Abstract-We describe the development, implementation, and outcomes of the first 2 years of the Electronic Stroke CarePath, an initiative developed for management of ischemic stroke patients in an effort to improve efficiency and quality of care for patients. The CarePath consists of care pathways for ischemic stroke that are integrated within the electronic health record. Patient-reported outcomes are collected using an external software platform. Documentation tools, order sets, and clinical decision support were designed to improve efficiency, optimize process measure adherence, and produce clinical data as a byproduct of care that are available for future analyses. Inpatient mortality and length of stay were compared before and after CarePath implementation in ischemic stroke patients after adjustment for case-mix. Postdischarge functional outcomes of patients with ischemic stroke were compared between the first 3 months of rollout and remainder of the study period. From January 2011 to December 2012, there were 1106 patients with ischemic stroke on the CarePath. There was a decline in inpatient mortality in patients with ischemic stroke, but not in control patients with intracerebral or subarachnoid hemorrhage.Completion rate of patient-reported questionnaires at postdischarge stroke follow-up was 72.9%. There was a trend toward improved functional outcomes at follow-up with CarePath implementation. Implementation of the Electronic Stroke CarePath is feasible and may be associated with a benefit in multiple different outcomes after ischemic stroke. This approach may be an important strategy for optimizing stroke care in the future. Goals and Vision of the ProgramImprovements in efficiency, quality, and coordination of care are essential for healthcare institutions to adapt successfully in an era of decreasing reimbursement. Heart disease and stroke, which are leading causes of morbidity, mortality, and healthcare costs in the United States, are often among the first diseases to be involved in healthcare innovations and policy changes. 1,2 They were among the first to have disease-specific process and outcome measures publically reported by the Center for Medicare and Medicaid services (CMS) and to have society supported quality registries. Regional and national systems of care are more advanced in stroke and myocardial infarction than in most other diseases. Solutions developed to improve delivery of care for patients with heart disease, and stroke can serve as models for the treatment of other conditions.One important strategy to improve the efficiency and quality of healthcare is standardization of care. This is often done by implementing evidence-based protocols that incorporate guidelines into care algorithms. Evidence-based protocols can improve quality by providing guidance on indications for tests or interventions. A related method is the use of care paths, also referred to as critical pathways or care pathways. These are management plans that additionally provide the sequence and timing of actions ...
Background: There is a continuous need to improve efficiency and quality of care. In response, the Electronic Stroke CarePath (ESCP) was developed for management of ischemic stroke patients. We describe the development, implementation and outcomes of the first 2 years of this initiative. Methods: The ESCP consists of care pathways for ischemic stroke that are integrated within the EHR (Epic) and includes systematic collection of patient-reported outcomes (PROs). Main components of the EHR integration included a navigation panel, the use of structured forms with elements that autopopulate templates, and clinical decision support. An external software platform was used to collect PROs. Inpatient mortality and length of stay (LOS) were compared before and after implementation in ischemic stroke patients and in 2 control groups: ICH and SAH patients, after adjustment for case-mix. Postdischarge functional outcomes of ischemic stroke patients were compared between the 1st 3 months of rollout and remainder of the study period.<br Results: The ESCP was implemented in Sep 2010 and modified over the first 3 months. Data were analyzed from Jan 2011- Dec 2012. There were 1106 patients with mean age 66.2 yrs and admission NIHSS 5; 46.1% were women. There was a significant reduction in observed/predicted inpatient mortality after implementation of the ESCP in ischemic stroke patients (OR 0.59 [95% CI 0.42-0.83], but not in the control patients with ICH (OR 0.90 [0.59 - 1.38]) or SAH (OR 1.05 [0.67 - 1.65]). . Similarly, a significant increase in the proportion with LOS < predicted after ESCP implementation was seen only in ischemic stroke pts (51.4% vs 56.0%, p=0.047). Compared to those admitted within the 1st 3 mo of ESCP rollout, ischemic pts admitted in the remainder of the study period demonstrated nonsignificant improvements in degree of impairment (NIHSS, 3.9 to 2.7, p=0.059), IADLs (modified Rankin, 2.6 to 2.2, p=0.079) and physical function (SIS16, 67.8 - 76.0, p=0.084) at followup. Conclusion: Implementation of the ESCP is feasible and may be associated with a benefit in multiple different outcomes after ischemic stroke. This approach, which combines carepaths, HIT, and the systematic collection of PROs, may be an important strategy for optimizing stroke care in the future.
Advanced age, arbitrarily defined as over 80 years, has been an exclusion criterion in many clinical trials for the treatment of acute ischemic stroke. The oldest person, to our knowledge, treated for acute ischemic stroke with intra-arterial therapy is presented and, importantly, this patient was excluded from intravenous tissue plasminogen activator due to an advanced age of 100 years and arrival in our emergency department within the 3-4.5 h time window. Utilizing an MRI based protocol to assess the risk-benefit ratio, treatment by intra-arterial mechanical embolectomy was commenced resulting in middle cerebral artery recanalization at 6 h 30 min. The patient improved, and ultimately returned to a baseline modified Rankin Scale score of 3. With careful selection, elderly patients may benefit from acute stroke therapies and may be considered on a case by case basis.
Background: Sex differences are encountered in many aspects of ischemic stroke, including risk factors, presenting symptoms, stroke mechanism, acute interventions and functional outcomes. As telestroke services continue to expand, many patients utilize telestroke for the evaluation and treatment of suspected stroke symptoms. To date, the existence of such differences between sexes has not been identified in the telestroke patient population. Methods: A retrospective observational study of the experience of a single teleneurology practice serving 340 hospitals from April 2018 to June 2021 was performed. Patients with a confirmed or suspected diagnosis of ischemic stroke were included. Data from the stroke encounter was abstracted from the medical record platform. Results: Within the queried period, there were 76,905 male and 90,243 female patients identified as having received a telestroke evaluation for suspected or confirmed stroke. No difference was seen in age, but females had a higher initial NIHSS score ( P =0.03). There were no differences in percentage of consults deemed emergent between males and females. Females were received thrombolysis at lower rates than males (4.86 vs 5.99%, P <0.01). Females refused thrombolysis at higher rates than males (3.44 vs 2.78%, P <0.01), while males were more likely to present outside the therapeutic window (46.72% vs 45.43%, P <0.01). Males and females did not receive thrombolysis due to symptom resolution/improvement at similar rates. Males were more likely to be on therapeutic anticoagulation precluding thrombolysis, ( P <0.01), while females were more likely to have a nondisabling deficit ( P <0.01). In the emergency consults subgroup, there were no differences between TLSW-to-arrival times, arrival-to-call times, and video start-to-thrombolysis decision times between the sexes. There were no differences in consult length times or door-to-needle times between the sexes. Conclusion: This review of a national heterogeneous telestroke patient population is indicative of sex differences in multiple aspects of acute ischemic stroke, most notably in thrombolysis rates and reasons thrombolysis not given. Further investigation is warranted into the disparities between the sexes in telestroke care.
Background: Administration of alteplase is the standard of care for eligible patients presenting with symptoms of acute ischemic stroke (AIS). Telemedicine is increasingly being used to deliver acute stroke care to patients without in-person access to stroke expertise. This study reviews the thrombolysis experience of the largest known teleneurology network spanning 39 states and distributed across a heterogeneous multihospital population throughout the nation. Methods: Data was abstracted from internal medical records systems and relevant medical records obtained from partner hospitals. A retrospective analysis on the prospectively maintained database of patients who have received alteplase was performed. Data was collected from December 1, 2015 to May 31, 2019. Outcome analysis was restricted to those patients with available complete discharge data. Results: The analysis revealed 8,399 patients as having received alteplase during the study period. Of these, 56.7% had discharge information available. The mean patient age was 68.5 years, with a mean age of 70.5 years for females and 66.5 years for males. The median initial NIHSS score was 7, with 31.2% of patients presenting with an initial NIHSS score ≤4, and 8.7% presenting with an initial NIHSS score ≥21. The transfer rate to another facility was 31.0%. There were 2,417 home discharges (48.2%), 1,057 acute rehabilitation discharges (21.1%), and 478 skilled nursing facility discharges (9.5%). There were 28 patients who left against medical advice (0.6%). The symptomatic hemorrhage rate in this population was 1.1% (92), and there were 234 patient deaths (4.7%). Conclusion: A large-scale teleneurology platform for the emergent treatment of patients presenting with AIS symptoms is both safe and feasible. Due to the heterogeneity of this patient and hospital population, higher level refinement of this analysis to include hyperacute metrics, transfer data, and more comprehensive clinical and functional outcomes is warranted.
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