Realistic simulation is associated with healthcare professionals’ increased self-perception of confidence in providing acute stroke care: a before-after controlled study

ABSTRACT Background: Simulations are becoming widely used in medical education, but there is little evidence of their effectiveness on neurocritical care. Because acute stroke is a neurological emergency demanding prompt attention, it is a promising candidate for simulation training. Objective: To assess the impact of a stroke realistic simulation course on clinicians’ self-perception of confidence in the management of acute stroke. Methods: We conducted a controlled, before-after study. For our intervention, 17 healthcare professionals participated in a stroke realistic simulation course. As controls, participants were chosen from a convenience sample of attendees to the courses Emergency Neurologic Life Support (ENLS) (18 participants) and Neurosonology (20 participants). All participants responded pre- and post-test questionnaires evaluating their self-perception of confidence in acute stroke care, ranging from 10 to 50 points. We evaluated the variation between pre- and post-test results to assess the change on trainees’ self-perception of confidence in the management of acute stroke. Multivariate analysis was performed to control for potential confounders. Results: Forty-six (83.63%) subjects completed both questionnaires. The post-test scores were higher than those from the pretests in the stroke realistic simulation course group [pretest median (interquartile range - IQR): 41.5 (36.7-46.5) and post-test median (IQR): 47 (44.7-48); p=0.033], but not in the neurosonology [pretest median (IQR): 46 (44-47) and post-test median (IQR): 46 (44-47); p=0.739] or the ENLS [pretest median (IQR): 46.5 (39-48.2), post-test median (IQR): 47 (40.2-49); p=0.317] groups. Results were maintained after adjustment for covariates. Conclusions: This stroke realistic simulation course was associated with an improvement on trainees’ self-perception of confidence in providing acute stroke care.

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Bottlenecks in the Acute Stroke Care System during the COVID-19 Pandemic in Catalonia

Cerebrovascular Diseases ◽

10.1159/000516309 ◽

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

Introduction: 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. Methods: 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. Results: 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], p 0.03) and good functional outcome decreased (mRS ≤2 at 90 days: OR 0.6 [0.4–0.9], p 0.015) during the pandemic period. Conclusion: 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.

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Abstract P141: Global Impact of Covid-19 Pandemic on Acute Stroke and Mechanical Thrombectomy - An International Survey

Stroke ◽

10.1161/str.52.suppl_1.p141 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Dileep R Yavagal ◽

Vasu Saini ◽

Violiza Inoa ◽

Hannah E Gardener ◽

Sheila O Martins ◽

...

Keyword(s):

Acute Stroke ◽

Mechanical Thrombectomy ◽

High Volume ◽

Stroke Care ◽

Acute Stroke Care ◽

Treatment Practices ◽

Global Impact ◽

Significant Difference ◽

The World ◽

The Impact

Introduction: The COVID-19 pandemic has strained the healthcare systems across the world but its impact on acute stroke care is just being elucidated. We hypothesized a major global impact of COVID-19 not only on stroke volumes but also on thrombectomy practice. Methods: A 19-item questionnaire survey aimed to identify the changes in stroke volumes and treatment practices seen during COVID-19 pandemic was designed using Qualtrics software. It was sent to stroke and neuro-interventional physicians around the world who are part of the executive committee of a global coalition, Mission Thrombectomy 2020 (MT2020) between April 5 th to May 15 th , 2020. Results: There were 113 responses across 25 countries. Globally there was a median 33% decrease in stroke admissions and a 25% decrease in mechanical thrombectomy (MT) procedures during COVID-19 pandemic compared to immediately preceding months (Figure 1A-B). This overall median decrease was despite a median increase in stroke volume in 4 European countries which diverted all stroke patients to only a few selected centers during the pandemic. The intubation policy during the pandemic for patients undergoing MT was highly variable across participating centers: 44% preferred intubating all patients, including 25% centers that changed their policy to preferred-intubation (PI) vs 27% centers that switched to preferred-conscious-sedation (PCS). There was no significant difference in rate of COVID-19 infection between PI vs PCS (p=0.6) or if intubation policy was changed in either direction (p=1). Low-volume (<10 stroke/month) compared with high-volume stroke centers (>20 strokes/month) are less likely to have neurointerventional suite specific written personal protective equipment protocols (74% vs 88%) and if present, these centers are more likely to report them to be inadequate (58% vs 92%). Conclusion: Our data provides a comprehensive snapshot of the impact on acute stroke care observed worldwide during the pandemic.

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Abstract P849: Effects of Standardized Stroke Protocols on Nursing Confidence and Knowledge in Low Volume Telestroke Emergency Departments

Stroke ◽

10.1161/str.52.suppl_1.p849 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Michelle Provencher ◽

Stephen A Figueroa ◽

Robin Novakovic ◽

Linda Hynan ◽

Daiwai M Olson ◽

...

Keyword(s):

Nursing Education ◽

Acute Stroke ◽

Emergency Departments ◽

Intervention Group ◽

Stroke Care ◽

Controlled Study ◽

Workflow Model ◽

Acute Stroke Care ◽

Post Intervention ◽

Care Protocol

Introduction: Nurses and staff in Emergency Departments (ED) with low monthly case volumes have few opportunities to build confidence and solidify skills in acute stroke management. The Nursing-driven Acute Stroke Care (NAS-Care) study tested a workflow model with empowerment of ED bedside nurses, clear role assignments for team members, and standardized protocols including a predefined run sheet. Methods: Seven Texas hospitals participated in this prospective, multisite, baseline-controlled study as part of the Lone Star Stroke Research Consortium. After three months of blinded baseline data collection, the following interventions were implemented: NIHSS certification, nursing education including mock stroke codes, and a standardized flowsheet for code organization and documentation (run sheet). Participating nurses were surveyed before and after implementation of this process. Results: The study was completed at 6 hospitals, with 180 patients in the pre-intervention group and 267 in the post-intervention group. The study intervention was found to improve Door-to-ED provider and Door-to-CT metrics but not physician-dependent metrics, Door-to-Needle or Door-to-Provider times (Provencher et al, ISC 2020). Completed surveys were returned by 97 nurses (pre-intervention) and 57 nurses (post-intervention). There were significant increases in the following questions (10 point scale, p<.001): “I understand goals and processes of stroke code activation”, “stroke codes at my institution are completed efficiently”, and “stroke codes are nursing-driven.” In the post-intervention surveys, nurses reported that the NAS-Care protocol improved understanding (mean score 8.0 +/- 2.4 SD/10) and efficiency (8.2 +/- 2.4/10), and reported that they would recommend NAS-Care to be adopted at other institutions (8.8 +/- 2.1/10). Conclusion: Standardized nurse-driven stroke protocols improved self-assessed knowledge and confidence for nurses in EDs utilizing telestroke, in addition to gains in staff-dependent stroke metrics.

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

Stroke ◽

10.1161/str.51.suppl_1.tmp86 ◽

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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The Impact of Ambulance Practice on Acute Stroke Care

Stroke ◽

10.1161/strokeaha.107.483446 ◽

2007 ◽

Vol 38 (10) ◽

pp. 2765-2770 ◽

Cited By ~ 74

Author(s):

Ian Mosley ◽

Marcus Nicol ◽

Geoffrey Donnan ◽

Ian Patrick ◽

Fergus Kerr ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Care ◽

Acute Stroke Care ◽

The Impact

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Abstract 3379: Benefiting the Community; The Impact of Joining a Regional Stroke Network

Stroke ◽

10.1161/str.43.suppl_1.a3379 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Nancy D Papesh ◽

James Gebel

Keyword(s):

Acute Stroke ◽

Care Center ◽

Tertiary Care ◽

Cleveland Clinic ◽

Stroke Care ◽

Stroke Patients ◽

Acute Stroke Care ◽

Stroke Treatment ◽

The Impact ◽

Iv Tpa

Background: The Cleveland Clinic Health System (CCHS) consists of a large tertiary care center and 10 regional hospitals. It is organized both clinically and administratively into multispecialty organ based Institutes rather than departments. The CCHS re-introduced a regional initiative to standardize stroke care in 2008. Medina Hospital is a 118-bed community hospital in rural North-eastern Ohio, where there is a high stroke burden and previously minimal IV tPA use. Medina Hospital joined the CCHS Stroke Network in November 2009. Hypothesis: We hypothesized that after joining the formally organized stroke CCHS system of care, the proportion of stroke patients receiving IV tPA and the timeliness of administration of acute thrombolytic therapy would both significantly increase. Methods: Data was analyzed from our prospective participation in the Get with the Guidelines-Stroke and the Ohio Coverdell Stroke Registries. Baseline data regarding quality, outcomes and stroke performance measures were reviewed. CCHS initially supported acute stroke care in early 2010 with a telemedicine cart and then introduced 24/7 emergency, on-site, CCHS neurologist, acute stroke call coverage in late 2010. Standardized CCHS stroke care pathways and order sets were also introduced in 2010. The proportion of stroke patients treated with IV tPA in 2010 and 2011 (post- joining CCHS) was compared to 2009 (2-sided Fisher’s exact test), and door-to-needle times were compared from 2010 to 2011 (unpaired t-test). Results: IV tPA treatment utilization increased from 0/69 patients (0%) in 2009 to 9/67 patients (11.8%) in 2010 [exact p=.0033] and 11/46 (19.3%) in the first 7 months of 2011 [exact p=.0001]. Door-to-needle times improved from a mean of 81.4 (95%CI 66.4 to 96.4) minutes in 2010 to 61.7 (95% CI 52.7 to 70.8) minutes in 2011 (p=.0158). Conclusions: Participation in an organized formal collaborative regional hospital stroke treatment network resulted in dramatic improvements from zero IV tPA utilization to greatly exceeding the national benchmark averages for both percentage treatment with IV tPA and door-to-needle time in a rural area where patients previously had minimal access to acute stroke expertise.

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The impact of the COVID‐19 outbreak on acute stroke care in Slovakia: Data from across the country

European Journal of Neurology ◽

10.1111/ene.14640 ◽

2020 ◽

Author(s):

Zuzana Gdovinová ◽

Marianna Vitková ◽

Anna Baráková ◽

Alena Cvopová

Keyword(s):

Acute Stroke ◽

Stroke Care ◽

Acute Stroke Care ◽

The Impact

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Three-month functional outcomes following endovascular thrombectomy during the first wave of the COVID-19 pandemic: a Canadian single-center cohort study

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017664 ◽

2021 ◽

pp. neurintsurg-2021-017664

Author(s):

Joel Neves Briard ◽

Gabrielle Dufort ◽

Grégory Jacquin ◽

Walid Alesefir ◽

Olena Bereznyakova ◽

...

Keyword(s):

Cohort Study ◽

Acute Stroke ◽

Functional Status ◽

Functional Outcomes ◽

High Volume ◽

Stroke Care ◽

Single Center ◽

Acute Stroke Care ◽

Baseline Characteristics ◽

The Impact

BackgroundThe COVID-19 pandemic has disrupted acute stroke care logistics, including delays in hyperacute management and decreased monitoring following endovascular therapy (EVT). We aimed to assess the impact of the pandemic on 90-day functional outcome among patients treated with EVT.MethodsThis is an observational cohort study including all patients evaluated for an acute stroke between March 30, 2020 and September 30, 2020 (pandemic cohort) and 2019 (reference cohort) in a high-volume Canadian academic stroke center. We collected baseline characteristics, acute reperfusion treatment and management metrics. For EVT-treated patients, we assessed the modified Rankin score (mRS) at 90 days. We evaluated the impact of the pandemic on a 90-day favourable functional status (defined as mRS 0–2) and death using multivariable logistic regressions.ResultsAmong 383 and 339 patients included in the pandemic and reference cohorts, baseline characteristics were similar. Delays from symptom onset to evaluation and in-house treatment were longer during the early first wave, but returned to reference values in the subsequent months. Among the 127 and 136 EVT-treated patients in each respective cohort, favourable 90-day outcome occurred in 53/99 (53%) vs 52/109 (48%, p=0.40), whereas 22/99 (22%) and 28/109 (26%, p=0.56) patients died. In multivariable regressions, the pandemic period was not associated with 90-day favourable functional status (aOR 1.27, 95% CI 0.60 to 2.56) or death (aOR 0.74, 95% CI 0.33 to 1.63).ConclusionIn this single-center cohort study conducted in a Canadian pandemic epicenter, the first 6 months of the COVID-19 pandemic did not impact 90-day functional outcomes or death among EVT-treated patients.

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The impact of COVID-19 on acute stroke care in Belgium

Acta Neurologica Belgica ◽

10.1007/s13760-021-01726-x ◽

2021 ◽

Author(s):

Vincent Raymaekers ◽

Jelle Demeestere ◽

Flavio Bellante ◽

Sofie De Blauwe ◽

Sylvie De Raedt ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Care ◽

Acute Stroke Care ◽

The Impact

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Abstract T P255: QCI-NASCAR - Quality Care Improvement with Nursing-driven Acute Stroke CARe

Stroke ◽

10.1161/str.46.suppl_1.tp255 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Julian P Yang ◽

Sonja Stutzman ◽

Laura Riise ◽

Donald Jones ◽

Amanda Dirickson ◽

...

Keyword(s):

Acute Stroke ◽

Quality Care ◽

Data Gathering ◽

Stroke Care ◽

University Hospital ◽

Acute Stroke Care ◽

Efficient Data ◽

Collection Form ◽

Care Improvement ◽

The Impact

Objective: To observe the impact on stroke code time metrics after applying a “pit stop” model of bedside nursing for telestroke encounters. Background: Despite the recent push for target treatment times in acute stroke codes, no guidelines exist for optimizing practices specific to stroke care via telemedicine. Effective telestroke is dependent on efficient data gathering by remote staff, and lengthy metrics for real-world telestroke often preclude timely tPA treatment. By co-opting “pit stops” as inspiration, an optimized nursing workflow for telestroke can be created on the following principles: Identification of Shared Goals; Organized Urgency with the Removal of Gatekeepers; Multi-personnel, Non-Sequential Processes; Focus on Defined Staged Roles; and Empowered Engagement/Responsibility. Methods: The QCI-NASCAR protocol was implemented in Oct 2013, and data was collected prospectively on consecutive stroke code activations through Apr 2014 at St. Paul University Hospital (Dallas, TX), a telestroke spoke site. The nurse-driven protocol was reinforced by a paper checklist (i.e. “Driver Sheet”), which doubled as a data collection form. Timestamps were recorded in real time for: door time, MD at bedside, CT arrival, needle time, and/or code cancellation. The primary outcome was Door-to-CT (D2CT) times to reflect the portion of the stroke code most impacted by the nursing protocol. Results: Mean D2CT times were: all cases (n=152, 33.2 min), intervention-eligible cases (n=71, 27.0 min), and thrombolytic-eligible cases (n=57, 22.2 min). A trend for lower D2CT times and standard deviations was noted in comparing the first half of the data (n=76, 38.04 ± 58.1 min) to the second (n=77, 27.8 ± 19.1 min; p<0.05). A similar pattern was noted in the subset of intervention-eligible cases: first half (n=36, 29.4 ± 37.4 min) vs. second half (n=35, 24.3 ± 18.6 min; p<0.05). IV tPA was administered 3 times, including an institutional best door-to-needle time of 32.0 min. Conclusion: QCI-NASCAR demonstrates the feasibility of implementing a nursing-driven protocol for telestroke encounters. A larger, multi-institutional trial will demonstrate if such a protocol can significantly and reproducibly lower stroke code metrics to national guideline parameters.

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