Influence of stroke coordinators on delivery of acute stroke care and hospital outcomes: An observational study

Background Stroke coordinators have been inconsistently used in various countries to support stroke care in hospital. Aim To investigate the association between stroke coordinators and the provision of evidence-based care and patient outcomes in hospitals with acute stroke units. Methods Observational study using cross-sectional data from the 2015 National Acute Services Audit Program (Australia): including a retrospective medical record audit (40 records from each hospital) and a self-reported survey of organizational resources for stroke. Multilevel random effects logistic regression for patient outcomes including complications, independence on discharge, and death. Median regression for length of stay comparisons. Results A total of 109 hospitals submitted 4060 cases; 59 (54%) had a stroke coordinator. Compared with patients from stroke unit hospitals with no stroke coordinator ( N = 33, 1333 cases), patients in stroke unit hospitals with a stroke coordinator ( N = 53, 2072 cases) were more likely to receive clinical practices including rehabilitation therapy within 48 hours of initial assessment (88 vs. 82%, p < 0.001), risk factor modification advice (62 vs. 55%, p = 0.003) and receive a discharge care plan (65 vs. 48%, p < 0.001). No differences in complications, independence on discharge, or deaths were evident. Patients from hospitals with a stroke coordinator were more likely to access inpatient rehabilitation (adjusted odds ratio 1.8, 95% confidence interval 1.1–2.8) and have a reduced length of acute stay if discharged (median 14 h, p = 0.03). Conclusion Presence of stroke coordinators was associated with reduced length of stay and improved delivery of evidence-based care in hospitals with a stroke unit.

Download Full-text

Is length of time in a stroke unit associated with better outcomes for patients with stroke in Australia? An observational study

BMJ Open ◽

10.1136/bmjopen-2018-022536 ◽

2018 ◽

Vol 8 (11) ◽

pp. e022536 ◽

Cited By ~ 1

Author(s):

Doreen Busingye ◽

Monique F Kilkenny ◽

Tara Purvis ◽

Joosup Kim ◽

Sandy Middleton ◽

...

Keyword(s):

Length Of Stay ◽

Observational Study ◽

Patient Outcomes ◽

Stroke Unit ◽

Stroke Care ◽

Aged Care ◽

Care Quality ◽

Residential Aged Care ◽

Cross Sectional ◽

Factors Associated

ObjectiveSpending at least 90% of hospital admission in a stroke unit (SU) is a recommended indicator of receiving high-quality stroke care. However, whether this makes a difference to patient outcomes is unknown. We aimed to investigate outcomes and factors associated with patients with acute stroke spending at least 90% of their admission in an SU, compared with those having less time in the SU.DesignObservational study using cross-sectional data.SettingData from hospitals which participated in the 2015 Stroke Foundation National Audit: Acute Services (Australia) and had an SU. This audit includes an organisational survey and retrospective medical record audit of approximately 40 admissions from each hospital.ParticipantsPatients admitted to an SU during their acute admission were included.Outcome measuresHospital-based patient outcomes included length of stay, independence on discharge, severe complications and discharge destination. Patient, organisational and process indicators were included in multilevel logistic modelling to determine factors associated with spending at least 90% of their admission in an SU.ResultsEighty-eight hospitals with an SU audited 2655 cases (median age 76 years, 55% male). Patients who spent at least 90% of their admission in an SU experienced: a length of stay that was 2 days shorter (coefficient −2.77, 95% CI −3.45 to –2.10), fewer severe complications (adjusted OR (aOR) 0.60, 95% CI 0.43 to 0.84) and were less often discharged to residential aged care (aOR 0.59, 95% CI 0.38 to 0.94) than those who had less time in the SU. Patients admitted to an SU within 3 hours of hospital arrival were three times more likely to spend at least 90% of their admission in an SU.ConclusionSpending at least 90% of time in an SU is a valid measure of stroke care quality as it results in improved patient outcomes. Direct admission to SUs is warranted.

Download Full-text

Processes of Stroke Unit Care and Outcomes at Discharge in Vietnam: Findings from the Registry of Stroke Care Quality (RES-Q) in a Major Public Hospital

Journal of Stroke Medicine ◽

10.1177/2516608519869132 ◽

2019 ◽

Vol 2 (2) ◽

pp. 119-127

Author(s):

Thang Huy Nguyen ◽

Seana Gall ◽

Dominique A. Cadilhac ◽

Hoang Nguyen ◽

Daniel Terry ◽

...

Keyword(s):

Developing Countries ◽

Stroke Unit ◽

Public Hospital ◽

Stroke Care ◽

Care Quality ◽

Stroke Severity ◽

Evidence Based ◽

Hospital Arrival ◽

Stroke Unit Care ◽

Evidence Based Care

Background: An essential strategy to reduce mortality and disability after stroke is to ensure access to evidence-based care. In developed countries, it has been shown that if hospitals improve the quality of care, the impact of stroke is attenuated. However, in developing countries, data on the processes of care and associated patient outcomes are scarce. We examined the care processes and outcomes among patients with acute stroke from a stroke unit in a major public hospital in Vietnam whereby there are approximately 15,000 hospital admissions for stroke per year. Methods: We included first-ever strokes admitted to the 115 People’s Hospital (June 2017-March 2018). Data were collected in the Registry of Stroke Care Quality which is used in >50 countries. Baseline characteristics, stroke-related factors (e.g., type and severity), processes of care (e.g., thrombolysis), and outcomes at discharge were examined including mortality and functional outcome, assessed as the walking ability without assistance. Results: Data were available for 6601 patients with first-ever stroke (44% women, 80% ischemic stroke [IS], median age: 62 years, interquartile range [IQR]: 53-72) who received stroke unit care. The median time from stroke onset to hospital arrival was 15.7 hours (IQR: 5.6-37.5). At admission, the median National Institute of Health Stroke Scale score indicating stroke severity was 7 (IQR: 4-12). Among those with IS, 9% received intravenous thrombolysis. Over 90% of the participants received recommended process of care including dysphasia screening (99%), antihypertensive agents (92%), cholesterol-lowering medication (IS = 99%), and antithrombotic medication (IS = 98%). At discharge (median length of stay: 4 days, IQR: 3-6), 3% of all cases died and 46% were able to walk independently. Advanced age, stroke severity, and not receiving antihypertensive agent(s) were contributing factors to mortality and poorer functional outcome. Conclusion: There was a considerable delay in the time from stroke onset to hospital arrival. Evidence-based care at the stroke unit was consistently provided. It remains unclear whether other hospitals in Vietnam and other developing countries perform as well. Greater public awareness of stroke to reduce onset to arrival times and more stroke units are warranted to achieve the excellent outcomes in the major public hospital.

Download Full-text

Comparison of Provision of Stroke Care in Younger and Older Patients: Findings from the South London Stroke Register

Stroke Research and Treatment ◽

10.1155/2012/319581 ◽

2012 ◽

Vol 2012 ◽

pp. 1-9 ◽

Cited By ~ 1

Author(s):

Siobhan L. Crichton ◽

Charles D. A. Wolfe ◽

Anthony G. Rudd ◽

Christopher McKevitt

Keyword(s):

Older Patients ◽

Stroke Unit ◽

Stroke Care ◽

Population Based ◽

Evidence Based ◽

Younger Adults ◽

Stroke Units ◽

Younger Age ◽

Evidence Based Care ◽

Stroke Register

Background. Evidence-based stroke care should be available to all patients. However, evidence exists of inequalities according to age. This study compared access to care for younger adults to that for over 65s.Methods. Using population-based data from 4229 patients with first-ever stroke between 1995 and 2010, associations between age and 21 care indicators were investigated using multivariable logistic regression.Results. Age was not associated with stroke unit admission for ischaemic stroke (P=0.666). Younger PICH patients were least likely to be admitted to stroke units (P=0.001), instead treated on neurosurgical or ICU wards. Younger age was also associated with admission to neurosurgery or ICU after SAH (P=0.006), increased occupational or physiotherapy at 1 year (P=0.043), and contact with a GP 3 months after stroke (P<0.001).Conclusion. Younger patients have equal or greater access to evidence-based care. However, there is a need to ensure that services meet the needs of this group.

Download Full-text

Retrospective Review and Proof of Concept of Asia’s First Mobile Stroke Unit Experience in Kovai Medical Center and Hospital

Journal of Stroke Medicine ◽

10.1177/2516608520968418 ◽

2020 ◽

Vol 3 (2) ◽

pp. 116-123

Author(s):

Mathew Cherian ◽

Pankaj Mehta ◽

Shriram Varadharajan ◽

Santosh Poyyamozhi ◽

Elango Swamiappan ◽

...

Keyword(s):

Acute Stroke ◽

Retrospective Review ◽

Stroke Unit ◽

Care Pathway ◽

Clinical Care ◽

Stroke Care ◽

First Year ◽

Proof Of Concept ◽

Mobile Stroke Unit ◽

Clinical Care Pathway

Background: We review our initial experience of India’s and Asia’s first mobile stroke unit (MSU) following the completion of its first year of operation. We outline the clinical care pathway integrating the MSU services using a case example taking readers along our clinical care workflow while highlighting the challenges faced in organizing and optimizing such services in India. Methods: Retrospective review of data collected for all patients from March 2018 to February 2019 transported and treated within the MSU during the first year of its operation. Recent case example is reviewed highlighting complete comprehensive acute clinical care pathway from prehospital MSU services to advanced endovascular treatment with focus on challenges faced in developing nation for stroke care. Results: The MSU was dispatched and utilized for 14 patients with clinical symptoms of acute stroke. These patients were predominantly males (64%) with median age of 59 years. Ischemic stroke was seen in 7 patients, hemorrhagic in 6, and 1 patient was classified as stroke mimic. Intravenous tissue plasminogen activator was administered to 3 patients within MSU. Most of the patients’ treatment was initiated within 2 h of symptom onset and with the median time of patient contact (rendezvous) following stroke being 55 mins. Conclusion: Retrospective review of Asia’s first MSU reveals its proof of concept in India. Although the number of patients availing treatment in MSU is low as compared to elsewhere in the world, increased public awareness with active government support including subsidizing treatment costs could accelerate development of optimal prehospital acute stroke care policy in India.

Download Full-text

Disabling stroke in persons already with a disability

Neurology ◽

10.1212/wnl.0000000000008964 ◽

2020 ◽

Vol 94 (7) ◽

pp. 306-310 ◽

Cited By ~ 5

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.

Download Full-text

Abstract 3446: Inpatient Code Stroke Protocol: A Quality Improvement and Knowledge Translation Strategy for a Challenging Scenario

Stroke ◽

10.1161/str.43.suppl_1.a3446 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Jacqueline D Willems ◽

Krsytyna Skrabka ◽

Roseane Nisenbaum ◽

Judith Barnaby ◽

Pawel Kostyrko ◽

...

Keyword(s):

Quality Improvement ◽

Acute Stroke ◽

Robust Regression ◽

Stroke Care ◽

Initial Assessment ◽

Stroke Severity ◽

Care Hospital ◽

Presenting Symptoms ◽

Number Of Patients ◽

Assessment And Treatment

Background: Stroke care faces a clinical challenge in treating inhospital strokes, which account for about 15% of all strokes. Prior studies showed an inequity in the assessment and treatment of inpatients who suffer a stroke versus out-of hospital. For example, inpatients have longer time to initial assessment, CT and are less likely (wait longer) to receive tissue plasminogen activator (t-PA). There is limited research evaluating the efficacy of inpatient code stroke protocols (ICSP) on access to and quality of hyper-acute stroke care. Objective: To evaluate the efficacy of the ICSP in a large tertiary care hospital. Methods: This prospective study evaluated a quality improvement strategy involving ICSP implementation at St Michael’s Hospital in 2009. The ICSP focuses on the identification of stroke symptoms and timely notification of most responsible physician, then leverages the Emergency Department code stroke process. A 3-month hospital-wide implementation period involved 60 min. education sessions with a minimum of 2 sessions per unit. Demographic factors, presenting symptoms, stroke severity, vascular risk factors as well as time of: symptoms onset, CT; and physician assessment were collected by chart abstraction after ethics approval. The primary outcomes was time from last seen normal (LSN) to CT scan. Secondary outcomes include time from LSN to initial assessment (IA), medical complications and number of patients receiving endovascular interventions or intravenous thrombolysis. The analysis was completed by comparing unadjusted and adjusted outcomes pre and post implementation of the ICSP. Descriptive statistics and robust regression was completed using SAS 9.0. Results: Overall, there were 245 inhospital strokes during the study period (152 pre and 93 post ICSP implementation). Mean age was 69.8 yrs, 60% were male. Most inpatient strokes occurred on cardiovascular services (42.9%). Main results summarized in table . There was no difference in the number of patients receiving thrombolysis or endovascular treatment. After adjustment for covariates, the ICS was associated with a significant reduction of 288 minutes (95%CI -566, -10) in time from LSN to CT. Similarly, there was significant reduction of 307 (95%CI -532, -82) in time from LSN to IA. Conclusions: Implementation of the ICSP resulted in improvements in the process indicators related to assessment and treatment of hyper-acute stroke. Similar quality improvement strategies can be implemented to ameliorate disparities between care for inpatients and outpatient presenting with an acute ischemic stroke.

Download Full-text

The role of cardiologists on the stroke unit

European Heart Journal Supplements ◽

10.1093/eurheartj/suaa160 ◽

2020 ◽

Vol 22 (Supplement_M) ◽

pp. M3-M12

Author(s):

Wolfram Doehner ◽

David Manuel Leistner ◽

Heinrich J Audebert ◽

Jan F Scheitz

Keyword(s):

Acute Stroke ◽

Stroke Unit ◽

Stroke Care ◽

Cardiovascular Complications ◽

Large Artery ◽

Stroke Management ◽

Acute Stroke Care ◽

Daily Work ◽

Cardiovascular Comorbidity ◽

Treatment And Prevention

Abstract Cardiologists need a better understanding of stroke and of cardiac implications in modern stroke management. Stroke is a leading disease in terms of mortality and disability in our society. Up to half of ischaemic strokes are directly related to cardiac and large artery diseases and cardiovascular risk factors are involved in most other strokes. Moreover, in an acute stroke direct central brain signals and a consecutive autonomic/vegetative imbalance may account for severe and life-threatening cardiovascular complications. The strong cerebro-cardiac link in acute stroke has recently been addressed as the stroke-heart syndrome that requires careful cardiovascular monitoring and immediate therapeutic measures. The regular involvement of cardiologic expertise in daily work on a stroke unit is therefore of high importance and a cornerstone of up-to-date comprehensive stroke care concepts. The main targets of the cardiologists’ contribution to acute stroke care can be categorized in three main areas (i) diagnostics workup of stroke aetiology, (ii) treatment and prevention of complications, and (iii) secondary prevention and sub-acute workup of cardiovascular comorbidity. All three aspects are by themselves highly relevant to support optimal acute management and to improve the short-term and long-term outcomes of patients. In this article, an overview is provided on these main targets of cardiologists’ contribution to acute stroke management.

Download Full-text

Feasibility of a hyper-acute stroke unit model of care across England: a modelling analysis

BMJ Open ◽

10.1136/bmjopen-2017-018143 ◽

2017 ◽

Vol 7 (12) ◽

pp. e018143 ◽

Cited By ~ 7

Author(s):

Michael Allen ◽

Kerry Pearn ◽

Emma Villeneuve ◽

Thomas Monks ◽

Ken Stein ◽

...

Keyword(s):

Acute Stroke ◽

Travel Time ◽

Stroke Unit ◽

Stroke Care ◽

Hyperacute Stroke ◽

Geographical Access ◽

Unit Model ◽

Stroke Services ◽

Time Critical ◽

Institutional Size

ObjectivesThe policy of centralising hyperacute stroke units (HASUs) in England aims to provide stroke care in units that are both large enough to sustain expertise (>600 admissions/year) and dispersed enough to rapidly deliver time-critical treatments (<30 min maximum travel time). Currently, just over half (56%) of patients with stroke access care in such a unit. We sought to model national configurations of HASUs that would optimise both institutional size and geographical access to stroke care, to maximise the population benefit from the centralisation of stroke care.DesignModelling of the effect of the national reconfiguration of stroke services. Optimal solutions were identified using a heuristic genetic algorithm.Setting127 acute stroke services in England, serving a population of 54 million people.Participants238 887 emergency admissions with acute stroke over a 3-year period (2013–2015).InterventionModelled reconfigurations of HASUs optimised for institutional size and geographical access.Main outcome measureTravel distances and times to HASUs, proportion of patients attending a HASU with at least 600 admissions per year, and minimum and maximum HASU admissions.ResultsSolutions were identified with 75–85 HASUs with annual stroke admissions in the range of 600–2000, which achieve up to 82% of patients attending a stroke unit within 30 min estimated travel time (with at least 95% and 98% of the patients being within 45 and 60 min travel time, respectively).ConclusionsThe reconfiguration of hyperacute stroke services in England could lead to all patients being treated in a HASU with between 600 and 2000 admissions per year. However, the proportion of patients within 30 min of a HASU would fall from over 90% to 80%–82%.

Download Full-text