Relevance of Stroke Code, Stroke Unit and Stroke Networks in Organization of Acute Stroke Care – The Madrid Acute Stroke Care Program

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.

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352 Grey and White Matters – Designing and Implementing an Acute Stroke Program in a level 3 Hospital

Age and Ageing ◽

10.1093/ageing/afz103.228 ◽

2019 ◽

Vol 48 (Supplement_3) ◽

pp. iii17-iii65

Author(s):

Bart Daly ◽

Richard Liston ◽

Susan Griffin

Keyword(s):

Acute Stroke ◽

Care Program ◽

Stroke Care ◽

Steering Committee ◽

National Standards ◽

Care Practice ◽

Acute Stroke Care ◽

Improvement Project ◽

Staff Members ◽

National Quality

Abstract Background Following the publication of the National Stroke Audit in 2015 with below the national average rates of thrombolysis – 3.3% versus 11% - there has been a number of initiatives launched to improve stroke care in this hospital. In 2018 we enrolled in the National Quality Improvement Project for the care of Patients with Acute Ischaemic Stroke run by the RCSI. A stroke steering committee was established consisting of a multi-disciplinary group encompassing all areas of acute stroke care. Methods Acute stroke care practice and factors causing sub-optimal management were examined by the committee and compared with national standards. A ‘3 jobs’ proforma for management and communication of Fast positive cases was designed to address the difficulties identified in stroke care and tailored to the resources available in this hospital. These simplified and standardised roles for all staff members involved, many of whom were unfamiliar with the practical delivery of thrombolysis and thrombectomy. Educational sessions were initiated for all those involved in acute stroke management. The acute stroke program was implemented as a 6 month pilot before official launch in April 2019 with necessary changes assessed weekly by the stroke committee. Stroke data is continually audited with the National Stroke Register. Key Performance Indicators (KPI’s) in the pilot were thrombolysis/thrombectomy rates and door to needle time. Results There were 164 patients admitted to the stroke unit in 2018. In 2018 prior to this initiative, the hospital had a 3% thrombolysis rate in 2018 and a 1% thrombectomy rate. Amongst FAST positive patients during the pilot period, 10/68 patients were thombolysed (15%) and 6/68 thrombectomies (9%). Average door to needle time for patients was 96 minutes. Conclusion The redesigning of the acute stroke care program has led to significant improvements in the identified KPI’s although door to needle times remain below the national target of 30 minutes.

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Functional stroke outcomes after mobile stroke unit deployment – the revised protocol for the Berlin Prehospital Or Usual Delivery of acute stroke care (B_PROUD) part 2 study

Neurological Research and Practice ◽

10.1186/s42466-019-0022-4 ◽

2019 ◽

Vol 1 (1) ◽

Author(s):

Peter Harmel ◽

Martin Ebinger ◽

Erik Freitag ◽

Ulrike Grittner ◽

Irina Lorenz-Meyer ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Unit ◽

Stroke Care ◽

Acute Stroke Care ◽

Stroke Outcomes ◽

Mobile Stroke Unit

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Three years of the nationwide post-acute stroke care program in Taiwan

Journal of the Chinese Medical Association ◽

10.1016/j.jcma.2017.09.003 ◽

2018 ◽

Vol 81 (1) ◽

pp. 87-88 ◽

Cited By ~ 4

Author(s):

Cheng-Yang Hsieh ◽

Wei-Chia Tsao ◽

Ruey-Tay Lin ◽

A-Ching Chao

Keyword(s):

Acute Stroke ◽

Care Program ◽

Stroke Care ◽

Acute Stroke Care

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Abstract 115: Current Status of Acute Stroke Management in Korea: A Nationwide Report Based on 19,608 Patients Treated in 216 Hospitals

Stroke ◽

10.1161/str.51.suppl_1.115 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Jun Yup Kim ◽

Keon-Joo Lee ◽

Jihoon Kang ◽

Beom Joon Kim ◽

Seong-Eun Kim ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Unit ◽

National Level ◽

Stroke Care ◽

Current Status ◽

Endovascular Coiling ◽

Stroke Management ◽

Acute Stroke Care ◽

Survey Period ◽

Stroke Units

Introduction: There have been few reports on status of acute stroke management at a national level worldwide, and none in Korea. This study is aimed to describe the current status and disparities of acute stroke management in Korea. Methods: Data from 5th (2013) and 6th (2014) national surveys for assessing quality of acute stroke care were used. Patients with principal diagnosis codes indicating subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), ischemic stroke (IS), who were admitted via emergency rooms within 7 days of onset at hospitals treating 10 or more stroke cases during the each 3-month survey period were selected. Results: A total of 19,608 stroke cases (age, 67.7±13.5years; female, 45%; IS, 76%; ICH, 15%; SAH, 9%) treated in 216 hospitals were analyzed. Thirty-one percent of hospitals had stroke units and 41% of stroke cases were treated at hospitals without stroke units. In IS, IV thrombolysis (IVT) and endovascular treatment (EVT) rates were 10.7% and 3.6%, respectively. Thirty-nine percent of IVT and fifty-two percent of EVT cases were performed in hospitals with annual volume of <25 IVT and <15 EVT. Centralization of EVT showed disparities by region (Figure). Carotid endarterectomy, carotid artery stenting, decompressive, bypass surgery was conducted in 0.2%, 1.4%, 1.0%, 0.2% of IS cases; decompressive surgery was done in 28.1% of ICH cases; surgical clipping, endovascular coiling was done in 17.2%, 14.3% of SAH cases, respectively. There were noticeable regional disparities in various interventions, use of ambulance, arrival time and provision of stroke unit service. Conclusions: This study is the first report on the status of acute stroke care in Korea on a national level. Large number of recanalization therapies were performed in low-volume-hospitals. Expansion of stroke unit service, stroke center certification or accreditation, and connections between stroke centers and EMS are highly recommended.

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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 ◽

10.1136/bmjopen-2018-025366 ◽

2019 ◽

Vol 9 (11) ◽

pp. e025366 ◽

Cited By ~ 1

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.

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Break in the Stroke Chain of Survival due to COVID-19

Stroke ◽

10.1161/strokeaha.120.030106 ◽

2020 ◽

Vol 51 (8) ◽

pp. 2307-2314 ◽

Cited By ~ 30

Author(s):

Joan Montaner ◽

Ana Barragán-Prieto ◽

Soledad Pérez-Sánchez ◽

Irene Escudero-Martínez ◽

Francisco Moniche ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Unit ◽

Descriptive Analysis ◽

Stroke Care ◽

Reperfusion Therapy ◽

Time Of Arrival ◽

Acute Stroke Care ◽

Before And After ◽

Chain Of Survival ◽

The Impact

Background and Purpose: Emergency measures to treat patients with coronavirus disease 2019 (COVID-19) and contain the outbreak is the main priority in each of our hospitals; however, these measures are likely to result in collateral damage among patients with other acute diseases. Here, we investigate whether the COVID-19 pandemic affects acute stroke care through interruptions in the stroke chain of survival. Methods: A descriptive analysis of acute stroke care activity before and after the COVID-19 outbreak is given for a stroke network in southern Europe. To quantify the impact of the pandemic, the number of stroke code activations, ambulance transfers, consultations through telestroke, stroke unit admissions, and reperfusion therapy times and rates are described in temporal relationship with the rising number of COVID-19 cases in the region. Results: Following confinement of the population, our stroke unit activity decreased sharply, with a 25% reduction in admitted cases (mean number of 58 cases every 15 days in previous months to 44 cases in the 15 days after the outbreak, P <0.001). Consultations to the telestroke network declined from 25 every 15 days before the outbreak to 7 after the outbreak ( P <0.001). The increasing trend in the prehospital diagnosis of stroke activated by 911 calls stopped abruptly in the region, regressing to 2019 levels. The mean number of stroke codes dispatched to hospitals decreased (78% versus 57%, P <0.001). Time of arrival from symptoms onset to stroke units was delayed >30 minutes, reperfusion therapy cases fell, and door-to-needle time started 16 minutes later than usual. Conclusions: The COVID-19 pandemic is disruptive for acute stroke pathways. Bottlenecks in the access and delivery of patients to our secured stroke centers are among the main challenges. It is critical to encourage patients to continue seeking emergency care if experiencing acute stroke symptoms and to ensure that emergency professionals continue to use stroke code activation and telestroke networks.

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Development of an acute stroke care pathway in a hospital with stroke unit

Neurología (English Edition) ◽

10.1016/s2173-5808(10)70004-3 ◽

2010 ◽

Vol 25 (1) ◽

pp. 17-26 ◽

Cited By ~ 1

Author(s):

P. Martínez-Sánchez ◽

B. Fuentes ◽

J. Medina-Báez ◽

M. Grande ◽

C. Llorente ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Unit ◽

Care Pathway ◽

Stroke Care ◽

Acute Stroke Care

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Acute stroke treatment

10.1093/med/9780198737889.003.0009 ◽

2017 ◽

Author(s):

Hugh Markus ◽

Anthony Pereira ◽

Geoffrey Cloud

Keyword(s):

Acute Stroke ◽

Acute Ischaemic Stroke ◽

Stroke Unit ◽

Recurrent Stroke ◽

Stroke Care ◽

Recent Application ◽

Acute Stroke Care ◽

Stroke Treatment ◽

Acute Stroke Treatment ◽

Stroke Unit Care

In this chapter the use of thrombolysis and the more recent application of thrombectomy in acute ischaemic stroke are covered. Organized stroke unit care has a major impact on both reducing mortality and improving outcome, and the chapter describes the evidence for this. It also covers other components of supportive acute stroke care, including the importance of instituting measures to avoid complications and to prevent early recurrent stroke.

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