Outcome of Patients with Acute Ischemic Stroke in the First Year after the Establishment of a Stroke Care Unit

Restoring perfusion to ischemic tissue is the primary goal of acute ischemic stroke care, yet only a small portion of patients receive reperfusion treatment. Since blood pressure (BP) is an important determinant of cerebral perfusion, effective BP management could facilitate reperfusion. But how BP should be managed in very early phase of ischemic stroke remains a contentious issue, due to the lack of clear evidence. Given the complex relationship between BP and cerebral blood flow (CBF)—termed cerebral autoregulation (CA)—bedside monitoring of cerebral perfusion and oxygenation could help guide BP management, thereby improve stroke patient outcome. The aim of INFOMATAS is to ‘ identify novel therapeutic targets for treatment and management in acute ischemic stroke’. In this review, we identify novel physiological parameters which could be used to guide BP management in acute stroke, and explore methodologies for monitoring them at the bedside. We outline the challenges in translating these potential prognostic markers into clinical use.

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Abstract TP251: Onset-to-Door Times and Means of Transportation for Acute Ischemic Stroke Patients Attending a Public Hospital in Bogota DC, Colombia. Is an Ambulance the Fastest Way to Reach the Hospital?

Stroke ◽

10.1161/str.47.suppl_1.tp251 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Javier Vicini-Parra ◽

Jenny Ospina ◽

Cristian Correa ◽

Natalia Gomez ◽

Stephania Bohorquez ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Public Transportation ◽

Public Hospital ◽

Descriptive Analysis ◽

First Year ◽

Stroke Patients ◽

Health Authorities ◽

Public Health Authorities ◽

Ischemic Attack

Introduction: A prospective stroke database was implemented as part of a still-growing comprehensive stroke centre (CSC). This CSC is located within a referral public hospital (Hospital Occidente de Kennedy) in Bogota DC, Colombia , that serves 2.3 million people of mainly low economic income. In this abstract, we present the data pertaining patients who were thrombolysed in our institution during the first year of data collection, and specify onset-to-door (OTD) times as they relate to the means of transportation used. Hypothesis: Acute stroke patients who arrive in ambulance have the shortest onset-to-door times. Methods: Printed forms were filled for every patient who arrived with diagnosis of acute ischemic stroke (AIS) or transient ischemic attack (TIA). Data was transcribed to an electronic database (Numbers, Apple Inc.) and analyzed with SPSS Statistics version 23 (IBM Corporation). A retrospective descriptive analysis was performed for central tendency and dispersion measures. Results: Since August 1st 2014 until July 31st 2015, 39 patients (17.7% of AIS patients) were thrombolysed. Mean onset-to-door times are shown in table 1. Prenotification was received for only 1 patient. All patients came from their homes. Conclusions: Almost half of our thrombolysed patients arrived in taxi to our institution. Taxi was the fastest means of transportation, ambulance was the slowest and private cars were in the middle of those. This confirmed our suspicion that the state-owned emergency medical services (SEMD) are suboptimal and that stroke patients prefer to use public transportation rather than SEMD. This should warn public health authorities on he urgent need to improve our SEMD. In the meantime, this finding prompts us to include taxi drivers in our periodic stroke campaigns.

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Abstract 115: Improving Door-to-Needle Times in Acute Ischemic Stroke: Interim Findings From Target: Stroke Phase II

Stroke ◽

10.1161/str.47.suppl_1.115 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Gregg C Fonarow ◽

Margueritte Cox ◽

Eric E Smith ◽

Jeffrey L Saver ◽

Mathew J Reeves ◽

...

Keyword(s):

Ischemic Stroke ◽

Phase I ◽

Acute Ischemic Stroke ◽

Phase Ii ◽

Best Practice ◽

Patient Characteristics ◽

Clinical Decision ◽

Absolute Difference ◽

First Year ◽

Rate Of Increase

Background: The benefits of intravenous tPA in acute ischemic stroke are time-dependent with guidelines recommending a door-to-needle (DTN) time of ≤60 minutes. The implementation of Target: Stroke Phase I in 2010 was associated with an increase in the proportion of patients with DTN times ≤60 minutes in the US from 28.9% in 2009 to 51.0% in 2013. This study aims to assess whether these improvements in DTN times could be maintained or further improved since the launch of Target: Stroke Phase II in Q2 2014. Methods: Target: Stroke Phase II identified and disseminated additional best practice strategies, provided updated clinical decision support tools, and set new hospital recognition goals. Rates of DTN times ≤60 minutes were compared during final 4 quarters of Phase I (Q4 2012-Q3 2013) vs. Phase II (Q2 2014-Q1 2015) and overall by linear weighted regression. Results: There were 99,176 intravenous tPA treated patients from 1228 GWTG-Stroke hospitals. Patient characteristics were similar during Phase I and II. Median DTN time significantly declined from the last 4 quarters of Phase I to the first 4 quarters of Phase II: 61 minutes (IQR 47-81) to 57 minutes (IQR 43-74) (P<0.0001). The % of patients with DTN times ≤60 minutes increased from last 4 quarters of Phase I to Phase II: 49.7% to 58.5%, absolute difference +8.8%, (P<0.0001). The % of patients with DTN times ≤45 minutes also increased from Phase I to Phase II: 22.0% to 29.2%, absolute difference +7.2%, (P<0.0001). The estimated annual rate of increase in patients with DTN times ≤60 minutes was 0.6% per year pre-Target Stroke, 5.6% per year during Phase I, and 8.6% in the first year of Phase II (P<0.0001) (Figure). Conclusions: The timeliness of tPA administration is continuing to improve in GWTG-Stroke hospitals participating in Target: Stroke Phase II. Nevertheless, ongoing quality improvement efforts will be required to meet the goals of ≥75% of patients with DTN times ≤60 minutes and ≥50% of patients with DTN times ≤ 45 minutes.

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Abstract WP399: Reduced Cost and Decreased Length of Stay Associated with Acute Ischemic Stroke Care Provided by Nurse Practitioners: A Single Primary Stroke Center Experience

Stroke ◽

10.1161/str.48.suppl_1.wp399 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Leah Roering ◽

Michelle Peterson ◽

Muhammad Shah Miran ◽

Melissa Freese ◽

Kenneth Shea ◽

...

Keyword(s):

Ischemic Stroke ◽

Length Of Stay ◽

Acute Ischemic Stroke ◽

Nurse Practitioners ◽

Acute Care Hospital ◽

Stroke Care ◽

Care Hospital ◽

Medical Provider ◽

The Mean ◽

Stroke Center

Background: Nurse practitioner (NP) have a wider role in modern stroke centers providing quality evidence based care to patients in both in and outpatient settings for acute ischemic stroke (AIS) and transient ischemic attack (TIA) patients. We studied the outcome measures, length of stay (LOS) and cost before and after implementation of nurse practitioners as the primary medical provider in a community based stroke center. Methods: St Cloud hospital is acute care hospital with dedicated stroke service responsible for workup and management of all patients admitted with AIS and TIA. From March 2014-March 2015, all patients were primarily managed by stroke neurologists with or without support of NP, representing physician driven arm. From June 2015-March 2016 all non-critical patients were managed primarily by NP, representing the NP driven arm of care. For this analysis, we excluded all patients with subarachnoid hemorrhage or intracerebral hemorrhage. Using ICD codes, we abstracted LOS and hospitalization cost for all patients, and compared between two arms. Results: A total of 822 patients were included in physician arm and 336 in NP arm. The mean age was 72±14 years for both arms, and 54.4% were male in physician arm and 57.4% were male in NP arm. The mean total LOS for the physician arm was 3.1 ±3.3 days while 2.9±3.6 for NP arm (p=0.6). The total cost for physician arm was $11,286.70 ±$10,920.90 while the NP arm was $10,277.30± $10,142.30 (p=0.1). Conclusion: There is a trend towards lower cost and length of stay with implementation of NP as primary stroke provider for patients admitted with acute ischemic stroke.

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Abstract T P188: Equivalency in Intravenous Thrombolytic Treatment Rates Between Primary Stroke Centers and Non-Primary Stroke Centers Through the Use of Telestroke

Stroke ◽

10.1161/str.45.suppl_1.tp188 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Archit Bhatt ◽

Elizabeth Barban ◽

Leslie Corless ◽

Tamela Stuchiner ◽

Amit Kansara

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Symptom Onset ◽

Stroke Care ◽

Bivariate Analysis ◽

Stroke Patients ◽

Acute Stroke Care ◽

Stroke Registry ◽

Patient Arrival ◽

History Of

Background: Research has shown that subjects evaluated at (Primary Stroke Centers) PSCs are more likely to receive rt–PA than those evaluated at non–PSCs. It is unknown if telestroke evaluation affects rt-PA rates at non-PSCs. We hypothesized that with a robust telestroke system rt-TPA rates among PSCs and non-PSCs are not significantly different. Methods and Results: Data were obtained from the Providence Stroke Registry from January 2010 to December 2012. We identified ischemic stroke patients (n=3307) who received care in Oregon and Southwest Washington, which include 2 PSCs and 14 non-PSCs. Intravenous rt–PA was administered to 7.3% (n=242) of ischemic patients overall, 8.4% (n=79) at non–PSCs and 6.9% (n=163) at PSCs (p=.135). Stroke neurologists evaluated 5.2 % (n=172) of all ischemic stroke patients (n=3307) were evaluated via telestroke robot. Our analysis included AIS (Acute Ischemic Stroke) patients, those presenting within 4.5 hours of symptom onset. We identified 1070 AIS discharges from 16 hospitals of which 77.9 % (n=833) were at PSCs and 22.1 % (n=237) non-PSCs. For acute ischemic stroke patients (AIS) patients, those presenting within 4.5 hours of symptom onset, 22.1% (n=237) received rt-PA; 21.5% (n=74) presented at non–PSCs and 23.7% (n=163) presented at PSCs. Among AIS, bivariate analysis showed significant differences in treatment rates by race, age, NIHSS at admit, previous stroke or TIA, PVD, use of robot, smoking and time from patient arrival to CT completed. Using multiple logistic regression adjusting for these variables, treatment was significantly related to admit NIHSS (AOR=1.67, p<.001), history of stroke (AOR=.323, p<.001), TIA (AOR=.303, p=.01) and PVD (AOR=.176, p=.02), time to CT (.971, p<.001), and use of robot (7.76, p<.001). PSC designation was not significantly related to treatment (p=.06). Conclusions: Through the use of a robust telestroke system, there are no significant differences in the TPA treatment rates between non-PSC and PSC facilities. Telestroke systems can ensure stroke patients access to acute stroke care at non-PSC hospitals.

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Abstract WP280: Use of Strategies to Improve Door-to-Needle Times with Tissue Plasminogen Activator in Acute Ischemic Stroke by US Hospitals: Findings from the Target: Stroke Survey

Stroke ◽

10.1161/str.44.suppl_1.awp280 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Gregg C Fonarow ◽

Eric E Smith ◽

Xin Zhao ◽

Eric D Peterson ◽

Ying Xian ◽

...

Keyword(s):

Emergency Department ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Stroke Care ◽

Ct Scanner ◽

Critical Pathways ◽

Intravenous Tissue Plasminogen Activator ◽

Tissue Plasminogen

Background: The benefits of intravenous tissue-plasminogen activator (tPA) in acute ischemic stroke are time-dependent and several strategies have been reported to be associated with more rapid door-to-needle (DTN) times. However, the extent to which hospitals are utilizing these strategies has not been well studied. Methods: We surveyed 304 hospitals joining Target: Stroke regarding their baseline use of strategies to reduce door-to-needle times in the 1/2008-2/2010 timeframe (prior to the initiation of Target: Stroke). The survey was developed based on literature review and expert consensus for strategies identified as being associated with shorter DTN times and further refined after pilot testing. Categorical responses are reported as frequencies. Results: Hospitals participating in the survey were 50% academic, median 163 (IQR 106-247) ischemic stroke admissions per year, median 10 (IQR 6-17) tPA treated patients per year, and had median 79 minute (IQR 71-89) DTN times. By survey, 214 of 304 hospitals (70%) reported initiating or revising strategies to reduce DTN times in the prior 2 years. Reported use of the different strategies varied in frequency, with use of ischemic stroke critical pathways, CT scanner located in the Emergency Department, and tPA being stored in the Emergency Department being the strategies least frequently employed (Table). As part of Target: Stroke participation, 279 of 304 hospitals (91.5%) indicated they planned to have a dedicated team focused on reducing DTN times. Conclusions: While most US hospitals participating in this survey report use of the strategies to improve the timeliness of tPA administration for acute ischemic stroke, significant variation exists. Further research is needed to understand which of these strategies are most effective in improving acute ischemic stroke care.

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Abstract MP25: Inequities in Interhospital Transfer for Acute Ischemic Stroke in the United States: Lower Odds for Women and the Underinsured

Stroke ◽

10.1161/str.52.suppl_1.mp25 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Daniel M Oh ◽

Daniela Markovic ◽

Amytis Towfighi

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Multinomial Logistic Regression ◽

Private Insurance ◽

Stroke Care ◽

The United States ◽

Primary Diagnosis ◽

Multinomial Logistic Model ◽

Lower Odds ◽

Interhospital Transfer

Background: Patients with acute ischemic stroke (AIS) may undergo interhospital transfer (IHT) for higher level of care. Although the Emergency Medical Treatment and Active Labor Act stipulates that patients should be transferred to and accepted by referral hospitals if indicated, it offers few concrete guidelines, making it vulnerable to bias. We hypothesized that (1) IHT for AIS has increased over recent years and (2) minorities, women, and those without insurance had lower odds of IHT. Methods: Using the National Inpatient Sample, adults (>18 yrs) with a primary diagnosis of AIS from 2010 to 2017 (n=770,970) were identified, corresponding to a weighted sample size of 3,798,440. Those transferred to another acute hospital were labeled IHT. Yearly rates of IHT were assessed. Adjusted odds ratio (AOR) of IHT (vs. not transferred) were compared in 2014-2017 vs. 2010-2013 using a multinomial logistic model, adjusting for socioeconomic, medical, and hospital characteristics. Multinomial logistic regression was used to determine odds of IHT by race/ethnicity, sex, and insurance status, adjusting for the above characteristics. Results: From 2010 to 2017, the proportion of IHT declined from 3.2% (SE 0.2) to 2.9% (SE 0.1). Comparing IHT in 2014-2017 to 2010-2013 showed lower odds of IHT (OR 0.93, 95% CI 0.88-0.99), but this difference did not remain significant in the fully adjusted model. Fully adjusted OR showed that black patients were more likely than white patients to undergo IHT (AOR 1.13, 1.07-1.20). Women were less likely than men to be transferred (AOR 0.89, 0.86-0.92). Compared to those with private insurance, those with Medicaid (AOR 0.86, 0.80-0.91), self-pay (0.64, 0.59-0.70), and no charge (0.64, 0.46-0.88) were less likely to undergo IHT. Conclusions: Adjusted odds of IHT for AIS did not change significantly. Blacks were more likely than whites to be transferred; however, women and the uninsured/underinsured were less likely to be transferred. Further studies are needed to further understand these inequities and develop interventions and policies to ensure that all individuals have equitable access to stroke care, regardless of their race, sex, or ability to pay.

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Abstract 5: Do Stroke Centers Reduce Mortality for Patients with Acute Ischemic Stroke? An Instrumental Variable Analysis

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.4.suppl_1.a5 ◽

2011 ◽

Vol 4 (suppl_1) ◽

Author(s):

Ying Xian ◽

Robert G Holloway ◽

Katia Noyes ◽

Manish N Shah ◽

Bruce Friedman

Keyword(s):

New York ◽

Ischemic Stroke ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

New York State ◽

Selection Effect ◽

Stroke Care ◽

Instrumental Variable Analysis ◽

All Cause Mortality ◽

Stroke Center

Background: Although the establishment of stroke centers based on the Brain Attack Coalition recommendations has great potential to improve quality of stroke care, little is known about whether stroke centers improve health outcomes such as mortality. Methods: Using 2005-2006 New York State Statewide Planning and Research Cooperative System data, we identified 32,783 hospitalized patients age 18+ with a principal diagnosis of acute ischemic stroke (ICD-9 433.x1, 434.x1 and 436). We compared in-hospital mortality and up to one year all-cause mortality between New York State Designated Stroke Centers and non-stroke center hospitals. Because patients were not randomly assigned to hospitals, stroke centers might treat different types of patients than other hospitals (a selection effect). We used a “natural randomization” approach, instrumental variable analysis (differential distance was the instrument), to control for this selection effect. To determine whether the mortality difference was specific to stroke care, we repeated the analysis using a different group of patients with gastrointestinal (GI) hemorrhage (N=53,077). Results: Of the 32,783 stroke patients, nearly 50% (16,258) were admitted to stroke centers. Stroke centers had lower unadjusted in-hospital mortality and 30-, 90-, 180-, and 365-day all-cause mortality than non-stroke centers (7.0% vs. 7.8%, 10.0% vs. 12.6%, 14.6% vs. 17.5%, 18.0% vs. 21.0%, 22.4% vs. 26.2%, respectively). After adjusting for patient and hospital characteristics, comorbidities, and the patient selection effect, stroke centers were associated with significantly lower all-cause mortality. The adjusted differences were -2.6%, -2.7%, -1.8%, and -2.3% for 30-, 90-, 180- and 365-day mortality (all p<0.05). The adjusted difference in in-hospital mortality was -0.8% but was not statistically significant. In a specificity analysis of patients with GI hemorrhage, stroke centers had slightly higher mortality. Conclusions: Hospitals that are Designated Stroke Centers had lower mortality for acute ischemic stroke than non-stroke center hospitals. The mortality benefit was specific to stroke and was not observed for GI hemorrhage. Providing stroke centers nationwide has the potential to reduce mortality.

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