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 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.

scholarly journals In-Hospital Intravenous Thrombolysis Offers No Benefit in Mechanical Thrombectomy in Optimized Tertiary Stroke Center Setting

2020 ◽  
Author(s):  
Juha-Pekka Pienimäki ◽  
Jyrki Ollikainen ◽  
Niko Sillanpää ◽  
Sara Protto
Keyword(s):  
Clinical Outcome ◽  
Acute Stroke ◽  
Mechanical Thrombectomy ◽  
Clinical Laboratory ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Ordinal Logistic Regression Analysis ◽  
Stroke Center

Abstract Purpose Mechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO. Materials and Methods We collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis. Results Fifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients. Conclusions MT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients.

Abstract P855: Importance of Compliance in Dysphagia Screening in Acute Stroke Care

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Patty Noah ◽  
Melanie Henderson ◽  
Rebekah Heintz ◽  
Russell Cerejo ◽  
Christopher T Hackett ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Aspiration Pneumonia ◽  
Hemorrhagic Stroke ◽  
Oral Intake ◽  
Stroke Care ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
Chi Square ◽  
Stroke Center

Introduction: Dysphagia occurs in up to two thirds of stroke patients and can lead to serious complications such as aspiration pneumonia, which is also linked to increased morbidity and mortality. Evidence-based guidelines recommend a bedside dysphagia assessment before oral intake in stroke patients regardless of initial stroke severity. Several studies have described registered nurses’ competency in terms of knowledge and skills regarding dysphagia screening. We aimed to examine the rate of aspiration pneumonia compared to the rate of dysphagia screening. Methods: A retrospective analysis of prospectively collected data at a single tertiary stroke center was carried out between January 2017 and June 2020. Data comparison was completed utilizing ICD-10 diagnosis codes to identify aspiration pneumonia in ischemic and hemorrhagic stroke patients. The data was reviewed to compare the compliance of a completed dysphagia screen prior to any oral intake to rate of aspiration pneumonia. Chi square tests were used to assess proportion differences in completed dysphagia screen and proportion of aspiration pneumonia diagnosis in the ischemic and hemorrhagic stroke patients. Results: We identified 3320 patient that met inclusion criteria. 67% were ischemic strokes, 22% were intracerebral hemorrhages and 11% were subarachnoid hemorrhages. Compliance with dysphagia screening decreased from 94.2% (n=1555/1650) in 2017-2018 to 74.0% (n=1236/1670) in 2019-2020, OR=0.17 (95%CI 0.14 - 0.22), p < 0.0001. Aspiration pneumonias increased from 58 (3.5%) in 2017-2018 to 77 (4.6%) in 2019-2020, but this difference was not statistically significant, OR=0.75 (95%CI 0.53 - 1.07), p = 0.11. Conclusion: We noted that the decrease in compliance with completing a dysphagia screen in patients with acute stroke prior to any oral intake was associated with a higher trend of aspiration pneumonia.

scholarly journals Reducing Door-to-Needle Times for Ischaemic Stroke to a Median of 30 Minutes at a Community Hospital

2018 ◽  
Vol 46 (1) ◽  
pp. 51-56 ◽  
Author(s):  
Noreen Kamal ◽  
Elaine Shand ◽  
Robert Swanson ◽  
Michael D. Hill ◽  
Thomas Jeerakathil ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Acute Stroke ◽  
Community Hospital ◽  
Annual Number ◽  
Intervention Period ◽  
Community Hospitals ◽  
Stroke Patients ◽  
Post Intervention ◽  
Post Intervention Period ◽  
Number Of Patients

AbstractBackgroundAlteplase is an effective treatment for ischaemic stroke patients, and it is widely available at all primary stroke centres. The effectiveness of alteplase is highly time-dependent. Large tertiary centres have reported significant improvements in their door-to-needle (DTN) times. However, these same improvements have not been reported at community hospitals.MethodsRed Deer Regional Hospital Centre (RDRHC) is a community hospital of 370 beds that serves approximately 150,000 people in their acute stroke catchment area. The RDRHC participated in a provincial DTN improvement initiative, and implemented a streamlined algorithm for the treatment of stroke patients. During this intervention period, they implemented the following changes: early alert of an incoming acute stroke patient to the neurologist and care team, meeting the patient immediately upon arrival, parallel work processes, keeping the patient on the Emergency Medical Service stretcher to the CT scanner, and administering alteplase in the imaging area. Door-to-needle data were collected from July 2007 to December 2017.ResultsA total of 289 patients were treated from July 2007 to December 2017. In the pre-intervention period, 165 patients received alteplase and the median DTN time was 77 minutes [interquartile range (IQR): 60–103 minutes]; in the post-intervention period, 104 patients received alteplase and the median DTN time was 30 minutes (IQR: 22–42 minutes) (p < 0.001). The annual number of patients that received alteplase increased from 9 to 29 in the pre-intervention period to annual numbers of 41 to 63 patients in the post-intervention period.ConclusionCommunity hospitals staffed with community neurologists can achieve median DTN times of 30 minutes or less.

scholarly journals Cohort profile: Thrombolysis in Ischemic Stroke Patients (TRISP): a multicentre research collaboration

BMJ Open ◽  
2018 ◽  
Vol 8 (9) ◽  
pp. e023265 ◽  
Author(s):  
Jan F Scheitz ◽  
Henrik Gensicke ◽  
Sanne M Zinkstok ◽  
Sami Curtze ◽  
Marcel Arnold ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Functional Outcome ◽  
Research Collaboration ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
Laboratory Findings ◽  
Endovascular Thrombectomy ◽  
Multicentre Research

PurposeThe ThRombolysis in Ischemic Stroke Patients (TRISP) collaboration aims to address clinically relevant questions about safety and outcomes of intravenous thrombolysis (IVT) and endovascular thrombectomy. The findings can provide observational information on treatment of patients derived from everyday clinical practice.ParticipantsTRISP is an open, investigator-driven collaborative research initiative of European stroke centres with expertise in treatment with revascularisation therapies and maintenance of hospital-based registries. All participating centres made a commitment to prospectively collect data on consecutive patients with stroke treated with IVT using standardised definitions of variables and outcomes, to assure accuracy and completeness of the data and to adapt their local databases to answer novel research questions.Findings to dateCurrently, TRISP comprises 18 centres and registers >10 000 IVT-treated patients. Prior TRISP projects provided evidence on the safety and functional outcome in relevant subgroups of patients who were excluded, under-represented or not specifically addressed in randomised controlled trials (ie, pre-existing disability, cervical artery dissections, stroke mimics, prior statin use), demonstrated deficits in organisation of acute stroke care (ie, IVT during non-working hours, effects of onset-to-door time on onset-to-needle time), evaluated the association between laboratory findings on outcome after IVT and served to develop risk estimation tools for prediction of haemorrhagic complications and functional outcome after IVT.Future plansFurther TRISP projects to increase knowledge of the effect and safety of revascularisation therapies in acute stroke are ongoing. TRISP welcomes participation and project proposals of further centres fulfilling the outlined requirements. In the future, TRISP will be extended to include patients undergoing endovascular thrombectomy.

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.’

The impact of tele-neurologists on acute stroke care at an advanced primary stroke centre

2020 ◽  
pp. 1357633X2092103
Author(s):  
Scott Gutovitz ◽  
Jonathan Leggett ◽  
Leslie Hart ◽  
Samuel M Leaman ◽  
Heather James ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Mechanical Thrombectomy ◽  
Stroke Care ◽  
Final Diagnosis ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
Care Guidelines ◽  
Stroke Center ◽  
The Impact ◽  
Stroke Centre

Introduction We evaluated the impact of tele-neurologists on the time to initiating acute stroke care versus traditional bedside neurologists at an advanced stroke center. Methods This observational study evaluated time to treatment for acute stroke patients at a single hospital, certified as an advanced primary stroke centre, with thrombectomy capabilities. Consecutive stroke alert patients between 1 March, 2016 and 31 March, 2018 were divided into two groups based on their neurology consultation service (bedside neurology: 1 March, 2016–28 February, 2017; tele-neurology: 1 April, 2017–31 March, 2018). Door-to-tPA time and door-to-IR time for mechanical thrombectomy were compared between the two groups. Results Nine hundred and fifty-nine stroke patients met the inclusion criteria (436 bedside neurology, 523 tele-neurology patients). There were no significant differences in sex, age, or stroke final diagnosis between groups ( p > 0.05). 85 bedside neurology patients received tPA and 35 had mechanical thrombectomy, 84 and 44 for the tele-neurology group respectively. Door-to-tPA time (median (IQR)) was significantly higher among tele-neurology (64 min (51.5–83.5)) than bedside neurology patients (45 min (34–69); p < 0.0001). There was no difference in door-to-IR times (mean ± SD) between bedside neurology (87.2 ± 33.3 min) and tele-neurology (90.4 ± 33.4 min; p = 0.67). Discussion At this facility, our tele-neurology services vendor was associated with a statistically significant delay in tPA administration compared with bedside neurologists. There was no difference in door-to-IR times. Delays in tPA administration make it harder to meet acute stroke care guidelines and could worsen patient outcomes.

Abstract 155: Treatment Outcomes After Regionalization of Acute Stroke Care

2012 ◽  
Vol 5 (suppl_1) ◽  
Author(s):  
Prasanthi Govindarajan ◽  
Steve Shiboski ◽  
Larry Cook ◽  
Barbara Grimes ◽  
S Claiborne Johnston
Keyword(s):  
Demographic Data ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
Discharge Diagnosis ◽  
Acute Stroke Care ◽  
Number Of Patients ◽  
Teaching Status ◽  
Independent Association ◽  
Stroke Center ◽  
Time Of Admission

Objective: To determine if regionalization of stroke care is associated with improved treatment rates. Methods: This is an observational study of all patients with a discharge diagnosis of stroke admitted to hospitals located in a Northern California county during a three year period. Patient and hospital demographic data, stroke center designation status, teaching status of the hospital, hospital discharge diagnosis and treatment with intravenous thrombolysis (IV t-PA) for the pre and post phase of regionalization were obtained from the statewide discharge database. We included patients ≥18 years of age with validated ICD- 9 code for stroke and excluded inter-facility transports and direct admissions. Logistic regression was performed to study the independent association of regionalization with IV t-PA treatment rates. Data analysis was performed using SAS 9.2 Results: Number of patients with a discharge diagnosis of stroke in the pre-regionalization phase was 2149 and in the post regionalization phase was 4261. In the regionalized phase, mean age at time of admission was 73 (+/-15) years; 54% of patients (n=2280) were females and 62% (n=2649) of the patients were whites. Majority of patients were transported from home (3647, 86%); 2847 (67%) were treated at stroke centers and 4133 (97%) were treated at community hospitals. After controlling for patient and hospital demographics, teaching status and stroke center status, regionalization was not associated with increase in IV t-PA use (OR 0.8, p <0.001) Conclusions: While county-wide treatment rates for stroke did not improve after regionalization of care, similar relationship in those transported by emergency medical services in a regionalized system should be explored.

Abstract W P194: Telestroke is Not Associated With a Lower Rate of IV Thrombolysis

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Neelofer Shafi ◽  
Sandra Hoelzel ◽  
Rebbeca Grysiewicz ◽  
Aslam Khaja ◽  
Fernando D Testai
Keyword(s):  
Acute Stroke ◽  
Local Community ◽  
Community Hospital ◽  
Stroke Patients ◽  
Number Of Patients ◽  
Coverage Model ◽  
Group 2 ◽  
Group 1

Background: Telestroke is an increasingly used mode of assessment of acute stroke patients when vascular neurologists are not available onsite. We provided onsite stroke hospitalist services at a local community hospital via onsite, bedside assessment for 18 months. Coverage was then transitioned to telestroke only assessment, at the same hospital with the same vascular neurologists. We sought to determine if IV r-tPA rates changed. Methods: Onsite coverage was from April 2011 through September 2012 (Group 1). Telestroke only coverage was from October 2012 through July 2013 (Group 2). We reviewed all acute stroke codes and determined which patients were treated with IV r-tPA. We also collected door to needle (DTN) times. Fisher’s exact and independent t-tests were used where appropriate. Results: In Group 1 there were 578 acute stroke codes. 52 of these patients (8.9%) received IV r-tPA. Group 2 had 356 acute stroke codes, 29 of which received IV r-tPA (8.1%). This difference was not statistically significant (p=0.7201). Mean number of patients treated with IV r-tPA per month was 2.8 for Group 1 and 2.9 for Group 2. Mean DTN time was 76.73 min for Group 1 and 90.63 min for Group 2. This shows a trend toward shorter DTN times with bedside assessment but this difference is not statistically significant (p=0.0798). Conclusion: IV r-tPA administration rates do not fall when a telestroke only coverage model replaces an onsite model. This suggests that telestroke coverage is sufficient to maintain IV r-tPA treatment rates, even when vascular neurologists are not available at the bedside.

scholarly journals Effect of the COVID-19 pandemic on acute stroke reperfusion therapy: data from the Lyon Stroke Center Network

2020 ◽  
Author(s):  
Cécile PLUMEREAU ◽  
Tae-Hee CHO ◽  
Marielle BUISSON ◽  
Camille AMAZ ◽  
Matteo CAPPUCCI ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Control Period ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
Reperfusion Therapy ◽  
Acute Stroke Care ◽  
Emergency Medical Dispatch ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
The Impact

Abstract BackgroundThe coronavirus disease 2019 (COVID-19) pandemic would have particularly affected acute stroke care. However, its impact is clearly inherent to the local stroke network conditions. We aimed to assess the impact of COVID-19 pandemic on acute stroke care in the Lyon comprehensive stroke center during this period.MethodsWe conducted a prospective data collection of patients with acute ischemic stroke (AIS) treated with intravenous thrombolysis (IVT) and/or mechanical thrombectomy (MT) during the COVID-19 period (from 29/02/2020 to 10/05/2020) and a control period (from 29/02/2019 to 10/05/2019). The volume of reperfusion therapies and pre and intra-hospital delays were compared during both periods.ResultsA total of 208 patients were included. The volume of IVT significantly decreased during the COVID-period (55 (54.5%) vs 74 (69.2%); p=0.03) and was mainly due to time delay among patients treated with MT. The volume of MT remains stable over the two periods (72 (71.3%) vs 65 (60.8%); p=0.14) but the door-to-groin puncture time increased in patients transferred for MT (237 [187-339] vs 210 [163-260]; p<0.01). The daily number of Emergency Medical Dispatch calls considerably increased (1502 [1133-2238] vs 1023 [960-1410]; p<0.01).ConclusionsOur study showed a decrease of the volume of IVT, whereas the volume of MT remained stable although intra-hospital delays increased for transferred patients during the COVID-19 pandemic. These results contrast in part with the national surveys and suggest that the impact of the pandemic may depend on local stroke care networks.

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