scholarly journals Improving Outcomes After Stroke: From Stroke Units to Mobile Stroke Units

Stroke ◽  
2021 ◽  
Author(s):  
Andrei V. Alexandrov ◽  
Yongchai Nilanont
Keyword(s):  
Stroke Care ◽  
Absolute Difference ◽  
Clinical Approach ◽  
Stroke Units ◽  
Stroke Treatment ◽  
Golden Hour ◽  
Systemic Thrombolysis ◽  
Improved Outcomes ◽  
Mobile Stroke Unit ◽  
The Impact

A proactive clinical approach to stroke care improved functional outcomes with implementation of specialized in-hospital stroke units, urgently delivered systemic thrombolysis, mechanical thrombectomy and most recently with mobile stroke units deployed in the field. An 18% absolute difference in outcomes as a shift across all modified Rankin Scale strata at 3 months in the recent Berlin study may not be explained by just 8.8% more patients treated within the golden hour for thrombolytic treatment from symptom onset. These findings parallel the findings in the largest controlled multi-center BEST-MSU trial (Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit) to date. A shortcoming in blinding of the investigators to the mode of transportation is similar to blinding to the endovascular treatment in PROBE (Prospective Randomized Open, Blinded End-Point) design used in thrombectomy trials. A faster access to stroke experts and brain imaging in the field for all patients suspect of stroke regardless symptom nature, severity, duration or resolution delivered by mobile stroke units is likely the reason for improved outcomes akin the impact observed in the initial multidisciplinary approach to in-hospital stroke units and reperfusion therapies delivery.

Abstract P354: Assessment of Phased Implementation of a Mobile Stroke Unit for Acute Ischemic Stroke Treatment

Circulation ◽  
2018 ◽  
Vol 137 (suppl_1) ◽  
Author(s):  
Soraya Sanchez Molero ◽  
Cynthia Diaz ◽  
James Boozan ◽  
Michael F Stiefel
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Stroke Unit ◽  
Stroke Care ◽  
Tissue Type ◽  
Retrospective Case ◽  
Stroke Treatment ◽  
Mobile Stroke Unit ◽  
Significant Difference ◽  
The Impact

Introduction: The timing of administering tissue-type plasminogen activator (tPA) in patients with an ischemic stroke is directly related to clinical outcomes. The use of a mobile stroke unit (MSU) is a strategy to provide acute ischemic stroke assessment and treatment in a more rapid fashion compared to standard stroke transport and management. Our program initiated the use of a MSU in 2017 as a part of a phased implementation program. We sought to determine the impact of the MSU on the timing of stroke care in the region as it related to proximity to the hospital. Methods: We collected data during the first 9 months of 2017 on patients who were transported to the hospital as pre-hospital stroke alerts (PHSA) via conventional ambulance or via the MSU. Using a retrospective case-controlled design we compared process metrics associated with the phased implementation of the MSU with conventional pre-hospital stroke alerts as standard of care (SOC). Results: There was a total of 178 stroke alert patients; 72 in the MSU group and 106 in the PHSA group. 35 patients received tPA, 16 in the MSU, 19 in SOC. There was no significant difference in age, body weight, race, gender, and length of stay in the hospital in the two groups. The time from 911 call to arrival on scene was 12.06 min versus 20.4 min in the PHSA and MSU groups, respectively. Despite a longer time for arrival TPA administration for patients within a 5 miles radius of the hospital was 89 ± 25 mins in the SOC group and 78±12 mins in the MSU group (p=0.11). For 911 calls originating 10-20 miles from the hospital, the time for 911 call to tPA was 106 ± 23 mins in the PHSA group (n = 4) and 86 ± 2 mins in the MSU group (n = 4). Conclusion: Our initial results are comparable with previously reported data . Our data suggests the MSU may have a greater impact on reducing time to tPA for those further from the hospital or where transport time is delayed. The role of the MSU for non tPA patients such as mechanical thrombectomy, intracerebral hemorrhage and subarachnoid hemorrhage warrants further investigation.

scholarly journals Impact of mobile stroke units

2021 ◽  
pp. jnnp-2020-324005
Author(s):  
Klaus Fassbender ◽  
Fatma Merzou ◽  
Martin Lesmeister ◽  
Silke Walter ◽  
Iris Quasar Grunwald ◽  
...  
Keyword(s):  
Cost Efficiency ◽  
Current Knowledge ◽  
Vascular Imaging ◽  
Vessel Occlusion ◽  
Stroke Units ◽  
Stroke Treatment ◽  
Stroke Research ◽  
Mobile Stroke Unit ◽  
Novel Strategy

Since its first introduction in clinical practice in 2008, the concept of mobile stroke unit enabling prehospital stroke treatment has rapidly expanded worldwide. This review summarises current knowledge in this young field of stroke research, discussing topics such as benefits in reduction of delay before treatment, vascular imaging-based triage of patients with large-vessel occlusion in the field, differential blood pressure management or prehospital antagonisation of anticoagulants. However, before mobile stroke units can become routine, several questions remain to be answered. Current research, therefore, focuses on safety, long-term medical benefit, best setting and cost-efficiency as crucial determinants for the sustainability of this novel strategy of acute stroke management.

Development of the Madrid Stroke Programme: Milestones and Changes in Stroke Trends and Mortality from 1997 to 2017

2021 ◽  
pp. 1-6
Author(s):  
Silvia Pastor ◽  
Elena de Celis ◽  
Itsaso Losantos García ◽  
María Alonso de Leciñana ◽  
Blanca Fuentes ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Hospital Admissions ◽  
Temporal Trends ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
Care Organization ◽  
Stroke Units ◽  
Health Region ◽  
Number Of Patients ◽  
The Impact

<b><i>Introduction:</i></b> Stroke is a serious health problem, given it is the second leading cause of death and a major cause of disability in the European Union. Our study aimed to assess the impact of stroke care organization measures (such as the development of stroke units, implementation of a regional stroke code, and treatment with intravenous thrombolysis and mechanical thrombectomy) implemented from 1997 to 2017 on hospital admissions due to stroke and mortality attributed to stroke in the Madrid health region. <b><i>Methods:</i></b> Epidemiological data were obtained from the National Statistics Institute public website. We collected data on the number of patients discharged with a diagnosis of stroke, in-hospital mortality due to stroke and the number of inhabitants in the Madrid health region each year. We calculated rates of discharges and mortality due to stroke and the number of inhabitants per SU bed, and we analysed temporal trends in in-hospital mortality due to stroke using the Daniels test in 2 separate time periods (before and after 2011). Figures representing annual changes in these data from 1997 to 2017 were elaborated, marking stroke care organizational measures in the year they were implemented to visualize their temporal relation with changes in stroke statistics. <b><i>Results:</i></b> Hospital discharges with a diagnosis of stroke have increased from 170.3/100,000 inhabitants in 1997 to 230.23/100,000 inhabitants in 2017. However, the in-hospital mortality rate due to stroke has decreased (from 33.3 to 15.2%). A statistically significant temporal trend towards a decrease in the mortality percentage and rate was found from 1997 to 2011. <b><i>Conclusions:</i></b> Our study illustrates how measures such as the development of stroke units, implementation of a regional stroke code and treatment with intravenous thrombolysis coincide in time with a reduction in in-hospital mortality due to stroke.

scholarly journals Organizational issues in stroke treatment: The Swiss paradigm - Stroke units

2013 ◽  
Vol 04 (S 01) ◽  
pp. S131-S133 ◽  
Author(s):  
Georgios K Matis ◽  
Olga I Chrysou ◽  
Theodossios A Birbilis
Keyword(s):  
Multidisciplinary Care ◽  
Stroke Care ◽  
Stroke Units ◽  
Stroke Treatment ◽  
Organizational Issues ◽  
Standardized Treatment ◽  
Socioeconomic Burden ◽  
New Guidelines ◽  
Acute Rehabilitation ◽  
Prompt Diagnosis

ABSTRACTStroke represents the leading cause of acquired disability in adults and poses a tremendous socioeconomic burden both on patients and the society. In this sense, prompt diagnosis and urgent treatment are needed in order to radically reduce the devastating consequences of this disease. Herein the authors present the new guidelines recently adopted by the Swiss Stroke Society concerning the establishment of stroke units. Standardized treatment and allocation protocols along with an acute rehabilitation concept seem to be the core of the Swiss stroke management system. Coordinated multidisciplinary care provided by specialized medical, nursing and therapy staff is of utmost importance for achieving a significant dependency and death reduction. It is believed that the implementation of these guidelines in the stroke care system would be beneficial not only for the stroke patients, but also for the health system.

Abstract 1122‐000242: Effect of Covid‐19 on Stroke Treatment in Australia and New Zealand

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Ela Machiroutu
Keyword(s):  
New Zealand ◽  
Stroke Care ◽  
Small Subset ◽  
Stroke Patients ◽  
Secondary Research ◽  
Stroke Treatment ◽  
Survey Tool ◽  
Early Adoption ◽  
Survey Responses ◽  
The Impact

Introduction : In general, compared to the rest of the world, the impact of Covid‐19 in the Australia and New Zealand regions has been minimal and this may be attributed to their early adoption of social distancing, stable governments, national wealth and geographic isolation. However, this research was designed to validate this perception amongst the stakeholders. Methods : This research included: primary and secondary research. First, secondary research about Covid‐19 and stroke treatment and Australia and New Zealand in particular was conducted and compiled in a Google spreadsheet. Research sources include Stroke Foundation, Brain Foundation, and World Meters. Data collected included the number of stroke and Covid‐19 cases in Australia and New Zealand as well as a list of stakeholders with their contact information. The stakeholders included neurosurgeons, hospitals, neurologists, interventionists, and vascular surgeons. A survey tool and an interview questions were prepared next. The survey request was emailed to stakeholders, requesting the stakeholders for an interview and survey response. Over the following weeks, survey results came in and interviews were conducted. Since only a small subset of stakeholders responded to the survey (6 survey responses and 4 interviews), this study must be considered to be primarily qualitative in nature. The interviews were conducted online using Zoom. After the interviews, I replayed the interviews and took notes of important details. Results : The survey showed that 83% of the doctors worked in a hospital that had a separate stroke unit and that they perform mechanical thrombectomies most often as a treatment for stroke. Most of the doctors suggested that the stroke numbers have not changed significantly since Covid‐19. Yet, 50% of the doctors said that there had been delays in admitting stroke patients. One third believed Covid‐19 may have made an impact on mortality of stroke patients. One of the interviewees revealed that the main barriers to access to stroke care are the time it takes to treat the patient, fewer locations that treat strokes or perform mechanical thrombectomy, and patients’ reluctance to go to the hospital during the pandemic. Another confirmed that she did think there had been delays due to Covid‐19. Conclusions : Counter to widespread perception, Covid‐19 pandemic DID worsen many barriers for stroke treatment in Australia and New Zealand. These regions have insufficient stroke centers and these are not spread out widely enough for accessibility. Stroke deaths have increased during the Covid‐19 pandemic. Barriers such as time, accessibility, and the patient’s fear of hospitals have affected stroke treatment during the pandemic. Several measures can alleviate the impact: stroke awareness is critical. Every hospital needs to have the ability to assess and treat stroke. Hospitals must run simulations to practice and prepare for different scenarios that they could encounter when dealing with stroke patients. In conclusion, stroke treatment has been affected by the Covid‐19 pandemic and it is critical to minimize and overcome these barriers as stroke is one of the leading causes of death in Australia and New Zealand.

Abstract TP358: Prehospital Diagnosis of Intracerebral Hemorrhage in a Mobile Stroke Treatment Unit

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Daniel Vela-Duarte ◽  
Ramnath Santosh Ramanathan ◽  
Atif Zafar ◽  
Ather Taqui ◽  
Stacey Winners ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Hematoma Expansion ◽  
Hospital Treatment ◽  
Treatment Team ◽  
Hematoma Volume ◽  
Treatment Unit ◽  
Stroke Treatment ◽  
Imaging Characteristics ◽  
Mobile Stroke Unit ◽  
The Impact

Introduction: The mobile stroke unit (MSTU) is an on-site pre-hospital treatment team that incorporates laboratory and CT scanner and reduces times to treatment for ischemic stroke thrombolysis. The impact of MSTU on treatment and outcomes of intracerebral hemorrhage (ICH) remains unknown. We report our initial experience with ICH encountered on MSTU. Hypothesis: ICH can be quickly identified using MSTU. Hypertension and coagulopathy are common in ICH evaluated on MSTU. Methods: We identified ICH cases from the prospectively collected database encounters. Demographics, clinical features, MSTU imaging and repeat imaging characteristics were reviewed. Initial and follow-up hematoma volume was calculated by the ABC/2 method. Results: Of 295 encounters on MSTU from July 2014 to July 2015, 20 (6.7%) had intracranial hemorrhage, which comprised of 17 intracerebral, 1 subarachnoid and 2 subdural hemorrhages. Median time to CT diagnosis of ICH from emergency medical dispatch was 31 minutes (interquartile range (IQR) 28-36) and that from last known well was 118 minutes (IQR 39-301). Of the 17 ICH patients, 15 (88%) were hypertensive, with a mean systolic blood pressure of 178.1 and diastolic 91.0 mm Hg. Five (29.4%) individuals were found with INR>1.4, 1 of whom received 4-factor prothrombin complex concentrate. Median NIH Stroke Scale was 11 (IQR 7.5-14.5), and median hematoma volume was 10.7 cc (IQR 4.3-30.8). One patient had significant hematoma expansion as defined by >6 cc or 33% relative volume increase. Conclusions: Over 5% of the cases evaluated in the unit presented with ICH, most of whom were hypertensive and had small hematoma volume. MSTU enables early diagnosis of ICH after activation of emergency system, can provide early treatment, and appropriate triage.

Abstract P293: Disparate Outcomes for Stroke Patients With Documented Substance Use Compared to Those Without Substance Use

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Leslie Corless ◽  
Tamela L Stuchiner ◽  
Cameron Garvin ◽  
Alexandra C Lesko ◽  
Elizabeth Baraban
Keyword(s):  
Substance Use ◽  
Patient Characteristics ◽  
Stroke Care ◽  
Stroke Patients ◽  
Chi Square ◽  
Stroke Treatment ◽  
Discharge Disposition ◽  
Healthcare Settings ◽  
Medical Histories ◽  
The Impact

Background: Few studies have shown the impact of substance use (SU) on treatment and outcomes of stroke patients. Research suggests stigma related to SU impacts patient experience in healthcare settings. In this study we assessed whether there were differences in patient characteristics and outcomes for stroke patients with SU compared to those with no substance use (NSU). Methods: Retrospective data from two Oregon hospitals included patients admitted with stroke diagnosis, 18 years or older, who discharged between October 2017 and May 2019. Patients with documented SU and specific SU type were compared to patients with NSU with regard to demographics, medical history, stroke subtypes, treatment, discharge disposition and length of stay (LOS). SU was defined as any documented abuse of alcohol (ETOH), methamphetamine (MA), cannabis, opiates, cocaine, benzodiazepines, and Methyl-enedioxy-methamphetamine (MDMA). Non parametric median tests and Pearson’s chi square tests were used. Results: Among 2,030 patients included in the analysis, 13.8% (n=280) were SU and 86.2% (n=1,750) were NSU. Patients with SU were significantly younger, median age (61 vs. 73, p <.001) and less were female (35.4% vs. 53.6%, p <0.001). Those with SU had lower prevalence of dyslipidemia (43.6% vs. 59.5%, p <0.001), AFIB (12.5% vs. 22.2%, p <0.001), and previous TIA (6.1% vs 10.8%, p=0.02), and more smoked (54.3% vs 13.3% p <0.001). More patients with SU arrived via transfer (38.4% vs 27.4%, p=.001). Fewer patients with SU expired or were discharged to hospice (8.9% vs 13.7%) and a greater percent left against medical advice (AMA) (3.2% vs 0.6%) (p<.001). When comparing specific SU types to NSU, all SU groups were younger, had similar medical histories and a greater proportion left AMA. Only MA users had differentiating stroke diagnoses with a higher percent of SAH (14.5% vs 5.6%) (p=.003) in addition to longer LOS (6 vs 4 days, p=.006). No differences were found in acute stroke treatment rates. Conclusion: Patients with SU were demographically different from the NSU population and did differentiate on some stroke care outcomes and processes, potentially indicating opportunities to address stigma around substance use to meet the needs of patients with both stroke and substance use.

Abstract T P276: Calling Stroke Alert: Does It Make a Difference in the Chain of Survival?

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Cristine W Small ◽  
Donald L Price ◽  
Jeffrey D Ferguson ◽  
Lawrence I Madubeze ◽  
Susan D Freeman
Keyword(s):  
Clinical Outcomes ◽  
Stroke Severity ◽  
Golden Hour ◽  
Discharge Disposition ◽  
Improved Outcomes ◽  
Stroke Team ◽  
Severity Scores ◽  
Response Team ◽  
Chain Of Survival ◽  
The Impact

Purpose: To determine whether the stroke alert process results in improved outcomes, as reflected in door to lytic times and other outcome measures. Introduction: The diagnosis and treatment of stroke is time-sensitive and should be inclusive of all seven D’s in the “chain of survival” - Detection, Dispatch, Delivery, Door, Data, Decision and Drug (Adams, Stroke, 2007). Early stroke activation is part of the “Delivery” which incorporates transport and management by Emergency Medical Services (EMS). Clinical suspicion of stroke by EMS resulted in a process of early activation which was labeled “Stroke Alert.” This expedited the code stroke process upon arrival, preparing the hospital based stroke team to provide immediate triage and evaluation. The goal was to improve clinical efficiency and possibly clinical outcomes. Methods: • Implementation of a notification process from EMS to ED - Stroke Alert • Incorporated Stroke Alert to include Stroke Response Team (SRT) nurses January 22, 2011 • Retrospective review of internal stroke database (January 22, 2011 to July 2013) for comparative analysis of Stroke Alerts called versus those where no stroke alert was called • Evaluate clinical outcomes directly related to Stroke Alert process Results: From January 22, 2011 to July 2013: Stroke Alert Called: • 37 t-PA patients and 14 of those, 37.8%, met the 60 minute benchmark • Average Door to Lytic time - 65 minutes Stroke Alert NOT Called: • 35 t-PA patients and 10 of those, 28.6% met the 60 minute benchmark • Average Door to Lytic time - 79 minutes Conclusions: The ability for a SRT to meet the golden hour of stroke benchmark occurs more frequently when a Stroke Alert is called to the SRT nurse. Future plans include review of stroke severity scores, length of stay (LOS), and discharge disposition, to determine the impact a Stroke Alert may have on clinical outcomes.

Establishing Stroke Services in the Republic of Georgia

2021 ◽  
pp. 1-9
Author(s):  
Zaza Katsarava ◽  
Tamar Akhvlediani ◽  
Tamar Janelidze ◽  
Tamar Gudadze ◽  
Marina Todua ◽  
...  
Keyword(s):  
Treatment Process ◽  
Stroke Care ◽  
Subsequent Treatment ◽  
National Guidelines ◽  
Ethical Problems ◽  
Stroke Units ◽  
Systemic Thrombolysis ◽  
Stroke Services ◽  
The Republic ◽  
Quality Reports

<b><i>Introduction:</i></b> This article summarizes the medical experience in establishing stroke units and systemic thrombolysis in Georgia, which, like many other post-Soviet countries, still faces problems in organizing stroke care even after 30 years of independence. <b><i>Patients and Methods:</i></b> We created an example of treating acute stroke with systemic thrombolysis and introduced stroke units in several hospitals in the country, including standardization of the diagnostic and treatment process, consistent evaluation, and monthly feedback to the stroke unit staff. <b><i>Results:</i></b> Systemic thrombolysis has become a clinical routine in some large hospitals and is meanwhile reimbursed by the state insurance. The data of consecutive 1,707 stroke patients in 4 major cities demonstrated significant time lost at the prehospital level, due to failure in identifying stroke symptoms, delay in notification, or transportation. The consequent quality reports resulted in a dramatic increase in adherence to the European and national guidelines. A mandatory dysphagia screening and subsequent treatment led to a decrease in pneumonia rates. <b><i>Discussion:</i></b> We discuss our experience and suggestions on how to overcome clinical, financial, and ethical problems in establishing a stroke services in a developing country. <b><i>Conclusion:</i></b> The Georgian example might be useful for doctors in other post-Soviet countries or other parts of the world.

Abstract TMP86: Telestroke Improves Guideline-Based Comprehensive Stroke Care: The TELECAST Trial

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Christopher D Streib ◽  
Oladi Bentho ◽  
Kathryn Bard ◽  
Eric Jaton ◽  
Sarah Engkjer ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Stroke Care ◽  
Composite Score ◽  
Stroke Recurrence ◽  
Acute Stroke Care ◽  
Specialist Service ◽  
Stroke Treatment ◽  
Chi Squared ◽  
Secondary Outcomes ◽  
The Impact

Introduction: Limited access to stroke specialist expertise produces disparities in inpatient stroke treatment. The impact of telestroke on the remote delivery of guideline-based inpatient stroke care is yet to be comprehensively studied. The TELECAST trial (NCT03672890) prospectively examined the impact of a 24-7 telestroke specialist service dedicated to inpatient acute stroke care spanning admission to discharge. Methods: AHA stroke guidelines were used to derive outcome metrics in the following acute stroke inpatient care categories: diagnostic stroke evaluation (DSE), secondary stroke prevention (SSP), health screening and evaluation (HSE), and stroke education (SE). Adherence to AHA guidelines for stroke inpatients pre-telestroke (July 1, 2016-June 30, 2018) and post-telestroke intervention (July 1, 2018-June 30, 2019) were studied. The primary outcome was a composite score of all guideline-based stroke care. Secondary outcomes consisted of subcategory composite scores in DSE, SSP, HSE, and SE. Chi-squared tests were utilized to assess primary and secondary outcomes. Statistical analysis was performed using STATA 15.0. Results: Following institution of a comprehensive inpatient telestroke service, overall adherence to guideline-based metrics improved (composite score: 85% vs 94%, p<0.01) as did adherence to DSE guidelines (subgroup score: 90 vs 95%, p<0.01). SSP, HSE, and SE subgroup scores were not significantly different. See Table 1. Conclusion: The implementation of a 24-7 inpatient telestroke service improved adherence to AHA guidelines for inpatient acute stroke care. Dedicated inpatient telestroke specialist coverage may improve inpatient stroke care and reduce stroke recurrence in hospitals without access to stroke specialists.

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