scholarly journals Changes in Interhospital Transfer Patterns of Acute Ischemic Stroke Patients in the Regional Stroke Care System After Designation of a Cerebrovascular-specified Center

2012 ◽  
Vol 48 (3) ◽  
pp. 169 ◽  
Author(s):  
Suck Ju Cho ◽  
Sang Min Sung ◽  
Sung Wook Park ◽  
Hyung Hoi Kim ◽  
Seong Youn Hwang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Stroke Care ◽  
Stroke Patients ◽  
Interhospital Transfer ◽  
Care System

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

Stroke ◽  
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.

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

Stroke ◽  
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.

scholarly journals Mandatory Neuroendovascular Evolution: Meeting the New Demands

2018 ◽  
Vol 8 (1) ◽  
pp. 69-82
Author(s):  
Mohammad El-Ghanem ◽  
Francisco E. Gomez ◽  
Prateeka Koul ◽  
Rolla Nuoman ◽  
Justin G. Santarelli ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Symptom Onset ◽  
Mechanical Thrombectomy ◽  
Stroke Care ◽  
Endovascular Intervention ◽  
Stroke Patients ◽  
Hub And Spoke ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: Traditionally, patients undergoing acute ischemic strokes were candidates for mechanical thrombectomy if they were within the 6-h window from onset of symptoms. This timeframe would exclude many patient populations, such as wake-up strokes. However, the most recent clinical trials, DAWN and DEFUSE3, have expanded the window of endovascular treatment for acute ischemic stroke patients to within 24 h from symptom onset. This expanded window increases the number of potential candidates for endovascular intervention for emergent large vessel occlusions and raises the question of how to efficiently screen and triage this increase of patients. Summary: Abbreviated pre-hospital stroke scales can be used to guide EMS personnel in quickly deciding if a patient is undergoing a stroke. Telestroke networks connect remote hospitals to stroke specialists to improve the transportation time of the patient to a comprehensive stroke center for the appropriate level of care. Mobile stroke units, mobile interventional units, and helistroke reverse the traditional hub-and-spoke model by bringing imaging, tPA, and expertise to the patient. Smartphone applications and social media aid in educating patients and the public regarding acute and long-term stroke care. Key Messages: The DAWN and DEFUSE3 trials have expanded the treatment window for certain acute ischemic stroke patients with mechanical thrombectomy and subsequently have increased the number of potential candidates for endovascular intervention. This expansion brings patient screening and triaging to greater importance, as reducing the time from symptom onset to decision-to-treat and groin puncture can better stroke patient outcomes. Several strategies have been employed to address this issue by reducing the time of symptom onset to decision-to-treat time.

scholarly journals Role of the Neurosurgeon in Acute Ischemic Stroke Treatment From Triage to Intensive Care Unit

Neurosurgery ◽  
2019 ◽  
Vol 85 (suppl_1) ◽  
pp. S47-S51
Author(s):  
Kimberly P Kicielinski ◽  
Christopher S Ogilvy
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Stroke Care ◽  
Stroke Patients ◽  
Acute Setting ◽  
Stroke Treatment

Abstract As ischemic stroke care advances with more patients eligible for mechanical thrombectomy, so too does the role of the neurosurgeon in these patients. Neurosurgeons are an important member of the team from triage through the intensive care unit. This paper explores current research and insights on the contributions of neurosurgeons in care of acute ischemic stroke patients in the acute setting.

Abstract 122: Quality of Care for Patients With Acute Ischemic Stroke as a Function of Hospital Intravenous Thrombolysis With Recombinant Tissue Plasminogen Activator Capability: Insights From China National Stroke Registry II

2017 ◽  
Vol 10 (suppl_3) ◽  
Author(s):  
Zhenzhen Rao ◽  
Zixiao Li ◽  
Hongqiu Gu ◽  
Yilong Wang ◽  
Yongjun Wang
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intravenous Thrombolysis ◽  
Recombinant Tissue Plasminogen Activator ◽  
Stroke Care ◽  
Care Quality ◽  
Composite Score ◽  
Stroke Patients ◽  
Stroke Registry

Background: Intravenous Thrombolysis with Recombinant Tissue Plasminogen Activator (rt-PA) availability at Chinese hospitals varies and may affect care quality for acute ischemic stroke patients. Limited research has shown whether there were differences in quality of care at China National Stroke Registry (CNSR II) hospitals based on rt-PA capability. Methods: For acute ischemic stroke patients admitted to CNSR II hospitals between 2012 and 2013, care quality at hospitals with or without Intravenous rt-PA capability was examined by evaluating conformity with performance and quality measures. The primary outcome was guideline-concordant care, defined as compliance with 10 predefined individual guideline-recommended performance metrics and composite score. A composite score was defined as the total number of interventions actually performed among eligible patients divided by the total number of recommended interventions among eligible patients. Propensity score matching was used to balance the baseline characteristics. We used cox model with shared frailty model and logistic regression with generalized estimating equation to compare the relationship between hospitals with rt-PA capability and hospitals without rt-PA on quality measures. Results: This study included 19604 acute ischemic stroke patients admitted to 219 CNSR II hospitals. Before matching, there were 7928 patients admitted to 86 (40.4%) hospitals with rt-PA capability and 11676 patients admitted to 133 (59.6%) hospitals without rt-PA capability. After matching, 7606 pairs of patients in rt-PA-capable hospitals and rt-PA-incapable hospitals were analyzed. Before matching, the composite score of guideline-concordant process of care was higher at hospitals with rt-PA capability than hospitals without rt-PA capability (74% versus 73%, P=0.0126). Hospitals with rt-PA capability were more likely to perform deep vein thrombosis prophylaxis within 48 hours of admission, dysphagia screening, assessment or receiving of rehabilitation, discharge antithrombotic, anticoagulation for atrial fibrillation and medications for lowering low-density lipoprotein (LDL) ≥100mg/dL. But hospitals with rt-PA capability were less likely to perform antithrombotic medication within 48 hours of admission and hypoglycemic therapy at discharge for patients with diabetes. After matching, differences of stroke care quality between hospitals with rt-PA capability and without rt-PA capability still exist after adjusting covariates. Conclusions: The CNSR II hospitals were associated with better performance in some of the hospitals but not all of them. The difference in conformity between rt-PA-capable hospitals and rt-PA-incapable hospitals was modest for performance measures of stroke care. However, more room for improvement still exists in key quality performance measures and further studies should be explored.

scholarly journals Admitting Acute Ischemic Stroke Patients to a Stroke Care Monitoring Unit Versus a Conventional Stroke Unit

Stroke ◽  
2003 ◽  
Vol 34 (1) ◽  
pp. 101-104 ◽  
Author(s):  
Geert Sulter ◽  
Jan Willem Elting ◽  
Marc Langedijk ◽  
Natasha M. Maurits ◽  
Jacques De Keyser
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Stroke Unit ◽  
Stroke Care ◽  
Stroke Patients

scholarly journals Why Stroke Patients Don’t Receive T-PA? An Analysis of Patient Eligibility: Implications for Improving Clinical Impact by Increasing Future Treatment Numbers

Stroke ◽  
2001 ◽  
Vol 32 (suppl_1) ◽  
pp. 372-372
Author(s):  
Philip A Barber ◽  
Jinijin Zhang ◽  
Andrew M Demchuk ◽  
Michael D Hill ◽  
Andrea Cole-Haskayne ◽  
...  
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Stroke Care ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
Stroke Registry ◽  
Specific Protocol ◽  
Stroke Type ◽  
Ischemic Attack

P183 Background T-PA is an effective treatment of acute ischemic stroke within 3 hours. However, the success of t-PA on reducing disability is dependent on it being accessible to more patients. We identified the reasons why patients with ischemic stroke did not receive intravenous t-PA and assessed the community impact of the therapy in a large North American city. Methods Consecutive patients with acute ischemic stroke were identified in a prospective stroke registry at a teaching hospital between October 1996 and December 1999. Additional patients with ischemic stroke admitted to one of three other hospitals during the study period were identified. The Oxford Community Stroke Program Classification was used to record stroke type. Results Of 2165 stroke patients presenting to the emergency department 1179 (54.5%) were diagnosed with ischemic stroke, 31.7% with intracranial hemorrhage, and 13.8 % with transient ischemic attack. 84/339 (29%) patients were admitted within 3 hours of stroke received intravenous t-PA. The major reasons for exclusion for stroke patients presenting within 3 hours were mild stroke (20%), clinical improvement (18.6%), and specific protocol exclusions (11.5%). Delay in presentation to emergency department excluded 840/1179 (71%). 1817 ischemic stroke patients were admitted to Calgary hospitals during the study period of which 4.6% received intravenous t-PA. Generalization of the Calgary experience to other Canadian communities suggests the benefit from t-PA for ischemic stroke may be substantial with an additional 460 independent survivors per annum. Conclusion The effectiveness of t-PA can be improved by understanding why patients are excluded from its use. The eligibility of patients for t-PA must increase by promoting health education programs and by developing organized acute stroke care infrastructure within the community.

scholarly journals Thrombolysis in Acute Stroke

2021 ◽  
Author(s):  
Mustafa Çetiner
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
Reperfusion Therapy ◽  
Clinical Findings ◽  
Stroke Patients ◽  
Acute Ischemic Stroke Patient ◽  
Patient Selection Criteria ◽  
Neuroimaging Techniques

The first step in stroke care is early detection of stroke patients and recanalization of the occluded vessel. Rapid and effective revascularization is the cornerstone of acute ischemic stroke management. Intravenous thrombolysis is the only approved pharmacological reperfusion therapy for patients with acute ischemic stroke. Patient selection criteria based on patient characteristics, time, clinical findings and advanced neuroimaging techniques have positively affected treatment outcomes. Recent studies show that the presence of salvageable brain tissue can extend the treatment window for intravenous thrombolysis and that these patients can be treated safely. Recent evidence provides stronger support for another thrombolytic agent, tenecteplase, as an alternative to alteplase. Endovascular thrombectomy is not a contraindication for intravenous thrombolysis. Evidence shows that the bridging approach provides better clinical outcomes. It is seen that intravenous thrombolysis is beneficial in stroke patients, whose symptom onset is not known, after the presence of penumbra tissue is revealed by advanced neuroimaging techniques. Reperfusion therapy with intravenous thrombolysis is beneficial in selected pregnant stroke patients. Pregnancy should not be an absolute contraindication for thrombolysis therapy. This chapter aims to review only the current evaluation of intravenous thrombolytic therapy, one of the reperfusion therapies applied in the acute phase of stroke.

Abstract P189: Using Telemedicine Eliminates The Weekend/after-hours Effect In Acute Ischemic Stroke Patients Receiving Thrombolysis During A Deadly Pandemic

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Maria V Diaz Rojas ◽  
Tzu-ching Wu ◽  
Liang Zhu ◽  
Christy T Ankrom ◽  
Alicia Zha ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Stroke Care ◽  
Weekend Effect ◽  
Stroke Patients ◽  
Safe Management ◽  
After Hours ◽  
Quality Check ◽  
Baseline Characteristics

Stroke care has been shown to be worse for patients presenting overnight/weekends (off-hours) to centers compare to those presenting during business hours (on-hours).Telemedicine (TM) helps provide safe management of stroke patients. The UT Teleneurology (UTT) hub provides acute neurological coverage by stroke specialists to 18 spoke centers. To our knowledge, the effect of the Covid-19 pandemic on the “weekend effect” has not been studied. The objective is to compare TM consult volumes and time metrics of stroke patients who received tPA via TM off-hours with those on-hours during the pandemic. In a retrospective query of the UTT registry from 3/20 - 6/20, we identified 122 stroke patients who received tPA - 109 were included in our analysis - 2 were excluded after quality check, 11 were excluded as inpatient strokes. We compared baseline characteristics and time metrics between the off-hours (5pm-7:59am, weekends) and on-hours (weekdays 8am-4:59pm) patients (Table 1). We also compared the number of TM consults between the height of the pandemic (3/20 - 6/20) and the previous year (3/19 - 6/19). Of 109 patients, 72 were managed via TM during off-hours, 37 during on-hours. Baseline characteristics were similar between groups. There were no differences in time metrics including door to needle time. Of note, there was no difference in the number of acute TM consults or patients receiving tPA. There were fewer routine TM consults during the pandemic, and a trend toward fewer phone consults. There was no difference in time metrics between the patients treated off-hours vs on-hours in the pandemic period. TM may be advantageous over in-person neurology coverage during crises, and is consistent regardless of the hour/day. Contrary to other studies, the number of acute TM consults and patients receiving tPA did not differ between the study periods. Routine consults decreased during the pandemic - perhaps coinciding with state closure mandates/fewer hospitalized stroke patients.

Abstract TP229: Change Takes Time: EMS as the Spark Plug for Faster Acute Ischemic Stroke Care

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Karen Greenberg ◽  
Alexandra Lesenskyj ◽  
Daniel Eichorn ◽  
Christina Maxwell ◽  
Grace DeWitt ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Retrospective Chart Review ◽  
Stroke Care ◽  
Admission Diagnosis ◽  
Stroke Patients ◽  
Delivery Of Care ◽  
Spark Plug ◽  
Significant Difference ◽  
The Times

Introduction: It is well documented that a Prehospital Stroke Alert (PHSA) protocol leads to decreased treatment times for stroke patients. Outcomes measured typically include Door to Physician (DTP), Door to CT (DTCT), and Door to Needle (DNT) times. Our comprehensive stroke center’s PHSA system has been in place since 2012. This study evaluates 3 specific endpoints. First, Emergency Medical Services (EMS) improve their recognition of stroke symptoms as they gain experience with PHSA. Second, a PHSA protocol decreases intervention times of DTP, DTCT, and DNT over a study period of 3 years. Third, when patients present to our Neurologic Emergency Department (Neuro ED) as a PHSA, rather than a non-PHSA, the intervention times are markedly decreased, and acute ischemic stroke care is significantly expedited. Methods: A retrospective chart review was conducted for patients who presented to our hospital with an admitting diagnosis of stroke from 2012-2014. Patients were screened for presentation to the Neuro ED and further stratified based on whether a PHSA was called. PHSA was called if EMS deemed the patient’s Cincinnati Stroke Scale score as positive, and symptom onset was within 6 hours. We recorded DTCT, DTP, and DTN times over the years for all patients meeting these inclusion criteria. Results: Three hundred and five patients with an admission diagnosis of stroke were seen in the Neuro ED (Hours are 0700-1800, 7 days a week) from 2012 to 2014, 128 of which presented as PHSAs. EMS responders accurately diagnosed stroke in 82% of cases. Previously, EMS assessment of stroke was accurate only 66% of the time. PHSA patients had decreased DTP, DTCT, and DTN times over the 3 year period. When comparing the PHSA group to non-PHSA group, statistically significant differences were found in DTP and DTCT times within each year (p≤0.0001). Discussion: In conclusion, gaining experience with a PHSA protocol did in fact lead to EMS better recognizing stroke symptoms, reduction in the times of delivery of care for acute ischemic stroke patients over the years 2012-2014, and a markedly statistically significant difference in intervention times if patients were seen as a PHSA as opposed to a non-PHSA.

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