Weekend effect in endovascular stroke treatment: do treatment decisions, procedural times, and outcome depend on time of admission?

2016 ◽  
Vol 9 (4) ◽  
pp. 336-339 ◽  
Author(s):  
Omid Nikoubashman ◽  
Thomas Probst ◽  
Kolja Schürmann ◽  
Ahmed E Othman ◽  
Oliver Matz ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Treatment Decision ◽  
Working Hours ◽  
Epidemiologic Studies ◽  
Weekend Effect ◽  
Out Of Hours ◽  
Stroke Treatment ◽  
Decision Bias ◽  
Angiography Suite ◽  
Time Of Admission

BackgroundEpidemiologic studies identified a ‘weekend effect’ or ‘out-of-hours effect’, which implies that procedural and clinical outcomes of patients with stroke, who are admitted out-of-hours, are less favorable than for patients admitted during working-hours.ObjectiveTo determine (1) whether our procedural times and clinical outcome were affected by an out-of-hours effect and (2) whether the decision in favor of, or against, endovascular stroke treatment (EST) depends on the time of admission.MethodsBetween February 2010 and January 2015, 6412 consecutive patients presenting with symptoms of acute ischemic stroke were evaluated for EST eligibility according to established local protocols and generally accepted consensus criteria, and dichotomized into working-hours and out-of-hours cohorts according to admission times. Within both groups, patients given EST were identified and the rate of treatment decision, procedural times, and clinical outcome were compared and analyzed.ResultsClinical and radiological features of patients admitted in working-hours and out-of-hours did not differ significantly. Procedural times and clinical outcome were not affected by an out-of-hours effect (p≥0.054). 221/240 (92.1%) out-of-hours patients and 154/166 (92.8%) working-hours patients who were eligible for EST were transferred to the angiography suite for EST (p=0.798). The rationale not to treat patients who were eligible for EST did not differ between working-hours and out-of-hours admission (p=0.756).ConclusionsIt is possible to produce competitive procedural times regardless of the time of admission and to prevent a treatment decision bias when standard operating procedures are applied consistently.

Abstract WP330: Protocol Approaches Negate the “Weekend Effect” for Endovascular Stroke Treatment

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Scott B Raymond ◽  
Feras Akbik ◽  
Joshua A Hirsch ◽  
Christopher J Stapleton ◽  
Ramon G Gonzalez ◽  
...  
Keyword(s):  
Endovascular Therapy ◽  
Care Delivery ◽  
Working Hours ◽  
Weekend Effect ◽  
Complication Rates ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Therapeutic Procedures ◽  
The Impact

Background: Endovascular management of stroke from acute large vessel occlusion (LVO) requires complex, emergent diagnostic and therapeutic procedures. The “weekend effect” (worsened outcomes from stroke presenting on weekends or evenings) is a recognized phenomenon, attributed to non-uniform availability of services throughout the week. We assessed the impact of institutional protocols for stroke patients undergoing endovascular therapy during off hours. Methods: We analyzed a prospective observational stroke database for consecutive patients with anterior circulation stroke undergoing endovascular therapy between 6/2012 and 10/2015. Patients were grouped and analyzed based on day of the week and time of presentation to the emergency department. Off-hours were considered between 1900hrs and 0700hrs on weekdays and 1900hrs on Friday to 0700hrs on Mondays for weekends. Functional outcome was assessed prospectively by 3 month modified Rankin scale (mRS), dichotomized into good (mRS 0-2) versus poor (mRS 3-6). Results: In a cohort of 129 patients, 75 (58%) patients were treated off-hours. Patients treated off-hours demonstrated equivalent imaging to groin puncture times (78 vs 72 min, p = 0.4) and procedure durations (75 vs 68 min, p = 0.3). Reperfusion rates (TICI 2b or 3) were 68% off hours and 76% during working hours (p = 0.4). Complication rates were similar between the two groups. Outcome at 90 days was no different in the patients treated off hours, with 35 of 75 treated off-hours achieving a good outcome (mRS 0-2) compared to 22 of 54 treated during working hours (p = 0.6). With protocol adherence, temporal improvement was noted in imaging to groin times. Discussion/Conclusions: Following recent evidence of benefit from endovascular therapy for LVOs there is increased attention to care delivery. Our findings demonstrate that under the guidance of protocols, the “weekend effect” was negated. Evaluation and treatment times, and 90 day outcomes were equivalent in patients treated off- vs business hours, with improving treatment times as familiarity with protocols increased. Our findings highlight the importance of establishing institutional and regional protocols in the optimized management of these patients.

scholarly journals Improvement of Endovascular Stroke Treatment: A 24-Hour Neuroradiological On-Site Service Is Not Enough

2018 ◽  
Vol 2018 ◽  
pp. 1-8 ◽  
Author(s):  
Omid Nikoubashman ◽  
Kolja Schürmann ◽  
Ahmed E. Othman ◽  
Jan-Philipp Bach ◽  
Martin Wiesmann ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Working Hours ◽  
Out Of Hours ◽  
Stroke Treatment ◽  
Workflow Optimization ◽  
Rescue Chain

Background and Purpose. With the advent of endovascular stroke treatment (EST) with mechanical thrombectomy, stroke treatment has also become more challenging. Purpose of this study was to investigate whether a fulltime neuroradiological on-site service and workflow optimization with a structured documentation of the interdisciplinary stroke workflow resulted in improved procedural times. Material and Methods. Procedural times of 322 consecutive patients, who received EST (1) before (n=96) and (2) after (n=126) establishing a 24-hour neuroradiological on-site service as well as (3) after implementation of a structured interdisciplinary workflow documentation (“Stroke Check”) (n=100), were analysed. Results. A fulltime neuroradiological on-site service resulted in a nonsignificant improvement of procedural times during out-of-hours admissions (p≥0.204). Working hours and out-of-hours procedural times improved significantly, if additional workflow optimization was realized (p≤0.026). Conclusions. A 24-hour interventional on-site service is a major prerequisite to adequately provide modern reperfusion therapies in patients with acute ischemic stroke. However, simple measures like standardized and focused documentation that affect the entire interdisciplinary pre- and intrahospital stroke rescue chain seem to be important.

scholarly journals Safety in out-of-hours operating in trauma and orthopaedics at a district general hospital

2017 ◽  
Vol 99 (5) ◽  
pp. 347-350
Author(s):  
MA Gulamhussein ◽  
S Chaudhry ◽  
S Noor ◽  
T Chaudhry ◽  
A Guha ◽  
...  
Keyword(s):  
Working Hours ◽  
District General Hospital ◽  
Alternative Methods ◽  
Clinical Safety ◽  
Out Of Hours ◽  
American Society ◽  
American Society Of Anesthesiologists ◽  
Time Of Admission ◽  
Operating Surgeon ◽  
Clinical Urgency

INTRODUCTION According to the National Confidential Enquiry into Perioperative Deaths (NCEPOD), out-of-hours operating in trauma and orthopaedics should be reserved for life or limb threatening cases only. The aim of our study was to determine the nature of non-emergency work carried out in our trust at night in 2015. The overall efficacy and clinical safety of the services provided was evaluated. METHODS Surgical activity undertaken after 9pm was reviewed along with patient ASA (American Society of Anesthesiologists) grade, grade of operating surgeon and any complications that occurred following the procedure. Furthermore, the clinical urgency and safety of cases was assessed based on whether there was any record of life or limb threatening indications at the time of admission. RESULTS Overall, 131 procedures were performed after 9pm, with 102 performed between 9pm and midnight, and 29 after midnight. Consultants performed 16 cases and the remaining 115 cases were operated on by middle grades or specialty trainees. A fifth (20%) of the cases were genuinely life or limb threatening. A total of 123 procedures were classed as having good outcomes. The complication rate was 8%. CONCLUSIONS In our study, 80% of the procedures performed after 9pm could not be categorised as life or limb threatening. Appropriate CEPOD classification would ensure that only life or limb threatening cases were listed for theatre after 9pm. Alternative methods of operating within working hours should be considered.

Evaluation of the clot burden score (cbs) for acute ischemic stroke (ais) in intent-to-treat patients.

2019 ◽  
Vol 1 (1) ◽  
pp. 11-15 ◽  
Author(s):  
Sarah Yaziz ◽  
Ahmad Sobri Muda ◽  
Wan Asyraf Wan Zaidi ◽  
Nik Azuan Nik Ismail
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Predictive Value ◽  
Area Under The Curve ◽  
Rank Correlation ◽  
Treatment Decision ◽  
Roc Curves ◽  
Significant Negative Correlation ◽  
Clot Burden

Background : The clot burden score (CBS) is a scoring system used in acute ischemic stroke (AIS) to predict patient outcome and guide treatment decision. However, CBS is not routinely practiced in many institutions. This study aimed to investigate the feasibility of CBS as a relevant predictor of good clinical outcome in AIS cases. Methods:  A retrospective data collection and review of AIS patients in a teaching hospital was done from June 2010 until June 2015. Patients were selected following the inclusion and exclusion criteria. These patients were followed up after 90 days of discharge. The Modified Rankin scale (mRS) was used to assess their outcome (functional status). Linear regression Spearman Rank correlation was performed between the CBS and mRS. The quality performance of the correlations was evaluated using Receiver operating characteristic (ROC) curves. Results: A total of 89 patients with AIS were analysed, 67.4% (n=60) male and 32.6% (n=29) female. Twenty-nine (29) patients (33.7%) had a CBS ?6, 6 patients (6.7%) had CBS <6, while 53 patients (59.6%) were deemed clot free. Ninety (90) days post insult, clinical assessment showed that 57 (67.6%) patients were functionally independent, 27 (30.3%) patients functionally dependent, and 5 (5.6%) patients were deceased. Data analysis reported a significant negative correlation (r= -0.611, p<0.001). ROC curves analysis showed an area under the curve of 0.81 at the cut-off point of 6.5. This showed that a CBS of more than 6 predicted a good mRS clinical outcome in AIS patients; with sensitivity of 98.2%, specificity of 53.1%, positive predictive value (PPV) of 76%, and negative predictive value (NPV) of 21%. Conclusion: CBS is a useful additional variable for the management of AIS cases, and should be incorporated into the routine radiological reporting for acute ischemic stroke (AIS) cases.

Mechanical thrombectomy for anterior circulation stroke: 5-year experience in a statewide service with differences in pretreatment time metrics across two hospitals sites

2016 ◽  
Vol 9 (6) ◽  
pp. 535-540 ◽  
Author(s):  
Ruchi Kabra ◽  
Timothy J Phillips ◽  
Jacqui-Lyn Saw ◽  
Constantine C Phatouros ◽  
Tejinder P Singh ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Clinical Outcomes ◽  
Mechanical Thrombectomy ◽  
Stroke Onset ◽  
Anterior Circulation ◽  
Stroke Treatment ◽  
Patient Demographics ◽  
Organizational Differences ◽  
Tertiary Hospitals ◽  
Pretreatment Time

ObjectiveTo audit our institutional mechanical thrombectomy (MT) outcomes for acute anterior circulation stroke and examine the influence of workflow time metrics on patient outcomes.MethodsA database of 100 MT cases was maintained throughout May 2010—February 2015 as part of a statewide service provided across two tertiary hospitals (H1 and H2). Patient demographics, stroke and procedural details, blinded angiographic outcomes, and 90-day modified Rankin Scale (mRS) scores were recorded. The following time points in stroke treatment were recorded: stroke onset, hospital presentation, CT imaging, arteriotomy, and recanalization. Statistical analysis of outcomes, predictors of outcome, and differences between the hospitals was carried out.ResultsThrombolysis in Cerebral Infarction (TICI) 2b/3 reperfusion was 79%. Forty-nine per cent of patients had good clinical outcomes (mRS 0–2). In a subgroup analysis of 76 patients with premorbid mRS 0–1 and first CT performed ≤4.5 h after stroke onset, 60% had good clinical outcomes. Patient and disease characteristics were matched between the two hospitals. H1 had shorter times between hospital presentation and CT (32 vs 55 min, p=0.01), CT and arteriotomy (33 vs 69 min, p=0.00), and stroke onset and recanalization (198 vs 260 min, p=0.00). These time metrics independently predicted good clinical outcome. Median days spent at home in the first 90 days was greater at H1 (61 vs 8, p=0.04) than at H2. A greater proportion of patients treated at H1 were independent (mRS 0–2) at 90 days (54% vs 42%); however, this was not statistically significant (p=0.22).ConclusionsOutcomes similar to randomized controlled trials are attainable in ‘real-world’ settings. Workflow time metrics were independent predictors of clinical outcome, and differed between the two hospitals owing to site-specific organizational differences.

Abstract TP9: Safety of Endovascular Treatment in Acute Stroke Patients Taking Oral Anticoagulants

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Timo Uphaus ◽  
Oliver C Singer ◽  
Joachim Berkefeld ◽  
Christian H Nolte ◽  
Georg Bohner ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Endovascular Treatment ◽  
Acute Stroke ◽  
Positive Impact ◽  
Therapeutic Option ◽  
Oral Anticoagulants ◽  
Intravenous Thrombolysis ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Male Patients

Introduction: The endovascular treatment (EVT) of cerebral ischemia in the case of large vessel occlusion has been established over recent years. Randomized trials showed a positive impact on the clinical outcome of endovascular treatment in addition to thrombolysis with respect to clinical outcome and safety, so that this therapeutic option will be implemented in future guidelines. The role of EVT in patients treated with oral anticoagulants remains uncertain. Hypothesis: We assessed the hypothesis that application of EVT is safe with regard to the occurrence of intracranial bleeding and clinical outcome in patients taking anticoagulants. Methods: The ENDOSTROKE-Registry is a commercially independent, prospective observational study in 12 stroke centers in Germany and Austria launched in January 2011. An online tool served for data acquisition of pre-specified variables concerning endovascular stroke therapy. Results: Data from 815 patients (median age 70, 57% male) undergoing EVT and known anticoagulation status were analyzed. A total of 85 (median age 76, 52% male) patients (10.4%) took oral anticoagulants prior to EVT. Anticoagulation status as measured with INR was 2.0-3.0 in 24 patients (29%), <2.0 in 52 patients (63%) and above 3.0 in 7 patients (8%) of 83 patients with valid INR data prior to EVT. Patients taking anticoagulants were significantly older (median age 76 vs. 69, p < 0.001). Comparing those patients taking anticoagulants and those not, there were no differences concerning NIHSS at admission (with anticoagulants Median-NIHSS 17 vs. without Median-NIHSS 15, p = 0.492, Mann Whitney Test) and the rate of intracranial hemorrhage after intervention (with anticoagulants 11.8% vs. without 12.2%, p = 0.538). After adjustment for age and NIHSS at admission there were no significant differences between the two groups with regard to good clinical outcome, as measured with the modified ranking scale (mRS, 90d-mRS 0-2, 39.2% of patients not receiving anticoagulants; 25.9% of those receiving anticoagulants). Conclusion: The application of endovascular treatment in patients taking oral anticoagulants is safe and should be considered in acute stroke treatment as an important alternative to contraindicated intravenous thrombolysis.

scholarly journals Recanalization and Angiographic Reperfusion Are Both Associated with a Favorable Clinical Outcome in the IMS III Trial

2016 ◽  
Vol 5 (3-4) ◽  
pp. 118-122 ◽  
Author(s):  
Marie L. Schmitz ◽  
Sharon D. Yeatts ◽  
Thomas A. Tomsick ◽  
David S. Liebeskind ◽  
Achala Vagal ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Scale Score ◽  
Predictive Accuracy ◽  
Favorable Outcome ◽  
Modified Rankin Scale ◽  
Arterial Tree ◽  
Stroke Treatment ◽  
Optimal Thresholds ◽  
Favorable Clinical Outcome

Background: Prompt revascularization is the main goal of acute ischemic stroke treatment. We examined which revascularization scale - reperfusion (modified Treatment in Cerebral Infarctions, mTICI) or recanalization (Arterial Occlusive Lesion, AOL) - better predicted the clinical outcome in ischemic stroke participants treated with endovascular therapy (EVT). Additionally, we determined the optimal thresholds for the predictive accuracy of each scale. Methods: We included participants from the Interventional Management of Stroke (IMS) III trial with complete occlusion in the internal carotid artery terminus or proximal middle cerebral artery (M1 or M2) who completed EVT within 7 h of symptom onset. The abilities of the AOL and mTICI scales to predict a favorable outcome (defined as a modified Rankin Scale score of 0-2 at 3 months) were compared by receiver operating characteristic analyses. The maximal sensitivity and specificity for each revascularization scale were established. Results: Among 240 participants who met the study inclusion criteria, 79 (33%) achieved a favorable outcome. Higher scores of mTICI and AOL increased the likelihood of a favorable outcome (2.7% with mTICI 0 vs. 83.3% with mTICI 3, and 3.0% with AOL 0 vs. 43% with AOL 3). The accuracy of mTICI reperfusion and AOL recanalization for a favorable outcome prediction was similar, with optimal thresholds of mTICI 2b/3 and AOL 3, respectively. Conclusion: Reperfusion (mTICI) and recanalization (AOL) predicted a favorable clinical outcome with comparable accuracy in ischemic stroke participants treated with EVT. Optimal revascularization goals to maximize clinical outcome (modified Rankin Scale score of 0-2) consisted of complete recanalization (AOL 3) and reperfusion of at least 50% of the arterial tree of the symptomatic artery (mTICI 2b/3) in the IMS III trial setting.

scholarly journals Time of admission and mortality after hip fracture: a detailed look at the weekend effect in a nationwide study of 55,211 hip fracture patients in Norway

2018 ◽  
Vol 89 (6) ◽  
pp. 610-614 ◽  
Author(s):  
Andreas Asheim ◽  
Sara Marie Nilsen ◽  
Marlen Toch-Marquardt ◽  
Kjartan Sarheim Anthun ◽  
Lars Gunnar Johnsen ◽  
...  
Keyword(s):  
Hip Fracture ◽  
Weekend Effect ◽  
Nationwide Study ◽  
Time Of Admission

Attendance rates during working-hours versus out-of-hours otolaryngology clinics

2008 ◽  
Vol 90 (9) ◽  
pp. 316-319 ◽  
Author(s):  
AJ Donne ◽  
D Siau ◽  
R Swindell ◽  
JJ Homer
Keyword(s):  
General Public ◽  
Working Hours ◽  
Social Attitudes ◽  
Attendance Rates ◽  
Out Of Hours

In the foreword to Choice matters: Increasing choice improves patients' experiences, the minister of state for delivery and quality states that patients want and expect convenient services tailored to accommodate their increasingly busy lives. The British Social Attitudes Survey 22nd Report indicated that patients with semi-routine and routine occupations were more interested in choice compared to patients with managerial and professional occupations. However, almost 60% of the latter group were still interested. Clearly a major proportion of the general public are keen to be empowered with greater choice.

scholarly journals Out-of-hours workload among Norwegian general practitioners – an observational study

2020 ◽  
Author(s):  
Ingrid Keilegavlen Rebnord ◽  
Tone Morken ◽  
Kjell Maartmann-Moe ◽  
Steinar Hunskaar
Keyword(s):  
General Practitioners ◽  
Rural Areas ◽  
Linear Regression Analysis ◽  
Working Hours ◽  
Clinical Work ◽  
Working Time ◽  
Medical Work ◽  
Out Of Hours ◽  
Electronic Survey ◽  
Regular Work

Abstract Background: Repeated studies of working hours among Norwegian regular general practitioners (RGPs) have shown that the average total number of weekly working hours has remained unchanged since 1994 and up until 2014. For both male and female RGPs, the mean total weekly working hours amounted to almost 50 hours in 2014. In recent years, Norwegian RGPs have become increasingly dissatisfied. They experience significantly increased workload without compensation in the form of more doctors or better payment. A study from the Norwegian Directorate of Health in 2018 (the RGP study) showed that Norwegian RGPs worked 55.6 hours weekly (median 52.5). 25% of the respondents worked more than 62.2 hours weekly. Based on data from the RGP study we investigated Norwegian RGP’s out-of-hours (OOH) work, how the working time was distributed, and to what extent the OOH work affected the regular working hours.Methods: In early 2018, an electronic survey was sent to all 4640 RGPs in Norway. Each RGP reported how many minutes that were spent that particular day on various tasks during seven consecutive days. Working time also included additional tasks in the municipality, other professional medical work and OOH primary health care. Differences were analysed by independent t-tests, and regression analyses. Results: 1876 RGPs (40.4%) responded, 640 (34.1%) had registered OOH work. Male RGPs worked on average 1.5 hours more doing regular work than did females (p=0.001) and on average 2.3 hours more OOH work than females (p=0.079). RGPs with no OOH work registered a mean of 1.0 hours more clinical work than RGPs working OOH (p=0.043). There was a large variation in OOH working hours. A linear regression analysis showed that male RGPs and RGPs in rural areas had the heaviest OOH workload. Conclusions: One in three Norwegian RGPs undertook OOH work during the registration week in the RGP study. OOH work was done in addition to a sizeable regular workload as an RGP. We found small gender differences. OOH work was not compensated with reduced regular RGP work.

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