stroke units which aspects of stroke unit care determine outcome? christine roffe
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Stroke Units
Which aspects of stroke unit care determine outcome?
Christine Roffe
National Sentinel Audit30-day Mortality
2002 Mortality ? (not recorded, 30-34% in WMIDS)
2004 Mortality 27%
2006 Mortality 22%
2008 Mortality 20%
2010 Mortality 17%
Cochrane Database of Systematic Reviews 2007, Issue 4. Frst published online: April 25. 1995Last assessed as up-to-date: November 28. 2006. Last viewed Mar 2013.
Cochrane Database of Systematic Reviews
Acute stroke management protocol of the Trondheim stroke unit
0-24 hours
Medical assessment Clinical examination, CT head, ECG, routine bloods
Observations BP, HR, SSS 4x/d
Temp 2x/d
Treatment iv saline (no glucose)
Oxygen for hypoxia drowsiness and heart failure
Paracetamol for temp>38
Heparin 5000 IU sc BD
Rehabilitation Stimulation, mobilization, sitting up, out of bed
24-72 hours
Observations as 0-24 h, plus check for complications 4x/d
Medical Carotid Doppler, Echo, 24 hour tape as required
Start secondary prophylaxis
Detect and treat complications
Rehabilitation mobilization, transfer training, sitting, walking, ADLS
Indredavik, Stroke 1999;30:917-23.
DIAGNOSIS
Immediate Computed Tomography Scanning of Acute Stroke Is Cost-
Effective and Improves Quality of Life
1 Scan all patients immediately Cost per quality adjusted life year =£ 5,041 (cheapest)
2 Scan pts on anticoagulants or in life-threatening condition immediately, the rest within 24 h
3 Scan pts on anticoagulants or in life-threatening condition immediately, the rest within 48 h
4 Scan pts on anticoagulants or in life-threatening condition immediately, the rest within 7d
5 Scan pts on anticoagulants or in life-threatening condition immediately, the rest within 14 d £6,519 (most expensive)
6. Scan pts on anticoag. or in life-threatening cond. or potential thrombolysis cand. immediately, the rest within 24 h £ 5,079 (NICE)
7. Scan pts on anticoag. or in life-threatening cond. or potential thrombolysis cand. immediately, the rest within 48 h
8. Scan pts on anticoag. or in life-threatening cond. or potential thrombolysis cand. immediately, the rest within 7d
9. Scan pts on anticoag. or in life-threatening cond. or potential thrombolysis cand. immediately, the rest within 14 d
10 Scan o`nly pts in AF or on anticoagulants or antiplatelet drugs within 7 d
11 Scan only pts with a life-threatening stroke or on anticoagulants within 7 d 12 Do not scan anyone £ 5,542
Wardlaw et al, Stroke. 2004;35:2477-2483
CT Head scan
Intracerebral haemorrhage
• Correct abnormal INR or low platelets immediately
• Neurosurgical referral
Cerebral Infarct• Thrombolysis or • immediate antiplatelet
treatment
Candelise Lancet 2007;369:299.
MRI Scan
7-DAY WORKING
Dying for the Weekend A Retrospective Cohort Study on the Association Between Day of Hospital Presentation and the Quality and
Safety of Stroke Care
Arch Neurol. 2012;69(10):1296-1302. doi:10.1001/archneurol.2012.1030
Performance of stroke care (odds ratios) by day of admission.
A, Unadjusted rates of same-day brain scans. B, Unadjusted rates of thrombolysis.
C, Adjusted rates of pneumonia. D, Adjusted rates of deaths within 7 days.
E, Adjusted rates of discharge to usual place of residence. F, Adjusted rates of emergency readmissions.
Data points represent odds ratios, with Monday used as a reference (1.00); vertical ranges, 95% confidence intervals.
7 day working in the UK would
•Save 350 deaths per annum•Allow 650 more to return home
TREATMENT
• Intravenous thrombolysis
• 7% of all strokes in the UK
• Within 4.4 h of symptom onset
• Time is brain
Rha et al. Stroke 2007;38:967-973.
Relationship of recanalization vs nonrecanalization to good outcome at 3 months
Mechanical thrombectomy
Intervention Trial n Base-line NIHSS
Recanalization MRS<=2 at 90 d
Mortality at 90 d
IMS II 2007 IV+IA EKOs PO 81 19 58% 46% 16%
MERCI 2007 IA+MERCI PO 141 20 60% 28% 44%
Multi MERCI 07 IV+IA+MERCI PO 164 19 68% 36% 34%
Mazighi 09 IV+IA ±MT Reg 53 87% 57% 17%
Penumbra 09 IA+Penumbra PO 125 17 82% 25% 33%
Abou-C 2010 IV+IA+MT/stent Open 55 19 84% 41 & 43% 29 & 23%
Bang 2011 IAT, MT, or both Open 220 17 64% Not given 29%
Brinjiki 2011 IAT±MT Reg 3864 Not given Not given Not given 24% A
Costalat 2011 IV+IAT+Solitaire PO 50 15 84% 54% 12%
Malik 2011 Angioplasty+stent+MT/IA
RO 77 15 75% 42% ICH 40%
Yoshimura 2011
IAT/angioplasty,stent,suction ±IV
Survey 223 Not given 25% ICA 37% M1 48% BA*
20% ICA
30% M1
39% BA
SICH 0% IV+EVT, 12% MT
Galimanis 2012 EVT (44% MT) Reg 623 15 70% 49% 19%
San Roman 2012
Trevo ± other±IA PO 60 18 87% 45% 28%
UHNS 2012 IA/Stenttriever+iv Reg 106 18 87% 47% 17%
EVT
Vs.
control
n Device
Territory
Age
Delay tPa Inclusion NIHSS
Proportion with MT
Recanalization
Complications of EVT
sICH
Mortality at 90d
mRS ≤2 at 90 d
MR Rescue
USA and B
118 M, P M1 M2**
18-85
<8h to rand
yes<3h
(44%)
6-29 most 67% TICI≥2a
Same as control
5% vs. 4%
19% vs. 24%
20% vs. 20%
IMS III**
USA
656 E+ia,ia, M, or P
Any* 18-82
<3h to rand
Yes <3h
>=10 44% 75%** TICI≥2a
41%
TICI≥2b
16% 6.2 vs.
5.9
19% vs. 22%
41% vs.
39%
SYNTHESIS
I
362 EVT Any *
18-80
<4.5 h to rand
Control only <4.5h
Any 30% Not reported
Same as control
6% vs. 6%
14% vs. 10%
42%
Vs.
46 %
Randomized controlled trials of endovascular treatments for stroke
Broderick et an NEJM Feb 2013, Kidwell et al NEJM Feb 2013, Ciccone NEJM Feb 2013
Malignant MCA syndrome
Mainly a problem in young patients with big strokes. Rapidly fatal if not treated.
Decmpressive hemicraniectomy
Figure 1
Source: The Lancet Neurology 2009; 8:602-603 (DOI:10.1016/S1474-4422(09)70157-7)
Terms and Conditions
Early Mobilization
Avert III RCT of very early mobilization after acute stroke , 1553 patients randomized by March 2013
Fever, sugar, swallowing (FeSS) intervention elements
Protocols for FeSS by nurses for first 72 h of ASU care19 ASUs Cluster randomized
Distribution of 90-day modified Rankin scale*No change in mortalityLess dead or dependent (mRS.2) With RsSS (42% vs 58%, p=0.002) NNT 6
Middleton et al, Lancet Oct 2011
Unexpected nocturnal hypoxia in stroke patients
Time spent with an oxygen saturation <90% at night
52% more than 5 minutes
23% more than 30 minutes
15% more than 1 hour
Roffe et al, Stroke 2003;34:2641-2645
Association Between Processes of Stroke Careand Outcome
Neurology assessment 1.13 (0.59-2.17)
Swallowing evaluation 0.64 (0.43-0.94)
DVT prophylaxis 0.60 (0.37-0.96)
Early mobilization present (vs absent) 0.69 (0.42-1.14)
Early mob. Contraind. present (vs absent) 0.83 (0.53-1.29)
BP managem: guideline concord (vs discord.) 1.00 (0.67-1.50)
BP managem. Contraind. present (vs discordant) 0.90 (0.47-1.70)
Fever, any (vs none) 1.51 (0.94-2.42)
Fever, some episodes given acetaminophen 1.87 (0.99-3.54)
Fever, all episodes given acetaminophen 0.71 (0.35-1.41)
Hypoxia, any (vs none) 2.89 (1.48-5.65)
Hypoxia, some episodes given oxygen 5.12 (1.68-15.61)
Hypoxia, all episodes given oxygen 0.26 (0.09-0.73)
Bravata Arch Intern Med 2012;170:804-10.
PREVENT PNEUMONIA
Prevent Pneumonia
NUTRITION
The Food Trial
1996-2003, enrolled within 7 d of stroke, if uncertain about which option to chooseoutcome death and disability (MRS 3-5) at 6 months.
Trial 1: supplements vs no supplementsn=4023, med age 73y, 8% undernourished, 54% could lift both armsavg amount of supplement 14 L /34 days=>no difference in death (12% vs 12.7%) and disability but: slightly less pressure sores in the control group
Trial 2: Early NGT vs delayed NGT (1 wk)n=859, med age 78, 9% undernourished, 16% able to lift both arms=> Mortality 48%->42% (p=0.08) but: excess of GI bleed s with early tube feeding
Trial 3: NGT vs early PEGn=32, med age 77y, 22% undernourished, 16% able to lift both armsmed time to put in PEG was 3 d, => mortality increase of 1% with early PEG feedingnote: PEG fed patients were 3x more likely to have pressure sores
They were less likely to return to normal feeding they were more likely to be discharged to NH
Lancet 2005;365:755-63 and 764-72.
AUDITUHNS Stroke Register Data
Discharge Destination for Stroke Patients 2001-2011
0%
10%20%
30%40%
50%
60%70%
80%90%
100%
Home
NH, RH, or Other
Dead
HSMR Mortality Overview (National)
“Dr Foster” July 2011-June 2012
RESEARCH
• Integration of Research into day to day clinical practice
– Many established treatments have no evidence base
– New treatments are needed
– Patients who participate in research have better outcomes
– Quality of care is better in research active stroke units