Telephone triage and dispatch of ambulances to patients with suspected and verified acute stroke - a descriptive study.

OBJECTIVES: In this study we aimed to explore EMCC triage of suspected and confirmed stroke patients to gain more knowledge about the initial phase of the acute stroke response chain. Accurate dispatch at the Emergency Medical Communication Center (EMCC) is crucial for optimal resource utilization in the prehospital service, and early identification of acute stroke is known to improve patient outcome. MATERIALS AND METHODS: We conducted a descriptive retrospective study based on data from the Emergency Department and EMCC records at a comprehensive stroke center in Oslo, Norway, during a six-month period (2019-2020). Patients dispatched with EMCC stroke criteria and/or discharged with a stroke diagnosis were included. We identified EMCC true positive, false positive and false negative stroke patients and estimated EMCC stroke sensitivity and positive predictive value (PPV). Furthermore, we analyzed prehospital time intervals and identified patient destinations to gain knowledge on ambulance services assessments. RESULTS: We included 1298 patients. EMCC stroke sensitivity was 77% (95% CI: 72 - 82%), and PPV was 16% (95% CI: 14 - 18%). EMCC false negative stroke patients experienced an increased median prehospital delay of 11 min (p < 0.001). Upon arrival at the scene, 68% of the EMCC false negative patients were identified as suspected stroke cases by the ambulance services. Similarly, 68% of the false positive stroke patients were either referred to a GP, out-of-hours GP acute clinic, local hospitals or left at the scene by the ambulance services, indicating that no obvious stroke symptoms were identified by ambulance personnel upon arrival at the scene. CONCLUSIONS: This study reveals a high EMCC stroke sensitivity and an extensive number of false positive stroke dispatches. By comparing the assessments made by both the EMCC and the ambulance service, we have identified specific patient groups that should be the focus for future research efforts aimed at improving the sensitivity and specificity of stroke recognition in the EMCC.

Stroke pathway performance assessment: a retrospective observational study.

BACKGROUND AND AIM: Performance assessment of the Stroke Pathway is a key element in healthcare quality. The aim of this study has been to carry out a retrospective assessment of the Stroke Pathway in a first level Stroke Unit in Italy, analyzing the temporal trend of the Stroke Pathway performance and the impact of the COVID-19 pandemic. METHODS: A retrospective observational study was carried out analyzing data from 1/01/2010 to 31/12/2020. The following parameters were considered: volume and characteristics of patients with ischemic stroke undergoing intravenous thrombolysis, baseline modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS) scores, Onset-to-Door (OTD), Door-To-Imaging (DTI) and Door-To-Needle (DTN) Times, mRS score 3 months after the ischemic event onset (3 m-mRS) and NIHSS score 24 h after the ischemic event onset (24 h-NIHSS). The study also compared the pre-COVID-19 pandemic period (March-December 2019) with the one immediately following it (March-December 2020). RESULTS: 418 patients were included. Over time, treatment was extended to older patients (mean age from 66.3 to 75.51 years; p = 0.006) and with a higher level of baseline disability (baseline mRS score from 0.22 to 1.22; p = 0.000). A statistically significant reduction over the years was found for DTN, going from 90 min to 61 min (p = 0.000) with also an increase in the number of thrombolysis performed within the "golden hour" - more than 50% in 2019 and more of 60% in 2020. Comparing pre- and during COVID-19 pandemic periods, the number of patients remained almost unchanged, but with a significantly higher baseline disability (mRS = 1.18 vs. 0.72, p = 0.048). The pre-hospital process indicator OTD increased from 88.13 to 118.48 min, although without a statistically significant difference (p = 0.197). Despite the difficulties for hospitals due to pandemic, the hospital process indicators DTI and DTN remained substantially unchanged, as well as the clinical outcome indicators 3 m-mRS, NHISS and 24 h-NHISS. CONCLUSIONS: The results of the retrospective assessment of the Stroke Pathway highlighted its positive impact both on hospital processes and patients' outcomes, even during the COVID-19 pandemic, so that the current performance is aligning itself with international goals. Moreover, the analysis showed the need of improvement actions for both hospital and pre-hospital phases. The Stroke Pathway should be improved with the thrombolysis starting in the diagnostic imaging department in order to further reduce the DTN score. Moreover, health education initiatives involving all the stakeholders should be promoted, also by using social media, to increase population awareness on timely recognition of stroke signs and symptoms and emergence medical services usage.

Impact of the COVID-19 outbreak on acute stroke pathways - insights from the Alsace region in France.

BACKGROUND AND PURPOSE: To date, no study has attempted to quantify the impact of the COVID-19 outbreak on the incidence and treatment of acute stroke. METHODS: This was a retrospective review of acute stroke pathway parameters in all three stroke units in the Alsace region during the first month of the outbreak (1-31 March 2020), using the similar period from 2019 as a comparator. A secondary detailed analysis of all stroke alerts and stroke unit admissions was performed in the centre with the largest case volume. RESULTS: Compared to the same period in 2019, in March 2020 there were 39.6% fewer stroke alerts and 33.3% fewer acute revascularization treatments [40.9% less intravenous thrombolysis (IVT) and 27.6% less mechanical thrombectomy (MT)]. No marked variation was observed in the number of stroke unit admissions (-0.6%). The proportion of patients with acute revascularization treatments (IVT or MT) out of the total number of stroke unit admissions was significantly lower in March 2020 (21.3%) compared to 2019 (31.8%), P = 0.034. There were no significant differences in time delays or severity of clinical symptoms for patients treated by IVT or MT, nor in the distribution of final diagnosis amongst stroke alerts and stroke unit admissions. CONCLUSION: These results suggest that the overall incidence of stroke remained the same, but fewer patients presented within the therapeutic time window. Increased public awareness and corrective measures are needed to mitigate the deleterious effects of the COVID-19 outbreak on acute stroke care.

Practice Implications for Acute Ischemic Stroke during the COVID-19 Pandemic for the Indian Scenario: Realistic and Achievable Recommendations by the Society of Neurocritical Care (SNCC), India.

COVID-19 disease caused by the SARS coronavirus has caused significant morbidity and mortality around the world ever since it was first declared as a pandemic by the World Health Organization (WHO) in March 2020. Acute neurological manifestations of this disease have also started emerging and being recognized around the world and acute ischemic stroke (AIS) or thrombotic stroke is becoming one of the major neurological illnesses related to COVID-19. The management of AIS is time-critical and major advances in its management over the recent years, such as bridging thrombolysis and mechanical thrombectomy (MT), are multidisciplinary activities requiring robust coordination and management in the acute setting. All these advances are severely challenged in the COVID-19 pandemic where severe pressures exist on the clinical resources and logistics required to deliver an effective stroke service. This is further compromised by legal and preventive measures during this pandemic like local lockdowns. Reporting of minor or initial symptoms has also been compromised due to the fear of approaching healthcare settings which are perceived as high-risk zones to catch the infection. The purpose of this document is to highlight these challenges and provide a guiding framework for the management of AIS under three principles: (a) Delivering an effective service, (b) Preventing infections within the healthcare setting, and (c) Optimizing resource utilization. How to cite this article: Kakkar G, Zirpe KG, Sapra H, Dixit S, Chugh C, Nagaiyan S, et al. Practice Implications for Acute Ischemic Stroke during the COVID-19 Pandemic for the Indian Scenario: Realistic and Achievable Recommendations by the Society of Neurocritical Care (SNCC), India. Indian J Crit Care Med 2020;24(9):757-762.

Better functional recovery after acute stroke in older patients managed in a new dedicated post-stroke geriatric unit compared to usual management.

OBJECTIVES: A Stroke care Pathway dedicated to the ELders (SPEL) for patients with acute stroke was created in 2013 at the hospitals Pitié-Salpêtrière-Charles Foix (Paris, France). It is characterized by a stroke unit dedicated to emergency stroke care, and a post stroke geriatric unit (PSGU) including rehabilitation and management of geriatric syndromes. The aim of the study was to compare the functional recovery of patients transferred to PSGU versus other rehabilitation care in patients over 70 years of age after stroke. DESIGN: A cohort observational study over a 4-year period. SETTING: Hospitals Pitié-Salpêtrière and Charles Foix (Paris, France). PARTICIPANTS: We studied patients over 70 years admitted to the participating stroke unit for acute stroke consecutively hospitalized from January 1, 2013, to January 1, 2017. INTERVENTION: Patients transferred in the PSGU were compared to those admitted in other rehabilitation units. MEASUREMENTS: The primary outcome was 3-month functional recovery after stroke. The secondary outcomes were the hospital length of stay and the returning home rate. A multivariable logistic regression was applied to adjust for confounding variables (age, sex, NIHSS score and Charlson's comorbidity score). RESULTS: Among the 262 patients included in the study, those in the PGSU were significantly older, had a higher Charlson's comorbidity score and a higher initial NIHSS severity score. As compared to the other patients, functional recovery at 3 months was better in the PSGU (Rankin's score decreased by 0.80 points versus 0.41 points, p = 0.01). The average total length of stay was reduced by 16 days in the patients referred to the PSGU (p = 0.002). There was no significant difference in the returning home rate between the two groups (p = 0.88). CONCLUSION: The SPEL which includes a post-stroke geriatric unit (PSGU) has been associated with improved recovery and had a positive impact in the management of older post-stroke patients.

Prehospital technologies for early stroke detection - A review.

The rate of neural circuitry loss in a typical large vessel occlusion well emphasizes that 'Time is Brain'. Every untreated minute in a large vessel ischaemic stroke results in loss of 1.9 million neurons and 13.8 billion synapses. As such, it is essential to optimize the flow-limiting steps in delivering the current standard of care. The current diagnostic model involves recognition of symptoms by patients, followed by access to Emergency Medical Services and subsequent physical examination and neuroimaging in the Emergency Department. With more than 50% of stroke patients using Emergency Medical Services as the first point of care contact, it can be deduced that the outcome of the 'stroke chain of survival' can be improved by addressing the bottleneck of prehospital stroke diagnosis. Here we present a review of the existing technologies.

"Decide and run!" The role of prehospital care providers in reducing time loss for patients with stroke diagnosis / "Dönts és siess!" A prehospitális ellátók szerepe az idoveszteség csökkentésében stroke-iránydiagnózisú betegek esetén.

Összefoglaló. Bevezetés: A stroke-betegek ellátásában arra kell törekedni, hogy a tünetek jelentkezését követoen minél elobb a szakmai centrumba kerüljön a beteg. Célkituzés: Kutatásunkban a terápiás idoablak tarthatósága céljából vizsgáltuk, hogy mely tényezok bírnak hatással a prehospitális ellátás idotartamaira. Módszer: Keresztmetszeti, kvantitatív kutatásunkhoz az adatgyujtést két magyarországi város mentoállomásán, orvosi kompetenciával rendelkezo (eset-, rohamkocsi) és orvosi kompetenciával nem rendelkezo (mentogépkocsi) mentoegység szintjén végeztük 2017-es adatok feldolgozásával olyan betegek körében, akiknek a mentoegység általi iránydiagnózisa stroke volt (n = 220). Vizsgáltuk, hogy a mentoegységek által elvégzett vizsgálatok, a tapasztalt tünetek, a terápiás idoablakon belüliség miként befolyásolta a prehospitális idoket. Az adatfeldolgozást SPSS 26.0 statisztikai programmal végeztük. Az elemzéshez leíró statisztikát, χ2-próbát, F-próbát és T-próbát alkalmaztunk. Eredmények: Megállapítottuk, hogy az alkalmazott score-rendszer vizsgálati elemei közül, ha aphasia volt észlelheto a betegnél, úgy szignifikánsan meghosszabbodott a helyszínen töltött ido (p = 0,003). A gyors ABCDE-betegvizsgálat D-lépésében kötelezo a betegnél a vércukorszintmérés, ugyanakkor ez mintánk 25,45%-ában elmaradt. A helyszíni muszeres vércukorszintmérés hatással van a prehospitális késés alakulására az orvosi kompetencia nélküli egységek vonatkozásában (p<0,001). Következtetés: A helyszínen töltött ido az emelt szintu mentoegységek esetében hosszabb, mint az alacsonyabb szintu egységeknél. Következtetésként levonhatjuk, hogy a motoros vagy szenzoros aphasia nem befolyásolja a terápiát, pusztán a stroke-diagnózis valószínuségét növelo egyik tünet, így a helyszíni ido emiatti megnyúlása mindenképpen kerülendo, amire javasolt a továbbképzések alkalmával is felhívni az ellátók figyelmét. Az orvosi kompetencia nélküli egységek esetében beavatkozást igényel a muszeres vércukormérés idorabló hatásának csökkentése, hiszen látható, hogy az orvosi kompetenciával rendelkezo egységeknél ez a vizsgálat nem jelenik meg mint késést okozó tényezo. Orv Hetil. 2022; 163(7): 279-287. INTRODUCTION: When treating stroke patients, the aim should be to get the patient to a specialist stroke centre as soon as possible. OBJECTIVE: In our study, in order to be able to stay within the therapeutic window, we investigated which variables affect the time period of prehospital treatment. METHOD: For our cross-sectional quantitative study, we gathered data from two ambulance stations in Hungary, comparing the competence of physician and non-physician units. We processed information from 2017 regarding patients whose initial diagnosis was stroke (n = 220). We examined how investigations by the ambulance unit, symptoms experienced and therapeutic time window have affected prehospital times. As for the statistic software, we used SPSS 26.0. The analysis was conducted by performing χ2 test, F-test and T-test. RESULTS: We identified that if the aphasia component of the used score system was positive, the on-scene time increased significantly (p = 0.003). In the D section of the rapid ABCDE assessment, it is mandatory to measure the blood glucose level of the patient, however, in our sample it was omitted in 25.45% of the cases. We identified that on-site blood glucose measurement has an effect on prehospital delay for non-physician units (p<0.001). CONCLUSION: We found that the on-scene time is longer for physician units than for non-physician units. We concluded that motor or sensory aphasia does not affect the therapy, it is just one of the symptoms that can increase the likelihood of stroke diagnosis, therefore prolonging time for assessing aphasia in the field should be avoided. Moreover, it is recommended to make care providers aware of this during training sessions. Improvements are required in non-physician units to reduce the time consumed by blood glucose measurement, as it has been shown that within physician units this test does not appear to be a delay-causing factor. Orv Hetil. 2022; 163(7): 279-287.