scholarly journals Break in the Stroke Chain of Survival due to COVID-19

Stroke ◽  
2020 ◽  
Vol 51 (8) ◽  
pp. 2307-2314 ◽  
Author(s):  
Joan Montaner ◽  
Ana Barragán-Prieto ◽  
Soledad Pérez-Sánchez ◽  
Irene Escudero-Martínez ◽  
Francisco Moniche ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Stroke Unit ◽  
Descriptive Analysis ◽  
Stroke Care ◽  
Reperfusion Therapy ◽  
Time Of Arrival ◽  
Acute Stroke Care ◽  
Before And After ◽  
Chain Of Survival ◽  
The Impact

Background and Purpose: Emergency measures to treat patients with coronavirus disease 2019 (COVID-19) and contain the outbreak is the main priority in each of our hospitals; however, these measures are likely to result in collateral damage among patients with other acute diseases. Here, we investigate whether the COVID-19 pandemic affects acute stroke care through interruptions in the stroke chain of survival. Methods: A descriptive analysis of acute stroke care activity before and after the COVID-19 outbreak is given for a stroke network in southern Europe. To quantify the impact of the pandemic, the number of stroke code activations, ambulance transfers, consultations through telestroke, stroke unit admissions, and reperfusion therapy times and rates are described in temporal relationship with the rising number of COVID-19 cases in the region. Results: Following confinement of the population, our stroke unit activity decreased sharply, with a 25% reduction in admitted cases (mean number of 58 cases every 15 days in previous months to 44 cases in the 15 days after the outbreak, P <0.001). Consultations to the telestroke network declined from 25 every 15 days before the outbreak to 7 after the outbreak ( P <0.001). The increasing trend in the prehospital diagnosis of stroke activated by 911 calls stopped abruptly in the region, regressing to 2019 levels. The mean number of stroke codes dispatched to hospitals decreased (78% versus 57%, P <0.001). Time of arrival from symptoms onset to stroke units was delayed >30 minutes, reperfusion therapy cases fell, and door-to-needle time started 16 minutes later than usual. Conclusions: The COVID-19 pandemic is disruptive for acute stroke pathways. Bottlenecks in the access and delivery of patients to our secured stroke centers are among the main challenges. It is critical to encourage patients to continue seeking emergency care if experiencing acute stroke symptoms and to ensure that emergency professionals continue to use stroke code activation and telestroke networks.

Abstract TP311: Multidisciplinary Stroke Simulation: Novel Team Based Approach to Decrease Door-to-Needle Times

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Christopher A Mutch ◽  
Zachary Threlkeld ◽  
Sara Cole ◽  
Christine Martin ◽  
Benjamin Kozak ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Ct Perfusion ◽  
Stroke Care ◽  
Simulated Patients ◽  
Ct Scanner ◽  
Acute Stroke Care ◽  
Before And After ◽  
Care Guidelines ◽  
Multidisciplinary Simulation ◽  
The Impact

Introduction: In acute stroke, time equals brain. Minimizing time to treatment maximizes eligibility and effectiveness of fibrinolytics. Timely treatment of acute stroke requires precise coordination of a multidisciplinary team ranging from first responders to neurointerventionalists. Simulation-based learning allows participants to hone their skills and make mistakes in a controlled environment. To our knowledge, the impact of multidisciplinary stroke simulation has not been reported in literature. Here we describe our initial experience implementing such a simulation. Hypothesis: Participation in stroke simulation will improve knowledge of acute stroke care guidelines and decrease door-to-needle time. Methods: Neurology, emergency medicine and radiology trainees, EMTs, nurses, medical students, technologists, and pharmacists took part in the evaluation and treatment of simulated patients with stroke symptoms in actual clinical settings from ambulance to ED to CT scanner to IR suite. Neurology and neuroradiology faculty debriefed participants following simulations. Questions on stroke care (derived from the 2013 AHA/ASA guideline and 2015 update) were sent to likely participants before and after the simulation; those who completed pre/post quizzes and the simulation were included in analysis. Results: Survey response rate was 86%. All participants had improved scores on the post-simulation quiz, scoring an average of 19% higher, 95% CI [8%, 29%]. For example, correct responses that IV tPA is not contraindicated prior to endovascular therapy improved from 64 to 100% after the simulation; responses correctly identifying the appearance of ischemic penumbra on CT perfusion imaging increased from 27 to 73%. Nearly all (92%) respondents would recommend the simulation to their peers. Conclusions: Simulation of acute stroke scenarios improves participants’ knowledge of acute stroke management guidelines and may improve door-to-needle time. We present a novel framework for multidisciplinary simulation, which could be implemented at other institutions. Further evaluation of simulation effect on door-to-needle time is ongoing.

scholarly journals Effect of the COVID-19 pandemic on acute stroke reperfusion therapy: data from the Lyon Stroke Center Network

2020 ◽  
Author(s):  
Cécile PLUMEREAU ◽  
Tae-Hee CHO ◽  
Marielle BUISSON ◽  
Camille AMAZ ◽  
Matteo CAPPUCCI ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Control Period ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
Reperfusion Therapy ◽  
Acute Stroke Care ◽  
Emergency Medical Dispatch ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
The Impact

Abstract BackgroundThe coronavirus disease 2019 (COVID-19) pandemic would have particularly affected acute stroke care. However, its impact is clearly inherent to the local stroke network conditions. We aimed to assess the impact of COVID-19 pandemic on acute stroke care in the Lyon comprehensive stroke center during this period.MethodsWe conducted a prospective data collection of patients with acute ischemic stroke (AIS) treated with intravenous thrombolysis (IVT) and/or mechanical thrombectomy (MT) during the COVID-19 period (from 29/02/2020 to 10/05/2020) and a control period (from 29/02/2019 to 10/05/2019). The volume of reperfusion therapies and pre and intra-hospital delays were compared during both periods.ResultsA total of 208 patients were included. The volume of IVT significantly decreased during the COVID-period (55 (54.5%) vs 74 (69.2%); p=0.03) and was mainly due to time delay among patients treated with MT. The volume of MT remains stable over the two periods (72 (71.3%) vs 65 (60.8%); p=0.14) but the door-to-groin puncture time increased in patients transferred for MT (237 [187-339] vs 210 [163-260]; p<0.01). The daily number of Emergency Medical Dispatch calls considerably increased (1502 [1133-2238] vs 1023 [960-1410]; p<0.01).ConclusionsOur study showed a decrease of the volume of IVT, whereas the volume of MT remained stable although intra-hospital delays increased for transferred patients during the COVID-19 pandemic. These results contrast in part with the national surveys and suggest that the impact of the pandemic may depend on local stroke care networks.

scholarly journals Bottlenecks in the Acute Stroke Care System during the COVID-19 Pandemic in Catalonia

2021 ◽  
pp. 1-9
Author(s):  
Anna Ramos-Pachón ◽  
Álvaro García-Tornel ◽  
Mònica Millán ◽  
Marc Ribó ◽  
Sergi Amaro ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Functional Outcome ◽  
Stroke Care ◽  
Care Quality ◽  
Point Of View ◽  
Stroke Severity ◽  
Acute Stroke Care ◽  
Vessel Occlusion ◽  
Prehospital Delays ◽  
The Impact

<b><i>Introduction:</i></b> The COVID-19 pandemic resulted in significant healthcare reorganizations, potentially striking standard medical care. We investigated the impact of the COVID-19 pandemic on acute stroke care quality and clinical outcomes to detect healthcare system’s bottlenecks from a territorial point of view. <b><i>Methods:</i></b> Crossed-data analysis between a prospective nation-based mandatory registry of acute stroke, Emergency Medical System (EMS) records, and daily incidence of COVID-19 in Catalonia (Spain). We included all stroke code activations during the pandemic (March 15–May 2, 2020) and an immediate prepandemic period (January 26–March 14, 2020). Primary outcomes were stroke code activations and reperfusion therapies in both periods. Secondary outcomes included clinical characteristics, workflow metrics, differences across types of stroke centers, correlation analysis between weekly EMS alerts, COVID-19 cases, and workflow metrics, and impact on mortality and clinical outcome at 90 days. <b><i>Results:</i></b> Stroke code activations decreased by 22% and reperfusion therapies dropped by 29% during the pandemic period, with no differences in age, stroke severity, or large vessel occlusion. Calls to EMS were handled 42 min later, and time from onset to hospital arrival increased by 53 min, with significant correlations between weekly COVID-19 cases and more EMS calls (rho = 0.81), less stroke code activations (rho = −0.37), and longer prehospital delays (rho = 0.25). Telestroke centers were afflicted with higher reductions in stroke code activations, reperfusion treatments, referrals to endovascular centers, and increased delays to thrombolytics. The independent odds of death increased (OR 1.6 [1.05–2.4], <i>p</i> 0.03) and good functional outcome decreased (mRS ≤2 at 90 days: OR 0.6 [0.4–0.9], <i>p</i> 0.015) during the pandemic period. <b><i>Conclusion:</i></b> During the COVID-19 pandemic, Catalonia’s stroke system’s weakest points were the delay to EMS alert and a decline of stroke code activations, reperfusion treatments, and interhospital transfers, mostly at local centers. Patients suffering an acute stroke during the pandemic period had higher odds of poor functional outcome and death. The complete stroke care system’s analysis is crucial to allocate resources appropriately.

Abstract P141: Global Impact of Covid-19 Pandemic on Acute Stroke and Mechanical Thrombectomy - An International Survey

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Dileep R Yavagal ◽  
Vasu Saini ◽  
Violiza Inoa ◽  
Hannah E Gardener ◽  
Sheila O Martins ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Mechanical Thrombectomy ◽  
High Volume ◽  
Stroke Care ◽  
Acute Stroke Care ◽  
Treatment Practices ◽  
Global Impact ◽  
Significant Difference ◽  
The World ◽  
The Impact

Introduction: The COVID-19 pandemic has strained the healthcare systems across the world but its impact on acute stroke care is just being elucidated. We hypothesized a major global impact of COVID-19 not only on stroke volumes but also on thrombectomy practice. Methods: A 19-item questionnaire survey aimed to identify the changes in stroke volumes and treatment practices seen during COVID-19 pandemic was designed using Qualtrics software. It was sent to stroke and neuro-interventional physicians around the world who are part of the executive committee of a global coalition, Mission Thrombectomy 2020 (MT2020) between April 5 th to May 15 th , 2020. Results: There were 113 responses across 25 countries. Globally there was a median 33% decrease in stroke admissions and a 25% decrease in mechanical thrombectomy (MT) procedures during COVID-19 pandemic compared to immediately preceding months (Figure 1A-B). This overall median decrease was despite a median increase in stroke volume in 4 European countries which diverted all stroke patients to only a few selected centers during the pandemic. The intubation policy during the pandemic for patients undergoing MT was highly variable across participating centers: 44% preferred intubating all patients, including 25% centers that changed their policy to preferred-intubation (PI) vs 27% centers that switched to preferred-conscious-sedation (PCS). There was no significant difference in rate of COVID-19 infection between PI vs PCS (p=0.6) or if intubation policy was changed in either direction (p=1). Low-volume (<10 stroke/month) compared with high-volume stroke centers (>20 strokes/month) are less likely to have neurointerventional suite specific written personal protective equipment protocols (74% vs 88%) and if present, these centers are more likely to report them to be inadequate (58% vs 92%). Conclusion: Our data provides a comprehensive snapshot of the impact on acute stroke care observed worldwide during the pandemic.

Abstract W MP104: Quality of Acute Stroke Care at Primary Stroke Centers Before and After Certification in Comparison to Never-Certified Hospitals

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Nerses Sanossian ◽  
May A Kim-Tenser ◽  
David S Liebeskind ◽  
Justina Breen ◽  
Scott Hamilton ◽  
...  
Keyword(s):  
Los Angeles ◽  
Acute Stroke ◽  
Stroke Care ◽  
Care Quality ◽  
Acute Stroke Care ◽  
Phase 3 ◽  
Before And After ◽  
Beneficial Impact ◽  
Mean Time

Background: Primary Stroke Centers (PSC) provide better acute stroke care than non-PSC hospitals, including faster times to imaging and lytic treatment, and higher rates of lytic delivery. Nationwide less than 1 in 3 hospital has achieved this designation. We aimed to determine the extent to which the better performance at PSC is driven by improvements within hospitals after PSC designation versus better baseline hospital care among facilities seeking PSC certification. Methods: From 2005 to 2012, the NIH Field Administration of Stroke Therapy -Magnesium (FAST-MAG) Phase 3 clinical trial enrolled subjects with likely stroke within 2 hours of onset in a study of prehospital start of a neuroprotective agent. Subjects were routed to 59 community and academic centers in Los Angeles and Orange Counties. Of the original 59 centers, 39 eventually achieved PSC status during the study period. Each subject was classified as enrolled at a PSC before certification (pre-PSC), at a PSC post certification (post-PSC), or at a hospital that never achieved PSC (non-PSC). Results: Of 1700 cases, 529 (31%) were enrolled at pre-PSC, 856 (50%) at post-PSC, and 315 (19%) at non-PSC hospitals. Mean time in minutes from ED arrival to first scan was 33 minutes at post-PSC, 47 minutes at pre-PSC and 49 at non-PSCs [p<0.001 by Mann-Whitney]. Among cases of cerebral ischemia (CI) [N=1223], rates of TPA utilization were 43% at post-PSC, 27% at pre-PSC and 28% at non-PSC hospitals [p<0.001 by X2]. Time in minutes from ED arrival to thrombolysis in treated cases was 71 at post-PSC, 98 at pre-PSC, and 95 at non-PSC hospitals [p<0.001 by Mann-Whitney]. Hospitals that achieved PSC showed improvements in pre-PSC and post-PSC performance on door to imaging time, from 47 to 33 minutes [p=0.014]; percent TPA use in CI, from 27% to 43% [p<0.001], and reduced door-to-needle times, from 98 to 71 minutes [p=0.003]. There was no difference in time to imaging [47 vs. 49 minutes], time to thrombolysis [98 vs. 95 minutes] and percent TPA use [27% vs. 28%] between pre-PSC hospitals and non-PSC hospitals. Conclusions: Better performance of Primary Stroke Centers on acute care quality metrics is primarily driven by a beneficial impact of the PSC-certification process, and not better performance prior to seeking PSC status.

Abstract TMP86: Telestroke Improves Guideline-Based Comprehensive Stroke Care: The TELECAST Trial

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Christopher D Streib ◽  
Oladi Bentho ◽  
Kathryn Bard ◽  
Eric Jaton ◽  
Sarah Engkjer ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Stroke Care ◽  
Composite Score ◽  
Stroke Recurrence ◽  
Acute Stroke Care ◽  
Specialist Service ◽  
Stroke Treatment ◽  
Chi Squared ◽  
Secondary Outcomes ◽  
The Impact

Introduction: Limited access to stroke specialist expertise produces disparities in inpatient stroke treatment. The impact of telestroke on the remote delivery of guideline-based inpatient stroke care is yet to be comprehensively studied. The TELECAST trial (NCT03672890) prospectively examined the impact of a 24-7 telestroke specialist service dedicated to inpatient acute stroke care spanning admission to discharge. Methods: AHA stroke guidelines were used to derive outcome metrics in the following acute stroke inpatient care categories: diagnostic stroke evaluation (DSE), secondary stroke prevention (SSP), health screening and evaluation (HSE), and stroke education (SE). Adherence to AHA guidelines for stroke inpatients pre-telestroke (July 1, 2016-June 30, 2018) and post-telestroke intervention (July 1, 2018-June 30, 2019) were studied. The primary outcome was a composite score of all guideline-based stroke care. Secondary outcomes consisted of subcategory composite scores in DSE, SSP, HSE, and SE. Chi-squared tests were utilized to assess primary and secondary outcomes. Statistical analysis was performed using STATA 15.0. Results: Following institution of a comprehensive inpatient telestroke service, overall adherence to guideline-based metrics improved (composite score: 85% vs 94%, p<0.01) as did adherence to DSE guidelines (subgroup score: 90 vs 95%, p<0.01). SSP, HSE, and SE subgroup scores were not significantly different. See Table 1. Conclusion: The implementation of a 24-7 inpatient telestroke service improved adherence to AHA guidelines for inpatient acute stroke care. Dedicated inpatient telestroke specialist coverage may improve inpatient stroke care and reduce stroke recurrence in hospitals without access to stroke specialists.

Abstract 184: Drivers of Costs Associated With Reperfusion Therapy in Acute Stroke: The IMS III Trial

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Kit N Simpson ◽  
Annie N Simpson ◽  
Patrick D Mauldin ◽  
Michael D Hill ◽  
Sharon D Yeatts ◽  
...  
Keyword(s):  
Acute Stroke ◽  
General Anesthesia ◽  
Endovascular Therapy ◽  
Stroke Care ◽  
Reperfusion Therapy ◽  
Hospital Charges ◽  
Acute Stroke Care ◽  
Initial Hospital ◽  
Initial Hospitalization ◽  
Mean Cost

Importance: The annual costs of stroke to the nation have been estimated to be over $38 billion, with nearly $22 billion attributed to direct medical costs. Objective: To understand cost drivers during the initial hospitalization for acute ischemic stroke subjects in the IMS III Trial. Design, Setting and Participants: Prospective cost analysis of subjects from U.S. centers treated with IV t-PA alone or IV t-PA followed by endovascular therapy in the IMS III trial. Cost of initial hospital admission was estimated from the actual hospital charges on UB04 billing forms provided by the treating hospitals. Cost profiles of the IMS III treatment groups were compared to profiles of a sample of US patients from the HCUP National Inpatient Sample (NIS) for 2010. Interventions: IV t-PA alone as compared to IV t-PA followed by endovascular therapy. Main Outcome Measure: Costs of hospitalization for acute stroke subjects. Results: The adjusted cost of a stroke admission in the study was $35,130 for subjects treated with endovascular therapy following IV t-PA and $25,630 for subjects treated with IV t-PA alone (p<0.0001). The higher cost in the endovascular therapy following IV t-PA treatment arm was largely explained by the costs of the devices. Significant factors related to costs included treatment group (higher costs with endovascular therapy), baseline NIH Stroke Scale (higher costs with higher severity), time from stroke onset to IV t-PA (lower costs with earlier treatment), age (higher costs with older age), stroke location (higher cost with right hemispheric location) and comorbid diabetes (higher costs with diabetes). The mean cost for subjects who had routine use of general anesthesia as part of endovascular therapy was $46,444 as compared to $30,350 for those who did not have general anesthesia. The costs of embolectomy for IMS III subjects and patients from the NIS cohort exceeded the Medicare DRG payment in more than 75% of hospitalized patients. Conclusions and Relevance: Changing the processes of acute stroke care, such as minimizing the time to start of IV t-PA and decreasing the use of routine general anesthesia, may improve the cost-effectiveness of medical and endovascular therapy for acute stroke.

scholarly journals The role of cardiologists on the stroke unit

2020 ◽  
Vol 22 (Supplement_M) ◽  
pp. M3-M12
Author(s):  
Wolfram Doehner ◽  
David Manuel Leistner ◽  
Heinrich J Audebert ◽  
Jan F Scheitz
Keyword(s):  
Acute Stroke ◽  
Stroke Unit ◽  
Stroke Care ◽  
Cardiovascular Complications ◽  
Large Artery ◽  
Stroke Management ◽  
Acute Stroke Care ◽  
Daily Work ◽  
Cardiovascular Comorbidity ◽  
Treatment And Prevention

Abstract Cardiologists need a better understanding of stroke and of cardiac implications in modern stroke management. Stroke is a leading disease in terms of mortality and disability in our society. Up to half of ischaemic strokes are directly related to cardiac and large artery diseases and cardiovascular risk factors are involved in most other strokes. Moreover, in an acute stroke direct central brain signals and a consecutive autonomic/vegetative imbalance may account for severe and life-threatening cardiovascular complications. The strong cerebro-cardiac link in acute stroke has recently been addressed as the stroke-heart syndrome that requires careful cardiovascular monitoring and immediate therapeutic measures. The regular involvement of cardiologic expertise in daily work on a stroke unit is therefore of high importance and a cornerstone of up-to-date comprehensive stroke care concepts. The main targets of the cardiologists’ contribution to acute stroke care can be categorized in three main areas (i) diagnostics workup of stroke aetiology, (ii) treatment and prevention of complications, and (iii) secondary prevention and sub-acute workup of cardiovascular comorbidity. All three aspects are by themselves highly relevant to support optimal acute management and to improve the short-term and long-term outcomes of patients. In this article, an overview is provided on these main targets of cardiologists’ contribution to acute stroke management.

scholarly journals Effects of centralizing acute stroke services

Neurology ◽  
2018 ◽  
Vol 91 (3) ◽  
pp. e236-e248 ◽  
Author(s):  
Sidsel Hastrup ◽  
Soren P. Johnsen ◽  
Thorkild Terkelsen ◽  
Heidi H. Hundborg ◽  
Paul von Weitzel-Mudersbach ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Acute Stroke ◽  
Stroke Care ◽  
Acute Hospital ◽  
Acute Stroke Care ◽  
Difference In Differences ◽  
Stroke Units ◽  
Before And After ◽  
Stroke Services

ObjectiveTo investigate the effects of centralizing the acute stroke services in the Central Denmark Region (CDR).MethodsThe CDR (1.3 million inhabitants) centralized acute stroke care from 6 to 2 designated acute stroke units with 7-day outpatient clinics. We performed a prospective “before-and-after” cohort study comparing all strokes from the CDR with strokes in the rest of Denmark to discover underlying general trends, adopting a difference-in-differences approach. The population comprised 22,141 stroke cases hospitalized from May 2011 to April 2012 and May 2013 to April 2014.ResultsCentralization was associated with a significant reduction in length of acute hospital stay from a median of 5 to 2 days with a length-of-stay ratio of 0.53 (95% confidence interval 0.38–0.75, data adjusted) with no corresponding change seen in the rest of Denmark. Similarly, centralization led to a significant increase in strokes with same-day admission (mainly outpatients), whereas this remained unchanged in the rest of Denmark. We observed a significant improvement in quality of care captured in 11 process performance measures in both the CDR and the rest of Denmark. Centralization was associated with a nonsignificant increase in thrombolysis rate. We observed a slight increase in readmissions at day 30, but this was not significantly different from the general trend. Mortality at days 30 and 365 remained unchanged, as in the rest of Denmark.ConclusionsCentralizing acute stroke care in the CDR significantly reduced the length of acute hospital stay without compromising quality. Readmissions and mortality stayed comparable to the rest of Denmark.

scholarly journals Quality of Acute Stroke Care at Primary Stroke Centers Before and After Certification in Comparison to Never-Certified Hospitals

2020 ◽  
Vol 10 ◽  
Author(s):  
Kristina Shkirkova ◽  
Theodore T. Wang ◽  
Lily Vartanyan ◽  
David S. Liebeskind ◽  
Marc Eckstein ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Stroke Care ◽  
Acute Stroke Care ◽  
Before And After
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