Integrated Stroke Care Research Articles

Integrated stroke care: providing tools for the evaluation of different parts of the care pathway – A systematic literature search.

Background: Worldwide, Stroke remains the second leading cause of death and the third leading cause of disability. Adequate treatment of stroke is key in the reduction of mortality and morbidity. Management of acute ischemic stroke implicates an evidence-based and multidisciplinary approach. However, integrated care and evaluation of this care process is still a major concern for healthcare professionals, managers, researchers and policymakers in many European countries. Currently, there is an abundance of guidelines describing the care for patients with ischemic stroke. The purpose of these guidelines is offering an easy way of access to evidence-based recommendations, to guide ischemic stroke care planning and delivery across the continuum of care. But it remains difficult to translate the enormous amount of recommendations into care pathways that can be used for patients with ischemic stroke.
 Aim and target audience: We aim to aid healthcare professionals in developing and evaluating care pathways for patients with ischemic stroke by giving them an overview of the most important recommendations and quality indicators for the different parts of the stroke care process.
 Materials and Methods: A systematic literature search was conducted in PubMed, from 2014 up to May 2021. The search string was designed on the basis of Medical Subject Heading (MeSH) terms. These included “ischemic stroke” and “guideline” and included all relevant synonyms of these terms. Papers were included if they described the entire care process from admission to the emergency department until discharge from a neuro-related ward. In total, 18 papers were included in this systematic review.
 Results: In total, 50 recommendations were extracted from the included papers. These recommendations could be divided into four clinical categories: 6 recommendations were subdivided into diagnostic recommendations, 7 into therapeutic, 26 recommendations are part of nursing care, 8 of post stroke rehabilitation and 5 structural recommendations were identified. Administration of thrombolysis was the most common used recommendation (16/18), followed by imaging via CT-scan (15/18), management of glucose (15/18) and blood pressure (15/18) and performing thrombectomy (15/18). The least frequently mentioned recommendations are: differential diagnosis, seizures assessment, early carotid imaging, advanced care planning, treatment of concomitant diseases and tobacco use counselling. They were each mentioned in only one of the 18 included papers. As there is currently a lot of variation on indicator definitions in the literature, making uniform comparisons difficult, we formulated indicator definitions for the most important recommendations. And in addition, we provide information on the validity, feasibility and actionability of these indicators in clinical practice.
 Practice implications: Our systematic literature search provides tools for healthcare professionals when they want to evaluate their entire or a part of the care pathway for patients with ischemic stroke. Furthermore, we provide an answer to the current variation in indicators for the evaluation of the stroke care process.
 Next steps: Future research can evaluate whether these recommendations and accompanying indicators are useful in practice and can identify which indicators are most important in stroke care pathways.

A Qualitative Study of Patients’ Perspectives regarding Digital Health Technology to Support Self-management and to Improve Integrated Stroke Care: The ValueCare study.

Background: Digital technologies, such as mobile apps and robotics, provide opportunities to involve stroke patients better in the care process and to promote self-management. Previous pilot studies suggest that technology could be a meaningful tool for post-acute stroke care. However, barriers exists constraining the adoption and acceptance of technology in clinical practice. Examples of barriers are privacy concerns, challenges regarding usability, and the perception that there is no need for technology. Co-design enables patients to reflect on their experiences of a service and to identify improvement priorities. This study uses data from co-design sessions with stroke patients conducted as part of the ValueCare study.
 Objective: The aim of this study is to explore what stroke patients’ perspectives are towards how digital health technology could support self-management regarding health and well-being, and integrated stroke care.
 Methods: A qualitative study was conducted to understand patient perspectives. Data was collected in co-design sessions of the ValueCare study. Patients from a Dutch hospital who experienced an ischemic stroke (n=36) within the past 18 months were invited to participate. Data collection took place between December 2020 and April 2021 via one-to-one telephone interviews. A short self-report questionnaire was used to collect data on socio-demographics, disease-specific information, and technology use. All interviews were audio-taped and transcribed verbatim. The interview data were analyzed using a thematic approach.
 Results: Patients held mixed attitudes towards how digital health technologies could support their self-management and the care they receive. Suggested digital features by stroke patients included (i) an easily accessible online library with relevant information regarding stroke-related health and care issues, (ii) a personal health record (PHR) by which patients can retrieve and manage their own health information, and (iii) a physical exercise module to empower patients to organize rehabilitation support at home. Regarding the user interface of future digital health technology, patients emphasized the need for a very easy-to-use and simple design.
 Conclusions: Stroke patients mentioned easy-to-find and credible health information, a PHR, and online-rehabilitation support as the main features to include in future digital health technologies. We recommend that developers and designers of digital health for stroke care listen to the ‘voice of the stroke patients’, with regard to both functionality and the characteristics of the interface. The findings of this study provide insight in the needs and preferences of stroke patients for using ICT to manage their health and care. These findings serve as touch points that can be explored further in co-design sessions. 
 Keywords: stroke patients, digital health technology, self-management, co-design, user-requirements, user-centered design, qualitative research

Patients' Perspectives Regarding Digital Health Technology to Support Self-management and Improve Integrated Stroke Care: Qualitative Interview Study.

Digital technologies such as mobile apps and robotics have the potential to involve stroke patients better in the care process and to promote self-management. However, barriers exist that constrain the adoption and acceptance of technology in clinical practice. Examples of barriers are privacy concerns, challenges regarding usability, and the perception that there is no need for health-related technology. To address these barriers, co-design can be used to enable patients to reflect on their experiences of a service and to tailor digital technologies to the needs and preferences of end users regarding content and usability. This study aims to explore the perspectives of stroke patients toward how digital health technology could support self-management regarding health and well-being, as well as integrated stroke care. A qualitative study was conducted to understand patient perspectives. Data were collected in co-design sessions during the ValueCare study. Patients from a Dutch hospital who experienced an ischemic stroke (n=36) within the past 18 months were invited to participate. Data collection took place between December 2020 and April 2021 via one-to-one telephone interviews. A short self-report questionnaire was used to collect data on sociodemographics, disease-specific information, and technology use. All interviews were audio-taped and transcribed verbatim. The interview data were analyzed using a thematic approach. Patients held mixed attitudes toward digital health technologies. Some patients viewed digital technology as a convenient product or service, while others expressed no desire or need to use technology for self-management or care. Digital features suggested by stroke patients included (1) information about the causes of stroke, medication, prognosis, and follow-up care; (2) an online library with information regarding stroke-related health and care issues; (3) a personal health record by which patients can retrieve and manage their own health information; and (4) online rehabilitation support to empower patients to exercise at home. Regarding the user interface of future digital health technology, patients emphasized the need for easy-to-use and simple designs. Stroke patients mentioned credible health information, an online library with stroke-related health and care information, a personal health record, and online rehabilitation support as the main features to include in future digital health technologies. We recommend that developers and designers of digital health for stroke care listen to the "voice of the stroke patients" regarding both functionality and the characteristics of the interface. RR2-10.1186/s12877-022-03333-8.

Inhibition of the LRRC8A channel promotes microglia/macrophage phagocytosis and improves outcomes after intracerebral hemorrhagic stroke.

Promoting microglial/macrophage (M/Mφ) phagocytosis accelerates hematoma clearance and improves the prognosis of intracerebral hemorrhagic stroke (ICH). Cation channels such as Piezo1 modulate bacterial clearance by regulating M/Mφ. Whether LRRC8A, an anion channel, affects M/Mφ erythrophagocytosis and functional recovery after ICH was investigated here. We found that LRRC8A is highly expressed on M/Mφ in the perihematomal region of ICH mice. Conditional knockout of Lrrc8a in M/Mφ or treatment with an LRRC8A channel blocker accelerated hematoma clearance, reduced neuronal death, and improved functional recovery after ICH. Mechanistically, the LRRC8A channel inhibition promoted M/Mφ phagocytosis by activating AMP-activated protein kinase (AMPK), thereby inducing nuclear translocation of nuclear factor-erythroid 2 related factor 2 (Nrf2) and increasing Cd36 transcription. Our findings illuminate the regulation of M/Mφ phagocytosis by the LRRC8A channel via the AMPK-Nrf2-CD36 pathway after ICH, suggesting that LRRC8A is a potential target for hematoma clearance in ICH treatment.

Hospital discharge for stroke patients: Transitional Care is Brain

Abstract Background Among cerebrovascular disease, stroke is a life-threatening neurological event and a main cause of serious long-term disability, with relevant healthcare and economic burden. Treatment of stroke is time dependent and organised integrated stroke care enables quick and effective responses to reduce stroke-related death and disability. This study aimed at evaluating the amount of hospital discharge to transitional care facilities for stroke patients to support integrated care models in the city of Pavia (Italy). Methods In 2017 in Pavia, Fondazione IRCCS Policlinico San Matteo started a partnership with Fondazione Mondino to build a specific stroke pathway, becoming a leading centre for stroke treatment. We conducted a retrospective chart review (RCR) of patient-centred data to quantify the volume of discharge for stroke patients. Two trained public health residents reviewed medical records with stroke admission diagnosis during 2021, analysing onset (e.g., Emergency Room, other hospital, emergency network), ward, treatment and discharge types (e.g., home, death, transitional care facility). Results Our RCR found 669 patients with a stroke diagnosis treated at San Matteo hospital in 2021, the vast majority of which were admitted to the neurology ward (375 patients, 56%). The recanalization rate was 32% (150 on 464 ischemic stroke patients). Regarding the discharge type, 299 patients (45%) were sent home, while 297 patients (44%) needed transfer to rehabilitation or long-term care facilities. About 8% (52 patients) of the overall sample died in hospital. Conclusions Our analysis showed that, while most stroke patients were discharged and sent home, more than two-third need to be transferred to continue to get the right healthcare from the right professional. Transitional care facilities should receive the greatest consideration by systems and providers seeking to implement care models to reduce residual neurological disabilities for stroke patients. Key messages • A fast and accessible emergency chain is essential to reduce residual neurological disabilities and the related healthcare and economic burden in stroke patients. • Extending the stroke path model to other time-dependent diseases is increasingly high-priority to shape a strong and resilient healthcare system, ensuring qualified health coverage.

Reconstruction of pseudonymized patient-trajectories in Austria's stroke cohort using medical record-linkage of in-patient routine documentation to establish a nation-wide acute stroke cohort of 102,107 pseudonymized patients between 2015 and 2019.

Administrative health data are increasingly used for disease surveillance, quality assurance and research purposes. In Austria, reporting of a standardized dataset is mandatory for each patient. Routine documentation includes administrative and medical data, including admission and discharge characteristics, disease-diagnosis using ICD-10, medical procedure codes, and coding of involved hospital departments. Since 2015, a three-step pseudonymization on these data is provided including a pseudonym using secure hash algorithm 256, a non-recalculable record-ID, and age-groups of 5 years, allowing the reconstruction of individual patient-trajectories. We included persons aged ⩾20 years with an in-patient treatment in Austrian hospitals for acute stroke or transient ischemic attack (TIA) between 01.01.2015 and 31.12.2019 using medical record-linkage. This totals 102,107 patients (49.3% women) with 107,055 treatment episodes. An ischemic stroke (IS) occurred in 60.9% (n = 65,133), 27.1% (n = 29,019) had a TIA, 3.3% (n = 3488) a subarachnoid hemorrhage, and 8.8% (n = 9415) an intracerebral hemorrhage (ICH). The study period covers 35.2 million person-years at risk, with a hospitalization rate for acute stroke of 221.8 per 100,000 person-years (95% CI 220.2-223.3), and 185.1 per 100,000 person-years (95% CI 183.7-186.5) for IS. Unscheduled re-admissions within 1 year occurred in 29.2% (95% CI 28.8-29.7) after IS, and 41.7% (95% CI 40.0-43.3) after ICH. Recurrent stroke occurred in 5.3% (95% CI 5.1-5.5) after IS, and 5.6% (95% CI 4.9-6.4) after ICH. We present herein the details of a novel methodology to establish a nation-wide unselected Austrian stroke cohort, and to reconstruct pseudonymized individual longitudinal patient-trajectories on a national level. This approach shows potential applications in epidemiological research, quality assessment and outcome measurement. This novel approach opens new research fields, facilitates international comparison, and is needed for national benchmarking to assess the achievement of goals according to the Stroke Action Plan for Europe and augment the quality of Austria's integrated stroke care.

Integrated care for optimizing the management of stroke and associated heart disease: a position paper of the European Society of Cardiology Council on Stroke.

The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient ‘journey’ or ‘patient pathway,’ supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management: A: Appropriate Antithrombotic therapy.B: Better functional and psychological status.C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).

Identification of Stroke and TIA in Patients With Acute Dizziness, Vertigo or Imbalance in Emergency Departments of Primary Care Hospitals: Early Experiences With a Network-Based Telemedical Approach.

BackgroundAcute dizziness, vertigo, and imbalance are frequent and difficult to interpret symptoms in the emergency department (ED). Primary care hospitals often lack the expertise to identify stroke or TIA as underlying causes. A telemedical approach based on telestroke networks may offer adequate diagnostics and treatment.AimThe aim of this study is to evaluate the accuracy of a novel ED algorithm in differentiating between peripheral and central vestibular causes.MethodsWithin the Telemedical Project for Integrative Stroke Care (TEMPiS), a telemedical application including a videooculography (VOG) system was introduced in 2018 in 19 primary care spoke hospitals. An ED triage algorithm was established for all patients with acute dizziness, vertigo, or imbalance of unknown cause (ADVIUC) as a leading complaint. In three predefined months, all ADVIUC cases were prospectively registered and discharge letters analyzed. Accuracy of the ED triage algorithm in differentiation between central and peripheral vestibular cases was analyzed by comparison of ED diagnoses to final discharge diagnoses. The rate of missed strokes was calculated in relation to all cases with a suitable brain imaging. Acceptance of teleconsultants and physicians in spoke hospitals was assessed by surveys.ResultsA total number of 388 ADVIUC cases were collected, with a median of 12 cases per months and hospital (IQR 8–14.5). The most frequent hospital discharge diagnoses are vestibular neuritis (22%), stroke/TIA (18%), benign paroxysmal positioning vertigo (18%), and dizziness due to internal medicine causes (15%). Detection of a central vestibular cause by the ED triage algorithm has a high sensitivity (98.6%), albeit poor specificity (45.9%). One stroke out of 32 verified by brain scan was missed (3.1%). User satisfaction, helpfulness of the project, improvement of care, personal competence, and satisfaction about handling of the VOG systems were rated consistently positive.DiscussionThe concept shows good acceptance for a telemedical and network-based approach to manage ADVIUC cases in the ED of primary care hospitals. Identification of stroke cases is accurate, while specificity needs further improvement. The concept could be a major step toward a broadly available state of the art diagnostics and therapy for patients with ADVIUC in primary care hospitals.

Feasibility of Telemedical HINTS (Head Impulse-Nystagmus-Test of Skew) Evaluation in Patients With Acute Dizziness or Vertigo in the Emergency Department of Primary Care Hospitals.

BackgroundAcute dizziness, vertigo and imbalance are common symptoms in emergency departments. Stroke needs to be distinguished from vestibular diseases. A battery of three clinical bedside tests (HINTS: Head Impulse Test, Nystagmus, Test of Skew) has been shown to detect stroke as underlying cause with high reliability, but implementation is challenging in primary care hospitals. Aim of this study is to prove the feasibility of a telemedical HINTS examination via a remotely controlled videooculography (VOG) system.MethodsThe existing video system of our telestroke network TEMPiS (Telemedic Project for Integrative Stroke Care) was expanded through a VOG system. This feature enables the remote teleneurologist to assess a telemedical HINTS examination based on inspection of eye movements and quantitative video head impulse test (vHIT) evaluation. ED doctors in 11 spoke hospitals were trained in performing vHIT, nystagmus detection and alternating cover test. Patients with first time acute dizziness, vertigo or imbalance, whether ongoing or resolved, presented to the teleneurologist were included in the analysis, as long as no focal neurological deficit according to the standard teleneurological examination or obvious internal medicine cause was present and a fully trained team was available. Primary outcome was defined as the feasibility of the telemedical HINTS examination.ResultsFrom 01.06.2019 to 31.03.2020, 81 consecutive patients were included. In 72 (88.9%) cases the telemedical HINTS examination was performed. The complete telemedical HINTS examination was feasible in 46 cases (63.9%), nystagmus detection in all cases (100%) and alternating covert test in 70 cases (97.2%). The vHIT was recorded and interpretable in 47 cases (65.3%). Results of the examination with the VOG system yielded clear results in 21 cases (45.7%) with 14 central and 7 peripheral lesions. The main reason for incomplete examination was the insufficient generation of head impulses.ConclusionIn our analysis the telemedical HINTS examination within a telestroke network was feasible in two thirds of the patients. This offers the opportunity to improve specific diagnostics and therapy for patients with acute dizziness and vertigo even in primary care hospitals. Improved training for spoke hospital staff is needed to further increase the feasibility of vHIT.

Auditing integrated stroke care to support quality improvement activities: development of a peer-to-peer audit framework

PurposeTo organize stroke care, multiple stakeholders work closely together in integrated stroke care services (ISCS). However, even a well-developed integrated care program needs a continuous quality improvement (CQI) cycle. The current paper aims to describe the development of a unique peer-to-peer audit framework, the development model for integrated care (DMIC), the Dutch stroke care standard and benchmark indicators for stroke.Design/methodology/approachA group of experts was brought together in 2016 to discuss the aims and principles of a national audit framework. The steering group quality assurance (SGQA) consisted of representatives of a diversity of professions in the field of stroke care in the Netherlands, including managers, nurses, medical specialists and paramedics.FindingsAuditors, coordinators and professionals evaluated the framework, agreed on that the framework was easy to use and valued the interesting and enjoyable audits, the compliments, feedback and fruitful insights. Participants consider that a quality label may help to overcome necessity issues and have health care insurers on board. Finally, a structured improvement plan after the audit is needed.Originality/valueAn audit offers fruitful insights into the functioning of an ISCS and the collaboration therein. Best practices and points of improvement are revealed and can fuel collaboration and the development of partnerships. Innovative cure and care may lead to an increasing area of support among professionals in the ISCS and consequently lead to improved quality of delivered stroke care.

Optimising Integrated Stroke Care in Regional Networks: A Nationwide Self-Assessment Study in 2012, 2015 and 2019.

Background:To help enhance the quality of integrated stroke care delivery, regional stroke services networks in the Netherlands participated in a self-assessment study in 2012, 2015 and 2019.Methods:Coordinators of the regional stroke services networks filled out an online self-assessment questionnaire in 2012, 2015 and 2019. The questionnaire, which was based on the Development Model for Integrated Care, consisted of 97 questions in nine clusters (themes). Cluster scores were calculated as proportions of the activities implemented. Associations between clusters and features of stroke services were assessed by regression analysis.Results:The response rate varied from 93.1% (2012) to 85.5% (2019). Over the years, the regional stroke services networks increased in ‘size’: the median number of organisations involved and the volume of patients per network increased (7 and 499 in 2019, compared to 5 and 364 in 2012). At the same time, fewer coordinators were appointed for more than 1 day a week in 2019 (35.1%) compared to 2012 (45.9%). Between 2012 and 2019, there were statistically significantly more elements implemented in four out of nine clusters: ‘Transparent entrepreneurship’ (MD = 18.0% F(1) = 10.693, p = 0.001), ‘Roles and tasks’ (MD = 14.0% F(1) = 9.255, p = 0.003), ‘Patient-centeredness’ (MD = 12.9% F(1) = 9.255, p = 0.003), and ‘Commitment’ (MD = 11.2%, F(1) = 4.982, p = 0.028). A statistically significant positive correlation was found for all clusters between implementation of activities and age of the network. In addition, the number of involved organisations is associated with better execution of implemented activities for ‘Transparent entrepreneurship’, ‘Result-focused learning’ and ‘Quality of care’. Conversely, there are small but negative associations between the volume of patients and implementation rates for ‘Interprofessional teamwork’ and ‘Patient-centredness’.Conclusion:This long-term analyses of stroke service development in the Netherlands, showed that between 2012 and 2019, integrated care activities within the regional stroke networks increased. Experience in collaboration between organisations within a network benefits the uptake of integrated care activities.

Perceived challenges in delivering comprehensive care for patients following stroke: a qualitative study of stroke care providers in Guangdong Province, China

Purpose To understand the challenges in delivering comprehensive care for patients recovering from stroke in Guangdong Province, China. Methods A cross-sectional qualitative study was conducted in two tertiary hospitals with different socio-economic characteristics in Guangdong Province, Southern China. Interviews were conducted with 16 stroke care providers including doctors, nurses, rehabilitation therapists and care workers. The interviews were audiotaped, transcribed and translated from Mandarin to English. Thematic analysis was used to draw out descriptive and analytical themes relating to care providers’ experiences of existing routine stroke care services and the perceptions of challenges in delivering comprehensive stroke care. Results The interviews with stroke care providers highlighted three key factors that hinder the capacity of the two hospitals to deliver comprehensive stroke care. First, expertise and knowledge regarding stroke and stroke care are lacking among both providers and patients; second, stroke care systems are not fully integrated, with inadequate coordination of the stroke team and inconsistency in care following discharge of stroke patients; third, stroke patients have insufficient social support. Conclusions While comprehensive stroke care has become a priority in China, our study highlights some important gaps in the current provision of stroke care. IMPLICATIONS FOR REHABILITATION Comprehensive integrated stroke care is essential to maximize the effectiveness of stroke services and in China it needs to be further improved. Multidisciplinary stroke care systems should strengthen collaborations across all relevant disciplines and should include a clear role for registered nurses. Follow-up care after discharge needs more engagement with family caregivers.

Implementation of Best Practices—Developing and Optimizing Regional Systems of Stroke Care: Design and Methodology

The AHA Guidelines recommend developing multi-tiered systems for the care of patients with acute stroke.1 An ideal stroke system of care should ensure that all patients receive the most efficient and timely care, regardless of how they first enter or access the medical care system. Coordination among the components of a stroke system is the most challenging but most essential aspect of any system of care.The Implementation of Best Practices For Acute Stroke Care—Developing and Optimizing Regional Systems of Stroke Care (IMPROVE Stroke Care) project, is designed to implement existing guidelines and systematically improve the acute stroke system of care in the Southeastern United States. Project participation includes 9 hub hospitals, approximately 80 spoke hospitals, numerous pre-hospital agencies (911, fire, and emergency medical services) and communities within the region. The goal of the IMPROVE Stroke program is to develop a regional integrated stroke care system that identifies, classifies, and treats acute ischemic stroke patients more rapidly and effectively with reperfusion therapy. The project will identify gaps and barriers to implementation of stroke systems of care, leverage existing resources within the regions, aid in designing strategies to improve care processes, bring regional representatives together to agree on and implement best practices, protocols, and plans based on guidelines, and establish methods to monitor quality of care. The impact of implementation of stroke systems of care on mortality and long-term functional outcomes will be measured.

Improvement of shared decision making in integrated stroke care: a before and after evaluation using a questionnaire survey

BackgroundShared decision making (SDM) is at the core of policy measures for making healthcare person-centred. However, the context-sensitive nature of the challenges in integrated stroke care calls for research to facilitate its implementation. This before and after evaluation study identifies factors for implementation and concludes with key recommendations for adoption.MethodsData were collected at the start and end of an implementation programme in five stroke services (December 2017 to July 2018). The SDM implementation programme consisted of training for healthcare professionals (HCPs), tailored support, development of decision aids and a social map of local stroke care. Participating HCPs were included in the evaluation study: A questionnaire was sent to 25 HCPs at baseline, followed by 11 in-depth interviews. Data analysis was based on theoretical models for implementation and 51 statements were formulated as a result. Finally, all HCPs were asked to validate and to quantify these statements and to formulate recommendations for further adoption.ResultsThe majority of respondents said that training of all HCPs is essential. Feedback on consultation and peer observation are considered to help improve performance. In addition, HCPs stated that SDM should also be embedded in multidisciplinary meetings, whereas implementation in the organisation could be facilitated by appointed ambassadors. Time was not seen as an inhibiting factor. According to HCPs, negotiating patients’ treatment decisions improves adherence to therapy. Despite possible cognitive or communications issues, all are convinced patients with stroke can be involved in a SDM-process. Relatives play an important role too in the further adoption of SDM. HCPs provided eight recommendations for adoption of SDM in integrated stroke care.ConclusionsHCPs in our study indicated it is feasible to implement SDM in integrated stroke care and several well-known implementation activities could improve SDM in stroke care. Special attention should be given to the following activities: (1) the appointment of knowledge brokers, (2) agreements between HCPs on roles and responsibilities for specific decision points in the integrated stroke care chain and (3) the timely investigation of patient’s preferences in the care process – preferably before starting treatment through discussions in a multidisciplinary meeting.

Do Integrated Sysyems of Stroke Care Improve Symptom to Surgery Times in Patients with Symptomatic Carotid Stenosis? A Decision Tree Analysis

Introduction - The objective of this study was to examine the impact of integrated systems of stroke care on symptom to surgery times, cost effectiveness and quality of life measures in patients with symptomatic carotid stenosis. Methods - Patients who underwent carotid endarterectomy in a regional vascular centre between 1st of April 2011 and 31st of March 2016 were identified from NVR. Risk of stroke on medical therapy for each patient was calculated using the Oxford stroke risk calculator. Symptom to surgery times were compared between patients referred from a stroke service providing an integrated stroke care and the stroke service in an adjacent NHS trust which provides standard urgent referral pathway. A decision-analytic Markov process model was constructed to determine the cost-effectiveness of CEA versus medical treatment in patients who followed the standard and integrated pathways. This model examined the lifetime costs and health benefits of carotid endarterectomy through each pathway. Results - 376 patients underwent carotid endarterectomy of whom, 243 were managed through the integrated stroke pathway and 133 through standard urgent referral pathway. Median symptom to surgery time was 11(0-66) days for the former and 15(3-90) days for the latter (P<0.001). Overall 30-day stroke-death rate was 1.87%. CEA through the integrated pathway improved quality adjusted life expectancy by an additional 0.13 [0.64 QALYs (Integrated pathway) to 0.51 QALYs (standard pathway)], as well as being associated with an incremental lifetime cost benefit of £2,203.4. Conclusion - Integrated stroke systems of care are cost effective and associated with significant improvements in quality adjusted life years.

The stroke pathway: an integrated approach to health care of stroke patients.

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)

Do Integrated Systems of Stroke Care Improve Symptom to Surgery Times in Patients with Symptomatic Carotid Stenosis? A Single Centre Decision Tree Analysis

The objective of this study was to examine the impact of an integrated system of stroke care on symptom to surgery times, cost-effectiveness, and quality of life measures in patients with symptomatic carotid stenosis. Patients who underwent carotid endarterectomy (CEA) in a regional vascular centre between April 1, 2011, and March 31, 2016, were identified from the National Vascular Registry (NVR). Risk of stroke on medical therapy for each patient was calculated using the Oxford stroke risk calculator. Symptom to surgery times were compared among patients referred from a stroke service providing an integrated stroke care and the stroke service in an adjacent NHS trust which provides standard urgent referral pathway. A decision analytic Markov process model was constructed to determine the cost-effectiveness of CEA versus medical treatment in patients who followed the standard and integrated pathways. This model examined the lifetime costs and health benefits of CEA through each pathway. A total of 376 patients underwent CEA, of whom 243 were managed through the integrated stroke pathway and 133 through the standard urgent referral pathway. Median symptom to surgery time was 11 (0-66) days for the former and 15 (3-90) days for the latter (p<.001). There was no significant difference in peri-operative stroke death rate between integrated (2.1%) and standard (1.5%) pathways (chi-square=0.14, p=.73). CEA through the integrated pathway improved quality adjusted life expectancy by an additional 0.13 (0.64 QALYs [integrated pathway] to 0.51 QALYs [standard pathway]) and was associated with an incremental lifetime cost benefit of £2203.4. An integrated stroke system of care is cost-effective and associated with significant improvements in quality adjusted life years.

Stroke : Highlights of Selected Articles

<i>Stroke</i> : Highlights of Selected Articles

Incorporating Nonphysician Stroke Specialists Into the Stroke Team.

Stroke care is team-based care, but trainees in neurology programs may have little experience in working directly with stroke specialists from other disciplines. Outside of an intensive care unit, nurses and physicians rarely round as a team, and stroke neurologists often have few interactions with prehospital care providers besides a quick handoff in the emergency room. However, nonphysician stroke specialists bring a broad base of expertise which overlaps with and complements the stroke neurologist’s knowledge. Increasingly, integrated stroke care is being provided by multidisciplinary teams. Team structures may vary from hospital to hospital and country to country, but often include integration of emergency medical services (EMS; particularly where mobile stroke treatment units are used); specialized nurses and nurse practitioners (NPs); and specialized therapy teams including speech and language pathologists, occupational therapists, and physical therapists with particular expertise in poststroke care. The stroke chain of survival begins with the 911 call, yet even high-level paramedics receive little formal stroke training outside of standard Advanced Cardiac Life Support protocols. EMS providers are often the first point of contact for the stroke patient and have the opportunity to collect vital information about timing of symptoms and medication use. First responders to stroke 911 calls may be Basic Life Support or Advanced Cardiac Life Support level. EMS providers should be familiar with validated prehospital stroke scales such as the Cincinnati Prehospital Stroke Scale.1 EMS providers who have more experience with stroke, such as paramedics who staff mobile stroke treatment units, find stroke to be an exciting field because of the time-critical nature of the treatment. Therefore, it is imperative that stroke neurologists reach out to EMS providers to offer additional training in stroke care. A basic understanding of stroke syndromes is both fascinating and extremely useful to EMS providers, who are often eager …

Thrombolysis in Postoperative Stroke.

Intravenous thrombolysis (IVT) is beneficial in reducing disability in selected patients with acute ischemic stroke. There are numerous contraindications to IVT. One is recent surgery. The aim of this study was to analyze the safety of IVT in patients with postoperative stroke. Data of consecutive IVT patients from the Telemedical Project for Integrative Stroke Care thrombolysis registry (February 2003 to October 2014; n=4848) were retrospectively searched for keywords indicating preceding surgery. Patients were included if surgery was performed within the last 90 days before stroke. The primary outcome was defined as surgical site hemorrhage. Subgroups with major/minor surgery and recent/nonrecent surgery (within 10 days before IVT) were analyzed separately. One hundred thirty-four patients underwent surgical intervention before IVT. Surgery had been performed recently (days 1-10) in 49 (37%) and nonrecently (days 11-90) in 85 patients (63%). In 86 patients (64%), surgery was classified as major, and in 48 (36%) as minor. Nine patients (7%) developed surgical site hemorrhage after IVT, of whom 4 (3%) were serious, but none was fatal. One fatal bleeding occurred remotely from surgical area. Rate of surgical site hemorrhage was significantly higher in recent than in nonrecent surgery (14.3% versus 2.4%, respectively, odds ratioadjusted 10.73; 95% confidence interval, 1.88-61.27). Difference between patients with major and minor surgeries was less distinct (8.1% and 4.2%, respectively; odds ratioadjusted 4.03; 95% confidence interval, 0.65-25.04). Overall in-hospital mortality was 8.2%. Intracranial hemorrhage occurred in 9.7% and was asymptomatic in all cases. IVT may be administered safely in postoperative patients as off-label use after appropriate risk-benefit assessment. However, bleeding risk in surgical area should be taken into account particularly in patients who have undergone surgery shortly before stroke onset.