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.

Quality of Acute Care and Long-Term Quality of Life and Survival: The Australian Stroke Clinical Registry.

BACKGROUND AND PURPOSE: Uncertainty exists over whether quality improvement strategies translate into better health-related quality of life (HRQoL) and survival after acute stroke. We aimed to determine the association of best practice recommended interventions and outcomes after stroke. METHODS: Data are from the Australian Stroke Clinical Registry during 2010 to 2014. Multivariable regression was used to determine associations between 3 interventions: received acute stroke unit (ASU) care and in various combinations with prescribed antihypertensive medication at discharge, provision of a discharge care plan, and outcomes of survival and HRQoL (EuroQoL 5-dimensional questionnaire visual analogue scale) at 180 days, by stroke type. An assessment was also made of outcomes related to the number of processes patients received. RESULTS: There were 17 585 stroke admissions (median age 77 years, 47% female; 81% managed in ASUs; 80% ischemic stroke) from 42 hospitals (77% metropolitan) assessed. Cumulative benefits on outcomes related to the number of care processes received by patients. ASU care was associated with a reduced likelihood of death (hazard ratio, 0.49; 95% confidence interval, 0.43-0.56) and better HRQoL (coefficient, 21.34; 95% confidence interval, 15.50-27.18) within 180 days. For those discharged from hospital, receiving ASU+antihypertensive medication provided greater 180-day survival (hazard ratio, 0.45; 95% confidence interval, 0.38-0.52) compared with ASU care alone (hazard ratio, 0.64; 95% confidence interval, 0.54-0.76). HRQoL gains were greatest for patients with intracerebral hemorrhage who received care bundles involving discharge processes (range of increase, 11%-19%). CONCLUSIONS: Patients with stroke who receive best practice recommended hospital care have improved long-term survival and HRQoL.

Excellence in regional stroke care: an evaluation of the implementation of a stroke care unit in regional Australia.

OBJECTIVE: To assess the effectiveness of a formalised stroke service in a regional hospital. DESIGN: A pretest post-test design. SETTING: An acute stroke unit in a regional health service. PARTICIPANTS: Overall sample comprised 80 patients with 36 (45.0%) men. Forty patients (19 men, 21 women) comprised pre-intervention group and 40 (17 men, 23 women) post-intervention group. INTERVENTIONS: Establishment of an acute stroke unit. MAIN OUTCOME MEASURE(S): Increased frequency in meeting key performance indicators for acute stroke care as recommended by National Stroke Foundation. RESULTS: On discharge, fewer survivors in the pre-intervention group were independent (n = 5) and returned home (n = 9) than the post-intervention group (n = 13) for both independent and returned home. More survivors in the pre-intervention group were discharged to aged care or inpatient rehab (n = 22) than the post-intervention group (n = 12). Within required time frames, the frequency of CT scans (chi(2) (1, 80) = 4.1, P < 0.05), swallow assessments (chi(2) (1, 80) = 9.0, P < 0.01), occupational therapy assessments (chi(2) (1, 80) = 14.5, P < 0.0001), multidisciplinary meetings involving patient and family (chi(2) (1, 80) = 19.9, P < 0.0001) and self-management plans (chi(2) (1, 80) = 10.9, P < 0.05) all increased significantly. CONCLUSIONS: Our evaluation demonstrated that introduction of formalised stroke care to a regional hospital resulted in improved compliance with key performance indicators and better patient outcomes. Thus evidence-based specialised stroke care can be offered with confidence in regional populations.