Abstract P93: The Effects of Covid-19 on Telestroke Care Delivery

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Johanna L Morton ◽  
Suraj Didwania ◽  
Eric Anderson ◽  
Jason Hallock
Keyword(s):  
Acute Stroke ◽  
Care Delivery ◽  
Stroke Care ◽  
Study Data ◽  
Stroke Severity ◽  
Acute Stroke Care ◽  
Significant Difference ◽  
Presentation Time ◽  
Stroke Group ◽  
The U.S

Background: Telestroke is increasingly being utilized to deliver acute stroke care to patients without in-person access to stroke expertise. After the U.S. emergence of the COVID-19 pandemic in March of 2020, reports of its effects on acute stroke care surfaced. This review examines the effect of the COVID-19 pandemic on telestroke care delivery in a large telestroke network, spanning 36 states and 340 hospitals throughout the nation. Methods: For this retrospective observational study, data was reported from the internal medical record platform from three separate time periods - a year before the pandemic (March 2019 - May 2019), the three months immediately prior to the pandemic (December 2019 - February 2020), and the height of the COVID-19 pandemic in the U.S. (March 2020 - May 2020). Two groups were studied, those seen in the emergency department (ED) with a suspected stroke diagnosis, and those who received alteplase in the ED. Results: The analysis revealed a decrease in patient volumes in both groups during the pandemic. The presentation time did not significantly vary between any of the stroke or alteplase groups. There was no significant difference in door-to-consult request times in the pandemic vs prior to the pandemic. The door-to-video time was shorter in the pandemic in alteplase patients compared to immediately prior ( P =0.04), but not compared to 2019 ( P =0.35). There was no significant difference in door-to-decision times or door-to-needle times in all of the groups. There was no difference in stroke severity in the alteplase group during the pandemic, but in the stroke group, stroke severity was higher during the pandemic ( P <0.01). Rates of thrombolysis did not decrease during the pandemic. Conclusion: COVID-19 has strained the U.S. emergency medical system and created unique challenges to treating patients with acute ischemic stroke. Likely due to the size and heterogeneity of the patient population, minimal adverse effects on telestroke process metrics were seen in this particular large teleneurology practice during the COVID-19 pandemic. This review highlights the resilience of our nation’s stroke system of care to withstand the stressor of a worldwide pandemic.

Abstract 352: Early Data From an Implementation Science Study Suggests the Need for Identification and Adoption of Best Practices to Improve the Timeliness of Stroke Treatment

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Lisa M Monk
Keyword(s):  
Best Practices ◽  
Acute Stroke ◽  
Care Delivery ◽  
Stroke Care ◽  
Early Data ◽  
Screening Tools ◽  
Stroke Severity ◽  
Ct Scanner ◽  
Acute Stroke Care ◽  
Stroke Treatment

There is a disconnect from discovery of best treatment options and application into clinical practice in a timely manner. The I M plementation of best Pr actices f O r acute stroke care-de v eloping and optimizing regional systems of Stroke Care (IMPROVE Stroke Care) goal is to develop a regional integrated stroke system that identifies, classifies, and treats patients with acute ischemic stroke more rapidly and effectively with reperfusion therapy. These improvements in acute stroke care delivery are expected to result in lower mortality, fewer recurrent strokes, and improved long term functional outcomes. Recent discoveries in stroke care and advancement in technology extends the window for both TPA administration and mechanical thombectomy. The challenge of implementing these latest advances are difficult considering the ability of hospitals to implement the original American Heart Association (AHA) Systems of Stroke Care recommendations. Early data from this project shows that the challenges continue to exist in recommendations that have been in place as early as 2005. EMS is not utilizing pre-hospital stroke screening tools, only 5% of the time, stroke severity tools, only 7% of the time, lytic checklists, 0% of the time, destination decision changed due to severity score, 0% of the time, and pre-notifying emergency rooms, only 63% of the time. Emergency departments door to CT <45 minutes, only 55% of the time, Lytic given in CT scanner, only 35% of the time, Door to lytic therapy< 45 minutes, 77% of the time, Door to Groin puncture, 81% of the time, and Door to TICI Flow 2c/3 flow <90 minutes, 39% of the time. The Systems of Stroke Care have recommendations that will improve time to treatment and outcomes for patients. This project is working to provide tools, guidance, data, and feedback to improve application of these recommendations and identify best practices and solutions to barriers.

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.

scholarly journals Disabling stroke in persons already with a disability

Neurology ◽  
2020 ◽  
Vol 94 (7) ◽  
pp. 306-310 ◽  
Author(s):  
Michael J. Young ◽  
Robert W. Regenhardt ◽  
Thabele M. Leslie-Mazwi ◽  
Michael Ashley Stein
Keyword(s):  
Clinical Practice ◽  
Health Outcomes ◽  
Acute Stroke ◽  
Care Delivery ◽  
Stroke Care ◽  
Clinical Practices ◽  
Acute Stroke Care ◽  
Persons With Disabilities ◽  
Stroke Research ◽  
Scant Attention

Stroke is the second leading cause of death worldwide and a leading cause of adult disability worldwide. More than a third of individuals presenting with strokes are estimated to have a preexisting disability. Despite unprecedented advances in stroke research and clinical practice over the past decade, approaches to acute stroke care for persons with preexisting disability have received scant attention. Current standards of research and clinical practice are influenced by an underexplored range of biases that may hinder acute stroke care for persons with disability. These trends may exacerbate unequal health outcomes by rendering novel stroke therapies inaccessible to many persons with disabilities. Here, we explore the underpinnings and implications of biases involving persons with disability in stroke research and practice. Recent insights from bioethics, disability rights, and health law are explained and critically evaluated in the context of prevailing research and clinical practices. Allowing disability to drive decisions to withhold acute stroke interventions may perpetuate disparate health outcomes and undermine ethically resilient stroke care. Advocacy for inclusion of persons with disability in future stroke trials can improve equity in stroke care delivery.

Abstract P141: Global Impact of Covid-19 Pandemic on Acute Stroke and Mechanical Thrombectomy - An International Survey

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Dileep R Yavagal ◽  
Vasu Saini ◽  
Violiza Inoa ◽  
Hannah E Gardener ◽  
Sheila O Martins ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Mechanical Thrombectomy ◽  
High Volume ◽  
Stroke Care ◽  
Acute Stroke Care ◽  
Treatment Practices ◽  
Global Impact ◽  
Significant Difference ◽  
The World ◽  
The Impact

Introduction: The COVID-19 pandemic has strained the healthcare systems across the world but its impact on acute stroke care is just being elucidated. We hypothesized a major global impact of COVID-19 not only on stroke volumes but also on thrombectomy practice. Methods: A 19-item questionnaire survey aimed to identify the changes in stroke volumes and treatment practices seen during COVID-19 pandemic was designed using Qualtrics software. It was sent to stroke and neuro-interventional physicians around the world who are part of the executive committee of a global coalition, Mission Thrombectomy 2020 (MT2020) between April 5 th to May 15 th , 2020. Results: There were 113 responses across 25 countries. Globally there was a median 33% decrease in stroke admissions and a 25% decrease in mechanical thrombectomy (MT) procedures during COVID-19 pandemic compared to immediately preceding months (Figure 1A-B). This overall median decrease was despite a median increase in stroke volume in 4 European countries which diverted all stroke patients to only a few selected centers during the pandemic. The intubation policy during the pandemic for patients undergoing MT was highly variable across participating centers: 44% preferred intubating all patients, including 25% centers that changed their policy to preferred-intubation (PI) vs 27% centers that switched to preferred-conscious-sedation (PCS). There was no significant difference in rate of COVID-19 infection between PI vs PCS (p=0.6) or if intubation policy was changed in either direction (p=1). Low-volume (<10 stroke/month) compared with high-volume stroke centers (>20 strokes/month) are less likely to have neurointerventional suite specific written personal protective equipment protocols (74% vs 88%) and if present, these centers are more likely to report them to be inadequate (58% vs 92%). Conclusion: Our data provides a comprehensive snapshot of the impact on acute stroke care observed worldwide during the pandemic.

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.

Critical factors determining access to acute stroke care

Neurology ◽  
1998 ◽  
Vol 51 (2) ◽  
pp. 427-432 ◽  
Author(s):  
Sindhu C. Menon ◽  
Dilip K. Pandey ◽  
Lewis B. Morgenstern
Keyword(s):  
Access To Care ◽  
Acute Stroke ◽  
Symptom Onset ◽  
Multivariate Regression ◽  
Stroke Care ◽  
Care Physician ◽  
Stroke Severity ◽  
Acute Stroke Care ◽  
Hospital Arrival ◽  
Ambulance Transport

Objective: Our objective was to assess gender, ethnic, and access-to-care factors critical in delay time (DT) for presentation to the hospital for acute stroke.Background: Little information is available on the effect of gender, ethnicity, and access issues on DT.Design: Demographic, access-to-care, and DT information was obtained from emergency department (ED) documentation of stroke patients admitted from July 1995 through June 1997 at Hermann Hospital, Houston, TX. Univariate and multivariate regression analyses were performed.Results: Of the 241 eligible patients, 126 were African American (AA), 82 were non-Hispanic white (NHW), and 33 were Hispanic American (HA). Median DT from symptom onset to presentation to the ED was 222 minutes for AAs, 280 minutes for HAs, and 230 minutes for NHWs. A multivariate regression model estimated DT to ED arrival decreased with ambulance transport (p= 0.003) and increased in patients with a primary care physician(p = 0.145) and in women (p = 0.052). DT to see an ED physician after hospital arrival decreased with ambulance transport (p < 0.001), hemorrhage patients (p = 0.006), and worse stroke severity (p = 0.038), and increased in women (p = 0.041). DT to see a neurologist decreased with hemorrhage (p = 0.002) and ambulance arrival (p = 0.010). Neurologists saw patients within 3 hours of symptom onset in 34% of NHWs, 28% of AAs, and 18% of HAs.Conclusion: Gender and access-to-care issues may be important determinants of delay in acute stroke care. Less than 20% of HAs presented to the ED within 3 hours of symptom onset.

Abstract MP22: Sex Differences in the Delivery of Acute Telestroke Care

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Johanna L Morton ◽  
Suraj Didwania ◽  
Eric Anderson ◽  
Jason Hallock
Keyword(s):  
Sex Differences ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Patient Population ◽  
Functional Outcomes ◽  
Stroke Care ◽  
Stroke Severity ◽  
Acute Stroke Care ◽  
Presenting Symptoms ◽  
Suspected Stroke

Background: Sex differences are encountered in many aspects of ischemic stroke, including risk factors, presenting symptoms, stroke mechanism, acute interventions and functional outcomes. As telestroke services continue to expand, many patients utilize telestroke for the evaluation and treatment of suspected stroke symptoms. To date, the existence of such differences between sexes has not been identified in the patient population having utilized telestroke for acute stroke care. Methods: A retrospective observational study of the experience of a single teleneurology practice serving 340 hospitals from April 2018 to June 2020 was performed. Patients seen in the emergency department (ED) with a diagnosis of suspected stroke were included. Data from the acute stroke encounter was reported through the current medical record platform. Results: Within the queried period, there were 11,454 male and 11,794 female patients identified as having received ED telestroke evaluation for suspected acute stroke. Males were younger than females (67 vs 70, P <0.01). Males had higher rates of prior stroke, hypertension, diabetes, hyperlipidemia, and coronary disease than females ( P <0.01), while females had higher rates of atrial fibrillation ( P =0.03) and TIA ( P <0.01). Rates of antiplatelet and anticoagulants were higher in males ( P <0.01) than females. There were no differences in time to ED presentation, time to request consult or make a thrombolysis decision, or length of consult. Females had higher stroke severity ( P <0.01) and door-to-needle times ( P <0.01), but lower alteplase rates ( P =0.02) compared to males. Conclusion: This review of a national heterogeneous telestroke patient population is indicative of sex differences in multiple aspects of acute ischemic stroke, most notably in thrombolysis delivered via telestroke. Further investigation into the etiology of such differences is warranted, as well as a survey of functional outcomes. As telemedicine continues to expand in the era of the COVID-19 pandemic, it is imperative that the reasons behind this disparity are investigated.

Abstract P863: Did Covid 19 Highlight Disparities in Stroke Care: A Real-World Study of Telehealth Utilization Between Urban and Suburban Populations in a Health Care System

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Maryika I Gibson ◽  
Ruchi Wanchoo
Keyword(s):  
Health Care ◽  
Health Care System ◽  
Care Delivery ◽  
Small Sample Size ◽  
National Level ◽  
Stroke Care ◽  
Small Sample ◽  
Acute Stroke Care ◽  
Significant Difference ◽  
Care System

A viable alternative to in person assessments, telemedicine offered providers cost effective and safe alternative to patient care delivery during COVID19. Resource limitations, state and organizational safety precautions accelerated our system adoption of video visits for stroke post hospitalization assessments. Utilizing mixed methods we aimed to investigate an association between patients characteristics (age, gender, race, Modified Rankin Score-mRS, residence) and their choice for post-acute care during a five-month period. The subset selecting in-person visits was further interviewed regarding perceptions of barriers to telehealth. We analyzed data from 85 patients’ records (45 in the urban telehealth and 40 in the suburban clinic visit groups) according to ICD10 codes. While total volume of televisits increased during COVID 19, stroke accounted for <1% of them. There was no significant difference in the mean age between the two groups-68.5 years in the clinic and 64.4 in the tele. The clinic subset had 42% of patients age greater than 75 years. Significant difference was detected in disabilities (t=3.5, p<.001) with one-point higher mean mRS (1.7 vs .7) and stronger positive correlation of age to disabilities in the suburban group (r2=.26 vs r2=.16). Patients selecting in-person care outlined as barriers to telehealth a lack of technology, poor connectivity, no caregiver availability for tele exam, inability to communicate or other major co-morbidities, family’s perception of complexity of patient’s condition, fragmentation of care during the period. Patients selecting video assessment were more connected with a health care system and from the urban center. Strengths of the study are the application of mix methods and investigation of suburban patients’ perceptions of barriers to telehealth. Limitations consist of small sample size and 90% Caucasian population. Current technology advancements, software applications, and the goal of Healthy People 2030 of removing disparities in heart and stroke disease will require a new multipronged approach to improving stroke telehealth at population level. Further studies at national level including social determinates of health need to examine barriers to telemedicine in post-acute stroke care.

Interaction between stroke severity and quality indicators of acute stroke care: a single-center retrospective analysis

2021 ◽  
Author(s):  
Sofie Ordies ◽  
Gwendolyne Peeters ◽  
Anouk Lesenne ◽  
Patrick Wouters ◽  
Ludovic Ernon ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Retrospective Analysis ◽  
Quality Indicators ◽  
Stroke Care ◽  
Stroke Severity ◽  
Single Center ◽  
Acute Stroke Care

scholarly journals 029 Time equals brain – retrospective analysis of thrombolysis in regional australia to determine factors which influence door to needle time

2019 ◽  
Vol 90 (e7) ◽  
pp. A10.3-A11
Author(s):  
Udit Nindra ◽  
Toni M Wonson ◽  
Karen Fuller
Keyword(s):  
Acute Stroke ◽  
Arrival Time ◽  
Cohort Analysis ◽  
Onset Time ◽  
Stroke Care ◽  
Tissue Type ◽  
Stroke Severity ◽  
List Type ◽  
Acute Stroke Care ◽  
Early Arrival

IntroductionMinimising delay in thrombolysis is a key outcome in acute stroke care.MethodsA 3 year retrospective cohort analysis of all acute stroke admissions in Wollongong Hospital, a major regional referral centre in New South Wales, was completed to determine the causes of in-hospital delays for thrombolysis. Data collected included age, baseline National Institute of Health Stroke Scale (NIHSS) score, onset time, arrival time, CT imaging & reporting time and outcomes of the event.ResultsFrom 656 admissions, 70 cases of thrombolysis were recorded 56 cases of endovascular thrombectomy. The mean time from onset to arrival was 85 minutes, from arrival to CT was 31 minutes and from door to needle time (DNT) was 108 minutes. Multiple regression analysis revealed a an inverse linear association between onset to arrival time and DNT. Age, stroke severity and gender were not shown to impact treatment times. The results showed that there was a paradoxical association between arrival time and DNT. The cause for this was not clearly identified but similar to previous studies is likely to be contributed by a lack of urgency when initiating management.1 2ConclusionFor every 30-minute delay in hospital arrival, there was a 13- minute reduction in DNT. In light of this, education trials to promote ‘time equals brain’ understanding amongst stroke first responders is being implemented to aim to reduce DNT to less than 80 minutes. The results of this are anticipated to be available in mid 2019.ReferencesAlbers GW, Bates VE, Clark WM. Intravenous tissue-type plasminogen activator for treatment of acute stroke: The Standard Treatment with Alteplase to Reverse Stroke (STARS) Study. Journal of the American Medical Association 2000; 283:1145–1150.Romano JG, Muller N, Merino JG, Forteza AM, Koch S, Rabinstein AA. In-hospital delays to stroke thrombolysis: paradoxical effct of early arrival. Neurological Research 2007;29:664–666.

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