Description of a novel telemedicine-enabled comprehensive system of care: drip and ship plus drip and keep within a system of stroke care delivery.

United States (US) and worldwide telestroke programs frequently focus only on emergency room hyper-acute stroke management. This article describes a comprehensive, telemedicine-enabled, stroke care delivery system that combines "drip and ship" and "drip and keep" models with a comprehensive stroke center primary hub at Ochsner Medical Center in New Orleans, advanced stroke-capable regional hubs, and geographically-aligned, "stroke-ready" spokes. The primary hub provides vascular neurology expertise via telemedicine and monitors care for patients remaining at regional hubs and spokes using a multidisciplinary team approach. By 2014, primary hub telestroke consults grew to ≈1000/year with 16 min average door to consult initiation and 20 min to completion, and 29% of ischemic stroke patients received recombinant tissue-type plasminogen activator (rtPA), increasing 275%. Most patients remained in hospitals close to home, but neurointensive care and interventional procedures were common reasons for primary hub transfer. Given the time sensitivity and expert consultation needed for complex acute stroke care delivery paradigms, telestroke programs are effective for fulfilling unmet care needs. Combining drip and ship and drip and keep management allows more patients to stay "local," limiting primary hub transfer unless more advanced services are required. Post admission telestroke management at spokes increases personnel efficiency and can positively impact stroke outcomes.

The Penumbra 5MAX ACE Catheter Is Safe, Efficient, and Cost Saving as a Primary Mechanical Thrombectomy Device for Large Vessel Occlusions in Acute Ischemic Stroke.

BACKGROUND: Reperfusion of large vessel occlusions in acute stroke can improve patient outcomes. The purposes of this study were to assess the safety and efficacy of the Penumbra 5MAX ACE catheter for revascularization of large vessels and to compare its cost to the cost of stent retrievers. METHODS: In this retrospective, single-center case review study, data were captured on consecutive patients treated with the Penumbra 5MAX ACE as first-line therapy during an 11-month period. Good functional outcome was defined as a modified Rankin Scale score of ≤2 at discharge. Results were directly compared with previously published data for stent retrievers, and length of stay was analyzed in relation to revascularization. RESULTS: The 31 patients studied had a mean age of 66.3 ± 17.8 years and a mean National Institutes of Health Stroke Scale score of 19.4 ± 5.7. Intravenous tissue recombinant plasminogen activator therapy was initiated in 35.5% (11/31) of patients. A Thrombolysis in Cerebral Infarction (TICI) grade of 2b-3 reperfusion after endovascular therapy was achieved in 26/31 (83.9%) of cases; TICI grade 3 was achieved in 19/31 (61.3%) patients. The average time from groin puncture to TICI grade 2b-3 reperfusion was 40 minutes. The average estimated cost for aspiration with the 5MAX ACE alone was $4,916 per case compared with an estimated cost of $9,620 if a stent retriever was used as the primary device. Our actual average cost per case, including all adjunctive devices used in the neurointerventional procedure, was $6,997. Good functional outcome was achieved in 19/31 (61.3%) patients. Two patients experienced symptomatic intracerebral hemorrhage (6.5%), and 1 (3.2%) patient died. The length of stay was significantly shorter among patients with TICI grade 2b-3 reperfusion compared to patients with TICI grade <2 (6.8 ± 5.34 days vs 15.8 ± 11.32 days, respectively; P<0.05). CONCLUSION: These findings suggest that direct aspiration with the large-bore 5MAX ACE catheter can be considered a first-line approach to mechanical thrombectomy for large vessel occlusions. Our results demonstrated high rates of successful reperfusion in a timely manner with excellent clinical outcomes, although our sample size was small. In addition, this direct-aspiration technique has important cost-savings potential compared to stent retrievers.

Clinical Outcomes among Transferred Children with Ischemic and Hemorrhagic Strokes in the Nationwide Inpatient Sample.

INTRODUCTION: Children with ischemic stroke (IS) and hemorrhagic stroke (HS) may require interfacility transfer for higher level of care. We compared the characteristics and clinical outcomes of transferred and nontransferred children with IS and HS. METHODS: Children aged 1-18 years admitted to hospitals in the United States from 2008 to 2011 with a primary discharge diagnosis of IS and HS were identified from the National Inpatient Sample database by ICD-9 codes. Using logistic regression, we estimated the odds ratios (OR) and 95% confidence intervals (CI) for in-hospital mortality and discharge to nursing facilities (versus discharge home) between transferred and nontransferred patients. RESULTS: Of the 2815 children with IS, 26.7% were transferred. In-hospital mortality and discharge to nursing facilities were not different between transferred and nontransferred children in univariable analysis or in multivariable analysis that adjusted for age, sex, and confounding factors. Of the 6879 children with HS, 27.1% were transferred. Transferred compared to nontransferred children had higher rates of both in-hospital mortality (8% versus 4%, P = .003) and discharge to nursing facilities (25% versus 20%, P = .03). After adjusting for age, sex, and confounding factors, in-hospital mortality (OR 1.5, 95% CI 1.1-2.4, P = .04) remained higher in transferred children, whereas discharge to nursing facilities was not different between the groups. CONCLUSION: HS but not IS was associated with worse outcomes for children transferred to another hospital compared to children who were not transferred. Additional study is needed to understand what factors may contribute to poorer outcomes among transferred children with HS.

Outcomes of transient ischemic attack in maintenance dialysis patients and those with chronic kidney disease.

BACKGROUND: In-hospital outcomes of transient ischemic attack (TIA) in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) requiring maintenance dialysis are largely unknown. We evaluated TIA-related in-hospital outcomes in these patients using a national database. METHODS: Our study is observational in nature. Data from all adult (≥ 18 years) patients admitted to US hospitals between 2005 and 2011 with a primary discharge diagnosis of TIA and secondary diagnosis of CKD and ESRD were included using the Nationwide In-Patient Sample. We aimed to compare the following TIA-related outcomes between CKD and ESRD patients: (i) degree of disability (mainly functional status) derived from discharge destination, (ii) length of stay, (iii) charges of hospitalization, and (iv) mortality. The comparisons of TIA-related mortality and discharge outcomes between CKD and ESRD were analyzed after adjusting for potential confounders using logistic regression analysis. We adjusted for age, sex, co-morbidities, hospital size and hospital teaching status. RESULTS: A total of 18 316 dialysis and 67 256 CKD patients were admitted with TIA in the study period (2005-11). On univariate analysis, there was no difference in the rates of moderate-to-severe disability (20.5% versus 20.2%, P = 0.7) and in-hospital mortality (0.4% versus 0.2%, P = 0.07) in ESRD patients compared with those with CKD. After adjusting for age, sex and potential confounders, ESRD patients with TIA had higher odds of moderate-to-severe disability at discharge [odds ratio (OR): 1.53, 95% confidence interval (CI): 1.37-1.71, P ≤ 0.0001] and in-hospital death (OR: 2.87, 95% CI: 1.29-6.37, P = 0.009). CONCLUSION: ESRD patients with TIA have significantly higher rates of moderate-to-severe disability at discharge and in-hospital mortality when compared with the patients of other stages of CKD who are not dialysis-dependent.

Acute renal failure is associated with higher death and disability in patients with acute ischemic stroke: analysis of nationwide inpatient sample.

BACKGROUND AND PURPOSE: Acute renal failure (ARF) in setting of acute ischemic stroke (AIS) is associated with worse outcome. We sought to determine the prevalence of ARF and effect on outcomes of patients with AIS. METHODS: Data from all patients admitted to US hospitals between 2002 and 2010 with a primary discharge diagnosis of ischemic stroke and secondary diagnosis of ARF were included. The effect of ARF on rates of intracerebral hemorrhage and discharge outcomes was analyzed after adjusting for potential confounders using logistic regression analysis. RESULTS: Of 7,068,334 patients with AIS, 372,223 (5.3%) had ARF during hospitalization. Dialysis was required in 2364 (0.6%) of 372,223 patients. Patients with AIS with ARF had higher rates of moderate to severe disability (41.3% versus 30%; P<0.0001), intracerebral hemorrhage (1.0% versus 0.5%; P<0.0001), and in-hospital mortality (8.4% versus 2.9%; P<0.0001) compared with those without ARF. After adjusting for confounding factors, patients with AIS with ARF had higher odds of moderate to severe disability (odds ratio, 1.3; 95% confidence interval, 1.3-1.4; P<0.0001), intracerebral hemorrhage (odds ratio, 1.4; 95% confidence interval, 1.3-1.6; P<0.0001), and death (odds ratio, 2.2; 95% confidence interval, 2.0-2.2; P<0.0001). CONCLUSIONS: ARF in patients with AIS is associated with significantly higher rates of moderate to severe disability at discharge and in-hospital mortality.