Abstract P128: Impact of the COVID-19 Pandemic in Houston on Stroke Care in a Health System of 10 Stroke Centers

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Sujan T Reddy ◽  
Tzu-ching Wu ◽  
Suja S Rajan ◽  
Amirali Tahanan ◽  
Mohammad H Rahbar ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Intracerebral Hemorrhage ◽  
Health System ◽  
Stroke Care ◽  
Pandemic Preparedness ◽  
Initial Drop ◽  
Mild Stroke ◽  
Transferred Patients ◽  
The Impact

Introduction: We assessed the impact of COVID-19 pandemic on stroke admissions and care metrics within a health system of 10 stroke centers, with 4 comprehensive stroke centers (CSC) in the greater Houston region. Methods: Between January-June 2019 and January-June 2020, we compared the proportion of ischemic strokes (total & direct CSC presentations) & intracerebral hemorrhage (ICH) relative to total admissions using logistic regression, and among the direct CSC presentations, we compared door to tPA and thrombectomy times using Wilcoxon Rank Sum. Results: A total of 4808 cases were assessed (Table 1). There was an initial drop of ~30% in cases at the pandemic onset (Fig.1). Numerically fewer patients in the 2020 period were seen at primary and CSCs (Table 1). Compared to 2019, there was a significant reduction in transferred patients [N(%), 829 (36) vs. 637 (34), p=0.02], in hospital strokes [N(%), 111 (5) vs. 69 (4), p=0.04], and mild strokes (NIHSS 1-5) [N (%), 891 (43) vs. 635 (40),p=0.02], and no significant differences in the proportions of total ischemic strokes [OR (95% CI)=0.92 (0.79, 1.06), p=0.23], direct CSC presentations [OR (95% CI) =0.96 (0.86, 1.08), p=0.48] and ICH [OR (95% CI) =1.14 (0.98, 1.33), p=0.08] in 2020 (Fig. 1). Among the direct ischemic strokes at CSCs, there were similar mean (SD) (mins) door to tPA [44 (17) vs. 42 (17), p=0.14] but significantly prolonged door to thrombectomy times [94 (15) vs. 85 (20), p=0.005] in 2020. Conclusion: COVID-19 pandemic led to reduced mild stroke admissions, transfers and in hospital stroke alerts, & prolonged door to thrombectomy times. Identifying reasons to mitigate this discrepancy is crucial for next pandemic preparedness.

scholarly journals 310. The Impact of Microscan versus Vitek-2 for Automated Susceptibility Testing on the Utilization of Vancomycin Alternatives for the Treatment of Methicillin-Resistant Staphylococcus aureus Bacteremia

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S152-S152
Author(s):  
Alexander Moskhos ◽  
Arya Wibisono ◽  
Kelly R Reveles ◽  
Dusten T Rose
Keyword(s):  
Staphylococcus Aureus ◽  
Logistic Regression ◽  
Propensity Score ◽  
Health System ◽  
Methicillin Resistant Staphylococcus Aureus ◽  
Susceptibility Testing ◽  
Positive Culture ◽  
Methicillin Resistant ◽  
Vitek 2 ◽  
The Impact

Abstract Background Automated susceptibility testing (AST) provides minimum inhibitory concentrations (MIC) to guide effective antibiotic therapy. AST is critical for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, as susceptible MIC values ≥ 1.5 µg/mL are associated with vancomycin (VAN) failure. The Microscan (MS) instrument may report elevated MIC values compared to Vitek-2 (VTK), thus impacting treatment. This study aimed to evaluate the impact of MS versus VTK on VAN alternative use in the treatment of MRSA bacteremia in a Texas health system. Methods This was a retrospective cohort study of patients admitted to the Ascension Seton health system in Austin, TX. Patient eligibility included: age ≥18 years, ≥1 positive MRSA blood culture, ≥72 hours of MRSA therapy, and VAN use within 48 hours of positive culture. Patients were stratified into the MS group (May 2013-Dec 2016) and VTK group (Jun 2017-Mar 2020). The primary outcome was therapy switch from VAN to VAN alternatives. Secondary endpoints include S. aureus MIC, 30-day all-cause mortality, 30 and 90-day readmission, and length of hospital stay (LOS). Outcomes were compared between groups using appropriate bivariable comparisons, as well as multivariable logistic regression and propensity score-adjusted logistic regression. Results A total of 199 patients were included: 91 in the MS group and 108 in the VTK group. Switch to VAN alternative was 56% vs. 19% (p< 0.0001) for MS and VTK, respectively. The median (interquartile range) MIC value reported was 2 μg/mL (2 – 2) and 1 μg/mL (0.5 – 1) for MS and VTK, respectively (p< 0.0001). Thirty-day readmission (19% vs. 20%, p=0.7647) and 30-day mortality (10% vs. 9%, p=0.5262) were comparable between MS and VTK groups, respectively. Hospital LOS significantly decreased in the VTK period (16 days vs. 12 days, p=0.0153). The MS group was the only independent positive predictor of VAN alternative therapy: logistic regression, OR 5.64 (95% CI 1.67–18.99) and propensity score adjusted, OR 4.21 (95% CI 1.32–13.48). Conclusion Since implementation of VTK from MS, Ascension Seton hospitals experienced a decreased median VAN MIC for MRSA bacteremia as well as therapy switches from VAN to VAN alternatives without affecting other patient health outcomes. Disclosures All Authors: No reported disclosures

Abstract WP314: Driving Stroke Care Within a Health System: The Impact of the University Hospitals System Stroke Program Clinical Practice Guideline for the Emergency Management of Acute Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Pavan Murty ◽  
Julie Fussner ◽  
Colin Beilman ◽  
Cathy Sila
Keyword(s):  
Clinical Practice ◽  
Health System ◽  
Clinical Practice Guideline ◽  
Practice Guideline ◽  
Medical Management ◽  
Stroke Care ◽  
University Hospitals ◽  
The University ◽  
The Impact ◽  
Iv Tpa

Introduction: With 18 University Hospitals at 12 locations, UH Case Medical Center is second in the University HealthSystem Consortium ranking for patient transfers at 24% of total volume. In 2009, the University Hospitals System Stroke Program developed a Clinical Practice Guideline (UHSSP-CPG) with the goal of providing the same, high quality stroke care throughout the health system that included a triage and transfer algorithm. Methods: From 2011-2q2016 (annualized), 5666 hospital discharges from MS-DRGs 61-66 representing medical management of cerebral infarction (CI) and intracerebral hemorrhage (ICH) were analyzed from 6 UH Legacy hospitals- UH-Case CSC, 4 PSCs and 2 Stroke Ready Facilities (SRF). Advanced expertise (AE) was developed at 2 PSCs for medical management of CI (2014) and low risk ICH (2015, 2016). Results: From 2011 to 2016, total stroke discharges increased across the UHSSP by 22%; total CI by 14%; and total ICH by 68%. Total IV-tPA cases increased by 174%, representing an increase in IV-tPA utilization from 6% to 15% of total CI. At UH-Case CSC, total stroke discharges increased by 15%, especially for ICH which increased by 63%. At the PSC-AE hospitals, total stroke discharges increased by 133%; IV-tPA Drip and Keep by 1300%; and total ICH by 700%. Total stroke discharges decreased by 28% at the other PSC hospitals. Conclusions: Implementation of the UHSSP-CPG triage and transfer algorithm resulted in an increase in total stroke volume across the health system but shifted more patients with lower risk ischemic and hemorrhagic stroke to PSC within their community. This strategy promotes enhanced access of more complex stroke patients to UH-Case CSC. As hospitals continue to coalesce into systems, robust triage and transfer algorithms will play an increasingly important role in systems stroke care.

scholarly journals Peak Troponin I Levels Are Associated with Functional Outcome in Intracerebral Hemorrhage

2018 ◽  
Vol 46 (1-2) ◽  
pp. 72-81 ◽  
Author(s):  
Stefan T. Gerner ◽  
Katrin Auerbeck ◽  
Maximilian I. Sprügel ◽  
Jochen A. Sembill ◽  
Dominik  Madžar ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Hospital Stay ◽  
Functional Outcome ◽  
Troponin I ◽  
Multivariable Analysis ◽  
Myocardial Damage ◽  
Stroke Care ◽  
Unfavorable Outcome ◽  
Acute Stroke Care ◽  
The Impact

Background: Troponin I is a widely used and reliable marker of myocardial damage and its levels are routinely measured in acute stroke care. So far, the influence of troponin I elevations during hospital stay on functional outcome in patients with atraumatic intracerebral hemorrhage (ICH) is unknown. Methods: Observational single-center study including conservatively treated ICH patients over a 9-year period. Patients were categorized according to peak troponin I level during hospital stay (≤0.040, 0.041–0.500, > 0.500 ng/mL) and compared regarding baseline and hematoma characteristics. Multivariable analyses were performed to investigate independent associations of troponin levels during hospital stay with functional outcome – assessed using the modified Rankin Scale (mRS; favorable 0–3/unfavorable 4–6) – and mortality after 3 and 12 months. To account for possible confounding propensity score (PS)-matching (1: 1; caliper 0.1) was performed accounting for imbalances in baseline characteristics to investigate the impact of troponin I values on outcome. Results: Troponin elevations (> 0.040 ng/mL) during hospital stay were observed in 308 out of 745 (41.3%) patients and associated with poorer status on admission (Glasgow Coma Scale/National Institute of Health Stroke Scale). Multivariable analysis revealed troponin I levels during hospital stay to be independently associated with unfavorable outcome after 12 months (risk ratio [95% CI]: 1.030 [1.009–1.051] per increment of 1.0 ng/mL; p = 0.005), but not with mortality. After PS-matching, patients with troponin I elevation (≥0.040 ng/mL) versus those without had a significant higher rate of ­unfavorable outcome after 3 and 12 months (mRS 4–6 at 3 months: < 0.04 ng/mL: 159/265 [60.0%] versus ≥0.04 ng/mL: 199/266 [74.8%]; p < 0.001; at 12 months: < 0.04 ng/mL: 141/248 [56.9%] versus ≥0.04 ng/mL: 179/251 [71.3%]; p = 0.001). Conclusions: Troponin I elevations during hospital stay occur frequently in ICH patients and are independently associated with functional outcome after 3 and 12 months but not with mortality.

Stroke Care During the COVID-19 Pandemic: Asian Stroke Advisory Panel Consensus Statement

2021 ◽  
pp. 251660852110009
Author(s):  
Jeyaraj D. Pandian ◽  
Yohanna Kusuma ◽  
Lyna Soertidewi Kiemas ◽  
Tsong-Hai Lee ◽  
Jose C. Navarro ◽  
...  
Keyword(s):  
Health Care ◽  
Health System ◽  
Stroke Unit ◽  
Consensus Statement ◽  
Mechanical Thrombectomy ◽  
Stroke Care ◽  
Advisory Panel ◽  
Stroke Patients ◽  
Number Of Patients ◽  
The Impact

The COVID-19 pandemic has impacted the health system worldwide. Stroke is one of the leading causes of death and disability in the world. Asia has a diverse health system and more than two-thirds of strokes occur in this region. The Asian Stroke Advisory Panel (ASAP) conducted a survey among the member countries to explore the impact of COVID-19 on stroke care. The stroke admission numbers have fallen, as have the number of patients who received thrombolysis and mechanical thrombectomy. The stroke unit and rehabilitation beds have been reallocated for COVID-19 care. ASAP recommends emergency department screening of stroke patients for COVID-19 and protected stroke code to be activated for COVID-19 suspect stroke patients. Noncontrast computed tomography (CT), CT angiography, and CT chest are the imaging modalities of choice. All health care professionals involved in triaging, imaging, and stroke care should wear appropriate personal protective equipment. All eligible stroke patients (COVID suspect/positive/non-COVID) should receive intravenous thrombolysis/mechanical thrombectomy. Mobile stroke units and robots can be used wherever available for evaluation and triaging. All stroke patients should receive standard stroke unit care. Limited rehabilitation should be offered to patients and training of caregivers if needed. Telemedicine/telestroke should be used for rehabilitation and follow-up. The ASAP consensus statement can be adapted to suit local and national health care systems.

The impact of SPY angiography on intraoperative decision making and outcomes for post-mastectomy reconstruction

2019 ◽  
pp. 1-5
Keyword(s):  
Decision Making ◽  
Logistic Regression ◽  
Skin Necrosis ◽  
Regression Models ◽  
Multivariable Analysis ◽  
P Value ◽  
Flap Necrosis ◽  
Single Institution ◽  
Logistic Regression Models ◽  
The Impact

Objective: While the use of intraoperative laser angiography (SPY) is increasing in mastectomy patients, its impact in the operating room to change the type of reconstruction performed has not been well described. The purpose of this study is to investigate whether SPY angiography influences post-mastectomy reconstruction decisions and outcomes. Methods and materials: A retrospective analysis of mastectomy patients with reconstruction at a single institution was performed from 2015-2017.All patients underwent intraoperative SPY after mastectomy but prior to reconstruction. SPY results were defined as ‘good’, ‘questionable’, ‘bad’, or ‘had skin excised’. Complications within 60 days of surgery were compared between those whose SPY results did not change the type of reconstruction done versus those who did. Preoperative and intraoperative variables were entered into multivariable logistic regression models if significant at the univariate level. A p-value <0.05 was considered significant. Results: 267 mastectomies were identified, 42 underwent a change in the type of planned reconstruction due to intraoperative SPY results. Of the 42 breasts that underwent a change in reconstruction, 6 had a ‘good’ SPY result, 10 ‘questionable’, 25 ‘bad’, and 2 ‘had areas excised’ (p<0.01). After multivariable analysis, predictors of skin necrosis included patients with ‘questionable’ SPY results (p<0.01, OR: 8.1, 95%CI: 2.06 – 32.2) and smokers (p<0.01, OR:5.7, 95%CI: 1.5 – 21.2). Predictors of any complication included a change in reconstruction (p<0.05, OR:4.5, 95%CI: 1.4-14.9) and ‘questionable’ SPY result (p<0.01, OR: 4.4, 95%CI: 1.6-14.9). Conclusion: SPY angiography results strongly influence intraoperative surgical decisions regarding the type of reconstruction performed. Patients most at risk for flap necrosis and complication post-mastectomy are those with questionable SPY results.

scholarly journals The impact of economic sanctions on health and health systems in low- and middle-income countries

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
M Suhrcke ◽  
M Pinna Pintor ◽  
C Hamelmann
Keyword(s):  
Health Outcomes ◽  
Health System ◽  
Health Systems ◽  
Grey Literature ◽  
Economic Sanctions ◽  
Political Crisis ◽  
Middle Income ◽  
Financial Flows ◽  
Adverse Health ◽  
The Impact

Abstract Background Economic sanctions, understood as measures taken by one state or a group of states to coerce another into a desired conduct (eg by restricting trade and financial flows) do not primarily seek to adversely affect the health or health system of the target country's population. Yet, there may be indirect or unintended health and health system consequences that ought to be borne in mind when assessing the full set of effects of sanctions. We take stock of the evidence to date in terms of whether - and if so, how - economic sanctions impact health and health systems in LMICs. Methods We undertook a structured literature review (using MEDLINE and Google Scholar), covering the peer-reviewed and grey literature published from 1970-2019, with a specific focus on quantitative assessments. Results Most studies (23/27) that met our inclusion criteria focus on the relationship between sanctions and health outcomes, ranging from infant or child mortality as the most frequent case over viral hepatitis to diabetes and HIV, among others. Fewer studies (9/27) examined health system related indicators, either as a sole focus or jointly with health outcomes. A minority of studies explicitly addressed some of the methodological challenges, incl. control for relevant confounders and the endogeneity of sanctions. Taking the results at face value, the evidence is almost unanimous in highlighting the adverse health and health system effects of economic sanctions. Conclusions Quantitatively assessing the impact of economic sanctions on health or health systems is a challenging task, not least as it is persistently difficult to disentangle the effect of sanctions from many other, potentially major factors at work that matter for health (as, for instance, war). In addition, in times of severe economic and political crisis (which often coincide with sanctions), the collection of accurate and comprehensive data that could allow appropriate measurement is typically not a priority. Key messages The existing evidence is almost unanimous in highlighting the adverse health and health system effects of economic sanctions. There is preciously little good quality evidence on the health (system) impact of economic sanctions.

scholarly journals Bottlenecks in the Acute Stroke Care System during the COVID-19 Pandemic in Catalonia

2021 ◽  
pp. 1-9
Author(s):  
Anna Ramos-Pachón ◽  
Álvaro García-Tornel ◽  
Mònica Millán ◽  
Marc Ribó ◽  
Sergi Amaro ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Functional Outcome ◽  
Stroke Care ◽  
Care Quality ◽  
Point Of View ◽  
Stroke Severity ◽  
Acute Stroke Care ◽  
Vessel Occlusion ◽  
Prehospital Delays ◽  
The Impact

<b><i>Introduction:</i></b> The COVID-19 pandemic resulted in significant healthcare reorganizations, potentially striking standard medical care. We investigated the impact of the COVID-19 pandemic on acute stroke care quality and clinical outcomes to detect healthcare system’s bottlenecks from a territorial point of view. <b><i>Methods:</i></b> Crossed-data analysis between a prospective nation-based mandatory registry of acute stroke, Emergency Medical System (EMS) records, and daily incidence of COVID-19 in Catalonia (Spain). We included all stroke code activations during the pandemic (March 15–May 2, 2020) and an immediate prepandemic period (January 26–March 14, 2020). Primary outcomes were stroke code activations and reperfusion therapies in both periods. Secondary outcomes included clinical characteristics, workflow metrics, differences across types of stroke centers, correlation analysis between weekly EMS alerts, COVID-19 cases, and workflow metrics, and impact on mortality and clinical outcome at 90 days. <b><i>Results:</i></b> Stroke code activations decreased by 22% and reperfusion therapies dropped by 29% during the pandemic period, with no differences in age, stroke severity, or large vessel occlusion. Calls to EMS were handled 42 min later, and time from onset to hospital arrival increased by 53 min, with significant correlations between weekly COVID-19 cases and more EMS calls (rho = 0.81), less stroke code activations (rho = −0.37), and longer prehospital delays (rho = 0.25). Telestroke centers were afflicted with higher reductions in stroke code activations, reperfusion treatments, referrals to endovascular centers, and increased delays to thrombolytics. The independent odds of death increased (OR 1.6 [1.05–2.4], <i>p</i> 0.03) and good functional outcome decreased (mRS ≤2 at 90 days: OR 0.6 [0.4–0.9], <i>p</i> 0.015) during the pandemic period. <b><i>Conclusion:</i></b> During the COVID-19 pandemic, Catalonia’s stroke system’s weakest points were the delay to EMS alert and a decline of stroke code activations, reperfusion treatments, and interhospital transfers, mostly at local centers. Patients suffering an acute stroke during the pandemic period had higher odds of poor functional outcome and death. The complete stroke care system’s analysis is crucial to allocate resources appropriately.

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