Quality Of Stroke Care Research Articles

Effect of the Coronavirus Disease 2019 Pandemic on the Quality of Stroke Care in Stroke Units and Alternative Wards: A National Comparative Analysis.

Background and PurposeChanges to hospital systems were implemented from March 2020 in Australia in response to the coronavirus disease 2019 pandemic, including decreased resources allocated to stroke units. We investigate changes in the quality of acute care for patients with stroke or transient ischemic attack during the pandemic according to patients’ treatment setting (stroke unit or alternate ward). MethodsWe conducted a retrospective cohort study of patients admitted with stroke or transient ischemic attack between January 2019 and June 2020 in the Australian Stroke Clinical Registry (AuSCR). The AuSCR monitors patients’ treatment setting, provision of allied health and nursing interventions, prescription of secondary prevention medications, and discharge destination. Weekly trends in the quality of care before and during the pandemic period were assessed using interrupted time series analyses. ResultsIn total, 18,662 patients in 2019 and 8,850 patients in 2020 were included. Overall, 75% were treated in stroke units. Before the pandemic, treatment in a stroke unit was superior to alternate wards for the provision of all evidence-based therapies assessed. During the pandemic period, the proportion of patients receiving a swallow screen or assessment, being discharged to rehabilitation, and being prescribed secondary prevention medications decreased by 0.58% to 1.08% per week in patients treated in other ward settings relative to patients treated in stroke units. This change represented a 9% to 17% increase in the care gap between these treatment settings during the period of the pandemic that was evaluated (16 weeks). ConclusionsDuring the first 6 months of the pandemic, widening care disparities between stroke units and alternate wards have occurred.

Quality of acute ischemic stroke care at a tertiary Hospital in Ghana

BackgroundInformation on the quality of acute ischemic stroke care provided in lower-to-middle income countries is limited.ObjectiveThis study was undertaken to examine the quality of acute ischemic stroke care provided at Tamale Teaching Hospital in Ghana.MethodsThe medical records of patients admitted into the medical ward of the hospital between January to October 2021 were reviewed retrospectively. Extent of compliance to 15 stroke performance indicators were determined.ResultsUnder the study period, 105 patients were admitted at the hospital with acute ischemic stroke. The mean (±SD) age was 65 ± 12 years; 38.1% were males; 65.7% had National Health Insurance Scheme coverage. Glasgow Coma Scale was the only functional stroke rating scale used by physicians to rate stroke severity. About a quarter of the patients had CT scan performed within 24 h of admission. Less than a quarter of the patients had a last known well time documented. Rate of thrombolytic administration was 0%. Less than a quarter of the patients were prescribed venous thromboembolism prophylaxis on the day of admission or day after. Only 13.8% of patients had documented reasons for not being prescribed venous thromboembolism prophylaxis. Antiplatelet therapy was prescribed to 33.3% of the patients by the end of day 2 of admission. Anticoagulation was prescribed to all patients who had comorbid condition of atrial fibrillation as part of the discharge medications. More than half of the patients were discharged to go home with statin medications. Documented stroke education was provided to 31.4% caretakers or patients. Slightly less than half of the patients were assessed for or received rehabilitation. Less than a quarter had documented dysphagia screening within 24 h of admission. None of the patient had their stroke severity rated with National Institutes of Health Stroke Scale on arrival. No patient obtained carotid imaging assessment by end of day 2.ConclusionThere were several gaps in the quality of acute ischemic stroke care provided to patients at the Tamale Teaching Hospital. With the exception of discharging patients on statin medications, there was poor adherence to all other stroke performance indicators.

Association of the COVID‐19 outbreak with acute stroke care in Switzerland

Background and purposeIn Switzerland, the COVID‐19 incidence during the first pandemic wave was high. Our aim was to assess the association of the outbreak with acute stroke care in Switzerland in spring 2020.MethodsThis was a retrospective analysis based on the Swiss Stroke Registry, which includes consecutive patients with acute cerebrovascular events admitted to Swiss Stroke Units and Stroke Centers. A linear model was fitted to the weekly admission from 2018 and 2019 and was used to quantify deviations from the expected weekly admissions from 13 March to 26 April 2020 (the “lockdown period”). Characteristics and 3‐month outcome of patients admitted during the lockdown period were compared with patients admitted during the same calendar period of 2018 and 2019.ResultsIn all, 28,310 patients admitted between 1 January 2018 and 26 April 2020 were included. Of these, 4491 (15.9%) were admitted in the periods March 13–April 26 of the years 2018–2020. During the lockdown in 2020, the weekly admissions dropped by up to 22% compared to rates expected from 2018 and 2019. During three consecutive weeks, weekly admissions fell below the 5% quantile (likelihood 0.38%). The proportion of intracerebral hemorrhage amongst all registered admissions increased from 7.1% to 9.3% (p = 0.006), and numerically less severe strokes were observed (median National Institutes of Health Stroke Scale from 3 to 2, p = 0.07).ConclusionsAdmissions and clinical severity of acute cerebrovascular events decreased substantially during the lockdown in Switzerland. Delivery and quality of acute stroke care were maintained.

Annual Case Volume and One-Year Mortality for Endovascular Treatment in Acute Ischemic Stroke.

BackgroundThe association between endovascular treatment (EVT) case volume per hospital and clinical outcomes has been reported, but the exact volume threshold has not been determined. This study aimed to examine the case volume threshold in this context.MethodsNational audit data on the quality of acute stroke care in patients admitted via emergency department, within 7 days of onset, in hospitals that treated ≥ 10 stroke cases during the audit period were analyzed. Ischemic stroke cases treated with EVT during the last three audits (2013, 2014, and 2016) were selected for the analysis. Annual EVT case volume per hospital was estimated and analyzed as a continuous and a categorical variable (in quartiles). The primary outcome measure was 1-year mortality as a surrogate of 3-month functional outcome. As post-hoc sensitivity analysis, replication of the study results was examined using the 2018 audit data.ResultsWe analyzed 1,746 ischemic stroke cases treated with EVT in 120 acute care hospitals. The median annual EVT case volume was 12.0 cases per hospital, and mortality rates at 1 month, 3 months, and 1 year were 12.7%, 16.6%, and 23.3%, respectively. Q3 and Q4 had 33% lower odds of 1-year mortality than Q1. Adjustments were made for predetermined confounders. Annual EVT case volume cut-off value for 1-year mortality was 15 cases per year (P < 0.02). The same cut-off value was replicated in the sensitivity analysis.ConclusionAnnual EVT case volume was associated with 1-year mortality. The volume threshold per hospital was 15 cases per year.

Six years’ experience of participation of the Institute of Emergency Medicine from Chisinau, Republic of Moldova in the Registry of Stroke Care Quality

Background. The Institute of Emergency Medicine from Chisinau has joined the Registry of Stroke Care Quality (RES-Q) in 2017. Material and Methods. We have analyzed the stroke patients’ data introduced in RES-Q between 20172022. Baseline characteristics, stroke-related factors, processes of care, and discharge destination were examined. Results. Data were available for 489 stroke patients. The proportion of patients with ischemic strokes receiving thrombolysis therapy has substantially increased from 2.78% in 2017 to 20% in 2022, and the median door-toneedle time decreased from 85 minutes (2017) to 48 minutes (2021). Thrombectomy began to be performed in 2018 at the Institute of Emergency Medicine, the rate of stroke patients receiving thrombectomy increased from 3.23% in 2019 to 10% in 2022, median door-to-groin time decreased from 228.5 minutes in 2019 to 102 minutes in 2021. More than 80% of patients received secondary prevention therapies that were level-1 evidence-based processes of care: antihypertensive agents (89.47% – 98.44%), antiplatelet drugs (81.63% – 100%), anticoagulants for patients with atrial fibrillation (25% in 2018 vs 100% in 2021), but cholesterol-lowering medication was prescribed to approximately a half of the participants (44.23% – 60.0%). There were more deaths in the pandemic years (36.67% in 2021 vs 18.99% in 2017). Conclusion. Most hospitalized stroke patients admitted to the Institute of Emergency Medicine received evidence-based care. The COVID-19 pandemic has left its mark on the number of stroke hospitalizations, but the quality of in-hospital stroke care was not dramatically affected.

Nationwide Acute Stroke Care Quality and Disparity in Korea: Focusing on the Type of Healthcare Facilities and the Socioeconomic Status of Patients

Background: The quality ofstroke care has a significantimpact onmortality and complications. The purpose ofthisstudy wasto investigate the difference in the quality of acute stroke treatment according to the type of healthcare facility and the socioeconomic status of patients.Methods: Thisstudy used Health Insurance Review and Assessment Service’s Healthcare Quality Assessment for Stroke 2013 data and included 10,399 cases from 201 healthcare facilities. Quality of care was categorized from grade 1 (best group) to grade 5 (worst group) according to performance scores using 10 processindicators.Results: The mean performance score was 91.5. Only 31% of all patients received treatment at grade 1 hospitals while 10% received treatment at grade 3 or lower hospitals. The difference in performance score by the type of healthcare facility existed (tertiary hospitals: 94.3, general hospitals: 88.7).Ofthe 159 general hospitals, 66 hospitals provided grade 3 orlower quality care.NHI patients used more tertiary hospitalsthan MA patients(51% vs. 38%), and MA patientswere more likely to use general hospitals providing grade 3 or lower quality care (11% vs. 21%).Conclusions: This study showed that some general hospitals provided low quality stroke care, and MA patients were more likely to use those hospitals. In order to increase the quality and equity of stroke treatment, a strategy to gather patients at healthcare facilitiesthat provide appropriate medicalservices will be needed.

247 BENCHMARKING STROKE SERVICES TO INFORM A QUALITY IMPROVEMENT INIAITIVE

Abstract Background Stroke is a leading cause of death and disability in Ireland. Continuous audit and quality improvement is essential in the delivery of stroke care where the evidence basis is constantly changing. This helps to ensure the delivery of high quality stroke care and compliance with evidenced based guidelines. We aimed to assess stroke care at an Irish university teaching hospital. Methods Patients with a HIPE discharge diagnosis of Cerebral Infarction or Cerebral Haemorrhage (1st January-31st December 2019) were identified through both the HIPE database and the institutional Stroke Portal. Data was benchmarked against national (Irish National Audit of Stroke 2019) and international (6th SSNAP Annual Report; American Heart Association, 2013) practice and used to inform a quality improvement strategy. Results 419 patients were included (56.6% male, median 57 years). 75.9% were aged 65 years or older. We compared favourably with Irish National Audit of Stoke national indicators on the following: thrombolysis rates-10%; median door to needle time-60 mins; stroke unit admissions- 78.5%; median duration of symptoms- 3 hours 6 minutes; swallow assessment- 81.1%; in-patient mortality- 10.5%; rates of institutionalisation- 3.8%. Areas identified for improvement were: thrombectomy rates- 1.9%; median length of stay- 12 days; door to imaging time- median 104 minutes; mood screening- 11.5%. Conclusion International and national data is a useful benchmark against which local hospitals can assess the quality of their service. By completing this quality improvement initiative we identified areas to target resources in our centre, including mood screening, swallow screening, thrombectomy rates, length of stay and time to neuroimaging. An ongoing quality improvement process using ‘PDSA’ methodology is being carried out with an annual audit to monitor progress.

Оценка качества оказания инсультной помощи в стационарах по данным реестра RES-Q

Реестр качества лечения инсульта (REgistry of Stroke Care Quality, RES-Q) позволяет оценить качество оказания помощи больным с инсультом в стационарах и сравнить ее с качеством в других странах. Цель исследования. Оценить качество оказания стационарной помощи больным с мозговым инсультом в Украине. Материалы и методы. С 2017 года в реестр RES-Q внесена информация по 14 305 пациентам из 90 больниц Украины. Средний возраст больных составил 68 лет. 85,08 % больных были с ишемическим инсультом, 10,53 % — с внутримозговыми геморрагиями, 1,98 % — с субарахноидальным кровоизлиянием, 0,01 % — с венозным тромбозом, 0,27 % — с криптогенным инсультом, 2,13 % — с транзиторной ишемической атакой. У 19,33 % пациентов мозговой инсульт был повторным. Результаты. В инсультных отделениях лечилось 67,9 % больных, остальные — в отделениях реанимации, общей неврологии, нейрохирургии. КТ, МРТ проведены 92,1 % больных. Тяжесть инсульта по шкале NIHSS была оценена у 88,5 % больных (средний балл — 9). Тест на дисфагию проведен 86,71 % больных. Реканализация проведена 5,94 % пациентов с ишемическим мозговым инсультом (тромболитическая терапия — 5,33 %, механическая тромбэктомия — 0,61 %). Гемикраниэктомия проведена у 0,29 % пациентов. Удаление интракраниальной гематомы выполнено у 2,7 % пациентов с внутримозговыми геморрагиями. Реабилитационную помощь получили 71,98 % больных. Выводы. Проведение анализа реестра RES-Q позволило на небольшом количестве пациентов (5 % общего числа больных с мозговым инсультом за 3 года в Украине) оценить качество лечения и признать, что оно требует значительного улучшения и изменений в организации помощи больным.

Hospital Readmissions and Mortality Among Fee-for-Service Medicare Patients With Minor Stroke or Transient Ischemic Attack: Findings From the COMPASS Cluster-Randomized Pragmatic Trial.

BackgroundMortality and hospital readmission rates may reflect the quality of acute and postacute stroke care. Our aim was to investigate if, compared with usual care (UC), the COMPASS‐TC (Comprehensive Post‐Acute Stroke Services Transitional Care) intervention (INV) resulted in lower all‐cause and stroke‐specific readmissions and mortality among patients with minor stroke and transient ischemic attack discharged from 40 diverse North Carolina hospitals from 2016 to 2018.Methods and ResultsUsing Medicare fee‐for‐service claims linked with COMPASS cluster‐randomized trial data, we performed intention‐to‐treat analyses for 30‐day, 90‐day, and 1‐year unplanned all‐cause and stroke‐specific readmissions and all‐cause mortality between INV and UC groups, with 90‐day unplanned all‐cause readmissions as the primary outcome. Effect estimates were determined via mixed logistic or Cox proportional hazards regression models adjusted for age, sex, race, stroke severity, stroke diagnosis, and documented history of stroke. The final analysis cohort included 1069 INV and 1193 UC patients (median age 74 years, 80% White, 52% women, 40% with transient ischemic attack) with median length of hospital stay of 2 days. The risk of unplanned all‐cause readmission was similar between INV versus UC at 30 (9.9% versus 8.7%) and 90 days (19.9% versus 18.9%), respectively. No significant differences between randomization groups were seen in 1‐year all‐cause readmissions, stroke‐specific readmissions, or mortality.ConclusionsIn this pragmatic trial of patients with complex minor stroke/transient ischemic attack, there was no difference in the risk of readmission or mortality with COMPASS‐TC relative to UC. Our study could not conclusively determine the reason for the lack of effectiveness of the INV.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.

Ten Years of Improving Acute Stroke Management in a Metropolitan Area: A Population-Based Quantification of Quality Indicators

Background and Purpose: Rapid access to acute stroke treatment improves clinical outcomes in patients with ischemic stroke. We aimed to shorten the time to admission and to acute stroke treatment for patients with acute stroke in the Hamburg metropolitan area by collaborative multilevel measures involving all hospitals with stroke units, the Emergency Medical Services (EMS), and health-care authorities. Methods: In 2007, an area-wide stroke care quality project was initiated. The project included mandatory admission of all stroke patients in Hamburg exclusively to hospitals with stroke units, harmonized acute treatment algorithms among all hospitals, repeated training of the EMS staff, a multimedia educational campaign, and a mandatory stroke care quality monitoring system based on structured data assessment and quality indicators for procedural measures. We analyzed data of all patients with acute stroke who received inhospital treatment in the city of Hamburg during the evaluation period from the quality assurance database data and evaluated trends of key quality indicators over time. Results: From 2007 to 2016, a total of 83,395 patients with acute stroke were registered. During this period, the proportion of patients admitted within ≤3 h from symptom onset increased over time from 27.8% in 2007 to 35.2% in 2016 (p < 0.001). The proportion of patients who received rapid thrombolysis (within ≤30 min after admission) increased from 7.7 to 54.1% (p < 0.001). Conclusions: Collaborative stroke care quality projects are suitable and effective to improve acute stroke care.

Impact of COVID-19 related lockdown measures on stroke care quality in Careggi University Hospital, Florence

The COVID-19 pandemic and related restrictions has been disruptive for healthcare systems, especially for time-sensitive emergencies. During the viral outbreak, a reduction of stroke patients' volume in hospitals in Italy and worldwide has been extensively reported, as well as a severe delay in all integrated steps of hyperacute treatments and management.

Understanding Coordinator Roles in Acute Stroke Care: A National Survey

ObjectivesCoordinators contribute to stroke care quality. Evidence on the scope of practice of coordinator roles for stroke is lacking. We aimed to survey Australian stroke coordinators and describe their responsibilities and characteristics, and compare these based on perceived competency. Materials and MethodsOnline survey of non-physician coordinators with a clinical leadership position for acute stroke in Australian hospitals. Participants were identified from the Stroke Foundation National Audit, and advertising via national associations/networks. Quantitative data were analysed descriptively; characteristics and responsibilities assessed by Benner's self-perceived competency (novice/advanced beginner/competent, proficient or expert). Inductive thematic analysis was used for open-ended responses. ResultsResults from 105/141 coordinators (103 hospitals, 90% female, 90% registered nurses). Two-thirds developed the role/were self-taught, with 36% using the ‘stroke coordinator’ title. Perceived competency varied; 22% expert, 40% proficient, and 33% competent. A variety of important clinical tasks, along with leadership/management, education and research responsibilities were described. Most frequently reported clinical responsibility was discharge planning (77%), with patient and staff education (85% and 88%), and data collection (94%) common. Compared to those reporting lesser competency, ‘experts’ had greater involvement in outpatient clinics (50% vs 14%) and leadership/management responsibilities (e.g. local hospital committees 77% vs 46%). ‘Knowledge of evidence’ and ‘empowering others’ were important characteristics to ‘expert’ coordinators. ConclusionsA contemporary understanding of important responsibilities and characteristics of acute stroke coordinators are provided. Perceived competency affected scope of practice. Structured education, training and role delineation is warranted to improve competency. Career development of stroke coordinators is urgently needed to support optimal role performance.

Understanding the Role of External Facilitation to Drive Quality Improvement for Stroke Care in Hospitals.

The use of external facilitation within the context of multicomponent quality improvement interventions (mQI) is growing. We aimed to evaluate the influence of external facilitation for improving the quality of acute stroke care. Clinicians from hospitals participating in mQI (Queensland, Australia) as part of the Stroke123 study were supported by external facilitators in a single, on-site workshop to review hospital performance against eight clinical processes of care (PoCs) collected in the Australian Stroke Clinical Registry (AuSCR) and develop an action plan. Remote support (i.e., telephone/email) after the workshop was provided. As part of a process evaluation for Stroke123, we recorded the number and mode of contacts between clinicians and facilitators; type of support provided; and frequency of self-directed, hospital-level stroke registry data reviews. Analysis: We measured the association between amount/type of external facilitation, (i) development of action plans, and (ii) adherence to PoCs before and after the intervention using AuSCR data from 2010 to 2015. In total, 14/19 hospitals developed an action plan. There was no significant difference in amount or type of external facilitator support provided between hospitals that did, and did not, develop an action plan. There was no relationship between the amount of external facilitation and change in adherence to PoCs. Most (95%) hospitals accessed stroke registry performance data. In the Stroke123 study, the amount or type of external facilitation did not influence action plan development, and the amount of support did not influence the changes achieved in adherence to PoCs. Remote support may not add value for mQI.

Treat COVID-19, but Not Only COVID-19: Stroke Matters as Well

Introduction: During the COVID-19 pandemic, studies reported less number of hospitalizations for acute stroke and reduction in the use of recanalization treatments. This study analyzes nationwide data on stroke admissions and management in the Czech Republic during the first wave of the COVID-19 pandemic. Methods: We compared the early COVID-19 pandemic (March–May 2020) with the pre-pandemic period (January–February 2020 and March–May 2019): (a) the National Register of Reimbursed Health Services provided volume of all admissions for subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), and ischemic stroke (IS), and volume of recanalization treatments (intravenous thrombolysis [IVT] and mechanical thrombectomy [MT]); (b) Registry of Stroke Care Quality provided door-to-needle time (DNT), onset-to-door time (ODT), and stroke severity at admission (National Institutes of Health Stroke Scale, NIHSS) for IS. Results: During the pandemic (March–May 2020), the peak number of COVID-19 patients treated in Czech hospitals was 39 per million. In March–May 2020 versus March–May 2019, hospital admissions decreased as follows: stroke overall by 14% (p < 0.001), IS by 14% (p < 0.001), SAH by 15% (p = 0.07), and ICH by 7% (p = 0.17). The mean age was 74 years versus 74 years (p = 0.33), and 52% versus 51% were men (p = 0.34). The volumes of IVT and MT decreased by 14% (p = 0.001) and 19% (p = 0.01), respectively. The proportions of all IS patients receiving IVT or MT remained unchanged, with, respectively, 17% versus 17% receiving IVT (p = 0.86) and 5% versus 5% receiving MT (p = 0.48). DNT and ODT were 24 versus 25 min (p = 0.58) and 168 versus 156 min (p = 0.23), respectively. NIHSS at admission did not differ (6 vs. 6; p = 0.54). Conclusion: Even with a low burden of COVID-19 during the first wave and no change in organization and logistics of stroke services, stroke admissions and volume of recanalization treatments decreased. Public health communication campaigns should encourage people to seek emergency medical care for stroke symptoms during the COVID-19 pandemic.

The impact of COVID-19 on acute stroke care in Belgium.

A worldwide decline in stroke hospitalizations during the COVID-19 pandemic has been reported. Information on stroke care during the pandemic in Belgium is lacking. This study aims to analyze the impact of COVID-19 on acute stroke care in eight Belgian stroke centers. This Belgian study is part of an international observational and retrospective study in 70 countries and 457 stroke centers. We compared volumes of COVID-19 and stroke hospitalizations, intravenous thrombolysis and endovascular treatment rates, acute treatment time intervals and functional outcome at 90 days during the first wave of the pandemic to two control intervals (March–May 2019 and December–February 2020). From March 2020 to May 2020, 860 stroke patients were hospitalized. In the same time period, 2850 COVID-19 patients were admitted, of which 37 (1.3%) were diagnosed with a stroke. Compared to the months prior to the pandemic and the same time epoch one year earlier, stroke hospitalizations were reduced (relative difference 15.9% [p = 0.03] and 14.5% [p = 0.05], respectively). Despite a reduction in absolute volumes, there was no difference in the monthly proportion of thrombolysis or endovascular treatment provided to the overall stroke hospitalizations. Acute treatment time metrics did not change between COVID-19 pandemic and control time epochs. We found no difference in 90-day functional outcomes nor in mortality after stroke between patients admitted during the pandemic versus control periods. We found a decline in the volume of stroke hospitalizations during the first wave of the COVID-19 pandemic in Belgium. Stroke care quality parameters remained unchanged.

Simple but Organized Neurology Residency Training Improves the Quality of Acute Stroke Care: From the Outset to Long-Term Effect.

Simple but Organized Neurology Residency Training Improves the Quality of Acute Stroke Care: From the Outset to Long-Term Effect.

Bottlenecks in the Acute Stroke Care System during the COVID-19 Pandemic in Catalonia

Introduction: The COVID-19 pandemic resulted in significant healthcare reorganizations, potentially striking standard medical care. We investigated the impact of the COVID-19 pandemic on acute stroke care quality and clinical outcomes to detect healthcare system’s bottlenecks from a territorial point of view. Methods: Crossed-data analysis between a prospective nation-based mandatory registry of acute stroke, Emergency Medical System (EMS) records, and daily incidence of COVID-19 in Catalonia (Spain). We included all stroke code activations during the pandemic (March 15–May 2, 2020) and an immediate prepandemic period (January 26–March 14, 2020). Primary outcomes were stroke code activations and reperfusion therapies in both periods. Secondary outcomes included clinical characteristics, workflow metrics, differences across types of stroke centers, correlation analysis between weekly EMS alerts, COVID-19 cases, and workflow metrics, and impact on mortality and clinical outcome at 90 days. Results: Stroke code activations decreased by 22% and reperfusion therapies dropped by 29% during the pandemic period, with no differences in age, stroke severity, or large vessel occlusion. Calls to EMS were handled 42 min later, and time from onset to hospital arrival increased by 53 min, with significant correlations between weekly COVID-19 cases and more EMS calls (rho = 0.81), less stroke code activations (rho = −0.37), and longer prehospital delays (rho = 0.25). Telestroke centers were afflicted with higher reductions in stroke code activations, reperfusion treatments, referrals to endovascular centers, and increased delays to thrombolytics. The independent odds of death increased (OR 1.6 [1.05–2.4], p 0.03) and good functional outcome decreased (mRS ≤2 at 90 days: OR 0.6 [0.4–0.9], p 0.015) during the pandemic period. Conclusion: During the COVID-19 pandemic, Catalonia’s stroke system’s weakest points were the delay to EMS alert and a decline of stroke code activations, reperfusion treatments, and interhospital transfers, mostly at local centers. Patients suffering an acute stroke during the pandemic period had higher odds of poor functional outcome and death. The complete stroke care system’s analysis is crucial to allocate resources appropriately.

Impact of Hospital Level on Stroke Outcomes in the Thrombolytic Therapy Era in Northeast Thailand: A Retrospective Study.

IntroductionStroke is a common neurological disease. Thrombolytic therapy has been shown to be beneficial in acute ischemic stroke. This treatment can be given in various hospital levels. This study aimed to evaluate the quality of acute ischemic stroke care among various hospital levels.MethodsData were randomly selected from the medical records that were sent to the National Health Security Office (NHSO) for reimbursement purposes between October 2015 and August 2016. Patient demographics, risk factors, stroke subtypes, stroke severity, quality of care indicators, and complications were recorded. Paired comparisons between two groups were carried out using the Bonferroni correction.ResultsA total of 947 patients, including 169 patients from community hospitals (CHs), 629 from regional hospitals (RHs), and 149 from tertiary hospitals (THs), were included in the final analysis. The CH group had a higher median age but lower median initial National Institutes of Health Stroke Scale (NIHSS) score than the RH and TH groups (median age = 70, 66, and 67 years, respectively, and initial NIHSS = 6, 8, and 9, respectively). The CH group had shorter onset-to-needle times for intravenous recombinant tissue plasminogen activator (rt-PA) treatment than the other two groups (147 vs. 178.5 and 180 min). After adjustment for baseline characteristics, stroke type, and stroke severity, the CH group was significantly associated with lower mortality and presence of complications. The adjusted odds ratios (95% confidence intervals) for the two factors were 0.13 (0.03, 0.67) and 0.59 (0.35, 0.99). None of the patients received endovascular therapy or non-thrombolytic interventional therapy.ConclusionCHs may have the potential for acute ischemic stroke care in the same way as RHs or THs, with faster rt-PA treatment, in northeast Thailand. However, further studies should be performed to evaluate appropriate patient characteristics for CHs.

Stroke Care in the United Kingdom During the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has potentially caused indirect harm to patients with other conditions via reduced access to health care services. We aimed to describe the impact of the initial wave of the pandemic on admissions, care quality, and outcomes in patients with acute stroke in the United Kingdom. Registry-based cohort study of patients with acute stroke admitted to hospital in England, Wales, and Northern Ireland between October 1, 2019, and April 30, 2020, and equivalent periods in the 3 prior years. One hundred fourteen hospitals provided data for a study cohort of 184 017 patients. During the lockdown period (March 23 to April 30), there was a 12% reduction (6923 versus 7902) in the number of admissions compared with the same period in the 3 previous years. Admissions fell more for ischemic than hemorrhagic stroke, for older patients, and for patients with less severe strokes. Quality of care was preserved for all measures and in some domains improved during lockdown (direct access to stroke unit care, 1-hour brain imaging, and swallow screening). Although there was no change in the proportion of patients discharged with good outcome (modified Rankin Scale score, ≤2; 48% versus 48%), 7-day inpatient case fatality increased from 6.9% to 9.4% (P<0.001) and was 22.0% in patients with confirmed or suspected COVID-19 (adjusted rate ratio, 1.41 [1.11-1.80]). Assuming that the true incidence of acute stroke did not change markedly during the pandemic, hospital avoidance may have created a cohort of untreated stroke patients at risk of poorer outcomes or recurrent events. Unanticipated improvements in stroke care quality should be used as an opportunity for quality improvement and to learn about how to develop resilient health care systems.

Exploring advanced nursing practice in stroke services: a scoping review

Background: Stroke care is becoming increasingly reliant on advanced nursing practice (ANP); however, little is known about these roles within the stroke specialty. Aims: To explore the current knowledge of advanced nursing practice in stroke services internationally, specifically, the conceptualisation of ANP and the rationale for its implementation. Methods: Arskey and O'Malley's scoping review methodology was employed, and six academic databases were used. Findings: Two key themes were identified; ‘role development’ and ‘four pillars of advanced practice’. The review identifies that ANP is implemented primarily to provide acute stroke care. Conclusions: Current research does not clarify the rationale for implementing these posts or how ANP is conceptualised. This review does identify that stroke ANP incorporates the four pillars of advanced practice (clinical, research, leadership and education) and was implemented to improve the quality of stroke care. Barriers and facilitators to implementation were also identified.