Care For Acute Stroke Patients Research Articles

Stroke patients’ delay of emergency treatment

Scand J Caring Sci; 2010; 24; 307-311 Stroke patients' delay of emergency treatment Treatment of stroke victims with fibrinolysis should take place within a time limit of 3 hours. In spite of comprehensive endeavours to reduce hospital arrival time, too many patients still delay arrival beyond this time limit. This qualitative case study explored the meaning of acute stroke and treatment to four patients with more than 24-hour delayed arrival. The setting of the study was the catchment area of a university hospital. Semi-structured interviews were analysed through the empirical psychological, phenomenological method. An essence was found which was constituted by four themes. The essence of stroke symptoms and treatment was: 'Threatened control of bodily function, autonomy and integrity'. When the patients fell ill they acted as if nothing had happened. They treated their body like a defective device. In encounters with physicians they demanded to be met as a person by a person; otherwise they rejected both the physician and her or his prescriptions. They did not involve their near ones in decision-making. The conclusions were the following: Health care information about how to act in cases of early stroke symptoms may need to imbue people with an understanding of how early treatment of neurological symptoms and preserved control of life are intimately connected. Furthermore emergency care of acute stroke patients might need to take place in an organisation where patients are sure to be met by physicians as a person by a person.

The role of hospitalists in the acute care of stroke patients.

Opinion statementStroke care has become progressively more complicated with advances in therapies necessitating timely intervention. There are multiple potential providers of stroke care, which traditionally has been the province of general neurologists and primary care physicians. These new players, be they vascular neurologists, neurohospitalists, internal medicine hospitalists, or neurocritical care physicians, at the bedside or at a distance, are poised to make a significant impact on our care of stroke patients. The collaborative model of care may be or become the most prevalent as physicians apply their distinct skill sets to the complex care of inpatients with cerebrovascular disease.

Hyperdense artery sign on computed tomography in acute ischemic stroke

Despite the advent and growing availability of magnetic resonance imaging, the imaging modality of choice in the acute care of stroke patients in many institutions remains computed tomography. The hyperdense artery sign is the earliest marker of acute ischemic stroke. In this short review, we discuss the pathology, incidence, clinical aspects, imaging findings, significance and future questions that need to be addressed concerning this important sign.

Thrombolysis for Cerebral Ischemia

The care for patients with acute ischemic stroke has been revolutionized by the clinical application of fibrinolysis. Intravenous recombinant tissue plasminogen activator (rt-PA) has been proven to improve functional outcomes following acute ischemic stroke and can be administered to a select group of patients up to 4.5 h after symptom onset. Time from symptom onset to thrombolysis is the most important determinant of the success of treatment, with greatest efficacy if given within 90 min. Hospitals should implement standardized processes and protocols for acute stroke to guide immediate patient assessment, brain imaging, drug administration, and post-thrombolysis care. In this article we review the clinical application of thrombolysis, care of acute stroke patients, current evidence regarding fibrinolysis, and future direction of penumbral imaging to select candidates for reperfusion therapies.

Gradient echo MRI

Recent studies have demonstrated that gradient echo (GRE) MRI sequences are as accurate as CT for the detection of intracerebral hemorrhage (ICH) in the context of acute stroke. However, many physicians who currently read acute stroke imaging studies may be unfamiliar with interpretation of GRE images. An NIH Web-based training program was developed including a pretest, tutorial, and posttest. Physicians involved in the care of acute stroke patients were encouraged to participate. The tutorial covered acute, chronic, and mimic hemorrhages as they appear on CT, diffusion-weighted imaging, and GRE sequences. Ability of users to identify ICH presence, type, and age on GRE was compared from the pretest to posttest timepoint. A total of 104 users completed the tutorial. Specialties represented included general radiology (42%), general neurology (16%), neuroradiology (15%), stroke neurology (14%), emergency medicine (1%), and other (12%). Median overall score improved pretest to posttest from 66.7% to 83.3%, p < 0.001. Improvement by category was as follows: acute ICH, 66.7%-100%, p < 0.001; chronic ICH, 33.3%-66.7%, p < 0.001; ICH negatives/mimics, 100%-100%, p = 0.787. Sensitivity for identification of acute hemorrhage improved from 68.2% to 96.4%. Physicians involved in acute stroke care achieved significant improvement in gradient echo (GRE) hemorrhage interpretation after completing the NIH GRE MRI tutorial. This indicates that a Web-based tutorial may be a viable option for the widespread education of physicians to achieve an acceptable level of diagnostic accuracy at reading GRE MRI, thus enabling confident acute stroke treatment decisions.

European Stroke Facilities Survey: The German and Austrian Perspective

Background: The aim of this nested analysis was to identify the major components of stroke centers and other facilities actually available for acute stroke patients in hospitals of Germany and Austria. Methods: This analysis is part of a much larger European Stroke Facility Survey of 886 hospitals treating stroke patients all over Europe initiated by the European Stroke Initiative. Three levels of stroke care were predefined: comprehensive stroke centers (CSC), primary stroke centers (PSC) and a minimum level required for any hospital ward (AHW) admitting stroke patients. Hospitals providing even less than that were indicated in the ‘none’ category. Results: The present survey was conducted in 178 (166 and 12) German and Austrian hospitals which returned the questionnaire (41% response rate). They treated a total of 54,257 acute stroke patients per year (25% of all strokes in Germany and Austria), with a mean of 376 patients per year per hospital. 2,168 patients were given recombinant tissue plasminogen activator (4.7%), a proportion much higher than the pan-European average, but strongly dependent on the level of the facility considered (range 7.5–1.3%). Criteria for CSC were met in 13 hospitals (7.3%), for PSC in 15 (8.4%) and for AHW in 85 (47.7%). The minimum level required for AHW was not met in 65 hospitals (36.5%). 15.7% of German and Austrian hospitals provide stroke center facilities at the CSC or PSC level, as compared with 8.5% in Europe. A 24-hour availability of a stroke-trained physician was met by 100% of CSC, 73% of PSC, 85% of AHW and by 62% at the ‘none’ level of care. At the levels of CSC and PSC, a 100% availability was achieved for multidisciplinary stroke team, stroke-trained nurses, in-house emergency department, physiotherapy and speech therapy within 2 days, 24-hour brain CT and CT or MR angiography, as well as for transesophageal echocardiography and automated 24-hour monitoring of vital parameters. Nearly all these hospitals had training programs, stroke pathways, thrombolysis protocols and prevention procedures in place for the acute care of stroke patients. Conclusions: This survey shows that the minimum level of care is met in Germany and Austria in 63% of hospitals treating stroke patients, whereas the European average is 48.6%. However, the lack of stroke center coverage should encourage health policy decision makers to further improve the infrastructure for acute stroke care in order to make stroke centers available to every stroke victim.

A Lancet Issue Devoted to Stroke

Marc Fisher MD Kennedy Lees MD Section Editors: The dominant theme of the January 27, 2007 issue of Lancet is stroke. In a new editorial policy the Lancet decided to publish themed issues of particular interest to both general clinicians and specialist researchers. Stroke is undoubtedly a disease that requires special attention: approximately 1% of the 6.5 billion people living on our planet—twice the population of Canada or 8 times the population of Switzerland—will die each year of stroke. Many of these strokes are either preventable or could be delayed to a more advanced age. Considering such figures, the Lancet editors have to be congratulated for their decision, which is an important step in the struggle to reduce the burden of stroke in our societies. They have carefully selected original articles, seminars, and reviews on stroke. In the following we will comment on the 4 original articles. ### Wahlgren N, Ahmed N, Davalos A, Ford GA, Grond M, Hacke W, Hennerici MG, Kaste M, Kuelkens S, Larrue V, Lees KR, Roine RO, Soinne L, Toni D, Vanhooren G, for the SITS-MOST investigators. Thrombolysis with alteplase for acute ischemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet. 2007;369:275–282. The European Agency for the Evaluation of Medicinal Products (EMEA) mandated a postlicensing observational registry of thrombolysis use in Europe as a condition of licensing. The web-based SITS-MOST registry was launched in response to this need and collected more than 6000 patients from nearly 300 European centers. #### Methods Any European center was eligible as long as they agreed to enter all consecutive patients and agreed to site monitoring and aggregrate data reporting. Both experienced and inexperienced thrombolysis sites were eligible. The primary outcomes were safety outcomes: symptomatic ICH and death at 3 months from treatment. #### Results Patients enrolled in the registry were typically similar to those enrolled in prior trials and stroke thrombolysis registries. The mortality rate was 11.3% and symptomatic ICH rate 7.3%. Excellent functional outcome was achieved in 39% of patients. #### Interpretation This experience represents the largest stroke thrombolysis registry globally. It documents the safety and effectiveness of alteplase for stroke in routine clinical …

Role of Early Supported Discharge in Acute Stroke Patients

Role of Early Supported Discharge in Acute Stroke Patients

Stroke-unit care for acute stroke patients: an observational follow-up study

Large numbers of stroke patients arrive at hospital at a very early stage, and effective treatments for the acute phase of the disease are available. However, evidence that patients with acute stroke benefit from stroke-unit care is scarce. Our aim was to determine whether admission to a stroke unit, rather than a conventional ward, affected the outcome of patients with acute stroke. We did an observational follow-up study of 11 572 acute stroke patients hospitalised within 48 h of the onset of symptoms either in a stroke unit (n=4936) or in a conventional ward (6636). Patients were identified retrospectively from discharge records from 260 Italian hospitals. The primary outcome was mortality or disability (Rankin score greater than two), assessed prospectively by independent, masked assessors 2 years after admission. Analyses were adjusted for patient characteristics and clustered at the hospital level. Overall, 1576 patients died in hospital; 2169 died during the follow-up period. 347 patients were lost to follow-up. Compared with conventional-ward care, stroke-unit care was associated with a reduced probability of death or being disabled at the end of follow-up (odds ratio 0.81, 95% CI 0.72-0.91; p=0.0001). The potential benefit was significant across all age ranges and clinical characteristics, except for unconsciousness. No specific elements of setting, organisation, or process of care were associated with outcome. Admission to a stroke-unit ward with dedicated beds and staff within 48 h of onset should be recommended for all patients with acute stroke.

Towards effective and efficient care pathways: thrombolysis in acute ischaemic stroke

Over the past decade, specialist services for stroke patients have been introduced, and evidence suggests that they are both effective and efficient. 1–5 In many European countries, these services consist of stroke units in hospitals, rehabilitation facilities and community care organizations. In such networks, health professionals and organizations must coordinate their work to ensure that patients receive appropriate timely care, in appropriate settings. However, the pathway from stroke onset to hospital treatment is often far from seamless. Many stroke patients are admitted too late for appropriate treatment, or not at all. With the increasing effectiveness of acute stroke unit care and of thrombolysis, it is vital that this situation changes. If patients with an acute ischaemic stroke receive thrombolytic therapy within 3 h, they have an increased chance of recovery with a good outcome. 6 We therefore need to identify and use tools and strategies for creating an effective and efficient continuum of care for acute stroke patients. 7,,8 In this paper, we summarize the evidence in favour of a beneficial effect of intravenous thrombolysis, explore the barriers for the delivery of this treatment, suggest ways to overcome these barriers, and discuss an approach to measuring improvements in the organization of stroke care. The NINDS-rtPA trial is the only phase III trial of thrombolysis for acute ischaemic stroke that showed an unequivocal positive result. 9 In this study, patients were treated with intravenous alteplase within 3 h from onset of symptoms. Other trials showed no comparable results, partly because of difficulties with the design and choice of outcome parameters, and perhaps also because of a longer (6 h) time window, and higher doses of thrombolytic agent. 10 Wardlaw and colleagues 10 included all published randomized controlled trials of thrombolysis in a Cochrane review. They concluded that thrombolytic therapy, administered up to …

Use of Performance Indicators for Assessment of Quality of Care of Acute Stroke Patients in a Health Insurance Hospital in Alexandria

Performance indicators are usually one component of an overall strategy for quality improvement in health care. However, their use depends on adequate documentation in medical records. The aim of this study is to assess the quality of care provided to hospitalized stroke patients in Health Insurance hospital in Alexandria using performance indicators, and to determine the feasibility of abstraction of indicator data based on the level of documentation in medical records. Data elements for ten performance indicators were abstracted through retrospective review of randomly selected 170 records of acute stroke patients [out of 850 discharges] during the year 2003-2004. Results indicated that documentation in medical records was adequate for computing five of the ten performance indicators, namely, use of antithrombotic medication within 48 hours of hospitalization, prescription of anticoagulant therapy for patients with atrial fibrillation, prescription of antithrombotic on discharge, lipid profile during hospitalization, and plan for rehabilitation, with figures ranging between 71.2% and 14.5%. Due to the deficiency of recorded data, it was not possible to reliably compute the following five indicators: deep vein prophylaxis, tissue plasminogen activator considered, screen for dysphagia, stroke education, and adult smoking cessation advice. It was concluded that management of stroke patients needs to be better documented, along with more provider education for proper management of stroke.

Services for Reducing the Duration of Hospital Care for Acute Stroke Patients

In most developed countries, stroke patients are admitted to hospital for a period of acute care and rehabilitation. Services have been developed to try and accelerate discharge home and reduce the duration of hospital stay. These have been termed early supported discharge (ESD) services. This review tested whether ESD services could reduce length of stay and improve patient outcome compared with conventional hospital care and discharge arrangements. We searched the Cochrane Specialist Register of Controlled Trials (to August 2004). The contact trialist of all eligible studies was then contacted and asked to provide details of their intervention and control services and to provide individual patient data. We included randomized controlled trials (RCTs) that compared an ESD service with conventional care for hospitalized stroke …

Secondary prevention for stroke in the United Kingdom: results from the National Sentinel Audit of Stroke.

To measure the quality of secondary prevention of stroke provided to patients in England, Wales and Northern Ireland. Retrospective case note analysis. 235 hospitals (95% of all such hospitals), providing care for acute stroke patients in England, Wales and Northern Ireland and primary health care for follow-up data. 8,200 patients admitted with stroke between 1(st) April and 30(th) June 2001. Data on up to 40 consecutive cases submitted by each hospital. AUDIT TOOL: Royal College of Physicians Intercollegiate Stroke Working Party Stroke Audit. 24% of patients with previous cerebrovascular disease were not on anti-thrombotic medication at the time of admission. Nine percent of appropriate patients were not taking anti-thrombotic medication at discharge. Patients left with moderate to very severe disability (Barthel scores 14 or less) compared with those independent with mild disability (Barthel score 15-20) were more likely not to have anti-thrombotic treatment (18% versus 8%). Fifty-four percent of patients with known hyperlipidaemia and 21% of those with previous ischaemic heart disease were on lipid lowering therapy on admission. Sixty-four percent of patients had lipids measured during their hospital stay and of those with high total cholesterol or LDL the rate of non-treatment was 36%. Older patients (75+ years) were less likely to be treated (54%) than those <65 years (71%). Seventy-nine percent of known patients with hypertension were on treatment at admission, with 78% being treated by discharge from hospital. At 6 months after stroke a systolic blood pressure of 140 mmHg or less, and a diastolic of 85 mmHg or less, was achieved in 41% of known pre-stroke hypertensives on treatment, 31% of previously untreated hyper-tensives but on treatment at follow-up and 40% of patients not previously labelled as hypertensive. Major deficiencies in delivery of secondary prevention after stroke have been demonstrated. Services need reorganisation to prevent unnecessary mortality and morbidity in this group of patients.

Stroke and neurodegenerative disorders. 1. acute stroke evaluation, management, risks, prevention, and prognosis

O’Neill BJ, Geis CC, Bogey RA, Moroz A, Bryant PR. Stroke and neurodegenerative disorders. 1. Acute stroke evaluation, management, risks, prevention, and prognosis. 2004;85(3 Suppl 1):S3–10. This self-directed learning module highlights recent developments in the acute care of stroke patients, prediction of outcome after stroke, evaluation of risk factors, secondary prevention of stroke, and the evaluation of the young adult with stroke. It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article contains sections on the acute evaluation and management of the stroke patient, prediction of functional outcome after stroke, and secondary prevention of stroke. Special emphasis is given to the evaluation of the young adult with stroke. Overall article objectives (a) To summarize the acute evaluation and management of stroke, particularly in the young stroke patient; and (b) to review the risk factors for stroke and secondary prevention measures.

Paramedic and Emergency Department Care of Stroke: Baseline Data From a Citywide Performance Improvement Study

Rapid diagnosis and transport by paramedics and efficient, effective emergency management are essential to improving care of acute stroke patients. To measure the performance of paramedics and emergency departments providing care for patients with suspected acute stroke. Two stroke centers and 4 other hospitals where most patients with acute stroke in Houston, Tex, are admitted participated. Hospital and paramedic performance data were collected prospectively on 446 patients with suspected acute stroke transported by paramedics between September 1999 and February 2000. Paramedics had a sensitivity of 66%, specificity of 98%, and overall accuracy of 72% in diagnosing stroke. For patients with suspected stroke, 58.5% arrived in the emergency department within 120 minutes of symptom onset; in confirmed cases, that percentage was 67%. Mean total transport time was 42.2 minutes and was significantly longer (P < .001) to inner-city hospitals (44 minutes) than to suburban, community-based centers (39 minutes). Door to computed tomography times were significantly (P < .001) shorter for the 2 stroke centers than the other hospitals. Overall thrombolysis treatment rate among patients with confirmed ischemic stroke was 7.4% (range, 0-19.4%); treatment rates at the 2 stroke centers were 5.9% and 19.4%. More than half of patients with suspected stroke arrive at hospitals while thrombolytic treatment is still feasible. Although the current rate for thrombolytic treatment in Houston exceeds the national rate, performance of paramedics and hospitals in treating acute stroke can be improved by increasing efficiency and standardizing medical practices.

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Rehabilitation Interventions During Acute Care of Stroke Patients

The immediate care of a stroke patient admitted to hospital is best provided in a dedicated stroke unit, within which all of the key components of care can be coordinated. Neurologic diagnosis and intervention and general medical care are essential elements of acute stroke management. However, optimal outcome requires a comprehensive and multidisciplinary approach, which includes rehabilitation interventions. During the initial phases of care, rehabilitation interventions are mostly passive and emphasize prevention of secondary co-impairments such as contractures, pressure ulcers, and deconditioning. Rehabilitation interventions should be incorporated into care protocols for all patients and should begin immediately. As the patient becomes stable, more intensive therapy can be initiated in preparation for transition into the postacute phase of active rehabilitation.

Sources and reasons for delays in the care of acute stroke patients

Objective: This study aimed to identify sources and reasons for delays in the care of our acute stroke patients. Methods: Data on time interval from symptom onset or awareness to initial presentation, to neurology assessment, to performance of cranial CT scan, and demographic and medical factors associated with delays among stroke patients admitted at St. Luke's Medical Center from May to October 2000 were obtained by interview and record review. Results: Of 259 patients (mean age 61.5±13.6 years, 43% females), 63% had infarction (INF), 32% intracerebral hemorrhage (ICH) and 5% subarachnoid hemorrhage (SAH). Fifty-nine percent presented within 3 h of symptom onset or awareness, 73% within 6 h (median=2 h). Patients with ICH presented earlier than those with infarction. Reasons for delayed consultation included failure to recognize symptoms as serious and stroke-related. A non-neurologist was initially consulted in 97% of cases. Median delay from presentation to neurology evaluation was 7.5 h. Median time from presentation to brain imaging was significantly shorter for patients brought to CT-equipped facilities (2 h) than for those needing transfer to other hospitals (11.5 h). Conclusions and Recommendations: Patient delay in presentation is only one cause of delay in acute stroke care. Longer delays arise from healthcare-related factors such as delays in neurologist referral and neuroradiologic diagnosis. Professional and public education on the necessity of early neurologic evaluation and patient transport to CT-equipped “Stroke Centers” is recommended.

Services for reducing duration of hospital care for acute stroke patients.

Stroke patients conventionally receive a substantial part of their rehabilitation in hospital. Services have now been developed which offer patients in hospital an early discharge with community-based rehabilitation (early supported discharge, ESD). The objective of this review is to establish the costs and effects of ESD services compared with conventional services. The Cochrane Stroke Group Specialised Register was searched and supplemented with information from individual trialists. Searching was completed in March 1999. Randomised controlled trials recruiting stroke patients in hospital to receive either conventional care or any intervention which has provided rehabilitation and support in a community setting with an aim of reducing the duration of hospital care. Two reviewers scrutinised trials and categorised them on their eligibility. Standardised information was then obtained from the primary trialists. Results were analysed for all trials and for two subgroups depending on whether the intervention was provided by a coordinated multidisciplinary team (coordinated ESD team) or not. Outcome data are currently available for four trials. Patients tended to be a selected elderly group with disability. Overall, the odds ratio (95% confidence interval) for death, death or institutionalisation, death or dependency at the end of scheduled follow up were 0.87 (0.39-1.93), 0.69 (0.36-1.31) and 0.88 (0.49-1. 57) respectively. Apparent benefits more evident in the three trials evaluating a coordinated ESD team. The ESD group showed significant reductions (P<0.001) in the length of hospital stay equivalent to approximately nine days. ESD services provided for a selected group of stroke patients can reduce the length of hospital stay. However, the relative risks and benefits and overall costs of such services remain unclear.

Hospital Costs for Stroke Care in Singapore

We performed this prospective study to determine the cost of care for acute stroke patients admitted to hospital. Stroke was subtyped into subarachnoid hemorrhage (SAH), intraparenchymal hemorrhage (IPH), nonlacunar infarct (NLC), lacunar infarct (LAC) and transient ischemic attack (TIA). Cost of care was computed for the various services the patient received. At the time of the study, US$ 1 = S$1.50. 426 patients were studied. Mean length of stay (LOS) was 17 days. Mean cost/discharge was S$7,547. Ward charges accounted for 38.2%, radiology 14.5%, doctors’ fees 10.3%, drugs 8.4%, therapy 7.3%. Cost was highly correlated with LOS, r² = 0.73. Mean cost/discharge was SAH S$28,539, IPH S$14,398, NLC S$7,476, LAC S$3,517, TIA S$1,962. Initial hospitalization cost for stroke is highly correlated with LOS. The bulk of cost is attributable to ward stay. Cost/discharge is highest with SAH, and in descending order IPH, NLC, LAC, TIA.