Exploring the Inclusion of Person-Centered Care Domains in Stroke Transitions of Care Interventions: A Scientific Statement From the American Heart Association.

BACKGROUND: Health care teams along the stroke recovery continuum have a responsibility to support care transitions and return to the community. Ideally, individualized care will consider patient and family preferences, best available evidence, and health care professional input. Person-centered care can improve patient-practitioner interactions through shared decision-making in which health professionals and institutions are sensitive to those for whom they provide care. However, it is unclear how the concepts of person-centered care have been described in reports of stroke transitional care interventions. METHODS: A secondary analysis of a systematic review and meta-analysis was undertaken. We retrieved all included articles (n=17) and evaluated the extent to which each intervention explicitly addressed 7 domains of person-centered care: alignment of care with patients' values, preferences, and needs; coordination of care; information and education; physical comfort; emotional support; family and friend involvement; and smooth transition and continuity of care. RESULTS: Most of the articles included some aspects of person-centeredness; we found that certain domains were not addressed in the descriptions of transitional care interventions, and no articles mentioned all 7 domains of person-centered care. We identified 3 implications for practice and research: (1) delineating person-centered care components when reporting interventions, (2) elucidating social and cultural factors relevant to the study sample and intervention, and (3) clearly describing the role of family and nonmedical support in the intervention. CONCLUSIONS: There is still room for greater consistency in the reporting of person-centeredness in stroke transitions of care interventions, despite a long-standing definition and conceptualization of person-centered care in academic and clinically focused literature.

Ideal Foundational Requirements for Stroke Program Development and Growth: A Scientific Statement From the American Heart Association.

Stroke center certification has evolved at a rapid pace and is now available at 4 different levels of service in the United States. Although certification standards provide guidance on stroke center process elements, lack of guidance on structural components such as workforce, staffing, and unit operations has resulted in heterogeneous services among hospitals credentialed at the same stroke center level. Such heterogeneity challenges public expectations and transparency about actual service capabilities within American stroke centers and in some cases may foster leniency in credentialing agency certification methods. Standards for other time-dependent diagnoses, including trauma, provide detailed guidance on structural elements that has improved patient triage and resuscitative care while enabling practitioners and administrators to more accurately gauge and plan service development to better support their communities. This scientific statement aims to provide similar structural guidance defined by each level of hospital stroke center services to reduce operational inconsistencies, to foster planning for service development, and to improve the interprofessional care of patients with acute stroke.

Pennsylvania comprehensive stroke center collaborative: Statement on the recently updated IV rt-PA prescriber information for acute ischemic stroke.

OBJECTIVE: Recently, the FDA guidelines regarding the eligibility of patients with acute ischemic stroke to receive IV rt-PA have been modified and are not in complete accord with the latest AHA/ASA guidelines. The resultant differences may result in discrepancies in patient selection for intravenous thrombolysis. METHODS: Several comprehensive stroke centers in the state of Pennsylvania have undertaken a collaborative effort to clarify and unify our own recommendations regarding how to reconcile these different guidelines. RESULTS: Seizure at onset of stroke, small previous strokes that are subacute or chronic, multilobar infarct involving more than one third of the middle cerebral artery territory on CT scan, hypoglycemia, minor or rapidly improving symptoms should not be considered as contraindications for intravenous thrombolysis. It is recommended to follow the AHA/ASA guidelines regarding blood pressure management and bleeding diathesis. Patients receiving factor Xa inhibitors and direct thrombin inhibitors within the preceding 48 h should be excluded from receiving IV rt-PA. CT angiography is effective in identifying candidates for endovascular therapy. Consultation with and/or transfer to a comprehensive stroke center should be an option where indicated. Patients should receive IV rt-PA up to 4.5h after the onset of stroke. CONCLUSIONS: The process of identifying patients who will benefit the most from IV rt-PA is still evolving. Considering the rapidity with which patients need to be evaluated and treated, it remains imperative that systems of care adopt protocols to quickly gather the necessary data and have access to expert consultation as necessary to facilitate best practices.

Caring for Patients Treated With Therapeutic Hypothermia.

Numerous studies have indicated that therapeutic hypothermia can improve neurological outcomes after cardiac arrest. This treatment has redefined care after resuscitation and offers an aggressive intervention that may mitigate postresuscitation syndrome. Caregivers at Lehigh Valley Health Network, Allentown, Pennsylvania, an academic, community Magnet hospital, treated more than 200 patients with therapeutic hypothermia during an 8-year period. An interprofessional team within the hospital developed, implemented, and refined a clinical practice guideline for therapeutic hypothermia. In their experience, beyond a protocol, 5 critical elements of success (interprofessional stakeholders, coordination of care delivery, education, interprofessional case analysis, and participation in a global database) enhanced translation into clinical practice.

Therapeutic medical hypothermia--a multispecialty approach.

Cardiac arrest remains one of the most common causes of death in developed countries. Those who survive may have significant neurologic morbidity. In the current decade, therapeutic medical hypothermia (TMH) has emerged as the only treatment that unequivocally improves neurologic outcomes in post ventricular fibrillation / ventricular tachycardia induced cardiac arrest. The role of TMH in other forms of cardiac arrest continues to evolve. We present the current status of medical hypothermia, recent patents and recent advances of this evolving therapy.

Strokes after cardiac surgery and relationship to carotid stenosis.

OBJECTIVE: To critically examine the role of significant carotid stenosis in the pathogenesis of postoperative stroke following cardiac operations. DESIGN: Retrospective cohort study. SETTING: Single tertiary care hospital. PARTICIPANTS: A total of 4335 patients undergoing coronary artery bypass grafting, aortic valve replacement, or both. MAIN OUTCOME MEASURES: Incidence, subtype, and arterial distribution of stroke. RESULTS: Clinically definite stroke was detected in 1.8% of patients undergoing cardiac operations during the same admission. Only 5.3% of these strokes were of the large-vessel type, and most strokes (76.3%) occurred without significant carotid stenosis. In 60.0% of cases, strokes identified via computed tomographic head scans were not confined to a single carotid artery territory. According to clinical data, in 94.7% of patients, stroke occurred without direct correlation to significant carotid stenosis. Undergoing combined carotid and cardiac operations increases the risk of postoperative stroke compared with patients with a similar degree of carotid stenosis but who underwent cardiac surgery alone (15.1% vs 0%; P = .004). CONCLUSIONS: There is no direct causal relationship between significant carotid stenosis and postoperative stroke in patients undergoing cardiac operations. Combining carotid and cardiac procedures is neither necessary nor effective in reducing postoperative stroke in patients with asymptomatic carotid stenosis.

Predicting mortality after intracerebral hemorrhage: comparison of scoring systems and influence of withdrawal of care.

OBJECTIVE: The Broderick system and the intracerebral hemorrhage (ICH) score are two systems for predicting 30-day mortality in patients with spontaneous ICH. No previous study has compared two ICH scoring systems in an independent patient cohort. Our purpose was to externally validate and directly compare these two systems and evaluate the effect of withdrawal of care on system performance. METHODS: In all, 307 consecutive patients admitted with ICH between 1998 and 2002 were evaluated. Broderick exclusion criteria were used, resulting in a cohort of 241 patients. Admission Glasgow Coma Scale score, ICH volume, 30-day mortality, and day-30 location were collected. The sensitivity, specificity, receiver operator characteristic curves, and model explained variance (R2) of the two systems were directly compared. The statistical performances of both systems were then compared in subsets that included or excluded patients from whom care was withdrawn. RESULTS: Overall mortality was 76 of 241 (31.5%). The ICH score had significantly higher sensitivity (66% v 45%, P = .001) and higher receiver operator characteristic curves (0.814 v 0.773, P < .001) for predicting 30-day mortality. The model R2 and specificity were not significantly different between systems. Both systems were significantly associated with 30-day location stratified as home, acute rehabilitation, skilled nursing facility, or death (ICH score Chi square = 79.28, P < .001; Broderick Chi square = 60.63, P < .001). Inclusion or exclusion of patients who had supportive care withdrawn did not significantly affect overall statistical performance. CONCLUSIONS: The ICH score performed significantly better than the Broderick system. Overall statistical performance of both systems was not influenced by withdrawal of care.