Stroke Unit Admission Research Articles

Abstract TP325: Impact of Nocturnal Desaturation on Early Neurological Deterioration Following Ischemic Stroke

Introduction: The mechanisms of early neurological deterioration (END) in patients with acute stroke remain unclear. Despite that systemic hypoxia is associated with stroke risk and poor outcome following acute stroke, the association between nocturnal desaturation and END remains to be elucidated Hypothesis: We assessed the relationship between nocturnal oxygen desaturation in the stroke unit and END in patients with acute stroke. Methods: A consecutive 225 patients with acute ischemic stroke who were admitted to the stroke unit within 7 days after stroke onset between July 2013 and June 2014 were included for analysis Physiological variables including pulse oximetry were sampled every 1 minute. The ODI was calculated using pulse oximetry data during 9 hours on the first night (10:00 PM-7:00 AM) of the stroke unit admission and nocturnal oxygen desaturation was defined as an ODI of 5 or greater per hour. We compared the clinical characteristics, nocturnal oxygen desaturation, laboratory findings, and radiologic findings in patients with and without END. Results: Among the total patients, 52.4 % were male, with a mean age of 66.8 years. Twenty patients experienced early neurological worsening after stroke onset. The proportion of patients with nocturnal desaturation was significantly greater in the group of patients who also showed END (40.0% vs. 9.8%, P < 0.001). Moreover, more patients with END showed poor outcomes at 3 months (65.0% vs. 28.8%, P = 0.001). The stroke lesion locations did not significantly differ between the two groups. After controlling for relevant confounding factors, we found that nocturnal oxygen desaturation was associated with a risk of END (Odds ratio, 5.81; 95% confidence interval, 1.57-21.51). Conclusions: In conclusion, our study found that recurrent nocturnal desaturation in the stroke unit was associated with END in patients with acute stroke. In this context, our data could suggest that intensive monitoring of nocturnal desaturation in the stroke unit could be an important factor in preventing the risk of END and poor outcomes following acute stroke. .

Factors influencing nondirect admission in a French stroke unit and impact of prehospital regulation on access to intravenous thrombolysis

Objectif Dans notre centre, l’unite neurovasculaire (UNV) et le service d’accueil des urgences (SAU) ne sont pas sur le meme site. Cet eloignement geographique a conduit a l’existence de facto de deux filieres neurovasculaires, l’une permettant l’acces direct en UNV, et l’autre conduisant a un passage au SAU ou la thrombolyse n’est pas possible. L’objectif de ce travail etait d’identifier des facteurs de nonadmission directe en UNV des patients victimes d’AVC ou d’accident ischemique transitoire (AIT) admis au CHU de Tours, conduisant a un passage initial par le SAU, sans certitude d’acces a l’UNV dans un second temps.

Stroke patients admitted within normal working hours are more likely to achieve process standards and to have better outcomes

BackgroundThe presence of a ‘weekend’ effect has been shown across a range of medical conditions, but has not been consistently observed for patients with stroke.AimsWe investigated the impact of admission...

Effects of Centralizing Acute Stroke Services on Stroke Care Provision in Two Large Metropolitan Areas in England.

In 2010, Greater Manchester and London centralized acute stroke care into hyperacute units (Greater Manchester=3, London=8), with additional units providing ongoing specialist stroke care nearer patients' homes. Greater Manchester patients presenting within 4 hours of symptom onset were eligible for hyperacute unit admission; all London patients were eligible. Research indicates that postcentralization, only London's stroke mortality fell significantly more than elsewhere in England. This article attempts to explain this difference by analyzing how centralization affects provision of evidence-based clinical interventions. Controlled before and after analysis was conducted, using national audit data covering Greater Manchester, London, and a noncentralized urban comparator (38 623 adult stroke patients, April 2008 to December 2012). Likelihood of receiving all interventions measured reliably in pre- and postcentralization audits (brain scan; stroke unit admission; receiving antiplatelet; physiotherapist, nutrition, and swallow assessments) was calculated, adjusting for age, sex, stroke-type, consciousness, and whether stroke occurred in-hospital. Postcentralization, likelihood of receiving interventions increased in all areas. London patients were overall significantly more likely to receive interventions, for example, brain scan within 3 hours: Greater Manchester=65.2% (95% confidence interval=64.3-66.2); London=72.1% (71.4-72.8); comparator=55.5% (54.8-56.3). Hyperacute units were significantly more likely to provide interventions, but fewer Greater Manchester patients were admitted to these (Greater Manchester=39%; London=93%). Differences resulted from contrasting hyperacute unit referral criteria and how reliably they were followed. Centralized systems admitting all stroke patients to hyperacute units, as in London, are significantly more likely to provide evidence-based clinical interventions. This may help explain previous research showing better outcomes associated with fully centralized models.

Arritmias cardiacas en la unidad de ictus: análisis de los datos de la monitorización cardiaca

IntroductionCardiac arrhythmias are frequent in acute stroke. Stroke units are widely equipped with cardiac monitoring systems. Pre-existing heart diseases and heart-brain interactions may be implicated in causing cardiac arrhythmias in acute stroke. This article analyses cardiac arrhythmias detected in patients hospitalised in a stroke unit. MethodProspective observational study of consecutive patients admitted to a stroke unit with cardiac monitoring. We collected clinical data from patients and the characteristics of their cardiac arrhythmias over a 1-year period (2013). Time of arrhythmia onset, associated predisposing factors, and the therapeutic decisions made after detection of arrhythmia were examined. All patients underwent continuous cardiac monitoring during no less than 48hours. ResultsOf a total of 332 patients admitted, significant cardiac arrhythmias occurred in 98 patients (29.5%) during their stay in the stroke unit. Tachyarrhythmia (ventricular tachyarrhythmias, supraventricular tachyarrhythmias, complex ventricular ectopy) was present in 90 patients (27.1%); bradyarrhythmia was present in 13 patients (3.91%). Arrhythmias were independently associated with larger size of brain lesion and older age. In 10% of the patient total, therapeutic actions were taken after detection of significant cardiac arrhythmias. Most events occurred within the first 48hours after stroke unit admission. ConclusionsSystematic cardiac monitoring in patients with acute stroke is useful for detecting clinically relevant cardiac arrhythmias. Incidence of arrhythmia is higher in the first 48hours after stroke unit admission. Age and lesion size were predicted appearance of arrhythmias. Detection of cardiac arrhythmias in a stroke unit has important implications for treatment

Implementing a Simple Care Bundle Is Associated With Improved Outcomes in a National Cohort of Patients With Ischemic Stroke

Further research is needed to better identify the methods of evaluating processes and outcomes of stroke care. We investigated whether achieving 4 evidence-based components of a care bundle in a Scotland-wide population with ischemic stroke is associated with 30-day and 6-month outcomes. Using national datasets, we looked at the effect of 4 standards (stroke unit entry on calendar day of admission [day 0] or day following [day 1], aspirin on day 0 or day 1, scan on day 0, and swallow screen recorded on day 0) on mortality and discharge to usual residence, at 30 days and 6 months. Data were corrected for the validated 6 simple variables, admission year, and hospital-level random effects. A total of 36,055 patients were included. Achieving stroke unit admission, swallow screen, and aspirin standards were associated with reduced 30-day mortality (adjusted odds ratio [95% confidence interval]: 0.82 [0.75-0.90], 0.88 [0.77-0.99], and 0.39 [0.35-0.43], respectively). Thirty-day all-cause mortality was higher when fewer standards were achieved, from 0 versus 4 (adjusted odds ratio [95% confidence interval], 2.95 [1.91-4.55]) to 3 versus 4 (adjusted odds ratio [95% confidence interval], 1.21 [1.09-1.34]). This effect persisted at 6 months. When less than the full care bundle was achieved, discharge to usual residence was less likely at 6 months (3 versus 4 standards; adjusted odds ratio [95% confidence interval], 0.91 [0.85-0.98]). Achieving a care bundle for ischemic stroke is associated with reduced mortality at 30 days and 6 months and increased likelihood of discharge to usual residence at 6 months.

Abstract W P291: Long-term Stroke Awareness Among Stroke Survivors is Suboptimal

Background/Objective: Stroke survivors are at high-risk for recurrent stroke. Stroke education attempts to reduce this risk by emphasizing stroke warning signs and need to call 911. Long-term stroke awareness has been under-studied in stroke survivors. We aimed to assess stroke awareness at 1 year among stroke survivors and identify factors associated with poor performance. Methods: From a single center prospective cohort study of consecutive patients diagnosed with acute ischemic stroke or transient ischemic stroke (TIA), we identified stroke survivors able to complete telephone interviews at 1 year. All patients were provided standardized educational materials during index hospitalization. We used the validated Stroke Action Test (STAT) to assess stroke knowledge at 1 year. The STAT is a 28-item questionnaire that asks respondents to choose 1 of 4 answers to each scenario (call 911, call doctor, wait 1 hour, or wait 1 day). We also assessed cognitive status at 1 year using the validated telephone interview for Cognitive Status (TICS). We identified factors associated with STAT score (number of correct responses) using univariate and multivariate regression. Results: Among 254 patients who completed 1 year follow-up (65.8 years; 55.5% male; 68.5% white; 94.1% modified Rankin 0-1 at 1 year), the median STAT score was 57.1% (range 2.1-75.0%). In multivariate regression, TICS score (B=0.533; p<0.001) and ethnicity (B=-2.357, p=0.006) were independently associated with STAT score. Age, race, insurance, arrival by ambulance at time of index hospitalization, stroke unit admission, length of stay, discharge to rehabilitation, post-stroke hospital/clinic visits were not associated with STAT score. Conclusion: Despite hospitalization and standardized education at time of index event, most stroke survivors are unaware of stroke warning signs at 1 year. Besides cognitive status and Hispanic ethnicity, no other factors were identified that predicted STAT score performance. Future studies should focus on improving hospital-based stroke educational programs and consider novel strategies in patients with cognitive impairment and differing language/cultural backgrounds.

Thyroid function tests and early outcomes of acute ischemic stroke in older euthyroid patients

Blood thyroid function tests (TFT) are routinely used to screen for thyroid disorders in several clinical settings. TFT on hospital admission may also be useful prognostic predictors of acute IS: according to recent evidence, poststroke outcome is better in patients with lower thyroid function and worse in those with higher thyroid function. However, previous reports are few and mostly compared patients with thyroid disorders to euthyroid patients. Thyroid disorders are known risk factors for cerebrovascular disease. However, hyperthyroidism is related to cardioembolic IS whereas hypothyroidism is related to atherosclerotic risk factors. Therefore, findings from available studies of TFT might just reflect the worse prognosis of cardioembolic IS compared to other IS subtypes. Another limitation of previous studies is the lack of information for older persons, who represent three quarters of all IS patients. In this paper, we investigated whether serum thyroid stimulating hormone (TSH), free thyroxine (FT4) and free triiodothyronine (FT3) measured on Stroke Unit (SU) admission are associated with early outcomes of acute IS in 775 euthyroid patients aged ≥65years (mean age 80.1±8.7years). Two composite outcomes were investigated: poor functional outcome (death during SU stay or disability at SU discharge), and unfavorable discharge setting (death during SU stay, transfer from SU to other acute hospital unit or transfer from SU to long-term care-facilities as opposed to direct discharge home). Analyses were performed using logistic regression models. Curvilinear associations were tested including TFT as polynomial terms. Models were adjusted for demographics, prestroke, and IS-related confounders. We found that lower TSH had a complex curvilinear association with poor functional outcome and that the shape of the associations changed with age. At age 65, the curve was U-shaped: outcome risk decreased with increasing TSH, reached its minimum at TSH near 3.00mUI/L and then started to rise. Between ages 70 and 75, however, the shape of the curve straightened and, starting from age 80 took an inverted U-shape: outcome risk rose with increasing TSH, reached its maximum at TSH values that progressively shifted upward with increasing age (from 1.70mU/L at age 80 to about 2.20mUI/L at age 90), then started to decrease. A linear inverse association was found between FT3 and unfavorable discharge setting. Our study suggests that measurement of TFT on SU admission can provide independent prognostic information for early outcomes of acute IS in older euthyroid patients.

The impact of stroke unit care on outcome in a Scottish stroke population, taking into account case mix and selection bias

Background and aimRandomised trials indicate that stroke unit care reduces morbidity and mortality after stroke. Similar results have been seen in observational studies but many have not corrected for selection...

Cog-4 Has Limited Diagnostic Test Accuracy and Validity for Cognitive Assessment in Stroke Survivors

Guidelines recommend cognitive screening for all stroke survivors but do not suggest a preferred tool. Certain elements (orientation, executive function, language, and inattention) of the impairment scale, National Institutes of Health Stroke Scale (NIHSS), have been suggested as a short cognitive screening test-Cog-4. We aimed to describe accuracy and validity of Cog-4 against a more detailed cognitive assessment (Montreal Cognitive Assessment [MoCA]). We assessed consecutive acute stroke unit admissions in 2 hospitals over 3 months. Four independent blinded assessors performed NIHSS and MoCA between days 1 and 4 poststroke. We described test properties of Cog-4 for MoCA-defined cognitive impairment using usual thresholds (Cog-4≥1 and MoCA<26 of 30) and described the correlations of individual Cog-4 components with broadly equivalent MoCA domains. We assessed 173 participants; 166 had Cog-4 data and 148 MoCA. MoCA described 84% (n=124) of assessed participants as having cognitive impairment and the Cog-4, 37% (n=62). Cog-4 had a sensitivity of .36 (95% confidence interval [CI]: .28-.45) and a specificity of .96 (95% CI: .80-.99) (positive predictive value: .98, negative predictive value: .23) for MoCA-defined cognitive impairment. Individual Cog-4 items correlated with certain MoCA domains, but the strength of association was modest (r=-.44 orientation, -.37 language, -.19 for inattention, and no significant correlation for executive function, P=.72). Our data suggest that many stroke survivors with MoCA-defined cognitive problems would not be detected by Cog-4. Subtest correlations suggest that Cog-4 may not be a valid measure of the cognitive domains that it purports to describe. Other brief cognitive screening tests may be better suited to acute stroke.

Advances in Stroke

Since the last advances article on health policy and outcomes,1 selected developments include new knowledge on long-term outcomes after stroke and their policy relevance, associations of neighborhood disadvantage with stroke mortality, growth and effect of regionalized systems of stroke care, and preliminary research relevant to policies on early stroke mortality as a hospital performance measure. The South London Stroke Register of incident strokes across a multiethnic, urban population reported that long-term survival gradually improved in consecutive cohorts of patients with stroke from 1995 to 2010, and higher survival was associated with stroke unit admission (hazard ratio, 0.75; P <0.0001).2 Concurrently, stroke unit admission had increased dramatically from 19% in 1995 to 1997 to 78% by 2007 to 2009. Although evidence of benefit from stroke units has existed for several decades, there have been barriers to widespread adoption that may be addressed through local or national policies. Annual assessments for depressive symptoms in this registry cohort demonstrated that the presence of depressive symptoms after stroke is dynamic, often being of short duration but with a high risk of recurrence over time.3 About one third of patients were depressed at 3 months after stroke, with resolution of symptoms among half of those by 1 year. However, depression was detected …

Prehospital Triage to Primary Stroke Centers and Rate of Stroke Thrombolysis

Implementation of prehospital stroke triage is a public policy intervention that can have an immediate impact on acute stroke care in a region. OBJECTIVE To evaluate the impact that a citywide policy recommending prehospital triage of patients with suspected stroke to the nearest primary stroke center had on intravenous tissue plasminogen activator (tPA) use in Chicago, Illinois. Retrospective multicenter cohort study from September 1, 2010, to August 31, 2011 (6 months before and after intervention that began March 1, 2011). Ten primary stroke center hospitals in Chicago. All admitted patients with stroke and transient ischemic attack. INTERVENTION Prehospital triage policy of patients with stroke to primary stroke centers. Intravenous tPA use (measured as a fraction of patients with ischemic strokes arriving through the emergency department). RESULTS There were 1075 stroke and transient ischemic attack admissions in the pretriage period and 1172 in the posttriage period. Patient demographic characteristics including age, sex, and risk factors were similar between the 2 periods (mean age, 65 years; 53% female). Compared with the pretriage period, use of emergency medical services increased from 30.2% to 38.1% (P < .001) and emergency medical services prenotification increased from 65.5% to 76.5% (P = .001) after implementation. Rates of intravenous tPA use were 3.8% and 10.1% (P < .001) and onset-to-treatment times decreased from 171.7 to 145.7 minutes (P = .03) in the pretriage and posttriage periods, respectively. Stroke unit admission, symptomatic intracranial hemorrhage rates, and in-hospital mortality were not significantly different between periods. Adjusting for mode of arrival, prehospital notification, and onset-to-arrival time, the posttriage period was independently associated with increased tPA use for patients with ischemic stroke presenting through the emergency department (adjusted odds ratio = 2.21; 95% CI, 1.34-3.64). Implementation of a prehospital stroke triage policy in Chicago resulted in significant improvements in emergency medical services use and prenotification and more than doubled intravenous tPA use at primary stroke centers.

Test Accuracy of Short Screening Tests for Diagnosis of Delirium or Cognitive Impairment in an Acute Stroke Unit Setting

Guidelines recommend cognitive screening in acute stroke. Various instruments are available, with no consensus on a preferred tool. We aimed to describe test accuracy of brief screening tools for diagnosis of cognitive impairment and delirium in acute stroke. We collected data on sequential stroke unit admission in a single center. Four assessors trained in cognitive testing independently performed screening and reference tests. Brief assessments comprised the following: 10- and 4-point Abbreviated Mental Test (AMT-10; AMT-4); 4-A Test (4AT); Clock Drawing Test (CDT); Cog-4; and Glasgow Coma Scale (GCS). We also recorded the multidisciplinary team's informal review using single question (SQ). We compared against reference standards of Montreal Cognitive Assessment (MoCA) and Confusion Assessment Method for delirium using usual diagnostic cutpoints. For MoCA, we described effects of lowering the diagnostic threshold to MoCA <24 and MoCA <20. We described sensitivity, specificity, and positive and negative predictive values. Over a 10-week period, 111 subjects had cognitive assessment data. Subjects were 50% male (n=55), and median age was 74 years (interquartile range, 64-85). AMT-4, AMT-10, and SQ all had excellent (1.00) specificity for detection of cognitive impairment, although sensitivity was poor (all <0.60). The 4AT had greatest sensitivity for detecting delirium (1.00 [confidence interval [CI], 0.74-1.00]) and reasonable specificity (0.82 [CI, 0.72-0.89]). Properties of 4AT for detection of cognitive impairment, at the traditional MoCA threshold, were also good (sensitivity, 0.86; specificity, 0.78). Using diagnostic thresholds of MoCA ≤26, <24, and <20 gave proportions with cognitive impairments of 86%, 61%, and 49%, respectively, with resulting changes in screening test properties. At lower MoCA thresholds, CDT had favorable sensitivity and specificity (MoCA <20: sensitivity, 0.93, specificity, 0.66; MoCA <24: sensitivity, 0.85, specificity, 0.77). Many brief screening assessments are specific but not sensitive for detection of cognitive impairment in acute stroke. Our primary analysis suggests that 4AT is a reasonable choice for delirium and cognitive screening in this setting. However, these data are based on standard MoCA diagnostic threshold and may not be suited for an acute stroke population.

Abstract WP281: Post-tPA Care for Acute Stroke Patients; Comparison between Intensive Care Unit Admission and Stroke Unit Admission.

Backgound: The American Stroke Association guidelines for acute stroke indicate that patients receiving tPA can be admitted to an ICU or a stroke unit (SU). Admission to a SU could result in cost savings and better resource allocation. We sought to compare a strategy of admitting all tPA-treated stroke patients to the ICU vs. admitting them to a SU. Material and Methods: Retrospective observational study. During the initial 3 years of the study all tPA patients were admitted to the ICU as we lacked a SU. In the following 2 years, patients were admitted to a new SU. We obtained baseline demographics, past medical history, admission NIHSS, treatment interventions, neurologic and medical complications, and mortality for both groups to determine if ICU admission resulted in better outcome and less complications than SU admission. Fishers exact test was used for categorical variables and proportion of the means test (t-test) for continuous variables. Results: A total of 71 patients were admitted to the ICU and 104 were admitted to the SU. ICU admission included 54% males and SU admission included 59% males (NS). The median age for ICU and SU admission was 69 and 70 respectively (NS). The admission NIHSS was 11 for ICU patients and 9 for SU patients (NS). The median length of stay in the ICU was 1 day (as per protocol) and the median SU length of stay was 4 days. Intravenous hypertensives (bolus) were used in 30% of ICU patients and in 18% of SU patients (p= 0.09) and continuous infusions were required in 11% of ICU patients and 6% of SU patients (p=0.04). Initial NIHSS scale of &gt; 15 predicted need for mechanical ventilation and ICU admission (p=0.002). Intracranial hemorrhage occurred in 3% of ICU and 3% of SU patients (NS). There was no difference in medical complications (pneumonia, venous thromboembolism, sepsis, or death) in the 2 groups. There was no significant difference in the proportion of patients with excellent outcome (mRS of 1 or less) in the two groups (38% vs 36%). Stroke unit admission saves $70,000 per 100 patients per day. Conclusions: Stroke patients receiving intravenous tPA can be safely admitted to a SU resulting in significant savings. Patients with NIHSS &gt; 15 are likely to need ICU admission for mechanical ventilation.

Abstract 5: Management Of Intravenous tPA In Non-ICU Environments: Safety, Clinical Outcome, And Cost Savings

Background: Administration of IV tPA has traditionally necessitated admission to an ICU solely for monitoring, with relatively no need for extensive critical care services. Stroke Units that are capable of monitoring IV tPA patients have been proposed to reduce ICU use, but limited data exist that demonstrate safety. We report the largest series of non-ICU managed tPA cases in relation to safety and discharge outcomes. Methods: Consecutive cases admitted to our intermediate-level Stroke Unit spanning 2009-2011 were assembled. Unit capabilities include IV tPA management with nicardipine infusion for blood pressure control as needed, non-invasive or direct central/arterial line and cardiac monitoring, and BiPAP ventilation. Stroke Unit nurses underwent extensive orientation and participate in NET SMART Junior for continuing education. Overall sICH, and drip/ship sICH (parenchymal hemorrhage in combination with &gt; 4 point increase on the NIHSS), systemic hemorrhage, and tPA related death rates were calculated, along with discharge mRS and total ICU cost savings per day. Results: A total of 302 Stroke Unit admissions for intravenous tPA occurred over the 3 year period, while another 31 (10%) were excluded due to critical care admission for systemic hemodynamic or pulmonary instability. Nicardipine infusions were used in 9 (10.5%) Stroke Unit tPA cases in 2009, 10 (9%) in 2010, and 14 (13%) in 2011. Overall sICH rate was 3.3% (n=10) and systemic hemorrhage rate was 2.9% (n=9) with 5 of these (56%) requiring transfusion. Estimated cost savings in total for this 3 year period was $362,400 for “avoided” ICU days. Conclusions: Intravenous tPA patients may be safely managed on non-ICU Stroke Units when nurses undergo extensive education to ensure clinical competence. Use of the ICU solely for management of tPA monitoring needs may constitute significant overuse of system resources at an expense that is not associated with additional safety benefit.

Trends and Survival Between Ethnic Groups After Stroke

To identify trends and differences between ethnic groups in survival after first-ever stroke and examine factors influencing survival. Population-based stroke register of first in a lifetime strokes between 1995 and 2010. Baseline data were collection of sociodemographic factors, stroke subtype, case mix, risk factors before stroke, and receipt of effective acute stroke processes. Survival curves were estimated with Kaplan-Meier methods, and survival analyses were undertaken using Cox Proportional-hazards models. Survival improved significantly over this 16-year period (P<0.0001). Black Caribbean and black African had a reduced risk of all-cause mortality compared with white patients (hazard ratio, 0.85 [95% confidence interval, 0.74-0.98] and 0.61 [0.49-0.77], respectively) after adjustment for confounders. This survival advantage of black Caribbean/black African over white mainly existed in older patients (over 65). Recent stroke, being black Caribbean/black African, and stroke unit admission were associated with better survival. Survival has improved in a multiethnic population over time. The independent survival advantage of black Caribbean and black African over White group in those aged over 65 may be a healthy migrant effect of first generation migrants. The increase in admission to a stroke unit may contribute to the improvement in survival after stroke.

Socioeconomic Status and Care After Stroke

Socioeconomic status is inversely associated with mortality after stroke; however, the reasons behind this finding are not well-understood. We undertook a study to determine whether posthospitalization care and medication adherence vary with neighborhood income. We conducted a cohort study of 11 050 patients with ischemic stroke or transient ischemic attack admitted to any of 11 specialized stroke centers in Ontario, Canada, between July 1, 2003 and March 31, 2008. Socioeconomic status measured as neighborhood income quintiles was imputed from the 2006 Canadian Census. We used linkages to administrative databases to evaluate processes of stroke care and medication adherence within 1 year of discharge. We used multivariable analyses to assess whether differences in stroke care and medication adherence existed across income groups after adjustment for age, sex, stroke severity, and comorbid conditions. Higher income was associated with higher rates of stroke unit admission, neurology consultations, referrals to secondary prevention clinics, and physician visits after hospital discharge; however, the absolute differences in rates were small. There was no difference across income quintiles in the use of postdischarge homecare services or in adherence to antihypertensive, antithrombotic, or lipid-lowering medications. Higher income is associated with improvements in some aspects of stroke care delivery. However, the magnitude of the care gap across income quintiles is small and is unlikely to account for the previously observed association between socioeconomic status and survival after stroke.

Quality of Acute Ischemic Stroke Care in Thailand: A Prospective Multicenter Countrywide Cohort Study

Data concerning quality of acute stroke care and outcome are scarce in developing countries. This study aimed to evaluate quality of acute stroke care and stroke outcomes in Thailand. We performed a multicenter countrywide prospective cohort study. Consecutive patients with an acute ischemic stroke admitted to the participating institutions between June 2008 and November 2010 were included. Baseline characteristics, process measures including thrombolysis use, acute stroke unit admission, initiation of aspirin within 48 hours, and antithrombotic and/or anticoagulation medication at discharge were recorded. Main outcome measures were death and disability at discharge as well as in-hospital complications. A total of 1222 patients were included with a mean (±SD) age of 65.0 ± 13 years, and 55.0% were men. Median National Institutes of Health Stroke Scale score was 6.5. Patients were given aspirin within 48 hours, admitted to acute stroke unit, and given thrombolytic therapy in 71.1%, 24.6%, and 3.8%, respectively. Good recovery at discharge (modified Rankin scale score 0-1) was found in 26.1%, and 3.2% of patients died during hospitalization. The median length of stay was 4 days. Factors predicting poor outcome (modified Rankin scale score 5-6) at discharge included: age (by 10-year increments: adjusted odds ratio [OR] 1.23; 95% confidence interval [CI], 1.06-1.43), female sex (adjusted OR 1.52; 95% CI, 1.05-2.19), initial National Institutes of Health Stroke Scale score (adjusted OR 1.35; 95% CI, 1.27-1.43), and in-hospital complications (adjusted OR 3.16; 95% CI, 1.58-6.35). Limited access to acute ischemic stroke care interventions were observed in many domains especially thrombolysis and stroke unit admission. These findings emphasize an urgent need for strategies to improve standard acute stroke care among developing countries.

Impact of an Electronic Medical Record-Based Clinical Decision Support Tool for Dysphagia Screening on Care Quality

Dysphagia screening (DS) before oral intake in patients with acute stroke is a hospital-level performance measure. We report outcomes of an initiative to improve compliance to this quality measure. The design was a pre- versus postintervention comparison study. The Intervention was an electronic medical record-based clinical DS system embedded within stroke admission orders. The clinical DS was designed to facilitate DS in patients with stroke. The primary outcome was compliance to a process measure in patients with ischemic stroke: performance of a swallow screen before oral intake. DS measure compliance increased from 36% to 74% (P=0.001). Chart audits found screened patients were more likely to have clinical DS-embedded admission orders initiated or stroke unit admission. The electronic medical record offers a ready platform for clinical DS implementation. DS is a difficult performance measure to improve. The described clinical DS has the potential for improving performance on this challenging care quality measure.

Airborne pollutants and lacunar stroke: a case cross-over analysis on stroke unit admissions

Particulate air pollution is known to be associated with cardiovascular disease. The relation of particulate air pollution with cerebrovascular disease (CVD) has not been extensively studied, particularly in relation to different subtypes of stroke. A time-series study was conducted to evaluate the association between daily air pollution and acute stroke unit hospitalizations in Mantua, Italy. We analyzed 781 CVD consecutive patients living in Mantua county admitted between 2006–08. Data on stroke types, demographic variables, risk factors were available from the Lombardia Stroke Registry. Daily mean value of particulate matter with a diameter <10 µm (PM10), carbon monoxide, nitric oxide, nitrogen dioxide, sulphur dioxide, benzene and ozone were used in the analysis. The association between CVD, ischemic strokes subtypes and pollutants was investigated with a case-crossover design, using conditional logistic regression analysis, adjusting for temperature, humidity, barometric pressure and holidays. Among the 781 subjects admitted 75.7% had ischemic stroke, 11.7% haemorrhagic stroke 12.6% transient ischemic attack. In men admission for stroke was associated with PM10 [odds ratio (OR) 1.01, 95%; confidence interval (CI) 1.00–1.02; P<0.05]. According to the clinical classification, lacunar anterior circulation syndrome stroke type was related to PM10 level registered on the day of admission for both genders (OR: 1.01, 95%; CI: 1.00–1.02; P<0.05) while for total anterior circulation syndrome stroke only in men (OR: 1.04, 95%; CI 1.01–1.07; P<0.05).In conclusion, our study confirms that air pollution peaks may contribute to increase the risk of hospitalization for stroke and particulate matter seems to be a significant risk factor, especially for lacunar stroke.