the evidence for t-PA use in stroke within 4.5 hours of stroke onset to be controversial, and 41% recommend against its use due to lack of proven efficacy (37%), the risk of hemorrhagic complications (35%), lack of stroke expertise (21%), and medicolegal liability (9%). Nearly half were willing to administer IV t-PA for ischemic stroke in collaboration with remote stroke neurology consultation if telestroke is implemented. Conclusion. Our study detected inadequate knowledge and a negative attitude among Saudi emergency physicians toward t-PA use in acute stroke. This might negatively impact patient outcome. Therefore, we recommend developing urgent strategies to improve emergency physicians’ knowledge, attitudes, and beliefs in the management of acute stroke.

Download Full-text

Abstrick of the month: PsychOSocial effecTs Of aCute stroke thrombolysIS programs on neurologists and Emergency physicians: A proSpectIve comparativE cohoRt (POST ‘OC IS EASIER) study.

CJEM ◽

10.1017/s1481803500008332 ◽

2003 ◽

Vol 5 (02) ◽

pp. 133

Author(s):

P Brewer ◽

A. Vadeboncoeur ◽

Keyword(s):

Acute Stroke ◽

Emergency Physicians ◽

Psychosocial Effects ◽

Stroke Thrombolysis

Download Full-text

Optimal patient protocols in regional acute stroke care

Health Care Management Science ◽

10.1007/s10729-020-09524-2 ◽

2021 ◽

Author(s):

B. L. Garcia ◽

R. Bekker ◽

R. D. van der Mei ◽

N. H. Chavannes ◽

N. D. Kruyt

Keyword(s):

Acute Stroke ◽

Rural Areas ◽

Interventional Procedure ◽

Treated Patient ◽

Stroke Care ◽

Mixed Integer ◽

Acute Stroke Care ◽

Mixed Integer Linear Program ◽

Patient Allocation ◽

Stroke Centre

AbstractIn acute stroke care two proven reperfusion treatments exist: (1) a blood thinner and (2) an interventional procedure. The interventional procedure can only be given in a stroke centre with specialized facilities. Rapid initiation of either is key to improving the functional outcome (often emphasized by the common phrase in acute stroke care “time=brain”). Delays between the moment the ambulance is called and the initiation of one or both reperfusion treatment(s) should therefore be as short as possible. The speed of the process strongly depends on five factors: patient location, regional patient allocation by emergency medical services (EMS), travel times of EMS, treatment locations, and in-hospital delays. Regional patient allocation by EMS and treatment locations are sub-optimally configured in daily practice. Our aim is to construct a mathematical model for the joint decision of treatment locations and allocation of acute stroke patients in a region, such that the time until treatment is minimized. We describe acute stroke care as a multi-flow two-level hierarchical facility location problem and the model is formulated as a mixed integer linear program. The objective of the model is the minimization of the total time until treatment in a region and it incorporates volume-dependent in-hospital delays. The resulting model is used to gain insight in the performance of practically oriented patient allocation protocols, used by EMS. We observe that the protocol of directly driving to the nearest stroke centre with special facilities (i.e., the mothership protocol) performs closest to optimal, with an average total time delay that is 3.9% above optimal. Driving to the nearest regional stroke centre (i.e., the drip-and-ship protocol) is on average 8.6% worse than optimal. However, drip-and-ship performs better than the mothership protocol in rural areas and when a small fraction of the population (at most 30%) requires the second procedure, assuming sufficient patient volumes per stroke centre. In the experiments, the time until treatment using the optimal model is reduced by at most 18.9 minutes per treated patient. In economical terms, assuming 150 interventional procedures per year, the value of medical intervention in acute stroke can be improved upon up to € 1,800,000 per year.

Download Full-text

Abstract WMP1: Implementation of a Telestroke Program Based on a Smartphone Application

Stroke ◽

10.1161/str.51.suppl_1.wmp1 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Sheila C Martins ◽

Octavio Pontes-Neto ◽

Leonardo A Carbonera ◽

Ana Claudia Souza ◽

Diogenes Guimaraes Zan ◽

...

Keyword(s):

Acute Stroke ◽

Low Cost ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Smartphone Application ◽

Smartphone App ◽

Emergency Physicians ◽

Remote Communication ◽

Increasing Demand ◽

The Times

Background: The increasing demand and shortage of experts to evaluate and treat acute stroke patients has led to the development of remote communication tools to aid stroke management. We aimed to describe the experience of the Brazilian Stroke Network in the implementation of a telemedicine stroke program using a low-cost smartphone application system (JOIN App, Allm, Japan) for rapid sharing of clinical and neuroimaging patient data. Methods: We evaluated the initial experience of the telestroke program using a smartphone app measuring its feasibility, safety and speed in the acute stroke decision-making process, with a particular focus on intravenous thrombolysis. The App was implemented in hospitals without neurologists available for acute stroke evaluation and was connected with a stroke team to support the decision for thrombolysis. We analyzed the times of acute treatment and safety through the rate of symptomatic intracranial hemorrhage (sICH) in 24hours. The program was implemented as part of the partnership with the Angels Initiative in Brazil supported by Boehringer Ingelheim to improve stroke care across the globe. Results: The telestroke program started in May 2019 and since then 7 hospitals, in 5 Brazilian states, were included. Only 2 of these hospitals had previous experience with stroke thrombolysis. In all hospitals, the patients were assisted by emergency physicians with eventual support of local neurologists. The telestroke program was activated for 58 patients. The median age was 68yo (IQR58-72), 47% were female and the baseline NIHSS was 11 (IQR8-16). In 69% of the activation the diagnosis was ischemic stroke (IS), 7% hemorrhagic, 5% TIA and 28% other diagnosis. Thrombolysis was suggested in 48% of all evaluations (70% of IS patients). A total of 53% of IS were actually treated with thrombolys. The response-time of the stroke experts was 2.6 minutes (2-6), door-to-CT scan 20min (15-31) and door-needle time 59min (27-81). None of the patients had sICH. Conclusion: In a telestroke program using a smartphone App, thrombolysis performed by emergency physicians was feasible and safe. This mobile low cost technology can increase the possibility of patients with stroke to receive treatment in regions without neurologists across the globe.

Download Full-text

Abstract P168: Who Are You Going to Call?: Emergency Physician Stroke Champions

Stroke ◽

10.1161/str.52.suppl_1.p168 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Erol Veznedaroglu ◽

Thomas Kurtz ◽

Mandy J Binning ◽

Kenneth M Liebman ◽

Zakaria Hakma ◽

...

Keyword(s):

Acute Stroke ◽

Emergency Physician ◽

Core Competencies ◽

Direct Care ◽

Emergency Physicians ◽

Stroke Patients ◽

Promising Alternative ◽

Phone Calls ◽

Neurologic Emergency ◽

American Academy Of Neurology

Introduction: A 2013 study supported by the American Academy of Neurology showed an 11% shortage of neurologists with a projected 19% shortage by 2025. An additional supply of 3000 neurologists is needed by 2025 to meet the looming demand. To help ease the shortage, teleneurology has been implemented by neurologists, mainly for acute stroke patients. We present our model of emergency physician Stroke Champions (SCs) to direct care for stroke patients. Methods: Administering thrombolytics for stroke is a key component of emergency medicine core competencies. Our health system consists of 4 hospitals; a main hub and 3 spoke hospitals. The hub hospital innovatively developed a Neurologic Emergency Department (Neuro ED) with 5 board certified emergency physicians dedicated to caring for patients with any type of neurological complaint. The Neuro ED physicians are also designated as SCs that have specialized training to provide teleneurology to fellow emergency physicians caring for acute stroke patients at the additional hospitals. This supplementary training consists of a mini neurology fellowship with rotations through the neurologic ICU, specialized stroke floor, neurointerventional suite, and neuroradiology. Results: Over a 90-day period the command center received 67 phone calls for patients that met stroke alert criteria. Calls entailed managing BP, dosing alteplase, and recommendations for advanced neuroimaging. Most importantly, the SCs extensively reviewed inclusion and exclusion criteria for IV alteplase with the spoke emergency physician. Three patients were deemed eligible for IV alteplase, with no cases of intracranial hemorrhage. Seven patients required transfer and was facilitated by the SCs, reducing any delays. Reasons for transfer included 3 cases of hemorrhagic stroke, 3 large vessel occlusions for mechanical thrombectomy - one of which received IV alteplase, and 1 brain tumor. Conclusion: Teleneurology is a reliable means of reaching and treating stroke patients. With the severe current shortage of neurologists in the U.S., we now demonstrate a promising alternative of emergency physician Stroke Champions providing telestroke care. This model has produced a high success rate raising the standard of acute neurological care.

Download Full-text

(P2-5) Pre- and in-Hospital Time Delays in Acute Stroke Management in Estonia

Prehospital and Disaster Medicine ◽

10.1017/s1049023x11004493 ◽

2011 ◽

Vol 26 (S1) ◽

pp. s136-s137

Author(s):

K. Gross-Paju ◽

R. Adlas ◽

U. Sorro

Keyword(s):

Acute Stroke ◽

Time Delays ◽

Treatment Guidelines ◽

Hospital Staff ◽

Stroke Management ◽

Hospital Data ◽

Stroke Patients ◽

Ambulance Personnel ◽

Procedure Guidelines ◽

Stroke Centre

BackgroundShort intervals between stroke onset and thrombolysis determine the efficacy of this procedure. Guidelines for stroke management were introduced in 2005 in the West-Tallinn Stroke Centre and in 2008 in the Tallinn Emergency Medical Services. Since 2006, annual joint stroke meetings of pre- and in-hospital staff have been held. These meetings included analysis of time delays of thrombolyzed patients.ObjectiveThe aim of the study was to analyze changes in time delays in acute stroke management and adherence to treatment guidelines.MethodsPre- and in-hospital data of all consecutive ischemic stroke patients who received intravenous thrombolytic therapy were recorded prospectively at the Stroke Centre. Data from the implementation period of thrombolysis (2005–2008 i.e., 1st period) were compared to recent data from 2009 to 01 September 2010 (2nd period). The data from all stroke patients presenting to ambulance services were analyzed separately from 01 September 2009 to 01 September 2010. Recorded procedures were compared to current treatment guidelines.ResultsA total of 115 patients received thrombolysis at the Stroke Centre. The Alarm Centre assigned the correct priority (C, lights and sirens) for 31% of thrombolyzed patients during the 1st period, and for 80% during the 2nd period. The mean time ambulance personnel spent at the home was 20 minutes during both periods. In-hospital door-to-needle time was < 60 minutes in 11% of patients during the 1st period, and in 56% during the 2nd period. Ambulance personnel treated 1,094 stroke patients during the study. All procedures were performed and documented correctly in 10% of visits. The most frequent deviation from guidelines was under-reported values of blood glucose. In 44.7% of patients, an ECG was performed, which is not required by guidelines.ConclusionsAcute stroke management improved significantly. Adherence to recently developed stroke guidelines in the ambulance services must be improved.

Download Full-text