Impact of COVID-19 on the stroke rehabilitation pathway: multidisciplinary team reflections on a patient and carer journey from acute to community stroke services

A 62-year old man attended accident and emergency in June 2020 with dense right sided weakness, aphasia and confusion. Investigations revealed a left middle cerebral artery infarct, and he was admitted under the stroke team for ongoing inpatient rehabilitation. He was discharged home in September 2020 and received community stroke rehabilitation from physiotherapy, nursing, occupational therapy and speech and language therapy. He is now working towards a graded discharge from the Community Stroke and Neuro Rehab Team, after achieving his rehabilitation goals. In this case, the multidisciplinary team adopted different ways of working to accommodate the patients’ priorities while also negotiating the COVID-19 pandemic. This included taking a transdisciplinary approach to rehabilitation and considering alternative supported self-management strategies. This case highlighted several learning points, particularly the potential benefits of shared goal setting for patients with communication difficulties and transdisciplinary approaches to community stroke rehabilitation.

Measuring Patient Safety Climate in Acute Stroke Therapy

Background: Treatment of acute stroke is highly time-dependent and performed by a multiprofessional, interdisciplinary team. Interface problems are expectable and issues relevant to patient safety are omnipresent. The Safety Attitudes Questionnaire (SAQ) is a validated and widely used instrument to measure patient safety climate. The objective of this study was to evaluate the SAQ for the first time in the context of acute stroke care.Methods: A survey was carried out during the STREAM trial (NCT 032282) at seven university hospitals in Germany from October 2017 to October 2018. The anonymous survey included 33 questions (5-point Likert scale, 1 = disagree to 5 = agree) and addressed the entire multiprofessional stroke team. Statistical analyses were used to examine psychometric properties as well as descriptive findings.Results: 164 questionnaires were completed yielding a response rate of 66.4%. 67.7% of respondents were physicians and 25.0% were nurses. Confirmatory Factor Analysis revealed that the original 6-factor structure fits the data adequately. The SAQ for acute stroke care showed strong internal consistency (α = 0.88). Exploratory analysis revealed differences in scores on the SAQ dimensions when comparing physicians to nurses and when comparing physicians according to their duration of professional experience.Conclusion: The SAQ is a helpful and well-applicable tool to measure patient safety in acute stroke care. In comparison to other high-risk fields in medicine, patient safety climate in acute stroke care seems to be on a similar level with the potential for further improvements.Trial registration:www.ClinicalTrials.gov Identifier: NCT032282.

Development and Clinical Application of a Deep Learning Model to Identify Acute Infarct on Magnetic Resonance Imaging

BackgroundStroke is a leading cause of death and disability. The ability to quickly identify the presence of acute infarct and quantify the volume on magnetic resonance imaging (MRI) has important treatment implications. MethodsWe developed a machine learning model that used the apparent diffusion coefficient and diffusion weighted imaging series. It was trained on 6,657 MRI studies. All studies were labelled positive or negative for infarct (classification annotation) with 377 having the region of interest outlined (segmentation annotation). The different annotation types facilitated training on more studies while not requiring the extensive time to manually segment every study. We initially validated the model on studies sequestered from the training set. We then tested the model on studies from three clinical scenarios: consecutive stroke team activations for 6-months at the hospital that provided training data, consecutive stroke team activations for 6-months at a hospital that did not provide training data, and an international site. The model results were compared to radiologist ground truth interpretations.ResultsThe model performed better when trained on classification and segmentation annotations (area under the receiver operating curve [AUROC] 0.995 [95% CI, 0.992-0.998] and median Dice coefficient for segmentation overlap of 0.797 [IQR, 0.642-0.861]) compared to segmentation annotations alone (AUROC 0.982 [95% CI, 0.972-0.990] and Dice coefficient 0.776 [IQR, 0.584-0.857]). The model accurately identified infarcts for training hospital stroke team activations (AUROC 0.964 [95% CI, 0.943-0.982], 381 studies), non-training hospital stroke team activations (AUROC 0.981 [95% CI, 0.966-0.993], 247 studies), and at the international site (AUROC 0.998 [95% CI, 0.993-1.000], 171 studies). The model accurately segmented infarcts with Pearson correlation comparing model output and ground truth volumes between 0.968-0.986 for the three scenarios.ConclusionsAcute infarct can be accurately detected and segmented on MRI in real-world clinical scenarios using a machine learning model.

Evaluating Improvement in Acute Stroke Management following Pre-hospital Initiation of Acute Stroke Service

Prehospital notification of the stroke team in alerting incoming acute stroke patient has been practiced in several countries worldwide. Currently this is not practiced in Malaysia. This study evaluates feasibility and impact to stroke team door to review time when prehospital notification is employed. Duration of case control study was between June 2018 to January 2019. Control phase consists of conventionally activating stroke team after in-hospital assessment by emergency medical officer. This was then followed by an intervention phase where on scene activation of stroke team was done by the Prehospital Emergency Care (PHC) staff. Training of PHC staff in recognising an acute stroke was based on identification of BE-FAST (Balance, Eyes, Face, Arm and Speech Test) abnormalities. The objectives were to compare the mean between two groups for acute stroke team review time, door to computerised tomography (CT) scan and door to thrombolysis time. Thirty-nine patients were analysed (control n=29, intervention n=10). Results were insignificant (p>0.05). Mean time in minutes for control phase vs. intervention phase was as follows: Door to stroke team review time, 25.96 + 39.16 vs. 15.9 + 13.14, door to CT scan was 43.04 + 40.00 vs. 25.8 + 11.35. Only 3 patients underwent thrombolytic therapy during study period. Limitation was non-parametric data with lack of number of acute stroke cases responded during the intervention period. With continual training of pre-hospital staff in detecting acute stroke, feasibility can be improved.

EXPRESS: Longer term patient management following stroke A systematic review

<b>Background</b> Tremendous progress in acute stroke therapy has improved short-term outcome but part of this achievement may be lost in the long run. Concepts for a better long-term management of stroke survivors are needed to address their unmet needs and to reduce the burden of post-stroke complications, residual deficits and recurrent vascular events. <b>Aims</b> This review summarizes current knowledge on post-hospital care and the scientific evidence supporting individual programs. <b>Summary of review</b> A systematic search of electronic databases according to PRISMA guidelines identified 10,374 articles, 77 of which met the inclusion criteria. One large randomised controlled trial on a multifaceted care program delivered by the multidisciplinary stroke team reduced recurrent vascular events and improved quality of life and functional outcome one year after the event while a number of studies offer solutions for individual components of post-hospital disease management like patient education, counselling, and self-management or the management of post-stroke complications and residual deficits. A majority of studies, however, was small in size and limited by a short follow-up. Most initiatives with a narrow focus on risk factor control failed to lower the risk of recurrent events. The caregivers’ central role in post-stroke patient management is broadly neglected in research. <b>Conclusions</b> Over the past years, first knowledge on how to best organize post-hospital care of stroke patients has emerged. Comprehensive and pragmatic programs operated by the multidisciplinary stroke team hold promise to reduce the long-term health burden of stroke. There is a clear need for further high-quality studies with both clinical endpoints and patient-reported outcomes to establish sustainable solutions in different settings and regions to improve life after stroke, a key priority of the Stroke Action Plan for Europe 2018-2030.

In-Hospital Stroke Care: A Six-Year Community-Based Primary Stroke Center Experience

Background and purpose: In-hospital stroke-onset assessment and management present numerous challenges, especially in community hospitals. Comprehensive analysis of key stroke care metrics in community-based primary stroke centers is under-studied. Methods: Medical records were reviewed for patients admitted to a community hospital for non-cerebrovascular indications and for whom a stroke alert was activated between 2013 and 2019. Demographic, clinical, radiologic and laboratory information were collected for each incident stroke. Descriptive statistical analysis was employed. When applicable, Kruskal-Wallis and Chi-Square tests were used to compare median values and categorical data between pre-specified groups. Statistical significance was set at alpha = 0.05. Results: There were 192 patients with in-hospital stroke-alert activation; mean age (SD) was 71.0 years (15.0), 49.5% female. 51.6% (99/192) had in-hospital ischemic and hemorrhagic stroke. The most frequent mechanism of stroke was cardioembolism. Upon stroke activation, 45.8% had ischemic stroke while 40.1% had stroke mimics. Stroke team response time from activation was 26 minutes for all in-hospital activations. Intravenous thrombolysis was utilized in 8% of those with ischemic stroke; 3.4% were transferred for consideration of endovascular thrombectomy. In-hospital mortality was 17.7%, and the proportion of patients discharged to home was 34.4% for all activations. Conclusion: The in-hospital stroke mortality was high, and the proportions of patients who either received or were considered for acute intervention were low. Quality improvement targeting increased use of acute stroke intervention in eligible patients and reducing hospital mortality in this patient cohort is needed.

Multidisciplinary assessment of patients with ischemic stroke, the structure of a stroke team, and first Egyptian experience in adults undergoing transcatheter PFO closure for PFO-related stroke

Background Patent foramen ovale closure in the setting of stroke was debatable until the recent data from the long-term follow-up of multiple randomized control trials. These recent data have led to increase the number of the procedure worldwide. To our knowledge, there was no previous formal structured program in Egypt between cardiologists and neurologists for investigation and management of patients with cryptogenic stroke. The first Egyptian-dedicated stroke team was created in two large tertiary centers with collaboration between cardiologists, dedicated cardiac imagers, and neurologists for investigation and management of patients with cryptogenic stroke. Results Sixty-three patients with cryptogenic stroke were identified from a total of 520 patients admitted to the stroke units between 2016 and 2019. Twenty-five patients had a proven PFO-related stroke. Three patients were referred for surgical closure, 19 patients underwent transcatheter PFO closure, and procedural success was met in 18 patients (94.7%). We did not experience any major procedure-related complication. Complete closure was achieved in 83.3% of patients at 6 months. One patient had a single attack TIA within the first 3 months after device closure; one patient had a device-related thrombosis; both were managed successfully. Conclusion Our initial experience in collaboration between cardiologist and neurologist with the establishment of a dedicated cryptogenic stroke team added significantly to the management of patients with stroke. The results of the first Egyptian cohort who underwent transcatheter PFO closure demonstrated procedural feasibility, safety, and efficacy with very low incidence of major complications. A nationwide program is needed to reduce the ischemic stroke disease burden and the risk of recurrence.

Abstract P121: Update on Regional Stroke Activation Trends During Covid-19 Mitigation

Background: The University of Cincinnati Stroke Team provides acute stroke care to the southwest Ohio, northern Kentucky, and southeast Indiana catchment area of ~2 million people and 30 healthcare facilities. We previously published a significant decline in stroke activations and reperfusion treatment (IV thrombolysis and EVT) rates following state announcements of COVID-19 mitigation measures. Here, we update these trends after state reopening guidelines. Methods: We compared Stroke Team activations and reperfusion treatments logged in a prospectively collected database, comparing the same period in 2020 versus 2019. Kentucky and Ohio announced school and restaurant closures on March 12 and 13, respectively, followed by Indiana. A stepwise reopening of our tristate area started on May 1, 2020. We also compared trends in activations and treatment rates before (Weeks 1-10), during (Weeks 11-17), and after (Weeks 18-26) the lifting of COVID-19 mitigation efforts using the Poisson test, and graphically with segmented regression analysis. Results: Compared to 2019, stroke team activations declined by 12% in 2020 (95% CI 7 - 16%; p<0.01). During 2020, an initial decline in stroke activations following COVID-19 mitigation announcements was followed by a 28% increase in activations after reopening (Weeks 18-26: 95% CI 15 - 42%; p<0.01). In contrast, compared to 2019, treatment rates were unchanged (0%, 95% CI -15 - 18%; p=1.00), including specifically IV thrombolysis and thrombectomy rates. Similarly, an initial decline in reperfusion treatments was followed by a 24% nonsignificant increase after reopening (95% CI -10 - 71%; p=0.19) in 2020. Conclusion: The initial decline in stroke team activations during COVID-19 mitigation efforts was followed by an increase in activations after reopening. Hospital capacity and 911 services remained fully intact, suggesting that the reduction in activations were related to reduced presentation by patients for emergent stroke care.

Abstract P287: Delays in the Identification and Assessment of In-Hospital Stroke Patients

Introduction: In-hospital stroke is associated with worse outcomes and fewer stroke interventions compared to patients with community-acquired stroke. We assessed factors associated with delays in symptom identification and stroke team alerting, and use of acute interventions for in-hospital strokes. Methods: The local Get With The Guidelines-Stroke and an in-hospital quality improvement database at our tertiary care hospital were screened over a 26-month period ending 10/2019, yielding 98 in-hospital strokes. Results: Strokes were more common on surgery services (70%), were predominantly ischemic (83%), and were moderate-to-severe (median NIHSS 16; interquartile range [IQR] 6-24). There were long delays from the time of last known normal (LKN) until stroke symptom identification (SxID) (median 5.1 hours, IQR 1.0-19.7 hours) and from SxID to stroke alert (median 2.1 hours, IQR 0.5-9.9 hours). In univariable analysis, being in an ICU, being intubated, being on a surgical service, having no lateralized weakness or neglect, and higher NIHSS were associated with delays; in multivariable analysis only intubation was associated with being above median from LKN to SxID (OR 4.3, 95% CI 1.2-16.2, p=0.03) and above median for SxID to stroke alert (OR 8.5, 95% CI 2.0-36.4). Acute stroke interventions were given to 15 patients (15%), including 3 (3%) who received IV tPA and 12 (12%) who underwent IA thrombectomy. Patients who received stroke interventions had shorter times from last normal to SxID (median 0.7 vs 8.2 hours, p=0.002) and times from SxID to stroke alert (median 0.2 vs 3.4 hours, p=0.006). Urgent vascular imaging occurred in 68/98 (69%) of patients and 23/68 (34%) had a large vessel occlusion (LVO). Of those patients with an LVO, 78% had lateralizing arm weakness or neglect on exam. Conclusions: There are long delays from LKN to SxID and from SxID to stroke alert in hospitalized patients leading to low rates of acute stroke treatment. Intubation was a robust risk factor for delays and protocols should be established to monitor these patients more carefully. Despite these delays, 1/3 of patients who had vascular imaging had an LVO identified that might have been eligible for intervention.

Abstract P118: Process Improvement for Stroke/EMS Run Sheets Available in Medical Record

Background and Purpose: When stroke patients arrive to the hospital, it is imperative to have a clear picture of what occurred during transport from home, scene or other facility. The stroke team encountered difficulties in obtaining emergency medical services (EMS) run sheets in real time. We also found that these records, even when obtained, were often not scanned into the electronic medical record (EMR). Methods: We created a plan of action with our ED Stroke Champions, which involved development of an automated system to streamline the process of the run sheet scanning into EMR. In December 2019 barcode scanning devices were purchased and placed in the ED to facilitate this process. Ongoing education of the new process was conducted via email to notify our EMS partners of these changes, as well as face to face discussions whenever possible. Laminated color copies of the visual aide were posted at the central scanner location and in the EMS room in the ED. The process was that the EMS partners would:•receive the patient’s medical record number with barcode•stop at a central scanner•send the EMS run sheet directly into the EMR This process began on December 16, 2019. Three days before, another email went out to all EMS partners describing the process with a visual aide. Laminated color copies of the visual aide were posted at the central scanner location and in the EMS room in the ED. Results: In November 2019, 20 eligible ground EMS run sheets were sent to the Medical Records department for EMR scanning. After review, 13 (65%) were found scanned into the EMR. A review of January-July 2020 showed the following eligible scanned run sheets into EMR.•January 2020, 1 out of 21 (4.5%)•February 2020, 4 out of 26 (1.5%)•March 2020, 2 out of 17 (12%)•April 2020, 5 out of 15 (33%)•May 2020, 12 out of 18 (67%)•June 2020, 7 out of 7 (100%) Conclusions: With implementation of an automated process, significant improvement has been seen in obtaining and scanning run sheets. This will lead to better decision making regarding acute treatments in stroke patients.