Stroke systems of care in high-income countries: what is optimal?

Abstract

Stroke is a complex, time-sensitive, medical emergency that requires well-functioning systems of care to optimise treatment and improve patient outcomes. Education and training campaigns are needed to improve both the recognition of stroke among the general public and the response of emergency medical services. Specialised stroke ambulances (mobile stroke units) have been piloted in many cities to speed up the diagnosis, triage and emergency treatment of people with acute stroke symptoms. Hospital-based interdisciplinary stroke units remain the central feature of a modern stroke service. Many have now developed a role in the very early phase (hyperacute units) plus outreach for patients who return home (early supported discharge services). Different levels (comprehensive and primary) of stroke centre and telemedicine networks have been developed to coordinate the various service components with specialist investigations and interventions including rehabilitation. Major challenges include balancing the resources for stroke across the whole patient journey including the rapid, accurate triage of those patients who require highly specialised treatment in comprehensive stroke centres and developing technology to improve communication across different parts of a service. (178 words) A major focus of public health initiatives has been to improve the time to treatment for 91 patients with ischaemic stroke. There are several inter-related reasons that contribute to 92 patients with stroke experiencing delays with the provision of reperfusion therapies. In a 93 recent systematic review, 8 four categories of factors associated with delays were identified: 1) 94 patient-related factors, plus health system factors related to 2) training, 3) resources, and 4) 95 lack of coordination. In another similar systematic review, 10 the authors reported that 96 patients' attitudes, knowledge, and education were associated with time to presentation to 97 hospital after stroke. Visiting the primary care physician after stroke was associated with 98 delayed presentation. 99Various strategies directed at the public and emergency medical services appear to improve stroke recognition and time to presentation and treatment for people with stroke. A systematic review of 39 studies of stroke knowledge conducted in the UK, North America, Asia and Australia 11 provided an illustration of the wide variability between studies in terms of the ability of the public to name stroke risk factors, to name signs and symptoms of stroke, and the decision to call emergency medical services. In other studies it was also found that the general public would opt to contact or attend their primary care physician first, rather than emergency medical services following onset of their symptoms. 11 Public awareness campaigns are designed to improve time to diagnosis and treatment metrics.However, of the studies of educational campaigns and stroke awareness conducted in Europe, Asia, North America, and Australia, few have been found to be effective for improving resp...

Drip-and-Ship for Thrombectomy Treatment in Patients With Acute Ischemic Stroke Leads to Inferior Clinical Outcomes in a Stroke Network Covering Vast Rural Areas Compared to Direct Admission to a Comprehensive Stroke Center

“…Corresponding research projects are currently getting under way. 2 A different approach consists in piloting specialized stroke ambulances (mobile stroke units) that are supposed to speed up diagnosis, triage, and emergency treatment of patients with acute ischemic stroke symptoms (19,20).…”

The effectiveness of quality improvement collaboratives in improving stroke care and the facilitators and barriers to their implementation: a systematic review

“…3 Faculty of Allied Health and Wellbeing, University of Central Lancashire (UCLan), Preston, UK. 4 Faculty of Health and Care, University of Central Lancashire (UCLan), Preston, UK.…”

“…To successfully reduce the negative impacts of stroke, high-quality health and care practices are needed across the entire stroke care pathway. Reorganising stroke services and implementing changes at a system-level are increasingly being recognised as ways of enhancing coordination across the pathway, optimising care processes, and improving outcomes for stroke patients [3][4][5]. Implementing these transformative changes in stroke care is likely to involve a critical mass of stakeholders across different organisations and will require the application of effective quality improvement (QI) methodologies.…”

The Stroke Unit Story: Where Have We Been and Where Are We Going?

“…Stroke units in high-income countries -when the first stroke units were developed, there was no proven medical or surgical intervention for ischaemic or haemorrhagic stroke. Since then, a number of interventions have been developed particularly for very early reperfusion in proximal vessel ischaemic stroke [42]. As a result, many services are being re-shaped with the explicit aim of providing emergency thrombolysis and/or thrombectomy [43].…”

“…While these developments make planning patient care more complex, it should be possible to match the clinical services to the needs of the patient [42]. This requires a focus on the best timing of the most appropriate care for the individual patient.…”