Letter by Morelli et al Regarding Article, “Acute Stroke Care Is at Risk in the Era of COVID-19: Experience at a Comprehensive Stroke Center in Barcelona”

Background and Purpose: The purpose of the study is to analyze how the coronavirus disease 2019 (COVID-19) pandemic affected acute stroke care in a Comprehensive Stroke Center. Methods: On February 28, 2020, contingency plans were implemented at Hospital Clinic of Barcelona to contain the COVID-19 pandemic. Among them, the decision to refrain from reallocating the Stroke Team and Stroke Unit to the care of patients with COVID-19. From March 1 to March 31, 2020, we measured the number of emergency calls to the Emergency Medical System in Catalonia (7.5 million inhabitants), and the Stroke Codes dispatched to Hospital Clinic of Barcelona. We recorded all stroke admissions, and the adequacy of acute care measures, including the number of thrombectomies, workflow metrics, angiographic results, and clinical outcomes. Data were compared with March 2019 using parametric or nonparametric methods as appropriate. Results: At Hospital Clinic of Barcelona, 1232 patients with COVID-19 were admitted in March 2020, demanding 60% of the hospital bed capacity. Relative to March 2019, the Emergency Medical System had a 330% mean increment in the number of calls (158 005 versus 679 569), but fewer Stroke Code activations (517 versus 426). Stroke admissions (108 versus 83) and the number of thrombectomies (21 versus 16) declined at Hospital Clinic of Barcelona, particularly after lockdown of the population. Younger age was found in stroke admissions during the pandemic (median [interquartile range] 69 [64–73] versus 75 [73–80] years, P =0.009). In-hospital, there were no differences in workflow metrics, angiographic results, complications, or outcomes at discharge. Conclusions: The COVID-19 pandemic reduced by a quarter the stroke admissions and thrombectomies performed at a Comprehensive Stroke Center but did not affect the quality of care metrics. During the lockdown, there was an overload of emergency calls but fewer Stroke Code activations, particularly in elderly patients. Hospital contingency plans, patient transport systems, and population-targeted alerts must act concertedly to better protect the chain of stroke care in times of pandemic.

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

10.21203/rs.3.rs-56553/v1 ◽

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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Abstract W P334: VA Healthcare System Responses to National Stroke Care Reorganization

Stroke ◽

10.1161/str.45.suppl_1.wp334 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Teresa M Damush ◽

Kristine K Miller ◽

Laurie Plue ◽

Arlene A Schmid ◽

Laura Myers ◽

...

Keyword(s):

Acute Stroke ◽

Nurse Managers ◽

Stroke Care ◽

Structured Interviews ◽

Acute Stroke Care ◽

Major Barrier ◽

Ongoing Work ◽

Final Sample ◽

Cross Training ◽

Stroke Center

Aims: In 2011, the VA released the Acute Ischemic Stroke (AIS) Directive which mandated reorganization of acute stroke care, including self-designation as Primary (P), Limited Hours (LH), or Supporting (S) stroke center. We conducted interviews across stroke centers to understand barriers and facilitators faced in response. Methods: The final sample included 38 (84% invited) facilities: 9 P, 24 LH, and 5 S facilities. In total, 107 persons were interviewed including ED Chiefs, Chiefs of Neurology, ED Nurse Managers/Nurses and other staff. Semi-structured interviews were based on the AIS Directive. Completed interviews were transcribed and analyzed using Nvivo 10. Results: Barriers reported were a lack of personnel assigned to coordinate the facility response to the directive. Data collection and lack of staff were likewise commonly reported as barriers. For thrombolysis measures, the low number of eligible Veterans was another major barrier. LH and S facilities reported some unique barriers: access to radiology and neurology services; EMS diverting stroke patients to nearby stroke centers, maintaining staff competency, and a lack of stroke clinical champions. Some solutions applied included cross training X-ray technicians to provide head CT coverage, developing stroke order sets and templates, and staff training. Larger facilities added a stroke code pager system and improved upon its use, and established ED nurses to become first alerts for an acute stroke patient. LH and S facilities also responded by attempting to secure additional services and by establishing formal transfer agreements to improve Veteran tPA access. Conclusions: The AIS Directive brought focused attention to reorganizing and improving stroke care across a range of facility types. Larger VA facilities tended to follow established practices for organizing stroke care, but the unique LH designation presented challenges to consistently organize systems. Since Veterans have financial interest in presenting to a VA facility, ongoing work to organize VA care and to improve access to thrombolysis at smaller VA facilities is needed. This protocol was supported by Genentech Inc. Protocol ML 28238, VA HSRD QUERI Rapid Response Project 11-374, and the VA Stroke QUERI Center.

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

Stroke ◽

10.1161/str.52.suppl_1.p855 ◽

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.

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JCAHO Stroke Center Certification as a Strategy for a Statewide System of Acute Stroke Care in North Carolina

Academic Emergency Medicine ◽

10.1197/j.aem.2007.03.776 ◽

2007 ◽

Vol 14 (5 Supplement 1) ◽

pp. S31-S32

Author(s):

A. Asimos ◽

S. Huston ◽

L. Mettam ◽

D. Enright

Keyword(s):

North Carolina ◽

Acute Stroke ◽

Stroke Care ◽

Acute Stroke Care ◽

Stroke Center

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Abstract WP248: Methods to Achieving a 9-minute Door to TPA Time

Stroke ◽

10.1161/str.44.suppl_1.awp248 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Deepak S Nair ◽

Arun Talkad ◽

Clayton McNeil ◽

Jan Jahnel ◽

Teresa Swanson-Devlin ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Care ◽

Time Of Day ◽

National Average ◽

Acute Stroke Care ◽

Stroke Treatment ◽

The Past ◽

Stroke Center

Introduction Despite guidelines recommending “door to needle times” (DTN) of ≤60 minutes and the Target: Stroke program, the national average for stroke treatment is 79 minutes. We present the factors that have reduced DTN in our Stroke Center. Methods We retrospectively identified all patients who received IV rt-PA using our acute stroke code database, from 2007 to 2012. The patients were organized by their DTN into four groups: <20min, 20-39min, 40-59min, and ≥60min. Median NIHSS scores were calculated, along with median DTN per group and annually. We also specified median lab times, the source of the stroke code (EMS or ED), and time of day for the code. Results There were 180 patients that received IV rt-PA: 7 patients in <20min, 49 in 20-39min, 52 in 40-59min, and 72 in ≥60min. Median DTN was 14min, 30min, 46.5min, and 76min, respectively, with the overall fastest DTN being 9 minutes. Median NIHSS scores were 7, 12, 13, and 8, respectively. EMS initiated the code in 100% of the <20min cases, 45% in 20-39min, 44% in 40-59min, and 40% in ≥60min. Eighty-six percent of the <20min cases arrived during the day, as did 84% of the 20-39min, 65% of the 40-59min, and 42% of the ≥60min cases. When rt-PA was given before labs were resulted, the median DTN was 30min; otherwise, the median DTN was 54min. All cases with <20min DTN presented after May 2011, when the first such case occurred. The median DTN was 65.5min in 2007, 51min in 2008, 61min in 2009, 59.5min in 2010, 47min in 2011, and 35min in 2012. Conclusions Our experience suggests that the “Target: Stroke” strategies (EMS initiation of stroke codes, rapid triage, rt-PA before labs) can significantly reduce the time to thrombolysis. However, our significant improvement over the past two years followed a singular 13-minute DTN, which demonstrated that teamwork and passion for acute stroke care can catalyze the consistent delivery of efficient stroke treatment.

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Abstract TP244: A Successful Statewide Initiative to Designate Hospital as Remote Treatment Stroke Centers

Stroke ◽

10.1161/str.47.suppl_1.tp244 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Shelley Nichols ◽

Debbie Camp ◽

McCord Smith ◽

Chris Threlkeld ◽

James Lugtu ◽

...

Keyword(s):

Acute Stroke ◽

Systems Of Care ◽

Standard Of Care ◽

Stroke Care ◽

Acute Stroke Care ◽

Stroke Registry ◽

Remote Treatment ◽

Stroke Systems Of Care ◽

Stroke Center ◽

Iv Tpa

Background: As treatment of acute ischemic stroke (AIS) with IV tPA has become standard of care, smaller hospitals with limited resources have struggled to conform to consensus guidelines. To fill this practice gap, stroke systems of care were developed to support smaller, often rural, hospitals in providing standard stroke care to the patients they serve. Methods: As a result of legislative support from the Coverdell-Murphy Act, the Georgia Coverdell Acute Stroke Registry (GCASR) in collaboration with the Georgia Office of EMS (GA OEMS), the Georgia Hospital Association (GHA), and other state partners, developed a method for designating hospitals as Remote Treatment Stroke Centers (RTSC). The primary focus of performance improvement was treatment with IV tPA in eligible patients. Data collection and process change were used to improve the following quality indicators: percentage of eligible AIS patients treated with IV tPA and number of stroke alert notifications. Hospitals were required to partner with an accredited stroke center and use telemedicine to support the decision for administering IV tPA. GA OEMS was charged with reviewing and surveying individual hospitals applying for RTSC status. The GCASR served as the central repository to facilitate data sharing and benchmarking across hospitals. An inter-hospital transfer tool was created for EMS providers, adopted by GA OEMS, and disseminated throughout the state to guide management of patients receiving IV tPA who required transfer from a RTSC to an accredited stroke center. Results: Starting in 2014, pertinent information was distributed and assistance provided to the 24 RTSC eligible GCASR hospitals. At present, 4 hospitals have achieved designation; 1 hospital is pending survey; and several are considering application. In 2012-13 the now 4 RTSC hospitals gave IV tPA to 8 patients. In 2014-15 as these hospitals sought and achieved designation, this number rose to 24. During this same period, stroke alerts increased from 76 to 308. Conclusion: A state-based public health stroke initiative is effective in facilitating the designation of RTSC and thereby improving the delivery of acute stroke care in underserved areas.

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Abstract MP24: Pitfalls of Mobile Stroke Treatment Unit - A Single Center Review

Stroke ◽

10.1161/str.52.suppl_1.mp24 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Mangala Gopal ◽

Ciaran Powers ◽

Shahid M Nimjee ◽

Sharon Heaton ◽

Vivien Lee

Keyword(s):

Intravenous Thrombolysis ◽

Stroke Care ◽

Final Diagnosis ◽

Acute Stroke Care ◽

Treatment Unit ◽

Stroke Treatment ◽

The Mean ◽

Suspected Stroke ◽

Comprehensive Stroke Center ◽

Stroke Center

Introduction: Although Mobile Stroke Treatment Units (MSTU) can reduce time to intravenous thrombolysis (IVtPA), limitations in MSTU care have not been well described. Methods: We retrospectively reviewed consecutive patients transported by MSTU to our academic comprehensive stroke center (CSC) from May 2019 to August 2020 for suspected stroke to assess for potential limitations of care. The Columbus MSTU is owned by a separate health system, but represents a collaborative venture with 3 CSCs and the Columbus Division of Fire, operating daily from 7am-7pm. Data was abstracted on demographics, clinical presentation, last known normal (LKN) time, initial National Institutes of Health Stroke Scale (NIHSS), neuroimaging, and IVtPA administration. Results: Among 93 patients transported to our CSC by MSTU, the mean age was 65 years (range, 21-93) and 61 (66%) were female. The mean initial NIHSS was 7.1 (range, 0 to 33) and 52 (55.9%) had a final diagnosis of stroke (4 hemorrhagic, 48 ischemic). IVtPA was administered in 15 (16.1%) with a mean LKN to IVtPA time of 120 minutes (range, 41 to 243). Among 15 patients treated with IVtPA, 10 received IVtPA in MSTU and 5 in CSC ED. In 7 patients who underwent thrombectomy, mean door to groin time was 57 minutes (range, 28 to 88). Among the overall group, 9 (9.7%) cases were identified with limitations in MSTU care, including 2 patients who received IVtPA by MSTU that were more than 10% off from ideal dosing (underdosed by 9mg and overdosed by 21mg), 1 warfarin-associated hemorrhage requiring intubation who did not receive reversal in MSTU but did upon arrival to CSC ED, and 5 patients who received IVtPA after arrival to CSC ED. The reasons for withholding IVtPA included inability to confirm LKN, patient declination, lack of translator, incorrect LKN, and seizure requiring intubation. The LKN to IVtPA time was significantly longer in the ED compared to MSTU (197 vs 82 minutes, p <0.0001). Conclusion: In our series of suspected stroke patients evaluated by MSTU, gaps identified within MSTU acute stroke care were related to limitations of resources and included errors in weight-based IVtPA dosing, inability to administer IVtPA, or reversal for anti-coagulation related hemorrhage. Clinicians need to be aware of potential pitfalls of MSTU evaluation.

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Stroke care: initial data from a county-based bypass protocol for patients with acute stroke

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012476 ◽

2016 ◽

Vol 9 (7) ◽

pp. 631-635 ◽

Cited By ~ 45

Author(s):

Syed F Zaidi ◽

Julie Shawver ◽

Aixa Espinosa Morales ◽

Hisham Salahuddin ◽

Gretchen Tietjen ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Care ◽

Diagnostic Specificity ◽

Treatment Rate ◽

Systemic Thrombolysis ◽

Advanced Therapy ◽

Tissue Plasminogen ◽

Lucas County ◽

Comprehensive Stroke Center ◽

Stroke Center

BackgroundEarly identification and transfer of patients with acute stroke to a primary or comprehensive stroke center results in favorable outcomes.ObjectiveTo describe implementation and results of an emergency medical service (EMS)-driven stroke protocol in Lucas County, Ohio.MethodAll county EMS personnel (N=464) underwent training in the Rapid Arterial oCclusion Evaluation (RACE) score. The RACE Alert (RA) protocol, whereby patients with stroke and a RACE score ≥5 were taken to a facility that offered advanced therapy, was implemented in July 2015. During the 6-month study period, 109 RAs were activated. Time efficiencies, diagnostic accuracy, and mechanical thrombectomy (MT) outcomes were compared with standard ‘stroke-alert’ (N=142) patients from the preceding 6 months.ResultsAn increased treatment rate (25.6% vs 12.6%, p<0.05) and improved time efficiency (median door-to-CT 10 vs 28 min, p<0.05; door-to-needle 46 vs 75 min, p<0.05) of IV tissue plasminogen activator within the RA cohort was achieved. The rate of MT (20.1% vs 7.7%, p=0.06) increased and treatment times improved, including median arrival-to-puncture (68 vs 128 min, p=0.04) and arrival-to-recanalization times (101 vs 205 min, p=0.001) in favor of the RA cohort. A non-significant trend towards improved outcome (50% vs 36.4%, p=0.3) in the RA cohort was noted. The RA protocol also showed improved diagnostic specificity for ischemic stroke (52.3% vs 30.1%, p<0.05).ConclusionsOur results indicate that EMS adaptation of the RA protocol within Lucas County is feasible and effective for early triage and treatment of patients with stroke. Using this protocol, we can significantly improve treatment times for both systemic thrombolysis and MT.

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