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.

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.

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.

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.

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.

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.

scholarly journals Cost burden and cost-effective analysis of the nationwide implementation of the Quality in Acute Stroke Care protocol in Australia

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
C M Marquina ◽  
Z A Ademi ◽  
E Z Zomer ◽  
R O A Ofori-Asenso ◽  
R T Tate ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Societal Perspective ◽  
Stroke Care ◽  
Decision Analytic Model ◽  
Stroke Severity ◽  
Acute Stroke Care ◽  
Stroke Incidence ◽  
Care Protocol ◽  
Life Years ◽  
The Cost

Abstract Background The Quality in Acute Stroke Care (QASC) protocol is a multidisciplinary approach to implement evidence-based treatment after acute stroke that reduces death and disability. Aim This study sought to evaluate the cost-effectiveness of implementing the QASC protocol across Australia, from a healthcare and a societal perspective. Methods A decision-analytic model was constructed to reflect one-year outcomes post-stroke, aligned with the stroke severity categories of the modified Rankin scale (mRS). Decision analysis compared outcomes following implementation of the QASC protocol versus no implementation. Population data were extracted from Australian databases and data inputs regarding stroke incidence, costs, and utilities were drawn from published sources. The analysis assumed a progressive uptake and efficacy of the QASC protocol over five years. Health benefits and costs were discounted by 5% annually. The cost of each year lived by an Australian, from a societal perspective, was based on the Australian Government's “value of statistical life year” (AUD 213,000). Results Over five years, the model predicted 263,722 strokes among the Australian population. The implementation of the QASC protocol was predicted to prevent 1,154 deaths and yield a gain of 876 years of life (0.003 per stroke), and 3,180 quality-adjusted life years (QALYs) (0.012 per stroke). There was an estimated net saving of AUD 65.2 million in healthcare costs (AUD 247 per stroke) and AUD 251.7 million in societal costs (AUD 955 per stroke). Conclusions Implementation of the QASC protocol in Australia represents both a dominant (cost-saving) strategy, from a healthcare and a societal perspective. FUNDunding Acknowledgement Type of funding sources: None. Decision tree PSA

Abstract WP317: The Impact of Post-acute Discharge Disposition on Outcomes in the SWIFT PRIME Trial

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Samir R Belagaje ◽  
Diogo C Haussen ◽  
Jeffrey L Saver ◽  
Mayank Goyal ◽  
David S Liebeskind ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Skilled Nursing Facility ◽  
Inpatient Rehabilitation ◽  
Stroke Care ◽  
Favorable Outcome ◽  
Stroke Severity ◽  
Acute Stroke Care ◽  
Stroke Treatment ◽  
Discharge Disposition ◽  
The Impact

Intro: Post-acute stroke care in an inpatient rehabilitation facility (IRF) demonstrates better outcomes compared to a skilled nursing facility (SNF). With advancements in endovascular acute stroke, the impact that post-acute care plays is unclear. Here, we analyze a successful endovascular acute stroke trial to demonstrate that more improvement is seen in patients discharged to an IRF compared to a SNF. Methods: From SWIFT PRIME, a prospective, multi-center randomized acute endovascular trial, subject characteristics, and modified Rankin scores (mRS) were obtained. Post-acute hospital discharge was classified as home, IRF, and SNF. A favorable outcome was defined as 90 day mRS ≤ 2 and improvement was defined as ≥ 1 point decrease in mRS score. The effect of each disposition on a favorable outcome was calculated overall and stratified by stroke severity class (defined as discharge mRS 0-3, 4, 5) Results: A total of 165 subjects (mean age 64.8 years, mean initial NIHSS= 16.5, and 50 % male) were analyzed. Discharge disposition included: 51 (31%) going home, 92 (56%) IRF, 22 (13%) SNF. The baseline characteristics were similar between patients that went to IRF and SNF: age (p =0.76), gender (p= 0.81), baseline NIHSS (p=0.055), final infarct volumes (p=0.20), and recanalization rates (p=0.19). However, IRF subjects had lower NIHSS (p<0.001) and mRS (p=0.017) at day 7. Time to treatment defined as symptom onset to groin puncture was not significantly associated with discharge disposition (p=0.119). Only 1/22 (4.5%) subjects who were discharged to SNF achieved a 90 day mRS ≤2, compared to 41/92 (44.6%) in the IRF group or 48/51 (94.1%) in the home group (p < 0.001). When stratified by stroke severity: for mRS=0-3, there were no differences in favorable outcomes; mRS=4, 1/7 (14.3%) showed improvement at SNF compared to 21/27 (77.8%) at IRF (p=0.008); mRS =5, 5/14 (35.7%) showed improvement at SNF compared to 28/37 (75.7%) at IRF (p=0.013). Conclusions: Despite having similar characteristics following acute stroke treatment, not only did subjects who went to SNF compared to IRF have more unfavorable outcomes, they were less likely to make improvement. These findings show the continued importance of post-stroke rehabilitation, even in the endovascular era.

Abstract TP236: Geographical Disparity of Acute Stroke Care Capabilities in Japan From a Nationwide Database: J-ASPECT Study

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Koichi Arimura ◽  
Kunihiro Nishimura ◽  
Akiko Kada ◽  
Satoru Kamitani ◽  
Kuniaki Ogasawara ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Acute Stroke ◽  
Rural Areas ◽  
Patient Characteristics ◽  
Stroke Care ◽  
International Classification Of Diseases ◽  
Stroke Severity ◽  
Acute Stroke Care ◽  
Nationwide Database ◽  
Geographical Disparity

Objective: We previously demonstrated comprehensive stroke care (CSC) capabilities of the hospitals affect in-hospital mortality of patients with acute stroke. With the advent of unprecedented aging society, proper implementation of stroke centers requires understanding of geographical disparity of patient characteristics as well as stroke care capabilities. The aim of this study was to elucidate such geographical disparity regarding acute stroke care in Japan using a nationwide database. Materials and methods: We analyzed the data obtained from the Japanese Diagnosis Procedure Combination-based Payment System in 445 institutions between 2010 and 2012. Patients hospitalized emergently for ischemic stroke(IS), non-traumatic intracerebral hemorrhage(ICH) and non-traumatic subarachnoid hemorrhage(SAH) were identified using International Classification of Diseases-10 diagnosis codes. We classified the location of the hospitals into 4 areas, “Metropolitan Employment Area-Central (MEA-C)”, “ Metropolitan Employment Area-Outlying (MEA-O)”, “Micropolitan Employment Area-Central (McEA-C)”, and “ Micropolitan Employment Area-Outlying (McEA-O)”. We investigated patient characteristics, medical backgrounds, interventions and outcomes for each area. Results: Data obtained from a total of 214,910 patients with acute strokes (136,753 IS, 60,379 ICH and 17,778 SAH) were analyzed. As for patient characteristics, elderly patients and those with hypertension were more common in McEA-C and McEA-O, and stroke severity was more severe in McEA-C in all stroke types. As for hospital characteristics, proportion of admission by ambulance and CSC capabilities of the hospitals were smaller in all stroke types. Moreover, emergent interventions such as intravenous rt-PA infusion were performed at a lesser extent and in-hospital mortality was higher in McEA-C and McEA-O, and severe disability with mRS 3-6 was more often noted in McEA-C in all stroke types. Conclusion: We demonstrated geographical disparity of acute stroke care in Japan from a nationwide database. For proper implementation of stroke centers, centralization of acute stroke care capabilities should be considered in the rural areas to improve outcomes of acute stroke.

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.

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