Effect of implementing care protocols on acute ischemic stroke outcomes: a systematic review

Abstract

Background Implementing stroke care protocols has intended to provide better care quality, favor early functional recovery, and achieving long-term results for the rehabilitation of the patient.

Objective To analyze the effect of implementing care protocols on the outcomes of acute ischemic stroke.

Methods Primary studies published from 2011 to 2020 and which met the following criteria were included: population should be people with acute ischemic stroke; studies should present results on the outcomes of using protocols in the therapeutic approach to acute ischemic stroke. The bibliographic search was carried out in June 2020 in 7 databases. The article selection was conducted by two independent reviewers and the results were narratively synthesized.

Results A total of 11,226 publications were retrieved in the databases, of which 30 were included in the study. After implementing the protocol, 70.8% of the publications found an increase in the rate of performing reperfusion therapy, such as thrombolysis and thrombectomy; 45.5% identified an improvement in the clinical prognosis of the patient; and 25.0% of the studies identified a decrease in the length of hospital stay. Out of 19 studies that addressed the rate of symptomatic intracranial hemorrhage, 2 (10.5%) identified a decrease. A decrease in mortality was mentioned in 3 (25.0%) articles out of 12 that evaluated this outcome.

Conclusions We have identified the importance of implementing protocols in increasing the performance of reperfusion therapies, and a good functional outcome with improved prognosis after discharge. However, there is still a need to invest in reducing post-thrombolysis complications and mortality.

Resumo

Antecedentes A implementação de protocolos de acidente vascular cerebral (AVC) visa proporcionar uma melhor qualidade da assistência, favorecer a recuperação funcional precoce e alcançar resultados para a reabilitação do paciente.

Objetivo Analisar o efeito da implantação de protocolos nos desfechos do AVC isquêmico agudo.

Métodos Foram incluídos estudos primários publicados entre 2011 e 2020 e que atendiam aos seguintes critérios: população deveria ser constituída de pessoas com AVC isquêmico agudo; apresentar resultados sobre os desfechos do uso de protocolos na abordagem terapêutica ao AVC isquêmico agudo. A busca bibliográfica foi realizada em junho de 2020 em 7 bases de dados. A seleção dos artigos foi feita por dois revisores independentes e a síntese dos resultados foi feita de forma narrativa.

Resultados Foram recuperadas 11.226 publicações, das quais 30 foram incluídas no estudo. Após a implementação do protocolo, 70,8% das publicações constataram aumento na taxa de realização de terapia de reperfusão, como a trombólise e a trombectomia; 45,5% identificaram melhora no prognóstico clínico do paciente; e 25,0% dos estudos identificaram diminuição no tempo de internação hospitalar. De 19 estudos que abordaram a taxa de hemorragia intracraniana sintomática, 2 (10,5%) identificaram diminuição nesta taxa. A diminuição da mortalidade foi citada em 3 (25,0%) artigos de 12 que avaliaram tal desfecho.

Conclusões Identificou-se a importância da implantação de protocolos no aumento da realização das terapias de reperfusão, e ao bom desfecho funcional com melhora do prognóstico após a alta. No entanto, ainda há que se investir na diminuição das complicações pós trombólise e da mortalidade.

Keywords

Ischemic Stroke - Acute Disease - Emergencies - Clinical Protocols - Treatment Outcome

Palavras-chave

AVC Isquêmico - Doença Aguda - Emergências - Protocolos Clínicos - Resultado do Tratamento

• References

• 1 Kobayashi A, Czlonkowska A, Ford GA. et al. European Academy of Neurology and European Stroke Organization consensus statement and practical guidance for pre-hospital management of stroke. Eur J Neurol 2018; 25 (03) 425-433
• 2 Vanhoucke J, Hemelsoet D, Achten E. et al. Impact of a code stroke protocol on the door-to-needle time for IV thrombolysis: a feasibility study. Acta Clin Belg 2020; 75 (04) 267-274
• 3 World Health Organization. The top 10 causes of death. Genebra: WHO; 2020. https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death
• 4 Rolim CLRC, Martins M. [Quality of care for ischemic stroke in the Brazilian Unified National Health System]. Cad Saude Publica 2011; 27 (11) 2106-2116
• 5 Oliveira-Filho J, Martins SCO, Pontes-Neto OM. et al; Executive Committee from Brazilian Stroke Society and the Scientific Department in Cerebrovascular Diseases. Guidelines for acute ischemic stroke treatment: part I. Arq Neuropsiquiatr 2012; 70 (08) 621-629
• 6 Jauch EC, Saver JL, Adams Jr HP. et al; American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44 (03) 870-947
• 7 Powers WJ, Rabinstein AA, Ackerson T. et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50 (12) e344-e418
• 8 Hoffmeister L, Lavados PM, Comas M, Vidal C, Cabello R, Castells X. Performance measures for in-hospital care of acute ischemic stroke in public hospitals in Chile. BMC Neurol 2013; 13: 23
• 9 Xian Y, Smith EE, Zhao X. et al. Strategies used by hospitals to improve speed of tissue-type plasminogen activator treatment in acute ischemic stroke. Stroke 2014; 45 (05) 1387-1395
• 10 National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333 (24) 1581-1587
• 11 Moher D, Liberati A, Tetzlaff J, Altman DG. PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6 (07) e1000097
• 12 Galvão TF, Pereira MG. Revisões sistemáticas da literatura: passos para sua elaboração. Epidemiol Serv Saude 2014; 23: 183-184
• 13 Moola S, Munn Z, Tufanaru C. et al. Chapter 7: Systematic Reviews of Etiology and Risk. In: Aromataris E, Munn Z. eds. JBI Manual for Evidence Synthesys. Adelaide: Joanna Briggs Institute; 2020. https://doi.org/10.46658/JBIMES-20-08
• 14 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev 2016; 5 (01) 210
• 15 Ursi ES. Prevenção de lesões de pele no perioperatório: revisão integrativa da literatura [Master degree]. Ribeirão Preto: Universidade de São Paulo; 2005. https://doi.org/10.11606/D.22.2005.tde-18072005-095456
• 16 Ye S, Hu S, Lei Z. et al. Shenzhen stroke emergency map improves access to rt-PA for patients with acute ischaemic stroke. Stroke Vasc Neurol 2019; 4 (03) 115-122
• 17 Yang SJ, Franco T, Wallace N, Williams B, Blackmore C. Effectiveness of an Interdisciplinary, Nurse Driven In-Hospital Code Stroke Protocol on In-Patient Ischemic Stroke Recognition and Management. J Stroke Cerebrovasc Dis 2019; 28 (12) 104398
• 18 Madhok DY, Keenan KJ, Cole SB, Martin C, Hemphill III JC. Prehospital and Emergency Department-Focused Mission Protocol Improves Thrombolysis Metrics for Suspected Acute Stroke Patients. J Stroke Cerebrovasc Dis 2019; 28 (12) 104423
• 19 Ajmi SC, Advani R, Fjetland L. et al. Reducing door-to-needle times in stroke thrombolysis to 13 min through protocol revision and simulation training: a quality improvement project in a Norwegian stroke centre. BMJ Qual Saf 2019; 28 (11) 939-948
• 20 de Belvis AG, Lohmeyer FM, Barbara A. et al. Ischemic stroke: clinical pathway impact. Int J Health Care Qual Assur 2019; 32 (03) 588-598
• 21 Silsby M, Duma SR, Fois AF. et al. Time to acute stroke treatment in-hours was more than halved after the introduction of the Helsinki Model at Westmead Hospital. Intern Med J 2019; 49 (11) 1386-1392
• 22 Nguyen-Huynh MN, Klingman JG, Avins AL. et al; KPNC Stroke FORCE Team. Novel Telestroke Program Improves Thrombolysis for Acute Stroke Across 21 Hospitals of an Integrated Healthcare System. Stroke 2018; 49 (01) 133-139
• 23 Zakaria MF, Aref H, Abd ElNasser A. et al. Egyptian experience in increasing utilization of reperfusion therapies in acute ischemic stroke. Int J Stroke 2018; 13 (05) 525-529
• 24 Koge J, Matsumoto S, Nakahara I. et al. Improving treatment times for patients with in-hospital stroke using a standardized protocol. J Neurol Sci 2017; 381: 68-73
• 25 Cheng T-J, Peng G-S, Jhao W-S, Lee J-T, Wang T-H. Nationwide “Hospital Emergent Capability Accreditation by Level-Stroke” Improves Stroke Treatment in Taiwan. J Stroke 2017; 19 (02) 205-212
• 26 Zinkstok SM, Beenen LF, Luitse JS, Majoie CB, Nederkoorn PJ, Roos YB. Thrombolysis in Stroke within 30 Minutes: Results of the Acute Brain Care Intervention Study. PLoS One 2016; 11 (11) e0166668-e0166668
• 27 Liang Z, Ren L, Wang T. et al. Effective management of patients with acute ischemic stroke based on lean production on thrombolytic flow optimization. Australas Phys Eng Sci Med 2016; 39 (04) 987-996
• 28 Li Z, Wang C, Zhao X. et al; China National Stroke Registries. Substantial Progress Yet Significant Opportunity for Improvement in Stroke Care in China. Stroke 2016; 47 (11) 2843-2849
• 29 Moran JL, Nakagawa K, Asai SM, Koenig MA. 24/7 Neurocritical Care Nurse Practitioner Coverage Reduced Door-to-Needle Time in Stroke Patients Treated with Tissue Plasminogen Activator. J Stroke Cerebrovasc Dis 2016; 25 (05) 1148-1152
• 30 Hsieh F-I, Jeng J-S, Chern C-M. et al; BTS-Stroke Investigators. Quality Improvement in Acute Ischemic Stroke Care in Taiwan: The Breakthrough Collaborative in Stroke. PLoS One 2016; 11 (08) e0160426
• 31 Ibrahim F, Akhtar N, Salam A. et al. Stroke Thrombolysis Protocol Shortens “Door-to-Needle Time” and Improves Outcomes-Experience at a Tertiary Care Center in Qatar. J Stroke Cerebrovasc Dis 2016; 25 (08) 2043-2046
• 32 Rai AT, Smith MS, Boo S, Tarabishy AR, Hobbs GR, Carpenter JS. The 'pit-crew' model for improving door-to-needle times in endovascular stroke therapy: a Six-Sigma project. J Neurointerv Surg 2016; 8 (05) 447-452
• 33 Mascitelli JR, Wilson N, Shoirah H. et al. The impact of evidence: evolving therapy for acute ischemic stroke in a large healthcare system. J Neurointerv Surg 2016; 8 (11) 1129-1135
• 34 Kendall J, Dutta D, Brown E. Reducing delay to stroke thrombolysis–lessons learnt from the Stroke 90 Project. Emerg Med J 2015; 32 (02) 100-104
• 35 Atsumi C, Hasegawa Y, Tsumura K. et al. Quality assurance monitoring of a citywide transportation protocol improves clinical indicators of intravenous tissue plasminogen activator therapy: a community-based, longitudinal study. J Stroke Cerebrovasc Dis 2015; 24 (01) 183-188
• 36 Van Schaik SM, Van der Veen B, Van den Berg-Vos RM, Weinstein HC, Bosboom WMJ. Achieving a door-to-needle time of 25 minutes in thrombolysis for acute ischemic stroke: a quality improvement project. J Stroke Cerebrovasc Dis 2014; 23 (10) 2900-2906
• 37 Chen C-H, Tang S-C, Tsai L-K. et al. Stroke code improves intravenous thrombolysis administration in acute ischemic stroke. PLoS One 2014; 9 (08) e104862
• 38 Handschu R, Scibor M, Wacker A. et al. Feasibility of certified quality management in a comprehensive stroke care network using telemedicine: STENO project. Int J Stroke 2014; 9 (08) 1011-1016
• 39 Fonarow GC, Zhao X, Smith EE. et al. Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative. JAMA 2014; 311 (16) 1632-1640
• 40 Ruff IM, Ali SF, Goldstein JN. et al. Improving door-to-needle times: a single center validation of the target stroke hypothesis. Stroke 2014; 45 (02) 504-508
• 41 Ford AL, Williams JA, Spencer M. et al. Reducing door-to-needle times using Toyota's lean manufacturing principles and value stream analysis. Stroke 2012; 43 (12) 3395-3398
• 42 Lin CB, Peterson ED, Smith EE. et al. Emergency medical service hospital prenotification is associated with improved evaluation and treatment of acute ischemic stroke. Circ Cardiovasc Qual Outcomes 2012; 5 (04) 514-522
• 43 Tai YJ, Weir L, Hand P, Davis S, Yan B. Does a 'code stroke' rapid access protocol decrease door-to-needle time for thrombolysis?. Intern Med J 2012; 42 (12) 1316-1324
• 44 O'Brien W, Crimmins D, Donaldson W. et al. FASTER (Face, Arm, Speech, Time, Emergency Response): experience of Central Coast Stroke Services implementation of a pre-hospital notification system for expedient management of acute stroke. J Clin Neurosci 2012; 19 (02) 241-245
• 45 Sung S-F, Huang Y-C, Ong C-T, Chen Y-W. A Parallel Thrombolysis Protocol with Nurse Practitioners As Coordinators Minimized Door-to-Needle Time for Acute Ischemic Stroke. Stroke Res Treat 2011; 2011: 198518
• 46 Campbell BC. Advances in stroke medicine. Med J Aust 2019; 210 (08) 367-374
• 47 van Wijngaarden JDH, Dirks M, Niessen LW, Huijsman R, Dippel DWJ. Do centres with well-developed protocols, training and infrastructure have higher rates of thrombolysis for acute ischaemic stroke?. QJM 2011; 104 (09) 785-791
• 48 Marta Moreno J, Bestué Cardiel M, Giménez Muñoz A, Palacín Larroy M. Grupo de Seguimiento y Mejora del Programa de Atención al Ictus en Aragón (PAIA). Programa de Atención al Ictus en Aragón (PAIA) Stroke care programme in Aragon (PAIA): strategy and outcomes for the period 2009-2014. Neurologia (Engl Ed) 2018; 33 (05) 301-312
• 49 Boden-Albala B, Edwards DF, St Clair S. et al. Methodology for a community-based stroke preparedness intervention: the Acute Stroke Program of Interventions Addressing Racial and Ethnic Disparities Study. Stroke 2014; 45 (07) 2047-2052
• 50 Machline-Carrion MJ, Santucci EV, Damiani LP. et al; BRIDGE-Stroke Investigators. Effect of a Quality Improvement Intervention on adherence to therapies for patients with acute ischemic stroke and transient ischemic attack: a cluster randomized clinical trial. JAMA Neurol 2019; 76 (08) 932-941
• 51 Asimos AW, Ward S, Brice JH. et al. A geographic information system analysis of the impact of a statewide acute stroke emergency medical services routing protocol on community hospital bypass. J Stroke Cerebrovasc Dis 2014; 23 (10) 2800-2808