The Investigation on the Burden of Neurology Residents to Manage the Patient who Received Thrombolytic Treatment in the Emergency Department with Hyperacute Stroke

Background: Because Korea is the fastest aging country, the stroke incidence is increasing rapidly. We investigate the trend of the number of patients with acute stroke in recent years and estimate the burden of the neurologist to treat the acute stroke patient visited the emergency department.Methods: We requested a questionnaire survey to all teaching hospitals on the number of hospital beds, the number of stroke patients who visited the emergency department, the number of stroke patients in charge of the neurologist, and the number of days on duty of residents from 2016 to 2019.Results: Of 69 teaching hospitals, 41 hospitals answered the survey. The average hospital beds per hospital were increased annually from 909 to 916. The average patients who visited the emergency department with stroke and were in charged to neurologists were rapidly increased from 799 to 867 per hospital. In particular, the number of patients with hyperacute cerebral infarction requiring the thrombolytic administration or mechanical thrombectomy were rapidly increased from 105 to 131. On the other hand, the average number of residents per hospital was decreased from 5.1 to 4.8. Therefore, the days on duty per resident were increased from 74 to 77.Conclusions: The number of acute stroke patients, especially, hyperacute stroke required the rapid cooperation and high labor were increasing rapidly in recent years. However, because the number of residents were decreased, the burden was increasing. To improve the quality of acute stroke treatment, it is necessary to increase the number of residents.

Accuracy and Prognostic Role of NCCT-ASPECTS Depend on Time from Acute Stroke Symptom-onset for both Human and Machine-learning Based Evaluation

Purpose We hypothesize that the detectability of early ischemic changes on non-contrast computed tomography (NCCT) is limited in hyperacute stroke for both human and machine-learning based evaluation. In short onset-time-to-imaging (OTI), the CT angiography collateral status may identify fast stroke progressors better than early ischemic changes quantified by ASPECTS. Methods In this retrospective, monocenter study, CT angiography collaterals (Tan score) and ASPECTS on acute and follow-up NCCT were evaluated by two raters. Additionally, a machine-learning algorithm evaluated the ASPECTS scale on the NCCT (e-ASPECTS). In this study 136 patients from 03/2015 to 12/2019 with occlusion of the main segment of the middle cerebral artery, with a defined symptom-onset-time and successful mechanical thrombectomy (MT) (modified treatment in cerebral infarction score mTICI = 2c or 3) were evaluated. Results Agreement between acute and follow-up ASPECTS were found to depend on OTI for both human (Intraclass correlation coefficient, ICC = 0.43 for OTI < 100 min, ICC = 0.57 for OTI 100–200 min, ICC = 0.81 for OTI ≥ 200 min) and machine-learning based ASPECTS evaluation (ICC = 0.24 for OTI < 100 min, ICC = 0.61 for OTI 100–200 min, ICC = 0.63 for OTI ≥ 200 min). The same applied to the interrater reliability. Collaterals were predictors of a favorable clinical outcome especially in hyperacute stroke with OTI < 100 min (collaterals: OR = 5.67 CI = 2.38–17.8, p < 0.001; ASPECTS: OR = 1.44, CI = 0.91–2.65, p = 0.15) while ASPECTS was in prolonged OTI ≥ 200 min (collaterals OR = 4.21,CI = 1.36–21.9, p = 0.03; ASPECTS: OR = 2.85, CI = 1.46–7.46, p = 0.01). Conclusion The accuracy and reliability of NCCT-ASPECTS are time dependent for both human and machine-learning based evaluation, indicating reduced detectability of fast stroke progressors by NCCT. In hyperacute stroke, collateral status from CT-angiography may help for a better prognosis on clinical outcome and explain the occurrence of futile recanalization.

Hyperacute stroke and the specialist nursing impact: exploring the cause and context of feelings of secondary traumatic stress – a qualitative inquiry

Background Secondary traumatic stress (STS) has been defined as the stress resulting from helping or wanting to help a traumatised or suffering person. The hyperacute nature of stroke specialist nurses’ work places them at risk of developing STS. Aims To explore the factors that are influential in stroke specialist nurses' experience of STS development within hyperacute practice. Methods This study is qualitative with a narrative design. Data were collected from a purposive sample of stroke specialist nurses (20 female and 2 male) working in hyperacute services during the years 2016 and 2017. Data were analysed using Polkinghorne’s approach. Results This research identified four themes: exposure to acute suffering and death- young presentations; moral distress; interactions with relatives and problematic healthcare systems. Conclusion The findings from this study suggest that stroke specialist nurses are exposed to multiple triggers which are commensurate with the potential for STS development. The findings contribute a new understanding of the emotional burden of hyperacute specialist stroke nursing that has implications for patient safety and satisfaction, services provision and staff well-being.

Adverse consequences of immediate thrombolysis-related complications: a multi-centre registry-based cohort study of acute stroke

Complications following thrombolysis for stroke are well documented, and mostly concentrated on haemorrhage. However, the consequences of patients who experience any immediate thrombolysis-related complications (TRC) compared to patients without immediate TRC have not been examined. Prospectively collected data from the Sentinel Stroke National Audit Programme were analysed. Thrombolysis was performed in 451 patients (52.1% men; 75.3 years ± 13.2) admitted with acute ischaemic stroke (AIS) in four UK centres between 2014 and 2016. Adverse consequences following immediate TRC were assessed using logistic regression, adjusted for age, sex and co-morbidities. Twenty-nine patients (6.4%) acquired immediate TRC. Compared to patients without, individuals with immediate TRC had greater adjusted risks of: moderately-severe or severe stroke (National Institutes of Health for Stroke Scale score ≥ 16) at 24-h (5.7% vs 24.7%, OR 3.9, 95% CI 1.4–11.1); worst level of consciousness (LOC) in the first 7 days (score ≥ 1; 25.0 vs 60.7, OR 4.6, 95% CI 2.1–10.2); urinary tract infection or pneumonia within 7-days of admission (13.5% vs 39.3%, OR 3.2, 95% CI 1.3–7.7); length of stay (LOS) on hyperacute stroke unit (HASU) ≥ 2 weeks (34.7% vs 66.7%, OR 5.2, 95% CI 1.5–18.4); mortality (13.0% vs 41.4%, OR 3.7, 95% CI 1.6–8.4); moderately-severe or severe disability (modified Rankin Scale score ≥ 4) at discharge (26.8% vs 65.5%, OR 4.7, 95% CI 2.1–10.9); palliative care by discharge date (5.1% vs 24.1%, OR 5.1, 95% CI 1.7–15.7). The median LOS on the HASU was longer (7 days vs 30 days, Kruskal–Wallis test: χ2 = 8.9, p = 0.003) while stroke severity did not improve (NIHSS score at 24-h post-thrombolysis minus NIHSS score at arrival = − 4 vs 0, χ2 = 24.3, p < 0.001). In conclusion, the risk of nosocomial infections, worsening of stroke severity, longer HASU stay, disability and death is increased following immediate TRC. The management of patients following immediate TRC is more complex than previously thought and such complexity needs to be considered when planning an increased thrombolysis service.

Diagnostic Accuracy of Diffusion-Weighted MR Imaging Versus CT Brain in Hyperacute Stroke – A Prospective Study, Rohtas, Bihar

BACKGROUND The purpose of imaging is multifaceted, ranging from selecting the most appropriate patients for treatment, to avoiding those who are unlikely to benefit. In the present situation, imaging methods basically include cross-sectional imaging by computed tomography (CT) or magnetic resonance imaging (MRI). The target of the assessment is the vessels that supply the brain parenchyma and its associated part at the same / distant perfusion level. In this study, we wanted to evaluate the diagnostic accuracy of diffusion-weighted MR imaging with nonenhanced CT in the diagnosis of hyperacute stroke. METHODS This prospective study was conducted in Radiology Department at Narayan Medical College Rohtas, Bihar. The study group includes a sample of 45 patients who had come to the Department of Radiology within 6 hours of onset of stroke symptoms. Non-enhanced computed tomography (NECT) and MRI were done in all the patients and the results were studied. Study subjects were recruited as following inclusion and exclusion criteria. Data was collected, entered and analysed using Microsoft Excel, Epi Info and statistical package for social sciences (SPSS) software. RESULTS The hyperintense ischemic lesions on diffusion-weighted imaging (DWI) were typically more visually distinct and easier to distinguish than the EIS on CT scans, resulting in better overall values. When the five regions were looked at separately, DWI had higher sensitivity than CT studies, which was close to the overall EIS ranking. The basal ganglia and the insular ribbon had the greatest sensitivity in both modalities. Eight of the 14 patients were classified in the consensus rating of CT and DW imaging, resulting in a sensitivity of 57 percent for both methods, with a bad value of 0.40 for CT and a good value of 0.68 for DW imaging. CONCLUSIONS DW imaging had a higher sensitivity and interrater agreement than CT imaging in detecting early infarction. KEYWORDS Stroke, Computed tomography, MRI, Ischaemia

Multiperspective simulations for implementing a change in service: stroke telethrombolysis

Simulation-based training has been used in a variety of ways to demonstrate and improve process elements of patient care. One example of this is in improving door-to-needle times in hyperacute stroke care. Changes in service by one team which affect another bring difference of opinions between service providers involved and can lead to interdepartmental conflict. In this report, we use Kurt Lewin’s model for change to describe how a series of multiperspective simulation-based exercises were used in implementing a change in practice with the introduction of telethrombolysis within a large tertiary stroke referral hospital. The use of multiperspective or bidirectional simulation allowed a ‘meeting of minds’ with each service able to illustrate key themes to the other service. This was demonstrated through a series of simulation-based exercises. Following successful simulation-based exercises and subsequent interdepartmental agreement, a telethrombolysis pilot has been conducted within our centre. Ongoing audit of practice continues as this method of treatment delivery is continued. Further simulation work is planned as a national thrombectomy service is instigated.

Abstract P108: Impact of the Covid-19 Pandemic on Hyperacute Stroke Treatment: Experience From a Comprehensive Stroke Centre in Singapore

Background: The Coronavirus disease 2019 (COVID-19) pandemic is rapidly evolving and affecting healthcare systems across the world. Singapore has escalated its alert level to Disease Outbreak Response System Condition (DORSCON) Orange, signifying severe disease with community spread. Objectives: We aimed to study the overall volume of AIS cases and the delivery of hyperacute stroke services during DORSCON Orange. Methods: This was a single-centre, observational cohort study performed at a comprehensive stroke centre responsible for AIS cases in the western region of Singapore, as well as providing care for COVID-19 patients. All AIS patients reviewed as an acute stroke activation in the Emergency Department (ED) from November 2019 to April 2020 were included. System processes timings, treatment and clinical outcome variables were collected. Results: We studied 350 AIS activation patients admitted through the ED, 206 (58.9%) pre- and 144 during DORSCON Orange. Across the study period, number of stroke activations showed significant decline (p =0.004, 95% CI 6.513 - -2.287), as the number of COVID-19 cases increased exponentially, whilst proportion of activations receiving acute recanalization therapy remained stable ( p = 0.519, 95% CI -1.605 - 2.702). Amongst AIS patients that received acute recanalization therapy, early neurological outcomes in terms of change in median NIHSS at 24 hours (-4 versus -4, p = 0.685) were largely similar between the pre- and during DORSCON orange periods. Conclusions: The number of stroke activations decreased while the proportion receiving acute recanalization therapy remained stable in the current COVID-19 pandemic in Singapore.

Abstract P853: Covid-19: A Catalyst for Change in the Code Brain Pathway

Background: Acute stroke care is constantly evolving and often necessitates rapid change. When COVID-19 struck our community, our team determined that we needed to change our approach to emergent stroke cases without sacrificing efficiency and safety. Our goals with the changes in our hyperacute stroke response pathway (called Code Brain) in our ED was to minimize COVID-19 exposure to our team, reduce PPE usage, and maintain an environment of safety and readiness, all while providing the same high-quality stroke care. Purpose: The purpose of this study was to determine if the changes we made to our Code Brain pathway in the ED effected our door-to-needle time for tissue plasminogen activator (t-PA) administration our door-to-groin puncture (DTG) times, or our CT scan turn-around times (CT TAT) under 45 minutes percentage. Implementation: It was decided that the stroke team RNs would respond to the bedside and a neurology resident or fellow would respond via telemedicine robot at bedside. The stroke team nurse is the safety monitor who ensures proper PPE use. The patient is moved through the Code Brain pathway with the telemedicine robot in tow, assuring constant contact with the patient by the stroke physician and stroke nurse. We implemented our revised Code Brain pathway on March 17, 2020. We retrospectively collected data from November 2019 to July 2020 and extracted our DTN, DTG and CT TAT times for a 4 ½ month comparison. Results: From November 2019 through March 17, 2020, our DTN median time was 39 minutes, DTG median time was 101 minutes, and CT TAT under 45 minutes was 97%. From March 18, 2020 to July 2020, our DTN median time was 54 minutes, DTG median time was 101 minutes, and CT TAT under 45 minutes was 95%. Variables to consider are the length of time it takes to apply the appropriate PPE for the stroke nurse, obtaining the telemedicine robot from our ED storage area and connectivity issues. Conclusion: Although we radically changed the way we approach our Code Brain patients, our response and treatment times changed only slightly. We will continue to streamline this process for optimal outcomes.