Multidisciplinary Stroke Unit Research Articles

Abstract WMP7: Bridging Thrombolysis For Large Vessel Occlusion: Who Benefits Most? Analysis Of A Prospective Endovascular Therapy Registry

Introduction: Recent meta-analytic evidence supported efficacy and safety of bridging intravenous thrombolysis (IVT) prior to endovascular therapy (EVT) for large vessel occlusion (LVO) but large confirmatory trials are still lacking and optimal candidates for treatment have been a topic of contention lately. Objectives: We aimed to determine a cut-off in treatment times that allows identification of those who would benefit most from bridging IVT. Methods: We analyzed prospectively collected data from consecutive LVO patients who underwent EVT at a tertiary stroke center in Germany from 01/2017 to 12/2021. Patients underwent detailed cardiovascular phenotyping, repeated cranial imaging, and received standardized multidisciplinary stroke unit care. Functional outcome was assessed via modified Rankin scale three months after discharge. Ordinary ridge regression models were built to assess the impact of treatment time cut-offs on functional outcome with adjustment for age, sex, cardiovascular risk factors, baseline NIHSS, cerebrovascular territory, ASPECT score, stroke etiology and carotid artery stenting. Results: Out of 935 patients who had undergone EVT, 170 received bridging IVT (median age 74 [63-82, IQR], 52.4% females), fulfilled our criteria and were included in our analysis. Overall, onset-to-recanalization time but not onset-to-needle time was associated with functional outcome (β1=0.36, 95%CI [0.14,0.58], p=0.001 vs. p=ns). However, those who received EVT with a time delay longer than 190 minutes additionally displayed an association of onset-to-needle time and functional outcome (β1=0.64, 95%CI [0.25,1.04], p=0.02 vs. β2= 2.96, 95%CI [1.32,4.60], p=0.016). Conclusions: Our data indicates that the beneficial effect of swift bridging IVT on functional outcome is most pronounced in cases where initiation of subsequent EVT is substantially delayed.

Improving stroke care in Nova Scotia, Canada: a population-based project spanning 14 years

Stroke is a complex disorder that challenges healthcare systems. An audit of in-hospital stroke care in the province of Nova Scotia, Canada, in 2004–2005 indicated that many aspects of care...

Use of audit, feedback and education increased guideline implementation in a multidisciplinary stroke unit

BackgroundThe audit-feedback cycle is a behaviour change intervention used to reduce evidence-practice gaps. In this study, repeat audits, feedback, education and training were used to change practice and increase compliance...

Beneficial Effects of Implementing Stroke Protocols Require Establishment of a Geographically Distinct Unit.

Usefulness of multidisciplinary stroke units in acute stroke patients is well established. There is extensive western literature on usefulness of stroke units in outcome, but limited evidence from the rest of the world. We aim to evaluate the impact of establishing a stroke unit on outcome in patients presenting to a tertiary care facility. This is a retrospective study of 1003 patients with acute stroke admitted to Hamad General Hospital, Qatar, between January 2014 and February 2015. Patients directly admitted to intensive care unit (132) were excluded. We compared outcomes of pre- and poststroke ward (SW) establishment and in SW patients versus those of general medical wards. Before the establishment of the SW, 175 patients were admitted to the hospital. From April 2014 to February 2015, 696 patients were admitted (SW, 545; medical ward, 151). There was a significant reduction in length of stay from 14.7±27.7 to 6.2±20.2 days (P=0.0001) and incidence of complications (23.6% versus 6.4%, P=0.0001) after implementation of stroke-specific protocols. Prognosis at discharge (modified Rankin Scale 0-2 in 56.0% versus 70.4%, P=0.001) and at 90 days (modified Rankin Scale 0-2 in 70.6% versus 95.0%, P=0.001) also significantly improved. Compared with medical ward patients, outcome was significantly better in SW patients with fewer complications (10.9% versus 5.0%, P=0.013) and shorter length of stay (8.9±30.7 versus 5.4±16.1 days, P=0.05). Establishing a distinct SW is essential for achieving full benefits of stroke protocols implementation. SW patients have significantly fewer complications and better prognosis when compared with patients in medical wards.

Understanding nursing practice in stroke units: a Q-methodological study

Purpose: Nurses represent the largest professional group working with stroke-survivors, but there is limited evidence regarding nurses’ involvement in post-stroke rehabilitation. The purpose of this study was to identify and explore the perspectives of nurses and other multidisciplinary stroke team members on nurses’ practice in stroke rehabilitation. Method: Q-methodological study with 63 multidisciplinary stroke unit team members and semi-structured interviews with 27 stroke unit team members. Results: Irrespective of their professional backgrounds, participants shared the view that nurses can make an active contribution to stroke rehabilitation and integrate rehabilitation principles in routine practice. Training in stroke rehabilitation skills was viewed as fundamental to effective stroke care, but nurses do not routinely receive such training. The view that integrating rehabilitation techniques can only occur when nursing staffing levels were high was rejected. There was also little support for the view that nurses are uniquely placed to co-ordinate care, or that nurses have an independent rehabilitation role. Conclusions: The contribution that nurses with stroke rehabilitation skills can make to effective stroke care was understood. However, realising the potential of nurses as full partners in stroke rehabilitation is unlikely to occur without introduction of structured competency-based multidisciplinary training in rehabilitation skills.Implications for RehabilitationMultidisciplinary rehabilitation in stroke units is a cornerstone of effective stroke care.Views of stroke unit team members on nurses’ involvement in rehabilitation have not been reported previously.Nurses can routinely incorporate rehabilitation principles in their care.Specialist competency-based stroke rehabilitation training needs to be provided for nurses as well as for allied health professionals.

Preferences, barriers and facilitators for establishing comprehensive stroke units: a multidisciplinary survey

To determine the preferences of multidisciplinary stroke clinicians for models of inpatient stroke unit care and perceived barriers to establishing a comprehensive stroke unit (CSU) model (acute and rehabilitation care in the same ward). Written questionnaires distributed and completed at multidisciplinary stroke unit case conferences in NSW, Australia. Twenty hospitals with 22 stroke units were surveyed, 13 acute stroke units, 7 rehabilitation stroke units, 2 CSUs. Two hundred and twenty-eight respondents: 99 (43.4%) allied health, 72 (31.6%) nurses and 57 (25.0%) doctors. One hundred and fifty-one respondents (67.0%) thought CSU to be the best model. Seventy-three % of doctors and 79% of allied health preferred CSU v. 57% of nurses (P=0.041). Of doctors, rehabilitation specialists were most likely to favour comprehensive model (84.2%) and neurologists least (57.0%). The main perceived advantages of CSU were reduced cost and improved functional outcomes; perceived disadvantages were increased workload and unwell patients unable to participate in rehabilitation. Main perceived barriers to establishing CSU were lack of space, money, staffing and time. Although most current stroke unit care in NSW is based on the traditional model of acute and rehabilitation components in separate wards or hospitals, the majority of multidisciplinary stroke team clinicians believe CSU is the optimum model. What is known about the topic? Stroke unit care is known to improve survival and dependency but the optimum model of care is unproven, despite some small studies suggesting that the CSU model may result in better outcomes. What does this paper add? This paper is the first to survey stroke clinicians from various disciplines and types of unit, to determine their preferences for stroke unit model. What are the implications for practitioners? A majority of clinicians expressed a preference for the CSU model, suggesting that most would be comfortable caring for patients in both acute and rehabilitation phases of stroke care if further such units are established.

Stress of caring and nurses' beliefs in the stroke rehabilitation environment: a cross-sectional study

Background: Part of the multidisciplinary stroke unit team nurses report their role as complex and demanding. Aims: To explore stress of caring in nursing nurses'and its relationship with perception of the work environment and beliefs about stroke. Methods: This cross sectional study recruited a convenience sample of nursing staff from stroke units (n=44), 99% female; mean age 39 years (s.d. 9.6). The Stress of Caring Scale (SCS) and an adapted Illness Perception Questionnaire (IPQ-R: HP) were completed. The responses on the IPQ-R: HP were compared to stroke survivors (n=106) responses to the original IPQ-R completed in an earlier study. Results: Nurses' stress was positively correlated with perceptions of demand, strain and effort, and reward imbalance (P<.001) and negatively correlated with decisional control and helpfulness of support (P<05). Nurses believed stroke to incur greater symptoms, consequences, emotional impact, and a longer duration (P<.01) and that the patient's role and their treatment (P<.05) to be less salient than stroke survivors. Stress of caring was associated with the nurses’ beliefs about stroke (P<.05). Conclusions: Work environment and discrepancies between patients' and nurses’ beliefs may account for perceived stress and possibly impact on the nurse's role in rehabilitation.

South African guideline for management of ischaemic stroke and transient ischaemic attack 2010: A guideline from the South African Stroke Society (SASS) and the SASS Writing Committee

Stroke is a leading cause of death and disability in South Africa. An increase in the burden of stroke is predicted as the population is undergoing a rapid epidemiological transition with increased exposure to, and development of, stroke risk factors, together with aging of the population. Objective. The objective was to update the guideline published in 2000, to place the recommendations within the current South African context, and to grade evidence according to the level of scientific rigour. Ideally, all patients with acute stroke should be managed in a dedicated stroke unit. There is ample evidence that protocol-driven multidisciplinary stroke unit care within a hospital improves recovery from stroke. Treatment in a stroke unit has been shown to reduce mortality as well as reduce the likelihood of dependency after stroke. An effective stroke service requires the establishment of a seamless network consisting of acute stroke units, post-acute care and rehabilitation, and further care in the community. Primary preventive measures reduce stroke incidence and should be universally available and actively promoted at all levels of health care in South Africa. Successful care of a stroke patient begins with recognition by the public and health professionals that stroke should be considered an emergency. Avoiding delay should be the major aim of the prehospital phase of acute stroke care. Acute stroke or transient ischaemic attack (TIA) should be treated as a medical emergency and evaluated with minimum delay. General supportive treatment is emphasised and is directed at maintaining homeostasis and the treatment of complications. Intravenous thrombolytic therapy with recombinant tissue plasminogen activator (tPA) is an accepted therapy for acute ischaemic stroke within 4.5 hours of onset of symptoms, but can only be administered at centres with specific resources. Awareness and treatment of the neurological and systemic complications of acute stroke are an integral part of management. Patients with suspected TIA and minor stroke with early spontaneous recovery should be evaluated as soon as possible after an event. Brain imaging is recommended, and non-invasive imaging of the cervicocephalic vessels should be performed urgently and routinely as part of the evaluation. Carotid endarterectomy (CEA) is recommended for patients with severe (70 - 99%) ipsilateral stenosis, and the procedure should be performed as soon as possible after the last ischaemic event - ideally within 2 weeks - in centres with a peri-operative complication rate (all strokes and death) of less than 6%. Survivors of a TIA or stroke have an increased risk of another stroke, which is a major source of increased mortality and morbidity. Secondary prevention strategies are aimed at reducing this risk. Stroke rehabilitation is a goal-orientated process that attempts to obtain maximum function in patients who have had strokes and who suffer from a combination of physical, cognitive and language disabilities.

Development of Stroke Performance Measures

In the United States and elsewhere, stroke performance measures have been developed to monitor and improve the quality of care. The process by which these measures are developed, implemented, and evaluated is complex, evolving, and not widely understood. We review the methodological development of stroke performance measures in the United States. A literature search identified articles that addressed the development and endorsement of performance measures for stroke care. Emphasis was given to articles specific to acute stroke, but when these were lacking, other cardiovascular diseases were included. Ten process-based performance measures relevant to acute hospital-based stroke care have now been developed and endorsed. These measures include intravenous thrombolysis, deep vein thrombosis prophylaxis, dysphagia screening, stroke education, and discharge-related medications and assessments. There are currently at least 5 major US-based stroke quality improvement programs implementing stroke measures. Data indicate that rapid improvements in the quality of stroke care can be induced by the systematic collection and evaluation of stroke performance measures. However, current stroke measures are relatively limited, addressing only inpatient care and mostly patients with ischemic stroke. Stroke quality improvement is still in its early stages, but data suggest that large-scale improvements in stroke care can result from the implementation of stroke performance measures. Performance measures that address multidisciplinary stroke unit care, outpatient-based care, and patient-oriented outcomes such as functional recovery should be considered. Ongoing challenges relevant to stroke quality improvement include the role of public reporting and the need to link better stroke care to improved patient outcomes.

Does Multidisciplinary Stroke Care Improve Outcome in A Secondary-Level Hospital in South Africa?

The improved outcome (survival and function) of stroke patients admitted to multidisciplinary stroke units (SU) in developed countries has not been replicated in developing countries in sub-Saharan Africa. This study documents the outcome of patients admitted to the first multidisciplinary SU opened at a secondary hospital in Cape Town, South Africa. Patient outcomes including in-hospital mortality, resource utilization (length of hospital stay, CT brain scans performed, and tertiary hospital referral), and access to inpatient rehabilitation were recorded for all patients admitted to the hospital for 3 months before initiating multidisciplinary stroke care and for 3 months after implementing multidisciplinary stroke care. One hundred and ninety-five patients were studied; 101 of these were managed in the SU. Inpatient mortality decreased from 33% to 16% after initiating multidisciplinary stroke care (P=0.005). The length of hospital stay increased from a mean (SD, 95% CI) of 5.1 (6.5, 3.8-6.4) days to 6.8 (4.5, 5.9-7.6) days (P=0.01). Referral to inpatient rehabilitation increased from 5% to 19% (P=0.04) for those who survived to discharge. The number of CT brain scans performed and the number of referrals to the tertiary academic hospital did not increase significantly. Multidisciplinary stroke care was successfully implemented in a resource-constrained secondary-level hospital in South Africa and despite the limitations of the study, the significant reduction in inpatient mortality and increase in referral for inpatient rehabilitation would suggest an improvement in stroke care. Resource utilization in terms of length of hospital stay increased by a mean of 2 days but the number of CT brain scans performed and referral to a tertiary hospital did not increase significantly.

Impact of a Stroke Unit on Length of Hospital Stay and In-Hospital Case Fatality

Randomized trials have demonstrated reduced morbidity and mortality with stroke unit care; however, the effect on length of stay, and hence the economic benefit, is less well-defined. In 2001, a multidisciplinary stroke unit was opened at our institution. We observed whether a stroke unit reduces length of stay and in-hospital case fatality when compared to admission to a general neurology/medical ward. A retrospective study of 2 cohorts in the Foothills Medical Center in Calgary was conducted using administrative databases. We compared a cohort of stroke patients managed on general neurology/medical wards before 2001, with a similar cohort of stroke patients managed on a stroke unit after 2003. The length of stay was dichotomized after being centered to 7 days and the Charlson Index was dichotomized for analysis. Multivariable logistic regression was used to compare the length of stay and case fatality in 2 cohorts, adjusted for age, gender, and patient comorbid conditions defined by the Charlson Index. Average length of stay for patients on a stroke unit (n=2461) was 15 days vs 19 days for patients managed on general neurology/medical wards (n=1567). The proportion of patients with length of stay >7 days on general neurology/medical wards was 53.8% vs 44.4% on the stroke unit (difference 9.4%; P<0.0001). The adjusted odds of a length of stay >7 days was reduced by 30% (P<0.0001) on a stroke unit compared to general neurology/medical wards. Overall in-hospital case fatality was reduced by 4.5% with stroke unit care. We observed a reduced length of stay and reduced in-hospital case-fatality in a stroke unit compared to general neurology/medical wards.

Techniques in carotid artery surgery

The major objective in carotid endarterectomy is to achieve safe and complete removal of intimal plaque and provide lasting, nonstenotic closure. Controversy exists as to which technical variation best achieves this. In this paper, the authors review the operative nuances and outcomes with conventional and eversion endarterectomy, with a focus on the latter. The views expressed reflect specific neurosurgical and vascular perspectives in the context of a multi-disciplinary stroke unit, where carotid stenosis is managed with all available open and endovascular means. The neurosurgical approach was almost entirely conventional endarterectomy with primary repair, while the vascular surgeons used the eversion method with few exceptions.

Neurorehabilitation nach Hirnschlag

Summary Neurorehabilitation after stroke Stroke is one of the commonest causes of long-term disability. Multidisciplinary management in a stroke unit or by a stroke team has beenshown to improve the outcome significantly. In the setting of a multidisciplinary stroke unit, neurorehabilitation con-tributes decisively to optimising recovery and a favourable long-term outcome. Neurorehabilitative treatment should be administered in a multidisciplinarymanner on a specialised rehabilitation ward by a team skilled in stroke reha-bilitation. Clinical studies indicate that an early start to treatment and highly inten-sive therapy are decisive for a favourable long-term outcome. There is no evidence to support immobilisation of all stroke patients for several days, except for unstable subjects with critical cerebral perfusion. 1 Bitte beachten Sie dazu ebenfalls den Artikel Neurorehabilitation nach Hirnschlag – Alter ist kein limitierender Faktor in der «Schweizerischen Arztezeitung», Heft 12/2007.

Treatment of stroke in older patients. A state of the art review.

The treatment of stroke in older patients is the rule rather than the exception in most parts of the world. Thus, an understanding of the effects of aging on pharmacological aspects of treatment, recovery and rehabilitation is very important. A considerable amount of work has now been completed looking for therapeutic interventions that might ameliorate the effects of stroke disease. Sadly, none has yet proved to be effective, but much is still awaited. In contrast, recent work has clarified the place of treatment in stroke prevention, particularly in hypertension and atrial fibrillation, which should help reduce the burden of stroke disease. In addition, it is now clear that well organised stroke care can dramatically reduce mortality and disability. The state of art in stroke treatment is now encapsulated in the multidisciplinary stroke unit and well coordinated hospital and community care.