Identifying factors in the provision of intravenous stroke thrombolysis in Malaysia: a multiple case study from the healthcare providers' perspective.

BACKGROUND: Translation into clinical practice for use of intravenous thrombolysis (IVT) for the management of ischemic stroke remains a challenge especially across low- and middle-income countries, with regional inconsistencies in its rate. This study aimed at identifying factors that influenced the provision of IVT and the variation in its rates in Malaysia. METHODS: A multiple case study underpinning the Tailored Implementation for Chronic Diseases framework was carried out in three public hospitals with differing rates of IVT using a multiple method design. Twenty-five in-depth interviews and 12 focus groups discussions were conducted among 89 healthcare providers, along with a survey on hospital resources and a medical records review to identify reasons for not receiving IVT. Qualitative data were analysed using reflective thematic method, before triangulated with quantitative findings. RESULTS: Of five factors identified, three factors that distinctively influenced the variation of IVT across the hospitals were: 1) leadership through quality stroke champions, 2) team cohesiveness which entailed team dynamics and its degree of alignment and, 3) facilitative work process which included workflow simplification and familiarity with IVT. Two other factors that were consistently identified as barriers in these hospitals included patient factors which largely encompassed delayed presentation, and resource constraints. About 50.0 - 67.6% of ischemic stroke patients missed the opportunity to receive IVT due to delayed presentation. CONCLUSIONS: In addition to the global effort to explore sustainable measures to improve patients' emergency response for stroke, attempts to improve the provision of IVT for stroke care should also consider the inclusion of interventions targeting on health systems perspectives such as promoting quality leadership, team cohesiveness and workflow optimisation.

Prevalence and factors associated with pre-hospital delay among acute stroke patients at Mulago and Kiruddu national referral hospitals, Kampala: a cross-sectional study.

BACKGROUND: Despite advancements in acute stroke care, acute stroke patients present late for care resulting in high mortality and poor functional outcomes. This study determined the prevalence of pre-hospital delay and associated factors among adult acute stroke patients in Uganda. METHODS: In a hospital based, cross-sectional study, one hundred and forty-three study participants with confirmed acute stroke presenting to the emergency units of Mulago and Kiruddu national referral hospitals were enrolled. Using an interviewer-administered questionnaire, details on sociodemographics, onset of stroke, arrival at the tertiary facility, health system and clinical factors were collected. Descriptive statistics and modified Poisson regression analyses were performed to determine factors associated with prehospital delay. RESULTS: Among the 143 study participants, nearly two-thirds (79/146) had ischemic stroke while a third (59/143) had haemorrhagic stroke. The mean age was 59 years (SD 16) and 51.7% of acute stroke patients were males. Ninety one percent (130/143) presented to the emergency unit after 3 hours. The majority (124/143) reported visiting lower-level facilities prior to referral to the tertiary facility. Staying outside Kampala district (PR: 1.28 (1.22-1.34), p < 0.001), and using hired or government ambulance for transport to tertiary facility (PR: 1.17 (1.13-1.20), p < 0.001) were associated with pre-hospital delay. CONCLUSIONS: Prevalence of pre-hospital delay among acute stroke patients presenting to public tertiary hospitals in Uganda is very high. The causes of pre hospital delay should be further explored qualitatively. Efforts to reduce prehospital delay should include improving pre-hospital transport systems for stroke patients.

Impact of the lockdown on acute stroke treatments during the first surge of the COVID-19 outbreak in the Netherlands.

INTRODUCTION: We investigated the impact of the Corona Virus Disease 2019 (COVID-19) pandemic and the resulting lockdown on reperfusion treatments and door-to-treatment times during the first surge in Dutch comprehensive stroke centers. Furthermore, we studied the association between COVID-19-status and treatment times. METHODS: We included all patients receiving reperfusion treatment in 17 Dutch stroke centers from May 11th, 2017, until May 11th, 2020. We collected baseline characteristics, National Institutes of Health Stroke Scale (NIHSS) at admission, onset-to-door time (ODT), door-to-needle time (DNT), door-to-groin time (DGT) and COVID-19-status at admission. Parameters during the lockdown (March 15th, 2020 until May 11th, 2020) were compared with those in the same period in 2019, and between groups stratified by COVID-19-status. We used nationwide data and extrapolated our findings to the increasing trend of EVT numbers since May 2017. RESULTS: A decline of 14% was seen in reperfusion treatments during lockdown, with a decline in both IVT and EVT delivery. DGT increased by 12 min (50 to 62 min, p-value of < 0.001). Furthermore, median NIHSS-scores were higher in COVID-19 - suspected or positive patients (7 to 11, p-value of 0.004), door-to-treatment times did not differ significantly when stratified for COVID-19-status. CONCLUSIONS: During the first surge of the COVID-19 pandemic, a decline in acute reperfusion treatments and a delay in DGT was seen, which indicates a target for attention. It also appeared that COVID-19-positive or -suspected patients had more severe neurologic symptoms, whereas their EVT-workflow was not affected.

Value of treatment by comprehensive stroke services for the reduction of critical gaps in acute stroke care in Europe.

Stroke is the second leading cause of death and dependency in Europe and costs the European Union more than €30bn, yet significant gaps in the patient pathway remain and the cost-effectiveness of comprehensive stroke care to meet these needs is unknown. The European Brain Council Value of Treatment Initiative combined patient representatives, stroke experts, neurological societies and literature review to identify unmet needs in the patient pathway according to Rotterdam methodology. The cost-effectiveness of comprehensive stroke services was determined by a Markov model, using UK cost data as an exemplar and efficacy data for prevention of death and dependency from published systematic reviews and trials, expressing effectiveness as quality-adjusted life-years (QALYs). Model outcomes included total costs, total QALYs, incremental costs, incremental QALYs and the incremental cost-effectiveness ratio (ICER). Key unmet needs in the stroke patient pathway included inadequate treatment of atrial fibrillation (AF), access to neurorehabilitation and implementation of comprehensive stroke services. In the Markov model, full implementation of comprehensive stroke services was associated with a 9.8% absolute reduction in risk of death of dependency, at an intervention cost of £9566 versus £6640 for standard care, and long-term care costs of £35 169 per 5.1251 QALYS vs. £32 347.40 per 4.5853 QALYs, resulting in an ICER of £5227.89. Results were robust in one-way and probabilistic sensitivity analyses. Implementation of comprehensive stroke services is a cost-effective approach to meet unmet needs in the stroke patient pathway, to improve acute stroke care and support better treatment of AF and access to neurorehabilitation.

National Trends in Telestroke Utilization in a US Commercial Platform Prior to the COVID-19 Pandemic.

OBJECTIVES: Most data on telestroke utilization come from single academic hub-and-spoke telestroke networks. Our objective was to describe characteristics of telestroke consultations among a national sample of telestroke sites on one of the most commonly used common vendor platforms, prior to the COVID-19 public health emergency. MATERIALS AND METHODS: A commercial telestroke vendor provided data on all telestroke consultations by two specialist provider groups from 2013-2019. Kendall's τ ß nonparametric test was utilized to assess time trends. Generalized linear models were used to assess the association between hospital consult utilization and alteplase use adjusting for hospital characteristics. RESULTS: Among 67,736 telestroke consultations to 132 spoke sites over the study period, most occurred in the emergency department (90%) and for stroke indications (final clinical diagnoses: TIA 13%, ischemic stroke 39%, hemorrhagic stroke 2%, stroke mimics 46%). Stroke severity was low (median NIHSS 2, IQR 0-6). Alteplase was recommended for 23% of ischemic stroke patients. From 2013 to 2019, times from ED arrival to NIHSS, CT scan, imaging review, consult, and alteplase administration all decreased (p<0.05 for all), while times from consult start to alteplase recommendation and bolus increased (p<0.01 for both). Transfer was recommended for 8% of ischemic stroke patients. Number of patients treated with alteplase per hospital increased with increasing number of consults and hospital size and was also associated with US region in unadjusted and adjusted analyses. Longer duration of hospital participation in the network was associated with shorter hospital median door-to-needle time for alteplase delivery (39 min shorter per year, p=0.04). CONCLUSIONS: Among spoke sites using a commercial telestroke platform over a seven-year time horizon, times to consult start and alteplase bolus decreased over time. Similar to academic networks, duration of telestroke participation in this commercial network was associated with faster alteplase delivery, suggesting practice improves performance.

Acute Stroke Care for Patients with Chronic Kidney Disease.

Chronic kidney disease is a common comorbidity in patients presenting to emergency departments with acute ischemic stroke. There are numerous considerations that must be taken into account in the acute diagnosis and management of these patients. CKD patients may have different stroke presentations compared to the general population that may make diagnosis more challenging. With the expanding use of endovascular thrombectomy for acute ischemic stroke, more contrasted studies are being employed as part of the acute evaluation, particularly in the identification of patients with large vessel occlusion and demonstration of salvageable penumbra. For most patients with renal dysfunction, studies such as CT angiography and perfusion may still be performed despite concerns of acute kidney injury. Although patient outcomes with reperfusion therapies such as intravenous alteplase and endovascular thrombectomy are not as robust as those seen within the general population, the available data supports utilization of these therapies among CKD patients. This article provides a review of the factors that must be considered in the acute management of the CKD patient presenting with acute ischemic stroke.

Centralising acute stroke care within clinical practice in the Netherlands: lower bounds of the causal impact.

BACKGROUND: Authors in previous studies demonstrated that centralising acute stroke care is associated with an increased chance of timely Intra-Venous Thrombolysis (IVT) and lower costs compared to care at community hospitals. In this study we estimated the lower bound of the causal impact of centralising IVT on health and cost outcomes within clinical practice in the Northern Netherlands. METHODS: We used observational data from 267 and 780 patients in a centralised and decentralised system, respectively. The original dataset was linked to the hospital information systems. Literature on healthcare costs and Quality of Life (QoL) values up to 3 months post-stroke was searched to complete the input. We used Synthetic Control Methods (SCM) to counter selection bias. Differences in SCM outcomes included 95% Confidence Intervals (CI). To deal with unobserved heterogeneity we focused on recently developed methods to obtain the lower bounds of the causal impact. RESULTS: Using SCM to assess centralising acute stroke 3 months post-stroke revealed healthcare savings of $US 1735 (CI, 505 to 2966) while gaining 0.03 (CI, - 0.01 to 0.73) QoL per patient. The corresponding lower bounds of the causal impact are $US 1581 and 0.01. The dominant effect remained stable in the deterministic sensitivity analyses with $US 1360 (CI, 476 to 2244) as the most conservative estimate. CONCLUSIONS: In this study we showed that a centralised system for acute stroke care appeared both cost-saving and yielded better health outcomes. The results are highly relevant for policy makers, as this is the first study to address the issues of selection and unobserved heterogeneity in the evaluation of centralising acute stroke care, hence presenting causal estimates for budget decisions.

Acute stroke care algorithm in a private tertiary hospital in the Philippines during the COVID-19 pandemic: A third world country experience.

BACKGROUND AND PURPOSE: Since the declaration of the Novel Coronavirus Disease (COVID-19) pandemic, ensuring the safety of our medical team while delivering timely management has been a challenge. Acute stroke patients continue to present to the emergency department and they may not have the usual symptoms of COVID-19 infection. Stroke team response and management must be done within the shortest possible time to minimize worsening of the functional outcome without compromising safety of the medical team. METHODS: Infection control recommendations, emergency department protocols and stroke response pathways utilized prior to the COVID 19 pandemic within our institution were evaluated by our stroke team in collaboration with the multidisciplinary healthcare services. Challenges during the COVID-19 scenario were identified, from which a revised acute stroke care algorithm was formulated to adapt to this pandemic. RESULTS: We formulated an algorithm that incorporates practices from internationally devised protocols while tailoring certain aspects to suit the available resources in our system locally. We highlighted the significance of the following: team role designation, coordination among different subspecialties and departments, proper use of personal protective equipment and resources, and telemedicine use during this pandemic. CONCLUSIONS: This pandemic has shaped the stroke team's approach in the management of acute stroke patients. Our algorithm ensures proper resource management while optimizing acute stroke care during the COVID-19 pandemic in our local setting. This algorithm may be utilized and adapted for local practice and other third world countries who face similar constraints.

The effect of COVID-19 on stroke hospitalizations in New York City.

BACKGROUND: Little is known about the effect of the Coronavirus disease 2019 pandemic on stroke care and the impact of the epidemic on acute stroke hospitalizations has not been described. METHODS: We analyze the stroke admission rate in three hospitals in New York City from January 1, 2020 through April 17, 2020, identifying all cases of acute ischemic stroke, intraparenchymal hemorrhage and subarachnoid hemorrhage. RESULTS: We confirmed 518 cases of out-of-hospital stroke. During the baseline period up to February 25, 2020, the daily stroke admission rate was stable, with the slope of the regression describing the number of admissions over time equal to -0.33 (se = 1.21), not significantly different from 0 (p = 0.79), with daily admissions averaging 41. During the pandemic period, the slope was -4.4 (se = 1.00); i.e., the number of stroke admissions decreased an average of 4.4 per week, (p = 0.005), with weekly admissions averaging 23, a reduction of 44% versus baseline. This general result was not different by patient age, sex, or race/ethnicity. CONCLUSIONS: The weekly stroke admission rate started declining two weeks prior to the local surge of coronavirus admissions. The consequences of lack of diagnosis and treatment of a large proportion of acute stroke patients are likely severe and lasting.

Variability and Delay in Telestroke Physician Alert among Spokes in a Telestroke Network: A Need for Metric Benchmarks.

INTRODUCTION: Telestroke has increased access to acute management of ischemic stroke in areas that lack stroke care expertise, yet delays persist in evaluation and treatment. We describe variation in time to alert a telestroke physician of suspected acute ischemic stroke patients potentially eligible for acute stroke therapies among community hospitals in our telestroke network, and explore demographic and spoke-related characteristics associated with delays. METHODS: From our telestroke registry, we identified suspected acute ischemic stroke patients who arrived within 6 hours of symptom onset and underwent video consultation at 1 of 17 community hospitals in our hub-and-spoke network. We compared time between patient arrival to telestroke alert (door-to-page-time) and to tissue plasminogen activator (tPA) administration for eligible patients (door-to-needle-time). We identified factors associated with prolonged metrics. RESULTS: Of 1020 cases between 9/2015 and 3/2017, 47% received tPA. Sixty percent had door-to-page-time more than 15 minutes (median 19.5; IQR, 11-34). Door-to-page-time more than 15 minutes was associated with an 8-fold increase in likelihood of door-to-needle-time more than 60 minutes. Patients with severe stroke experienced faster door-to-page-times. Hospitals with more beds had prolonged door-to-page-time. Full time in-house neurology presence, even when not covering emergent consultations, was associated with faster door-to-page-time over telestroke. Seventy-one percent of patients underwent CT brain prior to the telestroke physician alert; this scenario delayed door-to-page and door-to-needle times. CONCLUSIONS: Door-to-page-time varied considerably among spokes. Awaiting CT scan prior to alerting the telestroke consultant of a stroke code delayed metrics. Telestroke physician alert standards are needed, as are educational initiatives on acute ischemic stroke management and workflow.

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

OBJECTIVE: The quality of acute stroke care in a regional Victorian hospital (study hospital) was assessed by comparing with selected standard indicators of Acute Stroke Clinical Care. DESIGN: A retrospective review of records of patients with stroke was performed manually and by reviewing electronic database. SETTING: The study was carried out in Goulburn Valley Health, one of the five regional referral and teaching hospitals in Victoria, Australia. PARTICIPANTS: Patients with stroke who were discharged from the study hospital between October 2015 and March 2016. MAIN OUTCOME MEASURES: Timeliness of brain imaging, proportion of patients thrombolysed if arrived within 4.5 hours of stroke and timeliness of thrombolysis. RESULTS: A total of 66 patients' records was found. Brain imaging was completed for 45%, compared to 25.8% nationally, if arrived to the study hospital within 1 hour of stroke and 100% imaging completed within 24 hours of arrival, compared to 75.6% nationally. When patients arrived to the emergency department within 4.5 hours of stroke, 37.5% (23.6% nationally and 18.6% in similar- sized hospitals) of them were thrombolysed, while none was thrombolysed within 60 minutes of arrival. Door-to-thrombolysis time was 85 minutes, 7 minutes longer than national standard. Symptoms onset to thrombolysis time was 225 minutes, 55 minutes longer than national standard. CONCLUSION: The timeliness of brain imaging and thrombolysis was comparable in the study hospital to that of the national standard, while other stroke management indicators still require improvement. Continuing efforts for improvement and revisiting possible areas of delay are warranted.

Novel Telestroke Program Improves Thrombolysis for Acute Stroke Across 21 Hospitals of an Integrated Healthcare System.

BACKGROUND AND PURPOSE: Faster treatment with intravenous alteplase in acute ischemic stroke is associated with better outcomes. Starting in 2015, Kaiser Permanente Northern California redesigned its acute stroke workflow across all 21 Kaiser Permanente Northern California stroke centers to (1) follow a single standardized version of a modified Helsinki model and (2) have all emergency stroke cases managed by a dedicated telestroke neurologist. We examined the effect of Kaiser Permanente Northern California's Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke program on door-to-needle (DTN) time, alteplase use, and symptomatic intracranial hemorrhage rates. METHODS: The program was introduced in a staggered fashion from September 2015 to January 2016. We compared DTN times for a seasonally adjusted 9-month period at each center before implementation to the corresponding 9-month calendar period from the start of implementation. The primary outcome was the DTN time for alteplase administration. Secondary outcomes included rate of alteplase administrations per month, symptomatic intracranial hemorrhage, and disposition at time of discharge. RESULTS: This study included 310 patients treated with alteplase in the pre-EXpediting the PRrocess of Evaluating and Stopping Stroke period and 557 patients treated with alteplase in the EXpediting the PRrocess of Evaluating and Stopping Stroke period. After implementation, alteplase administrations increased to 62/mo from 34/mo at baseline (P<0.001). Median DTN time decreased to 34 minutes after implementation from 53.5 minutes prior (P<0.001), and DTN time of <60 minutes was achieved in 87.1% versus 61.0% (P<0.001) of patients. DTN times <30 minutes were much more common in the Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke period (40.8% versus 4.2% before implementation). There was no significant difference in symptomatic intracranial hemorrhage rates in the 2 periods (3.8% versus 2.2% before implementation; P=0.29). CONCLUSIONS: Introduction of a standardized modified Helsinki protocol across 21 hospitals using telestroke management was associated with increased alteplase administrations, significantly shorter DTN times, and no increase in adverse outcomes.

Infections Diagnosed after Admission to a Stroke Unit and Their Impact on Hospital Mortality in Poland from 1995 to 2015.

BACKGROUND: Implementation of modern stroke unit care might have attenuated the negative effect of infections on stroke outcome. Our aim was to investigate changes in the occurrence of pneumonia and urinary infections diagnosed after admission to experienced Polish stroke center between 1995 and 2015, and their association with hospital mortality. MATERIALS AND METHODS: This is a retrospective registry-based analysis of consecutive patients with acute stroke from highly urbanized area (Warsaw, Poland) in years 1995-2015. A total of 5174 patients were divided to 4 time periods: 1995-2000 (n = 883), 2001-2006 (n = 1567), 2006-2010 (n = 1539), and 2011-2015 (n = 1183). Odds ratios (ORs) for hospital death were calculated after adjustment for age, congestive heart failure, preexisting disability, stroke type, and baseline neurological deficit, separately in years 1995-2015, 1995-2000, and 2011-2015. RESULTS: Over time there was a significant decrease in the proportion of patients diagnosed with pneumonia (20%, 19%, 9%, and 15%, respectively) or urinary tract infection (29%, 21%, 24%, and 18%, respectively) and in the proportion of patients having body temperature of 38.0°C or higher at least once within first 7 days of hospital stay (20%, 20%, 13%, and 13%, respectively), without significant change in the use of antibiotics (range 35%-37%). Hospital mortality was strongly predicted by pneumonia (OR 3.6-4.2) and fever (OR 2.7-4.7) but not urinary infections. CONCLUSIONS: Over the last 2 decades there was a decrease in the proportion of patients with acute stroke diagnosed with pneumonia or urinary tract infection during stroke unit stay. Hospital death was strongly predicted by pneumonia and fever but no by urinary infections.

Testing a systematic approach to identify and prioritise barriers to successful implementation of a complex healthcare intervention.

BACKGROUND: Multiple barriers may inhibit the adoption of clinical interventions and impede successful implementation. Use of standardised methods to prioritise barriers to target when selecting implementation interventions is an understudied area of implementation research. The aim of this study was to describe a method to identify and prioritise barriers to the implementation of clinical practice elements which were used to inform the development of the T3 trial implementation intervention (Triage, Treatment [thrombolysis administration; monitoring and management of temperature, blood glucose levels, and swallowing difficulties] and Transfer of stroke patients from Emergency Departments [ED]). METHODS: A survey was developed based on a literature review and data from a complementary trial to identify the commonly reported barriers for the nine T3 clinical care elements. This was administered via a web-based questionnaire to a purposive sample of Australian multidisciplinary clinicians and managers in acute stroke care. The questionnaire addressed barriers to each of the nine T3 trial clinical care elements. Participants produced two ranked lists: on their perception of: firstly, how influential each barrier was in preventing clinicians from performing the clinical care element (influence attribute); and secondly how difficult the barrier was to overcome (difficulty attribute). The rankings for both influence and difficulty were combined to classify the barriers according to three categories ('least desirable', desirable' or 'most desirable' to target) to assist interpretation. RESULTS: All invited participants completed the survey; (n = 17; 35% medical, 35% nursing, 18% speech pathology, 12% bed managers). The barriers classified as most desirable to target and overcome were a 'lack of protocols for the management of fever' and 'not enough blood glucose monitoring machines'. CONCLUSIONS: A structured decision-support procedure has been illustrated and successfully applied to identify and prioritise barriers to target within an implementation intervention. This approach may prove to be a useful in other studies and as an adjunct to undertaking barrier assessments within individual sites when planning implementation interventions.

On- versus Off-Hour Patient Cohorts at a Primary Stroke Center: Onset-to-Treatment Duration and Clinical Outcomes after IV Thrombolysis.

BACKGROUND: The symptom onset-to-treatment (OTT) duration predicts symptomatic intracerebral hemorrhage (sICH) and adverse outcomes after ischemic stroke. Previous studies found disparities in OTT durations and clinical outcomes between stroke patients with symptom onset during on-hours versus off-hours, which led to the initiation of nationwide efforts to provide consistent 24-hour stroke care. GOAL: Our objective is to compare OTT durations and clinical outcomes in ischemic stroke patients whose symptoms originated during on- versus off-hours at a primary stroke center. METHODS: We analyzed clinical data from 210 consecutive patients receiving intravenous recombinant tissue plasminogen activator therapy between January 2009 and December 2013 at Yale-New Haven Stroke Center, a primary stroke center. Stroke severity was assessed by baseline National Institutes of Health Stroke Scale (NIHSS) scores. Clinical outcomes were assessed by presence of sICH and by stroke-related fatalities. OTT durations and clinical outcomes were compared using Mann-Whitney tests, 2-sample tests of proportions, and 2-sample t-tests after testing for equal variance. FINDINGS: We found no significant differences in OTT durations between on-hour and off-hour patient cohorts (137 minutes versus 145 minutes, P = .53). There were also no differences in stroke severity (mean NIHSS score 12.4 versus 11.3, P = .27), sICH rates (4.6% versus 6.5%, P = .56), or stroke fatality rates (9.2% versus 9.8%, P = .89) between the 2 cohorts. CONCLUSIONS: Our results represent progress in emergency response and acute stroke care, and reinforce ongoing nationwide efforts to increase stroke awareness and provide consistent quality care for patients with acute stroke.

Telephone audit for monitoring stroke unit facilities: a post hoc analysis from PROSIT study.

BACKGROUND: Although several valid approaches exist to measure the number and the quality of acute stroke units, only few studies tested their reliability. This study is aimed at establishing whether the telephone administration of the PROject of Stroke unIt ITaly (PROSIT) audit questionnaire is reliable compared with direct face-to-face interview. METHODS: Forty-three medical leaders in charge of in-hospital stroke services were interviewed twice using the same PROSIT questionnaire with 2 different modalities. First, the interviewers approached the medical leaders by telephone. Thereafter, they went to the hospital site and performed a direct face-to-face interview. Six independent couples of trained researchers conducted the audit interviews. The degree of intermodality agreement was measured with kappa statistic. RESULTS: We found a perfect agreement for stroke units identification between the 2 different audit modalities (K = 1.00; standard error [SE], 1.525). The agreement was also very good for stroke dedicated beds (K = 1.00; SE, 1.525) and dedicated personnel (K = 1.00; SE, 1.525), which are the 2 components of stroke unit definition. The agreement was lower for declared in use process of care and availability of diagnostic investigations. CONCLUSIONS: The telephone audit can be used for monitoring stroke unit structures. It is more rapid, less expensive, and can repeatedly be used at appropriate intervals. However, a reliable description of the process of care and diagnostic investigations indicators should be obtained by either local site audit visit or prospective stroke register based on individual patient data.

Prehospital Stroke Identification: Factors Associated with Diagnostic Accuracy.

BACKGROUND: Stroke patients misdiagnosed by emergency medical services (EMS) providers have been shown to receive delayed in-hospital care. We aim at determining the diagnostic accuracy of Fire Department of New York (FDNY) EMS providers for stroke and identifying potential reasons for misdiagnosis. METHODS: Prehospital care reports of all patients transported by FDNY EMS to 3 hospitals from January 1, 2010, to December 31, 2011, were compared against the American Heart Association Get With The Guidelines (GWTG) database (reference standard) for the diagnosis of stroke. Age-adjusted logistic regression models were generated to explore prehospital patient characteristics which are associated with stroke misdiagnosis. RESULTS: Of 72,984 patient transports during the study period, 750 had a GWTG diagnosis of stroke, 468 (62%) of which were identified correctly in the field and 282 (38%) were missed. An additional 268 patients were misdiagnosed as stroke when in fact they had an alternative diagnosis. Overall sensitivity was 62.4% (95% confidence interval [CI], 58.9-65.8) and specificity was 99.6% (95% CI, 99.6-99.7). No patients who presented with unilateral weakness, facial weakness, or speech problems were missed, whereas patients with atypical complaints like general malaise, dizziness, and headache were more likely to be missed. Seizures led the EMS providers to both overcall a stroke and miss the diagnosis. CONCLUSIONS: FDNY EMS care providers missed more than a third of stroke cases. Seizures and other atypical presentations contribute significantly to stroke misdiagnosis in the field. Our findings highlight the need for better prehospital stroke identification methods.

Stroke units in Italy: engaging the public in optimizing existing resources.

BACKGROUND AND PURPOSE: The lack of a wide implementation of stroke units (SU)s in Italy appears to accompany the underuse of the operating units. Community awareness of acute stroke care options may affect stroke resource use. Our aim was to determine the level of knowledge about SUs and tissue-plasminogen activator (t-PA) treatment amongst Italian adults and investigate its relationship to local stroke services implementation. METHODS: A nation-based telephone survey was carried out in a sample of 1000 residents aged >18 years in May-June 2010. The questionnaire included close-ended questions regarding knowledge of SUs and t-PA treatment. Number and location of both SUs and t-PA treatments were provided by a concurrent national hospital-based survey. The prevalence and distribution of acute stroke care awareness in the community was examined and multivariate analyses were generated. RESULTS: Amongst the 1000 participants (474 men, mean age 48.8 ± 17.2), only 26.2% reported knowing about the availability of t-PA treatment and only 15% were aware of the existence of SUs. Awareness of both SUs and t-PA was significantly associated only with education. These associations remained significant in the multivariate analyses. The degree of stroke services implementation (in terms of SUs/inhabitant rates and number of t-PA treatments) was not associated with SU and t-PA awareness. CONCLUSIONS: This is the first European study that explored public knowledge about t-PA treatment and SUs. Italian adults proved insufficiently educated about SUs and t-PA; there is no higher awareness in areas with a greater supply of stroke services. This might partially explain the underuse of Italian SUs.

Quality of acute ischemic stroke care in Thailand: a prospective multicenter countrywide cohort study.

BACKGROUND: Data concerning quality of acute stroke care and outcome are scarce in developing countries. OBJECTIVE: This study aimed to evaluate quality of acute stroke care and stroke outcomes in Thailand. METHODS: We performed a multicenter countrywide prospective cohort study. Consecutive patients with an acute ischemic stroke admitted to the participating institutions between June 2008 and November 2010 were included. Baseline characteristics, process measures including thrombolysis use, acute stroke unit admission, initiation of aspirin within 48 hours, and antithrombotic and/or anticoagulation medication at discharge were recorded. Main outcome measures were death and disability at discharge as well as in-hospital complications. RESULTS: A total of 1222 patients were included with a mean (±SD) age of 65.0 ± 13 years, and 55.0% were men. Median National Institutes of Health Stroke Scale score was 6.5. Patients were given aspirin within 48 hours, admitted to acute stroke unit, and given thrombolytic therapy in 71.1%, 24.6%, and 3.8%, respectively. Good recovery at discharge (modified Rankin scale score 0-1) was found in 26.1%, and 3.2% of patients died during hospitalization. The median length of stay was 4 days. Factors predicting poor outcome (modified Rankin scale score 5-6) at discharge included: age (by 10-year increments: adjusted odds ratio [OR] 1.23; 95% confidence interval [CI], 1.06-1.43), female sex (adjusted OR 1.52; 95% CI, 1.05-2.19), initial National Institutes of Health Stroke Scale score (adjusted OR 1.35; 95% CI, 1.27-1.43), and in-hospital complications (adjusted OR 3.16; 95% CI, 1.58-6.35). CONCLUSIONS: Limited access to acute ischemic stroke care interventions were observed in many domains especially thrombolysis and stroke unit admission. These findings emphasize an urgent need for strategies to improve standard acute stroke care among developing countries.

The Role of the Vascular Neurologist in Optimizing Stroke Care.

The article summarizes the training pathways and vocational opportunities within the field of vascular neurology. It highlights the groundbreaking clinical trials that transformed acute stroke care and the resultant increased demand for readily available vascular neurology expertise. The article emphasizes the need to train a larger number of diverse physicians in the subspecialty and the role of vascular neurologists in improving outcomes across demographic and geographic lines.