An interdisciplinary approach to inhospital stroke improves stroke detection and treatment time

Abstract

BackgroundInhospital stroke (IHS) is associated with high morbidity and mortality, likely related to multiple factors, including delayed time to recognition, associated comorbidities, and initial care from non-stroke trained providers. We hypothesized that guided revision of a formalized ‘stroke code’ system can improve diagnosis and time to thrombolysis and thrombectomy.MethodsIHS activations occurring at a comprehensive stroke center between 2013 and 2016 were retrospectively analyzed to guide revisions of an established stroke code protocol to improve provider communication and time to imaging, reduce stroke mimic rate, and improve the use of parallel processing. After protocol implementation, we prospectively collected data between 2016 and 2017 for comparison with the pre-implementation group, including diagnostic accuracy and relevant time points (code call to examination, examination to imaging, and imaging to intervention). We report descriptive statistics for comparison of patient characteristics and time metrics (time to imaging and reperfusion after IHS activation). Multivariable regression analysis was performed to identify independent predictors of stroke mimics and time metrics.ResultsThere were 136 cases in the pre-implementation group and 69 in the post-implementation group. A reduction in stroke mimics (52% vs 33%, P=0.01) occurred after protocol initiation. Mean time to imaging after stroke code call was 7.6 min shorter (P=0.026) and mean time from imaging to acute reperfusion therapy was 45.7 vs 19.8 min (P=0.05) in the pre- versus the post-implementation group.ConclusionRevision of an existing IHS protocol was associated with a lower rate of stroke mimics, and a shorter time to intravenous and intra-arterial intervention.

Optimizing Door-to-Groin Puncture Time: The Mayo Clinic Experience

“…All the articles were case-control observational studies with a IIIb level of evidence. 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 Critical appraisal classified all the included studies as “good” quality ( Supplemental Table 3 , available online at http://www.mcpiqojournal.org ). The interobserver agreement for selecting the relevant studies to be included was excellent ( k =0.78).…”

“…In this group, the most common changes implemented were EMS before notification (n=3), a rapid triage protocol and stroke team notification (n=3), modified CT flow (n=3), and a team-based approach (n=3). Manners et al 29 appeared to select the most effective combination of strategies (SMD=1.41), which included the implementation of a stroke severity scale, direct communication between the rapid response and neurology teams, and the neurology team meeting the patient directly in the radiology department. 29 The remaining multiple-strategy studies had a similar level of efficacy.…”

Identifying Best Practices to Improve Evaluation and Management of In-Hospital Stroke: A Scientific Statement From the American Heart Association

“…Additional challenges include less stroke education for key multidisciplinary teams and lack of multidisciplinary assessment and workflow after a stroke alert, in-hospital stroke kits for rapid intravenous thrombolysis, and standardized computerized physician order entry sets. 10,21,30,52 Studies consistently demonstrate that community hospitals have less consistent adherence to treatment guidelines. 2,3 Telemedicine may be beneficial in bridging the gap when medical expertise is needed, and models to enhance coverage should be explored.…”

Comparison of Clinical Features, Immune-Inflammatory Markers, and Outcomes Between Patients with Acute In-Hospital and Out-of-Hospital Ischemic Stroke

“…An interdisciplinary team that follows appropriate specialized protocol for patients with IHIS, including a special contact window for emergent liaison, rapid transportation of patients for cranial imaging study, and a clear pathway for medicine delivery to the bed side, has been reported to effectively shorten the intrahospital delay. 16,34 Furthermore, widespread educational programs for all hospital staff to more effectively recognize stroke symptoms, rapidly convey the bedside information from caregivers to physicians in charge, and understand the concept of therapeutic time windows, are vital for increasing the reperfusion rate for eligible patients. Stroke incidence is lower in the ward than in the ED.…”