Paula Bourke

Prolonged Stay of Stroke Patients in the Emergency Department May Lead to an Increased Risk of Complications, Poor Recovery, and Increased Mortality

BACKGROUND AND AIM Following an acute stroke (AS), patients are at an increased risk of developing complications that may affect prognosis. With overcrowding in the emergency department (ED), patients stay longer hours to days before transfer to a proper stroke ward. The aim of this study was to evaluate the effect of increasing length of stay (LOS) in the ED on the risk of stroke-related complications. METHODS We analyzed data from our stroke registry of patients admitted with AS during 2014. Stay in ED was divided into 2 groups: less than 8 hours and more than 8 hours. Data regarding demographics, stroke type, severity of stroke, ED (LOS) in hours, total LOS in hospital, number and types of complications, and prognosis were collected. RESULTS Mean age was 54.8 years and 78.9% were males (total n = 894). Prior to ward admission, 265 (29.5%) patients remained in the ED for less than 8 hours and 629 (70.4%) remained for more than 8 hours. There was no significant difference in comorbidities or the severity of stroke at admission between the 2 groups. An ED LOS of less than 8 hours was associated with reduced risk of complications (14.3% versus 19.2%, P = .06), reduced LOS in hospital, better prognosis at discharge (72.5% versus 57.6% had modified Rankin Scale of ≤2, P = .001) and at 90 days (89% versus 78.8%, P = .007) and lower in-hospital mortality (1.5% versus 5.4 %, P = .004). CONCLUSION Delays in transferring AS patients from the ED may lead to an increase in complications resulting in an increased LOS and slower recovery.

Beneficial Effects of Implementing Stroke Protocols Require Establishment of a Geographically Distinct Unit

Background and Purpose— Usefulness of multidisciplinary stroke units in acute stroke patients is well established. There is extensive western literature on usefulness of stroke units in outcome, but limited evidence from the rest of the world. We aim to evaluate the impact of establishing a stroke unit on outcome in patients presenting to a tertiary care facility. Methods— This is a retrospective study of 1003 patients with acute stroke admitted to Hamad General Hospital, Qatar, between January 2014 and February 2015. Patients directly admitted to intensive care unit (132) were excluded. We compared outcomes of pre- and poststroke ward (SW) establishment and in SW patients versus those of general medical wards. Results— Before the establishment of the SW, 175 patients were admitted to the hospital. From April 2014 to February 2015, 696 patients were admitted (SW, 545; medical ward, 151). There was a significant reduction in length of stay from 14.7±27.7 to 6.2±20.2 days (P=0.0001) and incidence of complications (23.6% versus 6.4%, P=0.0001) after implementation of stroke-specific protocols. Prognosis at discharge (modified Rankin Scale 0–2 in 56.0% versus 70.4%, P=0.001) and at 90 days (modified Rankin Scale 0–2 in 70.6% versus 95.0%, P=0.001) also significantly improved. Compared with medical ward patients, outcome was significantly better in SW patients with fewer complications (10.9% versus 5.0%, P=0.013) and shorter length of stay (8.9±30.7 versus 5.4±16.1 days, P=0.05). Conclusions— Establishing a distinct SW is essential for achieving full benefits of stroke protocols implementation. SW patients have significantly fewer complications and better prognosis when compared with patients in medical wards.

Corneal Confocal Microscopy Detects Corneal Nerve Damage in Patients Admitted With Acute Ischemic Stroke

Background and Purpose— Corneal confocal microscopy can identify corneal nerve damage in patients with peripheral and central neurodegeneration. However, the use of corneal confocal microscopy in patients presenting with acute ischemic stroke is unknown. Methods— One hundred thirty patients (57 without diabetes mellitus [normal glucose tolerance], 32 with impaired glucose tolerance, and 41 with type 2 diabetes mellitus) admitted with acute ischemic stroke, and 28 age-matched healthy control participants underwent corneal confocal microscopy to quantify corneal nerve fiber density, corneal nerve branch density, and corneal nerve fiber length. Results— There was a significant reduction in corneal nerve fiber density, corneal nerve branch density, and corneal nerve fiber length in stroke patients with normal glucose tolerance (P<0.001, P<0.001, P<0.001), impaired glucose tolerance (P=0.004, P<0.001, P=0.002), and type 2 diabetes mellitus (P<0.001, P<0.001, P<0.001) compared with controls. HbA1c and triglycerides correlated with corneal nerve fiber density (r=−0.187, P=0.03; r=−0.229 P=0.01), corneal nerve fiber length (r=−0.228, P=0.009; r=−0.285; P=0.001), and corneal nerve branch density (r=−0.187, P=0.033; r=−0.229, P=0.01). Multiple linear regression showed no independent associations between corneal nerve fiber density, corneal nerve branch density, and corneal nerve fiber length and relevant risk factors for stroke. Conclusions— Corneal confocal microscopy is a rapid noninvasive ophthalmic imaging technique that identifies corneal nerve fiber loss in patients with acute ischemic stroke.

Ethnic variation in acute cerebrovascular disease: Analysis from the Qatar stroke registry

Objective We analysed the Qatar stroke registry for ethnic variations in patients admitted with cerebrovascular disease at Hamad General Hospital, Qatar. Methods Patients admitted with acute stroke from January 2014 to December 2015, enrolled in the registry were included in the study. We evaluated the clinical presentation, risk factors, and outcome at discharge and 90 days post-discharge in relation to the patient’s ethnic background. Results A total of 1727 patients were enrolled in the Hamad General Hospital stroke registry (Middle Eastern 594 (34.4%), South East Asian 924 (53.5%) and Far Eastern 209 (12.1%)). There were significant differences in risk factors, clinical presentation and prognosis. Compared to Middle Eastern patients, Far Eastern patients were younger (62.8 ± 13.7 vs. 48.9 ± 9.1 years; p < 0.001). Diabetes and hypertension were significantly more common in Middle Eastern patients (358 (60.3%), 458 (77.1%)) compared to South East Asian patients (420 (45.5%), 596 (64.5%)) and Far Eastern patients (57 (27.3%), 154 (73.7%)), respectively (p < 0.001). Stroke was more severe in the Far Eastern group (median (interquartile range) – 5.0 (2–11.5)) compared to the Middle Eastern group (median (interquartile range) – 4.0 (1–8)) and South East Asian (median (interquartile range) – 4.0 (2–9)), p = 0.011. Mortality at 90 days was highest in patients from the Far East (15/209 (8.2%)) compared to the Middle East (35/594 (6.5%)) and South East Asia (33/924 (4.0)), p = 0.028. Patients from the Far East had significantly higher rates of intracranial hemorrhage compared to the Middle East and South East Asia (70/209 (33.5%), 77/594 (13.0%), and 169/924 (18.3%)), respectively (p < 0.001). Conclusion The early age at presentation and the poor control of risk factors, especially in patients from South East Asia and the Far East requires attention.

Waiting for a stroke bed: Planning stroke unit capacity using queuing theory

Abstract Background: Access to rapidly advancing healthcare technologies is often limited due to lack of appropriate capacity. As stroke care continues to advance creating dedicated units with appropriate and effective capacity is paramount to maximizing the potential outcomes for patients. Queuing theory methodologies are widely used in industries, but infrequently in healthcare. Yet they provide the opportunity for more effective capacity planning. Method: This paper utilizes a standard queuing model in order to effectively define stroke unit capacity with less than 1% turn-away. Data regarding admission rates, Length of stay, and current bed availability was collected from a large teaching hospital and the middle east during quarter 1, 2014. This data was then and used to develop two queuing models. Results: The study demonstrated that the current bed capacity was considerably less than that required to provide effective care that maximizes the potential outcome for patients. Based on arrival patterns and length of stay the stroke unit requires 21 beds if the probability of a patient being turned away is to be less than 1%. This results in a bed occupancy considerably lower than the recommended 80-85%. Given the size of the unit at the time of the study (8 beds), 44.5% of patients would be turned away and managed on other units. Conclusion: The study demonstrates the use of queuing theory to more effectively plan capacity for a stroke unit. In order to maximize outcome for patients units may need to run at lower occupancy than often recommended in the literature. Queuing theory provides an additional framework to help clinicians and managers more effectively plan in the future. Their advantage is that they are relatively straightforward to build, require no additional software other than a spreadsheet, and are relatively low on data requirements. The authors recommend that such modelling techniques should utilized more widely in healthcare planning.

Correction to: Pre-existing Small Vessel Disease in Patients with Acute Stroke from the Middle East, Southeast Asia, and Philippines

The author names “Dr. Pablo Garcia Bermejo” and “Dr. Muhammad Faisal Wadiwala” needed to be added as the 6th and 7th authors, respectively. The authors regret this error.