scholarly journals Enhancing acute stroke services: a quality improvement project

2018 ◽  
Vol 7 (3) ◽  
pp. e000258 ◽  
Author(s):  
Keith McGrath ◽  
Nora Cunningham ◽  
Elizabeth Moloney ◽  
Margaret O’Connor ◽  
John McManus ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Ischaemic Stroke ◽  
Acute Stroke ◽  
Acute Ischaemic Stroke ◽  
Intravenous Thrombolysis ◽  
University Hospital ◽  
Acute Stroke Care ◽  
Improvement Project ◽  
Stroke Team ◽  
Stroke Services

BackgroundIn a busy stroke centre in Ireland, care for acute stroke was provided by a mixture of general physicians. In acute ischaemic stroke, speed is essential for good outcomes.AimTo improve acute stroke services and decrease door-to-needle (DTN) time to less than 60 min by December 2016 in patients with acute ischaemic stroke who are eligible for intravenous thrombolysis.Design: A quality improvement (QI) project was undertaken in a 438 bed, acute, university hospital.MethodsMixture of qualitative and quantitative data collected. A process map and driver diagram were created. Interventions tested with Plan-Do-Study-Act cycles. Times compared between July and December 2015, January and July 2016, July and December 2016, when a new stroke team and pathway were introduced.ResultsBetween July and December 2015, the total number of ischaemic strokes was 216. 17 were thrombolysed (7.8%). Median door-to-CT (DTCT) time was 36 min (range 21–88). Median DTN time was 99 min (range 52–239). Between July and December 2016, there were 214 ischaemic strokes. 29 were thrombolysed (13.5%). 9 were seen directly by the stroke team during normal hours. With stroke team involvement, median DTCT time was 34 min (range 14–60) and DTN time was 43.5 min (range 24–65).ConclusionsThis project led to a significant and sustained improvement in acute stroke care in our hospital with the use of quality improvement techniques. A comprehensive protocol, recurrent and ongoing staff education, and good communication helped to mitigate delays and further enhance care provided to patients presenting with stroke. The approach described may be valuable to the improvement of other services.’

scholarly journals Implementation of regional Acute Stroke Care Map increases thrombolysis rates for acute ischaemic stroke in Chinese urban area in only 3 months

2020 ◽  
pp. svn-2020-000332
Author(s):  
Yi Sui ◽  
Jianfeng Luo ◽  
Chunyao Dong ◽  
Liqiang Zheng ◽  
Weijin Zhao ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Acute Stroke ◽  
Urban Area ◽  
Acute Ischaemic Stroke ◽  
Urban Areas ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
Care Quality ◽  
Acute Stroke Care ◽  
Tertiary Hospitals

BackgroundThe rate of intravenous thrombolysis for acute ischaemic stroke remains low in China. We investigated whether the implementation of a citywide Acute Stroke Care Map (ASCaM) is associated with an improvement of acute stroke care quality in a Chinese urban area.MethodsThe ASCaM comprises 10 improvement strategies and has been implemented through a network consisting of 20 tertiary hospitals. We identified 7827 patients with ischaemic stroke admitted from April to October 2017, and 506 patients underwent thrombolysis were finally included for analysis.ResultsCompared with ‘pre-ASCaM period’, we observed an increased rate of administration of tissue plasminogen activator within 4.5 hours (65.4% vs 54.5%; adjusted OR, 1.724; 95% CI 1.21 to 2.45; p=0.003) during ‘ASCaM period’. In multivariate analysis models, ‘ASCaM period’ was associated with a significant reduction in onset-to-door time (114.1±55.7 vs 135.7±58.4 min, p=0.0002) and onset-to-needle time (ONT) (169.2±58.1 vs 195.6±59.3 min, p<0.0001). Yet no change was found in door-to-needle time. Clinical outcomes such as symptomatic intracranial haemorrhage, favourable functional outcome (modified Rankin Scale ≤2) and in-hospital mortality remained unchanged.ConclusionThe implementation of ASCaM was significantly associated with increased rates of intravenous thrombolysis and shorter ONT. The ASCaM may, in proof-of-principle, serve as a model to reduce treatment delay and increase thrombolysis rates in Chinese urban areas and possibly other highly populated Asian regions.

scholarly journals Clopidogrel resistance in stroke patients (The CRISP Trial)

2020 ◽  
Vol 11 (1) ◽  
pp. 1-5
Author(s):  
E Qazi, ◽  
Syed AH Zaidi ◽  
Olukolade O Owojori ◽  
LJ Bonnett ◽  
PR Fitzsimmons ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Acute Stroke ◽  
Acute Ischaemic Stroke ◽  
University Hospital ◽  
P Value ◽  
Clopidogrel Resistance ◽  
Appropriate Treatment ◽  
Unit Increase ◽  
Acute Stroke Unit

Objective: To investigate the incidence of clopidogrel resistance in patients with acute ischaemic stroke and to evaluate whether there is an association between clopidogrel resistance and the occurrence of a further cerebrovascular ischaemic event using the vasodilator-stimulated phosphoprotein (VASP) index as a marker of clopidogrel resistance. Methods: It is a prospective cohort study that recruited 120 patients from the acute stroke unit at the Royal Liverpool University Hospital. All patients with confirmed acute ischaemic stroke had clopidogrel 75mg/day at discharge or after 14 days of acute stroke if deemed by the direct clinical team to be the most appropriate treatment. After at least 7 days of clopidogrel 75mg/day, all those patients fulfilling inclusion/exclusion criteria had phosphorylation of vasodilator-stimulated phosphoprotein (VASP) measured. If VASP measured ≥50% after ≥7 days of clopidogrel maintenance, these patients were deemed as ‘clopidogrel resistant’, while those with VASP <50% were deemed as ‘clopidogrel responder’. Statistical analysis was by univariable analysis which considered the association of each variable – diagnosis, age, duration of clopidogrel, VASP, days to VASP, and number of comorbidities – with the outcome. Risk of second stroke after a first at 6, 12 and 24 months was estimated using logistic regression. Results: No variables were significantly associated with risk of stroke at 6 months with clopidogrel resistance having no significant effect on likelihood of a further stroke compared to the no clopiodgrel resistance cohort (p value= 0.39). Results were similar at 12 months follow up. However, at 24 months VASP index was significantly associated with risk of a further stroke; each one unit increase in VASP was associated with a 3% increase in risk of stroke at 24 months (p value = 0.05, CI Interval of 1.00- 1.06). Conclusion: No variables were significantly associated with risk of further stroke at 6 months and 12 months after a first stroke. However, VASP was significantly associated with risk of further stroke at 24 months with increasing VASP leading to a higher risk of further stroke.

scholarly journals 53 Improving Door to Needle Times in Acute Stroke

2019 ◽  
Vol 48 (Supplement_3) ◽  
pp. iii1-iii16
Author(s):  
Dzulkarnain Khalil ◽  
Fiona Connaughton ◽  
Danielle Carolan ◽  
Mihaela Sirbu ◽  
Bernadette Lynch ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Decision Making ◽  
Quality Improvement ◽  
Acute Stroke ◽  
Clinical Condition ◽  
Intravenous Thrombolysis ◽  
Hospital Inpatient ◽  
Stroke Team ◽  
Significant Disability ◽  
Iv Tpa

Abstract Background During an acute stroke, 2 million neurons are lost every minute. When compared with aging, 2 million neurons are lost every 22 days. Prompt reperfusion of an acute stroke, in the form of intravenous thrombolysis (IV tPA) or intraarterial thrombectomy (IAT) would save these neurons and result in saving significant disability. We endeavoured as part of a quality improvement (QI) project to improve our times. Methods A local QI steering group was formed which comprised of representatives from the stroke team, radiology, emergency, laboratory, telephone and clerical departments. We outlined our stroke pathway from when the patient arrives to when the patient received IVtPA or IAT. Data was collected prospectively and retrospectively from real time, chart reviews, radiology Picture Archiving Communication System (PACS) and Hospital Inpatient Patient Enquiry (HIPE) stroke data system. We recorded times from door to computed tomography (CT), CT to issue of report and CT report to IVtpA or IAT. The data was reviewed to ascertain if there were any delays at each stage of the pathway. Results There were steps in the pathway that were non-variable and those that were highly variable. In general, steps from door to CT, were consistent each time. In contrast, steps from CT completion to IVtPA or IAT, was highly variable dependent on a patient’s clinical condition and decision making expertise available. We addressed duplication of tasks and additional non-urgent investigations. The presence of the stroke team for IVtPA and IAT made decision making faster. The overall median door to CT time reduced by 9 minutes, from 22 to 13 minutes. The overall median door to IVtPA time decreased by 24 minutes, from 83 to 59 minutes. Our hospital had the fastest door to CT time for IAT patients in 2018 nationally. Conclusion Delays in the stroke pathway were rectifiable by change of practice. Most changes were simple without need of any additional resource.

Abstract T P205: Efficacy and Safety of Telemedicine in Acute Stroke Care in a Metropolitan Area: Final Results of the Madrid Telestroke Project

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Patricia Martinez Sanchez ◽  
María Alonso de Leciñana ◽  
Ambrosio Miralles ◽  
Nuria Huertas Gonzalez ◽  
Blanca Fuentes ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Metropolitan Area ◽  
Community Hospital ◽  
Intravenous Thrombolysis ◽  
University Hospital ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
Phone Calls ◽  
Number Of Patients ◽  
Stroke Center

Introduction: our primary objective was to analyze the efficacy of a Telestroke system in terms of an increase in the number of patients treated with intravenous thrombolysis (IVT) and a shorter door-to-needle time, in the metropolitan area of Madrid, Spain. Our secondary objective was to analyze the safety of Telestroke in terms of mortality and symptomatic hemorrhagic transformation (SHT). Methods: prospective observational cohort study: 1) cohort exposed to Telestroke: acute ischemic stroke patients attended at Infanta Sofia University Hospital (community hospital) connected by Telestroke with the Stroke Center at La Paz University Hospital; 2) Non-exposed cohort: acute stroke patients who are attended at Severo Ochoa University Hospital (community hospital) connected by phone with the Stroke Center at Ramon y Cajal University Hospital. The number of patient attended, number of IVT, times (min), 3-months outcome (mRS), the number of unnecessary transfers and safety parameters (mortality and SHT by ECAS III criteria) were recorded. We analyzed the first 34 months of the Telestroke (March 2011-december 2013). Results: in the Telestroke cohort the system was activated in 59 patients, being stroke code in 42 cases. In the non-exposed cohort 45 phone calls were made, being stroke code in 42 cases. In the Telestroke cohort, IVT were administrated in 61.9% (26/42) of patients whereas in the non-exposed only 28.6% (12/42) received this treatment (P=0,002). The door-to-needle time was shorter in Telestroke cohort than in the non-exposed cohort (mean [SD]) (86.9 [41.7] vs. 149.7 [68.2], P=0.001). The 3-month outcomes were better in the Telestroke cohort (mRS 0-3: 92.9% vs. 73.8%, P=0.038). Mortality (4,8% vs. 4.8%) and SHT (0% vs. 4.8%) were similar in both groups (P = NS). In addition, there were fewer unnecessary secondary transfers in the Telestroke cohort (4.3% vs. 20%, P=0.027). Conclusion: the implementation of a Telestroke system in a metropolitan area is effective and safe, increasing the number of IV thrombolysis and reducing the door-to-needle times. Furthermore, the Telestroke reduces the number of unnecessary secondary transfers.

scholarly journals Clopidogrel resistance in stroke patients (The CRISP Trial)

2021 ◽  
Vol 11 (1) ◽  
pp. 1-5
Author(s):  
E Qazi, ◽  
Syed AH Zaidi ◽  
Olukolade O Owojori ◽  
 LJ Bonnett ◽  
PR Fitzsimmons ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Acute Stroke ◽  
Acute Ischaemic Stroke ◽  
University Hospital ◽  
P Value ◽  
Clopidogrel Resistance ◽  
Appropriate Treatment ◽  
Unit Increase ◽  
Acute Stroke Unit

Objective: To investigate the incidence of clopidogrel resistance in patients with acute ischaemic stroke and to evaluate whether there is an association between clopidogrel resistance and the occurrence of a further cerebrovascular ischaemic event using the vasodilator-stimulated phosphoprotein (VASP) index as a marker of clopidogrel resistance. Methods: It is a prospective cohort study that recruited 120 patients from the acute stroke unit at the Royal Liverpool University Hospital. All patients with confirmed acute ischaemic stroke had clopidogrel 75mg/day at discharge or after 14 days of acute stroke if deemed by the direct clinical team to be the most appropriate treatment. After at least 7 days of clopidogrel 75mg/day, all those patients fulfilling inclusion/exclusion criteria had phosphorylation of vasodilator-stimulated phosphoprotein (VASP) measured. If VASP measured ≥50% after ≥7 days of clopidogrel maintenance, these patients were deemed as ‘clopidogrel resistant’, while those with VASP <50% were deemed as ‘clopidogrel responder’. Statistical analysis was by univariable analysis which considered the association of each variable – diagnosis, age, duration of clopidogrel, VASP, days to VASP, and number of comorbidities – with the outcome. Risk of second stroke after a first at 6, 12 and 24 months was estimated using logistic regression. Results: No variables were significantly associated with risk of stroke at 6 months with clopidogrel resistance having no significant effect on likelihood of a further stroke compared to the no clopiodgrel resistance cohort (p value= 0.39). Results were similar at 12 months follow up. However, at 24 months VASP index was significantly associated with risk of a further stroke; each one unit increase in VASP was associated with a 3% increase in risk of stroke at 24 months (p value = 0.05, CI Interval of 1.00- 1.06). Conclusion: No variables were significantly associated with risk of further stroke at 6 months and 12 months after a first stroke. However, VASP was significantly associated with risk of further stroke at 24 months with increasing VASP leading to a higher risk of further stroke.

Carotid endarterectomy following thrombolysis for acute ischaemic stroke

VASA ◽  
2017 ◽  
Vol 46 (2) ◽  
pp. 116-120 ◽  
Author(s):  
Naz Ahmed ◽  
Damian Kelleher ◽  
Manmohan Madan ◽  
Sarita Sochart ◽  
George A. Antoniou
Keyword(s):  
Ischaemic Stroke ◽  
Carotid Endarterectomy ◽  
Acute Ischaemic Stroke ◽  
Intravenous Thrombolysis ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Wound Complications ◽  
Cardiac Complications ◽  
High Dependency ◽  
Low Incidence

Abstract. Background: Insufficient evidence exists to support the safety of carotid endarterectomy (CEA) following intravenous thrombolysis (IVT) for acute ischaemic stroke. Our study aimed to report a single-centre experience of patients treated over a five-year period. Patients and methods: Departmental computerised databases were interrogated to identify patients who suffered an ischaemic stroke and subsequently underwent thrombolysis followed by CEA. Mortality and stroke within 30 days of surgery were defined as the primary outcome end points. Results: Over a five-year period, 177 out of a total of 679 carotid endarterectomies (26 %) were performed in patients presenting with acute ischaemic stroke. Twenty-five patients (14 %) received IVT prior to CEA in the form of alteplase. Sixty percent of patients were male with a mean age of 68 years. Sixteen patients (64 %) underwent CEA within 14 days of IVT and the median interval between thrombolysis and CEA was 7.5 days (range, 3–50 days). One female patient died of a further intraoperative stroke within 30 days of surgery, yielding a mortality rate of 4 %. Two patients (8 %) suffered from cardiac complications postoperatively resulting in a short high dependency unit stay. Another two patients (8 %) developed local wound complications, which were managed conservatively without the need for re-operation. The median hospital length of stay was 4.5 days (range, 1–33 days). Conclusions: Our experience indicates that CEA post-thrombolysis has a low incidence of mortality. Further high quality evidence is required before CEA can be routinely recommended following IVT for acute ischaemic stroke.

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