Stroke Care Delivery Research Articles

Reimagining Cryptogenic Stroke Care: Collaborative Care and Inpatient Insertable Cardiac Monitors for Detection of Atrial Fibrillation

BACKGROUND Atrial fibrillation (AF) is a known risk factor of ischemic stroke, and AF‐related stroke is twice more likely to be fatal. Long‐term cardiac rhythm monitoring using insertable cardiac monitors (ICMs) has greater diagnostic yield compared with conventional monitoring in detecting AF, and the clinical utility of ICMs is established in cryptogenic stroke, strokes attributable to large‐artery atherosclerosis, and strokes attributable to small‐vessel disease. A registry‐based study was conducted to evaluate the inpatient implantation of ICMs and the feasibility of vascular and interventional neurologists as implanters using novel collaborative clinical care pathway for cryptogenic stroke. METHODS Multiyear data from a hospital‐based registry at a comprehensive stroke center were reviewed to evaluate inpatient ICM implantation and test feasibility of vascular and interventional neurologists as implanters of ICMs together with cardiology using a novel collaborative care pathway. Reviewed data included the number of ICMs, implantation trend, inpatient versus outpatient setting, time to ICM implantation, inpatient workflow, including defined roles of team members, and AF detection rate. RESULTS A total of 290 ICMs for cryptogenic stroke were implanted when patients were in the hospital and 78 as outpatients after discharge during the study period of 3 years. Most inpatient ICM implants were performed by vascular and interventional neurology (n = 181), and ICM use for cryptogenic stroke increased by 130%. The average time to inpatient ICM implant was 4.1 days, with 77% in 5 days and 95.5% within 10 days poststroke. The average time to out‐patient ICM placement was 57 days. AF detection rate of 36.5% was noted at 24 months with a collaborative care pathway. CONCLUSION Inpatient implantation of ICMs is feasible and was performed safely and efficiently by vascular and interventional neurology together with cardiology using a collaborative care pathway. An increase in use of ICMs and higher AF detection rates were noted. Findings support innovative efforts to improve access and close the gaps in the delivery of cryptogenic stroke care to ultimately reduce the secondary stroke burden.

Influence of Stroke-Onset Location on the Efficacy of Endovascular Thrombectomy: Comparison of Outcomes between In-Hospital versus Community-Onset Strokes.

Previous studies have suggested that patients experiencing an in-hospital stroke may face delays in treatment and worse outcomes compared with patients with community-onset strokes. However, most studies occurred when IV thrombolysis was the primary treatment. This study aimed to examine the outcomes of patients experiencing an in-hospital stroke in the endovascular thrombectomy era. This was a single-center retrospective cohort study of patients older than 18 years of age with acute ischemic stroke treated with endovascular thrombectomy within 12 hours of stroke onset from January 1, 2015, to April 30, 2021. Patients were classified into 2 groups: in-hospital strokes and community-onset strokes. We compared the time metrics of stroke care delivery, the rate of successful reperfusion, and functional outcome as scored using the mRS score at 90 days (favorable outcome was defined as mRS 0-2). Differences in proportions were assessed using the Fisher exact and χ2 tests as appropriate. For continuous variables, differences in medians between groups were evaluated using Mann-Whitney U tests. A total of 676 consecutive patients were included, with 69 (10%) comprising the in-hospital stroke group. Patients experiencing in-hospital stroke were more likely to have diabetes (36% versus 18%, P = .02) and less likely to receive thrombolysis (25% versus 68%, P < .001) than those in the community-onset stroke group, but they were otherwise similar. Patients with in-hospital stroke had significantly faster overall time metrics, most notably from stroke recognition to imaging (median, 70 [interquartile range, 38-141] minutes versus 121 [74-228] minutes, P < .001). Successful recanalization was achieved in >75% in both groups (P = .39), with a median NIHSS score at discharge of <4 (P = .18). The 90-day mRS was similar in both groups, with a trend toward higher in-hospital mortality in the in-hospital stroke group (P = .06). Patients with in-hospital stroke had shorter workflow delays to initiation of endovascular thrombectomy compared with their community counterparts but with a similar rate of successful recanalization and clinical outcomes. Most important, 90-day mortality and mRS scores were equivalent between in-hospital stroke and community-onset stroke groups.

Nurse-Led Novel Stroke Response Unit Improves Door-to-Needle Metrics and Patient Outcomes

BackgroundTimely treatment of stroke patients is critical for improving outcomes. Emergency Department-Stroke Response Units (ED-SRUs) have emerged as effective models for enhancing stroke care. PurposeThis study aims to describe the implementation and outcomes of a specialty nurse-led ED-SRU staffed by highly trained neuroscience specialty nurses. MethodWe analyzed the collaboration between neuroscience and emergency-trained nurses in the ED-SRU and its impact on stroke treatment metrics, focusing on door-to-needle time for intravenous thrombolytics. FindingsThe implementation of the ED-SRU resulted in a significant reduction in door-to-needle times, allowing the hospital to surpass national benchmarks for timely stroke treatment. DiscussionThe success of the ED-SRU underscores the importance of interdisciplinary nursing in effectively triaging and caring for complex stroke patients. This model can serve as a framework for other institutions aiming to enhance stroke care delivery.

Starting continuous improvement; creating a common understanding of stroke care delivery in a general hospital

BackgroundContinuous improvement is based on fostering practitioners’ suggestions to modify their own work processes This improvement strategy is widely applied in healthcare but difficult to maintain. The cross-disciplinary nature of many care processes constitutes an extra impediment.MethodsThe study had an explorative design with a qualitative single-case approach. The case presents a project to improve the treatment of patients with thrombotic stroke. Data was obtained via hands on involvement, documents, observations, and interviews with participants in a cross-functional improvement group. A thematic analysis method was employed.ResultsThrough learning how tasks were carried out in other disciplines, the participants developed a common understanding of why it took so long to provide treatment to stroke patients. These insights were used to implement practical changes, leading to immediate improvements in stroke care delivery. The results were fed back so that successes became visible. Participants’ understandings of the local context enabled them to convince peers of the rationale of changes, setting in motion a permanent improvement structure. The participants considered that mapping and then assessing the entire workflow across disciplines were relevant methods for improving the quality of patient care.ConclusionStarting an improvement project in a cross disciplinary environment requires deep engagement on the part of professionals. A quintessential prerequisite is therefore the realization that the quality of care depends on cross-disciplinary cooperation. A facilitated learning arena needs to (1) create insights into each other’s colleagues’ tasks and process interdependencies, (2) increase understanding of how the distribution of tasks among specialist units affects the quality of care, and (3) frequently report and provide feedback on results to keep the process going.

Stroke 5.0: A Technology Ecosystem to Support Acute Stroke Integrated Clinical Management.

Stroke remains a significant global health burden, with substantial costs and morbidity associated with its occurrence. To address this challenge, STROKE 5.0 proposes a comprehensive approach to stroke care management, integrating advanced digital technologies and clinical expertise. This paper presents the rationale, design, and potential impact of the STROKE 5.0 platform, which aims to optimize stroke care delivery from pre-hospital assessment through acute hospitalization. The platform facilitates early symptom recognition, efficient emergency response, and streamlined hospital management through intelligent decision support systems. By leveraging predictive analytics and personalized care pathways, STROKE 5.0 seeks to enhance clinical outcomes while providing a platform capable of optimizing the efficiency of service delivery. This innovative model represents a proactive shift towards evidence-based, patient-centered stroke care, with implications for healthcare quality improvement and resource allocation in the digital health domain.

Impact of a novel pre-hospital stroke notification programme on acute stroke care key performance indicators in Hong Kong: a multicentre prospective cohort study with historical controls.

Early identification and initiation of reperfusion therapy is essential for suspected acute ischaemic stroke. A pre-hospital stroke notification (PSN) protocol using FASE (facial drooping, arm weakness, speech difficulties, and eye palsy) was implemented to improve key performance indicators (KPIs) in acute stroke care delivery. We assessed KPIs and clinical outcomes before and after PSN implementation in Hong Kong. This prospective cohort study with historical controls was conducted in the Accident and Emergency Departments of four public hospitals in Hong Kong. Patients were screened using the PSN protocol between August 2021 and February 2022. Suspected stroke patients between August 2020 and February 2021 were included as historical controls. Door-to-needle (DTN) and door-to-computed tomography (DTC) times before and after PSN implementation were compared. Clinical outcomes including National Institutes of Health Stroke Scale score at 24 hours and modified Rankin Scale score at 3 months after intravenous recombinant tissue-type plasminogen activator (IV-rtPA) were also assessed. Among the 715 patients (266 PSN and 449 non-PSN) included, 50.8% of PSN patients and 37.7% of non-PSN patients had a DTC time within 25 minutes (P<0.001). For the 58 PSN and 134 non-PSN patients given IV-rtPA, median DTN times were 67 and 75.5 minutes, respectively (P=0.007). The percentage of patients with a DTN time within 60 minutes was higher in the PSN group than in the non-PSN group (37.9% vs 21.6%; P=0.019). No statistically significant differences in clinical outcomes were observed. Although the PSN protocol shortened DTC and DTN times, clinical outcomes did not significantly differ.

Use of Adult Gerontology Acute Care Nurse Practitioners on a Neurocardiology Team

The neurocardiology team provides innovative, evidence-based care for patients with cryptogenic stroke, stroke associated with a patent foramen ovale, and atrial fibrillation-related stroke in patients unsuitable for long-term anticoagulation. Considerable evidence supports the value of advanced practice registered nurses on process improvement metrics and clinical outcomes; however, current literature in stroke management almost exclusively emphasizes interdisciplinary collaboration between physicians. This clinical feature discusses ways in which the adult gerontology acute care nurse practitioner can aid in the delivery of evidence-based stroke care and contribute to educational, administrative, and research missions as a collaborative member of a multidisciplinary neurocardiology team.

Service delivery in acute ischemic stroke patients: Does sex matter?

Women with acute ischemic stroke (AIS) are older and have greater preexisting handicap than men. Given that these factors do not fully explain their poorer long-term outcomes, we sought to investigate potential sex differences in the delivery of acute stroke care in a large cohort of consecutive AIS patients. We analyzed all patients from ASTRAL (Acute Stroke Registry and Analysis of Lausanne) from March 2003 to December 2019. Multivariable analyses were performed on acute time metrics, revascularization therapies, ancillary examinations for stroke workup, subacute symptomatic carotid artery revascularization, frequency of change in goals of care (palliative care), and length of hospital stay. Of the 5347 analyzed patients, 45% were biologically female and the median age was 74.6 years. After multiple adjustments, female sex was significantly associated with higher onset-to-door (adjusted hazard ratio [aHR] = 1.09, 95% confidence interval [CI] = 1.04-1.14) and door-to-endovascular-puncture intervals (aHR = 1.15, 95% CI = 1.05-1.25). Women underwent numerically fewer diagnostic examinations (adjusted odds ratio [aOR] = 0.94, 95% CI = 0.85-1.04) and fewer subacute carotid revascularizations (aOR = 0.69, 95% CI = 0.33-1.18), and had longer hospital stays (aHR = 1.03, 95% CI = 0.99-1.07), but these differences were not statistically significant. We found no differences in the rates of acute revascularization treatments, or in the frequency of change of goals of treatments. This retrospective analysis of a large, consecutive AIS cohort suggests that female sex is associated with unfavorable pre- and in-hospital time metrics, such as a longer onset-to-door and door-to-endovascular-puncture intervals. Such indicators of less effective stroke care delivery may contribute to the poorer long-term functional outcomes in female patients and require further attention.

Reporting and analysis of process-of-care time measures in clinical trials for hyperacute stroke interventions: a scoping review protocol.

The objective of this scoping review is to investigate the reporting and comparison of process-of-care time measures in hyperacute stroke trials and systematic reviews of trials (subsequently referred to as "studies"). Stroke is a leading cause of death and disability worldwide. A crucial factor in determining the effectiveness of stroke care in improving patient outcomes is time; therefore, time measures are frequently reported in studies of hyperacute stroke interventions. However, there is inconsistency in how these measures are reported and compared. Furthermore, there is a lack of clarity in how compatible the reporting methods are with the statistical analysis methods. This scoping review will include studies that report and/or compare time measures between key events of interest in the delivery of hyperacute stroke care. Studies of thrombolytic therapy and/or thrombectomy, as well as controlled trials of mobile stroke unit interventions, will be included. The scoping review will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) and the JBI methodology for scoping reviews. The search will be executed in MEDLINE (PubMed), Embase (Ovid), and clinical trial registries ANZCTR, ISRCTN, and ClinicalTrials.gov. Title and abstract screening will be followed by full-text screening and subsequent data extraction from eligible studies. The results from this scoping review will be presented in tables and narratively summarized. Open Science Framework https://osf.io/y98wz.

“Coming home was a disaster, I didn’t know what was going to happen”: a qualitative study of survivors’ and family members’ experiences of navigating care post-stroke

Purpose Understanding navigational barriers and facilitators has the potential to advance equitable stroke care delivery. The aim of this study was to explore, using a qualitative study, the experiences of stroke survivors and their families as they journey through the stroke care system, both before and during the COVID-19 pandemic. Methods In-depth semi-structured interviews were conducted with 18 stroke survivors and 12 family members during 2021 and 2022. Participants were recruited through voluntary organisations, social media, and stroke support groups. Data analysis followed a systematic process guided by the framework method with steps including familiarisation, coding, framework development, and charting and interpretation. Results The experiences of navigating stroke care were particularly challenging following discharge from hospital into the community. Barriers to stroke care continuity included insufficient appropriate services and information, unsatisfactory relationships with healthcare professionals and distressed mental health. There were particular navigational challenges for survivors with aphasia. Facilitators to effective navigation included having prior knowledge of the health system, harnessing support for care co-ordination, and being persistent. Conclusion Greater support for patient navigation, and person-centred referral pathways, particularly during times of increased pressure on the system, have the potential to improve access to services and wellbeing among stroke survivors.

Abstract TP115: Stroke Metrics Reporting to Hospital Leadership Advances Thrombolysis and Thrombectomy Rates in a Competitive Region: Analysis of SETRAC Registry

Background: The SouthEast Texas Regional Advisory Council (SETRAC) has actively engaged representatives from regional healthcare systems who collectively work towards advancing stroke care delivery. SETRAC has demonstrated its efficacy in improving thrombolysis rates in patients with acute ischemic stroke. We analyzed our regional data from 2014-2023 to evaluate the continued efficacy of acute stroke care. Hypothesis: We hypothesized that consistently and periodically reporting acute stoke metrics to the hospital leaders in a competitive environment improves acute stroke care as measured by: a) Percentage of patients receiving thrombolysisb) Time to receive thrombolysisc) Percentage of patients receiving thrombectomy Methods: We analyzed the stroke care metrics of our regional centers from the Get With The Guidelines (GWTG)®-Stroke registry. SETRAC stroke committee compiled and shared this data with the coordinators and hospital administrators on a quarterly basis. Blinded metrics were shared utilizing visual tools such as bar graphs. We performed linear analyses to evaluate the increase in the percentage of patients receiving thrombolysis, and those treated within 45 minutes. Results: 31 hospitals reported treating a total of 93,688 patients from 2014-2023. The rates of thrombolysis increased from 7.10% in 2014 to 11.8% in 2023 (p&lt;0.001). We also observed that the mean time to thrombolysis decreased from 66 minutes in 2014 to 48 minutes in 2023 (p-value &lt;0.001). We also observed that the percentage of patients who received endovascular intervention significantly increased from 0.02% to 6.2% (p-value&lt;0.001). Conclusion: In our community-facing approach, we demonstrated that engaging hospital leadership and utilizing structured GWTG metrics and consistent reporting resulted in higher proportions of patients receiving thrombolysis and thrombectomy.

Abstract 94: Sex Disparities in a Telestroke Network: From Treatment Times to Outcomes

Background: The structure of the stroke care delivery system in rural South Carolina has been changed by the Medical University of South Carolina tele-stroke program with &gt;40 spoke sites with improved treatment times and outcomes overall. Disparities at the level of primary stroke centers and acute stroke ready hospitals have not been well studied. The aim of this study is to retrospectively analyze data from the tele-stroke network for sex differences in stroke care processes at spoke sites to identify disparities in treatment times and outcomes between men and women. Methods: Data was collected and analyzed for 21,549 patients between 1/1/2012 and 12/31/2022 for whom a telestroke was paged out. Statistical analysis was completed using SPSS version 28 (IBM corporation, Armonk, NY). Variables with continuous outcomes were assessed using independent samples median tests and categorical variables were assessed using X 2 . Results: Of 10,713 (49.7%) males and 10,836 (50.3%) females, females were older (68.29±15.5 vs 66.09±13.7, p&lt;0.01) and more likely to be to be African American (20.4% vs16.8%, p&lt;0.05) as compared to males. Females were more likely to get thrombolytic therapy (29.06% vs 27.2%, p&lt;0.05) but there was no difference in endovascular therapy between both sexes. Treatment times showed that door-to-registration timing (F: 18±27 vs M: 17±26, p&lt;0.05) and door to telestroke page timing (F: 22±27 vs M: 20±26, p&lt;0.05) was significantly higher in females compared to males with ultimately door to needle time having the expected disparity between men and women (F: 59±36 vs M: 55±35, p&lt;0.05). Women also had significantly higher mean discharge NIHSS (M: 4.17±6.20 vs F: 4.61±6.70 (p&lt;0.001) and mRS score (M:2.24±1.93 vs F:2.43±1.95 (p&lt;0.001)). More males were discharged home (62.4% vs 60.4%, (p&lt;0.001) and more females were discharged to nursing home (8.1% vs 6.2%, p&lt;0.001) and hospice (3.9% vs 2.9%, p&lt;0.001) post admission. Conclusions: Females are older at the time of stroke onset, have longer times to treatment and poorer outcomes and discharge dispositions. Our findings highlight the opportunities to ameliorate sex disparities in developing telestroke networks in the United States. Future studies should target these disparities to improve outcomes.

Abstract HUP10: Sex Disparities In A Telestroke Network: From Treatment Times To Outcomes

Background: The structure of the stroke care delivery system in rural South Carolina has been changed by the Medical University of South Carolina tele-stroke program with &gt;40 spoke sites with improved treatment times and outcomes overall. Disparities at the level of primary stroke centers and acute stroke ready hospitals have not been well studied. The aim of this study is to retrospectively analyze data from the tele-stroke network for sex differences in stroke care processes at spoke sites to identify disparities in treatment times and outcomes between men and women. Methods: Data was collected and analyzed for 21,549 patients between 1/1/2012 and 12/31/2022 for whom a telestroke was paged out. Statistical analysis was completed using SPSS version 28 (IBM corporation, Armonk, NY). Variables with continuous outcomes were assessed using independent samples median tests and categorical variables were assessed using X 2 . Results: Of 10,713 (49.7%) males and 10,836 (50.3%) females, females were older (68.29±15.5 vs 66.09±13.7, p&lt;0.01) and more likely to be to be African American (20.4% vs16.8%, p&lt;0.05) as compared to males. Females were more likely to get thrombolytic therapy (29.06% vs 27.2%, p&lt;0.05) but there was no difference in endovascular therapy between both sexes. Treatment times showed that door-to-registration timing (F: 18±27 vs M: 17±26, p&lt;0.05) and door to telestroke page timing (F: 22±27 vs M: 20±26, p&lt;0.05) was significantly higher in females compared to males with ultimately door to needle time having the expected disparity between men and women (F: 59±36 vs M: 55±35, p&lt;0.05). Women also had significantly higher mean discharge NIHSS (M: 4.17±6.20 vs F: 4.61±6.70 (p&lt;0.001) and mRS score (M:2.24±1.93 vs F:2.43±1.95 (p&lt;0.001)). More males were discharged home (62.4% vs 60.4%, (p&lt;0.001) and more females were discharged to nursing home (8.1% vs 6.2%, p&lt;0.001) and hospice (3.9% vs 2.9%, p&lt;0.001) post admission. Conclusions: Females are older at the time of stroke onset, have longer times to treatment and poorer outcomes and discharge dispositions. Our findings highlight the opportunities to ameliorate sex disparities in developing telestroke networks in the United States. Future studies should target these disparities to improve outcomes.

The impact of hospital presentation time on stroke outcomes: A nationally representative Irish cohort study.

There is conflicting evidence regarding the outcomes of acute stroke patients who present to hospital within normal working hours ('in-hours') compared with the 'out-of-hours' period. This study aimed to assess the effect of time of stroke presentation on outcomes within the Irish context, to inform national stroke service delivery. A secondary analysis of data from the Irish National Audit of Stroke (INAS) from Jan 2016 to Dec 2019 was carried out. Patient and process outcomes were assessed for patients presenting 'in-hours' (8:00-17:00 Monday-Friday) compared with 'out-of-hours' (all other times). Data on arrival time were available for 13,996 patients (male 56.2%; mean age 72.5 years), of which 55.7% presented 'out-of-hours'. In hospital mortality was significantly lower among those admitted 'in-hours' (11.3%, n = 534) compared with 'out-of-hours' (12.8%, n = 749); (adjusted Odds Ratio (OR) 0.82; 95% Confidence Interval CI [95% CI] 0.72-0.89). Poor functional outcome at discharge (Modified Rankin Scale ≥ 3) was also significantly lower in those presenting 'in-hours' (adjusted OR 0.79; 95% CI 0.68-0.91). In patients receiving thrombolysis, mean door to needle time was shorter for 'in-hours' presentation at 55.8 mins (n = 562; SD 35.43 mins), compared with 'out-of-hours' presentation at 80.5 mins (n = 736; SD 38.55 mins, p < .001). More than half of stroke patients in Ireland present 'out-of-hours' and these presentations are associated with a higher mortality and a lower odds of functional independence at discharge. It is imperative that stroke pathways consider the 24 hour period to ensure the delivery of effective stroke care, and modification of 'out-of-hours' stroke care is required to improve overall outcomes.

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

Background: Worldwide, Stroke remains the second leading cause of death and the third leading cause of disability. Adequate treatment of stroke is key in the reduction of mortality and morbidity. Management of acute ischemic stroke implicates an evidence-based and multidisciplinary approach. However, integrated care and evaluation of this care process is still a major concern for healthcare professionals, managers, researchers and policymakers in many European countries. Currently, there is an abundance of guidelines describing the care for patients with ischemic stroke. The purpose of these guidelines is offering an easy way of access to evidence-based recommendations, to guide ischemic stroke care planning and delivery across the continuum of care. But it remains difficult to translate the enormous amount of recommendations into care pathways that can be used for patients with ischemic stroke.&#x0D; Aim and target audience: We aim to aid healthcare professionals in developing and evaluating care pathways for patients with ischemic stroke by giving them an overview of the most important recommendations and quality indicators for the different parts of the stroke care process.&#x0D; Materials and Methods: A systematic literature search was conducted in PubMed, from 2014 up to May 2021. The search string was designed on the basis of Medical Subject Heading (MeSH) terms. These included “ischemic stroke” and “guideline” and included all relevant synonyms of these terms. Papers were included if they described the entire care process from admission to the emergency department until discharge from a neuro-related ward. In total, 18 papers were included in this systematic review.&#x0D; Results: In total, 50 recommendations were extracted from the included papers. These recommendations could be divided into four clinical categories: 6 recommendations were subdivided into diagnostic recommendations, 7 into therapeutic, 26 recommendations are part of nursing care, 8 of post stroke rehabilitation and 5 structural recommendations were identified. Administration of thrombolysis was the most common used recommendation (16/18), followed by imaging via CT-scan (15/18), management of glucose (15/18) and blood pressure (15/18) and performing thrombectomy (15/18). The least frequently mentioned recommendations are: differential diagnosis, seizures assessment, early carotid imaging, advanced care planning, treatment of concomitant diseases and tobacco use counselling. They were each mentioned in only one of the 18 included papers. As there is currently a lot of variation on indicator definitions in the literature, making uniform comparisons difficult, we formulated indicator definitions for the most important recommendations. And in addition, we provide information on the validity, feasibility and actionability of these indicators in clinical practice.&#x0D; Practice implications: Our systematic literature search provides tools for healthcare professionals when they want to evaluate their entire or a part of the care pathway for patients with ischemic stroke. Furthermore, we provide an answer to the current variation in indicators for the evaluation of the stroke care process.&#x0D; Next steps: Future research can evaluate whether these recommendations and accompanying indicators are useful in practice and can identify which indicators are most important in stroke care pathways.&#x0D;

Regionalization of stroke systems of care in the stroke belt states: The IMPROVE stroke care quality improvement program

Despite guidelines and strong evidence supporting intravenous thrombolysis and endovascular thrombectomy for acute stroke, access to these interventions remains a challenge. The objective of the IMPROVE stroke care program was to accelerate acute stroke care delivery by implementing best practices and improving the regional systems of care within comprehensive stroke networks. The IMPROVE Stroke Care program was a prospective quality improvement program based on established models used in acute coronary care. Nine hub hospitals (comprehensive stroke centers), 52 regional/community referral hospitals (spokes), and over 100 emergency medical service agencies participated. Through 6 regional meetings, 49 best practices were chosen for improvement by the participating sites. Over 2 years, progress was tracked and discussed weekly and performance reviews were disseminated quarterly. Data were collected on 21,647 stroke code activations of which 8,502 (39.3%) activations had a final diagnosis of stroke. There were 7,226 (85.0%) ischemic strokes, and thrombolytic therapy was administered 2,814 times (38.9%). There was significant overall improvement in the proportion that received lytic therapy within 45 minutes (baseline of 44.6%-60.4%). The hubs were more frequently achieving this at baseline, but both site types improved. A total of 1,455 (17.1%) thrombectomies were included in the data of which 401 (27.6%) were transferred from a spoke. There was no clinically significant change in door-to-groin times for hub-presenting thrombectomy patients, however, significant improvement occurred for transferred cases, 46 minutes (interquartile range [IQR] 36, 115.5) at baseline to 27 minutes (IQR 10, 59). The IMPROVE program approach was successful at improving the delivery of thrombolytic intervention across the consortium at both spoke and hub sites through collaborative efforts to operationalize guideline-based care through iterative sharing of performance and best practices for implementation. Our approach allowed identification of both opportunities for improvement and operational best practices providing guidance on how best to create a regional stroke care network and operationalize the published acute stroke care guidelines.

Applying the World Stroke Organization roadmap in planning a model for stroke service implementation in Matrouh Governorate-Egypt: a World Stroke Organization young future stroke leaders’ analytical study

BackgroundThe global incidence of stroke is on the rise, primarily due to an increase in the aging population and the prevalence of vascular risk factors among the elderly. However, stroke is a treatable condition if promptly recognized and managed effectively. To optimize stroke management, it is crucial to establish a well-prepared infrastructure comprising adequately trained physicians working in collaboration with multidisciplinary teams. Equipped stroke units, easily accessible emergency medical services with a stroke code, and interconnected telestroke networks, further enhance stroke care delivery. Along with the current study, conducted by a task force from the World Stroke Organization’s Future Stroke Leaders Program, an assessment of the stroke infrastructure within Matrouh governorate in Egypt for stepwise implementation of stroke services, based on the World Stroke Organization’s stroke roadmap took place. The study consisted of two levels: Level One involved analyzing existing gaps that may impede the implementation of stroke services, while Level Two proposed strategies to address these gaps using a problem-solving approach.ResultsThe study identified the Matrouh governorate as a suitable region for stroke service implementation. The region exhibits a blend of urban and rural areas and is geographically distant from major healthcare centers. Matrouh also possesses a diverse population, subject to seasonal variations. Currently, it offers a mix of minimum and essential stroke services, which can be expanded and improved through a step-by-step approach guided by the World Stroke Organization’s stroke roadmap.ConclusionsMapping stroke infrastructures allows for the identification of potential gaps to optimize the potential for implementation of stroke services.

Mobile point-of-care MRI demonstration of a normal volunteer in a telemedicine-equipped ambulance

ObjectiveSeveral centers have implemented ambulances equipped with CT scanners and telemedicine capabilities, known as mobile stroke units (MSU), to expedite acute stroke care delivery in the pre-hospital setting. While MSUs have been shown to improve outcomes compared with standard emergency medical management, there are limitations to incorporating CT, including radiation exposure to emergency medical services personnel. Recently, a portable, low-field strength MRI (Swoop®, Hyperfine, Inc., Guilford, CT) received FDA clearance for in-hospital use. Here, as proof-of-concept, we explore the possibility of performing MRI in a telemedicine-equipped ambulance during active transport. Materials and MethodsIn this initial technical demonstration, we imaged an MR phantom and a normal human volunteer using a standard stroke protocol during active ambulance transport. ResultsImages of the MR phantom and volunteer were successfully obtained and were immediately available for viewing in the hospital PACS system. The images were deemed of diagnostic quality by the radiologist. Active motion correction maintained superior image quality despite vehicle and scanner motion. In-plane, low contrast resolution of greater than 4 × 4 mm was achieved. Average transmit speeds were calculated to be 3.54 Megabits/second and upload data rates varied while in transit ranging from 8.54 to 4.13 Megabits/second. ConclusionWhile MRI is not yet ready for clinical use in the MSU setting, our initial experience suggests potential technological feasible of this approach following future technical and MRI sequence development. Additional studies, incorporating patients, would be required to determine clinical feasibility.

The early impact of COVID-19 pandemic on mobile stroke unit care delivery: A worldwide survey

ObjectiveTo report COVID −19 pandemic impact on mobile stroke units (MSUs) a world-wide survey of MSU programs. MethodsContact information of MSU program was obtained through the Pre-hospital Stroke Treatment Organization. Anonymous electronic questionnaire was developed and sent through the email to one representative of each program on May 15, 2020. ResultsOf 26 programs queried, 20 responded and completed survey based on the data or personal impression. Eighteen programs were in the regions with pandemic lockdown. Six either suspended or reduced MSU availability at some point. The reasons given for change in availability were as follows: decreased personnel availability (5 programs), risk of exposure (5 programs), and financial concerns (1 program). Staff availability was a concern among 8 programs. MSU activations were reported to be unchanged by 10 programs, but 9 programs experienced decline in activation, 1 program had more activations. Sixteen programs reported change in MSU protocol including introduction of screening questionnaire, PPE, reducing patient contact, and cleaning protocols. Nine reported that the crew was under greater stress. Only 2 respondents felt that the pandemic delayed stroke care on MSU and the remainder did not. ConclusionOverall Stroke care delivery had no major disruptions despite COVID 19 pandemic posed challenges to MSU Operations.

Twenty years of monitoring acute stroke care in Australia through the national stroke audit programme (1999-2019): A cross-sectional study.

National organisational surveys and clinical audits to monitor and guide improvements to the delivery of evidence-based acute stroke care have been undertaken in Australia since 1999. This study aimed to determine the association between repeated national audit cycles on stroke service provision and care delivery from 1999 to 2019. Cross-sectional study using data from organisational surveys (1999, 2004, 2007-2019) and clinical data from the biennial National Stroke Acute Audit (2007-2019). Age-, sex-, and stroke severity-adjusted proportions were reported for adherence to guideline-recommended care processes. Multivariable, logistic regression models were performed to determine the association between repeated audit cycles and service provision (organisational) and care delivery (clinical). Overall, 197 hospitals provided organisational survey data (1999-2019), with 24,996 clinical cases from 136 hospitals (around 40 cases per audit) (2007-2019). We found significant improvements in service organisation between 1999 and 2019 for access to stroke units (1999: 42%, 2019: 81%), thrombolysis services (1999: 6%, 2019: 85%), and rapid assessment/management for patients with transient ischaemic attack (1999: 11%, 2019: 61%). Analyses of patient-level audits for 2007 to 2019 found the odds of receiving care processes per audit cycle to have significantly increased for thrombolysis (2007: 3%, 2019: 11%; OR 1.15, 95% CI 1.13, 1.17), stroke unit access (2007: 52%, 2019: 69%; OR 1.15, 95% CI 1.14, 1.17), risk factor advice (2007: 40%, 2019: 63%; OR 1.10, 95% CI 1.09, 1.12), and carer training (2007: 24%, 2019: 51%; OR 1.12, 95% CI 1.10, 1.15). Between 1999 and 2019, the quality of acute stroke care in Australia has improved in line with best practice evidence. Standardised monitoring of stroke care can inform targeted efforts to reduce identified gaps in best practice, and illustrate the evolution of the health system for stroke.