Hospital overcrowding and care of stroke patients: Irish national audit of stroke.

INTRODUCTION: Hospital overcrowding where patient admissions exceed capacity is associated with worse outcomes in Emergency Department. Developments in emergency stroke care have been associated with improvements in stroke outcome but are dependent on effective, organised care. We examined if overcrowding in the hospital system was associated with negative changes in stroke outcome. METHODS: Data on overcrowding were obtained from the Irish Nurses and Midwives Organisation (INMO) 'Trolley Count' database recording the number of patients cared for on trolleys/chairs in all acute hospitals each midnight. These were compared with quarterly data from the Irish National Audit of Stroke from 2013 to 2021 inclusive. Variables analysed were inpatient mortality rate, thrombolysis rate for ischaemic stroke, median door to needle time and median length of stay. RESULTS: 579449 patient episodes were recorded by Trolley Watch over the period, (Quarterly Median 16719.5, range 3389-27015). Average Quarterly Thrombolysis rate was 11.3% (sd 1.3%) Median Quarterly Inpatient Mortality rate was 11.8% (Range 8.9-14.0%). Median Quarterly Length of stay was 9 days (8-11 days). Median quarterly door to needle was 65 min (45-80 min). Q1 was typically the worst for overcrowding with on average 19777 incidences (sd 4786). This was significantly higher than for Q2 (mean 13540 (sd 4785) p = 0.005 t-test) and for Q3 (mean 14542 (sd 4753) p = 0.03). No significant correlation was found between quarterly Trolley watch episodes and inpatient mortality (r = 0.084, p = 0.63), median length of stay r=-0.15, p = 0.37) or thrombolysis rate (r = 0.089 p = 0.61). There was an unexpected significant negative correlation between trolley watch data and median door to needle time (r=-0.36, p = 0.03). CONCLUSION: Despite increasing hospital overcrowding, stroke services still managed to preserve standard of care. We could find no association between levels of overcrowding and deterioration in selected indices of patient care.

The association between increasing oral anticoagulant prescribing and atrial fibrillation related stroke in Ireland.

AIMS: Recent increases in the number of patients with atrial fibrillation (AF) prescribed oral anticoagulants (OAC) are evident in Ireland and internationally, largely due to the availability of direct oral anticoagulants (DOACs). This study aimed to determine the rate of stroke in the context of increasing anticoagulation utilisation, with a focus on AF-related ischaemic stroke (IS). METHODS: Dispensing data for OACs were identified for the period 2010-2018 as well as hospital discharges for IS (2005-2018). Irish National Stroke Register data were used to elucidate the characteristics of patients with acute ischaemic stroke. RESULTS: The number of patients prescribed OACs increased by 94% from 2010-2018 with a significant change from 2013 (ß = 2.57, P = .038), associated with a large increase in the number of patients on DOACs. There was 3.3-fold increase in expenditure on OACs nationally from 2013 to 2018, of which 94% was DOAC related. Using the 2013 timepoint, ischaemic stroke rates until 2018 did not show a significant deviation from the previous trend (ß = 0.00, P = .898). The percentage of AF-related ischaemic stroke was stable from 2013 to 2017 with a 4.5% decrease in 2018. The percentage of ischaemic stroke patients with previously diagnosed AF decreased from 2013 to 2018; however, there was an increase in the percentage of ischaemic strokes while on OAC in this cohort. CONCLUSION: Large increases in OAC utilisation have not resulted in changes in ischaemic stroke rates at a national level. The percentage of ischaemic strokes with a previous diagnosis of AF has decreased indicating a possible benefit from greater OAC utilisation. However, the percentage presenting with an ischaemic stroke while on OAC treatment is increasing. The increase in patients presenting with stroke while treated with OAC may largely reflect the national increase in patients prescribed DOACs but the findings raise concerns about treatment failures. The real-world effectiveness of DOACs requires further examination.

Changes in anticoagulation practice in subjects admitted with stroke associated with atrial fibrillation, following introduction of direct oral anticoagulants over 2013-2021.

BACKGROUND: The adoption of direct oral anticoagulants (DOACs) has changed practice in prevention of stroke in atrial fibrillation (AF). We used Irish data national data on stroke and anticoagulation therapy over 9 years to investigate changes in anticoagulation practice and potential consequences on stroke prevalence and thrombolysis. METHODS: AF, anticoagulation, thrombolysis, and stroke data from the Irish National Audit of Stroke (INAS) 2013-2021 were reviewed. The proportion of patients with ischemic stroke (IS) and intracerebral hemorrhage (IH) with known AF admitted on anticoagulation was determined. Effects on age distribution in the population and thrombolysis practice were assessed. RESULTS: AF data were available on 34,630 of 35,241 individuals (98.3%) included in INAS; median age was 74 years and 56% were male. AF was found in 10,016 (28.9%, 9059 IS, 957 IH). 6313 had known AF prior to stroke (63.1%). The proportion all total IS due to AF decreased by 15.3% (31.3%-26.5%, chi-square = 24.6, p < 0.0001). The proportion of IH did not change significantly (21.6%-20.2%, chi-square = 1.8, p = 0.18). Over the 9 years, 3875 (38.6%) of the subjects with AF were recorded as receiving anticoagulants at admission. In 2013, 4.4% of AF-associated strokes were admitted on a DOAC and 21.4% on warfarin; by 2021, 44.1% were receiving a DOAC and 6.2% warfarin. There was a strong inverse correlation between the proportion of anticoagulated stroke patients and the total proportion of AF-associated strokes over time (r = -0.82, p = 0.006). In contrast, no correlation was found between increasing DOAC usage and IH (r = 0.14, p = 0.71). Increased anticoagulation usage correlated with a reduction in patients ⩾ 80 years (r = -0.83, p = 0.006) and also correlated with a relative reduction of 30.1% in subjects thrombolysed <4 h from onset (r = -0.89, p = 0.001). CONCLUSION: DOACs have led to increased use of anticoagulation, but warfarin use fell by two-thirds. There has been a reduction in the proportion of AF-associated IS without a noticeable increase in IH. Increased anticoagulation correlated with reduced numbers of strokes in those >80 years and in the proportion of patients thrombolysed.

The impact of hospital presentation time on stroke outcomes: A nationally representative Irish cohort study.

OBJECTIVES: There is conflicting evidence regarding the outcomes of acute stroke patients who present to hospital within normal working hours ('in-hours') compared with the 'out-of-hours' period. This study aimed to assess the effect of time of stroke presentation on outcomes within the Irish context, to inform national stroke service delivery. MATERIALS AND METHODS: A secondary analysis of data from the Irish National Audit of Stroke (INAS) from Jan 2016 to Dec 2019 was carried out. Patient and process outcomes were assessed for patients presenting 'in-hours' (8:00-17:00 Monday-Friday) compared with 'out-of-hours' (all other times). RESULTS: Data on arrival time were available for 13,996 patients (male 56.2%; mean age 72.5 years), of which 55.7% presented 'out-of-hours'. In hospital mortality was significantly lower among those admitted 'in-hours' (11.3%, n = 534) compared with 'out-of-hours' (12.8%, n = 749); (adjusted Odds Ratio (OR) 0.82; 95% Confidence Interval CI [95% CI] 0.72-0.89). Poor functional outcome at discharge (Modified Rankin Scale ≥ 3) was also significantly lower in those presenting 'in-hours' (adjusted OR 0.79; 95% CI 0.68-0.91). In patients receiving thrombolysis, mean door to needle time was shorter for 'in-hours' presentation at 55.8 mins (n = 562; SD 35.43 mins), compared with 'out-of-hours' presentation at 80.5 mins (n = 736; SD 38.55 mins, p < .001). CONCLUSION: More than half of stroke patients in Ireland present 'out-of-hours' and these presentations are associated with a higher mortality and a lower odds of functional independence at discharge. It is imperative that stroke pathways consider the 24 hour period to ensure the delivery of effective stroke care, and modification of 'out-of-hours' stroke care is required to improve overall outcomes.

Hospital size, remoteness and stroke outcome.

INTRODUCTION: Previous studies have shown an association between number of stroke admissions and outcomes. Small hospitals often support more remote areas and we studied national data to determine if an association exists between hospital remoteness and stroke care. METHODS: Data from the Irish National Audit of Stroke (INAS) on average stroke admissions, adjusted mortality for ischaemic stroke, thrombolysis rate and proportion with door to needle (DTN) ≤45 min were analysed. Hospital remoteness was quantified by distance to the next hospital, nearest neurointerventional centre and location within 10 km of the national motorway network. RESULTS: Data for 23 of 24 stroke services were evaluated. Median number of strokes admitted per year was 186 (range 84-497). Nine hospitals (39%) admitted ≥200 stroke patients per year (mean 332). Average adjusted mortality (7.0 vs. 7.3, P = 0.67 t-test), mean thrombolysis rate (12.1% vs. 9.2%, P = 0.09) and mean proportion of patients treated ≤45 min (40.4% vs. 31.3%, P = 0.2) did not differ significantly between higher and lower volume hospitals.Hospitals close to the motorway network (n = 15) had a higher mean thrombolysis rate (11.9% vs. 7.5%, P = 0.01 t-test) and proportion DTN ≤45 min (43.7-18.4%, P < 0.001).Number of stroke admissions did not correlate with mortality (r = 0.06, P = 0.78), DTN (r = 0.12, P = 0.95) or thrombolysis rate (r = 0.35, P = 0.20). Distance to next hospital correlated strongly negatively with DTN (r = -0.47, P = 0.02) and thrombolysis rate (-0.43, P = 0.04). CONCLUSION: Remoteness of hospitals is associated with worse measures of stroke outcome and management.

Development of a national stroke audit in Ireland: scoping review protocol.

Introduction Recent advances in stroke management and care have resulted in improved survival and outcomes. However, providing equitable access to acute care, rehabilitation and longer-term stroke care is challenging. Recent Irish evidence indicates variation in stroke outcomes across hospitals, and a need for continuous audit of stroke care to support quality improvement. The aim of this project is to develop a core minimum dataset for use in the new Irish National Audit of Stroke (INAS), which aims to improve the standard of stroke care in Ireland. This paper outlines the protocol for conducting a scoping review of international practice and guidelines in auditing acute and non-acute stroke care. Objective Identify data items that are currently collected by stroke audits internationally, and identify audit guidelines that exist for recommending inclusion of content in stroke audit datasets. Methods and analysis This scoping review will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews extension for Scoping Reviews (PRISMA-ScR). We will search the following databases: Medline Ovid; Embase; CINAHL EBSCOHost. Grey literature will also be searched for relevant materials, as will relevant websites. Study selection and review will be carried out independently by two researchers, with discrepancies resolved by a third. Data charting and synthesis will involve sub-dividing relevant sources of evidence, and synthesising data into three categories: i) acute stroke care; ii) non-acute stroke care; and iii) audit data collection procedures and resourcing. Data will be charted using a standardised form specific to each category. Consultation with knowledge users will be conducted at all stages of the scoping review. Discussion This scoping review will contribute to a larger project aimed at developing an internationally benchmarked stroke audit tool that will be used prospectively to collect data on all stroke admissions in Ireland, encompassing both acute and non-acute data items.

Drip and ship versus direct to endovascular thrombectomy: The impact of treatment times on transport decision-making.

INTRODUCTION: In ischaemic stroke care, fast reperfusion is essential for disability free survival. It is unknown if bypassing thrombolysis centres in favour of endovascular thrombectomy (mothership) outweighs transport to the nearest thrombolysis centre for alteplase and then transfer for endovascular thrombectomy (drip-and-ship). We use conditional probability modelling to determine the impact of treatment times on transport decision-making for acute ischaemic stroke. MATERIALS AND METHODS: Probability of good outcome was modelled using a previously published framework, data from the Irish National Stroke Register, and an endovascular thrombectomy registry at a tertiary referral centre in Ireland. Ireland was divided into 139 regions, transport times between each region and hospital were estimated using Google's Distance Matrix Application Program Interface. Results were mapped using ArcGIS 10.3. RESULTS: Using current treatment times, drip-and-ship rarely predicts best outcomes. However, if door to needle times are reduced to 30 min, drip-and-ship becomes more favourable; even more so if turnaround time (time from thrombolysis to departure for the endovascular thrombectomy centre) is also reduced. Reducing door to groin puncture times predicts better outcomes with the mothership model. DISCUSSION: This is the first case study modelling pre-hospital transport for ischaemic stroke utilising real treatment times in a defined geographic area. A moderate improvement in treatment times results in significant predicted changes to the optimisation of a national acute stroke patient transport strategy. CONCLUSIONS: Modelling patient transport for system-level planning is sensitive to treatment times at both thrombolysis and thrombectomy centres and has important implications for the future planning of thrombectomy services.

A comparison of service organisation and guideline compliance between two adjacent European health services.

INTRODUCTION: Outcomes in stroke patients are improved by a co-ordinated organisation of stroke services and provision of evidence-based care. We studied the organisation of care and application of guidelines in two neighbouring health care systems with similar characteristics. METHODS: Organisational elements of the 2015 National Stroke Audit (NSA) from the Republic of Ireland (ROI) were compared with the Sentinel Stroke National Audit Programme (SSNAP) in Northern Ireland (NI) and the United Kingdom (UK). Compliance was compared with UK and European guidelines. RESULTS: Twenty-one of 28 ROI hospitals (78%) reported having a stroke unit (SU) compared with all 10 in NI. Average SU size was smaller in ROI (6 beds vs. 15 beds) and bed availability per head of population was lower (1:30,633 vs. 1:12,037 p < 0.0001 Chi Sq). Fifty-four percent of ROI patients were admitted to SU care compared with 96% of UK patients (p < 0.0001). Twenty-four-hour physiological monitoring was available in 54% of ROI SUs compared to 91% of UK units (p < 0.0001). There was no significant difference between ROI and NI in access to senior specialist physicians or nurses or in SU nurse staffing (3.9/10 beds weekday mornings) but there was a higher proportion of trained nurses in ROI units (2.9/10 beds vs. 2.3/10 beds (p = 0.02 Chi Sq). CONCLUSION: Whilst the majority of hospitals in both jurisdictions met key criteria for organised stroke care the small size and underdevelopment of the ROI units meant a substantial proportion of patients were unable to access this specialised care.