Acute Stroke Centers Research Articles

The MAPSTROKE project: A computational strategy to improve access to acute stroke care.

Global access to acute stroke treatment is variable worldwide, with notable gaps in low and middle-income countries (LMIC), especially in rural areas. Ensuring a standardized method for pinpointing the existing regional coverage and proposing potential sites for new stroke centers is essential to change this scenario. To create and apply computational strategies (CSs) to determine optimal locations for new acute stroke centers (ASCs), with a pilot application in nine Latin American regions/countries. Hospitals treating acute ischemic stroke (AIS) with intravenous thrombolysis (IVT) and meeting the minimum infrastructure requirements per structured protocols were categorized as ASCs. Hospitals with emergency departments, noncontrast computed tomography (NCCT) scanners, and 24/7 laboratories were identified as potential acute stroke centers (PASCs). Hospital geolocation data were collected and mapped using the OpenStreetMap data set. A 45-min drive radius was considered the ideal coverage area for each hospital based on the drive speeds from the OpenRouteService database. Population data, including demographic density, were obtained from the Kontur Population data sets. The proposed CS assessed the population covered by ASCs and proposed new ASCs or artificial points (APs) settled in densely populated areas to achieve a target population coverage (TPC) of 95%. The observed coverage in the region presented significant disparities, ranging from 0% in the Bahamas to 73.92% in Trinidad and Tobago. No country/region reached the 95% TPC using only its current ASCs or PASCs, leading to the proposal of APs. For example, in Rio Grande do Sul, Brazil, the introduction of 132 new centers was suggested. Furthermore, it was observed that most ASCs were in major urban hubs or university hospitals, leaving rural areas largely underserved. The MAPSTROKE project has the potential to provide a systematic approach to identify areas with limited access to stroke centers and propose solutions for increasing access to AIS treatment. Data used for this publication are available from the authors upon reasonable request.

Abstract TMP41: Mapping Accessibility Differences of Acute Stroke Centers in the United States

Background: One of the keys to mitigating adverse outcomes of an ischemic or hemorrhagic stroke is timely access to a stroke center. Every minute of a large vessel occlusion results in the mean loss rate of 2 million neurons. Every 20-minute reduction in time to reperfusion increases disability-free lifespan by 3 months. For intracerebral hemorrhage, early intensive blood pressure lowering within 2 hours of onset improved outcomes . For aneurysmal subarachnoid hemorrhage, more than one-third of rebleeds occur within 3 hours. Accessibility of acute stroke centers varies drastically across the United States, both between states and between localities. There is a need to characterize accessibility not only based on the population and distance to the nearest center but also using average travel time per area. Methods: To understand the accessibility of the 2,446 stroke centers in the US we performed geospatial mapping by combining distance and average travel time as part of an interactive map. The map can be used to visually identify regions lacking timely access to a stroke center. Through linking highly granular demographic and socio-economic census data, we can better understand populations effected by long travel times. To identify the nearest stroke center for every census tract in the US, the distance between centroids and the KNN algorithm was used. By adding the average commute times of the counties that intersected the straight line, travel time to the nearest stroke center was estimated. Results: Approximately 45 million people live over 90 minutes away from a stroke center. Increasing stroke center access should be prioritized for populations over 1.5 hours from the nearest stroke center. The map highlights regions of particular concern with 2.5 - 4+ hour travel times (Fig. 1). Conclusion: We demonstrate that accessibility differences of stroke centers can be better understood using an interactive map. Our map highlights regions and populations in need of a stroke center.

Artificial intelligence-based decision support software to improve the efficacy of acute stroke pathway in the NHS: an observational study.

In a drip-and-ship model for endovascular thrombectomy (EVT), early identification of large vessel occlusion (LVO) and timely referral to a comprehensive center (CSC) are crucial when patients are admitted to an acute stroke center (ASC). Several artificial intelligence (AI) decision-aid tools are increasingly being used to facilitate the rapid identification of LVO. This retrospective cohort study aimed to evaluate the impact of deploying e-Stroke AI decision support software in the hyperacute stroke pathway on process metrics and patient outcomes at an ASC in the United Kingdom. Except for the deployment of e-Stroke on 01 March 2020, there were no significant changes made to the stroke pathway at the ASC. The data were obtained from a prospective stroke registry between 01 January 2019 and 31 March 2021. The outcomes were compared between the 14 months before and 12 months after the deployment of AI (pre-e-Stroke cohort vs. post-e-Stroke cohort) on 01 March 2020. Time window analyses were performed using Welch's t-test. Cochran-Mantel-Haenszel test was used to compare changes in disability at 3 months assessed by modified Rankin Score (mRS) ordinal shift analysis, and Fisher's exact test was used for dichotomised mRS analysis. In the pre-e-Stroke cohort, 19 of 22 patients referred received EVT. In the post-e-Stroke cohort, 21 of the 25 patients referred were treated. The mean door-in-door-out (DIDO) and door-to-referral times in pre-e-Stroke vs. post-e-Stroke cohorts were 141 vs. 79 min (difference 62 min, 95% CI 96.9-26.8 min, p < 0.001) and 71 vs. 44 min (difference 27 min, 95% CI 47.4-5.4 min, p = 0.01), respectively. The adjusted odds ratio (age and NIHSS) for mRS ordinal shift analysis at 3 months was 3.14 (95% CI 0.99-10.51, p = 0.06) and the dichotomized mRS 0-2 at 3 months was 16% vs. 48% (p = 0.04) in the pre- vs. post-e-Stroke cohorts, respectively. In this single-center study in the United Kingdom, the DIDO time significantly decreased since the introduction of e-Stroke decision support software into an ASC hyperacute stroke pathway. The reduction in door-in to referral time indicates faster image interpretation and referral for EVT. There was an indication of an increased proportion of patients regaining independent function after EVT. However, this should be interpreted with caution given the small sample size. Larger, prospective studies and further systematic real-world evaluation are needed to demonstrate the widespread generalisability of these findings.

Development and validation of comprehensive clinical outcome prediction models for acute ischaemic stroke in anterior circulation based on machine learning

The current prediction models for the clinical outcome of acute ischaemic stroke (AIS) remain insufficient for individualized patient management strategies. We aimed to investigate machine learning (ML) performance in the clinical outcome prediction of AIS in anterior circulation and evaluate the clinical outcome by combining the quantitative evaluation indicators of perfusion features and basic clinical information. Four ML classifiers, support vector machine (SVM), naive Bayes (NB), logistic regression (LR), and random forest (RF) were trained on a cohort of 389 adult patients (training cohort [70 %]; external validation cohort [30 %]) from the Acute Stroke Center Registry of Huashan Hospital. Model performance was compared by a range of learning metrics. Most imaging parameters were strongly correlated with the outcome (range, 0.57 to 0.81), and the correlation between relative cerebral blood flow (rCBF) < 30 % and clinical outcome was the strongest (ρ = 0.81). As the reference parameters increased, the performance of the four models was greatly improved [SVM (AUC: from 0.79 to 0.99, F1-score: from 0.61 to 0.90), RF (AUC: from 0.88 to 0.98, F1-score: from 0.71 to 0.96), LR (AUC: from 0.80 to 0.97, F1-score: from 0.64 to 0.95), and NB (AUC: from 0.74 to 0.97, F1-score: from 0.66 to 0.92)]. The ensemble classifier model with all parameters had the highest F1-score (0.97). All the ML models, jointly considering the basic clinical information and quantitative evaluation indicators of computed tomography perfusion (CTP), showed good performance in the prediction of clinical outcome of AIS in anterior circulation.

Estimated Population Access to Acute Stroke and Telestroke Centers in the US, 2019

Estimated Population Access to Acute Stroke and Telestroke Centers in the US, 2019

İnmeli Hastalarda Öz Etkililik ve Yaşam Kalitesinin Değerlendirilmesi

Backgrounds: The study was designed as a methodological and randomized controlled experimental study to analyze self-efficacy and quality of life of stroke patients. &#x0D; Methods: The population of the study included stroke patients who received outpatient care at an acute stroke center between March –November, 2016. The study was performed with 72 patients. The patients in the experimental group received educational booklet and were included in a 3-month follow-up. The data for the study were collect using a Questionnaire Form, Quality of Life Scale for Stroke Patients, SSEQ and Monthly Follow-up Form. &#x0D; Results: It was determined that the experimental group given the educational booklet and monthly follow-up had higher scores in both self-efficacy and quality of life than the patients in control group. In the experimental group, the analysis between total scores from SSEQ and SS-QOL demonstrated increased correlation coefficient for the second visit compared with the first visit. Self-efficacy was positively correlated with the mobility, upper extremity function and self-care domains, and was negatively correlated with the language domain. &#x0D; Conclusion: As a result, it was determined that education and follow-up in stroke patients are effective and has positive impact on self-efficacy and quality of life.

Assessing the readiness of hospitals in Riyadh Province for efficient and timely stroke management: A pilot study.

Objectives:To assess the readiness of hospitals in Riyadh to establish acute stroke centers by following the Australian Clinical Guidelines for Stroke Management.Methods:This study was a quantitative cross-sectional observational study conducted among hospitals in the central region of Saudi Arabia (Jan 2018 – April 2018). A self-administered questionnaire/survey tool was adapted from an Australian survey developed by the Stroke Foundation in Melbourne, Australia.The data were analyzed using SPSS version 21.0. Appropriate statistical tests (chi-square and Fisher’s exact test) were used for bivariate analyses.Results:A total of 3932 stroke patient visits were recorded in 37 hospitals in the central region of Saudi Arabia. The most common limitations of acute stroke services were that 25 (67.57%) of the hospitals had no stroke unit and 21 (56.76%) had inadequate clinical staff. Magnetic resonance imaging and computed tomography were available in 32 (86.49%) and 36 (97.30%) hospitals, respectively. Only two-thirds of hospitals 25 (67.57%) followed protocols for rapid Emergency Department (ED) triage.Conclusion:We found that most of our hospitals were not fully prepared to address acute stroke management in a manner that was reasonably consistent with international guidelines. We recommend raising the hospital’s requirements a higher level to be in line with the stroke guidelines.

Modification of In-Hospital Recommendation and Prescription of Anticoagulants for Secondary Prevention of Stroke after Launch of Direct Oral Anticoagulants and Change of National Guidelines

Introduction: Approximately 1 out of 4 stroke patients suffers ischemic stroke secondary to atrial fibrillation (AF). Although indicated, withholding of anticoagulants for secondary prevention is a widespread phenomenon. Objective: We examined the longitudinal change of recommendation and prescription of secondary preventive anticoagulation in AF patients in an acute stroke center setting focusing on the impact of the introduction of direct oral anticoagulants (DOACs) and the change of national stroke prevention guidelines. Methods: Consecutive patients admitted with an acute cerebrovascular ischemic event underwent regular diagnostic work-up. Pseudonymized clinical data were entered into the institution’s stroke registry. In those patients with AF, discharge letters were collected and evaluated for temporal trends and affecting factors of recommended and prescribed antithrombotic secondary medication at the time of discharge from hospital. Results: Of 7,175 patients admitted between January 2009 and December 2018, 1,812 (25.3%) suffered stroke caused by AF. Frequency of patients with recommended anticoagulation increased within the observation period from 66.7 to 95.8% (per year; adjusted odds ratio [OR], 1.309; confidence interval [CI], 1.153–1.486). Independently from this time trend, DOAC approval (adjusted OR, 4.026; CI 1.962–8.265) and guideline change (adjusted OR, 2.184; CI, 1.006–4.743) were associated with an increasing frequency of recommendation for anticoagulation. The rate of patients already receiving recommended anticoagulation for secondary prevention at discharge increased from 42.1 to 62.5%. Introduction of DOACs was not associated with this trend, and guideline change was even associated with decreasing frequency of anticoagulated patients at hospital discharge (adjusted OR, 0.641; CI, 0.414–0.991). Fear of early intracerebral bleeding was the most common reason for withholding anticoagulation (37%) at hospital discharge and stayed stable during the observation period. Conclusions: Changing national guidelines with discard of contraindications for anticoagulation and the introduction of DOACs led to a broader recommendation of oral anticoagulation. However, both, new guidelines and DOACs, were not found to be associated with an increasing percentage of patients discharged from our hospital already on recommended anticoagulant prevention. This might be explained by the decreasing length of hospital stay during the study period and a missing evidence of early bleeding risk of DOACs in patients with acute brain infarction. Evidence-based data to close this therapeutic gap are needed.

Impact of disease-specific care certification on clinical outcome and healthcare performance of myocardial infarction in Taiwan.

The relationship between certification for specific disease care and clinical outcome was not well known. Previous studies regarding the effect of certification for acute stroke centers were limited by their cross-sectional design. This study aimed to investigate the effect of disease-specific care (DSC) certification on healthcare performance and clinical outcome of acute myocardial infarction (AMI). This retrospective, longitudinal, controlled study was performed by analyzing the nationwide Taiwan Clinical Performance Indicators dataset from 2011 to 2018. Hospitals undergoing DSC certification for coronary care and reporting AMI indicators 1 year before, during, and 1 year after certification were included in group C, whereas hospitals not seeking DSC certification but reporting AMI indicators during the same period were included in group U. The primary endpoint was in-hospital mortality of AMI. In total, 20 hospitals (9 in group C and 11 in group U) and up to 16 173 AMI cases were included for analysis. In-hospital mortality was similar between both groups at baseline. However, the in-hospital mortality was significantly improved during and after certification periods in comparison with that at baseline in group C (6.8% vs 8.4%, p = 0.04; 6.7% vs 8.4%, p = 0.02), whereas there was no significant change in group U, resulting in a statistically significant difference between both groups during and after certification periods (odds ratio = 0.74 [95% CI = 0.60-0.91] and 0.78 [95% CI = 0.64-0.96]). Compared with group U, the improvement in healthcare performance indicators, such as door-to-electrocardiography time <10 minutes, blood testing for low-density lipoprotein cholesterol level, prescribing a beta-blockade or a P2Y12 receptor inhibitor during hospitalization, prescribing a statin on discharge, and consultation for cardiac rehabilitation, was significant in group C. The current study demonstrated the beneficial effect of DSC certification on clinical outcome of AMI probably mediated through quality improvement during the healthcare process.

Patients With Greater Stroke Severity and Premorbid Disability Are Less Likely to Receive Therapist Consultations and Intervention During Acute Care Hospitalization.

A substantial number of patients with stroke never receive acute care therapy services, despite the fact that therapy after stroke reduces the odds of death and disability and improves patients' functioning. The aim of this study was to estimate the proportion of and factors associated with receipt of therapist consultations and interventions during acute care hospitalization following ischemic and hemorrhagic stroke. This was a single-center longitudinal observational study. Adults with a diagnosis of ischemic or hemorrhagic stroke (N=1366) were enrolled during their hospitalization in an acute stroke center in a large metropolitan area. The main outcomes were receipt of therapist consultations, interventions, or both. Participants with acute hemorrhagic stroke (intracerebral: odds ratio [OR]=0.34 [95% CI=0.19-0.60]; subarachnoid: OR=0.52 [95% CI=0.28-0.99]) and with greater stroke severity by National Institutes of Health Stroke Scale (NIHSS) score (NIHSS score of > 15: OR=0.34 [95% CI=0.23-0.51]) were less likely to receive therapist consultations. Participants with moderate stroke severity (NIHSS score of 6-15: OR=1.43 [95% CI=1.01-2.33]) were more likely to receive therapy interventions. Those who were able to ambulate before admission were more than 5 times as likely to receive therapy interventions (OR=5.08 [95% CI=1.91-13.52]). Also, participants with longer lengths of stay (ie, more intensive care unit and non-intensive care unit days) were more likely to receive therapist consultations and interventions. Tests or procedures were the most common reasons for unsuccessful attempts to complete therapist consultations. Lack of operational and qualitative data prohibited detailed explorations of barriers to delivery of therapist consultations and interventions. Approximately 1 in 4 participants with acute stroke received neither a consultation nor an intervention. Efforts to improve the delivery of acute care therapy services are needed to optimize care for these people.

2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: A proposal to optimize care for patients with valvular heart disease: A Joint Report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.

This statement was commissioned as a Multisociety Expert Consensus Systems of Care Document by the American Association for Thoracic Surgery (AATS), American College of Cardiology (ACC), American Society of Echocardiography (ASE), Society for Cardiovascular Angiography and Interventions (SCAI), and

The practice and predictors of early mobilization of patients post-acute admission to a specialized stroke center

ABSTRACTBackground: Early mobilization (EM) post-stroke is recommended; however, the ideal timing and nature of EM, and factors that may influence EM practice are unclear.Objectives: The primary objective was to describe the type and extent of mobilization 0–48 h post-stroke admission to acute hospital care. A secondary objective was to evaluate whether pre-stroke functional level, stroke severity, tissue plasminogen activator (tPA) administration, and level of consciousness (LOC) predicted any passive, any active, and out-of-bed mobilization (i.e. sitting at edge-of-bed, standing, or ambulation) 0–24 h post-admission.Methods: A quantitative, cross-sectional, retrospective review of health records of patients admitted to a specialized acute stroke center in 2016 was conducted.Results: Data from 296 eligible health records were abstracted. Median age was 73 years, and 87% of patients had sustained an ischemic stroke. Active, passive, and out-of-bed mobilization occurred in 91.6%, 57.1%, and 24.3% of patients by 12 h post-admission, respectively, and 99.3%, 78.4%, and 77.4% of patients by 48 h post-admission, respectively. Administration of tPA, stroke severity, and impaired LOC, were each associated with any passive mobilization, and no tPA administration, stroke severity, and normal LOC were each associated with out-of-bed mobilization 0–24 h post-admission (p < 0.05).Conclusions: Almost all patients receive active mobilization by 12 h post-admission whereas out-of-bed mobilization is infrequent. In the first 24 h post-admission, clinicians may prioritize passive over out-of-bed mobilization when patients have received tPA, present with severe stroke, and have impaired LOC. This conservative approach is unsurprising given the lack of clear practice recommendations for these situations.

High patient participation rate in Post-Stroke Depression screening at an Acute Stroke Center (P4.168)

High patient participation rate in Post-Stroke Depression screening at an Acute Stroke Center (P4.168)

A qualitative study of clinical champions in context: Clinical champions across three levels of acute care.

Objectives:To compare activities and field descriptions of clinical champions across three levels of stroke centers.Methods:A cross-sectional qualitative study using quota sampling was conducted. The setting for this study was 38 acute stroke centers based in US Veterans Affairs Medical Centers with 8 designated as Primary, 24 as Limited Hours, and 6 as Stroke Support Centers. Key informants involved in stroke care were interviewed using a semi-structured approach. A cross-case synthesis approach was used to conduct a qualitative analysis of clinical champions’ behaviors and characteristics. Clinical champion behaviors were described and categorized across three dimensions: enthusiasm, persistence, and involving the right people.Results:Clinical champions at Primary Stroke Centers represented diverse medical disciplines and departments (education, quality management); directed implementation of acute stroke care processes; coordinated processes across service lines; and benefited from supportive contexts for implementation. Clinical champions at Limited Hours Stroke Centers varied in steering implementation efforts, building collaboration across disciplines, and engaging in other clinical champion activities. Clinical champions at Stroke Support Centers were implementing limited changes to stroke care and exhibited few behaviors fitting the three clinical champion dimensions. Other clinical champion behaviors included educating colleagues, problem-solving, implementing new care pathways, monitoring progress, and standardizing processes.Conclusion:These data demonstrate clinical champion behaviors for implementing changes to complex care processes such as acute stroke care. Changes to complex care processes involved coordination among clinicians from multiple services lines, persistence facing obstacles to change, and enthusiasm for targeted practice changes.

Peri-interventional management of acute endovascular stroke treatment

Due to the ground breaking consistent evidence that supports the effect of endovascular stroke treatment (EST), many acute care hospitals and stroke centers will have to be prepared to provide this treatment in an optimal way within the coming years. In addition to the intervention itself, patient preparation, stabilization and monitoring during the treatment as well as the aftercare represent significant challenges and have mostly not yet been sufficiently investigated. Under these aspects, the questions of optimal sedation and airway management have received the highest attention. Based on retrospective study results it already seems to be justified, respecting certain criteria, to prefer EST with the patient under conscious sedation (CS) in comparison to general anesthesia (GA) and to only switch to GA in cases of emergency until this question has been clarified by prospective studies. This and other aspects of peri-interventional management, such as logistics, monitoring, blood pressure, ventilation settings, postprocedural steps of intensive or stroke unit care and imaging follow-up are summarized in this overview. The clinical and radiological selection of patients and thus the decision for intervention or technical aspects of the intervention itself will not be part of this article.

CNS Francis McNaughton Memorial Prize

Background: This study examines whether abnormal blood hemoglobin concentration (bHB) is associated with worse clinical outcomes and poorer prognosis after acute ischemic stroke. Methods: We included data from the Registry of the Canadian Stroke Network on consecutive patients with ischemic stroke who were admitted between July/2003 and March/2008. Patients were divided into groups as follows: low bHB, normal bHB, and high bHB. Primary outcome measures were the frequency of moderate/severe strokes on admission (Canadian Neurological Scale: &lt;8), greater degree of disability at discharge (modified Rankin score: 3-6), and 30-day and 90-day mortality. Results: Higher bHB than the superior normal limit is associated with greater degree of impairment (OR=1.45, 95%CI: 1.06-1.95, p=0.0195) and disability (OR=1.49, 95%CI: 1.03-2.15, p=0.0331), and higher 30-day mortality (HR=1.98, 95%CI: 1.44-2.74, p&lt;0.0001) after adjustment for major potential confounders. The Kaplan-Meier curves indicate that abnormal bHB is associated with higher mortality after acute ischemic stroke (p&lt;0.0001). Lower bHB than the inferior normal limit is associated with longer stay in the acute stroke care center (OR=1.11, 95%CI: 1.02-1.22, p=0.017). Conclusions: Polycythemia on the initial admission is associated with poorer prognosis regarding the degree of impairment and disability, and 30-day mortality after an acute ischemic stroke. Anemia on admission is associated with longer stay in the acute stroke center.

Relative Distributions

Analyses of trends in the delivery of time critical treatments typically report the median, but measures of central tendency may ignore important changes for specific patient groups. We considered whether this was an important effect during comparison of onset to treatment (OTT) time between 2 cohorts of patients with stroke receiving intravenous thrombolysis. After controlling for stroke severity, a relative distributions technique compared OTT for UK patients treated with recombinant tissue-type plasminogen activator registered within the first and last quarters (each n=661) of the Safe Implementation of Thrombolysis in Stroke-Monitoring Study database between January 2003 and September 2010. Significant differences were found between OTT distributions. Overall, the second cohort's OTT distribution demonstrated simultaneous increases in the proportion of patients with faster and slower OTT, which resulted in no net effect on the median after correction for stroke severity. Medians did not adequately describe distributional changes. Faster OTT may be because of more efficient processes in acute stroke centers and improved symptom recognition by the public. Slower OTT is likely to reflect movement from a 3- to a 4.5-hour OTT target. Relative distributions offer new insights into historical trends and service evaluation where time critical treatments are involved.

Out-of-Hospital Stroke Screen Accuracy in a State With an Emergency Medical Services Protocol for Routing Patients to Acute Stroke Centers

Emergency medical services (EMS) protocols, which route patients with suspected stroke to stroke centers, rely on the use of accurate stroke screening criteria. Our goal is to conduct a statewide EMS agency evaluation of the accuracies of the Cincinnati Prehospital Stroke Scale (CPSS) and the Los Angeles Prehospital Stroke Screen (LAPSS) for identifying acute stroke patients. We conducted a retrospective study in North Carolina by linking a statewide EMS database to a hospital database, using validated deterministic matching. We compared EMS CPSS or LAPSS results (positive or negative) to the emergency department diagnosis International Classification of Diseases, Ninth Revision codes. We calculated sensitivity, specificity, and positive and negative likelihood ratios for the EMS diagnosis of stroke, using each screening tool. We included 1,217 CPSS patients and 1,225 LAPSS patients evaluated by 117 EMS agencies from 94 North Carolina counties. Most EMS agencies contributing data had high annual patient volumes and were governmental agencies with nonvolunteer, emergency medical technician-paramedic service level providers. The CPSS had a sensitivity of 80% (95% confidence interval [CI] 77% to 83%) versus 74% (95% CI 71% to 77%) for the LAPSS. Each had a specificity of 48% (CPSS 95% CI 44% to 52%; LAPSS 95% CI 43% to 53%). The CPSS and LAPSS had similar test characteristics, with each having only limited specificity. Development of stroke screening scales that optimize both sensitivity and specificity is required if these are to be used to determine transport diversion to acute stroke centers.

Abstract T P122: Functional Independence Measure Scores Predict Self-care Levels Required for Post-acute Stroke Patients Classified by the Long-Term Care Insurance System in Japan: A Multicenter Retrospective Cohort Study

Background and purpose: Early prediction of clinical outcomes in stroke patients is socioeconomically important. The aim of this study was to clarify whether Functional Independence Measure (FIM) scores on admission can predict their discharge destinations and future self-care levels required for post-acute stroke patients classified by the Long-Term Care Insurance (LTCI) system, the national insurance plan for care in Japan. Methods: We enrolled post-acute stroke patients admitted to 12 convalescent rehabilitation wards (CRW) from 9 acute stroke centers. A CRW was defined as a specialized ward for intensive rehabilitation to prevent a bedridden state and to promote home rehabilitation by improving ability to perform activities of daily living. We evaluated self-care abilities using FIM scores and modified Rankin Scale (mRS) scores as traditional assessment scales and compared with certified self-care levels within the LTCI system (seven levels; slight impairment to bedridden). We divided patients into those who were discharged home from a CRW and all others. Results: Among 1261 patients (47% female, mean age 75 years), 984 (78%) were discharged home. FIM scores at discharge were significantly correlated with both mRS scores at discharge and certified self-care levels within the LTCI system (P &lt; .001). The cut-off values for home discharge were a FIM score on admission of 50 points and an age of 75 years. On multivariate analysis, FIM scores ≥50 on admission [odds ratio (OR), 95% confidence interval (95% CI); 5.80, 4.30-7.91] and age &lt;75 years (2.16, 1.60-2.95) were independently associated with home discharge. Conclusions: FIM scores in post-acute stroke patients can predict self-care levels within the LTCI system. Early prediction of self-care levels may promote careful preparation of healthcare planning and improve the efficiency of stroke management.

Abstract WP233: Prehospital Stroke Screen Accuracy in a State with an Emergency Medical Services Protocol for Routing Patients to Acute Stroke Centers

Background: A growing number of states are enacting legislation or regulations that direct emergency medical service (EMS) routing to state designated or Joint Commission Certified Stroke Centers, based on prehospital stroke screens performed by EMS providers. Objective: Assess the sensitivity and specificity of the Cincinnati Prehospital Stroke Screen (CPSS) and the Los Angeles Prehospital Stroke Screen (LAPSS) when performed by EMS providers in the context of a state-wide EMS stroke patient transport protocol. Methods: We used a validated method of deterministic matching to link a statewide Prehospital Medical Information System database, that includes prehospital stroke screen results, to a Statewide Emergency Department (ED) Surveillance System database containing ED disposition diagnosis ICD-9 codes. We compared EMS stroke screen results to the ED ICD-9 codes for ischemic and hemorrhagic stroke and TIA. Results: Over a 24 month period, we identified 3,901 linked records with a prehospital impression of acute stroke. This included 2,419 (62%) records with a completed and conclusive stroke screen result. There were 1,202 patients (50%) with a completed CPSS and 1,217 patients (50%) with a completed LAPSS. Ninety-four EMS agencies from 65 of the state’s 100 counties were represented in the complete data. The CPSS was 80% (95% CI 76-83%) sensitive and 46% (95% CI 42-50%) specific, whereas the LAPSS was 73% (95% CI 69-76%) sensitive and 42% (95% CI 38-46%) specific for identifying patients with an ED diagnosis of stroke or TIA. Conclusion: When performed and conclusively recorded by many different EMS agencies across one state, the CPSS and LAPSS had similar test characteristics. If prehospital screening is to be used to determine transport diversion to acute stroke centers, improving the specificity of these screens would be optimum.