Stroke Unit Care Research Articles

Impact of quality of care on outcomes in survivors of stroke with aphasia: A linked registry and hospital data observational study

BackgroundThe impact of hospital care quality on patient outcomes in post-stroke aphasia remains unclear. We investigated the impact of nationally-endorsed acute stroke treatments on outcomes post-stroke, by aphasia status. MethodsPatient-level data from the Australian Stroke Clinical Registry (2009–2013) linked to national deaths, hospital emergency presentations and admissions data were used. Aphasia was identified for the index stroke event (ICD-10 diagnosis code R47.0). Impact of receiving an optimal stroke care bundle (stroke unit care, antihypertensive medication at discharge and discharge care plan) and an acute ischemic stroke (AIS) care bundle (stroke unit care, intravenous thrombolysis and aspirin within 48 h of admission) on outcomes were analysed using multivariable regression models with propensity score adjustment. ResultsThe study included 12,690 patients with a median age of 76, 54 % male, and 26 % with aphasia. Non-receipt of the optimal stroke care bundle was associated with worse survival, compared to optimal care, in people with aphasia (HR: 3.37; 95 % CI 2.10, 5.40; p < 0.05) and without aphasia (HR: 2.10; 95 % CI 1.19, 3.69; p < 0.05). Notably, the dose-response effect on survival was more pronounced in individuals with aphasia. In those who received the AIS care bundle, readmission within 12 months was greater in those without aphasia (vs aphasia, p-value interaction = 0.001), whereas survival was similar (p-value interaction = 0.731). ConclusionsSurvivors of stroke with aphasia who did not receive the optimal stroke care bundle, had worse survival at 12 months post-stroke. Ensuring eligible patients receive the optimal stroke care bundle is crucial for improving their 12-month survival.

From ‘strong recommendation’ to practice: A pre-test post-test study examining adherence to stroke guidelines for fever, hyperglycaemia, and swallowing (FeSS) management post-stroke

BackgroundThe Quality in Acute Stroke Care (QASC) Trial demonstrated that assistance to implement protocols to manage Fever, hyperglycaemia (Sugar) and Swallowing (FeSS) post-stroke reduced death and disability. In 2017, a ‘Strong Recommendation’ for use of FeSS Protocols was included in the Australian Clinical Guidelines for Stroke Management. We aimed to: i) compare adherence to FeSS Protocols pre- and post-guideline inclusion; ii) determine if adherence varied with prior participation in a treatment arm of a FeSS Intervention study, or receiving treatment in a stroke unit; and compare findings with our previous studies. MethodsPre-test post-test study using Australian acute stroke service audit data comparing 2015/2017 (pre-guideline) versus 2019/2021 (post-guideline) adherence. Primary outcome was adherence to all six FeSS indicators (composite), with mixed-effects logistic regression adjusting for age, sex, stroke type and severity (ability to walk on admission), stroke unit care, hospital prior participation in a FeSS Intervention study, and correlation of outcomes within hospital. Additional analysis examined interaction effects. ResultsOverall, 112 hospitals contributed data to ≥1 one Audit cycle for both periods (pre=7011, post=7195 cases); 42 hospitals had participated in any treatment arm of a FeSS Intervention study. Adherence to FeSS Protocols post-guideline increased (pre: composite measure 35% vs post: composite measure 40 %, aOR:1.2 95 %CI: 1.2, 1.3). Prior participation in a FeSS Intervention study (aOR:1.6, 95 %CI: 1.2, 2.0) and stroke unit care (aOR 2.3, 95 %CI: 2.0, 2.5) were independently associated with greater adherence to FeSS Protocols. There was no change in adherence over time based on prior participation in a FeSS Intervention study (p = 0.93 interaction), or stroke unit care (p = 0.07 interaction). ConclusionsThere is evidence of improved adherence to FeSS Protocols following a ‘strong recommendation’ for their use in the Australian stroke guidelines. Change in adherence was similar independent of hospital prior participation in a FeSS Intervention study, or stroke unit care. However, maintenance of higher pre-guideline adherence for hospitals prior participation in a FeSS Intervention study suggests that research participation can facilitate greater guideline adherence; and confirms superior care received in stroke units. Nevertheless, less than half of Australian patients are being cared for according to the FeSS Protocols, providing impetus for additional strategies to increase uptake.

Uptake of Dual Antiplatelet Therapy After High-Risk Transient Ischemic Attack at a University Hospital.

Multiple randomized controlled trials have demonstrated that dual antiplatelet therapy (DAPT) significantly reduces the risk of subsequent stroke as compared to aspirin monotherapy after high-risk transient ischemic attack (TIA) or minor ischemic stroke. We sought to evaluate the uptake of DAPT after high-risk TIA at a single center. We conducted a retrospective cohort study of consecutive TIA patients admitted via the Emergency Department (ED) of Bern University Hospital (1/1/2018-12/31/2019). We use descriptive statistics to detail cohort characteristics and compared patients treated with DAPT to those not treated. Statistical significance was set at α = 0.05 and all tests of comparison were two-sided. A total of 383 TIA patients were seen during the study period, 247 were eligible for DAPT. Among those eligible for DAPT, mean age was 72years and 51% were female. A total of 49 (19.8%) eligible TIA patients were treated with DAPT; use of DAPT significantly increased from 2018 to 2019. Patients admitted to the stroke unit or intensive care unit (n = 33) had a significantly higher proportion of DAPT treatment as compared to those admitted to the general neurology ward or discharged to home from the ED. DAPT use was also significantly higher in patients with large artery atherosclerotic disease (n = 23) as compared to other etiological subtypes and significantly higher among patients who arrived to the ED within 24h of symptom onset (n = 178). In conclusion, we found that only 2 out of every 10 high-risk TIA patients received DAPT in the years following its introduction in the clinical practice. Our results suggest that strategies to improve the uptake of new, evidence-based secondary stroke prevention treatment after high-risk TIA are needed.

The supportive care needs of stroke patients: A scoping review.

The aims of the current review were to identify the current supportive care needs of stroke patients, categorize those needs according to the supportive care needs framework (SCNF), and to form a SCNF of stroke patients. Preferred Reporting Items for Systematic Reviews and Meta-Extension for Scoping Reviews (PRISMA-ScR) and Guidance for conducting systematic scoping reviews were followed. Ten databases were searched, including six English databases: PubMed, Embase, Web of Science, Cumulative Index to Nursing Allied Health Literature, Cochrane Library, and PsycINFO, and four Chinese databases: China National Knowledge Infrastructure, Wan Fang, China Biology Medicine Database and Chongqing VIP. The search period covers from the establishment of the database to December 31, 2022. Three thousand twenty-nine hits were screened resulting in the inclusion of 34 articles in the final literature review. The greatest need identified by stroke patients was information, followed by psychological, social, rehabilitation, practical, physical, emotional, and spiritual needs. The supportive care needs of stroke patients were identified. A preliminary SCNF of stroke patients was developed according to Fitch's SCNF. The multitude of existing needs of stroke patients need to be addressed. This review may represent the first time that SCNF for stroke patients has been developed. This work may lay the foundation for future research on the supportive care needs of stroke patients and provide a framework for the implementation of supportive care in clinical stroke units.

Predictors of functional outcome after stroke: Sex differences in older individuals.

Sex differences in stroke are well documented, with females being older at onset, with more severe strokes and worse outcomes than males. Females receive less comprehensive stroke unit treatment. Similarly, older individuals receive poorer quality care than younger ones. There is limited research on sex differences in factors that impact 3-month poststroke functional outcome in people older than 80 years. This register-based and cross-sectional study analyzed data from two stroke quality registers in Sweden from 2014 through 2019. The study included patients aged ≥80 with a diagnosis of ischemic or hemorrhagic stroke. Sociodemographic features, prestroke condition, stroke severity on admission (National Institutes of Health Stroke Scale [NIHSS]), stroke unit care, rehabilitation plans, and 3-month poststroke functional outcome measured with the modified Rankin Scale were analyzed. Ordinal regression analyses stratified by sex were conducted to assess sex differences in factors that impact poststroke functional outcome 3 months after the stroke. A total of 2245 patients were studied with the majority (59.2%) being females. Females experienced more severe strokes (NIHSS median 4 vs. 3, p = 0.01) and were older at stroke onset than males (87.0 vs. 85.4, p < 0.001). Females were also less independent prestroke (69.9% vs. 77.4%, p < 0.001) and a higher proportion of females lived alone (78.2% vs. 44.2%, p < 0.001). Males received intravenous thrombolysis more often than females (16.3% vs. 12.0%, p = 0.005). Regarding 3-month functional outcome, males benefited more from thrombolysis (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.30-0.83), whereas females benefited more from thrombectomy (OR 0.40, 95% CI 0.20-0.71). Stroke care should be adapted to sex disparities in older individuals, while clinicians should be aware of these sex disparities. Further research could clarify the mechanisms behind these disparities and lead to a more personalized approach to stroke care of the older population.

Association between the quantity of stroke care units and the complement of neurosurgical and neurology specialists in Japan: A retrospective study

BackgroundStroke care units provide advanced intensive care for unstable patients with acute stroke. We conducted a survey to clarify the differences in stroke care units between urban and regional cities and the relationship between the number of stroke care unit beds and neurologists. MethodsThis retrospective observational study was conducted in 2,857 and 4,184 hospitals in urban and regional cities in 47 provinces of Japan, respectively, between January 2020 and August 2023. Tokyo and ordinance-designated cities in provinces were defined as urban cities, and those without such cities were defined as regional cities. The primary endpoint was the presence or absence of a stroke care unit. ResultsMultiple linear regression analysis revealed that the presence of stroke care units was significantly associated with the number of neurosurgical specialists. Receiver operating characteristic curve analysis was performed to predict the number of personnel required for stroke care unit installation based on the number of neurosurgical specialists. The area under the receiver operating characteristic curve, Youden index, sensitivity, and specificity were 0.721, 0.483, 0.783, and 0.700, respectively. ConclusionsOur study underscores the indispensability of SCUs in stroke treatment, advocating for a strategic allocation of medical resources, heightened accessibility to neurosurgical specialists, and a concerted effort to address geographic and resource imbalances. The identified cutoff value of 8.99 neurosurgical specialists per 100,000 population serves as a practical benchmark for optimizing SCU establishment, thereby potentially mitigating stroke-related mortality.

Erratum: "The Effect of Mobile Stroke Unit Care on Functional Outcomes: An Application of the Front-door Formula".

Erratum: "The Effect of Mobile Stroke Unit Care on Functional Outcomes: An Application of the Front-door Formula".

Longitudinal Changes in Iron and Myelination Within Ischemic Lesions Associate With Neurological Outcomes: A Pilot Study.

Combined quantitative susceptibility mapping and R2* relaxometry can distinguish iron and myelin components in ischemic lesions. We aimed to investigate whether longitudinal changes in magnetic susceptibility and R2* values within ischemic lesions were associated with neurological outcomes. In this single-center prospective study, we included patients, 20 to 90 years of age, who were consecutively admitted to the stroke care unit between August 2020 and March 2022 due to acute ischemic stroke. The participants underwent 2 instances of quantitative susceptibility mapping and R2* relaxometry scanning before and after stroke rehabilitation. We compared the changes in these quantitative measures across different subtypes of acute ischemic stroke. Multiple linear regression models were used to investigate the associations between the National Institutes of Health Stroke Scale scores and the mean magnetic susceptibility and R2* values in ischemic lesions. Among a total of 112 patients with acute ischemic stroke, 32 participants (aged 73.3±9.4 years; 20 men and 12 women) were evaluated. The median time from stroke onset to the first imaging was 5 days and that to the second imaging was 102 days. The changes in magnetic susceptibility values of branch atheromatous disease were higher than those of cardioembolism (mean difference, 0.018 [95% CI, 0.009-0.027] ppm; P<0.001) and lacunar (mean difference, 0.013 [95% CI, 0.005-0.020] ppm; P=0.004). Across all patients, the changes in National Institutes of Health Stroke Scale scores were associated with those of magnetic susceptibility values (coefficient, 0.311 [95% CI, 0.098-0.520]; P=0.017) but not with R2* values (coefficient, 0.114 [95% CI, -0.127 to 0.345]; P=0.291). The longitudinal changes in the magnetic susceptibility values within ischemic lesions were associated with neurological outcomes during the restorative stages poststroke in patients experiencing acute ischemic stroke. URL: https://www.umin.ac.jp/ctr/; Unique identifier: UMIN000050719.

Current Status of Stroke Thrombolysis in the Mission Thrombectomy 2020+ Caribbean Region

Background Low‐ to middle‐income countries have limited access to thrombolytic therapy. To our knowledge, there is no validated tool available to objectively measure access to thrombolytic agents or barriers to routine clinical use. Methods We developed the 17‐item tissue plasminogen activator Spot Check tool to assess usage of acute stroke thrombolysis regarding local experience, financial constraints, and perceived barriers to care; evaluating the current state of clinical practices in the Mission Thrombectomy 2020+ Caribbean region. The survey was disseminated via an online link, and the information was collected and analyzed via SPSS. Results The tool was validated by 3 international experts with an Average Content Validity Index of 1 and a Universal Agreement Index of 1 across 3 domains: local experience, financial constraints, and barriers to usage. The participant survey response rate was 64%, representing 15 of 44 Mission Thrombectomy 2020+ Caribbean countries. There was limited or no access to thrombolytic agents in 40% of countries surveyed. Among cases treated with thrombolytics, 43% of patients had to pay out of pocket before treatment was provided, and l&lt;10% were covered by insurance/government. Among 51% of countries surveyed, no acute thrombolytic treatment was provided for acute stroke in the 2021 calendar year. Only 1 center treated &gt;100 cases per year. Most respondents (88%) agreed there were barriers to acute stroke thrombolysis in the region. The tissue plasminogen activator Spot Check tool was able to identify barriers impacting the number of cases per year, including absence of stroke protocol ( P &lt;0.001), upfront cost of alteplase ( P = 0.003), restricted the amount of thrombolytics ( P = 0.002), neurology intensive care unit or stroke unit monitoring of patients following thrombolytics ( P = 0.017), cost of thrombolytic agents to the hospital ( P = 0.042), and access to computed tomography scan ( P = 0.03). Conclusion This survey brings light to an enormous disparity in the care of stroke patients around the world, specifically in the Mission Thrombectomy 2020+ Caribbean region.

Health professional’s experiences during stroke care: a focus group study in Greece

Purpose The aim of the study was to investigate HPs experiences during stroke care and the way health services providing stroke care in Greece are organized. Materials and Methods This is an exploratory qualitative study with inter-professional focus groups. Nurses and physicians working in various Greek stroke care units were purposively sampled. Results Two focus groups’ interviews with nurses (n=5) and physicians (n=6) were conducted. In relation to the factors that affect stroke care provided by HPs, the covid pandemic, the management of time and patient, and the role of informal carers in the hospital were identified. Positive challenges that help HPs in their work with stroke patients included the quality of collaboration, self-resilience and the patient as a source of power. Regarding difficulties encountered by HPs during stroke care, organizational problems and educational deficiencies were highlighted. Suggestions to improve current clinical practice included education and collaboration among HPs, the need for a specialized stroke team and financial support. Conclusions Awareness concerning the stroke patient’s rehabilitation process after hospital discharge is highly supported by all HPs. The need for HPs specialized education on stroke care and funding for stroke unit structures in hospitals is essential for improving quality of services.

New Perspectives in Neuroprotection for Ischemic Stroke

The constant failure of new neuroprotective therapies for ischemic stroke has partially halted the search for new therapies in recent years, mainly because of the high investment risk required to develop a new treatment for a complex pathology, such as stroke, with a narrow intervention window and associated comorbidities. However, owing to recent progress in understanding the stroke pathophysiology, improvement in patient care in stroke units, development of new imaging techniques, search for new biomarkers for early diagnosis, and increasingly widespread use of mechanical recanalization therapies, new opportunities have opened for the study of neuroprotection. This review summarizes the main protective agents currently in use, some of which are already in the clinical evaluation phase. It also includes an analysis of how recanalization therapies, new imaging techniques, and biomarkers have improved their efficacy.

Patient experiences of physical activity and inactivity in the stroke unit: an interview study.

Stroke unit care is highly recommended after stroke, but patients in these units are often physically inactive. The aim of this study was to explore patient experiences of physical activity and inactivity in the stroke unit. Qualitative interview study. Sixteen participants with stroke; a heterogeneous sample with differences in sex, age, and stroke severity from 8 Swedish stroke units. In-depth interviews 1-2 weeks after discharge analysed using thematic analysis. The analysis resulted in three themes: 1: Dealing with the challenges of a changed body while striving to become independent; 2: The stroke unit is crucial for physical activity; and 3: Physical activity is important for interaction with others, autonomy, and feeling seen. Participants described how they coped with a new situation when finding new ways to move and function. In addition, they wanted to be involved in their own stroke rehabilitation. The participants expressed the following experiences of being in the stroke unit: movement is more important than physical activity and involves being seen and respected; physical activity and exercise are necessary to achieve independence; process involvement is of importance to regain abilities; physical activity offers the possibility of choosing between community and being alone and influences the ability to connect with others and the outside world.

Factors that Cause Recurrent Stroke amongst Ischemic Stroke Patients: A Literature Review

In patients, recurrent stroke is prevalent and could be avoided, but at the same time, stroke could recur due to various reasons. These comprised the same causes as it caused the initial stroke and with the incorporation of risk factors, like smoking, obesity, and diabetes. The prevalence of recurrent stroke is considered high and could increase as time goes by. As mentioned in research on hemorrhagic stroke, the risk significantly increases overtime, up to 45% within 5 years and if exposed to stroke unit care, the risk will be reduced [1.] However, because of the vagueness in specificity of whether the causes are the same, this research aims to dive into the specific factors that will eventually lead to recurrent stroke. Moreover, this research aims to underscore activities or practices that would reduce the risk of recurrent stroke. Recurrent stroke is seen as a relatively dangerous disease since it could possibly increase the mortality rates in an individual. Therefore, finding the main causes will underscore the significance of preventing recurrent stroke amongst ischemic stroke patients. All data are gathered from different sources of articles and publications to conclude. As a result, factors that cause recurrent ischemic stroke in patients are hypertension, diabetes, smoking, high cholesterol, physical inactivity, alcohol consumption, genetic factors, age, gender, and more.

Effects of Head Elevation on Cerebral Oxygenation in Acute Cerebral Infarction.

This study clarifies the effects of head elevation on cerebral oxygenation in patients with acute cerebral infarction. We included 76 patients with anterior circulation cerebral infarction admitted to the stroke care unit within 7days of symptom onset. Using near-infrared spectroscopy (NIRS), we measured regional saturation oxygen (rSO2), oxygenated haemoglobin (O2Hb), deoxygenated haemoglobin (HHb), and total haemoglobin (THb) in both the affected hemisphere (AH) and unaffected hemisphere (UH) after raising the head to 0°, 30°, and 60° for 1minute each. The mean arterial pressure (MAP) was measured non-invasively at each position. Our result demonstrated a significant decrease in O2Hb as the head elevation angle (HEA) increased, with no observable interaction between the AH and UH. A significant decrease in rSO2 interaction was observed. In contrast, the HHb and THb levels changed significantly as the HEA increased, although no interactions were identified. No significant correlations existed between the observed changes in O2Hb, HHb, THb, or rSO2 and changes in MAP at each HEA.

The RAPID-score: Risk Assessment and PredIction of Delirium in acute stroke patients based on very early clinical parameters.

Post-stroke delirium (PSD) is a common complication in acute stroke patients, and guidelines recommend routine screening and various preventive and treatment measures. However, there is a substantial lack of standardized approaches in diagnostic and therapeutic management of PSD. Here, we aimed to develop a new pragmatic and easily assessable screening tool to predict PSD based on early parameters, which are already integral to acute stroke diagnostics. We enrolled acute stroke patients admitted to our stroke unit or intensive care unit and developed the scoring system using retrospective single-center patient data. The Confusion Assessment Method for the Intensive Care Unit was used for prospective score validation. Logistic regression models were employed to analyze the association of early clinical and paraclinical parameters with PSD development. N = 525 patients (median age: 76 years; 45.7% female) were enrolled, with 29.7% developing PSD during hospitalization. The resulting score comprises 6 items, including medical history, clinical examination findings, and non-contrast computed tomography results at admission. Scores range from -15 to +15 points, with higher values indicating a higher likelihood of PSD, ranging from 4% to 79%. The accuracy was 0.85, and the area under the curve was 0.89. The new RAPID (Risk Assessment and PredIction of Delirium in acute stroke patients)-score shows high accuracy in predicting PSD among acute stroke patients and offers precise odds of PSD for each corresponding score value, utilizing routine early clinical and paraclinical parameters. It can identify high-risk populations for clinical study interventions and may be suitable to guide prophylactic PSD measures.

Stroke unit and Neurocritical Care Unit for acute neurological diseases in the USL Toscana Centro: a pilot model of Santo Stefano Hospital in Prato

BackgroundAcute neurological diseases are leading causes of disability and death. The need for specialist neurocritical care skills for managing neurological emergencies has increased. Promising opportunities exist to improve outcomes in acute phases of neurological diseases, such as, for example, the concept of a stroke unit for stroke patients. A similar concept was introduced for a neurocritical care unit, which is associated with improved clinical outcomes compared with more traditional management. However, neurocritical care is often not recognized as a separate specialty. Significant progress in neurology has enabled better approaches for the critically ill neurologic patient, in particular those with stroke and hemorrhage, but also with epileptic seizures and epileptic status, traumatic brain injury (TBI), subdural/epidural hematoma, acute inflammatory polyradiculoneuritis, encephalitis, myasthenia gravis, acute myelitis, etc.Assessment of policy/guidelines options and implicationsExcept for cerebrovascular diseases, for other acute neurological diseases, there is no standardized model care service recognized. A good patient outcome can be obtained by the choice of neurology setting for acute patients including nursing and medical staff with specific training in neurocritical care. As we believe neurocritical care practices should be implemented, we suggest a pilot model on the basis of our experience. In this report, we show a model of the 2A setting of the Santo Stefano Hospital (Prato, USL Toscana Centro), where, as well as stroke units for cerebrovascular events, we have neurocritical care unit and acute-neurology experts for all acute neurological diseases.Actionable recommendations: our pilot experienceThe 2A setting of Stroke Unit/Neurocritical Care of the Santo Stefano Hospital includes 15 beds; 8 ± 2 beds are monitored by portable multi-parameter monitoring devices. Following acute treatment, diagnostic/etiologic work-up and automated monitoring of vital functions are performed in addition to adapted secondary prevention, early rehabilitation, and prevention of complications in all acute patients. We retrospectively assessed the diagnoses in the hospital discharge forms (HDF) of Stroke Unit/Neurocritical Care (2A) of 249 patients consecutively analyzed between 1 January 2022 and 30 June 2022. Out of the 249 patients affected by acute neurological diseases, 155 had cerebrovascular diseases (62.2%). In particular, 100 (64.5%) were diagnosed with ischemic stroke and 44 (28.4%) with hemorrhagic stroke. Thirty-two patients (12.8%) were hospitalized following a TBI. Sixteen patients (6.4%) had a new diagnosis of epilepsy and three (1.2%) of epileptic status. In our setting, the 3-month modified Rankin Scale (mRS) in the 36 stroke patients treated with recombinant-tissue plasminogen activator (r-TPA) was 0–2 (low disability) in 60% of cases. Additionally, 31% of 44 intracerebral haemorrhage (ICH) patients reported a moderate-severe degree of disability. Regarding TBI patients, the mRS ranged from 1 to 5, with significate difference between patients in Stroke Unit/Neurocritical Care (2A) in comparison with those in other departments (2–3 vs. 3–4, respectively). Globally, the setting discharge of the acute neurological patients were: rehabilitation (26%), intermediate care hospitals (44%), long-term care (5%), and home (25%). The 1-month mortality rate was 1.8%.DiscussionWe provide a brief description of the cases treated over a 6-month period to draw attention to the possibility of the existence of a ward dedicated exclusively and specifically to all acute neurological diseases. The sample of patients is very varied and interesting. More than 60% of patients had cerebrovascular diseases. The paucity of outcome data makes this report limited, but the diagnostic-therapeutic strategies, the presence of staff trained in specific neurocritical care, and the use of inpatient hospital-based registries are, in our opinion, strengths. Our pilot model of the setting of Stroke Unit/Neurocritical Care (2A) in the Santo Stefano Hospital (Prato, USL Toscana Centro) should be further implemented, also to verify systematically the associations with measurable outcome improvements in patients affected by strokes and other neurological acute diseases.

Healthcare professionals' experience regarding competencies in specialized and primary stroke units: A qualitative study

AimTo describe healthcare professionals’ experience of needed competence in patient stroke care within specialist and primary healthcare. BackgroundHealthcare professionals who provide stroke care need multifaceted, multi-professional skills; ongoing training is important for competent stroke care. DesignA descriptive qualitative study. MethodsSix focus group interviews with semi-structured interviews were conducted in October and November 2020. Healthcare professionals (n = 25) working in stroke care units in both specialist and primary healthcare settings were interviewed. The interviews were recorded, transcribed and analyzed inductively by content analysis. The study was conducted, and results were reported according to the Consolidated Criteria for Reporting Qualitative Research. ResultsFive main categories were identified: clinical competence; multiprofessional networking competence; competence in interaction skills; emotional and psychoeducational support competence; and self-management and development competence. ConclusionCompetence in stroke care includes both in-depth and wide-ranging professional competences that require ongoing development. Utilizing various education models and collaborative learning approaches can help meet the requirements for developing competence in stroke care. Patient or public contributionNo patient or public contribution

A Recurring neurorenal affair; Post CKD stroke

Madam, The inability to speak, see, and move, medically known as aphasia, visual loss, and limb paralysis respectively, are well-known manifestations caused by inadequate blood supply or oxygen to the brain, leading to a condition known as Stroke. It is a major global health concern, and Pakistan is estimated to have 250 cases of Stroke annually per 100,000 population[1].Multiple known risk factors such as hypertension, diabetes, old age, myocardial infarction and chronic kidney disease contribute (CKD) to such high incidence. CKD is defined as kidney impairment or less than 60 mL/min/1.73 m (2) of glomerular filtration rate (GFR) for three months or longer. In 2021, CKD was established as an independent risk factor for stroke by Melaine and colleagues. [2] Further supporting the link between Stroke and CKD, a new recent study by Ueki et al. published in STROKE shows that the functional dysfunction of the kidney (eGFR) and the kidney damage (proteinuria) caused by CKD are associated both independently and synergistically with increased risk of not one-time but recurrent strokes. Out of 12576 enrolled stroke patients, 20% (2481 patients) who developed CKD suffered from recurrent Strokes. [3]. This raises significant concern, particularly in Pakistan, where there is only 1 neurologist per 1 million population [1] The decreased number of specialists is not the only reason why this study raises a cause of concern. With only 10 Stroke care units and just 6 out of them offering intravenous thrombectomy, managing Stroke is already a challenge. Pakistan unfortunately, also suffers from decreased availability of alteplase, an expensive drug required for timely management of Stroke leaving mechanical thrombectomy as the possible treatment option, which is again only offered at hospitals.[1] But what can be done to tackle this impending burden? The answer is prevention. In addition to the evident solution of increasing the number of stroke care facilities and improving the availability of alteplase, Transcranial Dopplers (TCD) can be utilized as a non-invasive screening test to monitor brain health in CKD patients [4]. People need to be made more educated on taking better control over their health by being compliant with medications if suffering from hypertension or diabetes, the two major risk factors of CKD. An integrative strategy should be employed, bringing nephrologists, neurologists, and patients together at one table to discuss the next steps and optimize stroke prevention and management.

Effect of admission in the stroke care unit versus intensive care unit on in-hospital mortality in patients with acute ischemic stroke

Background/objectiveFew reports have directly compared the outcomes of patients with acute ischemic stroke (AIS) who are managed in a stroke care unit (SCU) with those who are managed in an intensive care units (ICU). This large database study in Japan aimed to compare in-hospital mortality between patients with AIS admitted into SCU and those admitted into ICU.MethodsPatients with AIS who were admitted between April 1, 2014, and March 31, 2019, were selected from the administrative database and divided into the SCU and ICU groups. We calculated the propensity score to match groups for which the admission unit assignment was independent of confounding factors, including the modified Rankin scale (mRS) score. The primary outcome was in-hospital mortality, and secondary outcomes were the mRS score at discharge, length of stay (LOS), and total hospitalization cost.ResultsOverall, 8,683 patients were included, and 960 pairs were matched. After matching, the in-hospital mortality rates of the SCU and ICU groups were not significantly different (5.9% vs. 7.9%, P = 0.106). LOS was significantly shorter (SCU = 20.9 vs. ICU = 26.2 days, P < 0.001) and expenses were significantly lower in the SCU group than in the ICU group (SCU = 1,686,588 vs. ICU = 1,998,260 yen, P < 0.001). mRS scores (score of 1–3 or 4–6) at discharge were not significantly different after matching. Stratified analysis showed that the in-hospital mortality rate was lower in the ICU group than in the SCU group among patients who underwent thrombectomy.ConclusionsIn-hospital mortality was not significantly different between the ICU and SCU groups, with significantly lower costs and shorter LOS in the SCU group than in the ICU group.

Impact of pay-for-performance for stroke unit access on mortality in Queensland, Australia: an interrupted time series analysis

Stroke unit care provides substantial benefits for all subgroups of patient with stroke, but consistent access has been difficult to achieve in many healthcare systems. Pay-for-performance incentives have been introduced widely in attempt to improve quality and efficiency in healthcare, but there is limited evidence of positive impact when they are targeted at hospitals. In 2012, a pay-for-performance program targeting stroke unit access was co-designed and implemented within a clinical quality improvement network across public hospitals in Queensland, Australia. We assessed the impact on access to specialist care and mortality following stroke. We used interrupted time series analysis on linked hospital and death registry data to compare changes in level (absolute proportions) and trends in outcomes (stroke/coronary care unit admission, 6-month mortality) for stroke, and a control condition of myocardial infarction (MI) without pay-for-performance incentive, from 2009 before, to 2017 after introduction of the pay-for-performance scheme in2012. We included 23,572 patients with stroke and 39,511 with MI. Following pay-for-performance introduction, stroke unit access increased by an absolute 35% (95% CI 29, 41) more than historical trend prediction, with greater impact for regional/rural residents (41% vs major city 24%) where baseline access was lowest (18% vs major city residents 53%). Historical upward 6-month mortality trends following stroke (+0.11%/month) reversed to a downward slope (-0.05%/month) with pay-for-performance; difference-0.16%/month (95% CI-0.29,-0.03). In contrast, access to coronary care and mortality trends for MI controls were unchanged, difference-in-difference for mortality-0.18%, (95% CI-0.34,-0.02). This clinician led pay-for-performance incentive stimulated significant improvements in stroke unit access, reduced regional disparities; and resulted in a sustained decline in 6-month mortality. As our findings contrast with lack of effect in most hospital directed pay-for-performance programs, differences in design and context provide insights for optimal program design. Queensland Advancing Clinical Research Fellowship, National Health and Medical Research Council Senior Research Fellowship.