scholarly journals Feasibility of a hyper-acute stroke unit model of care across England: a modelling analysis

BMJ Open ◽  
2017 ◽  
Vol 7 (12) ◽  
pp. e018143 ◽  
Author(s):  
Michael Allen ◽  
Kerry Pearn ◽  
Emma Villeneuve ◽  
Thomas Monks ◽  
Ken Stein ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Travel Time ◽  
Stroke Unit ◽  
Stroke Care ◽  
Hyperacute Stroke ◽  
Geographical Access ◽  
Unit Model ◽  
Stroke Services ◽  
Time Critical ◽  
Institutional Size

ObjectivesThe policy of centralising hyperacute stroke units (HASUs) in England aims to provide stroke care in units that are both large enough to sustain expertise (>600 admissions/year) and dispersed enough to rapidly deliver time-critical treatments (<30 min maximum travel time). Currently, just over half (56%) of patients with stroke access care in such a unit. We sought to model national configurations of HASUs that would optimise both institutional size and geographical access to stroke care, to maximise the population benefit from the centralisation of stroke care.DesignModelling of the effect of the national reconfiguration of stroke services. Optimal solutions were identified using a heuristic genetic algorithm.Setting127 acute stroke services in England, serving a population of 54 million people.Participants238 887 emergency admissions with acute stroke over a 3-year period (2013–2015).InterventionModelled reconfigurations of HASUs optimised for institutional size and geographical access.Main outcome measureTravel distances and times to HASUs, proportion of patients attending a HASU with at least 600 admissions per year, and minimum and maximum HASU admissions.ResultsSolutions were identified with 75–85 HASUs with annual stroke admissions in the range of 600–2000, which achieve up to 82% of patients attending a stroke unit within 30 min estimated travel time (with at least 95% and 98% of the patients being within 45 and 60 min travel time, respectively).ConclusionsThe reconfiguration of hyperacute stroke services in England could lead to all patients being treated in a HASU with between 600 and 2000 admissions per year. However, the proportion of patients within 30 min of a HASU would fall from over 90% to 80%–82%.

scholarly journals Variation in quality of acute stroke care by day and time of admission: prospective cohort study of weekday and weekend centralised hyperacute stroke unit care and non-centralised services

BMJ Open ◽  
2019 ◽  
Vol 9 (11) ◽  
pp. e025366 ◽  
Author(s):  
Mariya Melnychuk ◽  
Stephen Morris ◽  
Georgia Black ◽  
Angus I G Ramsay ◽  
Jeannie Eng ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Stroke Unit ◽  
Performance Standards ◽  
Stroke Care ◽  
Acute Stroke Care ◽  
P Values ◽  
Stroke Units ◽  
Hyperacute Stroke ◽  
Time Of Admission

ObjectiveTo investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units compared with the rest of England.DesignProspective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme.SettingAcute stroke services in London hyperacute stroke units and the rest of England.Participants68 239 patients with a primary diagnosis of stroke admitted between January and December 2014.InterventionsHub-and-spoke model for care of suspected acute stroke patients in London with performance standards designed to deliver uniform access to high-quality hyperacute stroke unit care across the week.Main outcome measures16 indicators of quality of acute stroke care, mortality at 3 days after admission to the hospital, disability at the end of the inpatient spell, length of stay.ResultsThere was no variation in quality of care by day and time of admission to the hospital across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor was there variation in 3-day mortality or disability at hospital discharge (all p values>0.05). Other quality of care measures significantly varied by day and time of admission across the week in London (all p values<0.01). In the rest of England there was variation in all measures by day and time of admission across the week (all p values<0.01), except for mortality at 3 days (p value>0.05).ConclusionsThe London hyperacute stroke unit model achieved performance standards for ‘front door’ stroke care across the week. The same benefits were not achieved by other models of care in the rest of England. There was no weekend effect for mortality in London or the rest of the England. Other aspects of care were not constant across the week in London hyperacute stroke units, indicating some performance standards were perceived to be more important than others.

scholarly journals Impact and sustainability of centralising acute stroke services in English metropolitan areas: retrospective analysis of hospital episode statistics and stroke national audit data

BMJ ◽  
2019 ◽  
pp. l1 ◽  
Author(s):  
Stephen Morris ◽  
Angus I G Ramsay ◽  
Ruth J Boaden ◽  
Rachael M Hunter ◽  
Christopher McKevitt ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Acute Stroke ◽  
Stroke Unit ◽  
Acute Hospital ◽  
Evidence Based ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
Clinical Interventions ◽  
Hyperacute Stroke ◽  
Stroke Services

Abstract Objectives To investigate whether further centralisation of acute stroke services in Greater Manchester in 2015 was associated with changes in outcomes and whether the effects of centralisation of acute stroke services in London in 2010 were sustained. Design Retrospective analyses of patient level data from the Hospital Episode Statistics (HES) database linked to mortality data from the Office for National Statistics, and the Sentinel Stroke National Audit Programme (SSNAP). Setting Acute stroke services in Greater Manchester and London, England. Participants 509 182 stroke patients in HES living in urban areas admitted between January 2008 and March 2016; 218 120 stroke patients in SSNAP between April 2013 and March 2016. Interventions Hub and spoke models for acute stroke care. Main outcome measures Mortality at 90 days after hospital admission; length of acute hospital stay; treatment in a hyperacute stroke unit; 19 evidence based clinical interventions. Results In Greater Manchester, borderline evidence suggested that risk adjusted mortality at 90 days declined overall; a significant decline in mortality was seen among patients treated at a hyperacute stroke unit (difference-in-differences −1.8% (95% confidence interval −3.4 to −0.2)), indicating 69 fewer deaths per year. A significant decline was seen in risk adjusted length of acute hospital stay overall (−1.5 (−2.5 to −0.4) days; P<0.01), indicating 6750 fewer bed days a year. The number of patients treated in a hyperacute stroke unit increased from 39% in 2010-12 to 86% in 2015/16. In London, the 90 day mortality rate was sustained (P>0.05), length of hospital stay declined (P<0.01), and more than 90% of patients were treated in a hyperacute stroke unit. Achievement of evidence based clinical interventions generally remained constant or improved in both areas. Conclusions Centralised models of acute stroke care, in which all stroke patients receive hyperacute care, can reduce mortality and length of acute hospital stay and improve provision of evidence based clinical interventions. Effects can be sustained over time.

Developing a Hyperacute Stroke-Ready Nursing Workforce: a Service Improvement Initiative

2020 ◽  
Vol 16 (Sup5) ◽  
pp. S10-S16
Author(s):  
Nicola Turner ◽  
Pedro Duarte ◽  
Anthony Jones ◽  
Ian Dovaston ◽  
David Pitchforth
Keyword(s):  
Emergency Department ◽  
Acute Stroke ◽  
Stroke Unit ◽  
Stroke Care ◽  
Nursing Workforce ◽  
Service Improvement ◽  
Acute Stroke Care ◽  
Out Of Hours ◽  
Hyperacute Stroke ◽  
Stroke Thrombolysis

Background Thrombolysis treatment varies considerably between in- and out-of-hours services. Aims This improvement initiative aimed to upskill acute stroke unit nurses as stroke thrombolysis response nurses, testing a new model of nursing in readiness for hyperacute stroke unit developments. Methods Three registered nurses were trained to a specialist competency framework. The role was tested over 28 weeks, and times to treatment milestones were measured. Thrombolysed patients from the test period were statistically compared with a matched group using a two-sample t-test in Excel. Qualitative feedback was sought from the stroke team, medical and emergency department colleagues. Findings Median out-of-hours door-to-needle time reduced from 85 to 61.5 minutes. Statistically significant differences were seen in the time to stroke unit admission (p=0.012) and swallow screen (p=0.038). Stroke and emergency department colleagues considered the role essential to out-of-hours thrombolysis treatment. Conclusions The stroke thrombolysis response nurse role reduced variation in treatment and improved timely acute stroke care. This work may inform the development of stroke nursing workforce models.

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

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.

scholarly journals The role of cardiologists on the stroke unit

2020 ◽  
Vol 22 (Supplement_M) ◽  
pp. M3-M12
Author(s):  
Wolfram Doehner ◽  
David Manuel Leistner ◽  
Heinrich J Audebert ◽  
Jan F Scheitz
Keyword(s):  
Acute Stroke ◽  
Stroke Unit ◽  
Stroke Care ◽  
Cardiovascular Complications ◽  
Large Artery ◽  
Stroke Management ◽  
Acute Stroke Care ◽  
Daily Work ◽  
Cardiovascular Comorbidity ◽  
Treatment And Prevention

Abstract Cardiologists need a better understanding of stroke and of cardiac implications in modern stroke management. Stroke is a leading disease in terms of mortality and disability in our society. Up to half of ischaemic strokes are directly related to cardiac and large artery diseases and cardiovascular risk factors are involved in most other strokes. Moreover, in an acute stroke direct central brain signals and a consecutive autonomic/vegetative imbalance may account for severe and life-threatening cardiovascular complications. The strong cerebro-cardiac link in acute stroke has recently been addressed as the stroke-heart syndrome that requires careful cardiovascular monitoring and immediate therapeutic measures. The regular involvement of cardiologic expertise in daily work on a stroke unit is therefore of high importance and a cornerstone of up-to-date comprehensive stroke care concepts. The main targets of the cardiologists’ contribution to acute stroke care can be categorized in three main areas (i) diagnostics workup of stroke aetiology, (ii) treatment and prevention of complications, and (iii) secondary prevention and sub-acute workup of cardiovascular comorbidity. All three aspects are by themselves highly relevant to support optimal acute management and to improve the short-term and long-term outcomes of patients. In this article, an overview is provided on these main targets of cardiologists’ contribution to acute stroke management.

scholarly journals Effects of centralizing acute stroke services

Neurology ◽  
2018 ◽  
Vol 91 (3) ◽  
pp. e236-e248 ◽  
Author(s):  
Sidsel Hastrup ◽  
Soren P. Johnsen ◽  
Thorkild Terkelsen ◽  
Heidi H. Hundborg ◽  
Paul von Weitzel-Mudersbach ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Acute Stroke ◽  
Stroke Care ◽  
Acute Hospital ◽  
Acute Stroke Care ◽  
Difference In Differences ◽  
Stroke Units ◽  
Before And After ◽  
Stroke Services

ObjectiveTo investigate the effects of centralizing the acute stroke services in the Central Denmark Region (CDR).MethodsThe CDR (1.3 million inhabitants) centralized acute stroke care from 6 to 2 designated acute stroke units with 7-day outpatient clinics. We performed a prospective “before-and-after” cohort study comparing all strokes from the CDR with strokes in the rest of Denmark to discover underlying general trends, adopting a difference-in-differences approach. The population comprised 22,141 stroke cases hospitalized from May 2011 to April 2012 and May 2013 to April 2014.ResultsCentralization was associated with a significant reduction in length of acute hospital stay from a median of 5 to 2 days with a length-of-stay ratio of 0.53 (95% confidence interval 0.38–0.75, data adjusted) with no corresponding change seen in the rest of Denmark. Similarly, centralization led to a significant increase in strokes with same-day admission (mainly outpatients), whereas this remained unchanged in the rest of Denmark. We observed a significant improvement in quality of care captured in 11 process performance measures in both the CDR and the rest of Denmark. Centralization was associated with a nonsignificant increase in thrombolysis rate. We observed a slight increase in readmissions at day 30, but this was not significantly different from the general trend. Mortality at days 30 and 365 remained unchanged, as in the rest of Denmark.ConclusionsCentralizing acute stroke care in the CDR significantly reduced the length of acute hospital stay without compromising quality. Readmissions and mortality stayed comparable to the rest of Denmark.

Stroke Unit Development and Working Dynamics - Acute Stroke Care Program

2007 ◽  
Vol 14 (4) ◽  
pp. e76-e77
Author(s):  
J. Awruch ◽  
R. Valentini ◽  
L. Lemme-Pleghos ◽  
G. Janello ◽  
I. Bonelli ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Stroke Unit ◽  
Care Program ◽  
Stroke Care ◽  
Acute Stroke Care

Influence of stroke coordinators on delivery of acute stroke care and hospital outcomes: An observational study

2017 ◽  
Vol 13 (6) ◽  
pp. 585-591 ◽  
Author(s):  
Tara Purvis ◽  
Monique F Kilkenny ◽  
Sandy Middleton ◽  
Dominique A Cadilhac
Keyword(s):  
Length Of Stay ◽  
Observational Study ◽  
Acute Stroke ◽  
Patient Outcomes ◽  
Stroke Unit ◽  
Stroke Care ◽  
Initial Assessment ◽  
Evidence Based ◽  
Clinical Practices ◽  
Evidence Based Care

Background Stroke coordinators have been inconsistently used in various countries to support stroke care in hospital. Aim To investigate the association between stroke coordinators and the provision of evidence-based care and patient outcomes in hospitals with acute stroke units. Methods Observational study using cross-sectional data from the 2015 National Acute Services Audit Program (Australia): including a retrospective medical record audit (40 records from each hospital) and a self-reported survey of organizational resources for stroke. Multilevel random effects logistic regression for patient outcomes including complications, independence on discharge, and death. Median regression for length of stay comparisons. Results A total of 109 hospitals submitted 4060 cases; 59 (54%) had a stroke coordinator. Compared with patients from stroke unit hospitals with no stroke coordinator ( N = 33, 1333 cases), patients in stroke unit hospitals with a stroke coordinator ( N = 53, 2072 cases) were more likely to receive clinical practices including rehabilitation therapy within 48 hours of initial assessment (88 vs. 82%, p < 0.001), risk factor modification advice (62 vs. 55%, p = 0.003) and receive a discharge care plan (65 vs. 48%, p < 0.001). No differences in complications, independence on discharge, or deaths were evident. Patients from hospitals with a stroke coordinator were more likely to access inpatient rehabilitation (adjusted odds ratio 1.8, 95% confidence interval 1.1–2.8) and have a reduced length of acute stay if discharged (median 14 h, p = 0.03). Conclusion Presence of stroke coordinators was associated with reduced length of stay and improved delivery of evidence-based care in hospitals with a stroke unit.

scholarly journals P027: Development of a physician assistant lead stroke protocol to provide timely and equitable access to hyperacute stroke care in a telestroke community hospital

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S74-S74
Author(s):  
L. Shoots ◽  
V. Bailey
Keyword(s):  
Acute Stroke ◽  
Local Community ◽  
Community Hospital ◽  
Stroke Care ◽  
Physician Assistants ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
Hyperacute Stroke ◽  
Phone Calls ◽  
Triage Time

Background: The Brant Community Healthcare System (BCHS) has consistently been well above the recommended 30 minute benchmark for door-to-needle (DTN) for eligible acute stroke patients. As a large community hospital with no neurologists, and like many other hospitals internationally, we rely on telestroke support for every stroke case. This is a time-consuming process that requires a multitude of phone calls, and pulls physicians from other acutely ill patients. We sought to develop a system that would streamline our approach and care for hyperacute stroke patients by targeting improvements in DTN. Aim Statement: We will decrease the door-to-needle (DTN) time for stroke patients arriving at the BCHS Emergency Department (ED) who are eligible for tissue plasminogen activator (tPA) by 25% from a median of 87 minutes to 50 minutes by March 31, 2018 and maintain that standard. Measures & Design: Outcome Measures: Door-to-needle time for acute stroke patients receiving tPA Process Measures: Door-to-triage time, Door-to-CT time, Door-to-CTA time; INR collection-to-verification time, telestroke callback time Balancing Measures: Number of stroke protocol patients per month Model Design: We simultaneously designed and implemented a robust program to train physician assistants in hyperacute stroke care. Evaluation/Results: Through vast stakeholder engagement and implementing a multitude of change ideas, by March of 2018 we had achieved an average DTN of 53 minutes. Our door-to-triage time went from an average of 7 minutes to 3 minutes. Our door-to-CT time decreased from 17 minutes to 7 minutes and our time between CT and CTA from an average of 13 minutes to 3 minutes. One and a half years later, our average DTN is maintained at 55 minutes and physician assistants continue to effectively lead and liaise with telestroke neurologists and stroke patients. Discussion/Impact: Prior to this program, acute stroke care was a very contentious topic at our local community hospital. Creating a program that streamlined the care and standardized the work has proven successful, and not only allowed for improved DTN times but also freed up physicians to better simultaneously care for other acutely ill patients.

Sign in / Sign up

Export Citation Format

Share Document