Initial testing of an electronic application of the simplified modified Rankin Scale questionnaire (e-smRSq).

INTRODUCTION AND PURPOSE: To facilitate modified Rankin scale (mRS) assessments, we developed and tested a smartphone/web application of the simplified mRS questionnaire (e-smRSq). The e-smRSq guides raters towards a final score according to the smRSq algorithm, and offers hints for scoring based on the conventional mRS concepts. METHODS: Initially, three experienced mRS certified raters prepared 30 vignettes of unstructured stroke patient interviews, and determined consensus reference scores. Using the e-smRSq, 16 raters of varied professional backgrounds without mRS training scored the mRS for 24 randomly selected vignettes. Subsequently, 5 certified and 5 uncertified raters using the e-smRSq scored 23 mRS certification vignettes developed and used in the Strategies to Innovate Emergency Care Clinical Trials Network-Neurological Emergencies Treatment Trials (SIREN-NETT). Cohen's and Fleiss's kappa (κ), weighted kappa (κw), and intra-class correlation (ICC) compared rater scores with reference scores and assessed interrater reliability. RESULTS: For the 16 initial raters using the e-smRSq with 24 vignettes, the κ (Fleiss) was 0.62 and ICC 0.87 (CI 0.80-0.93). Comparing raters' scores with reference scores, Cohen's κ was 0.68 and κw 0.90. For the 10 subsequent raters using the e-smRSq on SIREN-NETT vignettes, κ (Fleiss) was 0.8 and ICC 0.95 (CI 0.91-0.97). Comparing all 10 raters scores with SIREN-NETT reference scores, Cohen's κ was 0.88 and κw 0.97. There was no significant difference between certified and uncertified raters. CONCLUSIONS: The e-smRSq appears to have good reproducibility and validity metrics among both certified and non-certified mRS raters, possibly owing to its simplicity. Further testing in stroke patients in warranted.

Mechanical thrombectomy in stroke - planning for service expansion using discrete event simulation.

Mechanical thrombectomy (MT) is a very effective, but highly time dependent, reperfusion technique in the management of acute ischaemic stroke caused by large artery occlusion. MT is provided by 24 neuroscience centres (NSCs) in the UK which receive patients directly ('mothership') and via transfer from district general hospitals (DGHs), the 'drip and ship' pathway. NSCs currently provide a within hours service but are working on service expansion to enable 24/7 availability. DGHs, too, will need to prepare for this service expansion to ensure good outcomes for their patients. We discuss options for service expansion in a DGH and regional stroke network in south-west England and use Sentinel Stroke National Audit Programme data and discrete event simulation to model and compare alternative workflow options to aid the planning process. We suggest that our modelled options could be considered by all NHS DGHs in their preparation for MT service expansion.

Evaluation of a single centre stroke service reconfiguration - the impact of transition from a combined (acute and rehabilitation) stroke unit to a hyperacute model of stroke care.

We reorganised the combined (acute and rehab) stroke unit (SU) at Gloucestershire Royal Hospital into a hyperacute stroke unit (HASU) and a rehab SU where patients are moved after spending about 72 hours on HASU. Continuous monitoring of physiological variables was introduced and consultant job plans were reorganised to provide a HASU physician of the week model with enhanced 7-day senior presence along with redistribution of junior medical staff. Sentinel Stroke National Audit Programme (SSNAP) data for 14 months preceding the reorganisation (n=1,049) and 14 months after (n=974) were accessed for outcomes. More patients were admitted directly to the HASU with favourable reductions in time to computerised tomography scanning and stroke consultant assessment after the change. There were significant reductions in length of stay, pneumonia and urinary tract infections at 7 days and a favourable shift in modified Rankin scores (odds ratio 1.60, 95% confidence interval 1.36-1.89, p<0.001) on discharge from hospital.