Quality Improvement Intervention for Reducing Acute Treatment Times in Ischemic Stroke: A Cluster Randomized Clinical Trial

 

Do you really think you can get your stroke patient treated in 3 minutes to get to full recovery?  NO? So, you fully expect your stroke medical 'professionals' to have EXACT 100% RECOVERY PROTOCOLS regardless of the time you present to the hospital? But they don't have that now and aren't working on it, ARE THEY?

Door to needle time is way to slow! It has to be as soon as the patient is identified with a stroke. Like maybe these fast diagnosis options?

Hats off to Helmet of Hope - stroke diagnosis in 30 seconds; February 2017 

Smart Brain-Wave Cap Recognises Stroke Before the Patient Reaches the Hospital

 October 2023

And then this to rule out a bleeder.

New Device Quickly Assesses Brain Bleeding in Head Injuries - 5-10 minutes April 2017

Electrical 'storms' and 'flash floods' drown the brain after a stroke

 In this research in mice the needed time frame for tPA delivery is 3 minutes for full recovery.

Saving lives is great but survivors want full recovery, or don't you ever talk to survivors?

The latest here:

Quality Improvement Intervention for Reducing Acute Treatment Times in Ischemic Stroke: A Cluster Randomized Clinical Trial

• December 2024
• JAMA Neurology

DOI:10.1001/jamaneurol.2024.4304

Authors:

Sanne J. den Hartog Nikki van Leeuwen

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To read the full-text of this research, you can request a copy directly from the authors.

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Abstract

Importance Efficient care processes are crucial to minimize treatment delays and improve outcome after endovascular thrombectomy (EVT) in patients with ischemic stroke. A potential means to improve care processes is performance feedback. Objective To evaluate the effect of performance feedback to hospitals on treatment times for EVT. Design, Setting, and Participants This cluster randomized clinical trial was conducted from January 1, 2020, to June 30, 2022. Participants were consecutive adult patients with ischemic stroke who underwent EVT in 13 Dutch hospitals. No patients were excluded. Data analysis took place from March to May 2023. Intervention The intervention consisted of feedback on hospital performance using structure, process, and outcome indicators. Indicator scores were based on data from a national quality registry and compared with a benchmark. Performance feedback was provided through a dashboard for local quality improvement teams who developed and implemented improvement plans based on the feedback. Every 6 months, 3 to 4 randomly selected hospitals switched to the intervention condition. Main Outcome and Measures The

primary outcome was time from door to groin puncture for all patients treated with EVT.(WRONG OUTCOME! The outcome to measure is 100% recovery! NOTHING LESS YOU BLITHERING IDIOTS!) Secondary outcomes included door-to-needle time, National Institutes of Health Stroke Scale (NIHSS) score at day 2, expanded Treatment in Cerebral Infarction (eTICI) score, and modified Rankin Scale (mRS) score at 3 months. The effect of the intervention was estimated with multivariable linear mixed models. Results A total of 4747 patients were included (intervention: 2431; control: 2316). Their mean (SD) age was 72 (13) years; 2337 (49.2%) were female and 2410 (50.8%) were male. The median (IQR) baseline NIHSS score was 14 (8-19). Median (IQR) door-to–groin puncture time under the intervention condition was 47 (25-71) minutes, compared with 52 (29-75) minutes under the control condition. The adjusted absolute reduction was 5 minutes (β = −4.8; 95% CI, −9.5 to −0.1; P = .04), corresponding to a relative reduction of 9.2% (95% CI, −18.3% to −0.2%). Conclusion and Relevance This study found that performance feedback provided through a dashboard used by local quality improvement teams reduced door-to–groin puncture time for EVT. Implementation of performance feedback in hospitals providing EVT can improve the quality of care for ischemic stroke. Trial Registration The Netherlands Trial Register: NL9090

A randomized controlled trial to optimize patient’s selection for endovascular treatment in acute ischemic stroke (SELECT2): Study protocol

You can see from the start of this research they have the wrong outcome measurements, mRS 0 or 1 should be the only measures needed, anything else should be considered failure. Unless failure is acknowledged it will NEVER BE FIXED. This just normalizes failure.

0  The patient has no residual symptoms.

1  The patient has no significant disability; able to carry out all pre-stroke activities.

2  The patient has slight disability; unable to carry out all pre-stroke activities but able to look after self without daily help.

3  The patient has moderate disability; requiring some external help but able to walk without the assistance of another individual.

4  The patient has moderately severe disability; unable to walk or attend to bodily functions without assistance of another individual.

5  The patient has severe disability; bedridden, incontinent, requires continuous care.

6  The patient has expired (during the hospital stay or after discharge from the hospital).

A randomized controlled trial to optimize patient’s selection for endovascular treatment in acute ischemic stroke (SELECT2): Study protocol

Amrou Sarrajhttps://orcid.org/0000-0001-5726-44781, Ameer E Hassanhttps://orcid.org/0000-0002-7148-76162, Michael Abraham3, Marc Ribo4, Spiros Blackburn5, Michael Chen6, Muhammad Shazam Hussain7, Vitor Mendes Pereira8, Santiago Ortega-Gutierrez9, Clark Sitton10, Phillip W Lavori11, Chunyan Cai12, Mohammed Rahbar12, Deep Pujarahttps://orcid.org/0000-0001-6187-894X1, Faris Shakerhttps://orcid.org/0000-0003-4462-52321, Maarten G Lansberghttps://orcid.org/0000-0002-3545-692713, Bruce Campbellhttps://orcid.org/0000-0003-3632-943314, James C Grotta15, Gregory W Albers13, and on behalf of the SELECT2 Investigators
Rationale

Randomized evidence for endovascular thrombectomy safety and efficacy in patients with large core strokes is lacking.
Aims

To demonstrate endovascular thrombectomy efficacy and safety in patients with large core on non-contrast CT or perfusion imaging (CT/MR) and determine if there is heterogeneity of treatment effect in large cores based on the imaging modality.
Design

SELECT2 is a prospective, randomized, multi-center, assessor-blinded controlled trial with adaptive enrichment design, enrolling up to 560 patients.
Procedure

Patients who meet the clinical criteria and have anterior circulation large vessel occlusions with large core on either NCCT (ASPECTS 3–5) or perfusion imaging (CTP [rCBF < 30%] and/or MRI [ADC < 620] ≥ 50 cc) will be randomized in a 1:1 ratio to undergo endovascular thrombectomy or medical management (MM) only up to 24 h of last known well.
Study outcomes

The distribution of 90-day mRS scores is the primary outcome. Functional independence (mRS = 0–2) rate is a secondary outcome. Other secondary outcomes include safety (symptomatic ICH, neurological worsening, mortality) and imaging outcomes.
Analysis

A normal approximation of the Wilcoxon-Mann-Whitney test (the generalized likelihood ratio test) to assess the primary outcome. Functional independence rates, safety and imaging outcomes will also be compared.
Discussion

The SELECT2 trial will evaluate endovascular thrombectomy safety and efficacy in large cores on either CT or perfusion imaging and may provide randomized evidence to extend endovascular thrombectomy eligibility to larger population.
Registration: ClinicalTrials.gov–NCT03876457
Keywords
Acute stroke therapy, thrombectomy, clinical trial, large vessel occlusion, ischemic stroke, protocols
1Department of Neurology, UT McGovern Medical School, Houston, USA
2Department of Neurology, Valley Baptist Medical Center, Harlingen, USA
3Department of Neurology, University of Kansas Medical Center, Kansas City, USA
4Department of Neurology, Vall d'Hebron Hospital Universitari, Barcelona, Spain
5Department of Neurosurgery, UT McGovern Medical School, Houston, USA
6Department of Neurosurgery, Rush University, Chicago, USA
7Department of Neurology, Cleveland Clinic, Cleveland, USA
8Department of Neurology, Toronto Western Hospital, Toronto, Canada
9Department of Neurology, University of Iowa Hospitals, Iowa City, USA
10Department of Neuroradiology, UT McGovern Medical School, Houston, USA
11Biomedical Data Science, Stanford University, Stanford, USA
12CCTS, UT McGovern Medical School, Houston, USA
13Department of Neurology, Stanford University, Stanford, USA
14Department of Neurology, Royal Melbourne Hospital, Parkville, Australia
15Department of Neurology, Memorial Hermann–Texas Medical Center, Houston, USA
*Investigators listed in eTable 3.
Corresponding author(s):
Amrou Sarraj, UT McGovern Medical School, 6431 Fannin St #7.044; Houston, TX 77030, USA. Email: Amrou.Sarraj@uth.tmc.edu

Sex-specific differences in presentations and determinants of outcomes after endovascular thrombectomy for large vessel occlusion stroke

If you don't use this information to update the appropriate stroke protocols you have just wasted your research. Writing in journals does nothing to get better treatments into hospitals. 

Sex-specific differences in presentations and determinants of outcomes after endovascular thrombectomy for large vessel occlusion stroke

• Robert W. Regenhardt,
• Ashby C. Turner,
• Joshua A. Hirsch,
• Michael J. Young,
• Naif M. Alotaibi,
• Christopher J. Stapleton,
• Aman B. Patel,
• Thabele M. Leslie-Mazwi,
• Natalia S. Rost &
• Mark R. Etherton 

Journal of Neurology (2021)Cite this article

• 3 Accesses

• 7 Altmetric

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Abstract

Introduction

Sex-specific differences in ischemic stroke outcomes are prevalent. We sought to investigate sex differences in the determinants of reperfusion and functional outcomes after endovascular thrombectomy (EVT) for emergent large vessel occlusion ischemic stroke (ELVO).

Methods

Patients presenting to a single referral center with an anterior circulation ELVO that underwent EVT from 2011 to 2019 were included in this retrospective analysis. Sex differences in history, presentation, adequate reperfusion (TICI 2b-3), and 90-day good outcome [delta modified Rankin Scale (mRS) ≤ 2 from pre-stroke] were examined. Multivariable logistic regression analyses were performed to assess sex-specific associations with outcomes.

Results

Three hundred and eighty-one consecutive ELVO patients were identified. Women (N = 193) were older (75 vs 64 years, p < 0.0001), had more pre-stroke disability (17% vs 9%, p = 0.032), more atrial fibrillation (41% vs 30%, p = 0.033), but less carotid atherosclerosis (8% vs 16%, p = 0.027). Rates of TICI 2b-3 and good outcome were similar between sexes. Carotid atherosclerosis (OR 0.315, 95% CI 0.130, 0.762) and dissection (OR 0.124, 95% CI 0.027, 0.569) independently decreased the odds of TICI 2b-3 among men but not women. Older age, more severe stroke, and not achieving TICI 2b-3 independently decreased the odds of good outcome among both sexes, while prior stroke (OR 0.258, 95% CI 0.083, 0.797) and hemorrhagic transformation (OR 0.111, 0.021, 0.592) were determinants exclusive to men.

Conclusion

In a real-world analysis of ELVO stroke patients treated with EVT, we found that despite advanced age and more pre-stroke disability, women have comparable reperfusion rates(Wrong outcome measurement) and functional outcomes compared to men. Sex-specific determinants of reperfusion and functional outcome were identified that require further study.

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Data availability

The data that support the findings of this study will be made available from the corresponding author upon reasonable request and pending approval of local institutional review board.