RESUMEN

Purpose: Stroke is the second leading cause of death worldwide with an annual mortality rate of 6.55 million, which accounts for 11.6% of the total number of deaths. Early diagnosis is crucial for improving treatment outcomes. Lean management is an approach originating in the car manufacturing process derived from the Toyota Production System, which healthcare providers have recently adapted. The objective is to examine the use of lean practices in managing AIS in hospital settings. Methods: A systematic literature search was performed using MEDLINE and SCOPUS databases, including publications from 1st January 2000 to 20th September 2022. Results: A total of 13 studies fulfilled the predefined inclusion criteria. The recombinant tissue plasminogen activator (rtPA) was used in 11 studies, in 2 studies in combination with mechanical thrombectomy (MT). MT alone was used in the other 2 studies. The value stream mapping was used in all included studies to analyze workflow in acute ischemic stroke (AIS) treatment. Outcome measures include mostly door-to-needle (DTN) time for rtPA treatment and door-to-puncture (DTP) time for mechanical thrombectomy. DTN time was assessed in nine studies and reached statistically significant results in five. DTP was examined in three studies; in two, statistically significant decreases in DTP were observed. Conclusions: Lean management can be a useful method for achieving key performance indicators in AIS, consistent with current guidelines. The results of this systematic literature review show that value stream mapping may improve the process of AIS treatment by reducing in-hospital delays. The field of research that focuses on implementing lean management tools in healthcare is increasing, with more publications appearing in recent years.

RESUMEN

Background and objective Khyber Pakhtunkhwa is the third largest province of Pakistan by population and has a high incidence of ischemic stroke. We evaluated all patients who presented to the largest tertiary care facility in the province to learn about the current trends in the management of ischemic stroke and explore future opportunities in this regard.  Materials and methods This prospective observational research was carried out at the Lady Reading Hospital-Medical Teaching Institute (LRH-MTI), Peshawar, in the province of Khyber Pakhtunkhwa (KP). The hospital's ethics committee granted the required permissions for the research. Any patient with an ischemic stroke diagnosis, regardless of age, met the inclusion criteria if their diagnosis was confirmed by clinical assessment, imaging (such as CT or MRI), or both. The clinical parameters that were evaluated included the duration since the patient's reported onset of symptoms, the patient's first mode of transfer to the hospital (such as ambulance, private vehicle, or other means), and the date and time of admission to the hospital. A structured database containing the data was utilized, and IBM SPSS Statistics for Windows, Version 25 (released 2017; IBM Corp., Armonk, New York, United States) was used for statistical analysis. Results One hundred fifty-six stroke patients were diagnosed throughout the study period, with 76 of them having an ischemic stroke, accounting for 49% of all stroke cases. Approximately 43% (n = 33) of the patients were from Peshawar, with the remaining patients coming from adjacent districts. There was only a small percentage (19%, n = 15) of patients who were eligible for any thrombolytic therapy, and the majority (93%) were brought by private vehicles. There was a significant association between age and arrival in the emergency room (p = 0.003). Conclusion The study reveals subpar ischemic stroke management in Khyber Pakhtunkhwa, requiring coordinated efforts, modernization of treatment methods, and increased public awareness to improve patient outcomes.

RESUMEN

BACKGROUND AND OBJECTIVES: To minimize stroke-related deaths and maximize the likelihood of cerebral reperfusion, medical professionals developed the "code stroke" emergency protocol, which allows for the prompt evaluation of patients with acute ischemic stroke symptoms in pre-hospital care and the emergency department (ED). This research will outline our experience in implementing the stroke code protocol for acute ischemic stroke patients and its impact on door-to-needle time (DTN) in the ED. METHODS: Our study included patients with a "code stroke alert" upon arrival at the emergency department. The final sample of this study consisted of 258 patients eligible for intravenous (IV) thrombolysis with an onset-to-door time < 4.5 h. ED admissions were categorized into two distinct groups: "day shift" (from 8 a.m. to 8 p.m.) (n = 178) and "night shift" (from 8 p.m. to 8 a.m.) (n = 80) groups. RESULTS: An analysis of ED time targets showed an increased median during the day shift for onset-to-ED door time of 310 min (IQR, 190-340 min), for door-to-physician (emergency medicine doctor) time of 5 min (IQR, 3-9 min), for door-to-physician (emergency medicine doctor) time of 5 min (IQR, 3-9 min), and for door-to-physician (neurologist) time of 7 min (IQR, 5-10 min), also during the day shift. During the night shift, an increased median was found for door-to-CT time of 21 min (IQR, 16.75-23 min), for door-to-CT results of 40 min (IQR, 38-43 min), and for door-to-needle time of 57.5 min (IQR, 46.25-60 min). Astonishingly, only 17.83% (n = 46) of these patients received intravenous thrombolysis, and the proportion of patients with thrombolysis was significantly higher during the night shift (p = 0.044). A logistic regression analysis considering the door-to-needle time (minutes) as the dependent variable demonstrated that onset-to-ED time (p < 0.001) and door-to-physician (emergency medicine physicians) time (p = 0.021) are predictors for performing thrombolysis in our study. CONCLUSIONS: This study identified higher door-to-CT and door-to-emergency medicine physician times associated with an increased DTN, highlighting further opportunities to improve acute stroke care in the emergency department. Further, door-to-CT and door-to-CT results showed statistically significant increases during the night shift.

RESUMEN

BACKGROUND: Tenecteplase (TNK) is considered a promising option for the treatment of acute ischemic stroke (AIS) with the potential to decrease door-to-needle times (DTN). This study investigates DTN metrics and trends after transition to tenecteplase. METHODS: The Lone Star Stroke (LSS) Research Consortium TNK registry incorporated data from three Texas hospitals that transitioned to TNK. Subject data mapped to Get-With-the-Guidelines stroke variables from October 1, 2019 to March 31, 2023 were limited to patients who received either alteplase (ALT) or TNK within the 90 min DTN times. The dataset was stratified into ALT and TNK cohorts with univariate tables for each measured variable and further analyzed using descriptive statistics. Logistic regression models were constructed for both ALT and TNK to investigate trends in DTN times. RESULTS: In the overall cohort, the TNK cohort (n = 151) and ALT cohort (n = 161) exhibited comparable population demographics, differing only in a higher prevalence of White individuals in the TNK cohort. Both cohorts demonstrated similar clinical parameters, including mean NIHSS, blood glucose levels, and systolic blood pressure at admission. In the univariate analysis, no difference was observed in median DTN time within the 90 min time window compared to the ALT cohort [40 min (30-53) vs 45 min (35-55); P = .057]. In multivariable models, DTN times by thrombolytic did not significantly differ when adjusting for NIHSS, age (P = .133), or race and ethnicity (P = .092). Regression models for the overall cohort indicate no significant DTN temporal trends for TNK (P = .84) after transition; nonetheless, when stratified by hospital, a single subgroup demonstrated a significant DTN upward trend (P = 0.002). CONCLUSION: In the overall cohort, TNK and ALT exhibited comparable temporal trends and at least stable DTN times. This indicates that the shift to TNK did not have an adverse impact on the DTN stroke metrics. This seamless transition is likely attributed to the similarity of inclusion and exclusion criteria, as well as the administration processes for both medications. When stratified by hospital, the three subgroups demonstrated variable DTN time trends which highlight the potential for either fatigue or unpreparedness when switching to TNK. Because our study included a multi-ethnic cohort from multiple large Texas cities, the stable DTN times after transition to TNK is likely applicable to other healthcare systems.

Asunto(s)

RESUMEN

Background: This retrospective observational cohort study aimed to evaluate whether tenecteplase's use for acute ischemic stroke (AIS) has time management advantages and clinical benefits. Methods: 144 AIS patients treated with alteplase and 120 with tenecteplase were included. We compared baseline clinical characteristics, key reperfusion therapy time indices [onset-to-treatment time (OTT), door-to-needle time (DNT), and door-to-puncture time (DPT)] and clinical outcomes (24-h post-thrombolysis NIHSS improvement, and intracranial hemorrhage incidence) between the groups using univariate analysis. We assessed hospital stay durations and used binary logistic regression to examine tenecteplase's association with DNT and DPT target times, NIHSS improvement, and intracranial hemorrhage. Results: Baseline characteristics showed no significant differences except hyperlipidemia and atrial fibrillation. OTT (133 vs. 163.72, p = 0.001), DNT (36.5 vs. 50, p < 0.001) and DPT (117 vs. 193, p = 0.002) were significantly faster in the tenecteplase group. The rates of DNT ≤ 45 min (65.83% vs. 40.44%, p < 0.001) and DPT ≤ 120 min (59.09% vs. 13.79%, p = 0.001) were significantly higher in the tenecteplase group. Tenecteplase was an independent predictor of achieving target DNT (OR 2.951, 95% CI 1.732-5.030; p < 0.001) and DPT (OR 7.867, 95% CI 1.290-47.991; p = 0.025). Clinically, the proportion NIHSS improvement 24 h post-thrombolysis was higher in the tenecteplase group (64.17% vs. 50%, p = 0.024). No significant differences were observed in symptomatic intracranial hemorrhage (sICH) or any intracranial hemorrhage (ICH). Patients receiving tenecteplase had shorter hospital stays (6 vs. 8 days, p < 0.001). Tenecteplase was an independent predictor of NIHSS improvement at 24 h (OR 1.715, 95% CI 1.011-2.908; p = 0.045). There was no significant association between thrombolytic choice and sICH or any ICH. Conclusion: Tenecteplase significantly reduced DNT and DPT. It was associated with early neurological function improvement (at 24 h), without compromising safety compared to alteplase. The findings support tenecteplase's application in AIS.

RESUMEN

BACKGROUND: Ischaemic strokes are medical emergencies, and reperfusion treatment, most commonly intravenous thrombolysis, is time-critical. Thrombolysis administration relies on well-organised pathways of care with highly skilled and efficient clinicians. Simulation training is a widespread teaching modality, but results from studies on the impact of this intervention have yet to be synthesised. This systematic review and meta-analysis aimed to synthesise the evidence and provide a recommendation regarding the effects of simulation training for healthcare professionals on door-to-needle time in the emergency thrombolysis of patients with ischaemic stroke. METHODS: Seven electronic databases were systematically searched (last updated 12th July 2023) for eligible full-text articles and conference abstracts. Results were screened for relevance by two independent reviewers. The primary outcome was door-to-needle time for recombinant tissue plasminogen activator administration in emergency patients with ischaemic stroke. The secondary outcomes were learner-centred, improvements in knowledge and communication, self-perceived usefulness of training, and feeling 'safe' in thrombolysis-related decision-making. Data were extracted, risk of study bias assessed, and analysis was performed using RevMan™ software (Web version 5.6.0, The Cochrane Collaboration). The quality of the evidence was assessed using the Medical Education Research Study Quality Instrument. RESULTS: Eleven studies were included in the meta-analysis and nineteen in the qualitative synthesis (n = 20,189 total patients). There were statistically significant effects of simulation training in reducing door-to-needle time; mean difference of 15 min [95% confidence intervals (CI) 8 to 21 min]; in improving healthcare professionals' acute stroke care knowledge; risk ratio (RR) 0.42 (95% CI 0.30 to 0.60); and in feeling 'safe' in thrombolysis-related decision-making; RR 0.46 (95% CI 0.36 to 0.59). Furthermore, simulation training improved healthcare professionals' communication and was self-perceived as useful training. CONCLUSION: This meta-analysis showed that simulation training improves door-to-needle times for the delivery of thrombolysis in ischaemic stroke. However, results should be interpreted with caution due to the heterogeneity of the included studies.

RESUMEN

OBJECTIVES: Prior to our study, little was known about factors related to time-to-treatment for stroke pre- and post-COVID-19. DESIGN: This was a retrospective cohort study to evaluate factors associated with delayed door-to-needle time among patients with acute ischemic stroke over two time-periods. RESULTS: Final sample consisted of 932 charts with mean age of 68.1(±15.6). Significant factors associated with shorter door-to-needle time included ≤ four hours since symptom onset and stroke occurring during post-Covid-19 time-period. Those on anti-coagulants had 72 % higher odds of longer door-to-needle time. As patients got older and stroke symptoms were more severe, less time was spent in door-to-imaging. CONCLUSION: Results highlight the importance of early recognition of stroke symptoms and rapid transport to the hospital. Faster response times in post-Covid-19 time-period may be attributable to systematic processes put in place to address pandemic-related challenges. Outcomes may depend on research to identify gaps in stroke treatment.

Asunto(s)

RESUMEN

Purpose: Intravenous thrombolysis has emerged as an effective approach to improve the long-term survival and functional status of patients with ischemic stroke. The aim of this study was to assess the impact of a national stroke project on the door-to-needle-time (DNT). Patients and Methods: The patients were divided into pre-construction and construction periods. Construction Measures were performed during the construction period. The DNT and onset-to-needle time (ONT) were compared in two period groups. Results: After participating in the National Stroke Center Project and effective measurements, the thrombolysis treatment metrics were improved significantly. The DNT (IQR) was shortened from 65.0 (54.5,85.0) minutes in the Pre-Construction period to 40.0 (33.0,53.0) minutes in the Construction period (p < 0.001). Similarly, the ONT was reduced from 157.0 (IQR) (115.0,184.0) minutes to 116.0 (87.8,170.0) minutes (p = 0.035). Conclusion: The DNT time and ONT time can be shortened by National Stroke Center Construction projects. More suitable hospitals should be encouraged to participate as the National Stroke Center.

RESUMEN

Background: The global COVID-19 pandemic has had a devastating effect on global health, resulting in a strain on healthcare services worldwide. The faster a patient with acute ischemic stroke (AIS) receives reperfusion treatment, the greater the odds of a good functional outcome. To maintain the time-dependent processes in acute stroke care, strategies to reorganize infrastructure and optimize human and medical resources were needed. Methods: Data from AIS patients who received thrombolytic therapy were prospectively assessed in the emergency department (ED) of Hospital de Clínicas de Porto Alegre from 2019 to 2021. Treatment times for each stage were measured, and the reasons for a delay in receiving thrombolytic therapy were evaluated. Results: A total of 256 patients received thrombolytic therapy during this period. Patients who arrived by the emergency medical service (EMS) had a lower median door-to-needle time (DNT). In the multivariable analysis, the independent predictors of DNT >60 min were previous atrial fibrillation (OR 7) and receiving thrombolysis in the ED (OR 9). The majority of patients had more than one reason for treatment delay. The main reasons were as follows: delay in starting the CT scan, delay in the decision-making process after the CT scan, and delay in reducing blood pressure. Several actions were implemented during the study period. The most important factor that contributed to a decrease in DNT was starting the bolus and continuous infusion of tPA on the CT scan table (decreased the median DNT from 74 to 52, DNT ≤ 60 min in 67% of patients treated at radiology service vs. 24% of patients treated in the ED). The DNT decreased from 78 min to 66 min in 2020 and 57 min in 2021 (p = 0.01). Conclusion: Acute stroke care continued to be a priority despite the COVID-19 pandemic. The implementation of a thrombolytic bolus and the start of continuous infusion on the CT scan table was the main factor that contributed to the reduction of DNT. Continuous monitoring of service times is essential for improving the quality of the stroke center and achieving better functional outcomes for patients.

RESUMEN

Introducción: El tiempo puerta-aguja (TPA) es el principal indicador del proceso del código ictus (CI). Según la guía de 2018 de la American Heart Association/American Stroke Associa-tion, el objetivo TPA debe ser inferior a 45 minutos. Para conseguirlo son necesarios protocolos eficaces y revisados de actuación extrahospitalaria e intrahospitalaria. Método: Analizamos la influencia de cambios organizativos entre 2011 y 2019 en el TPA y en la evolución clínica de los pacientes tratados con fibrinólisis. Utilizamos los datos de nuestro centro monitorizados y custodiados por el Pla Director en l’àmbit de la Malaltia Vascular Cerebral dela Generalitat de Catalunya. Entre otras medidas se han analizado las diferencias entre los a ̃nos y las derivadas de la implantación del modelo Helsinki. Resultados: Se estudiaron 447 pacientes, existiendo diferencias estadísticamente significativas en el TPA entre los diferentes a ̃nos. La activación del CI de forma extrahospitalaria en 315(70,5%) pacientes redujo el TPA una mediana de 14 minutos. Sin embargo, el modelo de regresión lineal sólo evidenció una relación inversamente proporcional entre la adopción del modelo deCI Helsinki (MH) y el TPA (coeficiente beta −0,42; p < 0,001). La eliminación de la figura delneurólogo vascular tras la adopción del MH empeoró el TPA y la mortalidad a los 90 días.Conclusión: El modelo organizativo influye en el TPA, siendo en nuestra muestra la aplicacióndel MH, la existencia de la figura del neurólogo vascular referente y la prenotificación del CIfactores claves para la reducción del TPA y la mejora clínica del paciente.(AU)

Introduction: Door-to-needle time (DNT) has been established as the main indicator in codestroke protocols. According to the 2018 guidelines of the American Heart Association/AmericanStroke Association, DNT should be less than 45 minutes; therefore, effective and revised pre-admission and in-hospital protocols are required. Method: We analysed organisational changes made between 2011 and 2019 and their influenceon DNT and the clinical progression of patients treated with fibrinolysis. We collected datafrom our centre, stored and monitored under the Master Plan for Cerebrovascular Disease ofthe regional government of Catalonia. Among other measures, we analysed the differencesbetween years and differences derived from the implementation of the Helsinki model.Results: The study included 447 patients, and we observed significant differences in DNTbetween different years. Pre-hospital code stroke activation, recorded in 315 cases (70.5%),reduced DNT by a median of 14 minutes. However, the linear regression model only showed aninversely proportional relationship between the adoption of the Helsinki code stroke model andDNT (beta coefficient, —0.42; P < .001). The removal of vascular neurologists after the adoptionof the Helsinki model increased DNT and the 90-day mortality rate. Conclusion: DNT is influenced by the organisational model. In our sample, the application ofthe Helsinki model, the role of the lead vascular neurologist, and notification of code strokeby pre-hospital emergency services are key factors for the reduction of DNT and the clinicalimprovement of the patient.(AU)

Asunto(s)

RESUMEN

Introducción: El tiempo sigue siendo una variable determinante para los tratamientos de reperfusión del ictus isquémico agudo. A pesar de las recomendaciones de las guías clínicas, solo alrededor de la tercera parte de los pacientes con ictus isquémico agudo son fibrinolizados en ≤ 60 min. El objetivo de este trabajo es describir nuestra experiencia implementando un protocolo específico de atención del ictus isquémico agudo y evaluar su impacto en nuestros tiempos puerta-aguja.MétodosA finales del 2015, se implantaron gradualmente unas medidas diseñadas para acortar los tiempos de actuación y optimizar la atención del ictus isquémico agudo incluyendo una guardia específica de Neurovascular. Se compararon los tiempos de actuación antes (2013-2015) y después (2017-2019) de la introducción de este protocolo.ResultadosSe incluyó a 182 pacientes antes y 249 después de la intervención. Cuando todas las medidas fueron introducidas, la mediana global de tiempo puerta-aguja fue de 45 min (previa 74 min, 39% menos, p < 0,001) con un 73,5% de pacientes tratados en ≤ 60 min (47% más que preintervención, p < 0,001). El tiempo global al tratamiento (inicio síntoma-aguja) se redujo en 20 min de mediana (p < 0,001).ConclusionesLas medidas asociadas en nuestro protocolo han conseguido una disminución del tiempo puerta-aguja de forma significativa y sostenida, aunque todavía nos queda margen de mejora, la dinámica establecida de control de resultados y mejora continua hará posible seguir avanzando en este sentido. (AU)

Introduction: Time continues to be a fundamental variable in reperfusion treatments for acute ischaemic stroke. Despite the recommendations made in clinical guidelines, only around one-third of these patients receive fibrinolysis within 60 minutes. In this study, we describe our experience with the implementation of a specific protocol for patients with acute ischaemic stroke and evaluate its impact on door-to-needle times in our hospital.MethodsMeasures were gradually implemented in late 2015 to shorten stroke management times and optimise the care provided to patients with acute ischaemic stroke; these measures included the creation of a specific on-call neurovascular care team. We compare stroke management times before (2013-2015) and after (2017-2019) the introduction of the protocol.ResultsThe study includes 182 patients attended before implementation of the protocol and 249 attended after. Once all measures were in effect, the overall median door-to-needle time was 45 minutes (vs 74 minutes before, a 39% reduction; P<.001), with 73.5% of patients treated within 60 minutes (a 47% increase; P<.001). Median overall time to treatment (onset-to-needle time) was reduced by 20 minutes (P<.001).ConclusionsThe measures included in our protocol achieved a significant, sustained reduction in door-to-needle times, although there remains room for improvement. The mechanisms established for monitoring outcomes and for continuous improvement will enable further advances in this regard. (AU)

Asunto(s)

RESUMEN

BACKGROUND: Door-to-needle time (DNT) is a critical consideration in emergency management of acute ischemic stroke (AIS). Deficiencies in the widely applied standard hospital workflow process, based on international guidelines, impede rapid treatment of AIS patients. We developed an in-hospital stroke system to reduce DNT and optimize hospitals' emergency procedures. OBJECTIVES: To investigate the effect of the in-hospital stroke system on the hospital workflow for AIS patients. METHODS: We performed a retrospective study on AIS patients between June 2017 and December 2021. AIS cases were assigned to a pre-intervention group (before the in-hospital stroke system was established) and a post-intervention group (after the system's establishment). We compared the two groups' demographic features, clinical characteristics, treatments and outcomes, and time metrics data. RESULTS: We analyzed 1031 cases, comprising 474 and 557 cases in the pre-intervention and post-intervention groups, respectively. Baseline data were similar for both groups. Significantly more patients in the post-intervention group (41.11%) were treated with intravenous thrombolysis (IVT) or endovascular therapy (ET) compared with those in the pre-intervention group (8.65%) (p < 0.001). DNT was markedly improved (decreasing from 118 (80.5-137) min to 26 (21-38) min among patients in the post-intervention group treated with IVT or bridging ET. Consequently, a much higher proportion of these patients (92.64%) received IVT within 60 min compared with those in the pre-intervention group (17.39%) (p < 0.001). Consequently, their hospital stays were shorter (8 [6-11] days vs. 10 [8-12] days for the pre-intervention group; p < 0.001), and they showed improved National Institutes of Health Stroke Scale (NIHSS) scores at discharge (-2 [-5-0] vs. -1 [-2-0], p < 0.001). CONCLUSION: DNT was significantly reduced following implementation of the in-hospital stroke system, which contributed to improved patient outcomes measured by the length of hospital stay and NIHSS scores.

Asunto(s)

RESUMEN

INTRODUCTION: Time continues to be a fundamental variable in reperfusion treatments for acute ischaemic stroke. Despite the recommendations made in clinical guidelines, only around one-third of these patients receive fibrinolysis within 60minutes. In this study, we describe our experience with the implementation of a specific protocol for patients with acute ischaemic stroke and evaluate its impact on door-to-needle times in our hospital. METHODS: Measures were gradually implemented in late 2015 to shorten stroke management times and optimise the care provided to patients with acute ischaemic stroke; these measures included the creation of a specific on-call neurovascular care team. We compare stroke management times before (2013-2015) and after (2017-2019) the introduction of the protocol. RESULTS: The study includes 182 patients attended before implementation of the protocol and 249 attended after. Once all measures were in effect, the overall median door-to-needle time was 45minutes (vs 74 minutes before, a 39% reduction; P<.001), with 73.5% of patients treated within 60minutes (a 47% increase; P<.001). Median overall time to treatment (onset-to-needle time) was reduced by 20minutes (P<.001). CONCLUSIONS: The measures included in our protocol achieved a significant, sustained reduction in door-to-needle times, although there remains room for improvement. The mechanisms established for monitoring outcomes and for continuous improvement will enable further advances in this regard.

Asunto(s)

RESUMEN

Background: Recombinant tissue plasminogen activator (rtPA) has revolutionized the management of acute ischemic stroke. Shorter door-to-imaging and door-to-needle (DTN) times are crucial for improving the outcomes in thrombolysed patients. Our observational study evaluated the door-to-imaging time (DIT) and DTN times for all thrombolysed patients. Materials and methods: The study was a cross-sectional observational study over a period of 18 months at a tertiary care teaching hospital and included 252 acute ischemic stroke patients of which 52 underwent thrombolysis with rtPA. The time intervals between arrival to neuroimaging and initiation of thrombolysis were noted. Result: Of the total patients thrombolysed, only 10 patients underwent neuroimaging [non-contrast computed tomography (NCCT) head with MRI brain screen] within 30 minutes of their arrival in the hospital, 38 patients within 30-60 minutes and 2 each within the 61-90 and 91-120 minute time frames. The DTN time was 30-60 minutes for 3 patients, while 31 patients were thrombolysed within 61-90 minutes, 7 patients within 91-120 minutes, while 5 each took 121-150 and 151-180 minutes for the same. One patient had a DTN between 181 and 210 minutes. Conclusion: Most patients included in the study underwent neuroimaging within 60 minutes and subsequent thrombolysis within 60-90 minutes of their arrival in the hospital. But the time frames did not meet the recommended ideal intervals, and further streamlining of stroke management is needed even at tertiary care centers in India. How to cite this article: Shah A, Diwan A. Stroke Thrombolysis: Beating the Clock. Indian J Crit Care Med 2023;27(2):107-110.

RESUMEN

How to cite this article: Samavedam S. If Time is Neuron, What Are We Waiting for? Indian J Crit Care Med 2023;27(2):87-88.

RESUMEN

OBJECTIVES: Time from onset to reperfusion affects mortality and favorable outcomes in patients with acute ischemic stroke (AIS). To evaluate effects of a real-time feedback mobile application on critical time intervals and functional outcomes in stroke emergency management. METHODS: We recruited patients with clinically suspected acute stroke from December 1st, 2020 until July 30st, 2022. All Patients had a non-contrast computed tomography (CT) and were included only if they had AIS. We divided the patients into two groups based on the date of availability on mobile application: pre-APP group and post-APP group. Onset to Door time (ODT), Door to Imaging Time (DIT), Door to Needle Time (DNT), Door to Puncture Time (DPT), Door to Recanalization Time (DRT), National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) were compared between two groups. RESULTS: We retrospectively enrolled 312 AIS patients who were assigned into the pre-APP group (n = 159) and post-APP group (n = 153). The median ODT time and median admission NIHSS score were not significantly different between the two groups at baseline assessment. The median (IQR) DIT [44 (30-60) min vs 28 (20-36) min, P < 0.01] and DNT [44 (36.25-52) min vs 39 (29-45) min, P = 0.02] both decreased significantly in two groups. However, median DPT and DRT time showed no significant differences. The proportion of mRS score of 0 to 2 at day 90 was significantly higher in the post-App group than in the pre-App group, at 82.4% and 71.7%, respectively (dominance ratio OR=1.84, 95% CI: 1.07 to 3.16, P = 0.03). CONCLUSION: The present findings indicate that the real-time feedback of stroke emergency management used by a mobile application have potential for shortening the DIT and DNT time and improve the prognosis of stroke patients.

Asunto(s)

RESUMEN

Introduction: Although stroke patients in Slovakia had been treated according to European recommendations, no network of primary and comprehensive stroke centers had been officially established; the ESO recommended quality parameters had not been fulfilled. Therefore, the Slovak Stroke Society decided to change the stroke management concept and introduced mandatory evaluation of quality parameters. This article focuses on key success factors of the change in stroke management in Slovakia and presents the 5-year results and perspectives for the future. Material and methods: We processed data from the stroke register at the National Health Information Center, which is mandatory in Slovakia for all hospitals designated as primary and secondary stroke care centers. Results: Since 2016, we have started to change stroke management. New National Guideline for Stroke Care was prepared in 2017 and published in 2018 as a Recommendation of the Ministry of Health of the Slovak Republic. The recommendation included pre-hospital as well as in-hospital stroke care, a network of primary stroke centers (hospitals administering intravenous thrombolysis - 37), and secondary stroke centers (hospitals treating with intravenous thrombolysis + endovascular treatment (ET) - 6). A stroke priority was instituted, having equally high priority as myocardial infarction. More efficient in-hospital workflow and pre-hospital patient triage shortened the time to treatment. Prenotification became mandatory in all hospitals. Non-contrast CT, and CT angiography is mandatory in all hospitals. In patients with suspected proximal large-vessel occlusion the EMS stays at the CT facility in primary stroke centers until the CT angiography is finished. If LVO is confirmed, the patient is transported to an EVT secondary stroke center by the same EMS. From 2019 all secondary stroke centers offer endovascular thrombectomy in a 24/7/365 system. We consider the introduction of quality control one of the most critical steps in stroke management. The result of these activities is 25.2% of patients treated with IVT and 10.2% by endovascular treatment, and median DNT 30 min. Number of patients screened for dysphagia increased from 26.4% in 2019 to 85.9% in 2020. In the most of the hospitals the proportion of ischemic stroke patients discharged with antiplatelets and in case of AF with anticoagulants was >85%. Discussion: Our results indicate that it is possible to change stroke management at a single hospital and national level. For continuous and further improvement, regular quality monitoring is necessary; therefore, the results of stroke hospital management are presented regularly once a year at national and international level. Collaboration with the "Second for Life" patient organization is very important for the "time is brain" campaign in Slovakia. Conclusion: Due to the change in stroke management over the last 5 years, we have reduced the time for acute stroke treatment and improved the proportion of patients with acute treatment, and in this area, we have achieved and exceeded the goals of the Stroke Action Plan for Europe for 2018-2030. Nevertheless, we still have many insufficiencies in stroke rehabilitation and post-stroke nursing that need to be addressed.

Asunto(s)

RESUMEN

INTRODUCTION: Door-to-needle time (DNT) has been established as the main indicator in code stroke protocols. According to the 2018 guidelines of the American Heart Association/American Stroke Association, DNT should be less than 45minuts; therefore, effective and revised pre-admission and in-hospital protocols are required. METHOD: We analysed organisational changes made between 2011 and 2019 and their influence on DNT and the clinical progression of patients treated with fibrinolysis. We collected data from our centre, stored and monitored under the Master Plan for Cerebrovascular Disease of the regional government of Catalonia. Among other measures, we analysed the differences between years and differences derived from the implementation of the Helsinki model. RESULTS: The study included 447 patients, and we observed significant differences in DNT between different years. Pre-hospital code stroke activation, recorded in 315 cases (70.5%), reduced DNT by a median of 14minutes. However, the linear regression model only showed an inversely proportional relationship between the adoption of the Helsinki code stroke model and DNT (beta coefficient, -0.42; P<.001). The removal of vascular neurologists after the adoption of the Helsinki model increased DNT and the 90-day mortality rate. CONCLUSION: DNT is influenced by the organisational model. In our sample, the application of the Helsinki model, the role of the lead vascular neurologist, and notification of code stroke by pre-hospital emergency services are key factors for the reduction of DNT and the clinical improvement of the patient.

Asunto(s)

RESUMEN

Objective: This study aims to investigate the effectiveness of a quality improvement program for reducing intravenous thrombolysis (IVT) delay in acute ischemic stroke (AIS). Materials and methods: We implement a quality improvement program consisting of 10 interventions for reducing IVT delay, including the establishment of an acute stroke team, standardized management of stroke teams, popularization of stroke and its treatment, emergency bypass route (BER), the achievement of computed tomography (CT) priority, no-delay CT interpretation, intravenous thrombolysis on the CT table, payment after treatment, whole recording, and incentive policy. We retrospectively analyzed the clinical time and outcome data of AIS patients treated with IVT in pre-intervention (108 patients) and post-intervention groups (598 patients), and further compared the differences between the non-emergency bypass route (NBER) and BER in the post-intervention group. Results: The thrombolysis rate increased from ~29% in the pre-intervention group to 48% in the post-intervention group. Compared with the pre-intervention group, the median of door-to-needle time (DNT) was greatly shortened from 95 to 26 min (P < 0.001), door-to-CT time (DCT) was noticeably decreased from 20 to 18 min (P < 0.001), and onset-to-needle time (OTT) significantly declined from 206 to 133 min (P = 0.001). Under the new mode after the intervention, we further analyzed the IVT delay difference between the NBER (518 patients) and BER groups (80 patients) from the post-intervention group. The median values of DNT (18 vs. 27 min, P < 0.001), DCT (10 vs. 19 min, P < 0.001), and OTT (99 vs. 143 min, P < 0.001) showed significant reductions in the BER group. The quality improvement program under the emergency platform successfully controlled the median of DNT to within 26 min. Conclusions: Collectively, the BER mode is a feasible scheme that greatly decreased DNT in AIS patients, and the secret to success was to accomplish as much as possible before the patient arrives at the emergency room.

RESUMEN

Ischemic stroke is defined as neurological deficit caused by brain infarction. The intravenous tissue plasminogen activator, alteplase, is an effective treatment. However, efficacy of this method is time dependent. An important step in improving outcome and increasing the number of patients receiving alteplase is the shortening of waiting times at the hospital, the so-called door-to-needle time (DNT). The comprehensive Helsinki model was proposed in 2012, which enabled the shortening of the DNT to less than 20 min. Background and Objectives: The aim of this study was to analyze the transferability of the suggested model to the West Tallinn Central Hospital (WTCH). Materials and Methods: Since the first thrombolysis in 2005, all patients are registered in the WTCH thrombolysis registry. Several steps following the Helsinki model have been implemented over the years. Results: The results demonstrate that the number and also the percent of thrombolysed stroke patients increased during the years, from a few thrombolysis annually, to 260 in 2021. The mean DNT dropped significantly to 33 min after the implementation of several steps, from the emergency medical services (EMS) prenotification with a phone call to the neurologists, to the setting-up of a thrombolysis team based in the stroke unit. Also, the immediate start of treatment using a computed tomography table was introduced. Conclusions: In conclusion, several implemented steps enabled the shortening of the DNT from 30 to 25.2 min. Short DNTs were achieved and maintained only with EMS prenotification.

Asunto(s)