Sentinel Stroke National Audit Programme Research Articles

Predicting Stroke Complications in Hospital and Functional Status at Discharge by Clustering of Cardiovascular Diseases a Multi-Centre Registry-Based Study of Acute Stroke

ObjectiveIndicators for outcomes following acute stroke are lacking. We have developed novel evidence-based criteria for identifying outcomes of acute stroke using the presence of clusters of coexisting cardiovascular disease (CVD). Materials and methodsAnalysis of prospectively collected data from the Sentinel Stroke National Audit Programme (SSNAP). A total of 1656 men (mean age ±SD=73.1yrs±13.2) and 1653 women (79.3yrs±13.0) were admitted with acute stroke (83.3% ischaemic, 15.7% intracranial haemorrhagic), 1.0% unspecified) in four major UK hyperacute stroke units (HASU) between 2014 and 2016. Four categories from cardiovascular disease Congestive heart failure, Atrial fibrillation, pre-existing Stroke and Hypertension (CASH).were constructed: CASH-0 (no coexisting CVD); CASH-1 (any one coexisting CVD); CASH-2 (any two coexisting CVD); CASH-3 (any three or all four coexisting CVD). These were tested against outcomes, adjusted for age and sex. ResultsCompared to CASH-0, individuals with CASH-3 had greatest risks of in-hospital mortality (11.1% vs 24.5%, OR=1.8, 95%CI=1.3-2.7) and disability (modified Rankin Scale score ≥4) at discharge (24.2% vs 46.2%, OR=1.9, 95%CI=1.4-2.7), urinary tract infection (3.8% vs 14.6%, OR= 3.3, 95%CI= 1.9-5.5), and pneumonia (7.1% vs 20.6%, OR= 2.6, 95%CI= 1.7-4.0); length of stay on HASU >14 days (29.8% vs 39.3%, OR=1.8, 95%CI=1.3-2.6); and joint-care planning (20.9% vs 29.8%, OR=1.4, 95%CI=1.0-2.0). ConclusionsWe present a simple tool for estimating the risk of adverse outcomes of acute stroke including death, disability at discharge, nosocomial infections, prolonged length of stay, as well as any joint care planning. CASH-0 indicates a low level and CASH-3 indicates a high level of risk of such complications after stroke.

Machine learning‐enabled multitrust audit of stroke comorbidities using natural language processing

With the increasing adoption of electronic records in the health system, machine learning-enabled techniques offer the opportunity for greater computer-assisted curation of these data for audit and research purposes. In this project, we evaluate the consistency of traditional curation methods used in routine clinical practice against a new machine learning-enabled tool, MedCAT, for the extraction of the stroke comorbidities recorded within the UK's Sentinel Stroke National Audit Programme (SSNAP) initiative. A total of 2327stroke admission episodes from three different National Health Service (NHS) hospitals, between January 2019 and April 2020, were included in this evaluation. In addition, current clinical curation methods (SSNAP) and the machine learning-enabled method (MedCAT) were compared against a subsample of 200 admission episodes manually reviewed by our study team. Performance metrics of sensitivity, specificity, precision, negative predictive value, and F1 scores are reported. The reporting of stroke comorbidities with current clinical curation methods is good for atrial fibrillation, hypertension, and diabetes mellitus, but poor for congestive cardiac failure. The machine learning-enabled method, MedCAT, achieved better performances across all four assessed comorbidities compared with current clinical methods, predominantly driven by higher sensitivity and F1 scores. We have shown machine learning-enabled data collection can support existing clinical and service initiatives, with the potential to improve the quality and speed of data extraction from existing clinical repositories. The scalability and flexibility of these new machine-learning tools, therefore, present an opportunity to revolutionize audit and research methods.

Adverse consequences of immediate thrombolysis-related complications: a multi-centre registry-based cohort study of acute stroke

Complications following thrombolysis for stroke are well documented, and mostly concentrated on haemorrhage. However, the consequences of patients who experience any immediate thrombolysis-related complications (TRC) compared to patients without immediate TRC have not been examined. Prospectively collected data from the Sentinel Stroke National Audit Programme were analysed. Thrombolysis was performed in 451 patients (52.1% men; 75.3 years ± 13.2) admitted with acute ischaemic stroke (AIS) in four UK centres between 2014 and 2016. Adverse consequences following immediate TRC were assessed using logistic regression, adjusted for age, sex and co-morbidities. Twenty-nine patients (6.4%) acquired immediate TRC. Compared to patients without, individuals with immediate TRC had greater adjusted risks of: moderately-severe or severe stroke (National Institutes of Health for Stroke Scale score ≥ 16) at 24-h (5.7% vs 24.7%, OR 3.9, 95% CI 1.4–11.1); worst level of consciousness (LOC) in the first 7 days (score ≥ 1; 25.0 vs 60.7, OR 4.6, 95% CI 2.1–10.2); urinary tract infection or pneumonia within 7-days of admission (13.5% vs 39.3%, OR 3.2, 95% CI 1.3–7.7); length of stay (LOS) on hyperacute stroke unit (HASU) ≥ 2 weeks (34.7% vs 66.7%, OR 5.2, 95% CI 1.5–18.4); mortality (13.0% vs 41.4%, OR 3.7, 95% CI 1.6–8.4); moderately-severe or severe disability (modified Rankin Scale score ≥ 4) at discharge (26.8% vs 65.5%, OR 4.7, 95% CI 2.1–10.9); palliative care by discharge date (5.1% vs 24.1%, OR 5.1, 95% CI 1.7–15.7). The median LOS on the HASU was longer (7 days vs 30 days, Kruskal–Wallis test: χ2 = 8.9, p = 0.003) while stroke severity did not improve (NIHSS score at 24-h post-thrombolysis minus NIHSS score at arrival = − 4 vs 0, χ2 = 24.3, p < 0.001). In conclusion, the risk of nosocomial infections, worsening of stroke severity, longer HASU stay, disability and death is increased following immediate TRC. The management of patients following immediate TRC is more complex than previously thought and such complexity needs to be considered when planning an increased thrombolysis service.

Variation of stroke-associated pneumonia in stroke units across England and Wales: A registry-based cohort study.

BackgroundPneumonia is common in stroke patients and is associated with worse clinical outcomes. Prevalence of stroke-associated pneumonia varies between studies, and reasons for this variation remain unclear. We aimed to describe the variation of observed stroke-associated pneumonia in England and Wales and explore the influence of patient baseline characteristics on this variation.MethodsPatient data were obtained from the Sentinel Stroke National Audit Programme for all confirmed strokes between 1 April 2013 and 31 December 2018. Stroke-associated pneumonia was defined by new antibiotic initiation for pneumonia within the first seven days of admission. The probability of stroke-associated pneumonia occurrence within stroke units was estimated and compared using a multilevel mixed model with and without adjustment for patient-level characteristics at admission.ResultsOf the 413,133 patients included, median National Institutes of Health Stroke Scale was 4 (IQR: 2–10) and 42.3% were aged over 80 years. Stroke-associated pneumonia was identified in 8.5% of patients. The median within stroke unit stroke-associated pneumonia prevalence was 8.5% (IQR: 6.1–11.5%) with a maximum of 21.4%. The mean and variance of the predicted stroke-associated pneumonia probability across stroke units decreased from 0.08 (0.68) to 0.05 (0.63) when adjusting for patient admission characteristics. This difference in the variance suggests that clinical characteristics account for 5% of the observed variation in stroke-associated pneumonia between units.ConclusionsPatient-level clinical characteristics contributed minimally to the observed variation of stroke-associated pneumonia between stroke units. Additional explanations for the observed variation in stroke-associated pneumonia need to be explored which could reduce variation in antibiotic use for stroke patients.

Abstract P99: Impact of the Covid-19 Pandemic on Stroke Thrombolysis Rate and Delay to Thrombolysis Treatment in a Regional Stroke Centre in London, UK

Introduction: There are reports of changes in the numbers of stroke admissions and time intervals to receiving emergency treatments during the COVID-19 pandemic. We examined the impact of the COVID-19 pandemic on the stroke thrombolysis rate and delay to thrombolysis treatment in a regional stroke centre in London, UK. Methods: COVID-19 testing began at our hospital on 3 March 2020. Clinical data for all acute stroke admissions were routinely collected as part of a national Sentinel Stroke National Audit Programme (SSNAP) and all thrombolysis data were entered into our local thrombolysis database. We retrospectively extracted the relevant patient data for the period of March to May 2020 (COVID group) and compared to the same period in 2019 (pre-COVID group). Results: Compared with pre-COVID, there was a 17.5% fall in total stroke admissions (from 315 to 260) during COVID; but there were no significant differences in the demographics, stroke severity, proportions with known time of onset, or median onset-to-arrival time. The thrombolysis rates amongst ischemic strokes were not significantly different between the two groups (59/260=23% pre-COVID vs. 41/228=18% COVID, p=.19). For thrombolysis patients, their stroke severity and demographics were similar between the two both groups. Median onset-to-needle time was significantly longer by 22 minutes during COVID [127 (IQR 94-160) vs. 149 (IQR 110-124) minutes, p=.045]; this delay to treatment was almost entirely due to a longer median onset-to-arrival time by 16 minutes during COVID (p=.029). Favorable early neurological outcomes post-thrombolysis (defined as an improvement in NIHSS by ≥4 points at 24 hours) were similar (45% vs. 46%, p=.86). Conclusion: COVID-19 pandemic had a negative impact on prehospital delays which in turn significantly increased onset-to-needle time, but without affecting the chance of a favorable early neurological outcome. Our data highlight the need to maintain public awareness of taking immediate action when stroke symptoms occur during the COVID-19 pandemic.

Effect of stroke early supported discharge on length of hospital stay: analysis from a national stroke registry

ObjectiveThe first observational study to investigate the impact of early supported discharge (ESD) on length of hospital stay in real-world conditions.DesignUsing historical prospective Sentinel Stroke National Audit Programme (SSNAP) data...

Stroke impairment categories: A new way to classify the effects of stroke based on stroke-related impairments

Objective: To create a classification system based on stroke-related impairments. Data source: All adults with stroke admitted for at least 72 hours in England, Wales and Northern Ireland from July 2013 to July 2015 extracted from the Sentinel Stroke National Audit Programme Analysis: Impairments were defined using the National Institute of Health Stroke Scale scores at admission. Common combinations of impairments were identified based on geometric coding and expert knowledge. Validity of the classification was assessed using standard descriptive statistics to report and compare patients’ characteristics, therapy received and outcomes in each group. Results: Data from 94,905 patients were extracted. The items of the National Institute of Health Stroke Scale (on admission) were initially grouped into four body systems: Cognitive, Motor, Sensory and Consciousness. Seven common combinations of these impairments were identified (in order of stroke severity); Patients with Loss of Consciousness (n = 6034, 6.4%); those with Motor + Cognitive + Sensory impairments (n = 28,226, 29.7%); Motor + Cognitive impairments (n = 16,967, 17.9%); Motor + Sensory impairments (n = 9882, 10.4%); Motor Only impairments (n = 20,471, 21.6%); Any Non-Motor impairments (n = 7498, 7.9%); and No Impairments (n = 5827, 6.1%). There was a gradation of age, premorbid disability, mortality and disability on discharge. People with the most and least severe categories were least likely to receive therapy, and received least therapy (−20 minutes/day of stay) compared to −35 minutes/day of stay for the moderately severe categories. Conclusions: A classification system of seven Stroke Impairment Categories has been presented.

Environmental Factors and Hyperacute Stroke Care Activity During the COVID-19 Pandemic: An Interrupted Time-Series Analysis

Background and aimsConcerns have arisen regarding patient access and delivery of acute stroke care during the COVID-19 pandemic. We investigated key population level events on activity of the three hyperacute stroke units (HASUs) within Greater Manchester and East Cheshire (GM & EC), whilst adjusting for environmental factors. MethodsWeekly stroke admission & discharge counts in the three HASUs were collected locally from Emergency Department (ED) data and Sentinel Stroke National Audit Programme core dataset prior to, and during the emergence of the COVID-19 pandemic (Jan 2020 to May 2020). Whilst adjusting for local traffic-related air pollution and ambient measurement, an interrupted time-series analysis using a segmented generalised linear model investigated key population level events on the rate of stroke team ED assessments, admissions for stroke, referrals for transient ischaemic attack (TIA), and stroke discharges. ResultsThe median total number of ED stroke assessments, admissions, TIA referrals, and discharges across the three HASU sites prior to the first UK COVID-19 death were 150, 114, 69, and 76 per week. The stable weekly trend in ED assessments and stroke admissions decreased by approximately 16% (and 21% for TIAs) between first UK hospital COVID-19 death (5th March) and the implementation of the Act-FAST campaign (6th April) where a modest 4% and 5% increase per week was observed. TIA referrals increased post Government intervention (23rd March), without fully returning to the numbers observed in January and February. Trends in discharges from stroke units appeared unaffected within the study period reported here. ConclusionDespite adjustment for environmental factors stroke activity was temporarily modified by the COVID-19 pandemic. Underlying motivations within the population are still not clear. This raises concerns that patients may have avoided urgent health care risking poorer short and long-term health outcomes.

Temporal variations in quality of acute stroke care and outcomes in London hyperacute stroke units: a mixed-methods study

Background Seven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of the day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units. Objectives To investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units, and to identify factors influencing such variations. Design This was a prospective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme. Factors influencing variations in care and outcomes were studied through interview and observation data. Setting The setting was acute stroke services in London hyperacute stroke units. Participants A total of 7094 patients with a primary diagnosis of stroke took part. We interviewed hyperacute stroke unit staff (n = 76), including doctors, nurses, therapists and administrators, and 31 patients and carers. We also conducted non-participant observations of delivery of care at different times of the day and week (n = 45, ≈102 hours). Intervention Hub-and-spoke model for care of suspected acute stroke patients in London with performance standards was designed to deliver uniform access to high-quality hyperacute stroke unit care across the week. Main outcome measures Indicators of quality of acute stroke care, mortality at 3 days after admission, disability at the end of the inpatient spell and length of stay. Data sources Sentinel Stroke National Audit Programme data for all patients in London hyperacute stroke units with a primary diagnosis of stroke between 1 January and 31 December 2014, and nurse staffing data for all eight London hyperacute stroke units for the same period. Results We found no variation in quality of care by day and time of admission across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor in 3-day mortality nor disability at hospital discharge. Other quality-of-care measures significantly varied by day and time of admission. Quality of care was better if the nurse in charge was at a higher band and/or there were more nurses on duty. Staff deliver ‘front-door’ interventions consistently by taking on additional responsibilities out of hours, creating continuities between day and night, building trusting relationships and prioritising ‘front-door’ interventions. Limitations We were unable to measure long-term outcomes as our request to the Sentinel Stroke National Audit Programme, the Healthcare Quality Improvement Partnership and NHS Digital for Sentinel Stroke National Audit Programme data linked with patient mortality status was not fulfilled. Conclusions Organisational factors influence 24 hours a day, 7 days a week (24/7), provision of stroke care, creating temporal patterns of provision reflected in patient outcomes, including mortality, length of stay and functional independence. Future work Further research would help to explore 24/7 stroke systems in other contexts. We need a clearer understanding of variations by looking at absolute time intervals, rather than achievement of targets. Research is needed with longer-term mortality and modified Rankin Scale data, and a more meaningful range of outcomes. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 34. See the NIHR Journals Library website for further project information.

Effectiveness of Stroke Early Supported Discharge: Analysis From a National Stroke Registry.

Implementation of stroke early supported discharge (ESD) services has been recommended in many countries' clinical guidelines, based on clinical trial evidence. This is the first observational study to investigate the effectiveness of ESD service models operating in real-world conditions, at scale. Using historical prospective data from the United Kingdom Sentinel Stroke National Audit Programme (January 1, 2016-December 31, 2016), measures of ESD effectiveness were "days to ESD" (number of days from hospital discharge to first ESD contact; n=6222), "rehabilitation intensity" (total number of treatment days/total days with ESD; n=5891), and stroke survivor outcome (modified Rankin scale at ESD discharge; n=6222). ESD service models (derived from Sentinel Stroke National Audit Programme postacute organizational audit data) were categorized with a 17-item score, reflecting adoption of ESD consensus core components (evidence-based criteria). Multilevel modeling analysis was undertaken as patients were clustered within ESD teams across the Midlands, East, and North of England (n=31). A variety of ESD service models had been adopted, as reflected by variability in the ESD consensus score. Controlling for patient characteristics and Sentinel Stroke National Audit Programme hospital score, a 1-unit increase in ESD consensus score was significantly associated with a more responsive ESD service (reduced odds of patient being seen after ≥1 day of 29% [95% CI, 1%-49%] and increased treatment intensity by 2% [95% CI, 0.3%-4%]). There was no association with stroke survivor outcome measured by the modified Rankin Scale. This study has shown that adopting defined core components of ESD is associated with providing a more responsive and intensive ESD service. This shows that adherence to evidence-based criteria is likely to result in a more effective ESD service as defined by process measures. Registration: URL: http://www.isrctn.com/; Unique identifier: ISRCTN15568163.

Factors influencing the amount of therapy received during inpatient stroke care: an analysis of data from the UK Sentinel Stroke National Audit Programme

Objectives: To understand why most stroke patients receive little therapy. We investigated the factors associated with the amount of stroke therapy delivered. Methods: Data regarding adults admitted to hospital with stroke for at least 72 hours (July 2013–July 2015) were extracted from the UK’s Sentinel Stroke National Audit Programme. Descriptive statistics and multilevel mixed effects regression models explored the factors that influenced the amount of therapy received while adjusting for confounding. Results: Of the 94,905 patients in the study cohort (mean age: 76 (SD: 13.2) years, 78% had a mild or moderate severity stroke. In all, 92% required physiotherapy, 87% required occupational therapy, 57% required speech therapy but only 5% were considered to need psychology. The average amount of therapy ranged from 2 minutes (psychology) to 14 minutes (physiotherapy) per day of inpatient stay. Unmodifiable characteristics (such as stroke severity) dominated the variation in the amount of therapy. However important, modifiable organizational factors were the day and time of admission, type of stroke team, timely therapy assessments, therapy and nursing staffing levels (qualified and support staff), and presence of weekend or early supported discharge services. Conclusion: The amount of stroke therapy is associated with unmodifiable patient-related characteristics and modifiable organizational factors in that more therapy was associated with higher therapy and nurse staffing levels, specialist stroke rehabilitation services, timely therapy assessments, and the presence of weekend and early discharge services.

Positive predictive value of stroke identification by ambulance clinicians in North East England: a service evaluation

Introduction/backgroundAccurate prehospital identification of patients who had an acute stroke enables rapid conveyance to specialist units for time-dependent treatments such as thrombolysis and thrombectomy. Misidentification leads to patients who had...

Prevalence of aphasia and dysarthria among inpatient stroke survivors: describing the population, therapy provision and outcomes on discharge

ABSTRACT Background: Stroke causes communication impairments but we lack the real-world population-level data needed to inform inpatient and community services. Aims: To establish prevalence of aphasia and dysarthria within inpatient stroke survivors, describe those affected, the amount of therapy they receive and their outcomes. Methods & Procedures: Secondary analysis of data from the Sentinel Stroke National Audit Programme, England, Wales and Norther Ireland, including inpatient stroke survivors after 72 hours, with completed National Institute of Health Stroke Scale data (communication items), excluding those already discharged, not conscious or with incomplete data. Outcomes & Results: 64% of the 88,974 stroke survivors meeting our criteria were communication impaired: 28% had both aphasia and dysarthria, 24% had dysarthria only and 12% had aphasia only. Those in the older age range and with more severe stroke were more likely to have a communication impairment and had a worse outcome than those without communication impairment. On average, those with both communication impairments had a 21 day length of stay and 10 minutes of speech and language therapy for communication and/or dysphagia per day of stay. Conclusions: Communication impairment is common during the inpatient phase of stroke care yet average therapy provision is below the recommended levels and is likely to include dysphagia assessment and intervention. Dysarthria is reported as more prevalent than aphasia at this early stage, although this is not necessarily diagnosed by a speech and language therapist. The most common presentation is to have a combination of aphasia and dysarthria for which there is limited clinical guidance.

Delivery, dose, outcomes and resource use of stroke therapy: the SSNAPIEST observational study

Background Therapy is key to effective stroke care, but many patients receive little. Objectives To understand how stroke therapy is delivered in England, Wales and Northern Ireland, and which factors are associated with dose, outcome and resource use. Design Secondary analysis of the Sentinel Stroke National Audit Programme, using standard descriptive statistics and multilevel mixed-effects regression models, while adjusting for all known and measured confounders. Setting Stroke services in England, Wales and Northern Ireland. Participants A total of 94,905 adults admitted with stroke, who remained an inpatient for &gt; 72 hours. Results Routes through stroke services were highly varied (&gt; 800), but four common stroke pathways emerged. Seven distinct impairment-based patient subgroups were characterised. The average amount of therapy was very low. Modifiable factors associated with the average amount of inpatient therapy were type of stroke team, timely therapy assessments, staffing levels and model of therapy provision. More (of any type of) therapy was associated with shorter length of stay, less resource use and lower mortality. More occupational therapy, speech therapy and psychology were also associated with less disability and institutionalisation. Large amounts of physiotherapy were associated with greater disability and institutionalisation. Limitations Use of observational data does not infer causation. All efforts were made to adjust for all known and measured confounding factors but some may remain. We categorised participants using the National Institutes of Health Stroke Scale, which measures a limited number of impairments relatively crudely, so mild or rare impairments may have been missed. Conclusions Stroke patients receive very little therapy. Modifiable organisational factors associated with greater amounts of therapy were identified, and positive associations between amount of therapy and outcome were confirmed. The reason for the unexpected associations between large amounts of physiotherapy, disability and institutionalisation is unknown. Prospective work is urgently needed to investigate further. Future work needs to investigate (1) prospectively, the association between physiotherapy and outcome; (2) the optimal amount of therapy to provide for different patient groups; (3) the most effective way of organising stroke therapy/rehabilitation services, including service configuration, staffing levels and working hours; and (4) how to reduce unexplained variation in resource use. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 17. See the NIHR Journals Library website for further project information.

Mechanical thrombectomy in stroke – planning for service expansion using discrete event simulation

Mechanical thrombectomy (MT) is a very effective, but highly time dependent, reperfusion technique in the management of acute ischaemic stroke caused by large artery occlusion. MT is provided by 24 neuroscience centres (NSCs) in the UK which receive patients directly ('mothership') and via transfer from district general hospitals (DGHs), the 'drip and ship' pathway. NSCs currently provide a within hours service but are working on service expansion to enable 24/7 availability. DGHs, too, will need to prepare for this service expansion to ensure good outcomes for their patients. We discuss options for service expansion in a DGH and regional stroke network in south-west England and use Sentinel Stroke National Audit Programme data and discrete event simulation to model and compare alternative workflow options to aid the planning process. We suggest that our modelled options could be considered by all NHS DGHs in their preparation for MT service expansion.

Prestroke Disability Predicts Adverse Poststroke Outcome: A Registry-Based Prospective Cohort Study of Acute Stroke.

Background and Purpose- Information on what effect disability before stroke can have on stroke outcome is lacking. We assessed prestroke disability in relation to poststroke hospital outcome. Methods- Analysis of prospectively collected data from the Sentinel Stroke National Audit Programme. A total of 1656 men (mean age ±SD =73.1±13.2 years) and 1653 women (79.3±13.0 years) were admitted to hyperacute stroke units with acute stroke in 4 major UK between 2014 and 2016. Prestroke disability, assessed by modified Rankin Scale (mRS), was tested against poststroke adverse outcomes, adjusted for age, sex, and coexisting morbidities. Results- Compared with patients with prestroke mRS score =0, individuals with prestroke mRS scores =3, 4, or 5 had greater adjusted risks of moderately severe or severe stroke on arrival (4.4% versus 16.7%; odds ratio [OR], 3.2 [95% CI, 2.3-4.6] P<0.001); urinary tract infection or pneumonia within 7 days of admission (9.6% versus 35.9%; OR, 3.7 [95% CI, 2.8-4.8] P<0.001); mortality (7.2% versus 37.1%; OR, 4.9 [95% CI, 3.7-6.5] P<0.001); requiring help with activities of daily living on discharge (12.3% versus 26.7%; OR, 3.1 [95% CI, 2.3-4.1] P<0.001); and transferred to new care home (2.4% versus 9.4%; OR, 2.1 [95% CI, 1.3-3.3] P=0.002). Patients with mRS scores =1 or 2 had intermediate risk of adverse outcomes. Overall, those with a mRS score =1 or 2 had length of stay on hyperacute stroke units extended by 5.3 days (95% CI, 2.8-7.7; P<0.001) and mRS score =3, 4 or 5 by 7.2 days (95% CI, 4.0-10.5; P<0.001). Conclusions- Individuals with evidence of prestroke disability, assessed by mRS, had significantly increased risk of poststroke adverse outcomes and longer length of stay on hyperacute stroke units and higher level of care on discharge.

Spatial Neglect in Stroke: Identification, Disease Process and Association with Outcome During Inpatient Rehabilitation.

We established spatial neglect prevalence, disease profile and amount of therapy that inpatient stroke survivors received, and outcomes at discharge using Sentinel Stroke National Audit Programme (SSNAP) data. We used data from 88,664 National Health Service (NHS) admissions in England, Wales and Northern Ireland (July 2013–July 2015), for stroke survivors still in hospital after 3 days with a completed baseline neglect National Institute for Health Stroke Scale (NIHSS) score. Thirty percent had neglect (NIHSS item 11 ≥ 1) and they were slightly older (78 years) than those without neglect (75 years). Neglect was observed more commonly in women (33 vs. 27%) and in individuals with a premorbid dependency (37 vs. 28%). Survivors of mild stroke were far less likely to present with neglect than those with severe stroke (4% vs. 84%). Those with neglect had a greatly increased length of stay (27 vs. 10 days). They received a comparable amount of average daily occupational and physiotherapy during their longer inpatient stay but on discharge a greater percentage of individuals with neglect were dependent on the modified Rankin scale (76 vs. 57%). Spatial neglect is common and associated with worse clinical outcomes. These results add to our understanding of neglect to inform clinical guidelines, service provision and priorities for future research.

P6542Early Prolonged Ambulatory Cardiac monitoring in Stroke (EPACS): an open-label randomised controlled trial and economic evaluation

Abstract Background Cardioembolism in paroxysmal atrial fibrillation (PAF) is a preventable cause of transient ischaemic attack (TIA) or ischaemic stroke, however, due its transient nature, a short-duration Holter monitor may miss a significant proportion of events. Methods We conducted an open-label randomised controlled trial of cardiac monitoring after a TIA or ischaemic stroke comparing a 14-day ECG monitoring patch with short-duration Holter monitoring for the detection of PAF. The primary outcome was the detection of one or more episodes of ECG-documented PAF lasting at least 30 seconds within 90 days in each of the study arms. A budget impact analysis from the healthcare perspective was performed to assess the theoretical economic implications of the patch-based service versus Holter monitoring. Based on the AF detection rates found in this study, Hospital Episode Statistics data for the incidence of stroke and TIA (October 2016-September 2017) and National Health Service reference costs, the cost-effectiveness of the patch-based service versus Holter monitoring was calculated. The Sentinel Stroke National Audit Programme estimate of £13,452 was used as the mean year one direct medical cost of a stroke. Results From February 2016 through February 2017, 43 (76.8%) of the 56 patients assigned to the patch-based monitoring group and 47 (78.3%) of the 60 patients assigned to the short-duration Holter monitoring group had successful monitor placement with 90 days of follow-up (Figure 1). Of the 26 protocol failures between the two groups, 23 (88.5%) were due to patient refusal for outpatient short-duration Holter monitor placement, whilst only 1 (3.8%) was due to unsuccessful patch placement. The rate of detection of PAF at 90 days was 16.3% in the patch-based monitoring group (7 patients) compared to 2.1% in the short-duration Holter monitoring group (1 patient), with an odds ratio of 8.9 (95% CI 1.1–76.0; P=0.026). Implementation of the patch-based service at our hospital would result in 10.8 more strokes avoided per year compared to current practice with short-duration Holter monitoring. This would equate to a yearly saving in direct medical costs of £57,481, increasing to £106,342 over 5 years. When social care costs are included, incremental savings of £154,716 can be achieved in the first year and £410,449 at 5 years. In addition, an analysis of the potential reduction in outpatient follow-up appointment costs resulted in a further saving of £56,149, giving a total potential saving of £113,630 over the first year with the use of the patch-based service compared to short-duration Holter monitoring, increasing to £162,491 over 5 years. Figure 1. Study participant flowchart Conclusions Early, prolonged, patch-based monitoring after an index stroke or TIA is superior to short-duration Holter monitoring in the detection of PAF and likely cost-effective for preventing recurrent strokes. Acknowledgement/Funding Bristol-Myers Squibb-Pfizer alliance (Grant Number CV185-475)

P3732Proportion of acute ischaemic strokes attributable to cardiac causes in an all-comer population of young patients

Abstract Introduction The incidence of stroke in young patients is increasing and is associated with significant morbidity, mortality and socioeconomic cost. Identifying potential underlying causes is central to their overall management to reduce recurrence and improve long-term outcomes. A proportion of these patients are found to have an underlying cardiac cause including atrial fibrillation (AF), patent foramen ovale (PFO) or an intracardiac source of embolus. This area has recently gained greater interest with evidence demonstrating a significant reduction in recurrent ischaemic events following PFO closure. The identification of these patients however, requires extensive investigation and has implications relating to cardiology resources. Outside of clinical trials the true incidence of these patients in a “real-world” population is poorly defined. Purpose The aim of this study was to determine the proportion of strokes attributable to cardiac causes in young patients presenting with ischaemic stroke. Methods The Sentinel Stroke National Audit Programme (SSNAP) database of a large UK stroke service was used to identify patients ≤55 years old presenting with stroke between 1/1/15 and 31/12/17. Clinical letters, imaging reports and laboratory reports were reviewed. Patients were then categorised by cause of stroke using the Trial of Acute Stroke Treatment (TOAST) criteria. Cardiac causes of stroke were defined as: AF, PFO and intracardiac source of embolus. Patients presenting with a haemorrhagic stroke or where an alternate diagnosis to stroke was more likely were excluded. Results During the study period, 206 patients were identified as having suffered a stroke. 35 patients were excluded resulting in a final study population of 171 patients (Figure). 24% (41/171) were identified as having a cardiac cause of stroke including 9.4% (16/171) PFO, 8.8% (15/171) intracardiac source of embolus and 5.8% (10/171) atrial fibrillation. 50.3% (86/171) were thought to have other causes: 24.6% (42/171) small vessel disease; 9.4% (16/171) large artery atherosclerosis; and 16.4% (28/171) other determined aetiology including 5.1% (8.8/171) with arterial dissection. 25.7% (44/171) presented with a stroke but with no clear underlying cause found. Causes of stroke in young patients Conclusion A high proportion (24%) of strokes in young patients were found to be likely secondary to a cardiac cause. With the significant benefit of intervention (medical or procedural) in this patient group, the resource provision allocated to this population does appear to be warranted and further demonstrates the importance of close interdisciplinary links between cardiologists and stroke physicians.

An Observational Cohort Study Investigating Risk of Malnutrition Using the Malnutrition Universal Screening Tool in Patients with Stroke

Background: Malnutrition in patients hospitalized with a stroke have been assessed using different nutritional screening methods but there is a paucity of data linking risk of malnutrition to clinical outcomes using a validated tool. Aims: To identify the prevalence of malnutrition risk in patients after a stroke and assess the predictive value of the Malnutrition Universal Screening Tool (MUST) on clinical outcomes. Patients and Methods: Using data from electronic records and the Sentinel Stroke National Audit Programme (January 2013 and March 2016), patients aged more than 18 years with confirmed stroke admitted to a tertiary care stroke unit were assessed for risk of malnutrition. The association between malnutrition risk and clinical outcomes was investigated and adjusted for confounding variables. Results: Of 1101 patients, 66% were screened at admission. Most patients (n = 571, 78.5%) were identified as being at low risk, 4.1% (n = 30) at medium risk, and 17.4% (n = 126) at high risk of malnutrition. Compared with low risk, patients with medium or high risk of malnutrition were more likely to have a longer hospital stay (IRR 1.30, 95% confidence interval [CI] 1.07, 1.58), and had greater risk of mortality (10.9% versus 3.5%, 95% CI .03, .13). Conclusions: Prevalence of malnutrition assessed by MUST in patients after a stroke was relatively low, but nearly a third of patients were not screened. Patients classified as being at medium or high risk of malnutrition were more likely to experience negative outcomes. Early identification of this population may improve outcome if appropriate care is provided.