Utstein recommendation for emergency stroke care

Background Recent advances in treatment for stroke give new possibilities for optimizing outcomes. To deliver these prehospital care needs to become more efficient. Aim To develop a framework to support improved delivery of prehospital care. The recommendations are aimed at clinicians involved in prehospital and emergency health systems who will often not be stroke specialists but need clear guidance as to how to develop and deliver safe and effective care for acute stroke patients. Methods Building on the successful implementation program from the Global Resuscitation Alliance and the Resuscitation Academy, the Utstein methodology was used to define a generic chain of survival for Emergency Stroke Care by assembling international expertise in Stroke and Emergency Medical Services (EMS). Ten programs were identified for Acute Stroke Care to improve survival and outcomes, with recommendations for implementation of best practice. Conclusions Efficient prehospital systems for acute stroke will be improved through public awareness, optimized prehospital triage and timely diagnostics, and quick and equitable access to acute treatments. Documentation, use of metrics and transparency will help to build a culture of excellence and accountability.

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The Dutch Acute Stroke Audit: Benchmarking acute stroke care in the Netherlands

European Stroke Journal ◽

10.1177/2396987318787695 ◽

2018 ◽

Vol 3 (4) ◽

pp. 361-368 ◽

Cited By ~ 8

Author(s):

Laurien S Kuhrij ◽

Michel WJM Wouters ◽

Renske M van den Berg-Vos ◽

Frank-Erik de Leeuw ◽

Paul J Nederkoorn

Keyword(s):

Acute Stroke ◽

Best Practice ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Favourable Outcome ◽

Hospital Level ◽

Acute Stroke Care ◽

Related Factors ◽

Variation In Care

Introduction In the nationwide Dutch Acute Stroke Audit (DASA), consecutive patients with acute ischaemic stroke (AIS) and intracranial haemorrhage (ICH) are prospectively registered. Acute stroke care is a rapidly evolving field in which intravenous thrombolysis (IVT) and intra-arterial thrombectomy (IAT) play a crucial role in increasing odds of favourable outcome. The DASA can be used to assess the variation in care between hospitals and develop ‘best practice’ in acute stroke care. Patients and methods: We describe the initiation and design of the DASA as well as the results from 2015 and 2016. Results In 2015 and 2016, 55,854 patients with AIS and 7727 patients with ICH were registered in the DASA. Treatment with IVT was administered to 10,637 patients (with an increase of 1.3% in 2016) and 1740 patients underwent IAT (with an increase of 1% in 2016). Median door-to-needle time for IVT and median door-to-groin time for IAT have decreased from 27 to 25 min and 66 to 64 min, respectively. Mortality during admission was 4.9% in patients with AIS, whereas 26% of patients with ICH died. Modified Rankin Scale score at three months was registered in 49% of AIS patients and 45% of ICH patients. Discussion During the nationwide DASA, time to treatment is reduced for IVT as well as IAT. With the rapidly evolving treatment of acute stroke care, the DASA can be used to monitor the quality provided on patient- and hospital level. Conclusion Increasing completeness of registration of the outcome, in combination with adjustment for patient-related factors, is necessary to define and further improve the quality of the acute stroke care.

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Abstract TP246: Emergency Medical Services Survey of a Low-cost, Ambulance-based System for Mobile Neurological Assessment: The iTREAT Study

Stroke ◽

10.1161/str.48.suppl_1.tp246 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

William M Clark ◽

Nicole A Chiota-McCollum ◽

Jack Cote ◽

Brett J Schneider ◽

Haydon Pitchford ◽

...

Keyword(s):

Acute Stroke ◽

Rural Areas ◽

Low Cost ◽

Prehospital Care ◽

Stroke Care ◽

Neurological Assessment ◽

Acute Stroke Care ◽

Prehospital Diagnosis ◽

Technical Challenges ◽

Survey Responses

Introduction: Modern advances in acute stroke care place an added emphasis on accurate prehospital diagnosis and triage. As part of the Improving Treatment with Rapid Evaluation of Acute Stroke via mobile Telemedicine (iTREAT) study, we assessed the EMS provider experience with a novel system for mobile telestroke assessment. Methods: We developed a 12-question survey with input from local participants in an EMS Council serving rural counties in central Virginia. Providers rated the iTREAT system on feasibility for acute stroke triage, potential effectiveness in prehospital neurological assessment, and interactions with prehospital care. All survey responses were voluntary and anonymous. Results: Since initiation of live patient enrollment, we have completed 34 ambulance-based telestroke encounters with the iTREAT system. Among 7 participating agencies, 19 EMS providers have served as tele-presenters during the telestroke assessment, and 17 EMS providers completed the voluntary survey. Of the respondents, 71% were certified EMS providers for over 5 years. Regarding technical feasibility, 69% experienced issues related to maintaining a video connection, 41% with logging in to the videoconferencing application, and 18% powering on the tablet. Of technical challenges, 41% of providers resolved the issue on their own, 18% with guidance from study staff, and 24% could not resolve the issue. Concerning patient care, 23% felt the system interfered, 35% were neutral, and 41% felt there was no interference. The majority of respondents (71%) agreed that the iTREAT system is feasible for acute stroke triage, and an effective tool (59%) for prehospital neurological assessment. In commentary, EMS participants emphasized the system’s utility in rural areas. Conclusion: This survey of the EMS experience with a low-cost, ambulance-based system for prehospital telestroke assessment reveals both technical challenges and clinical promise. Importantly, technical issues are mostly solvable in real time and correctable for further system refinement. As a novel tool for prehospital neurological assessment and acute stroke triage, the initial EMS evaluation supports further investigation of clinical efficacy, particularly in rural and underserved areas.

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Prehospital EMS Triage for Acute Stroke Care

Seminars in Neurology ◽

10.1055/s-0040-1722725 ◽

2021 ◽

Vol 41 (01) ◽

pp. 005-008

Author(s):

Ali Reza Noorian

Keyword(s):

Acute Stroke ◽

New Technologies ◽

Systems Of Care ◽

Prehospital Care ◽

Stroke Care ◽

Acute Stroke Care ◽

Stroke Units ◽

Levels Of Care ◽

Stroke Systems Of Care ◽

Efficient Care

AbstractAcute stroke has had major advances over the last two decades due to the introduction of pharmacologic and endovascular revascularization, which can improve functional outcome. Stroke systems of care have been developed to provide faster, more efficient care for stroke patients. A major part of these care pathways is prehospital care, when patients are triaged to appropriate levels of care. It is essential that prehospital scales are used accurately and effectively by emergency medical services to assist them with the triage process. New technologies including mobile stroke units, telemedicine, and wearable technology have been introduced as options for optimization of this emergent process.

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Factors Associated with Shortening of Prehospital Delay among Patients with Acute Ischemic Stroke

Journal of Clinical Medicine ◽

10.3390/jcm8101712 ◽

2019 ◽

Vol 8 (10) ◽

pp. 1712 ◽

Cited By ~ 5

Author(s):

Raúl Soto-Cámara ◽

Josefa González-Santos ◽

Jerónimo González-Bernal ◽

Asunción Martín-Santidrian ◽

Esther Cubo ◽

...

Keyword(s):

Acute Stroke ◽

Public Awareness ◽

Stroke Care ◽

University Hospital ◽

Medical Emergency ◽

Acute Stroke Care ◽

Cross Sectional ◽

Factors Associated ◽

Prehospital Delay ◽

Awareness Campaigns

Background: Despite recent advances in acute stroke care, only 1–8% of patients can receive reperfusion therapies, mainly because of prehospital delay (PHD). Objective: This study aimed to identify factors associated with PHD from the onset of acute stroke symptoms until arrival at the hospital. Methods: A cross-sectional study was conducted including all patients consecutively admitted with stroke symptoms to Burgos University Hospital (Burgos, Spain). Socio-demographic, clinical, behavioral, cognitive, and contextualized characteristics were recorded, and their possible associations with PHD were studied using univariate and multivariable regression analyses. Results: The median PHD of 322 patients was 138.50 min. The following factors decreased the PHD and time until reperfusion treatment where applicable: asking for help immediately after the onset of symptoms (OR 10.36; 95% confidence interval (CI) 4.47–23.99), onset of stroke during the daytime (OR 7.73; 95% CI 3.09–19.34) and the weekend (OR 2.64; 95% CI 1.19–5.85), occurrence of stroke outside the home (OR 7.09; 95% CI 1.97–25.55), using a prenotification system (OR 6.46; 95% CI 1.71–8.39), patient’s perception of being unable to control symptoms without assistance (OR 5.14; 95% CI 2.60–10.16), previous knowledge of stroke as a medical emergency (OR 3.20; 95% CI 1.38–7.40), call to emergency medical services as the first medical contact (OR 2.77; 95% CI 1.32–5.88), speech/language difficulties experienced by the patient (OR 2.21; 95% CI 1.16–4.36), and the identification of stroke symptoms by the patient (OR 1.98; 95% CI 1.03–3.82). Conclusions: The interval between the onset of symptoms and arrival at the hospital depends on certain contextual, cognitive, and behavioral factors, all of which should be considered when planning future public awareness campaigns.

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Towards best practice in acute stroke care in Ghana: a survey of hospital services

BMC Health Services Research ◽

10.1186/s12913-017-2061-2 ◽

2017 ◽

Vol 17 (1) ◽

Cited By ~ 16

Author(s):

Leonard Baatiema ◽

Michael Otim ◽

George Mnatzaganian ◽

Ama De-Graft Aikins ◽

Judith Coombes ◽

...

Keyword(s):

Acute Stroke ◽

Best Practice ◽

Stroke Care ◽

Hospital Services ◽

Acute Stroke Care

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Description of a novel telemedicine-enabled comprehensive system of care: drip and ship plus drip and keep within a system of stroke care delivery

Journal of Telemedicine and Telecare ◽

10.1177/1357633x16637967 ◽

2016 ◽

Vol 23 (3) ◽

pp. 428-436

Author(s):

Patricia Commiskey ◽

Arash Afshinnik ◽

Elizabeth Cothren ◽

Toby Gropen ◽

Ifeanyi Iwuchukwu ◽

...

Keyword(s):

Acute Stroke ◽

Care Delivery ◽

Medical Center ◽

Stroke Care ◽

Tissue Type ◽

Team Approach ◽

Care Needs ◽

Acute Stroke Care ◽

Time Sensitivity ◽

Comprehensive Stroke Center

United States (US) and worldwide telestroke programs frequently focus only on emergency room hyper-acute stroke management. This article describes a comprehensive, telemedicine-enabled, stroke care delivery system that combines “drip and ship” and “drip and keep” models with a comprehensive stroke center primary hub at Ochsner Medical Center in New Orleans, advanced stroke-capable regional hubs, and geographically-aligned, “stroke-ready” spokes. The primary hub provides vascular neurology expertise via telemedicine and monitors care for patients remaining at regional hubs and spokes using a multidisciplinary team approach. By 2014, primary hub telestroke consults grew to ≈1000/year with 16 min average door to consult initiation and 20 min to completion, and 29% of ischemic stroke patients received recombinant tissue-type plasminogen activator (rtPA), increasing 275%. Most patients remained in hospitals close to home, but neurointensive care and interventional procedures were common reasons for primary hub transfer. Given the time sensitivity and expert consultation needed for complex acute stroke care delivery paradigms, telestroke programs are effective for fulfilling unmet care needs. Combining drip and ship and drip and keep management allows more patients to stay “local,” limiting primary hub transfer unless more advanced services are required. Post admission telestroke management at spokes increases personnel efficiency and can positively impact stroke outcomes.

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Infrastructural and Knowledge Barriers to Accessing Acute Stroke Care at a Regional Tertiary Facility in Kenya

Journal of Stroke Medicine ◽

10.1177/25166085211018046 ◽

2021 ◽

Vol 4 (1) ◽

pp. 50-57

Author(s):

Caroline Mithi ◽

Jasmit Shah ◽

Peter Mativo ◽

Dilraj Singh Sokhi

Keyword(s):

Acute Stroke ◽

Public Awareness ◽

Stroke Care ◽

Stroke Onset ◽

Next Of Kin ◽

Acute Stroke Care ◽

Cross Sectional ◽

Stroke Treatment ◽

Early Arrival ◽

Cardinal Symptom

The delivery of definitive acute stroke care in Africaremains low due to prehospital barriers, and these are known to be country-specific. There have been no studies on elucidating these barriers in Kenya. Objectives: We sought to identify the nature of barriers to acute stroke care for patients presenting to our hospital in Nairobi, Kenya. Materials and Methods: We conducted a prospective cross-sectional study atour tertiary regional referral center from August 2018 to March 2019 for patients presenting with an acutestroke. We consented participants (patients or their registered next-of-kin) to fill out a questionnaire on their journey from stroke-onset to the ward bed, and about their knowledge about stroke. Results: We recruited 103 participants. Only 25.2% arrived to hospital within 3.5 h (early arrival) of stroke onset. The significant factors causing delay were:distance from hospital, traffic, visiting another hospital first, and lack of transport vehicle. Factors significantly associated ( P<.05) with early arrival were: older age, non-African ethnic origin, bystander present at stroke onset, living near (<15km) the hospital, and knowledge of stroke. Almost 80% believed stress was a major risk factor and that dizziness was a cardinal symptom. Only 50% knew of the availability of thrombolysis/thrombectomy and their roles in stroke treatment, and only 37.9% knew the correct time limits for these. Conclusions: We identified a number of prehospital barriers to reaching hospital on time for definitive stroke treatment, which have implications on the structure of emergency services for stroke in our city. Our study also revealed interesting observations on the public’s understanding about stroke, calling for a tailored public awareness campaign to improve stroke knowledge.

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