Stroke Clinical Pathway Research Articles

Pengembangan Clinical Pathway Stroke Hemoragik Berbasis 3S (SDKI, SLKI, SIKI)

This study aims to develop a clinical pathway for hemorrhagic stroke patients based on the 3S (SDKI, SLKI, SIKI). The method used is Research and Development with stages including literature study, observation evaluation, validity and reliability testing, and Focus Group Discussion (FGD). The research results show that developing a 3S-based hemorrhagic stroke clinical pathway is by clinical practice guidelines and service quality. The results of Pearson's product-moment correlation test are <0.514, and the reliability of the Cronbach alpha test is 0.906. Conclusion: The development of a 3S-based hemorrhagic stroke clinical pathway was prepared with nursing diagnoses, including ineffective airway clearance, decreased intracranial adaptive capacity, acute pain, impaired physical mobility, and risk of fluid imbalance. The development of a 3S-based hemorrhagic stroke clinical pathway is generally in good categories in terms of Functionality, Efficiency, and Usability so that it can be recommended for use by nurses and can improve the quality of hospital services.
 Keywords: Clinical Pathway, SDKI, SIKI, SLKI, Hemorrhagic Stroke

Statewide availability of acute stroke treatment, services, and programs: A survey of North Carolina Hospitals

IntroductionWe conducted a statewide assessment of the availability of stroke treatment, services, and programs in North Carolina (NC) hospitals. We also examined differences in stroke care capabilities between urban, suburban, and rural hospitals and trends over the past 2 decades. MethodsAn electronic survey was distributed to all 111 licensed hospitals in NC. Survey questions asked about stroke center certification status (i.e., standardized levels of stroke care capabilities), diagnostic testing, acute treatments and protocols, and post-acute management. Responses were collected from October 2020-April 2021. Select characteristics were compared to those from prior NC surveys in 1998, 2003, and 2008. ResultsAll 111 hospitals responded to the survey (100% response rate). Among 108 hospitals providing acute stroke care, 12 (11%) were Comprehensive Stroke Centers or Thrombectomy-Capable Stroke Centers, which were all located in urban or suburban areas. While 38% of urban/suburban hospitals were non-certified, 48% of rural hospitals were non-certified. Non-contrast computed tomography (CT), CT angiography, and alteplase treatment were widely available (100%, 95%, and 99%, respectively). Endovascular thrombectomy was solely available in urban/suburban hospitals (29%). Of non-tertiary hospitals, 81% were using telestroke for treatment and transfer decisions. Compared to prior survey results, the availability of CT angiography (76% in 2008 to 95% in 2020-2021), alteplase treatment (69% in 2008 to 99% in 2020-2021), and acute stroke clinical pathways (47% in 2008 to 90% in 2020-2021) increased. However, having an in-house neurologist on staff dropped from approximately 55% in prior surveys to 21% in the current survey. ConclusionsRural NC hospitals were less likely to have advanced diagnostic imaging and treatment capabilities for acute stroke. Temporal trends in staffing with an in-house neurologist and use of telestroke services should be further examined.

Benefit of linking hospital resource information and patient-level Stroke Registry data.

Variation in delivery of evidence-based care affects outcomes for patients with stroke. A range of hospital (organizational), patient and clinical factors can affect care delivery. Clinical registries are widely used to monitor stroke care and guide quality improvement efforts within hospitals. However, hospital features are rarely collected. We aimed to explore the influence of hospital resources for stroke, in metropolitan and regional/rural hospitals, on the provision of evidence-based patient care and outcomes. 2017 National Audit organizational survey (Australia) linked with patient-level data from the Australian Stroke Clinical Registry (AuSCR) (2016-2017 admissions). Regression models were used to assess the associations between hospital resources (based on the 2015 Australian National Acute Stroke Services Framework) and patient care (reflective of national guideline recommendations), as well as 90 to 180 day readmissions and health-related quality of life (HRQoL). Models were adjusted for patient factors, including severity of stroke. 52/127 hospitals with organizational survey data were merged with 22,832 AuSCR patients with first-ever stroke/transient ischemic attack (median age 75years; 55% male; 66% ischemic). In metropolitan hospitals (N=42, 20,977 patients; 1,701 thrombolyzed; 2,395 readmitted between 90 and 180 days post stroke), a faster median door-to-needle time for thrombolysis was associated with 500+ annual stroke admissions (-15.9min, 95%CI -27.2,-4.7), annual thrombolysis >20 patients (-20.2min, 95%CI -32.0,-8.3), and having specialist stroke staff (dedicated medical lead and stroke coordinator;-12.7min, 95%CI -25.0,-0.4). A reduced likelihood of all cause readmissions between 90 and 180 days was evident in metropolitan hospitals using care pathways for stroke management (OR 0.82, 95%CI 0.67, 0.99). In regional/rural hospitals (N=10, 1,855 patients), being discharged with a care plan was also associated with use of stroke clinical pathways (OR 3.58, 95%CI 1.45, 8.82). No specific hospital resources influenced 90 to 180-day HRQoL. Relevant to all international registries, integrating information about hospital resources with clinical registry data provides greater insights into factors that influence evidence-based care.

A hybrid model to support decision making in the stroke clinical pathway

Health processes are highly complex and sensitive, requiring continued improvement. Several methodologies have been developed to support these improvement processes, many of which apply Process Mining (PM) to investigate the current states of processes. Some even use Discrete Event Simulation (DES) techniques to explore alternative scenarios. Among the ones using DES, some rely on Multicriteria Decision-Making Methods (MCDM) to guide them in choosing the best scenario, especially in complex decision-making environments. However, no author presents a single framework combining all three techniques mentioned above, to wit, PM, DES, and MCDM. This paper targets developing this combination and exploring its usefulness in guiding process improvement in the health services area. The clinical path for stroke patients, covering from onset of symptoms to hospital discharge, was used as a test case. The research demonstrated that this proposal provided an innovative diagnostic of the process, identifying the activities that should be improved to obtain the most significant results in the process management indicators. Identifying the activities ensures that the impacts of these improvements are indicated with statistical accuracy and eliminating the need to perform on-site testing to test for the best solutions. The research does not address root cause diagnosis of activities to be improved. Therefore, further research needs to be undertaken on an extension of the model to enhance root cause analysis capabilities with a view to validating the framework proposed in other environments and, in this way, assess its replicability.

Abstract WP87: Statewide Availability Of Acute Stroke Treatment And Services In North Carolina Hospitals

Introduction: With recent advancements in acute stroke treatments, evidence-based care capabilities among hospitals are believed to vary widely; however, current data are limited. Therefore, we conducted a statewide assessment of hospital-based stroke care capabilities in North Carolina (NC). Methods: An online survey was emailed to each licensed hospital in NC. Based on prior surveys and current stroke care guidelines, questions asked about diagnostic testing, acute stroke treatments and protocols, and post-acute management. All 112 hospitals responded (100% response rate) between October 2020 and April 2021. Descriptive statistics were computed from responses for 109 hospitals that reported providing acute stroke care. Results: Among 109 hospitals, 10 (9%) were Comprehensive Stroke Centers, 2 (2%) were Thrombectomy-Capable Stroke Centers, 35 (32%) were Primary Stroke Centers, 16 (15%) were Acute Stroke Ready Hospitals, and 46 (42%) had no stroke certification. Ninety-eight (90%) had an acute stroke clinical care pathway, and 92 (84%) had pre-written stroke care orders. All 109 (100%) reported non-contrast CT imaging capability. Further, hospitals reported the following: CT angiography (104, 95%), CT perfusion (55, 50%), and diffusion-weighted MRI (63, 58%) . Almost all (108, 99%) administered intravenous alteplase for stroke, whereas only 16 (15%) had capabilities to provide endovascular thrombectomy for stroke. Ninety-five (87%) hospitals reported transferring stroke patients treated with alteplase or transferring those in need of endovascular treatment. Eighty-nine (82%) used telestroke services for the treatment and management of acute stroke patients, of which 78 (72%) relied on telestroke exclusively 24/7; and 80 (73%) used telestroke to decide when and where to transfer stroke patients. Conclusions: Among NC hospitals, basic capabilities, such as CT imaging and acute stroke care protocols, were widely available. However, advanced imaging and endovascular capabilities were less common. Most hospitals used telestroke services for treatment as well as transfer decisions. This statewide assessment is an important first step in improving access to evidence-based stroke care and developing stroke systems of care.

Abstract 49: Elevation Of Blood Viscosity In Acute Ischemic Stroke

Objectives: The blood viscosity would quantify the physiological state of abnormal blood flow and hypercoagulability, which are crucial predisposing factors of ischemic stroke. It investigated whether the viscosity increase in the stroke. Methods: It enrolled a series of patients who visited the hospital with any neurologic symptom or sign within 24 h of last well-being. Blood was immediately sampled at the time of hospital arrival as a routine clinical practice along the acute stroke clinical pathway. The viscosity was investigated in a point-of-care test manner using ARS M-200, Rheology Solutions, Korea. It placed the whole blood between the two plates and measured the viscosity by applying a torque of 10 Hz within 5 minutes of taking the blood sample. The primary outcome was an ischemic stroke and other diseases, and the difference in blood viscosity between the two groups was compared. Results: In 2021, it enrolled 47 subjects (age, 69.5 ± 12.9 years-old, male, 51.0%) of whose were diagnosed as ischemic stroke (n = 18) and other diseases (n = 29) consisted of hemorrhagic stroke, metabolic encephalopathy, vertigo, seizure, drug intoxication, and peripheral neuropathy. The viscosity of ischemic stroke with 10 Hz torque was significantly higher than those of non-stroke (22.7 ± 7.4 vs. 18.4 ± 7.0 Ps, P = 0.02). In stroke, the viscosity was significantly different between direct visits (25.5 ± 6.6 Ps) and transferred subjects with intravenous fluids (14.3 ± 1.4) (P = 0.003). In the case of hemorrhagic stroke, traumatic hemorrhage presented the highest values (27.1 ± 5.8), which was different from intracerebral hemorrhage (22.1 ± 7.3 Ps, Figure). Conclusion: The blood viscosity increased in acute ischemic stroke, which would be used as an auxiliary factor in the emergency setting. Also, it may be warranted the following studies for investigating their prognostic roles.

Impact of the COVID-19 pandemic on the organisation of stroke care. Madrid Stroke Care Plan

IntroductionThe overload of the healthcare system and the organisational changes made in response to the COVID-19 pandemic may be having an impact on acute stroke care in the Region of Madrid. MethodsWe conducted a survey with sections addressing hospital characteristics, changes in infrastructure and resources, code stroke clinical pathways, diagnostic testing, rehabilitation, and outpatient care. We performed a descriptive analysis of results according to the level of complexity of stroke care (availability of stroke units and mechanical thrombectomy). ResultsThe survey was completed by 22 of the 26 hospitals in the Madrid Regional Health System that attend adult emergencies, between 16 and 27 April 2020. Ninety-five percent of hospitals had reallocated neurologists to care for patients with COVID-19. The numbers of neurology ward beds were reduced in 89.4% of hospitals; emergency department stroke care pathways were modified in 81%, with specific pathways for suspected SARS-CoV2 infection established in 50% of hospitals; and SARS-CoV2-positive patients with acute stroke were not admitted to neurology wards in 42%. Twenty four hour on-site availability of mechanical thrombectomy was improved in 10 hospitals, which resulted in a reduction in the number of secondary hospital transfers. The admission of patients with transient ischaemic attack or minor stroke was avoided in 45% of hospitals, and follow-up through telephone consultations was implemented in 100%. ConclusionsThe organisational changes made in response to the COVID-19 pandemic in hospitals in the Region of Madrid have modified the allocation of neurology department staff and infrastructure, stroke units and stroke care pathways, diagnostic testing, hospital admissions, and outpatient follow-up.

Nurses' preferred items for dysphagia screening in acute stroke patients: A qualitative study

Background & Aim: Formal dysphagia screening protocols are not yet implemented in some hospitals although there is growing evidence that early dysphagia screening reduces pneumonia rates in stroke patients. Trained professionals are not often available outside weekdays working hours in stroke units, meaning that early screening is usually performed by nurses that use informal detection to screen dysphagia in acute stroke patients. The purpose of this study was to identify which items stroke nurses prioritize in their clinical practice to screen dysphagia in acute stroke patients. Methods & Materials: A qualitative study was developed using a focus group technique in five stroke units with a total of 20 stroke nurses selected by purposive sampling in march 2019. Qualitative Data Analysis Software Miner Lite 4.0 was used to assist in content analysis. Results: Two categories emerged: clinical data and swallowing and non-swallowing signs, each with a set of dimensions. In the category clinical data, relevance was noted for the dimension Glasgow Coma Scale and sex, identified as the most and least relevant, respectively, for dysphagia screening. In the category swallowing and non-swallowing signs no relevance evolved for preferred items. However, in this category, data suggest that nurses find less relevant in clinical practice speech disorders for dysphagia screening. Conclusions: Results reinforce the importance of a standardized approach through the use of valid and reliable dysphagia screening protocols, arguing the need for clear guidance in acute stroke clinical pathways on procedures for dysphagia screening.

Impacto de la pandemia de COVID-19 en la organización asistencial del ictus. Plan Ictus Madrid

IntroductionThe overload of the healthcare system and the organisational changes made in response to the COVID-19 pandemic may be having an impact on acute stroke care in the Region of Madrid. MethodsWe conducted a survey with sections addressing hospital characteristics, changes in infrastructure and resources, code stroke clinical pathways, diagnostic testing, rehabilitation, and outpatient care. We performed a descriptive analysis of results according to the level of complexity of stroke care (availability of stroke units and mechanical thrombectomy). ResultsThe survey was completed by 22 of the 26 hospitals in the Madrid Regional Health System that attend adult emergencies, between 16 and 27 April 2020. Ninety-five percent of hospitals had reallocated neurologists to care for patients with COVID-19. The numbers of neurology ward beds were reduced in 89.4% of hospitals; emergency department stroke care pathways were modified in 81%, with specific pathways for suspected SARS-CoV2 infection established in 50% of hospitals; and SARS-CoV2-positive patients with acute stroke were not admitted to neurology wards in 42%. Twenty-four hour on-site availability of mechanical thrombectomy was improved in 10 hospitals, which resulted in a reduction in the number of secondary hospital transfers. The admission of patients with transient ischaemic attack or minor stroke was avoided in 45% of hospitals, and follow-up through telephone consultations was implemented in 100%. ConclusionsThe organisational changes made in response to the SARS-Co2 pandemic in hospitals in the Region of Madrid have modified the allocation of neurology department staff and infrastructure, stroke units and stroke care pathways, diagnostic testing, hospital admissions, and outpatient follow-up.

Abstract TP300: Implementation of Stroke Pathways to Reduce Length of Stay, Cost, Readmissions, and Mortality

Introduction: Acute stroke is a major contributor to healthcare costs. In 2012, estimated direct costs associated with stroke was $71B, which is projected to double to $184B by 2030. As healthcare evolves and reimbursements decrease, cost control in disease specific populations is critical. In November 2017, length of stay (LOS) peaked at 5.78 days, as did variable and total cost/case (Table). In fiscal year 2017 the 30-d readmission rate was 9% and the mortality rate was 12%. Compliance with stroke admission order sets was at 55%. Methods: A multidisciplinary committee was formed in February 2017 to develop standardized, evidence-based clinical pathways for three populations: Ischemic stroke (IS) treated with IV tPA, TIA/IS without IV tPA, and intracerebral hemorrhage. The team met biweekly to standardize clinical pathways, decrease time to follow-up imaging, focus on physician order set utilization, and control costs. A comprehensive education program for all clinical staff was completed; official implementation of the pathways was in November 2017. A stroke financials team meets monthly to continue to look at opportunities and transitions of care. We reviewed a retrospective financial report of all in-hospital cases coded as MS-DRG 61-69 from 12/2017 through 7/31/2019 and compared it the 11/2017 report. Results: A total of 83 cases were available for 12/2017 and 2192 for 1/2018 through 7/2019. There was a reduced LOS by 26% (4.34 days), reduced variable cost/case by 24% ($5,958), reduced total cost/case by 23% ($13,790), reduced the 30-d readmission rate to 6%, and reduced the mortality rate to 4%. Case mix index was 12% higher at 1.3272 (vs. 1.2055 previously). Order set compliance improved to 94% (Table). A total cost saving dollar realization of $4.5 million. Discussion: Standardization of stroke clinical pathways led to improved order set compliance, almost 1/4 reduction in variable and total costs per case, shortened LOS, and reduced mortality and readmission rates.

Rapid Sequence MRI Protocol in the Evaluation of Pediatric Brain Attacks

BackgroundThe objective of our study was to evaluate the clinical utility of rapid sequence magnetic resonance imaging (MRI) utilizing diffusion-weighted imaging and fluid-attenuated inversion recovery sequences in children with acute ischemic strokes and nonstroke brain attacks. MethodsWe performed a retrospective chart review of patients aged one month to 25 years for whom a pediatric stroke clinical pathway was activated. Diffusion-weighted imaging and fluid-attenuated inversion recovery were obtained followed by a complete MRI. Imaging was interpreted by a pediatric radiologist and the study neurologist. We collected information regarding patient demographics, neuroimaging results, and final diagnosis. ResultsThe Pediatric Stroke Clinical Pathway was activated for 59 patients of whom 52 were included for analysis. The majority of patients were female (n = 29, 55.8%) and African American (n = 32, 61.5%), with a median age of 12 years (interquartile range 9, 16). Six patients had an ischemic stroke. Seizures, migraines, and psychosomatic disorders (each with n = 7; 13.5%) were the most common nonstroke diagnoses. Diffusion-weighted imaging was more sensitive (100% [55.0% to 100%] versus 80 % [32% to 99%]) and specific (73.9% [68% to 74%] versus 37.2% [32% to 39%]) compared with fluid-attenuated inversion recovery in identification of an ischemic stroke. However, fluid-attenuated inversion recovery was useful in the identification of inflammatory and metabolic disorders. ConclusionRapid sequence MRI can be utilized as a screening imaging modality in children with suspected brain attacks in cases where there may be delays in obtaining full sequence brain imaging.

AHA/ASA target: Stroke phase 2 goals achieved in UAE: “Acute stroke clinical pathway” significantly reduced ‘door-to-needle’ time in acute ischemic stroke

Target: Stroke was launched by the American Heart Association/American Stroke Association (AHA/ASA). Phase 1: To achieve Door-to-needle (DTN) within 60 minutes in ≥50%. of acute ischemic Stroke patients treated with IV rtPA. Phase 2: In acute ischemic stroke patients treated with IV rtPA, the Primary goal to achieve DTN times within 60 minutes in ≥75%; Secondary Goal to achieve DTN times within 45 minutes in ≥50%. We implemented “Acute Stroke Clinical Pathway” in 2015 to improve DTN time and Stroke care. We prospectively analysed 48 month (Jan 2015 – Dec 2018) data from Stroke Registry in AAH. We included patients who arrived within window period and received intravenous rtpA for acute ischemic stroke. Number of patients who met inclusion criteria was 21 in 2015, 20 in 2016, 10 in 2017 and 22 in 2018. In 2015, 86% were treated within 60 minutes and 38% within 45 minutes. In 2016, 100% were treated within 60 minutes and 45% within 45 minutes. In 2017, 80% were treated within 60 minutes and 40% within 45 minutes. In 2018, 100% were treated within 60 minutes and 73% within 45 minutes. We significantly improved DTN times since the implementation of “Acute Stroke Clinical Pathway”. In acute ischemic stroke patients treated with IV rtPA, we have achieved the Primary goal of AHA/ASA Target: Phase 2 to achieve DTN times within 60 minutes in ≥75% and the Secondary Goal of achieving DTN times within 45 minutes in ≥50%.

Short door-to-needle times in acute ischemic stroke: Report of 2 cases from UAE

Median Door-to-Needle (DTN) time ≤ 60 minutes in acute ischemic stroke is recommended by AHA/ASA. We present 2 patients with DTN time ≤ 23 minutes. 54 year old man with a background history of hypertension, ischemic heart disease, chronic kidney disease presented with acute onset speech difficulty and numbness right hand. NIHSS on admission was 6. CT brain showed dense left MCA sign. Patient came within window period for thrombolysis. rtpA was given. DTN time was 23 minutes. Post rtpA he developed hypertension which controlled with medicaiton. NIHSS post-rtpA was 2. MRI showed acute left MCA infarct. At discharge he was on dual antiplatelet, statin and antihypertensives. mRS at discharge was 0. 52 year old man with background history of CABG with poor compliance to Aspirin presented with acute onset dizziness and inability to walk. Exam showed significant ataxia. CT brain was normal. Patient came within window period for thrombolysis. rtpA was given. DTN time was 21 minutes. Post rtpA, there were no complications. NIHSS post-rtpA was 2. MRI showed acute right pontine infarct. At discharge he was on dual anti platelet and statin. mRS at discharge was 0 “Acute Stroke Clinical Pathway” in Al Ain hospital was designed in 2015 and is updated periodically. Successful implementation of this pathway is key in achieving short DTN times. We present the first reports of short DTN times in UAE thus reflecting the efficiency of our Stroke Code team.

Abstract TP464: System Changes Decrease Emergency Department Length of Stay for Hemorrhagic Stroke Patients

Background/Purpose: American Stroke Association guidelines recommend that a length of stay (LOS) in the Emergency Department (ED) of less than 6 hours improve outcomes in patients with hemorrhagic stroke. In the second quarter of 2017, patients at our academic medical facility averaged an ED LOS of 6.3 hours. Issues identified that extended LOS were: 1) a lack of process to alert required providers and stroke RN, 2) unfamiliarity of ED nurses with complex hemorrhagic stroke protocols, and 3) need for hemorrhagic stroke clinical care pathways with standardized order sets. Methods: Collaboration was formed between the emergency department, neurosurgery, neuro ICU, stroke program manager, and neuro ICU trained stroke nurses. The following improvements were implemented: 1) a subarachnoid hemorrhage and intra-cerebral hemorrhage (SAH/ICH) activation was developed to formalize a process to alert and mobilize specialty services upon patient arrival in the ED, 2) formation of a collaboration between an ED RN and expertly trained stroke nurses to provide care for the complex hemorrhagic stroke patient, and 3) implementation of standardized order sets for the electronic medical record. Results: Eleven months after the implementation of process improvements, there was a statistically significant reduction in ED LOS for hemorrhagic stroke patients. LOS decreased from an average of 6.3 hours to 3.1 hours. Conclusion: An activation system expediting specialty services and expert nursing care with the use of hemorrhagic stroke clinical care pathways and order sets reduces LOS in the ED and may improve patient outcomes. Future Recommendations: Monitor LOS statistics on a quarterly basis. Periodically re-evaluate the timeliness of SAH/ICH activation and compliance with clinical care pathways and standardized order sets to ensure sustainability.

Abstract TP374: Implementation of Stroke Pathways to Reduce Length of Stay, Cost, Readmissions, and Mortality

Introduction: Acute stroke is a major contributor to healthcare costs. In 2012, estimated direct costs associated with stroke was $71B, which is projected to double to $184B by 2030. As healthcare evolves and reimbursements decrease, cost control in disease specific populations is critical. In January 2017, length of stay (LOS) peaked at 5.25 days, as did variable and total cost/case (Table). In fiscal year 2017 the 30-d readmission rate was 9% and the mortality rate was 12%. Compliance with stroke admission order sets was at 55%. Methods: A multidisciplinary committee was formed in February 2017 to develop standardized, evidence-based clinical pathways for three populations: Ischemic stroke (IS) treated with IV tPA, TIA/IS without IV tPA, and intracerebral hemorrhage. The team met biweekly to standardize clinical pathways, decrease time to follow-up imaging, focus on physician order set utilization, and control costs. A comprehensive education program for all clinical staff was completed; official implementation of the pathways was in November 2017. Pathways are discussed in stroke multidisciplinary rounds and rapid discharge rounds daily to ensure compliance and identify opportunities for improvement. We reviewed a retrospective financial report of all in-hospital cases coded as MS-DRG 61-69 from 12/2017 through 6/2018 and compared it the 1/2017 report. Results: A total of 83 cases where available for 1/2017 and of 456 for 12/2017 through 6/2018. There was a reduced LOS by 10% (4.74 days), reduced variable cost/case by 24% ($5,958), reduced total cost/case by 23% ($13,790), reduced the 30-d readmission rate to 6%, and reduced the mortality rate to 9%. Case mix index was 6% higher at 1.2753 (vs. 1.2055 previously). Order set compliance improved to 91% (Table). Discussion: Standardization of stroke clinical pathways led to improved order set compliance, almost ¼ reduction in variable and total costs per case, shortened LOS, and reduced mortality and readmission rates.

Pediatric Stroke and Its Mimics: Limitations of a Pediatric Stroke Clinical Pathway

BackgroundAcute stroke protocols improve delivery of care but it is unclear whether these resource intensive protocols are able to differentiate stroke from mimics in children. The aim of this study is to describe our institution's experience with stroke mimics identified through our pediatric stroke clinical pathway (PSCP). MethodsThe PSCP was implemented in our level 1 pediatric emergency department in June 2014 for children aged one month to 18 years. For patients managed using the PSCP from June 2014 to December 2016, demographic and clinical data were compared for patients diagnosed with stroke or a stroke mimic. ResultsA total of 59 children were evaluated with the PSCP. Fourteen children were identified as having a stroke and 45 children had stroke mimics. The most common stroke mimics were functional neurological disorders (20.0%), transient neurological deficits (17.8%), migraine (15.6%), and seizure (11.1%). Patient demographics and time to neuroimaging did not differ between patients with and without stroke. Vomiting was commonly reported by patients with stroke (odds ratio: 4.00, 95% confidence interval: 1.12 to 14.35), whereas weakness was not (odds ratio: 0.7, 95% confidence interval: 0.07 to 0.90), but the physical examination did not differ between patients with and without stroke. ConclusionsThe PSCP ensures timely evaluation of patients presenting with neurological deficits but fails to reliably differentiate between patients with stroke and patients with stroke mimics. Further multicentered studies are needed to develop a “stroke screen” that reliably distinguishes pediatric stroke from its mimics.

Benefits of clinical facilitators on improving stroke care in acute hospitals: a new programme for Australia.

Care gaps for stroke lead to preventable disability and deaths. The Victorian State Government implemented a programme of employing clinical Facilitators on a fixed-term basis for up to 3 years (2008-2011) in eight hospitals to improve stroke care. The Facilitators were to establish stroke units where absent, implement evidence-based management protocols and provide staff education within an agreed work plan. To determine if the Facilitator role was associated with improved stroke care and to describe factors supporting or mitigating enhancements to care. A mixed methods design was employed with historical control using patient-level audit data (pre-Facilitator: n = 600; post-Facilitator: n = 387) and qualitative data from independently conducted semistructured interviews with hospital staff, including clinicians, executives and facilitators (n = 10 focus groups; 75 respondents). Stroke units, clinical pathways and outpatient clinics for managing transient ischaemic attacks (TIA) were established. Compared with the pre-Facilitator period, significant increases in patient access to stroke unit care (53% vs 86%, P < 0.001) and intravenous thrombolysis (2% vs 9%, P < 0.001) were achieved. Hospital staff reported that the Facilitator was integral to system improvements by fostering communication, encouraging team motivation and cohesiveness and increasing interest in stroke care. Ongoing barriers included limited resources to operate TIA clinics effectively, staff turnover requiring ongoing education, inconsistency in compliance with protocols and, in some hospitals, the need for formalised medical leadership. Fixed-term employment of Facilitators was effective in positively influencing stroke care in hospitals through a range of change management strategies where stroke-specific expertise had been previously limited.

Pediatric Stroke Clinical Pathway Improves the Time to Diagnosis in an Emergency Department

BackgroundIdentified barriers to the diagnosis of pediatric stroke include delays in provider recognition and definitive neuroimaging (magnetic resonance imaging). Clinical pathways are recommended to address these barriers; yet few studies have evaluated their impact. Our aim is to describe the effect of a pediatric stroke clinical pathway on the diagnosis of stroke in patients presenting with focal neurological dysfunction to a pediatric emergency department. MethodsThe pediatric stroke clinical pathway was implemented in our level 1 pediatric emergency department in June 2014 for children aged one month to 18 years. Demographic and clinical data were collected for patients ultimately diagnosed with stroke using the pediatric stroke clinical pathway and compared with data collected on patients diagnosed with stroke before implementation of the pediatric stroke clinical pathway. ResultsThe pediatric stroke clinical pathway was activated for 36 patients. Stroke was diagnosed in 11 patients (33%), of whom 55% were male with a median age 11 ± 7 years. Focal deficits (82%) and headache (55%) were common presenting complaints. There was a significant improvement in the median time to magnetic resonance imaging from arrival to the emergency department (before implementation of the pediatric stroke clinical pathway: 17 hours [interquartile range 6, 22] versus after implementation of the pediatric stroke clinical pathway: four hours [interquartile range 3, 12]; P = 0.02). ConclusionsThe pediatric stroke clinical pathway improved time to definitive diagnosis and streamlined the care provided to children presenting to the pediatric emergency department with focal neurological dysfunction.

Reduction of Length of Stay and Costs Through the Implementation of Clinical Pathways for Stroke Management in China

The aim of the clinical pathway is to establish a standardized healthcare plan for a specific disease in a specific patient cohort.1,2 To date, clinical pathways have been implemented for a great variety of diseases to improve the treatment effectiveness and to reduce the cost.3–9 Various clinical pathways on stroke management have been explored to enhance the interdisciplinary coordination, reduce the length of hospital stay, and facilitate the patients’ rehabilitation.6,8–10 Approximately 1.6 million patients died of stroke every year in China, which hugely strains the financial means of patients and the government.11 Therefore, the National Health and Family Planning Commission of China (formerly the Ministry of Health) commissioned a panel of physician experts to produce a draft of stroke clinical pathway and tested in a limited scale for 1 year. After the revision based on the feedbacks, the stroke clinical pathway entered a nationwide evaluation period from 2009 to 2013. Individual healthcare institutions were allowed to fine tune recommended protocols if necessary. The aim of this stroke clinical pathway study was to find a strategy to reduce the cost for healthcare without jeopardizing the quality of treatments by streamlining the stroke management. In this study, we …

Implementation and Impact of a Rural Emergency Department Acute Ischemic Stroke Clinical Pathway

In 1996, the FDA approved the use of systemic tissue plasminogen activator (tPA) for treatment of patients with acute ischemic stroke. Since its original approval, multiple prospective trials as well as meta-analyses have corroborated the benefits of tPA in appropriately selected patients. Despite this, tPA remains underused in clinical practice. This is particularly true in rural settings, where the infrequency of acute stroke cases and more limited resources and training may contribute to lower rates of treatment with tPA.