Background High insulin-like growth factor-1 (IGF-1), measured once during acute-stroke, is associated with greater survival rates and lower stroke severity. However, information is lacking regarding how IGF-1 availability, determined by IGF-1’s ratio to insulin-like growth factor binding protein-3 (IGFBP-3), relates to recovery and how the response of IGF-1 during the first week of stroke relates to outcomes. The purpose of this study was to determine: 1) the relationship between percent-change in IGF-1 and IGF-1 ratio during the first week of stroke and stroke outcomes; and 2) the difference in percent-change in IGF-1 and IGF-1 ratio in individuals who discharged home and individuals who discharged to inpatient facilities. Methods IGF-1 and IGFBP-3 were quantified from blood sampled twice (<72 hours of admission; 1-week post-stroke) in fifteen individuals with acute-stroke. Length of stay, modified Rankin Scale at one-month, and discharge destination were obtained from electronic medical records. Results Percent-change in IGF-1 ratio was related to length of stay (r=.54; p=.04). Modified Rankin Scale (n=10) was related to percent-change in IGF-1 (r=.90; p<.001) and IGF-1 ratio (r=.75 p=.01). Those who went home (n=7) had decreases in IGF-1 (−24±25%) and IGF-1 ratio (−36±50%), while those who went to inpatient facilities (n=8) had increases in IGF-1 (37±46%) and IGF-1 ratio (30±40%). These differences were significant (IGF-1: p=.008; IGF-1 ratio p=.01). Conclusion Our findings suggest that a decrease in IGF-1 and IGF-1 ratio during the first week of stroke is associated with favorable outcomes: shorter length of stay, greater independence at one-month on the modified Rankin Scale, and discharging home.
Background Insulin-like growth factor-1 (IGF-1) is neuroprotective after stroke and is regulated by insulin-like binding protein-3 (IGFBP-3). In healthy individuals, exercise and improved aerobic fitness (peak oxygen uptake; peak VO2) increases IGF-1 in circulation. Understanding the relationship between estimated pre-stroke aerobic fitness and IGF-1 and IGFBP-3 after stroke may provide insight into the benefits of exercise and aerobic fitness on stroke recovery. Objective The purpose of this study was to determine the relationship of IGF-1 and IGFBP-3 to estimated pre-stroke peak VO2 in individuals with acute stroke. We hypothesized that: 1) estimated pre-stroke peak VO2 would be related to IGF-1 and IGFBP-3; and 2) individuals with higher-than median IGF-1 levels will have higher estimated pre-stroke peak VO2 compared to those with lower-than median levels. Methods Fifteen individuals with acute stroke had blood sampled within 72 hours of hospital admission. Pre-stroke peak VO2 was estimated using a non-exercise prediction equation. IGF-1 and IGFBP-3 levels were quantified using enzyme-linked immunoassay. Results Estimated pre-stroke peak VO2 was significantly related to circulating IGF-1 levels (r = 0.60; p = .02), but not IGFBP-3. Individuals with higher-than median IGF-1 (117.9 ng/mL) had significantly better estimated aerobic fitness (32.4 ± 6.9 mL*kg−1*min−1) than those with lower-than median IGF-1 (20.7 ± 7.8 mL*kg−1*min−1; p = .03). Conclusions Improving aerobic fitness prior to stroke may be beneficial by increasing baseline IGF-1 levels. These results set the groundwork for future clinical trials to determine whether high IGF-1 and aerobic fitness are beneficial to stroke recovery by providing neuroprotection and improving function.
Background: In healthy individuals, higher circulating insulin-like growth factor-1 (IGF-1) is related to higher aerobic fitness, measured as peak VO 2 . IGF-1 has been shown to possess neuroprotective qualities after stroke. Prior work suggests that elevated IGF-1 within the first week of stroke lead to increased survival rates and less severe stroke impairments at one month. However, it is unclear whether higher aerobic fitness is related IGF-1 levels after stroke. It is difficult to measure peak VO2 during the acute hospital stay. However, using a previously established peak VO2 prediction equation would allow us to address this gap in knowledge. By understanding the interaction of IGF-1 and estimated peak VO 2 after stroke, knowledge can be gained in people post-stroke. We hypothesize that individuals with acute stroke and above median levels of IGF-1 will have significantly higher estimated peak VO 2 at the time of admission. Methods: Twenty-two individuals (10 male; 61 ± 11 years of age) with a diagnosis of acute stroke were enrolled into our study. Blood was sampled within 72 hours of hospital admission under fasting conditions between the hours of 7:30 and 9 am. Samples were centrifuged to obtain plasma, aliquotted, and frozen until assaying. Standard ELISA analyses were used to quantify total IGF-1. Upon enrollment, peak VO 2 was estimated using a previously established equation that considered a self-report measure of physical activity level, age, gender, BMI, and resting heart rate. Results: Median level of IGF-1 was 121 ng/mL. Those who had above median levels of IGF-1 had significantly higher estimated peak VO 2 (29.8 ± 7.9 ml/kg/min) compared to those with lower than median IGF-1 levels (20.9 ± 7.6 ml/kg/min; p = .014). Conclusion: Our data suggests that being physically active prior to stroke and possessing a higher estimated peak VO 2 may have higher IGF-1 levels in individuals after stroke. This may provide some neuroprotective benefit. Future trials with a larger sample size are needed to determine if higher IGF-1 is related to measured aerobic fitness after stroke.
Background and Purpose: Kansas is a rural state lacking geographically distributed Primary Stroke Centers. Of the 128 hospitals in the state, 88 are designated as Critical Access (< 25 beds). The IV r-tPA treatment rate in the state of Kansas is less than 2%. The pre-transport death rate for patients experiencing stroke is 55.4% .The Kansas Initiative for Stroke Survival (KISS) is a non-government task force with the goal of improving stroke survival among Kansans. The task force encourages hospitals to meet the criteria as Emergent Stroke Ready and based on this status engage with their individual communities, emphasizing the need to seek immediate assistance by EMS and arrive at the closest Emergent Stroke Ready hospital. Methods: The Kansas State Stroke Task force determined requirements for a facility to be considered Emergent Stroke Ready. This information was distributed to all acute care hospitals, asking them to attest to their current Emergent Stroke Ready status. Responding facilities were provided access to a 24 x 7 Stroke Support Line - providing access to stroke specialists for the purpose of guiding evaluation and treatment decisions for r-tPA administration or need to transfer to a higher level of care. Also provided is a community education kit. Data is reported through a monthly online survey or GWTG database. Results: In the first phase of the KISS project - forty-two hospitals attested as Emergent Stroke Ready Hospital or were certified Primary Stroke Centers representing an increase from 7% to 33% of hospitals in the state. The post-KISS implementation IV r-tPA treatment rate for the reporting Emergent Stroke Ready Hospitals was 48% compared with a pre-KISS treatment rate of 6%. The post-KISS implementation transfer rate was 26.7% compared with a pre-KISS transfer rate of 18%. Conclusions: The KISS program resulted in a significant increase in the number of Emergent Stroke Ready facilities, stroke patients reporting to their local hospitals, stroke specialist consultations and use of IV r-tPA. A low-cost, statewide program that provides standardized protocols and direct phone consultation can improve access to stroke specialists and approved stroke treatment while offering a cost effective, feasible alternative to telestroke.
Comprehensive Stroke Centers (CSCs) provide leadership to the surrounding communities they serve. Until state certification is mandated through legislative action, CSCs may be the best actors to create and improve stroke systems of care. Our CSC is in a state with 83 out of 126 Critical Access Hospitals. We launched the Kansas Initiative for Stroke Survival (KISS) in 2012, offering training and resources on quality measures and protocols necessary to recognize and treat stroke. Hospitals were invited to do an assessment of what they needed to do to become “stroke ready” and sign an attestation that acute therapy could be administered with telephonic assistance from a tertiary center and a transfer plan in place. In the first two years, over sixty hospitals participated, but those enrolled in KISS as emergent stroke ready did not show sustained improvement in stroke care. Door to needle time increased 25% in the last year. In response, our CSC created an independent executive board, representing professionals from nursing, emergency medical services, management, and medicine, to lead a broader statewide approach to education and accountability. Our new goals are to develop a statewide capability map, distribute a quarterly newsletter highlighting efforts across the state, and develop a website with links to presentations, protocols, and statewide data. We have already redesigned the data survey to enhance reporting and analysis, community-level boot camps have been implemented, and a statewide peer review has begun. Our CSC leads the quarterly peer review along with education that covers topics impacting outcomes, such as time from door to thrombolytic therapy and endovascular case selection; the first conference had 27 participants across the state. Our experience demonstrates that CSCs can lead statewide improvements in stroke care and that hospitals around the state are receptive to that leadership. Collaboration between hospitals can improve stroke outcomes.
Background: Comprehensive Stroke Centers provide hyperacute stroke care within hours of symptom onset. Patients benefit from this intervention but still have needs that have yet to be addressed. Health care must be delivered efficiently while meeting the expectations of the public. A methodical solution achieves excellent outcomes for providers, payers, and patients. Purpose: The goal of the health care team is to provide a clear assessment and discharge planning process that enhances communication amongst team members. With an annual volume increase of 10-20%, throughput is a daily challenge at this academic hospital due to rotating physicians and students. Methods: A comprehensive assessment is documented in the electronic medical record within 24 hours of admission by the case management team. This assessment includes screening for depression and need for respite services. A resource guide is immediately provided to the patient and family. Five days a week, the health care team is assembled for “patient care huddles”. These are attended by the vascular neurologist, case management social worker and nurse, speech and physical therapy, stroke program coordinator, pharmacist, utilization review, research coordinator, neurology residents, and each bedside nurse. The 2 minute per patient discussion centers on “plan for the day, plan for the stay”. Results: The number of ischemic stroke and TIA patients has increased 25% over two years. In the same time period, the average length of stay index has decreased from 1.17 to 1.00 and the average cost index is 1.08. Patient satisfaction, as measured by Press Ganey, is at the 98 th percentile for stroke patients over the last two years. Conclusion: Communication among all team members is enhanced through daily patient care huddles and allows discharge planning to start at admission. Comprehensive assessments leading to efficient discharge planning can be achieved without compromising patient satisfaction or increasing costs or length of stay. Throughput is impacted by an efficient, cohesive team.
Background and Purpose: Historically, Emergency Medical Services (EMS) and Emergency Department (ED) nursing staff have had no standardized method of hand-off reporting, and documentation of the communication has been difficult to locate in the medical record. Comprehensive Stroke Centers (CSC) are called to collaborate and communicate with all care delivery partners, including providers from transferring facilities. A standardized method of communication and documentation sets the stage for safe patient care transitions. Methods: Regional community discussion began in 2011. Proposals were made and no early adopters came forward. Internal discussion was readdressed. A team was assembled consisting of researchers and frontline staff from ED, EMS and the CSC. A hand-off communication tool was developed using Situation, Background, Assessment, and Treatments format. The tool includes stroke specific data points important to care and pilot data will be collected during fourth quarter of 2013. Metrics include compliance of tool use and an accurate medical history with home medications. Three EMS providers representing urban, suburban and rural services have been recruited. Each Paramedic-RN team involved in a hand-off will receive an electronic survey measuring engagement and satisfaction. Results: A standardized method for communicating important hand-off information was developed and will be demonstrated. Final analysis of the data at the end of the quarter will provide direction to further improve the tool with the goal of permanent implementation within the region. Ongoing data analysis will be communicated to all providers monthly via electronic communication. Sharing the story with the region on a regular basis presents a road-map for successful safe patient transitions. Conclusions: The development of consistent standardized hand-off communication between pre-hospital and hospital staff is essential to patient safety. Collaboration empowers best practice solutions. Accurate medical history assists in rapid emergent evaluation. Engaged pre-hospital and hospital personnel using standardized tools are likely to provide consistent safe patient transitions. Safe hand-off communication is paramount for all CSC partners.
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