Using body cameras to quantify the duration of a Code Stroke and identify workflow issues: a continuous observation workflow time study.

OBJECTIVE: 'Code Stroke' (Code) is used in health services to streamline hyperacute assessment and treatment delivery for patients with ischaemic stroke. However, there are few studies that detail the time spent on individual components performed during a Code. We sought to quantify the time taken for each process during a Code and investigate associations with modifiable and non-modifiable factors. DESIGN: Continuous observation workflow time study. SETTING AND PARTICIPANTS: Recordings of 100 Codes were performed at a high-volume primary stroke centre in Melbourne, Australia, between January and June 2020 using a body camera worn by a member of the stroke team. MAIN OUTCOME MEASURES: The main measures included the overall duration of Codes and the individual processes within the Code workflow. Associations between variables of interest and process times were explored using linear regression models. RESULTS: 100 Codes were captured, representing 19.2% of all Codes over the 6 months. The median duration of a complete Code was 54.2 min (IQR 39.1-74.7). Administrative work performed after treatment is completed (median 21.0 min (IQR 9.8-31.4)); multimodal CT imaging (median 13.0 min (IQR 11.5-15.7)), and time between decision and thrombolysis administration (median 8.1 min (IQR 6.1-10.8)) were the longest components of a Code. Tenecteplase was able to be prepared faster than alteplase (median 1.8 vs 4.9 min, p=0.02). The presence of a second junior doctor was associated with shorter administrative work time (median 10.3 vs 25.1 min, p<0.01). No specific modifiable factors were found to be associated with shorter overall Code duration. CONCLUSIONS: Codes are time intensive. Time spent on decision-making was a relatively small component of the overall Code duration. Data from body cameras can provide granular data on all aspects of Code workflow to inform potential areas for improvement at individual centres.

Practical utility of the ACT-FAST triage algorithm from a primary stroke centre perspective.

BACKGROUND: Rapid reperfusion in ischaemic stroke with emergent large vessel occlusion (ELVO) reduces morbidity and mortality. Limited distribution of endovascular clot retrieval (ECR) capable comprehensive stroke centres (CSCs) necessitates development of pre-hospital models of care to provide equitable and economical access to reperfusion therapy. We examine the time metrics of the traditional secondary transfer strategy in comparison to the direct bypass strategy and the potential utility of the ACT-FAST prehospital triage algorithm on a large volume Melbourne primary stroke centre (PSC). METHOD: Retrospective analysis of consecutive patients presenting to a PSC from 1 January 2020 to 31 December 2020. Clinical records were interrogated for ACT-FAST positive patients. Time metrics were established using Google Maps traffic modelling and local/published door-to-needle, door-in-door out and door-to-groin data. RESULTS: 88 patients during the study period were ACT-FAST positive. Of these, 49/88 (56%) cases had ELVO ischaemic strokes, 24/88 (27%) cases had intracranial haemorrhages and the remaining 15/88 (17%) had non ELVO ischaemic strokes or mimics (seizure, complex migraine, etc). 28/88 (32%) cases met indication for and were subsequently transferred to a CSC for consideration of ECR. The modelled median scene to groin time for the direct bypass strategy is 94 min whereas the median scene to groin time for the secondary transfer strategy is 109 min, giving a difference of 15 min. CONCLUSION: Time savings to groin puncture for the direct bypass strategy is substantially less than previous estimates and suggests that the secondary transfer strategy continues to be a viable pathway for a high efficiency PSC.

Trends in direct oral anticoagulant use in patients presenting with acute stroke.

Acute ischaemic strokes occur despite the use of direct oral anticoagulants (DOACs). A retrospective review was conducted at a high-volume primary stroke centre over a 3-year period to assess the acute management of stroke presentations in patients prescribed DOACs. During the time period of the study, 103 of 195 anticoagulated stroke patients presented within the timeframe for thrombolysis and only 15 patients had DOAC plasma level assays performed. Of these 103, 5 received thrombolysis; however, DOAC level was not a factor in these cases.

The quest to reduce stroke treatment delays at a Melbourne metropolitan primary stroke centre over the past two decades.

BACKGROUND: Reducing door-to-needle time (DNT) for intravenous thrombolysis in acute ischaemic stroke can lead to improved patient outcomes. Long-term reports on DNT trends in Australia are lacking in the setting of extension of the thrombolysis time window, addition of mechanical thrombectomy and increasing presentations. AIMS: To examine 17-year trends of DNT and identify factors associated with improved DNT at a high-volume, metropolitan primary stroke centre. METHOD: Retrospective study between 2003 and 2019 of all thrombolysis cases using departmental stroke database. Since most strategies were implemented from 2012 onwards, intervention period has been defined as period 2012-2019. Factors associated with DNT reduction were examined by regression modelling. RESULTS: Fifteen strategies were identified including alterations to 'Code Stroke' processes. One thousand, two hundred and fifty patients were thrombolysed, with 737 (58.8%) treated during the intervention period. The proportion of DNT ≤60-min rose from average of 22.5% during 2003-2012 to 63% during 2015-2018 and 71% in 2019. However, median DNT has only marginally improved from 58 to 51 min between 2015 and 2019. Faster DNT was independently associated with two modifiable workflow factors, 'Direct-to-CT' protocol (P < 0.001) and acute stroke nurse presence (P < 0.005). Over time, treated patients were older and less independent (P < 0.001), and the number of annual stroke admissions and 'Code Stroke' activations have risen by fourfold and 10-fold to 748 and 1298 by 2019 respectively. CONCLUSIONS: Targeted quality improvement initiatives are key to reducing thrombolysis treatment delays in the Australian metropolitan setting. Relative stagnation in DNT improvement is concerning and needs further investigation.

Door-in-Door-Out Time of 60 Minutes for Stroke With Emergent Large Vessel Occlusion at a Primary Stroke Center.

Background and Purpose- Rapid reperfusion with mechanical thrombectomy in ischemic strokes with emergent large vessel occlusions leads to significant reduction in morbidity and mortality. The door-in-door-out (DIDO) time is an important metric for stroke centers without an on-site mechanical thrombectomy service. We report the outcome of a continuous quality improvement program to improve the DIDO time since 2015. Methods- Retrospective analysis of consecutive patients transferred out from a metropolitan primary stroke center for consideration of mechanical thrombectomy between January 1, 2015, and October 31, 2018. Clinical records were interrogated for eligible patients with DIDO times and reasons for treatment delays extracted. Results- One hundred thirty-three patients were transferred over the 46-month period. Median DIDO time reduced by 14% per year, from 111 minutes interquartile range (IQR, 98- 142) in 2015 to 67 minutes (IQR, 55-94) in 2018. A median DIDO time of 59 minutes (IQR, 51-80) was achieved in 2018 during working hours (0800-1700 hours). Overall, 65 patients had no documented delays (49%) with a median DIDO time of 75 minutes (IQR, 54-93) and 103 minutes (IQR, 75-143) in those with at least one delay factor documented. Conclusions- A median DIDO time of <60 minutes can be achieved in a primary stroke center.

Association between excessive premature atrial complexes and cryptogenic stroke: results of a case-control study.

OBJECTIVE: Recent anticoagulation trials in all-comer cryptogenic stroke patients have yielded equivocal results, reinvigorating the focus on identifying reproducible markers of an atrial myopathy. We investigated the role of excessive premature atrial complexes (PACs) in ischaemic stroke, including cryptogenic stroke and its association with vascular risk factors. METHODS AND RESULTS: A case-control study was conducted utilising a multicentre institutional stroke database to compare 461 patients with an ischaemic stroke or transient ischaemic attack (TIA) with a control group consisting of age matched patients without prior history of ischaemic stroke/TIA. All patients underwent 24-hour Holter monitoring during the study period and atrial fibrillation was excluded. An excessive PAC burden, defined as ≥200 PACs/24 hours, was present in 25.6% and 14.7% (p<0.01), of stroke/TIA and control patients, respectively. On multivariate regression, excessive PACs (OR 1.97; 95% CI 1.29 to 3.02; p<0.01), smoking (OR 1.58; 95% CI 1.06 to 2.36; p<0.05) and hypertension (OR 1.53; 95% CI 1.07 to 2.17; p<0.05) were independently associated with ischaemic stroke/TIA. Excessive PACs remained the strongest independent risk factor for the cryptogenic stroke subtype (OR 1.95; 95% CI 1.16 to 3.28; p<0.05). Vascular risk factors that promote atrial remodelling, increasing age (≥75 years, OR 3.64; 95% CI 2.08 to 6.36; p<0.01) and hypertension (OR 1.54; 95% CI 1.01 to 2.34; p<0.05) were independently associated with excessive PACs. CONCLUSIONS: Excessive PACs are independently associated with cryptogenic stroke and may be a reproducible marker of atrial myopathy. Prospective studies assessing their utility in guiding stroke prevention strategies may be warranted.

Reliability of the Acutely Estimated Premorbid Modified Rankin Scale for Stroke Treatment Decision Making.

BACKGROUND: Premorbid functional status is an important factor in acute stroke treatment decision making. Determining the modified Rankin Score (mRS) accurately may be difficult due to deficits from stroke and lack of collateral information in the acute setting. Data on the reliability of the premorbid mRS in "real-world" practice outside of clinical trial or registry settings are limited. METHODS: A retrospective study at a high volume academic primary stroke center. For patients with acute ischemic stroke treated with alteplase between July 2012 and July 2016, hospital electronic records were reviewed for detailed inpatient occupational therapist (OT) assessment of premorbid functional status to determine mRS (OT-mRS). This was compared with premorbid mRS determined at acute emergency department assessment (Acute-mRS). Kappa statistic and Lin's concordance correlation coefficient was used to calculate agreement between Acute-mRS and OT-mRS. RESULTS: Among stroke patients treated with alteplase over the 4 years period, OT-mRS was available for 312 patients (79.0%), the mean age was 75.5 years (male 51.9%). 82.4%, 11.9%, and 5.8% of patients had Acute-mRS of 0-1, 2, and ≥3; while 84.9%, 8.0%, and 6.7% had OT-mRS of 0-1, 2, and ≥3, respectively. The agreement between Acute-mRS and OT-mRS was 83.3%, with κ = .64 and correlation coefficient r = .87 (95% CI .841-.896, P < .05). CONCLUSIONS: There was at least moderate agreement between Acute-mRS prior to thrombolysis and OT-mRS obtained by detailed assessment later. The number of patients with premorbid disability was small and may have positively influenced the agreement between the 2 scores.

Poor reliability of P-wave terminal force V1 in ischemic stroke.

INTRODUCTION: Several ECG markers are postulated to represent underlying atrial remodelling and have been associated with ischemic stroke. P-wave terminal force in lead V1 (PTFV1) is one such marker. We examined the factors that contribute to the reliability of PTFV1 and its association with ischemic stroke. MATERIAL AND METHODS: Four hundred and thirty-five patients that presented with an ischemic stroke or transient ischemic attack (TIA) were identified through a prospectively maintained multi-site institutional stroke database. Control group consisted of age matched patients without prior history of an ischemic stroke or TIA. All patients underwent a 12-lead ECG and 24-hour Holter monitoring during the study period to exclude atrial fibrillation. RESULTS: Morphology consistent with PTFV1 occurred commonly in both the stroke/TIA and control groups. There was no significant difference in the median PTFV1 value between the stroke 3.96 mV ms [Interquartile range (IQR) 2.78-5.58] and control 4.23 mV ms [IQR 2.91-5.57] groups. Measurements of PTFV1 demonstrated excellent intra-observer reliability on assessment of the same P-wave (Intra class correlation (ICC) 0.91, p < 0.001) with narrow limits of agreement 2.21 to -2.95 mV ms. A change in the P wave assessed led to a significant reduction in reliability (ICC 0.79, p < 0.001). Inter-observer, inter P-wave assessment demonstrated further reduction in reliability (ICC 0.68, p < 0.002) with wide limits of agreement 6.17 to -5.78 mV ms, indicating significant under and overestimation of PTFV1. CONCLUSION: The utility of PTFV1 as a clinical marker for ischemic stroke is limited by the reduction in reliability associated with inter-observer and inter P-wave measurements.

Acute Stroke Patients With Mild-to-Moderate Pre-existing Disability Should Be Considered for Thrombolysis Treatment.

BACKGROUND: Thrombolytic therapy in patients with pre-existing disability presenting with acute ischemic stroke (AIS) is controversial because of concerns regarding poor outcomes and futility of treatment. We hypothesized that a similar proportion of patients with and without pre-existing disability would return to their premorbid functional status following thrombolysis. METHODS: This was a retrospective study at a single high-volume academic primary stroke center. All patients with AIS treated with intravenous alteplase between January 2005 and July 2016 were included. Premorbid functional status was assessed using modified Rankin scale (mRS) and dichotomized as independent premorbid (mRS 0-1) or disabled premorbid (mRS 2-4) groups for comparison. Functional outcome was assessed by mRS at 90 days and compared between groups. RESULTS: Six hundred eighty patients independent premorbid (mean age 71.8 ± 13.1 years, 57.9% male) and 140 disabled premorbid (mean age 82.1 ± 8.7 years, 40.7% male) were included. Patients with pre-existing disability were older and had more vascular risk factors and more severe stroke on presentation (P < 0.05). A greater proportion of patients in the disabled premorbid group were dead at 90 days (35.7% versus 12.8%, P < 0.05). At 90 days, among patients with premorbid mRS 0, 1, 2, 3, and 4: 25%, 38%, 32%, 30%, and 25% of them returned to their respective premorbid mRS status. CONCLUSIONS: Irrespective of premorbid functional level, approximately one fourth to one third of thrombolyzed patients had returned to their premorbid functional levels at 90 days. Thrombolytic treatment should be considered in patients with mild-to-moderate pre-existing disability, taking into account the value placed on the chance of a return to premorbid functional status.

Utility of Computed Tomographic Perfusion in Thrombolysis for Minor Stroke.

BACKGROUND AND PURPOSE: The use of thrombolysis in acute minor ischemic stroke (MIS) remains controversial. We sought to determine the safety and efficacy of intravenous tissue-type plasminogen activator (IV-tPA) in acute MIS patients with demonstrable penumbra on computed tomographic perfusion study. METHODS: Consecutive MIS patients with National Institutes of Health Stroke Scale ≤3 were identified from a prospective single tertiary-center database over a 4.5-year period (2011-2015). Cases with demonstrable penumbra were analyzed according to treatment received: IV-tPA versus standard stroke-unit care without thrombolysis. RESULTS: Seventy-three patients of 195 acute MIS admissions had a demonstrable penumbra (34 IV-tPA versus 39 standard stroke-unit care). Overall median National Institutes of Health Stroke Scale and premorbid modified Rankin Scale were 2 and 0, respectively. Median age was 73.2 (interquartile range, 67.3-82.8) years. There were no differences in baseline demographics, risk factors, stroke localization and cause, rates of vascular occlusion (38.2% versus 38.5%; P=1.000), or mean penumbral volume (41.3 versus 25.1 mL; P=0.150; IV-tPA versus standard stroke-unit care) between groups. There were no symptomatic intracerebral hemorrhages in either group. Patients treated with IV-tPA were more likely to have an excellent functional outcome at discharge (88.2% versus 53.9%; P=0.002) and 90 days (91.2% versus 71.8%; P=0.042). Ordinal analysis demonstrated a favorable shift in modified Rankin Scale with IV-tPA both at discharge (odds ratio, 5.23; 95% confidence interval, 1.83-12.20) and 90 days (odds ratio, 4.35; 95% confidence interval, 1.77-11.36). CONCLUSIONS: In selected MIS patients with demonstrable penumbra on computed tomographic perfusion, IV-tPA is safe and associated with significant improvement in functional outcome at discharge and 90 days.