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