Semi-automated data collection from electronic health records in a stroke unit in Brazil

ABSTRACT Background: There is a high demand for stroke patient data in the public health systems of middle and low-income countries. Objective: To develop a stroke databank for integrating clinical or functional data and benchmarks from stroke patients. Methods: This was an observational, cross-sectional, prospective study. A tool was developed to collect all clinical data during hospitalizations due to stroke, using an electronic editor of structured forms that was integrated with electronic medical records. Validation of fields in the electronic editor was programmed using a structured query language (SQL). To store the results from SQL, a virtual table was created and programmed to update daily. To develop an interface between the data and user, the Embarcadero Delphi software and the DevExpress component were used to generate the information displayed on the screen. The data were extracted from the fields of the form and also from cross-referencing of other information from the computerized system, including patients who were admitted to the stroke unit. Results: The database was created and integrated with the hospital electronic system, thus allowing daily data collection. Quality indicators (benchmarks) were created in the database for the system to track and perform decision-making in conjunction with healthcare service managers, which resulted in improved processes and patient care after a stroke. An intelligent portal was created, in which the information referring to the patients was accessible. Conclusions: Based on semi-automated data collection, it was possible to create a dynamic and optimized Brazilian stroke databank.

Disparities in Care and Outcome of Stroke Patients from Culturally and Linguistically Diverse Communities in Metropolitan Australia

Background: Acute stroke is a time-critical emergency where diagnosis and acute management are highly dependent upon the accuracy of the patient’s history. We hypothesised that the language barrier is associated with delayed onset time to thrombolysis and poor clinical outcomes. This study aims to evaluate the effect of language barriers on time to thrombolysis and clinical outcomes in acute ischemic stroke. Concerning the method, this is a retrospective study of all patients admitted to a metropolitan stroke unit (Melbourne, Victoria, Australia) with an acute ischemic stroke treated with tissue plasminogen activator between 1/2013 and 9/2017. Baseline characteristics, thrombolysis time intervals, length of stay, discharge destination, and in-hospital mortality were compared among patients with and without a language barrier using multivariate analysis after adjustment for age, sex, stroke severity, premorbid modified Rankin Scale (mRS), and Charlson Comorbidity Index (CCI). Language barriers were defined as a primary language other than English. A total of 374 patients were included. Our findings show that 76 patients (20.3%) had a language barrier. Mean age was five years older for patients with language barriers (76.7 vs. 71.8 years, p = 0.004). Less non-English speaking patients had premorbid mRS score of zero (p = 0.002), and more had premorbid mRS score of one or two (p = 0.04). There was no statistically significant difference between the two groups in terms of stroke severity on presentation (p = 0.06). The onset to needle time was significantly longer in patients with a language barrier (188 min vs. 173 min, p = 0.04). Onset to arrival and door to imaging times were reassuringly similar between the two groups. However, imaging to needle time was 9 min delayed in non-English speaking patients with a marginal p value (65 vs. 56 min, p = 0.06). Patients with language barriers stayed longer in the stroke unit (six vs. four days, p = 0.02) and had higher discharge rates than residential aged care facilities in those admitted from home (9.2% vs. 2.3%, p = 0.02). In-hospital mortality was not different between the two groups (p = 0.8). In conclusion, language barriers were associated with almost 14 min delay in thrombolysis. The delay was primarily attributable to imaging to needle time. Language barriers were also associated with poorer clinical outcomes.

Determinants of falls after stroke based on data on 5065 patients from the Swedish Väststroke and Riksstroke Registers

We aimed to identify determinants in acute stroke that are associated with falls during the stroke unit stay. In order to enable individualized preventive actions, this knowledge is fundamental. Based on local and national quality register data on an unselected sample of 5065 stroke patients admitted to a stroke unit at a Swedish university hospital, univariable and multivariable logistic regression analyses were performed. The dependent variable was any fall during stroke unit stay. The independent variables related to function, activity, personal factors, time to assessment, comorbidities and treatments. Determinants of falls were: being male (odds ratio (OR) 2.25, 95% confidence interval (95% CI) 1.79–2.84), haemorrhagic stroke (OR 1.39, 95% CI 1.05–1.86), moderate stroke symptoms according to the National Institutes of Health Stroke Scale (NIHSS score 2–5 vs. NIHSS score 0–1) (OR 1.43, 95% CI 1.08–1.90), smoking (OR 1.70, 95% CI 1.29–2.25), impaired postural control in walking (OR 4.61, 95% CI 3.29–6.46), impaired postural control in standing (OR 1.60, 95% CI 1.25–2.05), stroke-related arm- and hand problems, OR 1.45, 95% CI 1.11–1.91), impaired cognition (OR 1.43, 95% CI 1.04–1.95), and urinary tract infection (OR 1.91, 95% CI 1.43–2.56). The findings from this study are useful in clinical practice and might help to improve patient safety after stroke.

A register-based study comparing planned rehabilitation following acute stroke in 2011 and 2017

This cross-sectional, register-based study aimed to explore patterns of planned rehabilitation at discharge from stroke units in Sweden in 2011 and 2017 and identify explanatory variables for planned rehabilitation. Multivariable binary logistic regression was used to identify variables that could explain planned rehabilitation. There were 19,158 patients in 2011 and 16,508 patients in 2017 with stroke, included in the study. In 2011, 57% of patients were planned for some form of rehabilitation at discharge from stroke unit, which increased to 72% in 2017 (p < 0.001). Patients with impaired consciousness at admission had increased odds for planned rehabilitation (hemorrhage 2011 OR 1.43, 95% CI 1.13–1.81, 2017 OR 1.66, 95% CI 1.20–2.32), (IS 2011 OR 1.21, 95% CI 1.08–1.34, 2017 OR 1.49, 95% CI 1.28–1.75). Admission to a community hospital (hemorrhage 2011 OR 0.56, 95% CI 0.43–0.74, 2017 OR 0.39, 95% CI 0.27–0.56) (IS 2011 OR 0.63, 95% CI 0.58–0.69, 2017 OR 0.54, 95% CI 0.49–0.61) or to a specialized non-university hospital (hemorrhage 2017 OR 0.66, 95% CI 0.46–0.94), (IS 2011 OR 0.90, 95% CI 0.82–0.98, 2017 OR 0.76, 95% CI 0.68–0.84) was associated with decreased odds of receiving planned rehabilitation compared to admission to a university hospital. As a conclusion severe stroke was associated with increased odds for planned rehabilitation and patients discharged from non-university hospitals had consistently decreased odds for planned rehabilitation.

Building a Mobile Stroke Unit Based on 5G Technology – A Study Protocol

Background: In-time treatment of acute stroke is critical to saving people’s lives and improving the quality of post-stroke life. A mobile stroke unit (MSU) with fifth-generation (5G) mobile networks strengthens the interaction of patient information and healthcare resources, thereby reducing response times and improving thrombolysis results. However, clinical evidence of better outcomes compared to regular care is still lacking.Method and Design: In this randomized controlled trial, 484 patients with acute stroke are allocated into the MSU and regular care groups. We establish medical records for each patient and conduct a follow-up of 90 days. The primary outcomes are functional results as defined by utility-weighted modified Rankin Scale (uw-mRS) 90 days after the incidence occurred, whereas secondary outcomes include the alarm to CT scan completed time, the alarm to treatment decision time, the alarm to thrombolytic time, quality of life, and symptomatic intracranial hemorrhage combined with NIHSS score as well as cost-effectiveness.Discussion: This study establishes an innovative MSU (based on 5G) to manage acute stroke, comparing its clinical and economic outcomes to regular care and informing decision-makers of the effectiveness of the stroke emergency system.Clinical Trial Registration: [http://www.chictr.org.cn/showproj.aspx?proj=63874], identifier [ChiCTR2000039695].

Stroke unities: the role of the occupational therapist and the perception of the multidisciplinary team

Every second a person in the world suffers from a stroke, not surprising, therefore, that stroke is the leading cause of death and morbidity in Portugal. Increasingly, acute stroke is considered a medical emergency. The evidence proves that the treatment of these patients in specialized units (stroke units) is effective in acute stroke. A stroke unit is a hospital area where professionals with specific, well-defined training work, who provide care to stroke patients who are already stabilized, but are still in an acute phase(DGS, 2001). The aim of this study is to understand the role of the occupational therapist in stroke units and to identify the perspective of the multidisciplinary team on their work, clarifying what are the advantages of this professional in the team. The study falls within the qualitative paradigm, exploratory and descriptive. Semi-structured interviews were performed to 39 health professionals. The technique used was the content analysis of interviews. Based on previously established categories, other categories emerged.

Very Early Cognitive Screening and Self-Reported Feeling of Fatigue Three Months After Stroke

Stroke is a major cause of disability and the second leading cause of death worldwide. Post-stroke fatigue has been reported as one of the most limiting symptoms after a stroke. Early identification of risk factors for developing post-stroke fatigue is important for providing timely rehabilitation. A correlation has been found between fatigue and cognitive impairment after stroke, but 2 months after stroke at the earliest. In the present study, we examined whether cognitive function screening using the Montreal Cognitive Assessment (MoCA) very early after stroke could explain fatigue 3 months after stroke. A total of 311 stroke patients admitted to a comprehensive stroke unit in Sweden between 2011 and 2016 were included in this longitudinal study. Cognition was screened within 2 days after admission to the stroke unit. Data on self-reported feeling of fatigue were retrieved from Riksstroke’s 3-month follow-up form. The data were analyzed using binary logistic regression. We found that the cognitive function in an acute phase after stroke could not explain self-reported feeling of fatigue in a later stage. The correlation between cognitive impairment and fatigue that has been reported may be detectable no earlier than the subacute phase of stroke. As previous studies have shown that functional outcome, severity of stroke, and sex also correlate with fatigue after stroke, we controlled for these variables in our analysis. In line with previous studies, we found that female patients had higher odds of experiencing fatigue. This is something that health care professionals should be aware of when working with stroke patients.

Dependency in Activities of Daily Living During the First Year After Stroke

Background: Dependency in personal activities of daily living (ADL) is a common short-term and long-term consequence of stroke and requires targeted rehabilitation. As the duration of hospital stay has become shorter in recent decades, early identification of patients who require rehabilitation has become vital. To our knowledge, no study has investigated whether ADL dependency in the very early stages after admission to the stroke unit can explain ADL dependency 3 and 12 months later. This knowledge would facilitate planning for very early discharge and patient-centered rehabilitation.Objective: This study evaluated whether ADL dependency within 2 days after stroke could explain ADL dependency at 3 and 12 months after stroke.Methods: This longitudinal cohort study included patients with stroke who were treated at a stroke unit in the Sahlgrenska University Hospital (Gothenburg, Sweden) between May 2011 and March 2016. The primary independent variable was ADL dependency at 36–48 h after admission to the stroke unit, which was assessed using a Barthel Index (BI) score of ≤90. The dependent variables were self-reported personal ADL dependency at 3 and 12 months after stroke. Binary logistic regression analyses were performed.Results: Of 366 eligible patients (58% male; median age 71 years), a majority (76%) had mild stroke and 60% were ADL dependent 36–48 h after stroke. Univariable and multivariable logistic regression analyses showed that patients who were dependent within the first 2 days after stroke had higher odds for being dependent 3 months as well as 12 months after stroke.Conclusion: The results indicated that dependency in personal ADL during the first 2 days can explain dependency at 3- and 12-month post-stroke. Therefore, early ADL assessments post-stroke can be used for understanding rehabilitation needs after stroke.

Cost-Effectiveness of Stroke Unit Compared With Routine Treatment For Stroke Patients In Iran

Background: Two approaches including stroke unit and routine treatment, are used to address stroke patients. Although stroke unit is a new intervention in Iran and its effectiveness has been proven, but there is little information on its costs. It is necessary to utilize the results of the studies of economic evaluation in order to choose the better treatment option between two alternatives. Due to the lack of studies in this field in Iran, the current study was conducted to assess the cost-effectiveness of stroke unit and routine treatment. Methods: A Markov model incorporating three health states of independent, dependent and death for a time horizon of 10 years with a 3-month cycle length was applied. Direct medical and non-medical costs, including pharmaceutical and hospital expenses, were calculated based on 2018 data from a health system perspective. Quality-adjusted life-years (QALYs) were taken as the outcome measure. The analysis of cost-effectiveness and sensitivity for uncertain parameters was carried out using TreeAge 2020. Results: The stroke unit had more costs and QALYs gain in comparison with routine treatment, and it was cost-effective with an ICER of 551 PPP dollars per QALY. Probabilistic sensitivity analysis showed that stroke unit cost-effectiveness probability is 78 percent, in the threshold of willingness to pay three times GDP per capita. Conclusion: Incremental cost-effectiveness ratio of stroke unit is far less than the threshold of willingness to pay, indicating the strategy is cost-effective. Therefore, implementing stroke unit in Iran health system leads to optimal use of resources.