Stroke Services Research Articles

Provision of Stroke Care Services by Community Disadvantage Status in the US, 2009-2022

Stroke center certification is granted to facilities that demonstrate distinct capabilities for treating patients with stroke. A thorough understanding of structural discrimination in the provision of stroke centers is critical for identifying and implementing effective interventions to improve health inequities for socioeconomically disadvantaged populations. To determine whether (1) hospitals in socioeconomically disadvantaged communities (defined using the Area Deprivation Index) are less likely to adopt any stroke certification and (2) adoption rates differ between entry-level (acute stroke-ready hospitals) and higher-level certifications (primary, thrombectomy capable, and comprehensive) by community disadvantage status. This cohort study used newly collected stroke center data merged with data from the American Hospital Association, Healthcare Cost Report Information datasets, and the US Census. All general acute hospitals in the continental US between January 1, 2009, and December 31, 2022, were included. Data analysis was conducted from July 2023 to May 2024. The primary outcome was the likelihood of hospitals adopting stroke care certification. Cox proportional hazard and competing risk models were used to estimate the likelihood of a hospital becoming stroke certified based on the socioeconomic disadvantage status of the community. Among the 5055 hospitals studied from 2009 to 2022, 2415 (47.8%) never achieved stroke certification, 602 (11.9%) were certified as acute stroke-ready hospitals, and 2038 (40.3%) were certified as primary stroke centers or higher. When compared with mixed-advantage communities, adoption of any stroke certification was most likely to occur near the most advantaged communities (hazard ratio [HR], 1.24; 95% CI, 1.07-1.44) and least likely near the most disadvantaged communities (HR, 0.43; 95% CI, 0.34-0.55). Adoption of acute stroke-ready certification was most likely in mixed-advantage communities, while adoption of higher-level certification was more likely in the most advantaged communities (HR,1.41; 95% CI, 1.22-1.62) and less likely for the most disadvantaged communities (HR, 0.31; 95% CI, 0.21-0.45). After adjusting for population size and hospital capacity, compared with mixed-advantage communities, stroke certification adoption hazard was still 20% lower for relatively disadvantaged communities (adjusted HR, 0.80; 95% CI, 0.73-0.87) and 42% lower for the most disadvantaged communities (adjusted HR, 0.58; 95% CI, 0.45-0.74). In this cohort study examining hospital adoption of stroke services, when compared with mixed-advantage communities, hospitals located in the most disadvantaged communities had a 42% lower hazard of adopting any stroke certification and relatively disadvantaged communities had a 20% lower hazard of adopting any stroke certification. These findings suggest that there is a need to support hospitals in disadvantaged communities to obtain stroke certification as a way to reduce stroke disparities.

Hourly effect of atmospheric reactive nitrogen species on the onset of acute ischemic stroke: Insight from the Shanghai Stroke Service System Database

Acute ischemic stroke (AIS) is one of the most predominant causes of mortality and disability in China. Significant uncertainties in stroke diagnosis and time of onset have resulted in inconsistent evidence on the association between ambient air pollution and the risk of AIS. The present study aimed to evaluate the impact of air pollution on AIS onset based on high time-resolution air pollution data and a stroke-specific registry across the past five years. Hourly concentrations of PM2.5, PM10, O3, SO2, CO, NO2 and nitrous acid (HONO) were monitored from 2017 to 2021, with which a distributed lag non-linear model and conditional logistic regression models coupled with a time-stratified case-crossover design were applied to 106,623 AIS cases recorded in the Shanghai Stroke Service (4S) database during the study period. Results from the conditional logistic regression models indicate that acute exposure to PM2.5, PM10, SO2, NO2 and HONO was found to be associated with AIS onset, respectively. The corresponding cumulative excessive risks of AIS onset were 0.8 %, 1 %, 2.4 %, 2.1 % and 1.8 % for each interquartile range increase in the respective concentration. The longest lag-effect (up to 13 h) was observed for reactive nitrogen species (RNS), such as NO2 and HONO, which remained robust in two-pollutant models. Similar important role of RNS in AIS onset were confirmed by the distributed lag non-linear model. By demonstrating the transient effect of ambient air pollution on AIS, especially the relationships between RNS and AIS for the first time, our study provides stringent evidence for future mitigation strategies for pollution emission and public health.

Stroke outcomes following cardiac and aortic surgery are improved by the involvement of a stroke team.

Post-cardiac and aortic surgery stroke is often underreported. We detail our single-centre experience the following introduction of comprehensive consultant-led daily stroke service, to demonstrate the efficacy of a stroke team in recovery from stroke following cardiac and aortic surgeries. This retrospective, single-centre observational cohort study analysed consecutive patients undergoing cardiac and aortic surgery at our institution from August 2014 to December 2020. Main outcomes included stroke rate, predictors of stroke, and neurological deficit resolution or persistence at discharge and clinic follow-up. A total of 12,135 procedures were carried out in the reference period. Among these, 436 (3.6%) suffered a stroke. Overall survival to discharge and follow-up were 86.0% and 84.0% respectively. Independent risk factors for post-operative stroke included advanced age (OR 1.033, 95% CI [1.023, 1.044], p < .001), female sex (OR 1.491, 95% [1.212, 1.827], p < .001), history of previous cardiac surgeries (OR 1.670, 95% CI [1.239, 2.218], p < .001), simultaneous coronary artery bypass graft + valve procedures (OR 1.825, 95% CI [1.382, 2.382], p < .001) and CPB time longer than 240 min (OR 3.384, 95% CI [2.413, 4.705], p < .001). Stroke patients managed by the multidisciplinary team demonstrated significantly higher rates of survival at discharge (87.3% vs. 61.9%, p = .001). Perioperative stroke can be debilitating immediately long term. The involvement of specialist stroke teams plays a key role in reducing the long-term burden and mortality of this condition.

Does an allied health transdisciplinary stroke assessment save time, improve quality of care, and save costs? Results of a pre-/post- clinical study

Purpose: Demand for stroke services is increasing. To save time and costs, stroke care could be reorganised using a transdisciplinary assessment model embracing overlapping allied health professional skills. The study compares transdisciplinary assessment to discipline-specific allied health assessment on an acute stroke unit, by evaluating assessment time, quality of care, and cost implications. Method: The pre-/post- clinical study used non-randomised groups and 3-month follow-up after hospital admission. Patients with confirmed/suspected stroke received usual discipline-specific allied health assessment (pre-implementation phase) or the novel transdisciplinary assessment (post-implementation phase). Staff/student assessment times (primary outcome) and medical record data (secondary outcomes) were collected. Time differences were estimated using multivariable linear regression controlling for confounding factors. Cost minimisation and sensitivity analyses estimated change in hospital resource use. Findings: When the transdisciplinary assessment was used ( N = 116), compared to usual assessment ( N = 63), the average time saving was 37.6 min (95% CI −47.5, −27.7; p &lt; 0.001) for staff and 62.2 min (95% CI −74.1, −50.3; p &lt; 0.001) for students. The median number of allied health occasions of service reduced from 8 (interquartile range 4–23) to 5 (interquartile range 3–10; p = 0.011). There were no statistically significant or clinically important changes in patient safety, outcomes or stroke guideline adherence. Improved efficiency was associated with an estimated cost saving of $379.45 per patient (probabilistic 95% CI −487.15, −271.48). Discussion and conclusion: Transdisciplinary stroke assessment has potential for reorganising allied health services to save assessment time and reduce healthcare costs. The transdisciplinary stroke assessment could be considered for implementation in other stroke services.

Stroke in Qatar: a decade of insights from a national registry

ABSTRACT Background Stroke is a major cause of death and disability worldwide and presents a significant burden on healthcare systems. This retrospective study aims to analyze the characteristics and outcomes of stroke patients admitted to Hamad General Hospital (HGH) stroke service in Qatar from January 2014 to July 2022. Methods The medical records of 15,859 patients admitted during the study period were analyzed. The data collected included patient demographics, stroke types, admission location, procedures performed, mortality rates, and other clinical characteristics. Results Of the total cohort, 70.9% were diagnosed with a stroke, and 29.1% were diagnosed with stroke mimics. Of the stroke patients, 85.3% had an ischemic stroke, and 14.7% had a hemorrhagic stroke. Male patients below 65 years old (80.2%) and of South Asian ethnicity (44.6%) were the most affected. The mortality rate was 4.6%, significantly higher for hemorrhagic stroke than ischemic stroke (12.6% vs. 3.2%). Female patients had a higher stroke-related mortality rate than male patients (6.8% vs. 4%). The thrombolysis rate was 9.5%, and the thrombectomy rate was 3.4% of the ischemic stroke cohort. The mean door-to-needle time for thrombolysis was 61.2 minutes, and the mean door-to-groin time for thrombectomy was 170 minutes. Stroke outcomes were good, with 59.3% of patients having favorable outcomes upon discharge (mRS ≤2), which improved to 68.2% 90 days after discharge. Conclusion This study provides valuable insights into stroke characteristics and outcomes in Qatar. The findings suggest that stroke mortality rates are low, and favorable long-term disability outcomes are achievable. However, the study identified a higher stroke-related mortality rate among female patients and areas for improvement in thrombolysis and thrombectomy time.

Characteristics and reasons for delayed presentation in acute ischemic stroke: single-centered study in Indonesia

BackgroundEffective therapy for acute ischemic stroke relies on timely intervention. We aimed to evaluate the factors associated with the onset-to-arrival time and delayed hospital presentation in acute ischemic stroke patients. Subjects with acute ischemic stroke in Bethesda Hospital Yogyakarta, Indonesia from March to June, 2023 were prospectively recruited. A questionnaire was used to collect the information by direct interviews. Prespecified variables were included in univariate and multivariable analyses to identify the predictors of delayed hospital presentation of more than 4.5 h.ResultsAmong a total of 175 patients, 64.6% of the patients arrived at the hospital more than 4.5 h after the stroke onset. Only 3 (1.7%) patients were eligible and received intravenous thrombolysis. In multivariable analysis, monthly income of more than IDR 550,000 (OR, 4.22; 95% CI 1.47–12.17; p = 0.007), wake-up stroke or unknown stroke onset (OR vs. known onset, 0.17; 95% CI 0.05–0.56; p = 0.004), distance from location of stroke onset more than 9.45 km (OR, 3.13; 95% CI 1.41–6.92; p = 0.005) and no history of coronary artery disease or heart failure (OR vs. present history, 0.12; 95% CI 0.04–0.37; p = 0.000) were related to delayed hospital presentation. The most frequently mentioned reasons for the delay were waiting for spontaneous improvement at home and unawareness of the stroke symptoms.ConclusionsThere is an enormous disparity in stroke services between developed and developing countries. This study highlighted the need to increase public stroke symptoms awareness.

P.028 Exploring young adult stroke patients’ lived experience, healthy lifestyle habits, and recommendations for designing innovative brain care-related initiatives

Background: Over the past decade, worldwide stroke incidence has been increasing among young adults (≤65years), which has implications during the most dynamic period of their life. There is a dearth of research exploring young adults stroke patients’ experiences, healthy lifestyle habits, preferences, and recommendations for brain care-related initiatives. The study aimed to gain knowledge and a deeper understanding of young adult stroke patients’ experiences, lifestyle habits, and support needs for brain care-related education and interventions. Methods: A descriptive qualitative study was used. Participants who took part in the quantitative phase of a larger mixed methods study (n=103 that expressed an interest in the qualitative phase, were invited to take part in semi-structured focus groups. Simultaneous data collection and analysis are being conducted. Data are being analyzed using inductive thematic analysis outlined by Braun and Clarke (2006). Results: Findings will be available by May 20, 2024. Conclusions: Study findings will be essential to 1) mobilize an understanding of young adult stroke patients’ lived experience; 2) reconceptualize the current model of stroke care and services that is traditionally geared towards older adults; and 3) inform the development of brain care-related education and interventions to meet the unique needs, priorities, and preferences of young adult stroke patients.

Use of the Head Impulse, Nystagmus, Test of Skew ('HINTS') assessment to aid differential diagnosis in acute vestibular syndrome in the hyperacute stroke setting.

Differential diagnosis of acute vertigo syndrome is challenging given the similarities between clinical presentations of posterior circulation stroke and peripheral vestibular dysfunction. The Head Impulse, Nystagmus, Test of Skew ('HINTS') assessment is a clinical bedside test used to aid diagnosis. Comprehensive training on use of the Head Impulse, Nystagmus, Test of Skew assessment was provided to one stroke consultant, and the effectiveness of the test in that setting was assessed. Further education was completed with more members of the stroke and emergency department multi-disciplinary team. Quality improvement measures including magnetic resonance imaging use and bed utilisation were explored. Following training of one stroke consultant, the Head Impulse, Nystagmus, Test of Skew assessment was found to be a feasible, accurate bedside test within this acute stroke service. Further training for the multi-disciplinary team was completed, but outcome measures were not explored because of the coronavirus disease 2019 pandemic and maternity leave. There is a role for trained members of the multi-disciplinary team to successfully use the Head Impulse, Nystagmus, Test of Skew assessment in hyperacute stroke settings, to aid diagnosis in acute vertigo syndrome.

A systematic review of the incidence and outcomes of ICD-11 defined stroke

BackgroundThe World Health Organisation has expanded the definition of stroke to include people with symptoms less than 24 h if they have evidence of stroke on neuroimaging. The impact is that people previously diagnosed as having a transient ischaemic attack (TIA) would now be considered to have had a stroke. This change will impact incidence and outcomes of stroke and increase eligibility for secondary prevention. We aimed to evaluate the new ICD-11 criteria retrospectively to previous TIA studies to understand the change in incidence and outcomes of this type of stroke. MethodsWe conducted a systematic review of observational studies of the incidence and outcomes of clinically defined TIA. We searched PubMed, EMBASE, and Google Scholar from inception to 23rd May 2023. Study quality was assessed using a risk of bias tool for prevalence studies. FindingsOur review included 25 studies. The rate of scan positivity for stroke among those with clinically defined TIA was 24 %, (95 % CI, 16–33 %) but with high heterogeneity (I2 = 100 %, p <0.001). Sensitivity analyses provided evidence that heterogeneity could be explained by methodology and recruitment method. The scan positive rate when examining only studies at low risk of bias was substantially lower, at 13 % (95 % CI, 11–15 %, I2 = 0, p = 0.77). We estimate from population-based incidence studies that ICD-11 would result in an increase stroke incidence between 4.8 and 10.5 per 100,000 persons/year. Of those with DWI-MRI evidence of stroke, 6 % (95 % CI, 3–11 %) developed a recurrent stroke in the subsequent 90 days, but with substantial heterogeneity (I2 = 67 %, p = 0.02). ConclusionThe impact of the ICD-11 change in stroke definition on incidence and outcomes may have been overestimated by individual studies. Community-based stroke services with access to DWI MRI are likely to accurately diagnose greater numbers of people with mild ICD-11 stroke, increasing access to effective prevention.

Investigating the Implementation of Community-Based Stroke Telerehabilitation in England; A Realist Synthesis Study Protocol.

Telerehabilitation (TR) shows promise as a method of remote service delivery, yet there is little guidance to inform implementation in the context of the National Health Service (NHS) in England. This paper presents the protocol for a realist synthesis study aiming to investigate how TR can be implemented to support the provision of high-quality, equitable community-based stroke rehabilitation, and under what conditions. Using a realist approach, we will synthesise information from (1) an evidence review, (2) qualitative interviews with clinicians (n ≤ 30), and patient-family carer dyads (n ≤ 60) from three purposively selected community stroke rehabilitation services in England. Working groups including rehabilitation professionals, service-users and policy-makers will co-develop actionable recommendations. Insights from the review and the interviews will be synthesised to test and refine programme theories that explain how TR works and for whom in clinical practice, and draw key messages for service implementation. This protocol highlights the need to improve our understanding of TR implementation in the context of multidisciplinary, community-based stroke service provision. We suggest the use of a realist methodology and co-production to inform evidence-based recommendations that consider the needs and priorities of clinicians and people affected by stroke.

Development and Implementation of a Stroke Nurse Navigator Position to Improve Program and Patient Outcomes

Background Transitions in stroke care across the healthcare system are complex, requiring significant patient and family support. Navigation has been used in other disease states including oncology but has not been described well in the stroke population. Methods Our stroke program leadership performed a gap analysis to identify opportunities to streamline the care transition process. The emerging stroke nurse navigator role was implemented to meet patient/family needs and ensure implementation of evidence-based stroke services throughout transitions across the stroke system of care. Results The stroke navigator role was formally implemented in April 2018, along with adaptive patient selection criteria that have evolved as expertise in navigation has grown. Clarity in role function between the stroke coordinator and stroke navigator positions was established demonstrating the synergistic relationships between these two roles. Similarly, interventions and services performed routinely by stroke navigators developed over time as navigators became well versed in the needs of patients and families in the post-acute phase of care. We provide a detailed history of our 6-year experience with stroke navigation and make recommendations for role adoption and enactment. Conclusion Stroke navigator roles are likely to continue to grow to support the complex needs of stroke survivors and family members. Flexibility in role development and reflective role evolution are encouraged to support growth of the stroke navigator position and measures of role effectiveness.

Current Status of Neurorehabilitation Services in the OIC Countries: Results of an International Online Survey

Objectives: Neurorehabilitation services are not widely available to most persons with disability (PWD) in the Organization of Islamic Cooperation countries. This study aimed to document status of neurorehabilitation services in OIC countries. Study Design and Setting: Cross-sectional online survey. Methods: Self-administered online survey conducted using Google Forms. Key resource persons for each OIC country working in field of neurorehabilitation were identified from various databases. The questionnaire was emailed to 20 identified resource persons. The response rate was 60% (12/20). Results: Neurorehabilitation services were available in 9 out of 12 surveyed countries. Only 2 countries reported providing access to neurorehabilitation services to 76-100% of their population. Five countries reported less than 25% of population had access to these services. Most commonly available neurorehabilitation services included services for stroke, spinal cord injury, pediatric neurorehabilitation, brain injury, and neuromuscular rehabilitation. Three countries had none of these specialized services. Five countries had neurorehabilitation training programs for physicians and other rehabilitation professionals. Patients had to pay out of pocket for these services in most of surveyed countries, followed by public funding and private insurance. Tele-neurorehabilitation and local disease-specific neurorehabilitation guidelines were not available in most of surveyed countries. Conclusion: Neurorehabilitation services in OIC region are not widely available, with significant variability in availability and quality. There is a need to develop and improve these services. Sharing knowledge and expertise through various forms, such as exchange visits and online sessions, can help improve neurorehabilitation services in these countries

A service evaluation of a new regional integrated stroke service in the NHS

Background: Stroke is the UK's leading cause of disability and contributes to numerous deaths. In response, centralised stroke care is on the rise, both globally and in the UK. A local trust has formed a regional stroke centre to provide efficient and timely emergency treatment. Aims: This article evaluates hyperacute performance in a new service, identifying areas for improvement and monitoring standards. It also aims to address and minimise shortfalls in preparation for the upcoming opening of a designated stroke hub, which will admit patients directly to the stroke team, bypassing the emergency department. Methods: Data were extracted from the Sentential Stroke National Audit Programme (SSNAP) database from 26 September 2022 to 26 January 2023. Comparison was made to national quarterly SSNAP data from October 2022 to December 2022, due to the corresponding publication dates. Literature was sourced from the Cumulative Index to Nursing &amp; Allied Health database. The main targets within SSNAP based on the first 4 hours of patient care were identified and analysed. Findings: From admission, 64% of patients underwent computer tomography scanning under 1 hour from admission, compared to a national average of 56.6%; 76% of patients underwent a swallow screening under 4 hours from admission, compared to a national average of 71.5%; and 37% of patients achieved admission to the hyperacute stroke unit under 4 hours from admission, compared to a national average of 39.5%. National average data were taken directly from SSNAP national averages from the report spanning October 2022 to December 2022. Conclusion: In comparison to national averages in many areas, the current service is performing well; however, there are many areas for improvement to address. Although the outlook for stroke care looks more promising as newer technologies emerge, stroke prevalence is increasing simultaneously. Stroke continues to cost the UK upwards of 26 billion pounds per year and causes significant detriment to survivors. Therefore, healthcare has a duty of care to continue to improve standards and innovate to improve outcomes.

Epidemiological profile of stroke in Qatar: Insights from a seven-year observational study

ObjectivesStroke prevalence is progressively increasing in developing countries due to increased vascular risk factors. This study aims to describe the epidemiology, prevalent risk factors, and outcomes of stroke in a multi-ethnic society of Qatar. Materials and MethodsWe conducted a retrospective analysis of all patients with suspected stroke admitted to stroke services between January 2014 and September 2020. ResultsA total of 11,892 patients were admitted during this period with suspected stroke. Of these, the diagnosis was ischemic stroke (48.8 %), transient ischemic attack (10.3 %), intracerebral hemorrhage (10.9 %), cerebral venous sinus thrombosis (1.3 %), and stroke mimics (28.6 %). The median age was 52 (43–62), with a male–female ratio of 3:1. The study population was predominantly Asian (56.8 %) and Arab (36 %). The majority of the patients were hypertensive (66.8 %), diabetic (47.9 %), and dyslipidemic (45.9 %). A history of prior stroke was observed in 11.7 %, while 0.9 % had prior transient ischemic attack. Among ischemic strokes, 31.7 % arrived within 4.5 h, 12.5 % received thrombolysis, and 4.6 % underwent thrombectomy. Median Door-to-Needle time was 51 (33–72) minutes. The average length of stay was 5.2 ± 9.0 days, with 71.5 % discharged home, 13.8 % transferred to rehabilitation, 9.3 % to other specialties, 3 % to long-term care, and 2.4 % suffered in-hospital mortality. ConclusionStroke in Qatar is characterized by a younger, expatriate-dominant cohort, with notable prevalence of ischemic and hemorrhagic stroke and a distinct risk factor profile. Further analysis of epidemiological differences among different population groups can inform targeted policies for prevention and management to reduce the burden of disease.

Abstract P388: Higher Social Vulnerability Was Associated With Less Community-Based Rehabilitation Utilization After Stroke

Background: Timely rehabilitation care significantly improves function and mobility after stroke, but barriers exist in access and utilization. The impact of neighborhood social determinants of health is not fully understood. Our study aims to estimate the association between Social Vulnerability Index (SVI), a measure of a community's need for support, and post-stroke rehabilitation utilization. Methods: This study is an observational, secondary analysis of the COMprehensive Post-Acute Stroke Services study, a pragmatic trial conducted in 41 North Carolina hospitals from 2016-2019. This analysis included 4765 individuals (51.2% female; 74.8% Whites; mean age 69.9) discharged directly home after stroke and linked to administrative claims. Utilization of physical or occupational therapy was obtained from outpatient, carrier file and home health claims. Geocoded participant addresses were linked to 2018 summary SVI percentile ranking and its four sub-domains at the Census tract level. Generalized estimation equations with cluster of Census tract and hospital were used to estimate the association between quintiles of SVIs and incidence proportion of rehabilitation use within 30 days. Covariates included patients’ socio-demographics, clinical characteristics, and comorbidities. Results: The overall proportion of rehabilitation use by 30 days was 38.6%, ranging from 34.6-46.5% across SVI quintiles. In multivariable analysis, quintiles of higher summary SVI were associated with lower rehabilitation use compared with the least vulnerable quintile (RD and 95% CI, Q5 vs Q1: -0.098 [-0.147 to -0.049]; Table). There was a significant decreasing trend across quintiles (P-trend &lt; 0.001). Similar results were observed for SVI sub-domains except for minority status and language. Conclusion: Higher social vulnerability was associated with less post-stroke rehabilitation use. The finding is useful to identify communities for targeted interventions to improve access and utilization to rehabilitation.

'Physical well-being is our top priority': Healthcare professionals'challenges in supporting psychosocial well-being in stroke services.

Following stroke, a sense of well-being is critical for quality of life. However, people living with stroke, and health professionals, suggest that well-being is not sufficiently addressed within stroke services, contributing to persistent unmet needs. Knowing that systems and structures shape clinical practice, this study sought to understand how health professionals address well-being, and to examine how the practice context influences care practice. Underpinned by Interpretive Description methodology, we interviewed 28 health professionals across multiple disciplines working in stroke services (acute and rehabilitation) throughout New Zealand. Data were analysed using applied tensionanalysis. Health professionals are managing multiple lines of work in stroke care: biomedical work of investigation, intervention and prevention; clinical work of assessment, monitoring and treatment; and moving people through service. While participants reported working to support well-being, this could be deprioritised amidst the time-oriented pressures of the other lines of work that were privileged within services, rendering it unsupported and invisible. Stroke care is shaped by biomedical and organisational imperatives that privilege physical recovery and patient throughput. Health professionals are not provided with the knowledge, skills, time or culture of care that enable them to privilege well-being within their work. This has implications for the well-being of people with stroke, and the well-being of health professionals. In making these discourses and culture visible, and tracing how these impact on clinical practice, we hope to provide insight into why well-being work remains other to the 'core' work of stroke, and what needs to be considered if stroke services are to better support people's well-being. People with stroke, family members and people who provide support to people with stroke, and health professionals set priorities for this research. They advised on study conduct and have provided feedback on wider findings from the research.

A qualitative exploration of ambulance clinician behaviour and decision making to identify factors influencing on-scene times for suspected stroke patients in North East England.

Ambulance clinician assessment of suspected stroke patients aims to provide rapid access to specialist care, however regional and national data show increasing pre-hospital times. This study explored paramedic views about factors contributing to on-scene time (OST) for suspected stroke patients, with a view to identifying opportunities for future interventions, to reduce OST. Views of paramedics from one regional service on factors influencing OST were explored using a qualitative approach. Semi-structured interviews with volunteers were recorded, transcribed and analysed using thematic analysis. Interviews were conducted with 13 paramedics between August and November 2021. Five interlinked themes were identified and described a range of factors influencing OST: 'Initial assessment and sources of information' describes how clinicians make assessments based on initial presentation, influenced by pre-arrival information from ambulance control and family members / bystanders at the scene, and how this influences OST.'Suitability for treatment and interventions' describes how paramedics consider actions such as the face, arms, speech test, cannulation, electrocardiograms and neurological assessments while recognising that pre-hospital interventions for suspected stroke are limited.'The environment' describes the influence of incident setting on OST, including the overall process needed to transport the patient to appropriate care.'Hospital interactions' describes how interactions with hospital staff influenced paramedic actions and OST.'Changing practice' describes the influence of experience and interaction with hospital staff leading to changes in paramedic practice over time. This study provides insight into how UK paramedics spend time on scene with stroke patients. Multiple factors influencing OST were identified which signpost opportunities for interventions designed to reduce OST. Standardising on-scene assessments for stroke patients, refining communication processes between ambulance services and hospital stroke services and increasing availability of stroke continuing professional development for paramedics were all identified as potential targets for improving OST.

Rapid outpatient transient ischemic attack clinic and stroke service activity during the SARS-CoV-2 pandemic: a multicenter time series analysis.

Rapid outpatient evaluation and treatment of TIA in structured clinics have been shown to reduce stroke recurrence. It is unclear whether short-term downtrends in TIA incidence and admissions have had enduring impact on TIA clinic activity. This study aims to measure the impact of the pandemic on hospitals with rapid TIA clinics. Relevant services were identified by literature search and contacted. Three years of monthly data were requested - a baseline pre-COVID period (April 2018 to March 2020) and an intra-COVID period (April 2020 to March 2021). TIA presentations, ischemic stroke presentations, and reperfusion trends inclusive of IV thrombolysis (IVT) and endovascular thrombectomy (EVT) were recorded. Pandemic impact was measured with interrupted time series analysis, a segmented regression approach to test an effect of an intervention on a time-dependent outcome using a defined impact model. Six centers provided data for a total of 6,231 TIA and 13,191 ischemic stroke presentations from Australia (52.1%), Canada (35.0%), Italy (7.6%), and England (5.4%). TIA clinic volumes remained constant during the pandemic (2.9, 95% CI -1.8 to 7.6, p = 0.24), as did ischemic stroke (2.9, 95% CI -7.8 to 1.9, p = 0.25), IVT (-14.3, 95% CI -36.7, 6.1, p < 0.01), and EVT (0, 95% CI -16.9 to 16.9, p = 0.98) counts. Proportion of ischemic strokes requiring IVT decreased from 13.2 to 11.4% (p < 0.05), but those requiring EVT did not change (16.0 to 16.7%, p = 0.33). This suggests that the pandemic has not had an enduring effect on TIA clinic or stroke service activity for these centers. Furthermore, the disproportionate decrease in IVT suggests that patients may be presenting outside the IVT window during the pandemic - delays in seeking treatment in this group could be the target for public health intervention.

Abstract WP49: Neuroscience Nurse Navigator Program Implementation: Impact on Inpatient &amp; Outpatient Post Stroke Continuum

Background: Comprehensive Stroke Program identified the need for a support system to ensure stroke patient [SP] follow-up [f/u] after discharge [DC] with [w/] Primary Care Physician [PCP] &amp; specialized stroke services [SSS]: Neurology [NEURO] &amp; Neurosurgery [NS]. The Neuroscience Nurse Navigator Program [NNN-P], implemented December 2019, included SP who received Alteplase [IV-A] or Mechanical Thrombectomy [MT]. Stroke order sets, revised 2020, included early DC planning [E-DC-P] for NNN-P coordination w/SSS &amp; PCP offices, &amp; updates to SP DC instructions. Individualized education included importance of f/u w/SSS &amp; PCP &amp; risk factor [RF] management, with barriers to care assessed. Contact information was verified with post DC calls at 3, 7, 30, &amp; 90 days [d] w/Modified Rankin Score assessment [mRS-A] at 90d. SP satisfaction [SP-S] assessed via paper tool changed to Press Ganey in 2021. Purpose: Evaluate NNN-P impact on the Inpatient &amp; Outpatient Post Stroke Continuum. Method: A retrospective review of 1,493 SP was conducted w/402 in the NNN-P. NNN-P records were reviewed for E-DC-P, days to f/u w/PCP &amp; SSS, 90d mRS-A, &amp; SP-S. Results: In the implementation year of 2020 there was an increase from 2019 in E-DC-P for PCP [60%], NEURO [38%], &amp; NS [13%] w/an 18% increase in completed 90d mRS-A. The year after implementation showed an additional increase from 2020 in E-DC-P for PCP [28%], NEURO [32%], &amp; NS [26%] w/a reduction in days to f/u for PCP [16d] &amp; NEURO [20d]. In 2022 SP-S improved from 2021 for f/u instructions &amp; RF [15%]. In 2023, sustained implementation, showed an overall increase from 2019 in E-DC-P for PCP [90%], NEURO [70%], &amp; NS [57%] w/an overall reduction in days to f/u for NEURO [30d] &amp; NS [16d] along w/improved SP-S for f/u instructions [27%] &amp; RF [11%]. Conclusion: The NNN-P established a support system that included coordination w/PCP &amp; SSS offices as well as relationship building w/SP &amp; family which resulted in improvement of timely f/u after DC, 90d mRS-A &amp; SP satisfaction.

Addressing disparities in the global epidemiology of stroke.

Stroke is the second leading cause of death and the third leading cause of disability worldwide. Though the burden of stroke worldwide seems to have declined in the past three decades, much of this effect reflects decreases in high-income countries (HICs). By contrast, the burden of stroke has grown rapidly in low-income and middle-income countries (LMICs), where epidemiological, socioeconomic and demographic shifts have increased the incidence of stroke and other non-communicable diseases. Furthermore, even in HICs, disparities in stroke epidemiology exist along racial, ethnic, socioeconomic and geographical lines. In this Review, we highlight the under-acknowledged disparities in the burden of stroke. We emphasize the shifting global landscape of stroke risk factors, critical gaps in stroke service delivery, and the need for a more granular analysis of the burden of stroke within and between LMICs and HICs to guide context-appropriate capacity-building. Finally, we review strategies for addressing key inequalities in stroke epidemiology, including improvements in epidemiological surveillance and context-specific research efforts in under-resourced regions, development of the global workforce of stroke care providers, expansion of access to preventive and treatment services through mobile and telehealth platforms, and scaling up of evidence-based strategies and policies that target local, national, regional and global stroke disparities.