Organization Of Stroke Services Research Articles

Challenges and needs in cerebrovascular disease pathway: A qualitative descriptive study from the patients' and healthcare professionals' perspectives.

To understand patients' and healthcare professionals' experiences to improve care in and across different domains of the cerebrovascular disease pathway. A qualitative descriptive study. Semi-structured in-person interviews were conducted among 22 patients diagnosed with acute cerebrovascular disease and 26 healthcare professionals taking care of them in a single tertiary-level hospital from August 2021 to March 2022. Data were analysed using deductive and inductive content analysis. The consolidated criteria for reporting qualitative research was used to ensure reliable reporting. Overall, 19 generic and 79 sub-categories describing perceived challenges with 17 generic and 62 sub-categories describing perceived needs were identified related to primary prevention, organization of stroke services, management of acute stroke, secondary prevention, rehabilitation, evaluation of stroke outcome and quality assessment, and life after stroke. Several challenges and needs were identified in and across the different domains of the cerebrovascular disease pathway. There is a requirement for adequate resources, early initiation of treatment, early diagnostics and recanalization, dedicated rehabilitation services, long-term counselling and support, and impact evaluation of services to improve cerebrovascular disease care. Future research on caregivers', and clinical leadership experiences in and across the cerebrovascular disease pathway is needed to explore the provision of services. The results of this study can be applied by organizations, managers and research for developing and improving services in the cerebrovascular disease pathway. This study identified several patient-related, organizational and logistical needs and challenges, with suggestions for required actions, that can benefit the provision of effective, high-quality cerebrovascular disease care. We have adhered to relevant EQUATOR guidelines with the COREQ reporting method. No patient or public involvement.

Stroke in India: A systematic review of the incidence, prevalence, and case fatality.

BackgroundThe burden of stroke is increasing in India; stroke is now the fourth leading cause of death and the fifth leading cause of disability. Previous research suggests that the incidence of stroke in India ranges between 105 and 152/100,000 people per year. However, there is a paucity of available data and a lack of uniform methods across published studies.AimTo identify high-quality prospective studies reporting the epidemiology of stroke in India.Summary of reviewA search strategy was modified from the Cochrane Stroke Strategy and adapted for a range of bibliographic databases from January 1997 to August 2020. From 7717 identified records, nine studies were selected for inclusion; three population-based registries, a further three population-based registries also using community-based ascertainment and three community-based door-to-door surveys. Studies represented the four cities of Mumbai, Trivandrum, Ludhiana, Kolkata, the state of Punjab, and 12 villages of Baruipur in the state of West Bengal. The total population denominator was 22,479,509 and 11,654 (mean 1294 SD 1710) people were identified with incident stroke. Crude incidence of stroke ranged from 108 to 172/100,000 people per year, crude prevalence from 26 to 757/100,000 people per year, and one-month case fatality rates from 18% to 42%.ConclusionsFurther high-quality evidence is needed across India to guide stroke policy and inform the development and organization of stroke services. Future researchers should consider the World Health Organization STEPwise approach to Surveillance framework, including longitudinal data collection, the inclusion of census population data, and a combination of hospital-registry and comprehensive community ascertainment strategies to ensure complete stroke identification.

Action Plan for Stroke in Europe 2018–2030

Two previous pan-European consensus meetings, the 1995 and 2006 Helsingborg meetings, were convened to review the scientific evidence and the state of current services to identify priorities for research and development and to set targets for the development of stroke care for the decade to follow. Adhering to the same format, the European Stroke Organisation (ESO) prepared a European Stroke Action Plan (ESAP) for the years 2018 to 2030, in cooperation with the Stroke Alliance for Europe (SAFE). The ESAP included seven domains: primary prevention, organisation of stroke services, management of acute stroke, secondary prevention, rehabilitation, evaluation of stroke outcome and quality assessment and life after stroke. Research priorities for translational stroke research were also identified. Documents were prepared by a working group and were open to public comments. The final document was prepared after a workshop in Munich on 21-23 March 2018. Four overarching targets for 2030 were identified: (1) to reduce the absolute number of strokes in Europe by 10%, (2) to treat 90% or more of all patients with stroke in Europe in a dedicated stroke unit as the first level of care, (3) to have national plans for stroke encompassing the entire chain of care, (4) to fully implement national strategies for multisector public health interventions. Overall, 30 targets and 72 research priorities were identified for the seven domains. The ESAP provides a basic road map and sets targets for the implementation of evidence-based preventive actions and stroke services to 2030.

Action Plan for Stroke in Europe 2018-2030.

Two previous pan-European consensus meetings, the 1995 and 2006 Helsingborg meetings, were convened to review the scientific evidence and the state of current services to identify priorities for research and development and to set targets for the development of stroke care for the decade to follow. Adhering to the same format, the European Stroke Organisation (ESO) prepared a European Stroke Action Plan (ESAP) for the years 2018 to 2030, in cooperation with the Stroke Alliance for Europe (SAFE). The ESAP included seven domains: primary prevention, organisation of stroke services, management of acute stroke, secondary prevention, rehabilitation, evaluation of stroke outcome and quality assessment and life after stroke. Research priorities for translational stroke research were also identified. Documents were prepared by a working group and were open to public comments. The final document was prepared after a workshop in Munich on 21–23 March 2018. Four overarching targets for 2030 were identified: (1) to reduce the absolute number of strokes in Europe by 10%, (2) to treat 90% or more of all patients with stroke in Europe in a dedicated stroke unit as the first level of care, (3) to have national plans for stroke encompassing the entire chain of care, (4) to fully implement national strategies for multisector public health interventions. Overall, 30 targets and 72 research priorities were identified for the seven domains. The ESAP provides a basic road map and sets targets for the implementation of evidence-based preventive actions and stroke services to 2030.

Nursing care for stroke patients: A survey of current practice in 11 European countries.

To conduct a survey of the clinical nursing practice in European countries in accordance with the European Stroke Strategies 2006 and to examine to what extent the European Stroke Strategies have been implemented in stroke care nursing in Europe. Stroke is a leading cause of death and disability globally. Optimal organisation of interdisciplinary stroke care is expected to ameliorate outcome after stroke. Consequently, universal access to stroke care based on evidence-based guidelines is a priority. This study is a descriptive cross-sectional survey. A questionnaire comprising 61 questions based on the European Stroke Strategies and scientific evidence in nursing practice was distributed to representatives of the European Association of Neuroscience Nurses, who sent the questionnaire to nurses active in stroke care. The questionnaire covered the following areas of stroke care: organisation of stroke services, management of acute stroke and prevention including basic care and nursing, and secondary prevention. Ninety-two nurses in stroke care in 11 European countries participated in the survey. Within the first 48hr after stroke onset, 95% monitor patients regularly, 94% start mobilisation after 24hr when patients are stable, and 89% assess patients' ability to swallow. Change of position for immobile patients is followed by 73%, and postvoid residual urine volume is measured by 85%. Some aspects needed improvement, for example, staff education (70%), education for patients/families/carers (55%) and individual care plans in secondary prevention (62%). The participating European countries comply well with the European Stroke Strategies guidelines, particularly in the acute stroke care, but not all stroke units have reached optimal development in all aspects of stroke care nursing. Our study may provide clinical administrators and nurses in stroke care with information that may contribute to improved compliance with the European Stroke Strategies and evidence-based guidelines.

Why Is It Worthwhile to Get Involved in Stroke Organizations?

In the first years of your career as a stroke physician, you are concerned with the patient you thrombolyzed yesterday and worry whether there is an intracerebral hemorrhage on the follow-up scan. Besides, you stress over the statistics for the paper your professor has been telling you to write for the past 6 months. While you are doing your best to become an excellent clinical stroke physician and you are trying hard to understand the world of academics, it is difficult to find the time for organizational work. The idea that you, as a trainee, may be able to influence global clinical practice and establish an international network may seem unrealistic. However, national and international stroke organizations act as platforms for influence, collaboration, inspiration, exchange of experiences, networking, and career promotion from early on. In the following article, we summarize why it is more than worthwhile to get involved in a stroke organization and we report our own experiences as members of the European Stroke Organisation (ESO) Young Stroke Physicians Committee. Vascular neurologists at the start of their careers are at the forefront in the emergency room, working directly with all disciplines involved in stroke care. They are exposed to the daily challenges of treating patients. Whether in a tertiary stroke center or in a hospital without a stroke unit, fellows get to see strengths and weaknesses of the pathways at their institutions. Nevertheless, the ability to change basic processes in patient care and in the organization of stroke services in general is limited. Involvement in a stroke organization yields opportunities to influence the direction of stroke care and research, for example, by contributing to guidelines, reviewing grant applications, reviewing papers, and rating abstracts for conferences. Being involved in these processes will improve skills needed for writing successful grant applications. …

Regional variation in acute stroke care organisation

BackgroundFew studies have assessed regional variation in the organisation of stroke services, particularly health care resourcing, presence of protocols and discharge planning. Our aim was to compare stroke care organisation within middle- (MIC) and high-income country (HIC) hospitals participating in the Head Position in Stroke Trial (HeadPoST). MethodsHeadPoST is an on-going international multicenter crossover cluster-randomized trial of ‘sitting-up’ versus ‘lying-flat’ head positioning in acute stroke. As part of the start-up phase, one stroke care organisation questionnaire was completed at each hospital. The World Bank gross national income per capita criteria were used for classification. Results94 hospitals from 9 countries completed the questionnaire, 51 corresponding to MIC and 43 to HIC. Most participating hospitals had a dedicated stroke care unit/ward, with access to diagnostic services and expert stroke physicians, and offering intravenous thrombolysis. There was no difference for the presence of a dedicated multidisciplinary stroke team, although greater access to a broad spectrum of rehabilitation therapists in HIC compared to MIC hospitals was observed. Significantly more patients arrived within a 4-h window of symptoms onset in HIC hospitals (41 vs. 13%; P<0.001), and a significantly higher proportion of acute ischemic stroke patients received intravenous thrombolysis (10 vs. 5%; P=0.002) compared to MIC hospitals. ConclusionsAlthough all hospitals provided advanced care for people with stroke, differences were found in stroke care organisation and treatment. Future multilevel analyses aims to determine the influence of specific organisational factors on patient outcomes.

Associations between the organisation of stroke services, process of care, and mortality in England: prospective cohort study

Objective To estimate the relations between the organisation of stroke services, process measures of care quality, and 30 day mortality in patients admitted with acute ischaemic stroke.Design Prospective cohort study.Setting...

Act on Stroke – Optimization of clinical processes and workflow for stroke diagnosis and treatment

Summary In the Helsingborg Declaration the continuum of care consisting of pre-, intra- and posthospital organization of stroke services combined with evaluation of outcome measures and dedicated quality assessments was considered as key for best outcome. Despite the evidence of such measures there are still striking disparities in organized stroke care all over Europe. Aim of this paper is to describe current concepts used for process optimization in stroke care and to evaluate if methodologies used in industry provide additional benefit in order to address this issue. We describe the transfer of a commonly accepted industrial maturity model to stroke care addressing structural, process and outcome quality. Moreover, this tool can be used to compare different stroke services and provides valuable information for their optimization by transferring best practices from “best in class” services as well as for prioritization of improvement measures.

Neurorehabilitation of stroke

Despite ongoing improvements in the acute treatment of cerebrovascular diseases and organization of stroke services, many stroke survivors are in need of neurorehabilitation, as more than two-thirds show persisting neurologic deficits. While early elements of neurorehabilitation are already taking place on the stroke unit, after the acute treatment, the patient with relevant neurologic deficits usually takes part in an organized inpatient multidisciplinary rehabilitation program and eventually continues with therapies in an ambulatory setting afterwards. A specialized multidisciplinary neurorehabilitation team with structured organization and processes provides a multimodal, intense treatment program for stroke patients which is adapted in detail to the individual goals of rehabilitation. There are many parallels between postlesional neuroplasticity (relearning) and learning in the development of individuals as well as task learning of healthy persons. One key principle of neurorehabilitation is the repetitive creation of specific learning situations to promote mechanisms of neural plasticity in stroke recovery. There is evidence of achieving a better outcome of neurorehabilitation with early initiation of treatment, high intensity, with specific goals and active therapies, and the coordinated work and multimodality of a specialized team. In this context, interdisciplinary goal-setting and regular assessments of the patient are important. Furthermore, several further potential enhancers of neural plasticity, e.g., peripheral and brain stimulation techniques, pharmacological augmentation, and use of robotics, are under evaluation.

Editorial Comment—Organized Stroke Care

The past decade has witnessed a dramatic change in treatment of acute stroke, leaving the era of an indifferent approach firmly behind. However, equally important to the development of particular emergency treatments is the recognition that the organization of stroke services per se plays a key role in the provision of effective therapies and in improving the overall outcome after stroke. In this issue of the journal, the consensus statement from the Brain Attack Coalition (BAC), a group with representatives from major professional and advocacy organizations involved in stroke care, with extensive recommendations for comprehensive stroke centers is published.1 The report is a companion to the recommendations for the establishment of primary stroke centers published by the same group in 2000.2 The previous report of the BAC2 detailed 11 key elements of a primary stroke center to improve patient care and outcomes. Recommendations included acute stroke teams, stroke units, written care protocols, and an integrated emergency response system. A major impetus for the recommendation was clearly to establish the infrastructure and logistics to permit broad implementation of intravenous tissue plasminogen activator therapy within the 3-hour window according to the criteria of the NINDS trial. A survey showed that in 2001, emergency services for acute stroke therapy were in place at the majority of hospitals,3 and the situation has further improved later on. However, and somewhat surprisingly from a non-US perspective, establishment of stroke units was given less emphasis in the BAC recommendations. Stroke units were not considered to be required for primary stroke centers that did not intend to provide care …

Acute Stroke

The treatment of patients with acute stroke is reviewed. Evidence of the existence of an ischemic penumbra in humans is presented. Different approaches to treatment of acute stroke include restoring blood flow by thrombolysis, neuroprotection, and early secondary prevention with aspirin. The evidence for each of these approaches is reviewed. Organization of stroke services, and particularly the use of stroke units, have been shown to significantly improve stroke outcome and these data are presented.

Organisation of Stroke Services: The Role of Stroke Units

Stroke units are gaining increasing popularity as a strategy for providing stroke care. Despite this, there continues to be considerable debate about the benefits and cost-effectiveness of such units.

Evaluation of a Clinical Score for Prognostic Stratification of Elderly Stroke Patients

Orpington Prognostic Score (OPS) is a clinically derived score which incorporates measures of motor deficit, proprioception, balance and cognition. OPS and urinary continence were measured prospectively in 217 stroke survivors over 75 years of age at 1, 2 and 4 weeks after stroke and were correlated with dependence at discharge. Three levels of dependence were defined based on personal self-care abilities. OPS ranged from 2.0 to 3.2 (median 2.8) at 2 weeks after stroke in patients independent at discharge (n = 54). Their initial median Barthel index of 4 improved by a median of 12. Urinary continence was achieved in 95% of these patients by 2 weeks. All patients were discharged home, 39 (72%) within 4 weeks. Patients with limited dependence at discharge (n = 129) had OPS of 3.2-4.8 (median 4.0) at 2 weeks. Two-thirds were continent at 2 weeks. Their initial median Barthel index was 2 and changed by a median of 12. Seventy-one (55%) of these patients went home. OPS ranged from 5.2 to 6.8 (median 6.0) at 2 weeks in patients dependent at discharge (n = 34). About 20% of these patients were continent. Their initial median Barthel index of 2 improved by a median of 6 at discharge. Only five (15%) patients in this group went home. OPS was comparable with urinary incontinence for sensitivity (96% vs. 90%), specificity (36% vs. 39%) and accuracy (75% vs. 66%) in identifying stroke patients achieving independent living. OPS had a greater predictive value than urinary incontinence in identifying patients requiring institutional care (82% vs. 57%). OPS is a simple objective predictor of outcome in elderly stroke patients, suitable for everyday clinical use. It also can facilitate stroke research by identifying a 'middle group' of patients who would be most sensitive to changes in therapy or organization of stroke services.