scholarly journals Temporal variations in quality of acute stroke care and outcomes in London hyperacute stroke units: a mixed-methods study

2020 ◽  
Vol 8 (34) ◽  
pp. 1-98
Author(s):  
Robert Simister ◽  
Georgia B Black ◽  
Mariya Melnychuk ◽  
Angus IG Ramsay ◽  
Abigail Baim-Lance ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Acute Stroke ◽  
Stroke Care ◽  
National Audit ◽  
Acute Stroke Care ◽  
Stroke Units ◽  
Hyperacute Stroke ◽  
Factors Influencing ◽  
Time Of Admission

Background Seven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of the day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units. Objectives To investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units, and to identify factors influencing such variations. Design This was a prospective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme. Factors influencing variations in care and outcomes were studied through interview and observation data. Setting The setting was acute stroke services in London hyperacute stroke units. Participants A total of 7094 patients with a primary diagnosis of stroke took part. We interviewed hyperacute stroke unit staff (n = 76), including doctors, nurses, therapists and administrators, and 31 patients and carers. We also conducted non-participant observations of delivery of care at different times of the day and week (n = 45, ≈102 hours). Intervention Hub-and-spoke model for care of suspected acute stroke patients in London with performance standards was designed to deliver uniform access to high-quality hyperacute stroke unit care across the week. Main outcome measures Indicators of quality of acute stroke care, mortality at 3 days after admission, disability at the end of the inpatient spell and length of stay. Data sources Sentinel Stroke National Audit Programme data for all patients in London hyperacute stroke units with a primary diagnosis of stroke between 1 January and 31 December 2014, and nurse staffing data for all eight London hyperacute stroke units for the same period. Results We found no variation in quality of care by day and time of admission across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor in 3-day mortality nor disability at hospital discharge. Other quality-of-care measures significantly varied by day and time of admission. Quality of care was better if the nurse in charge was at a higher band and/or there were more nurses on duty. Staff deliver ‘front-door’ interventions consistently by taking on additional responsibilities out of hours, creating continuities between day and night, building trusting relationships and prioritising ‘front-door’ interventions. Limitations We were unable to measure long-term outcomes as our request to the Sentinel Stroke National Audit Programme, the Healthcare Quality Improvement Partnership and NHS Digital for Sentinel Stroke National Audit Programme data linked with patient mortality status was not fulfilled. Conclusions Organisational factors influence 24 hours a day, 7 days a week (24/7), provision of stroke care, creating temporal patterns of provision reflected in patient outcomes, including mortality, length of stay and functional independence. Future work Further research would help to explore 24/7 stroke systems in other contexts. We need a clearer understanding of variations by looking at absolute time intervals, rather than achievement of targets. Research is needed with longer-term mortality and modified Rankin Scale data, and a more meaningful range of outcomes. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 34. See the NIHR Journals Library website for further project information.

scholarly journals Variation in quality of acute stroke care by day and time of admission: prospective cohort study of weekday and weekend centralised hyperacute stroke unit care and non-centralised services

BMJ Open ◽  
2019 ◽  
Vol 9 (11) ◽  
pp. e025366 ◽  
Author(s):  
Mariya Melnychuk ◽  
Stephen Morris ◽  
Georgia Black ◽  
Angus I G Ramsay ◽  
Jeannie Eng ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Stroke Unit ◽  
Performance Standards ◽  
Stroke Care ◽  
Acute Stroke Care ◽  
P Values ◽  
Stroke Units ◽  
Hyperacute Stroke ◽  
Time Of Admission

ObjectiveTo investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units compared with the rest of England.DesignProspective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme.SettingAcute stroke services in London hyperacute stroke units and the rest of England.Participants68 239 patients with a primary diagnosis of stroke admitted between January and December 2014.InterventionsHub-and-spoke model for care of suspected acute stroke patients in London with performance standards designed to deliver uniform access to high-quality hyperacute stroke unit care across the week.Main outcome measures16 indicators of quality of acute stroke care, mortality at 3 days after admission to the hospital, disability at the end of the inpatient spell, length of stay.ResultsThere was no variation in quality of care by day and time of admission to the hospital across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor was there variation in 3-day mortality or disability at hospital discharge (all p values>0.05). Other quality of care measures significantly varied by day and time of admission across the week in London (all p values<0.01). In the rest of England there was variation in all measures by day and time of admission across the week (all p values<0.01), except for mortality at 3 days (p value>0.05).ConclusionsThe London hyperacute stroke unit model achieved performance standards for ‘front door’ stroke care across the week. The same benefits were not achieved by other models of care in the rest of England. There was no weekend effect for mortality in London or the rest of the England. Other aspects of care were not constant across the week in London hyperacute stroke units, indicating some performance standards were perceived to be more important than others.

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.

FP22-TU-01 Quality of acute stroke care in Thailand, a prospective multicenter countrywide study

2009 ◽  
Vol 285 ◽  
pp. S91
Author(s):  
Y. Nilanont ◽  
S. Nidhinandana ◽  
N. Suwanwela ◽  
N. Poungvarin
Keyword(s):  
Acute Stroke ◽  
Stroke Care ◽  
Acute Stroke Care

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.

Ten Years of Improving Acute Stroke Management in a Metropolitan Area: A Population-Based Quantification of Quality Indicators

2021 ◽  
pp. 1-11
Author(s):  
Anna Alegiani ◽  
Michael Rosenkranz ◽  
Leonie Schmitz ◽  
Susanne Lezius ◽  
Günter Seidel ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Quality Indicators ◽  
Metropolitan Area ◽  
Stroke Care ◽  
Care Quality ◽  
Acute Stroke Care ◽  
Stroke Units ◽  
Stroke Treatment ◽  
Acute Stroke Treatment ◽  
Over Time

<b><i>Background and Purpose:</i></b> Rapid access to acute stroke treatment improves clinical outcomes in patients with ischemic stroke. We aimed to shorten the time to admission and to acute stroke treatment for patients with acute stroke in the Hamburg metropolitan area by collaborative multilevel measures involving all hospitals with stroke units, the Emergency Medical Services (EMS), and health-care authorities. <b><i>Methods:</i></b> In 2007, an area-wide stroke care quality project was initiated. The project included mandatory admission of all stroke patients in Hamburg exclusively to hospitals with stroke units, harmonized acute treatment algorithms among all hospitals, repeated training of the EMS staff, a multimedia educational campaign, and a mandatory stroke care quality monitoring system based on structured data assessment and quality indicators for procedural measures. We analyzed data of all patients with acute stroke who received inhospital treatment in the city of Hamburg during the evaluation period from the quality assurance database data and evaluated trends of key quality indicators over time. <b><i>Results:</i></b> From 2007 to 2016, a total of 83,395 patients with acute stroke were registered. During this period, the proportion of patients admitted within ≤3 h from symptom onset increased over time from 27.8% in 2007 to 35.2% in 2016 (<i>p</i> &#x3c; 0.001). The proportion of patients who received rapid thrombolysis (within ≤30 min after admission) increased from 7.7 to 54.1% (<i>p</i> &#x3c; 0.001). <b><i>Conclusions:</i></b> Collaborative stroke care quality projects are suitable and effective to improve acute stroke care.

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

scholarly journals The Dutch Acute Stroke Audit: Benchmarking acute stroke care in the Netherlands

2018 ◽  
Vol 3 (4) ◽  
pp. 361-368 ◽  
Author(s):  
Laurien S Kuhrij ◽  
Michel WJM Wouters ◽  
Renske M van den Berg-Vos ◽  
Frank-Erik de Leeuw ◽  
Paul J Nederkoorn
Keyword(s):  
Acute Stroke ◽  
Best Practice ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
Favourable Outcome ◽  
Hospital Level ◽  
Acute Stroke Care ◽  
Related Factors ◽  
Variation In Care

Introduction In the nationwide Dutch Acute Stroke Audit (DASA), consecutive patients with acute ischaemic stroke (AIS) and intracranial haemorrhage (ICH) are prospectively registered. Acute stroke care is a rapidly evolving field in which intravenous thrombolysis (IVT) and intra-arterial thrombectomy (IAT) play a crucial role in increasing odds of favourable outcome. The DASA can be used to assess the variation in care between hospitals and develop ‘best practice’ in acute stroke care. Patients and methods: We describe the initiation and design of the DASA as well as the results from 2015 and 2016. Results In 2015 and 2016, 55,854 patients with AIS and 7727 patients with ICH were registered in the DASA. Treatment with IVT was administered to 10,637 patients (with an increase of 1.3% in 2016) and 1740 patients underwent IAT (with an increase of 1% in 2016). Median door-to-needle time for IVT and median door-to-groin time for IAT have decreased from 27 to 25 min and 66 to 64 min, respectively. Mortality during admission was 4.9% in patients with AIS, whereas 26% of patients with ICH died. Modified Rankin Scale score at three months was registered in 49% of AIS patients and 45% of ICH patients. Discussion During the nationwide DASA, time to treatment is reduced for IVT as well as IAT. With the rapidly evolving treatment of acute stroke care, the DASA can be used to monitor the quality provided on patient- and hospital level. Conclusion Increasing completeness of registration of the outcome, in combination with adjustment for patient-related factors, is necessary to define and further improve the quality of the acute stroke care.

scholarly journals P027: Development of a physician assistant lead stroke protocol to provide timely and equitable access to hyperacute stroke care in a telestroke community hospital

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S74-S74
Author(s):  
L. Shoots ◽  
V. Bailey
Keyword(s):  
Acute Stroke ◽  
Local Community ◽  
Community Hospital ◽  
Stroke Care ◽  
Physician Assistants ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
Hyperacute Stroke ◽  
Phone Calls ◽  
Triage Time

Background: The Brant Community Healthcare System (BCHS) has consistently been well above the recommended 30 minute benchmark for door-to-needle (DTN) for eligible acute stroke patients. As a large community hospital with no neurologists, and like many other hospitals internationally, we rely on telestroke support for every stroke case. This is a time-consuming process that requires a multitude of phone calls, and pulls physicians from other acutely ill patients. We sought to develop a system that would streamline our approach and care for hyperacute stroke patients by targeting improvements in DTN. Aim Statement: We will decrease the door-to-needle (DTN) time for stroke patients arriving at the BCHS Emergency Department (ED) who are eligible for tissue plasminogen activator (tPA) by 25% from a median of 87 minutes to 50 minutes by March 31, 2018 and maintain that standard. Measures & Design: Outcome Measures: Door-to-needle time for acute stroke patients receiving tPA Process Measures: Door-to-triage time, Door-to-CT time, Door-to-CTA time; INR collection-to-verification time, telestroke callback time Balancing Measures: Number of stroke protocol patients per month Model Design: We simultaneously designed and implemented a robust program to train physician assistants in hyperacute stroke care. Evaluation/Results: Through vast stakeholder engagement and implementing a multitude of change ideas, by March of 2018 we had achieved an average DTN of 53 minutes. Our door-to-triage time went from an average of 7 minutes to 3 minutes. Our door-to-CT time decreased from 17 minutes to 7 minutes and our time between CT and CTA from an average of 13 minutes to 3 minutes. One and a half years later, our average DTN is maintained at 55 minutes and physician assistants continue to effectively lead and liaise with telestroke neurologists and stroke patients. Discussion/Impact: Prior to this program, acute stroke care was a very contentious topic at our local community hospital. Creating a program that streamlined the care and standardized the work has proven successful, and not only allowed for improved DTN times but also freed up physicians to better simultaneously care for other acutely ill patients.

scholarly journals Quality of acute stroke care in a regional Victorian hospital, Australia

2019 ◽  
Vol 27 (2) ◽  
pp. 153-157
Author(s):  
Tze Wei Wilson Yang ◽  
Md Rafiqul Islam
Keyword(s):  
Acute Stroke ◽  
Stroke Care ◽  
Acute Stroke Care
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