Stroke Team Research Articles

From passenger to driver: an interview study on person-centeredness in clinical reasoning during stroke rehabilitation

Purpose To explore how stroke survivors experience and prefer to participate in clinical reasoning processes in the subacute phase of stroke rehabilitation. Methods An explorative qualitative design was used. Individual interviews were conducted with 10 stroke survivors (4 women and 6 men, mean age 68 years) 4 weeks after their stroke, and follow-up interviews were conducted with 6 of them after 10 weeks. The interview settings were the patient’s home during their home rehabilitation, an inpatient and an outpatient rehabilitation unit. A reflexive thematic analysis was performed. Results Four themes were identified: discharge as a critical point for participation, describing a stressful time with varying involvement; supportive actions and context as crucial for participation, describing collaboration with the stroke team, the team’s consideration of the stroke survivor’s resources and needs, and a supportive home environment; the importance of goals and follow-up, describing goals as motivational and an unstructured use of goals; and difficulties in participation, describing a lack of dialogue with the stroke team and undetected resources and needs. Conclusions The stroke survivors experienced changes in their participation in the clinical reasoning process as their rehabilitation progressed. They moved from perceiving themselves as passengers at the time of their hospital discharge to gradually seeing themselves as the driver of their rehabilitation process. Some person-centered attributes, such as respectful relationships and a health focus, were incorporated into the clinical reasoning, while others, such as a holistic view and shared goal-setting, required further emphasis for improved person-centeredness in stroke rehabilitation.

National assessment of clinicians participating in stroke treatment decisions at strokenet regional coordinating centers: Clinicians Making Stroke Treatment Decisions

ObjectivesSince the introduction of thrombolytics, stroke teams evolved to improve thrombolytic care delivery. The impact of the advent of endovascular therapy on the composition of acute stroke teams is unknown. Materials and MethodsA two-part pilot-tested survey was deployed to site-Principal Investigators (PIs) of the 27 StrokeNet Regional Coordinating Centers (RCCs) regarding institutional acute stroke teams. Part A inquired about the participation of personnel in each type of stroke response. Part B identified stroke team physicians and the types of responses in which they participate to assess training background of stroke team members. ResultsResponse rates for Part A and B were 66% and 48%, respectively. In Part A, 67% (12/18) of sites reported trainees always responded to ED stroke activations with significant autonomy. 44% (7/16) and 27% (4/15) of sites reported NP and PA response to ED stroke alerts, respectively, but with limited autonomy. In Part B, 124 physicians involved in ED stroke alerts were identified, the large majority of whom (79%, 95% CI: 71-85) were vascular neurology trained. The 39 (23%) stroke team members involved in endovascular therapy had the following training: 49% (34-64) neurosurgery, 28% (17-44) radiology, 18% (9-33) vascular neurology 5% (1-16) neurology. ConclusionsWe identified modest heterogeneity in the composition of acute stroke team members across StrokeNet RCCs. Individuals performing endovascular therapy had a variety of clinical specializations, reflecting the evolving multidisciplinary nature of interventional acute stroke care. At StrokeNet RCCs, teams have significant trainee involvement in both ED and inpatient acute stroke responses.

Streamlining Acute Stroke Processes and Data Collection: A Narrative Review

(1) Background: Acute ischemic stroke treatment has been thoroughly studied to identify strategies to reduce treatment times. However, many centers still struggle to achieve fast treatment times. Additionally, studies primarily focus on larger, more advanced centers; yet, smaller centers often face longer treatment times. (2) Objectives: The aim of this study is to analyze the existing literature reviewing stroke treatment processes in primary and comprehensive stroke centers that investigated or reduced treatment times. The articles identified were categorized based on the focus areas and approaches used. (3) Results: Three main categories of improvements were identified in the literature: (1) standardization of processes, (2) resource management, and (3) data collection. Both primary and comprehensive stroke centers were able to reduce treatment times through standardization of the processes. However, challenges such as variations in hospital resources and difficulties incorporating data collection software into workflow were highlighted. Additionally, many strategies to optimize resources and data collection that can benefit primary stroke centers were only conducted in comprehensive stroke centers. (4) Conclusions: Many existing strategies to improve stroke treatment times, such as pre-notification and mass stroke team alerts, have been implemented in both primary and comprehensive stroke centers. However, tools such as simulation training are understudied in primary stroke centers and should be analyzed. Additionally, while data collection and feedback are recognized as crucial for process improvement, challenges persist in integrating consistent data collection methods into clinical workflow. Further development of easy-to-use software tailored to clinician needs can help improve stroke center capabilities to provide feedback and improve treatment processes.

Integrating RapidAI in an Evolving Hub and Spoke Center

Introduction/Background: As the rapid assessment of suspected stroke patients is imperative to reduce death and disability, rapid and reliable imaging studies are required to guide treatment decisions for thrombolytic therapies and thrombectomy. The integration of Artificial intelligence (AI) imaging platforms within acute stroke assessment has been shown to improve treatment times with the overall goal of improving outcomes. The process of adoption of this technology has not been well described. We sought to describe a process of adopting one AI imaging platform, RapidAI, within a hub and spoke health care system in the mid-south United States. Methods: Using a process improvement model which identified the need for more convenient and rapid interpretation of imaging, we sought to identify the specific steps of technology adoption, ensuring success in the transition to RapidAI to support faster interpretation times among multiple members of the acute stroke team. Results: Because of strong leadership at the system level, our organization has been able to incorporate RapidAI in all spoke centers for the acute evaluation and treatment of stroke patients. Conclusions: AI imaging platforms, such as RapidAI, can be incorporated within hub and spoke systems of care through strong system leadership and distinct steps. These steps could also be considered for stand-alone facilities with the creation of strong partnerships in the treatment of acute stroke patients.

Utilization of Artificial Intelligence to Improve Door-In Door-Out Times for Mechanical Thrombectomy-Eligible Patients at a Hub-and-Spoke Community-Based Comprehensive Stroke Center: A Single Case Study Presentation

Background: Delays in the transfer of patients with hyperacute stroke may lead to treatment ineligibility due to the degree of cerebral hypoxic injury suffered. Cloud-based artificial intelligence applications may improve transfer times and expand access to advanced therapies. One case between a community-based comprehensive stroke center (CSC) and a primary stroke center (PSC) using a third-party telemedicine service and shared cloud-based artificial intelligence application may provide insight in opportunities to improve stroke systems of care. Case Presentation: A 62-year-old female with a past medical history of hypertension, current everyday tobacco smoker, and marijuana user presented to an outlying emergency department (ED) with dense left-sided hemiplegia affecting the arm and leg, right-sided gaze preference, and severe dysarthria. Her last known well (LKW) time was 0900 hours. CNS imaging revealed a right middle cerebral artery occlusion, visible to members of the CSC stroke team through the use of a cloud-based artificial intelligence cell phone application. The patient was treated with intravenous thrombolytics at the PSC, and she was transferred to the CSC, where she underwent a diagnostic cerebral arteriogram with carotid artery stenting. Later, Magnetic Resonance Imaging (MRI) of the brain revealed a 3.5 cm x 2.5 cm hemorrhagic lesion in the right frontal lobe and diffusion restriction in the right frontal and right posterior temporal lobes. The patient’s hospital stay was three days and, at the time of discharged, her modified Rankin score and NIHSS were zero. She was discharged on dual antiplatelet therapy, statin therapy, and nicotine replacement. Utilization of Artificial Intelligence: Transfer delays are complicated by organizing care at PSC and CSC and can be lengthy when communication across different facilities and subspecialties. Implementing cloud-based AI image sharing in stroke systems of care has reduced DIDO times by providing rapid imaging interpretation, streamlining communication, and enhancing coordination between PSCs and CSCs. Conclusions: Our case presentation showed how a hub-and-spoke model combined with cloud-based AI utilization can improve DIDO times and enhance stroke systems of care.

Aphasia and acute care: a qualitative study of healthcare provider perspectives

ABSTRACT Background Poor communication between patients with aphasia and healthcare providers has many adverse consequences. Training healthcare providers to support communication not only improves skill in communicating with people with aphasia, but also potentially avoids adverse incidents. However, families have reported negative communication experiences for their relatives with aphasia during early acute hospitalization and healthcare providers in acute hospitals have reported multiple barriers to managing people with aphasia. Aims To gather information from healthcare providers about their experiences and needs relative to managing people with aphasia in the acute hospital setting as part of a larger implementation project designed to 1) improve acute care staff communication with patients with aphasia, and 2) help staff provide support to families of people with aphasia. Methods Qualitative methods were employed to gather perspectives of stroke team staff regarding the management of aphasia in early acute care. Methods for collecting data from staff in a large metropolitan hospital in Ontario, Canada included open-ended surveys, observations on acute stroke units, interviews, and focus groups. Data were transcribed and analyzed to identify themes that defined staff experiences and needs relative to caring for people with aphasia in the acute setting. Results The overall finding was that staff found communication and caring for people with aphasia and their families in the acute context to be challenging and frustrating. Themes included identification of the following barriers: fast-paced context with competing priorities; limited staff familiarity with communication access or support; priority given to swallowing by speech-language pathologists; and difficulty in addressing the pressing need to provide support and information to family members of patients with aphasia. In addition, a pervasive need for communication with patients with aphasia as part of staff responsibilities was also identified as a theme. Conclusions Findings demonstrate the need for healthcare systems to support acute care staff in their efforts to provide care for people with aphasia. Finding effective ways to influence system change is a priority and is in line with the rationale for the larger implementation project designed to improve staff and patient/family experiences in acute care.

Pulmonary vein stump thrombosis and organ infarction after lung lobectomy.

Lung resection surgery, which is performed as a treatment for lung cancer and metastatic lung tumors, is currently conducted via minimally invasive techniques such as video-assisted thoracoscopic surgery and robot-assisted methods. Postoperative complications related to this surgery, such as pulmonary vein thrombosis and cerebral and other organ infarctions, have been increasingly reported. The primary cause of these complications is thrombus formation in the pulmonary vein stump. Statistical data on the site of lung lobectomy have indicated that surgeries involving the left upper lobe are most frequently associated with embolic complications. Although this issue has not received considerable attention in anesthesiology, the importance of prevention and treatment in postoperative management is growing. The role of anesthesiologists in preventing these complications is critical. These roles involve careful fluid management to avoid hypercoagulable states, consideration of early postoperative anticoagulation therapy, assessment of the suitability of epidural anesthesia for postoperative anticoagulation, and improvement of hospital-wide safety systems and monitoring of high-risk patients. Anesthesiologists need to understand the pathology and risk factors involved and play an active role in preventing and treating these complications through effective collaboration with thoracic surgeons and the in-hospital stroke team.

Developing pre-licensure interprofessional and stroke care competencies through skills-based simulations

ABSTRACT Interprofessional collaboration (IPC) in stroke care is accepted as best practice and necessary given the multi-system challenges and array of professionals involved. Our two-part stroke team simulations offer an intentional interprofessional educational experience (IPE) embedded in pre-licensure occupational therapy, physical therapy, pharmacy, medicine, nursing and speech-language pathology curricula. This six-year mixed method program evaluation aimed to determine if simulation delivery differences necessitated by COVID-19 impacted students’ IPC perception, ratings, and reported learning. Following both simulations, the Interprofessional Collaborative Competency Assessment Scale (ICCAS) and free-text self-reported learning was voluntarily and anonymously collected. A factorial ANOVA using the ICCAS interprofessional competency factors compared scores across delivery methods. Content and category analysis was done for free-text responses. Overall, delivery formats did not affect positive changes in pre-post ICCAS scores. However, pre and post ICCAS scores were significantly different for interprofessional competencies of roles/responsibilities and collaborative patient/family centered approach. Analysis of over 10,000 written response to four open-ended questions revealed the simulation designs evoked better understanding of others’ and own scope of practice, how roles and shared leadership change based on context and client need, and the value of each team member’s expertise. Virtual-experience-only students noted preference for an in-person stroke clinic simulation opportunity.

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

AbstractObjectivesPost‐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.MethodsThis 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.ResultsA 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).ConclusionsPerioperative 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.

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.

Attitudes of cardiac rehabilitation and stroke teams towards integration of stroke survivors into adapted cardiac rehabilitation: A focus group study

Objective To explore the attitudes and beliefs of cardiac rehabilitation and stroke teams towards adapted cardiac rehabilitation, and the broader topics of exercise, healthy lifestyles and health behaviour change, for people with mild-to-moderate severity stroke in the sub-acute phase of recovery. Design Qualitative focus group-based study. Setting Acute and community national health service trusts. Participants Stroke and cardiac rehabilitation team members. Intervention Adapted cardiac rehabilitation. Main measures Focus groups. Thematic analysis was applied to the transcribed data. Results Overall, 57 health professionals participated in 12 focus groups. Positive impacts for teams and stroke survivors were identified particularly confidence. However, there were negatives, barriers and adaptations identified. In addition, there was a lack of knowledge for cardiac rehabilitation teams in relation to stroke survivors and stroke teams in relation to cardiac rehabilitation, exercise and healthy lifestyles. Conclusions Cardiac rehabilitation and stroke staff attitudes to cardiac rehabilitation for stroke survivors showed a range of benefits, negatives, barriers and adaptations needed. Confidence and knowledge of the cardiac rehabilitation and stroke teams needs to be addressed. Registration ISRCTN65957980.

First‐Line Treatment of Symptomatic Subocclusive Large‐Vessel Stroke: Results of a Nationwide StrokeNet Survey

Background Limited evidence is available for the treatment of acute symptomatic subocclusive lesions in ischemic stroke. We sought to identify current treatment patterns of stroke teams at academic health centers. Methods We conducted an email survey of the National Institutes of Health StrokeNet regional coordinating centers (RCCs). Each RCC principal investigator was asked to nominate a local stroke interventionalist, or a neurologist if the RCC principal investigator was an interventionalist, most aligned with the typical practice pattern of the RCC's lead hospital, to receive a survey. The survey consisted of a clinical vignette and displayed a subocclusive lesion in the left middle cerebral artery on computed tomography angiogram followed by subsequent scenarios, revising only 1 historical, clinical, or radiographic variable at a time. Participants were asked to select initial management for each scenario. Results were reviewed and analyzed by stroke‐trained physicians. Results Responses were received from 42 (77.8%) of 54 surveyed individuals, representing 25 (92.6%) of 27 RCCs nationwide, including 25 (59.5%) interventionalists. The majority (76.2%) of respondents treated the patient in the primary clinical vignette with mechanical thrombectomy. Among all 6 clinical scenarios, respondents chose mechanical thrombectomy with or without medical management as first‐line treatment for 4 (67%) vignettes. Exceptions were low National Institutes of Health Stroke Scale score and known ipsilateral stenosis, where respondents chose medical management as first‐line treatment. Conclusion Despite limited evidence to support mechanical thrombectomy versus other treatment strategies, the majority of StrokeNet RCC respondents would use mechanical thrombectomy with or without medical therapy to treat acute ischemic stroke due to intracranial subocclusive lesions.

Development of a stroke network in Kinshasa (Democratic Republic of the Congo): a humanitarian project of the Italian Stroke Association—Associazione Italiana Ictus

In sub-Saharan Africa (SSA), stroke incidence is ~316 cases per 100,000 inhabitants and in 75% of SSA countries stroke is among the top three causes of death. This epidemiological evolution results from the exponential growth of the African population as well as the lack of policies for prevention and therapy. The Democratic Republic of Congo is one of the countries included as a “low-income country” in the 2023 Organization for Economic Co-operation and Development's Development Assistance Committee List; its capital, Kinshasa, is a megalopolis with more than 18 million inhabitants. According to our knowledge, no hospital in Kinshasa is currently capable of admitting and treating patients with stroke according to international guidelines. The Italian Stroke Association—Associazione Italiana Ictus (ISA-AII) is a multidisciplinary scientific society for the fight against cerebrovascular diseases. Some members of the ISA-AII joined to form a working group dedicated to the care of stroke in Africa. In this article, we explain the project designed by ISA Africa that, in collaboration with the referral hospital of a district of Kinshasa, has the aim of building a network for diagnosing and treating stroke, including ambulance services, a stroke team in the emergency room, a stroke unit, an outpatient clinic, and primary prevention activities among the population.

P025 Routine Giant-cell arteritis turned Heidenhain variant of sporadic Creutzfeldt-Jakob disease: a mysterious case report!

Abstract Background/Aims Giant-cell arteritis (GCA) is a large vessel vasculitis predominantly affecting those above 50 years of age. Creutzfeldt-Jacob disease (CJD) is not a well-recognised differential diagnosis of GCA presentation. Prion diseases are progressive, currently untreatable and ultimately fatal. Methods We report the case of a 76-year-old female who had an eventful hospital stay of 37 days. She has a history of asthma, hypertension, ulcerative colitis and right-sided GCA 5 years back (normal inflammatory markers & biopsy). Results The patient presents to Harlow ED with a right temporal headache with tenderness, jaw claudication symptoms, blurred vision, diplopia, dizziness and painful right eye movements. Her CRP was <1 and ESR was 5. The plan was to treat it as a recurrence of her GCA and to continue with the high dose Prednisolone started by the ED. CT Head was normal. Owing to poor response, IV Methyl Pred was given. On day six, patient was re-admitted with worsening headache and generalised decline. Ophthalmology review noted multiple visual field defects and treated as GCA. A neurology review noted the patient to be encephalopathic. Advice was for MRI head and CSF analysis - both NAD. On day 12 she had ongoing headache, diplopia, poor vision/memory, and reduced hearing in right ear, but alert and following instructions. On day 17, ENT suggestion was to treat as Meniere’s and start on Betahistine. On day 22, the patient had a TIA episode and discussed with Stroke team. Repeat CT Head was nil acute. By day 26, the patient was unresponsive intermittently and was treated as hypoactive delirium. On day 31 a seizure activity was noticed. Neurology review on day 33 noted rapid decline- the patient being mute, seizure/atypical encephalitis. MRI-Head with contrast showed the possibility of CJD. The very next day patient was reviewed by the team from National CJD Research and Surveillance team, Edinburgh. The formal diagnosis given was: probable Sporadic CJD (visual/Heidanhain variant), rapidly progressive cognitive decline with visual signs, myoclonus, and akinetic mutism, positive MRIs, bland CSF, no clear iatrogenic or variant risk factors, and no credible alternative diagnosis. The distressed family members were updated and the patient was put on EoL pathway. She died peacefully four days later (Day 37). Conclusion The importance of this case is the conflicting inputs from at least five specialities in a rapidly deteriorating patient. A background of previous right-sided GCA did prompt initial treatment in those lines. MRI Head DWI sequence did show the classic ‘cortical ribboning’ with right caudate and lentiform hyperintensity; which clinched the mysterious diagnosis of this rare disease which requires public health surveillance. CJD is to be suspected in any undiagnosed rapidly progressive mental deterioration or dementia, often with behavioural abnormalities and myoclonus. Disclosure S. Narikkoottungal: None. K. Gunasekera: None. K. Ahmed: None.

P015 Nodular skin rash associated with relapsing polychondritis, a challenging diagnostic journey to VEXAS syndrome

Abstract Background/Aims VEXAS syndrome, first described in 2020, is a haemato-inflammatory disease caused by a mutation in the gene-UBA1.This syndrome can coexist with or without Myelodysplastic syndrome. What makes this case interesting is its long and challenging diagnostic journey and the involvement of different clinical specialties such as dermatology, ophthalmology, rheumatology, respiratory, haematology, and stroke teams. Ultimately, two years after the initial presentation, this appeared to be the first case of VEXAS with confirmed genetic mutation in the region. VEXAS being a relatively new entity, treating clinician/s were not aware of the possibility initially. Therefore, spreading awareness regarding the clinical picture of VEXAS is prudent. This case report highlights rheumatological and dermatological manifestations of the disease to aid in the timely diagnosis and management of future cases. Methods We report a 74-year-old previously healthy male presented in 2021 with a rash on his legs, arms, and torso since October 2019. It was progressive, painful, palpable, erythematous, non-pruritic, intermittent rash, cleared with hyperpigmentation. He also had oligoarticular arthritis, constitutional symptoms, recurrent episodes of polychondritis, uveitis, bibasal lung fibrosis, and an ESR and CRP above 100. He also had lymphadenopathy above the diaphragm, but the biopsy only showed necrotic material, and the bone marrow biopsy did not show any features of haematological malignancy. After excluding infections, he was started on high-dose oral prednisolone for relapsing polychondritis. The skin and inflammatory markers improved immediately following high doses of steroids. However, whenever steroids were weaned down, even with the help of Methotrexate, his skin was flaring. He also had unprovoked DVT and, while on anticoagulation, developed occipital infarction. He had extensive skin involvement when he had to stop Methotrexate following a chest infection. Results The skin biopsy was inconclusive. There was no significant cytopenia but persistent macrocytosis even after stopping Methotrexate. As a result, he underwent a repeat bone marrow biopsy, which showed Vacuoles and gene UBA1 mutation in 2023. Conclusion The heterogeneity and complexity of the disease are due to multi-organ involvement, including skin, joints, eyes, lungs, blood vessels, and cartilage, simultaneously or cumulatively. Skin involvement in VEXAS can also be vast, ranging from neutrophilic dermatosis, erythema nodosum-like lesions, leukocytoclastic, or urticarial vasculitis. Cutaneous manifestations develop in the majority with VEXAS syndrome and can be the first presenting symptom in this new rare syndrome. Disclosure M. Gunawardena: None. L. Yalakki: None. R. Moitra: None. E.L. Williams: None. H. Wong: None. D. D'Cruz: None.

Update on the Acute Management of Ischemic Stroke

Acute ischaemic stroke is a major public health priority and will become increasingly relevant to neurologists of the future. The cornerstone of effective stroke care continues to be timely reperfusion treatment. This requires early recognition of symptoms by the public and first responders, triage to an appropriate stroke centre and efficient assessment and investigation by the attending stroke team. The aim of treatment is to achieve recanalisation and reperfusion of the ischaemic penumbra with intravenous thrombolysis and/or endovascular thrombectomy in appropriately selected patients. All patients should be admitted directly to an acute stroke unit for close monitoring for early neurological deterioration and prevention of secondary complications. Prompt investigation of the mechanism of stroke allows patients to start appropriate secondary preventative treatment. Future objectives include improving accessibility to endovascular thrombectomy, using advanced imaging to extend therapeutic windows and developing neuroprotective agents to prevent secondary neuronal damage. Bangladesh Crit Care J March 2024; 12 (1): 41-49

An empirical analysis of process improvement from best practice adoption: A study of stroke care best practices

AbstractThis study empirically examines how induced learning through adopting a set of best practices and learning‐by‐doing improved a hospital's care of ischemic stroke patients using ad hoc teams. While previous studies in healthcare operations management conducted in ad hoc team environments predominantly focused on volume‐based learning (learning by doing, team familiarity via interactions among team members), our study focuses on induced learning in ad hoc teams through best practice adoptions. The analysis uses secondary data (Data period: January 2009–March 2017) about stroke patients from a comprehensive stroke center (CSC) in a U.S. tertiary teaching hospital as it adopted the U.S. American Heart Association/American Stroke Association (AHA/ASA) Target:Stroke best practices. The ad hoc stroke teams provide the initial care and their performance is measured using “Door‐to‐Needle (DTN)” time and its sub‐time segments. The DTN time is measured as the time elapsed between the stroke patient's arrival at the hospital's emergency department (ED) and the appropriate infusion of “Tissue Plasminogen Activator (TPA)” (i.e., a thrombolytic medication informally referred to as a “clot buster”). We found that adopting these best practices improved ischemic stroke care beyond improvement due to repetition. We also found that the neurologist's recent experience providing stroke care for the prior patient is positively associated with meeting the time performance goal for the current patient. This study provides insights into the use of management mechanisms to adopt and sustain best practices in healthcare that are generalizable to other organizations with ad hoc team environments.

873 Code Brain Ultra-Early Clinical Pathway for Patient Identification and Management in Spontaneous Non-traumatic Intracranial Hemorrhage Single-Institution Study

INTRODUCTION: Spontaneous non-traumatic intracranial hemorrhage causes high morbidity and mortality. Clinical pathways for the management of acute ischemic stroke are well established but fall short in identifying intracranial hemorrhage, preventing early therapy. METHODS: Using Class 1 recommendations from the AHA/ASA Spontaneous Intracranial Hemorrhage Guidelines, our multi-disciplinary stroke team developed a hyper-acute clinical pathway. Once the hemorrhagic stroke patient was identified, protocolized measures were immediately initiated to lower systolic blood pressure to 140 mmHg, institute factor replacement therapies in coagulopathic patients and anti-platelet reversal when appropriate. Key performance indicators and quality metrics were established to compare post-intervention groups to the baseline cohort. RESULTS: Of 180 patients, 113 and 67 patients were treated pre- and post-protocol, respectively. From pre- to post-protocol, diagnosis of hemorrhagic stroke using the alert increased from 59% to 81%. Anti-hypertensive initiation within 60 minutes increased from 79.5% to 88.7%, with the average time from CT result decreasing from 32.7 to 21.7 minutes. Time to reversal agent decreased from 53 to 23 minutes for pro-coagulation agents and 106 to 55 minutes for DDAVP. Reversal agent initiation within 60 minutes of CT result increased from 66.6% to 100% for pro-coagulation agents and 28.5% to 84.6% for DDAVP. CONCLUSIONS: The initiation of this management protocol for hemorrhagic stroke resulted in a higher proportion of patients being rapidly identified and earlier initiation of anti-hypertensive and hemostatic therapies. These processes are the key to important interventions designed to reduce injury extension associated with intracranial hemorrhage, like “time to thrombolysis” measures for acute ischemic stroke.

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 & 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.

Early Experience With Artificial Intelligence Software to Detect Intracranial Occlusive Stroke in Trauma Patients.

Objective Identifying ischemic stroke is a diagnostic challenge in the trauma subpopulation. We describe our early experience with artificial intelligence-assisted image analysis software for automatically identifying acute ischemic stroke in trauma patients. Methods Patients were retrospectively screened for (i) admission to the trauma service at a level one trauma center between 2020 and 2022, (ii) radiologist-confirmed intracranial occlusion, (iii) occlusion identified on computed tomography angiography performed within 24 hours of admission, (iv) no intracranial hemorrhage, and (v) contemporaneous analysis with the large vessel occlusion (LVO) detection program. Baseline characteristics, stroke detection, response-activation, and outcome data were summarized. Results Of 9893 trauma patients admitted, 88 (0.89%) patients had a cerebral stroke diagnosis, of which 10 patients (10/88; 11.4%) met inclusion criteria. Most patients were admitted following a fall (8/10; 80%). Six (6/10; 60.0%) patients had LVOs. The program correctly detected 83.3% (5/6) of patients, and these patients were triaged in less than one hour from arrival on average. The program did not falsely identify non-LVOs as LVOs for any patients. Conclusions Identifying adjunct tools to aid timely identification and treatment of ischemic stroke in trauma patients is necessary to increase the chances for meaningful neurological recovery. Our early experience exhibited potential for using automated software to aid occlusion identification and subsequent stroke team mobilization. Future studies in larger cohorts will expand upon these preliminary findings to establish the accuracy and clinical benefit of automated stroke detection tool integration for the trauma population.