Stroke unit development and evaluation Jacek Staszewski 2015
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This document discusses strategies to improve stroke care and treatment. It outlines the benefits of stroke unit care compared to general medical wards, including reduced mortality, dependency, and length of stay. It also discusses various quality indicators that stroke units and centers should monitor, such as thrombolysis rates and door-to-needle times. The document advocates for a tiered system of stroke care with certified acute stroke units and centers that can provide more advanced treatments and meet quality standards. It also discusses strategies to optimize pre-hospital management and in-hospital workflows to increase thrombolysis treatment rates and reduce treatment delays.
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Stroke unit development and evaluation Jacek Staszewski 2015
- 1. Stroke unit development and evaluation. What can we improve ? Jacek Staszewski, MD, PhD
- 2. Disclosures • No conflicts of interest
- 3. Benefits of stroke unit (SU) care 1. Stroke Unit Trialists’ Collaboration. Cochrane Library 2013, 2. Seenan EXC, et al. Stroke 2007;38, Tamm CLO, et al. Stroke 2014;45:211-216; 4. Schouten LM, et al. Stroke 2008;39:2515-2521; 5. Lannon R, et al. Ir J Med Sci 2011 Mar;180:37-40. 6. Ingeman A, et al. Stroke 2011;42:3214-3218. Mortality1,2 Dependency1,2 Complications6 Independence2 Discharge Home2,3 Length of stay1,4,5 Cumulative indirect costs $ 18.3 billion * Cumulative direct costs $ 13.8 billion * * estimated benefits of optimal stroke care in Canada: costs avoided 2010-2031 All patients regardless of age, sex, type of stroke, time of presentation benefit from stroke care.
- 4. % patients that can benefit ARR (%) death/ dependency No. of dead and dependent survivors avoided per yr/1 million Stroke Unit 100% 5 69 Thrombolysis 0-4.5 hr 25% ischaemic strokes 6 12 Aspirin 0-48hr 80% strokes 1 23 Hemicraniectomy 0-48hr 2% ischaemic strokes 16 7 All stroke patients should be treated in a stroke unit Helsingborg Declaration 2006 ESO 2013 (Class I, Level A) Hankey IMP. J R Coll Physicians Edinb 2010; 40; Gilligan EFF. Cerebrovasc Dis. 2005;20 To recover the patient must survive stroke complications ARR – absolute risk reduction
- 5. Stroke Unit A specified area in a hospital, staffed by a dedicated, multidisciplinary team with specialist knowledge and skill in stroke care. SU is a fundamental element of stroke care Stroke unit Ringelstein EB, et al. Stroke 2013;44 Stroke rehabilitation units Admit patients after a delay of 1-2 weeks, continue treatment and rehabilitation for several weeks Acute SUs Admit acute stroke patients and continue treatment for several days (≈ less than 1week) Integrated acute and rehabilitation SU Admit acute patients and continue treatment and rehabilitation for several weeks / months • acute –care-driven (GB) • intensive-care-like approach (DE) • rehabilitation driven approach (SCN)
- 6. Risk reduction in death or dependency: SU vs GMW GMW – general medical ward Candelise SU. Lancet 2007;369 13% RRR
- 7. connection with EMS transfer to the nearest SU quick CT/blood tests for urgent patients direct admission from ED multiprofessional team approach staff trained in delivering rt-PA careful nursing care: swallow screening cont. monitoring (ECG,BP), access to img. prevention, treatment of complications early mobilization /rehabilitation thx secondary prevention Coordination , Cooperation, Communication written institutional stroke protocols* Stroke treatment: process flow SSNAP&ESO*criteriaforthequalityof acuteSUorganisation SSNAP – Sentinel Stroke National Audit Programme, Dec 2014 Ringelstein EB, et al. Stroke 2013;44
- 8. Hyperacute stroke service Response times Ringelstein EB, et al. Stroke 2013;44 Door-to-neurologist 30 minutes Lab results in rtPA candidates Door-to-CT * 30 minutes Door-to-Needle* (80% threshold) 20 minutes asap ≤ 60 minutes * compulsory QI (ESO 2013) Performance metrics apply to all patients not only to rtPA candidates !
- 9. Stroke Unit Trialists' Collaboration 2007; Ringelstein EB, et al. Stroke 2013;44: SSNAP – Sentinel Stroke National Audit Programme, Dec 2014 General SU organisation Key features I. Consultant physician with responsibility for stroke • 7 day consultant ward rounds II. Weekly multidisciplinary meetings to plan/discuss pt care* • clinical psychology • palliative care treatment decisions III. Formal links with patient/carer organisations IV.Provision of information to patients about stroke • involvement in discharge planning • access to stroke-specific Early Supported Discharge team V. Continuing education (annual teaching course) for medical and nonmedical staff* SSNAP&ESO*criteriaforthequalityofstrokecare
- 10. ESO stroke units Hess DC et al. The history and future of telestroke. Nat. Ens. Neurol. 2013; Ringelstein EB, et al. Stroke 2013;44:828-840. Tiered system of stroke care Acute stroke patients should have access to high technology medical and surgical stroke care AHA/ASA 2013; Class III, Level B Development of clinical networks, including telemedicine, is recommended Class II, Level B •Part A : acute SU ≥ 4 beds 24h continous monitoring for ≥72hrs 1 monitored bed per 100 pts/yr ≥ 200 stroke or TIA patients /yr ≥ 16 rtPA pts/yr •Part B : postacute step-down SU 2x the number of beds in part A Drip and ship Spoke to hub ESO stroke centres • more advanced equipment • higher expertised staffing • neuro-, vascular-surgery, interv.card. • diversified and larger resources • multiprofessional ICU, in-house ED • hyperacute interventions • on-site hemicraniectomy, thrombectomy • stroke research
- 11. • to ensure EB requirements, standards are met • done by an outside, independent experts – Self-certification is not acceptable – Process is elaborated by ESO Stroke Unit Certification Committee • should include a site visit • assessment of facilities, personnel, level of care,outcomes • evaluation of stroke care pathway QIs Certification process and quality assessment QI - quality indicator Certification of stroke centers by an independent external body is recommended AHA/ASA 2013 Class I, Level B Hospitals should organise a multidisciplinary quality improvement committee to monitor QIs Class I, Level B AHA/ASA Guidelines. Jauch et al. Stroke 2013, 24; Ringelstein EB, et al. Stroke 2013;44
- 12. Compulsory QIs based on best practices ESO recommendation on quality measures Ringelstein EB, et al. Stroke 2013;44; Detre EM, et al. NEJM 2013, 46 1. % acute stroke patients treated with i.v. rtPA having a DTN time <60 min 2. % acute patients with stroke treated on the stroke unit 3. % brain imaging by CT or MRI in every suspected stroke 4. % ischaemic stroke pts with antithrombotic therapy at discharge 5. Corresponding anticoagulation at discharge in patients with atrial fibrillation 6. % stroke unit patients screened for swallowing disorders 1. Vascular imaging in patients with ischaemic stroke or TIA 2. Brain imaging ≤1 hr of admission in pts arriving within 2 hrs after onset 3. % eligible patients receiving i.v. rtPA therapy 4. Carotid revascularisation for ≥50% symptomatic carotid stenosis 5. Statin treatment at the end of hospital stay in atherothrombotic strokes 6. Antihypertensive treatment at the end of hospital stay for hypertensive pts 7. Pre-hospital training program for laypersons and medical personnel Every ESO Stroke Unit / Centre should at least work on 3 of the following 7 additional QIs A local register and transfer of QIs (+stroke severity, age, sex for benchmarking) into regional/ national databases is recommended ESO 2013 QI - quality indicator
- 13. • Thrombolysis is underused • 20–40% of EU hospitals treating stroke pts do not perform rt-PA! • Wide variability of national DTN times – 15-35 min FI, 20-60 min UK, 15-170 min FR – variations in a quality of care in existing SUs • The majority of pts who receive rt-PA have a DTN time ≥60 min Is current EU stroke care effective enough ? Budincevic H et al. Int J Stroke. 2015,10; Schwamm LH et al. Circulation 2013; 6 Scholten et al. Implement Sci 2015; Ferrari J et al. J Neurol 2013; Tai YJ et al. Int Med J 2013 11.8% 8.9% 7% 7% 18.3% rt-PA rates 39% EU
- 14. Chain of survival Stroke is an emergency Jauch et al. Stroke 2013; AHA/ASA Circulation 2005; Deng et al. Neurology 2006 • Public campaigns (knowledge of stroke symptoms & avoid delayed seeking medical attention) • Centralised emergency number (triage prior to dispatch of emergency team) • Standardised protocols & instruments for early stroke recognition (e.g. FAST, LAPSS) • Emergency and direct transfer to hospitals with stroke / endovascular expertise AHA/ASA 2013 Class I; Level of Evidence B Quick recognition Reaction to stroke signs Rapid dispatch Priority transport ER triage Rapid in-hospital diagnosis and treatment Patient EMS Transport CT/MRI Treatment 50–80% of delays Collaboration between pre- and in-hospital stroke care providers!
- 15. Pre-hospital notification Code Stroke • Mobilisation of appropriate hospital resources • Bypassing administrative admission • Activation of Code Stroke – decreases time to stroke team arrival & CT scan interpretation • Shortens door-to-needle time – 41 min vs. 57 min (Lille, FR) • Increases likelihood of rt-PA treatment – 22% vs. 5% Abdulah AR et al. Prehosp Emerg Care 2008; Casolla B et al. J Neurol 2012; Patel MD et al. Stroke 2011
- 16. Advanced pre-hospital stroke management • Telemedicine – supply 24/7 access to specialist stroke expertise – patient relevant data to the receiving site • Pre-hospital thrombolysis – call–to-needle time: 51 vs. 76 min in routine care – OTT ≤ 90 min: 58% vs. 37% – rt-PA rates: 33% vs. 21% – no difference in ICH, mortality rates – can be integrated into the service chain Ebinger PL et al. JAMA 2014; Weber ST et al. Neurology 2013
- 17. Single interventions to reduce rt-PA delays Eissa A et al. J Clin Pharm Ther 2012; Tai YJ et al. Int Med J 2013 % rt-PA 2% 11% Only the assessment of blood glucose must precede the initiation of intravenous rtPA AHA/ASA 2013 Class I; Level of Evidence B
- 18. Strategies of in-hospital acute stroke management Tai YJ et al. Int Med J 2013; Fonarow GC et al. Circulation 2011 Streamlined (Helsinki model) Stroke physician ED physician Emergency department Stroke team CT scanner DTN (median): 20 min vs. 105 min DTN ≤ 60 min: 94% Triage POC tests iv rt-PA Parallelprocessing Pre-notification History taking Pre-registration “Do as little as possible after the patient has arrived at the ER and as much as possible before the patient is being transported” Meretoja A et al. CT/testsrequests
- 19. Get with the Guidelines Target: Stroke • A national quality improvement initiative from the AHA/ASA • Aim: to ensure that as many patients as possible with AIS achieve a DTN time ≤60 min • 10 key best practice strategies, associated with faster DTN AIS = acute ischaemic stroke; DTN = door-to-needle; EMS = emergency medical service; POC = point-of-care; rt-PA = recombinant tissue plasminogen activator Fonarow GC et al. Stroke 2011;42:2983-9 1. EMS pre-notification 2. Rapid triage protocol and stroke team notification 3. Single call to active stroke team 4. Stroke tools 5. Rapid imaging and interpretation 6. Rapid laboratory testing and POC test 7. Premixing rt-PA 8. Rapid access to rt-PA 9. Team-based approach 10. Rapid data feedback
- 20. Before and after “Target: Stroke” DTN times ≤ 60 min AIS = acute ischaemic stroke; DTN = door-to-needle; rt-PA = recombinant tissue plasminogen activator Fonarow GC et al. JAMA 2014 Pre- Post-intervention Median DTN (min) 77 67 53.3% 29.6%
- 21. Before and after “Target: Stroke” Clinical outcomes Outcome* Before Target: Stroke (n=27,319) After Target: Stroke (n=43,850) Difference (before/after) P Value In-hospital mortality 9.93% 8.25% -1.68% <0.0001 Discharge home 37.6% 42.7% +5.1% <0.0001 Ambulatory status independent 42.2% 45.4% +3.2% <0.0001 Symptomatic ICH 5.68% 4.68% -1.00% <0.0001 Any rt-PA complications 6.68% 5.50% -1.18% <0.0001 * Significant after adjustment for potential confounders (age, baseline stroke severity, hospital characteristics) International Stroke Conference 2014 AIS = acute ischaemic stroke; DTN = door-to-needle; rt-PA = recombinant tissue plasminogen activator Fonarow GC et al. JAMA 2014
- 22. The QUICK Stroke Initiative Making Every Second Count Towards Stroke Recovery Objective of the QUICK Stroke Project: Reduce the delays in the stroke management process of participating hospitals By measuring the delays in the stroke management Pre-hospital phase Hospitalization phase Specialized care phase By identifying the points of improvement in each step By implementing a specific action plan By preparation of the comparative analysis 1 Y E A R 1st snapshot 2nd snapshot www.quick-initiative.com
- 23. The QUICK initiative in Poland Main actions taken Actions aiming at improving the hospital delays and the alert phase: • Procedures – implementation/re-evaluation of stroke alert procedure (in 10 hospitals) – new patient card to fill in ambulance during transport (2) • Training – neurology personnel (10) & ER staff, lab/CT technicians training (4) – training for ambulance service – “Load and go strategy” (2) • Communication – regular “stroke team” (10) & ER, CT, Lab meetings (3) – display of the stroke alert procedure in the ER (4) – site visits of centres by stroke experts for good practice sharing (2) – local patient awareness campaign (5) 10/25 selected hospitals finished the study 510 patients were recruited (2012-2013)
- 24. Main delays: Overall delay to medical decision 0 50 100 150 200 250 300 350 400 450 500 First symptoms to medical decision Median: - 50 min Med=225 Med=175 Snapshot 1 Sep 2012 Snapshot 2 Apr 2013 50-min reduction (22%) Alert phase: Onset of symptoms - to arrival at hospital • median ↓ 40 min (137 vs. 97 min) First symptoms to call to ambulance: ↓ 36 min (60 vs. 24 min) Call to ambulance to arrival at hospital: ↓ 8 min (50 vs. 42 min) Hospital phase: Arrival at the hospital - to medical decision • median ↓ 11 min (71 vs. 60 min) Arrival to laboratory results: ↓ 13 min (82 vs. 69 min) Arrival to consultation with neurologist : ↓ 2 min (7 vs. 5 min) Door-to-CT: 30 min
- 25. Main delays Hospital phase 9-min reduction (11%) Med=89 Med=80 Snapshot 1 Snapshot 2 Median: -9 min rt-PA rate (2012 vs 2013) 12.6% 16.6% 7/10 sites improved rates Door to medical decision ≤60 min: 31% vs 50%
- 26. New strategies to improve stroke management: ESO-EAST • ESO initiative to support Eastern European countries to optimise & implement best stroke care practice locally • AIM: to improve stroke treatment, research and education – developing a strategy to optimize and implement best practices – annual workshops over 5 years from 2015 – leading stroke specialists from 15 countries – facilitate interactions with government agencies, collaboration – unrestricted grants from industry (EVER, Boehringer Ingelheim) – leadership: V. Caso, R. Mikulik + ESO Board members
- 27. The angels initiative is a project sponsored by BI, aimed at optimising and setting up acute stroke networks in low- and middle-income countries with the support of local and international stroke societies. The angels initiative is only available in Africa, Brazil, China, Eastern Europe, India, Mexico, Middle East and South East Asia.
- 28. The angels initiative “start-up kit” for registered hospitals will contain… Checklists and scoring tools Standard forms & protocols Stroke treatment process flow Slide kits & training sets Expert help Body Interact simulations QUICK initiative quality control FAQ & tips and tricks International guidelines Motivational materials The angels initiative is only available in Africa, Brazil, China, Eastern Europe, India, Mexico, Middle East and South East Asia. http://www.angels-initiative.com/
- 29. Main goal: Perfect organisation of hyper/post-acute stroke service • Develop full emergency chain • Identify and track delays • Take effort to shorten time to treatment • The biggest gains and losses occur in the hyperacute phase • Decrease variation in pts management by use of internal protocols • Audit and feedback to improve organized stroke care • Expand the local stroke network to improve access to stroke service • Learn by doing & Share experience
- 30. Thank you for your attention
Editor's Notes
- Medicine has made a substantial progress in the past few years and at last stroke has become a treatable disease. The discussion about present stroke therapies should never omit what has been the main achievement in stroke treatment within last decades. Definitely it’s been the developement of specialised SUs. My task is to address a question how can we do better in terms of in-hospital management of hyper acute ischemic strokeBut first of all I’d like to thank the organisers for inviting me here and having a chance of sharing our experience on this topic and on this forum. 9:45-10:05 Tackling stroke in a developing country - CEE perspective Alexander Tsiskaridze 10:05-10:25 Stroke research activity – CEE perspective Robert Mikulik 10:25-10:45 Stroke unit development and evaluation – what we can improve? Jacek Staszewski 10:45-11:05 ESO EAST Initiative “Enhancing and Accelerating Stroke Treatment” Nikolay Shamalov 11:05-11:25 Challenges in stroke care organization -Ukraine perspective Jurij Flomin Organisation of stroke services varies across different countries due to variations in healthcare systems, financing, facilities and involvement of the government. We are concerned about new therapies and new treatment modalaities and sometimes we should not forget what Organisation of stroke services varies across different countries due to variations in healthcare systems, financing, facilities and involvement of the government. the introduction of the stroke tretment based o In majority of WE and CEE countries SU and modern stroke management are on a high level – and we can ask a question Is there antything we can improve ? In majority of WE and CEE countries SU and modern stroke management are on a high level – and we can ask a question Is there antything we can improve ? In Central and Eastern European countries, 60–70% of hospital beds are taken up by stroke patients in the majority of neurology departments. In the past few years, the diagnostic workup and management of stroke (lysis, mechanical thrombectomy etc.) have undergone revolutionary changes. Guideline recommendations cannot always be applied in real-life situations. The difference between a stroke specialist and a neurologist is that a stroke specialist has the kind of experience that allows for adequate therapeutic and diagnostic decision-making in situations that are not clearly covered by guidelines (some examples include acute stroke with acute or chronic coronary artery disease, multiplex vascular malformations, concomitant tumor, coagulation disorders etc.). Further advances could be achieved by equipping ambulances with CT scans, which would allow for the distinction between hemorrhagic and non-hemorrhagic strokes on the premises and prompt diagnosis, especially in polytrauma cases. Now that everyone has a mobil e phone, it would be nice to have an application that could send an alarm to a stroke center if the owner’s speech changes, e.g. becomes dysarthric. There should also be applications that would loudly remind patients to take their medications from time to time or call attention to missed doses. The operation of an acute stroke center is ideal if it has regular contact with previous stroke patients. Prescript_ions and regular check-ups should be performed by general physicians but patients should present at a stroke center at least every 6 months (especially patients with multiple comorbidities, and those with carotid artery stenosis). The stroke specialist of the stroke center should also monitor the quality of care provided by GPs. Transportation by helicopter and TeleStroke will become widespread in the following years, and comprehensive vascular intervention centers will be established that allow for the desobliteration of coronary and cerebral arteries and for intensive monitoring afterwards. I look forward to the development of thrombolytic agents that are more effective than t-PA. I expect a breakthrough in the field of hemorrhage, especially via the administration of tissue plasminogen activator or other thrombolytic agents into the hematoma. Public awareness is essential. You may have the best technology, the best physicians, the best prehospital management, but this will be completely unuseful if patients call 24 hours later. Guideline recommendations cannot always be applied in real-life situations. The difference between a stroke specialist and a neurologist is that a stroke specialist has the kind of experience that allows for adequate therapeutic and diagnostic decision-making in situations that are not clearly covered by guideline. Even in the United States, the rate of venous thrombolysis is under 10%. Although mechanical thrombectomy represents a significant progress in this field, the next breakthrough will be achieved when patients arriving beyond the time window (e.g. wake-up stroke) can be reliably classified based on the necessity for desobliteration.
- Stroke unit care remains an excellent example of closing the evidence-to-care gap, with Level 1 evidence for the benefits. It increases chances for independence, discharge home, reduces risk for mortality, dependency, complications and shortens lenght of stay in the hospital. Importantly all groups of patients regardless of age, sex, type of stroke and also those presenting late benefit from organised stroke care. These effects generate costs benefits in different models from different countries f.e. stroke care in Canada avoided more than 18 billion dollars indirect costs and 13 billion dollars direct costs within 20 years.
- SU care is so effective, because to recover, the patient must survive the complications of stroke . The effects of Sus improve outcomes of stroke to the level of thrombolysis, they apply universally, and have large population benefit. Taken it together SU care is the gold standard in stroke care and this is widely supported concept that has been recommended since the first high level stroke statement – the Helsingborg Declaration in 2006 to most current stroke guidelines. There is substantial evidence around what constitutes good IS care. Helsongborg declaration which was the first (high level ?) statement of the overall aims and goals of five aspects of stroke management to achieve till 2015. It has been established since the 1990s that appropriate organization of care in stroke has the same role as introduction of new therapies in the acute phase of stroke.
- Stroke unit is the fundamental, basic element of stroke care regardless of hospital level of reference. Conceptually, this is clear that grouping patients in a specified area in the hospital and providing care by a multidisciplinary team of professionals results in better outcomes. However there is no one general model of Stroke Unit care, as this reflects country specific approach. Nowadays in Europe, there are tendencies to establish SUs that incorporate features of the British acute care driven, the German intensive care like and Scandinavian „stroke-rehabilitation units” approaches or to establish comprehensive/integrated acute and rehabilitation SUs that admit acute patients and continue treatment and rehabilitation for a longer time. Effective stroke unit management must be organised˛and provided by coordinated team of profeesionals. : as it gives rise to effective stroke treatment in ordinary hospitals as well as in referral or academic centres and finally forms stroke unit networks. The first stroke units in EU were established in Scandsinavian hospiotals in the 1980s followed by other countries. Elements of are also considered important which emphasises the importance of multimodal monitoring, ultra early etiologiocal clarification and active medical treatment. Organisation of stroke services varies across different countries due to variations in healthcare systems, financing, facilities and involvement of the government. . [A stroke unit is defined as a specified area or ward in a hospital, staffed by a dedicated multidisciplinary team with specialist knowledge and skill in stroke care.] Integrated acute and rehabilitation (comprehensive) stroke unit The effectiveness may differ with regard to costs in selected country etc. What kind of stroke unuits
- Many studies confirmed the superiority of each of these approaches over general medical wards. According to a metanalysis of data there was a significant 13% of relative risk reduction in death and dependency in persons admitted to a SU compared with those admitted to a general medical ward. Stroke patients admitted directly to an acute stroke unit fare better than those admitted to a general medicine ward.
- However as stroke treatment is a complex process to achieve all of the benefits from SU care the following features need to be delivered. They comprise of: strict connection with the EMS with prenotified transfer of the pt to the nearest SU immediate access to CT/blood sampling at ED multiprofessional team approach, staff trained in delivering rtPA, careful nursing care with swallow screening, continous monitoring, quick access to neuroimaging, early prevention and treatment of complications and mobilization finally all of these actions should be coordinated and based on written institutional protocols that document responsiblities and time frames for each actions. Majority of these features form criteria for the assessment of the quality of acute SU organisation which fe. are evaluated by Sentinel Stroke National Audit Programme in the UK and are also specified (listed) by current ESO recommendations.
- Hyperacute stroke service should be well organised to meet the following response times which apply on 24/7 basis. They consist of: door-to-neurologist that need to be achieved within 30 min, lab results in candidates for the acute interventions to be obtained within 20 minutes, doortoCT within 30 min, and door-to-needle as soon as possible, preferably be maintained within 30 minutes, in majority of pts within 60 minutes. These performance metrics : door to Ct, door to neurologist apply to all patients not only to rtPA candidates. Door-to-ct and door-to-needle times are also recommended by ESO as compulsory quality indicators of the hyperacute stroke service. These response times serve as a easy to record performance metrics in many stroke registries such as GWTG, SITS They are similar but not identical for American and european recommendations and these discrepancies reflect difference in organisation models on national level.
- From the wider perspective, general SU organization should be characterized by the 5 following key features, which are evidence based and were evaluated in the Stroke Unit Trialists' Collaboration study. They consist of: wide availability of consultant physician with responsibility for stroke preferably 7 days a week weekly multidisciplinary meetings involving clinical psychology and pallative care specialists to discuss treatment decissions establishing formal links with patients or carer organisations provision of information to patients about stroke, discharge planning and access to stroke specific early supported discharge team if available and also providing continuing education for medical as well as nonmedical staff. These key features do not require financial resource and should be considered as fundamental for all sus. They also form criteria for the quality of stroke service assessed by Sentinel audit and required by the ESO.
- On a higher, national level the effective system of stroke care is based on regional (spoke) hospitals cooperating with comprehensive, reference stroke centre (hub) located on the top of the system. They form care networks with hospitals without stroke expertise : widely make use of telemedicine and drip and ship strategies to streamline acute stroke care. Latest ESO guidelines have introduced new therminology replacing older ones and specified the criteria for: the ESO SU and ESO stroke centres. ESO SU should consist of 2 functional parts : part A refers to acute SU and should have at least 4 beds and provide continous monitoring for the avarege of 72 hrs. One monitored bed is recommended per 100 patients a year. To ensure an acceptable level of expertise at least 200 stroke/TIA patients /yr should be admited , on average 16 pts per year’d be treated by iv rtPA. The postacute step-down SU should include twice the number of monitored beds as part A. For ESO stroke centres additional requirements are mandatory such as more advanced equipment, higher expertised staffing, 24/7 availability of neurovascular/vascular surgery services on site, diversified and larger resources enabling hyperacute interventions f.e. hemicranniectomy and thrombectomy oin site and stroke research.
- To ensure EB requiremnents, high standards and quality are met, stroke units should be: firstly certified by an outside, independent experts and secondly: regularly assessed by internal quality improvement committee organised by each hospital. Self-certification is not acceptable , currently the process of certification is being elaborated by the ESO stroke unit committee. Certification process should include a site visit to make assessment of facilities, personnel, protocols, and outcomes measurred by QIs These measures should also be monitored not only be external bodies but and wether it will be performed by that body or national experts is a matter of debate. The ESO proposes that different types of quality indicators may apply in different countries, ESO stroke units and c Formal certification is important to ensure requirements, standards, and performance are met entres and shouuld be certified! Must include an assessment of facilities, personnel, protocols, and outcomes Should include a site visit Some information submitted on-line
- Based on best practices, ESO endorsed (zatwierdzać) the 6 compulsory following quality measures : only 1 refers to rtPA pts, 1 refers to % of pts treated in the SU, the rest 4 refer to diagnostic procedures and prevention of stroke complications. Every SU should work on addidtional 3 of 7 Qis: referring to neuroimaging, % of pts receiving with tPA, carotid revascularisation, statin and antihypertensive tretament, and organisation of prehospital training program for laypersons. These data - as well as determinants of stroke outcome such as stroke severity, patients age, sex for benchmarking- should be transferred into local or national databases. However in many countries there is no consenus on how often, which variables and which platform to use to collect information – within ESO EAST group we are working on that. As prof. Mikulik said, probably platform created in SITS registry will be the most convinient for every day use.
- Why should this be done? Is not current stroke care not effective enough ? We still have a lot to do. According to the latest reports, in general only 39% stroke pts in Europe has admission to SU, it can be as high as in CZE >80%, >60% in PL, R, Estonia, Belarus, but can be lower than 50%. National registries are seldom conducted. RtPA treatment is underused and IV TPA rate also varies and based on the latest reports it is within wide range f.e. between 7% of all stroke admissions in Pl, US and 18% in Austria. 20-40% of EU hospitals treating stroke pts do not perform tPA at all. There is still wide variability of national DTN time what reflects variations in quality of care in existing Sus. So an ongoing effort should be made to overcome these delays as reducing the treatment times is the single most important modifiable factor to improve patient outcomes. Beside a growing numer of experienced stroke networks, approximately 50% of stroke patients arrive to ER outside of tPA therapeutic time window and majority of those who receive tPA have DTN time that exceeds recommended golden hour. So an ongoing effort should be made to first diagnose and then overcome these delays as reducing the treatment times is the single most important modifiable factor to improve patient outcomes. Suppl A100:125-7. doi: 10.1111/ijs.12575. Epub 2015 Jul 14. Management of ischemic stroke in Central and Eastern Europe. Budincevic H et al. Int J Stroke. 2015 Oct;10 admission to hospitals with no organised stroke care not evidence-based care From the every-day perspective tPA is still underused as only minority of AIS pts receive this treatment because of many different delays. Even within the hospital, time can be lost. Beside a growing numer of experienced stroke centers, many tPA treated pts have still DTN time that exceeds the recommended golden hour. So an ongoing effort should be made to overcome these delays as reducing the treatment times is the single most important modifiable factor to improve patient outcomes. These are theoretical assumptions but are they met in a real life ? Present situation. Why shall we discuss the development and function of SU ? If the % of rtPA is a marker of SU effectiveness the quality is far from optimal with [] Stroke - the most common disease worldwide incidence (M/F): 101–239 / 63–158 per 100,000 243,000 hospitalizations in Germany (2010) 92,500 in Poland (2013) Incidence will double in the next 20 years
- The effective management of acute stroke highly depends on cooperation between 5 pre-hospital and in-hospital links in the so called stroke chain of survival. All these links are equally important. More than half of the delays are generated in prehospital phase. To reduce them, many interventions have been recommended: public awareness campaigns to raise knowledge of stroke symptoms, to avoid delays in seeking medical attention and to use centralized emergency number. educational programmes for EMS personnel that promote „fast track for stroke” by using protocols for rapid dispatch and standardised instruments for diagnosis of stroke such as FAST scale which is easy and rieliable and can be used by either EMS or by community members. Emergency priority transport - the same as that for acute myocardial infarction with direct transfer to hospitals with stroke expertise But the most beneficial is continuous communication and collaboration between pre- and in-hospital stroke care providers based at the local level.
- Even basic communication between EMS and stroke/ER physicians befor the patient arrives to the hospital is crucial. Prenotification concept comes from battlefield from Vietnam war and was later succesfully adapted for other emergency services. It enables mobilisation of hospital resources, bypassing administrative admission and early activation of stroke team. These procedures decrease intra-hospital delays. F.e. in Lille in France, DTN time was reduced by 15 minutes and IV thrombolysis occurred 4 times more often in pts admitted after pre-hospital notification and code stroke activation.
- Future directions in prehospital acute stroke management will possibly comprise of: - telemedicine technologies which have great potential to supply immediate access to specialist stroke expertise and also can help to provide patient-relevant information to the receiving hospital. - pre-hospital thrombolysis in the mobile stroke unit staffed by a neurologist and equipped with a mobile CT scanner and a point-of-care laboratory. So called Strokebus was evaluated here in Berlin and the pilot study showed encouraging results for both treatment safety and efficacy. Probably mobile stroke unit could be integrated into routine service chain in the future especially in rural locations. But this is a future; coming back to Earth we should especialy be aware of hospital delays.
- To overcome these delays many single interventions have been proposed. Each of them may be especially essential in local, specific settings. Generally the most important is appropriate stroke triage in Emergency Department that means giving the same high priority for stroke patient as for an hemodynamically unstable or trauma patient. This intervention has been shown to reduce delays by almost an hour and significantly increase tPA rates. It should be stressed that in typical tPA candidate only the assessment of blood glucose must precede the initiation of intravenous rtPA. In warfarin anticoagulated pt POC INR testing is very helpfull and this can save half an hour compared with awaiting for central lab results. Also advanced imaging should not delay the treatment
- Any single intervention can result in optimal reductions in delays but they rather result from stepwise improvement of the system as a whole. The most effective and impressive model is – Helsinki model – It is streamlined and based on: prenotifiaction with medical history taking, and preregistreation together with preparing CT and tests requests before the pts arrives to Emergency Room. After arrival the pt is bypassing the ED and taken directly to the ct scanner on ambulance stretcher where he is parallely processed : he is being examined, has point of care INR test and finally receives treatment before the admission to stroke unit. This model was shown to reduce DTN down to amazing 20 minutes in Helsinki in majority of pts and what is important it did not result in any increase of misdiagnoses. The authors stress that to obtain maximal reductions of delay majority of actions should be done before the pt arrives to ED.
- To improve standards of hyperacute stroke care on larger scale, on national level: a Get with the guidelines target stroke initiative was launched over ten years ago in US. More that 1500 hospitals have participated and achieved improvements by implementing 10 preselected best practice strategies associated with faster DTN that we have already discussed.
- Basing on these actions: DTN time for tPA administration improved significantly from median of 77 minutes in the preintervention period to 67 minutes during the postintervention period. % of pts that received tPA<60 min increased from 29% to 53% within just 4 years.
- These gains resulted in lower in-hospital mortality and intracranial hemorrhage, along with an increase in patients independence and the percentage of patients discharged home. These findings remained highly statistcally significant after adjusting for patient and hospital characteristics.
- To improve management of hyperacute stroke in other countries, the quick stroke initiative project has been launched in 100 centres in Poland and other 12 mainly European countries. Quick was aimed to reduce delays in participating hospitals by first of all : measuring delays in prehospital, ED, specialized care phase in the first snapshot , then identifing the points of improvement , implementing a specific action plan and finally by preparation the comparative analysis in the 2nd snapshot.
- I am going to present the results from 10 Polish sites with primary or comprehensive stroke units which represent conventional model of stroke management in Poland. 510 pts – appx 50 per site were screened in 2 snapschots 3 main actions aiming at improving the hospital delays and the alert phase have been taken. They consisted of : reevaluation and implementation of stroke alert procedures, comprehensive training for neurologist, ER staff, paramedics and ambulance service with promotion of „load and go strategy, improving communication by setting up regular stroke team and ER staff meetings, and also setting up local patient awareness campaignes
- The QUICK initiative in Poland gave positive results: Within just a few months – thanks to the monitoring and action plan- the median dalay from first symptoms to medical decision decreased by 50 min. It was achiewed by significant decrease of predominantly alert phase –by 40 minutes and resulted from reductions of the hospital phase by 11 minutes due to primarly more effective blood samples management.
- The door to needle improved by 9 minutes from 89 minutes to 80 minutes and it still leaves a room for improvement, but door to medical decision increased significantly from 31 to 50%, 7 of 10 sites improved tPA rates from 12.6% to 16.6% based on this small could we say achievement.