Improving acute stroke care in regional hospitals: clinical evaluation of the Victorian Stroke Telemedicine program.

OBJECTIVES: To evaluate the impact of the Victorian Stroke Telemedicine (VST) program during its first 12 months on the quality of care provided to patients presenting with suspected stroke to hospitals in regional Victoria. DESIGN: Historical controlled cohort study comparing outcomes during a 12-month control period with those for the initial 12 months of full implementation of the VST program at each hospital. SETTING: 16 hospitals in regional Victoria that participated in the VST program between 1 January 2010 and 30 January 2016. PARTICIPANTS: Adult patients with suspected stroke presenting to the emergency departments of the participating hospitals. MAIN OUTCOME MEASURES: Indicators for key processes of care, including symptom onset-to-arrival, door-to-first medical review, and door-to-CT times; provision and timeliness of provision of thrombolysis to patients with ischaemic stroke. RESULTS: 2887 patients with suspected stroke presented to participating emergency departments during the control period, 3178 during the intervention period; the patient characteristics were similar for both periods. A slightly larger proportion of patients with ischaemic stroke who arrived within 4.5 hours of symptom onset received thrombolysis during the intervention than during the control period (37% v 30%). Door-to-CT scan time (median, 25 min [IQR, 13-49 min] v 34 min [IQR, 18-76 min]) and door-to-needle time for stroke thrombolysis (73 min [IQR, 56-96 min] v 102 min [IQR, 77-128 min]) were shorter during the intervention. The proportions of patients who received thrombolysis and had a symptomatic intracerebral haemorrhage (4% v 16%) or died in hospital (6% v 20%) were smaller during the intervention period. CONCLUSIONS: Telemedicine has provided Victorian regional hospitals access to expert care for emergency department patients with suspected acute stroke. Eligible patients with ischaemic stroke are now receiving stroke thrombolysis more quickly and safely.

Utility of Computed Tomographic Perfusion in Thrombolysis for Minor Stroke.

BACKGROUND AND PURPOSE: The use of thrombolysis in acute minor ischemic stroke (MIS) remains controversial. We sought to determine the safety and efficacy of intravenous tissue-type plasminogen activator (IV-tPA) in acute MIS patients with demonstrable penumbra on computed tomographic perfusion study. METHODS: Consecutive MIS patients with National Institutes of Health Stroke Scale ≤3 were identified from a prospective single tertiary-center database over a 4.5-year period (2011-2015). Cases with demonstrable penumbra were analyzed according to treatment received: IV-tPA versus standard stroke-unit care without thrombolysis. RESULTS: Seventy-three patients of 195 acute MIS admissions had a demonstrable penumbra (34 IV-tPA versus 39 standard stroke-unit care). Overall median National Institutes of Health Stroke Scale and premorbid modified Rankin Scale were 2 and 0, respectively. Median age was 73.2 (interquartile range, 67.3-82.8) years. There were no differences in baseline demographics, risk factors, stroke localization and cause, rates of vascular occlusion (38.2% versus 38.5%; P=1.000), or mean penumbral volume (41.3 versus 25.1 mL; P=0.150; IV-tPA versus standard stroke-unit care) between groups. There were no symptomatic intracerebral hemorrhages in either group. Patients treated with IV-tPA were more likely to have an excellent functional outcome at discharge (88.2% versus 53.9%; P=0.002) and 90 days (91.2% versus 71.8%; P=0.042). Ordinal analysis demonstrated a favorable shift in modified Rankin Scale with IV-tPA both at discharge (odds ratio, 5.23; 95% confidence interval, 1.83-12.20) and 90 days (odds ratio, 4.35; 95% confidence interval, 1.77-11.36). CONCLUSIONS: In selected MIS patients with demonstrable penumbra on computed tomographic perfusion, IV-tPA is safe and associated with significant improvement in functional outcome at discharge and 90 days.

Factors influencing the successful implementation of a novel digital health application to streamline multidisciplinary communication across multiple organisations for emergency care.

RATIONALE: Delivering optimal patient health care requires interdisciplinary clinician communication. A single communication tool across multiple pre-hospital and hospital settings, and between hospital departments is a novel solution to current systems. Fit-for-purpose, secure smartphone applications allow clinical information to be shared quickly between health providers. Little is known as to what underpins their successful implementation in an emergency care context. AIMS: To identify (a) whether implementing a single, digital health communication application across multiple health care organisations and hospital departments is feasible; (b) the barriers and facilitators to implementation; and (c) which factors are associated with clinicians' intentions to use the technology. METHODS: We used a multimethod design, evaluating the implementation of a secure, digital communication application (Pulsara™). The technology was trialled in two Australian regional hospitals and 25 Ambulance Victoria branches (AV). Post-training, clinicians involved in treating patients with suspected stroke or cardiac events were administered surveys measuring perceived organisational readiness (Organisational Readiness for Implementing Change), clinicians' intentions (Unified Theory of Acceptance and Use of Technology) and internal motivations (Self-Determination Theory) to use Pulsara™, and the perceived benefits and barriers of use. Quantitative data were descriptively summarised with multivariable associations between factors and intentions to use Pulsara™ examined with linear regression. Qualitative data responses were subjected to directed content analysis (two coders). RESULTS: Participants were paramedics (n = 82, median 44 years) or hospital-based clinicians (n = 90, median 37 years), with organisations perceived to be similarly ready. Regression results (F(11, 136) = 21.28, p = <0.001, Adj R2 = 0.60) indicated Habit, Effort Expectancy, Perceived Organisational Readiness, Performance Expectancy and Organisation membership (AV) as predictors of intending to use Pulsara™. Themes relating to benefits (95% coder agreement) included improved communication, procedural efficiencies and faster patient care. Barriers (92% coder agreement) included network accessibility and remembering passwords. PulsaraTM was initiated 562 times. CONCLUSION: Implementing multiorganisational, digital health communication applications is feasible, and facilitated when organisations are change-ready for an easy-to-use, effective solution. Developing habitual use is key, supported through implementation strategies (e.g., hands-on training). Benefits should be emphasised (e.g., during education sessions), including streamlining communication and patient flow, and barriers addressed (e.g., identify champions and local technical support) at project commencement.

Door-in-door-out times for patients with large vessel occlusion ischaemic stroke being transferred for endovascular thrombectomy: a Victorian state-wide study.

Background: Time to reperfusion is an important predictor of outcome in ischaemic stroke from large vessel occlusion (LVO). For patients requiring endovascular thrombectomy (EVT), the transfer times from peripheral hospitals in metropolitan and regional Victoria, Australia to comprehensive stroke centres (CSCs) have not been studied. Aims: To determine transfer and journey times for patients with LVO stroke being transferred for consideration of EVT. Methods: All patients transferred for consideration of EVT to three Victorian CSCs from January 2017 to December 2018 were included. Travel times were obtained from records matched to Ambulance Victoria and the referring centre via Victorian Stroke Telemedicine or hospital medical records. Metrics of interest included door-in-door-out time (DIDO), inbound journey time and outbound journey time. Results: Data for 455 transferred patients were obtained, of which 395 (86.8%) underwent EVT. The median DIDO was 107 min (IQR 84-145) for metropolitan sites and 132 min (IQR 108-167) for regional sites. At metropolitan referring hospitals, faster DIDO was associated with use of the same ambulance crew to transport between hospitals (75 (63-90) vs 124 (99-156) min, p<0.001) and the administration of thrombolysis prior to transfer (101 (79-133) vs 115 (91-155) min, p<0.001). At regional centres, DIDO was consistently longer when patients were transported by air (160 (127-195) vs 116 (100-144) min, p<0.001). The overall door-to-door time by air was shorter than by road for sites located more than 250 km away from the CSC. Conclusion: Transfer times differ significantly for regional and metropolitan patients. A state-wide database to prospectively collect data on all interhospital transfers for EVT would be helpful for future study of optimal transport mode at regional sites and benchmarking of DIDO across the state.

Real-world, feasibility study to investigate the use of a multidisciplinary app (Pulsara) to improve prehospital communication and timelines for acute stroke/STEMI care.

OBJECTIVES: To determine if a digital communication app improves care timelines for patients with suspected acute stroke/ST-elevation myocardial infarction (STEMI). DESIGN: Real-world feasibility study, quasi-experimental design. SETTING: Prehospital (25 Ambulance Victoria branches) and within-hospital (2 hospitals) in regional Victoria, Australia. PARTICIPANTS: Paramedics or emergency department (ED) clinicians identified patients with suspected acute stroke (onset <4.5 hours; n=604) or STEMI (n=247). INTERVENTION: The Pulsara communication app provides secure, two-way, real-time communication. Assessment and treatment times were recorded for 12 months (May 2017-April 2018), with timelines compared between 'Pulsara initiated' (Pulsara) and 'not initiated' (no Pulsara). PRIMARY OUTCOME MEASURE: Door-to-treatment (needle for stroke, balloon for STEMI) Secondary outcome measures: ambulance and hospital processes. RESULTS: Stroke (no Pulsara n=215, Pulsara n=389) and STEMI (no Pulsara n=76, Pulsara n=171) groups were of similar age and sex (stroke: 76 vs 75 years; both groups 50% male; STEMI: 66 vs 63 years; 68% and 72% male). When Pulsara was used, patients were off ambulance stretcher faster for stroke (11(7, 17) vs 19(11, 29); p=0.0001) and STEMI (14(7, 23) vs 19(10, 32); p=0.0014). ED door-to-first medical review was faster (6(2, 14) vs 23(8, 67); p=0.0001) for stroke but only by 1 min for STEMI (3 (0, 7) vs 4 (0, 14); p=0.25). Door-to-CT times were 44 min faster (27(18, 44) vs 71(43, 147); p=0.0001) for stroke, and percutaneous intervention door-to-balloon times improved by 17 min, but non-significant (56 (34, 88) vs 73 (49, 110); p=0.41) for STEMI. There were improvements in the proportions of patients treated within 60 min for stroke (12%-26%, p=0.15) and 90 min for STEMI (50%-78%, p=0.20). CONCLUSIONS: In this Australian-first study, uptake of the digital communication app was strong, patient-centred care timelines improved, although door-to-treatment times remained similar.

Stroke public awareness campaigns have increased ambulance dispatches for stroke in Melbourne, Australia.

BACKGROUND AND PURPOSE: Launch of the National Stroke Foundation stroke awareness campaigns has occurred annually during Stroke Week (September) since 2004. From 2006, the campaign used FAST (Face, Arm, Speech, Time) with calling an ambulance added in 2007. The aim of this study was to explore the impact of these campaigns on ambulance dispatches for stroke (Medical Priority Dispatch Card 28) in Melbourne, Australia. METHODS: A cross-sectional study examining the monthly proportions of ambulance dispatches for stroke between August 1999 and 2010 was conducted. The proportions of dispatches for stroke were used due to increases in the population and in ambulance dispatches over the study period. These proportions were statistically compared for the month before Stroke Week (August) and the month after Stroke Week (October) for each year and seasonal variation was examined. RESULTS: Between 1999 and 2009, the annual proportion of dispatches for stroke increased from 2.1% (n=4327) to 2.95% (n=9918). When stroke dispatches in August were compared with those in October, a significant increase in October was only detected since the call an ambulance message was added to FAST: 2007 (2.62% to 3.00%, P=0.006), 2008 (2.62% to 3.05%, P=0.003), and 2009 (2.70% to 3.09%, P=0.007). From 2005, the peak season for stroke dispatches shifted from winter to spring. CONCLUSIONS: Ambulance dispatches for stroke significantly increased after the National Stroke Foundation campaigns began, particularly in years receiving greater funding and featuring the FAST symptoms and the message to call an ambulance. Monitoring ambulance use appears to be an effective measure of campaign penetration.

Telestroke for acute ischaemic stroke: A systematic review of economic evaluations and a de novo cost-utility analysis for a middle income country.

INTRODUCTION: Telemedicine can alleviate the problems faced in rural settings in providing access to specialist stroke care. The evidence of the cost-effectiveness of this model of care outside high-income countries is limited. This study aimed to conduct: (a) a systematic review of economic evaluations of telestroke and (b) a cost-utility analysis of telestroke, using China as a case study. METHODS: We systematically searched Embase, Medline Complete and Cochrane databases. Inclusion criteria: full economic evaluations of telemedicine/telestroke networks examining the use of thrombolysis in patients with acute ischaemic stroke, published in English. A cost-utility analysis was undertaken using a Markov model incorporating a decision tree to simulate the delivery of telestroke for acute ischaemic stroke in rural China, compared to no telestroke from a societal and healthcare perspective. One-way deterministic sensitivity analyses and probabilistic sensitivity analyses were performed to test the robustness of results. RESULTS: Of 559 publications found, eight met the eligibility criteria and were included in the systematic review (two cost-effectiveness analyses and six cost-utility analyses, all performed in high-income countries). Telestroke was a cost-saving/cost-effective intervention in five out of the eight studies. In our modelled analysis for rural China, telestroke was the dominant strategy, with estimated cost savings of Chinese yuan 4,328 (US$627) and additional 0.0925 quality-adjusted life years per patient. Sensitivity analyses confirmed the base case results. DISCUSSION: Consistent with published economic evaluations of telestroke in other jurisdictions, telestroke represents a cost-effective solution to enhance stroke care in rural China.

Paramedic diagnosis of stroke: examining long-term use of the Melbourne Ambulance Stroke Screen (MASS) in the field.

BACKGROUND AND PURPOSE: Recent evidence suggests the Cincinnati Prehospital Stroke Scale is ineffectively used and lacks sensitivity and specificity. Melbourne (Australia) paramedics have been using the Melbourne Ambulance Stroke Screen (MASS) since 2005. The aim of this study was to review the real-world use of MASS 3 years after city wide implementation. METHODS: Two groups of consecutively admitted patients to an Australian hospital between January and May 2008 were used: (1) patients for whom paramedics performed MASS; and (2) patients with a discharge diagnosis of stroke or transient ischemic attack. Use of MASS was examined for all transports and for patients diagnosed with stroke or transient ischemic attack. The sensitivity and specificity of paramedic diagnosis, MASS, and Cincinnati Prehospital Stroke Scale were calculated. Paramedic diagnosis of stroke among patients with stroke was statistically compared with those obtained immediately post-MASS implementation in 2002. RESULTS: For the study period, MASS was performed for 850 (16%) of 5286 emergency transports, including 199 of 207 (96%) patients with confirmed stroke and transient ischemic attack. In patients in whom MASS was performed (n=850), the sensitivity of paramedic diagnosis of stroke (93%, 95% CI: 88% to 96%) was higher than the MASS (83%, 95% CI: 77% to 88%, P=0.003) and equivalent to Cincinnati Prehospital Stroke Scale (88%, 95% CI: 83% to 92%, P=0.120), whereas the specificity of the paramedic diagnosis of stroke (87%, 95% CI: 84% to 89%) was equivalent to MASS (86%, 95% CI: 83% to 88%, P=0.687) and higher than Cincinnati Prehospital Stroke Scale (79%, 95% CI: 75% to 82%, P<0.001). The initial improvement in stroke paramedic diagnosis seen in 2002 (94%, 95% CI: 86% to 98%) was sustained in 2008 (89%, 95% CI: 84% to 94%, P=0.19). CONCLUSIONS: In our experience, paramedics have successfully incorporated MASS into the assessment of neurologically compromised patients. The initial improvement to the paramedics' diagnosis of stroke with MASS was sustained 3 years after city wide implementation.

Effects of the end point adjudication process on the results of the Perindopril Protection Against Recurrent Stroke Study (PROGRESS).

BACKGROUND AND PURPOSE: End point adjudication committees (EPAC) are widely used in large-scale clinical trials to ensure the robustness of diagnosis for end points. METHODS: The Perindopril Protection Against Recurrent Stroke Study (PROGRESS) was a double-blind randomized trial of blood pressure lowering in 6105 participants with pre-existing cerebrovascular disease. Separate estimates of the effects of randomized treatment were determined using Cox regression models that were based on the unadjudicated events initially reported by the investigator and on the final events assigned by the EPAC. RESULTS: There were 992 strokes initially reported by the investigators and 894 (90%) retained these diagnoses after adjudication by the EPAC. The hazard ratios (95% CIs) for the effect of randomized treatment on stroke were 0.74 (0.64 to 0.85) based on the investigator diagnoses and 0.72 (0.62 to 0.83) based on the EPAC diagnoses (P homogeneity=0.7). For each stroke subtype reported, the corresponding numbers of diagnoses (investigators/EPAC) were ischemic (593/565), hemorrhagic (124/111), and unknown (124/93) with no impact of the EPAC review on the estimates of treatment effects (all P homogeneity >0.3). There was likewise no detectable effect of reclassification of diagnoses for the effect estimates calculated for myocardial infarction or the main causes of death (all P homogeneity >0.5). CONCLUSIONS: The EPAC process had no discernible impact on the trial conclusions. Very large trials powered to detect effects on stroke subtypes might obtain real scientific gain from an EPAC, but in the case of PROGRESS, the value of the EPAC was in the reassurance it provided.

Carotid endarterectomy: the change in practice over 11 years in a stroke centre.

BACKGROUND: Recent research evidence has impacted the practice of carotid endarterectomy (CEA). We aim to characterize changes in the practice and outcome of CEA over time in a single large-volume stroke centre. METHODS: All patients who underwent CEA from 2004 to 2014 and carotid angioplasty and stenting (CAS) from 2003 to 2008 at an Australian metropolitan tertiary stroke centre hospital were included. Clinical data were analysed to identify time trends in choice of intervention, patient selection, preoperative imaging utilization, surgical timing and outcome. RESULTS: There were 510 CEAs performed during 2004-2014 and 95 CASs during 2003-2008. The proportion of patients undergoing CEA compared to CAS increased from 60% to 90% from 2004 to 2008 (P < 0.001). CAS patients were more likely to have cardiac co-morbidities. From 2004 to 2014, the proportion of CEA patients aged ≥80 years increased (P = 0.001) and the proportion of asymptomatic patients decreased (P = 0.003) over time. Median time from symptom onset to surgery decreased from 52 days (Q1: 25, Q3: 74) in 2004 to 8 days (Q1: 5, Q3: 37) in 2014 (P < 0.001). Use of preoperative ultrasonography decreased whilst CT angiography and the number of imaging modalities applied to each patient increased over time (P < 0.001). Overall, 5.9% of CEAs were complicated by death, stroke or acute myocardial infarction with no significant change over time. CONCLUSION: The trends in CEA practice at our centre align with international trends and guidelines. This study provides a representative indicator of Australian hospital practice, and illustrates how evidence from research is translated into clinical care.

STroke imAging pRevention and treatment (START): A longitudinal stroke cohort study: Clinical trials protocol.

RATIONALE: Stroke and poststroke depression are common and have a profound and ongoing impact on an individual's quality of life. However, reliable biological correlates of poststroke depression and functional outcome have not been well established in humans. AIMS: Our aim is to identify biological factors, molecular and imaging, associated with poststroke depression and recovery that may be used to guide more targeted interventions. DESIGN: In a longitudinal cohort study of 200 stroke survivors, the START-STroke imAging pRevention and Treatment cohort, we will examine the relationship between gene expression, regulator proteins, depression, and functional outcome. Stroke survivors will be investigated at baseline, 24 h, three-days, three-months, and 12 months poststroke for blood-based biological associates and at days 3-7, three-months, and 12 months for depression and functional outcomes. A sub-group (n = 100), the PrePARE: Prediction and Prevention to Achieve optimal Recovery Endpoints after stroke cohort, will also be investigated for functional and structural changes in putative depression-related brain networks and for additional cognition and activity participation outcomes. Stroke severity, diet, and lifestyle factors that may influence depression will be monitored. The impact of depression on stroke outcomes and participation in previous life activities will be quantified. STUDY OUTCOMES: Clinical significance lies in the identification of biological factors associated with functional outcome to guide prevention and inform personalized and targeted treatments. Evidence of associations between depression, gene expression and regulator proteins, functional and structural brain changes, lifestyle and functional outcome will provide new insights for mechanism-based models of poststroke depression.

Implementation of evidence-based stroke care: enablers, barriers, and the role of facilitators.

A stroke care strategy was developed in 2007 to improve stroke services in Victoria, Australia. Eight stroke network facilitators (SNFs) were appointed in selected hospitals to enable the establishment of stroke units, develop thrombolysis services, and implement protocols. We aimed to explain the main issues being faced by clinicians in providing evidence-based stroke care, and to determine if the appointment of an SNF was perceived as an acceptable strategy to improve stroke care. Face-to-face semistructured interviews were used in a qualitative research design. Interview transcripts were verified by respondents prior to coding. Two researchers conducted thematic analysis of major themes and subthemes. Overall, 84 hospital staff participated in 33 interviews during 2008. The common factors found to impact on stroke care included staff and equipment availability, location of care, inconsistent use of clinical pathways, and professional beliefs. Other barriers included limited access to specialist clinicians and workload demands. The establishment of dedicated stroke units was considered essential to improve the quality of care. The SNF role was valued for identifying gaps in care and providing capacity to change clinical processes. This is the first large, qualitative multicenter study to describe issues associated with delivering high-quality stroke care and the potential benefits of SNFs to facilitate these improvements.

A multicentre, randomized, double-blinded, placebo-controlled Phase III study to investigate EXtending the time for Thrombolysis in Emergency Neurological Deficits (EXTEND).

BACKGROUND AND HYPOTHESIS: Thrombolytic therapy with tissue plasminogen activator is effective for acute ischaemic stroke within 4·5 h of onset. Patients who wake up with stroke are generally ineligible for stroke thrombolysis. We hypothesized that ischaemic stroke patients with significant penumbral mismatch on either magnetic resonance imaging or computer tomography at three- (or 4·5 depending on local guidelines) to nine-hours from stroke onset, or patients with wake-up stroke within nine-hours from midpoint of sleep duration, would have improved clinical outcomes when given tissue plasminogen activator compared to placebo. STUDY DESIGN: EXtending the time for Thrombolysis in Emergency Neurological Deficits is an investigator-driven, Phase III, randomized, multicentre, double-blind, placebo-controlled study. Ischaemic stroke patients presenting after the three- or 4·5-h treatment window for tissue plasminogen activator and within nine-hours of stroke onset or with wake-up stroke within nine-hours from the midpoint of sleep duration, who fulfil clinical (National Institutes of Health Stroke Score ≥4-26 and prestroke modified Rankin Scale <2) will undergo magnetic resonance imaging or computer tomography. Patients who also meet imaging criteria (infarct core volume <70 ml, perfusion lesion : infarct core mismatch ratio >1·2, and absolute mismatch >10 ml) will be randomized to either tissue plasminogen activator or placebo. STUDY OUTCOME: The primary outcome measure will be modified Rankin Scale 0-1 at day 90. Clinical secondary outcomes include categorical shift in modified Rankin Scale at 90 days, reduction in the National Institutes of Health Stroke Score by 8 or more points or reaching 0-1 at day 90, recurrent stroke, or death. Imaging secondary outcomes will include symptomatic intracranial haemorrhage, reperfusion and or recanalization at 24 h and infarct growth at day 90.

Is FAST stroke smart? Do the content and language used in awareness campaigns describe the experience of stroke symptoms?

BACKGROUND: Public education campaigns for stroke are used worldwide. However, there are few published evaluations of such campaigns. AIM: This cross-sectional study examined patient and bystander awareness of two Australian campaigns, 'FAST' (face, arm, speech, time) and 'Signs of Stroke', and evaluated the campaigns ability to identify stroke and to describe the symptom experience. METHODS: Interviews were conducted with either stroke patients or a key bystander for consecutive eligible cases admitted to two metropolitan hospitals between August 2006 and April 2008. Participants were asked to describe awareness of the FAST campaign, the symptoms experienced and to evaluate the symptom descriptions of Signs of Stroke against their own experience. RESULTS: A total of 100 patients and 70 bystanders were interviewed for 170 cases (71% of eligible cases). Only 12% of those interviewed were aware of the FAST campaign, and of these few (19%) were able to recall all FAST symptoms, with only one bystander using the FAST assessments to identify stroke. At least one FAST symptom was reported by 84% and one Signs of Stroke symptom by 100%. Less than half of those experiencing 'weakness or paralysis' thought this description exactly described their experience. Common descriptors of symptoms were: face or mouth droop or drop; trouble using, coordinating or moving arm, hand or leg; trouble walking or standing; numbness; and slurring or loss of speech. CONCLUSION: Awareness of the FAST and Signs of Stroke campaigns was low, with poor recall and little use of the FAST assessments. Some symptom descriptions used in the campaign were not reflective of the symptom experience. The content and language of these campaigns could be improved to portray stroke symptoms more realistically.