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Introduction: In 2020, stroke and ambulance clinicians in North Central (NC) London and East Kent introduced prehospital video triage, which permitted stroke specialist assessment of suspected stroke patients on scene. Key aims included reducing conveyance of non-stroke patients to stroke services and reducing transmission of Covid-19. Method(s): Rapid, mixed-method evaluation of prehospital video triage in NC London and East Kent (conducted July 2020-September 2021), drawing on: * Interviews with ambulance and stroke clinicians (n=27);observations (n=12);documents (n=23). * Survey of ambulance clinicians (n=233). * Descriptive analysis of local ambulance conveyance data (n=1,400;April-September 2020). * Difference-in-differences regression analysis: team-level national audit data, assessing changes in delivery of clinical interventions in NC London and East Kent relative to elsewhere in England (n=137,650;2018-2020). Result(s): Clinicians perceived prehospital video triage as usable, safe, and preferable to 'business-as-usual'. Several interrelated factors influenced implementation: impetus of Covid- 19, facilitative local governance, receptive professional values, engaging clinical leadership, active training approaches, and stable audio-visual signal. Stroke clinician capacity was a risk to sustainability. Neither area saw increased time from symptom onset to arrival at services. Delivery of clinical interventions either remained unchanged or improved significantly, relative to elsewhere in England. Conclusion(s): Prehospital video triage in NC London and East Kent was perceived as usable, acceptable, and safe;it was associated with some significant improvements in secondary care processes. Key influences included national and local context, characteristics of triage services, and implementation approaches.
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Introduction: Effective multidisciplinary team working enhances patient care and staff performance and reduces length of stay. In stroke services, this has recently been strained by challenges of staff shortages, team exhaustion and COVID-19, in addition to SSNAP data reporting responsibilities. Consequently, psychological distress has heightened in these healthcare workers. Understanding staff experiences in stroke team environments is crucial to staff retention, wellbeing, and reshaping effective multidisciplinary processes. Method(s): Clinical staff in emergency, hyperacute, and acute stroke units at our hospital were invited in May 2022 to complete an online questionnaire based on validated measures of teamwork, stress, and burnout. Result(s): Twenty-seven respondents represented across therapy, medical (29.6%), and nursing (29.6%) teams. Teamworking was rated as positive by most staff (63%), relating this to open communication and diverse, specialised stroke knowledge. Over 75% of the sample experienced moderate to high burnout, with prevalent experiences of emotional exhaustion. External pressures to meet SSNAP requirements was a time resource barrier that lowered sense of both personal achievement and input into directing work duties. Stress was in the severe-dangerous range for 37% of respondents. Key themes identified for improvement were opportunities for education and service development, and efficiency of knowledge sharing. Conclusion(s): Our multidisciplinary stroke teams reported high levels of stress and burnout, associated with challenging staff to patient ratios, and feeling professional autonomy is compromised to meet stroke service standards. Positive experiences of teamworking were viewed as partially protective against further distress escalations. Results highlight the critical need for novel implementations focusing on team support and development.
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Background: COVID-19 is associated with arterial thromboembolism, including acute ischaemic stroke (AIS). An association with antiphospholipid antibodies (aPL) has been noted;however, the prevalence of aPL and their clinical relevance in COVID 19-associated AIS are undefined. Aim(s): The aim was to assess the prevalence, subtypes and persistence of aPL in COVID-19- associated AIS. Method(s): We retrospectively reviewed AIS patients consecutively admitted to the Hyperacute Stroke Unit, University College London Hospitals, during local COVID-19 admission waves (18-Mar- 2020 to 31-May- 2020 and 01-Dec- 2020 to 24-Feb- 2021). Electronic patient records were reviewed for relevant study data, including COVID-19 and aPL status (in accordance with international consensus criteria). Result(s): 380 patients with AIS were identified (median age 74 years, range 24-99);35/380 (9.2%) had active/recent COVID-19 infection (median age 79 years, range 37-93). 132/380 patients were further analysed (those <=65 years), including 11/132 with COVID-19- associated- AIS. Overall, 105/132 (79.5% [including 31/32 (97.9%) patients < 50]), were screened for aPL, of which 26/105 (24.8% [including 7/31 (22.6%) patients < 50]) were aPL positive. In patients with AIS that were screened, aPL prevalence was significantly higher in those associated with COVID-19 than those not associated with COVID-19: 10/11 (90.9%) vs. 16/94 (17.0%), p< 0.05 (Fisher's exact test). Within the COVID-19 AIS group, 8/10 aPL positive patients had an isolated lupus anticoagulant (LA);1/10 was double aPL positive. Five of 10 patients with COVID-19- associated AIS underwent repeat aPL assessment: aPL were persistently positive beyond 12 weeks in 1/5, and transient in 4/5. In the non-COVID- 19 AIS group, 7/16 underwent repeat aPL testing, with 4/7 (57.1%) demonstrating persistence. aPL subtypes are shown in Table 1. Conclusion(s): Among AIS patients, aPL, mainly LA, are more frequent in those with COVID-19 infection. Patients with AIS (with or without COVID-19) found to have aPL should be retested for aPL persistence, potentially leading to a diagnosis of antiphospholipid syndrome.
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BACKGROUND: In response to COVID-19, alongside other service changes, North Central London and East Kent implemented prehospital video triage: this involved stroke and ambulance clinicians communicating over FaceTime (Apple Inc., Cupertino, CA, USA) to assess suspected stroke patients while still on scene. OBJECTIVE: To evaluate the implementation, experience and impact of prehospital video triage in North Central London and East Kent. DESIGN: A rapid mixed-methods service evaluation (July 2020 to September 2021) using the following methods. (1) Evidence reviews: scoping review (15 reviews included) and rapid systematic review (47 papers included) on prehospital video triage for stroke, covering usability (audio-visual and signal quality);acceptability (whether or not clinicians want to use it);impact (on outcomes, safety, experience and cost-effectiveness);and factors influencing implementation. (2) Clinician views of prehospital video triage in North Central London and East Kent, covering usability, acceptability, patient safety and implementation: qualitative analysis of interviews with ambulance and stroke clinicians (n = 27), observations (n = 12) and documents (n = 23);a survey of ambulance clinicians (n = 233). (3) Impact on safety and quality: analysis of local ambulance conveyance times (n = 1400;April to September 2020). Analysis of national stroke audit data on ambulance conveyance and stroke unit delivery of clinical interventions in North Central London, East Kent and the rest of England (n = 137,650;July 2018 to December 2020). RESULTS: (1) Evidence: limited but growing, and sparse in UK settings. Prehospital video triage can be usable and acceptable, requiring clear network connection and audio-visual signal, clinician training and communication. Key knowledge gaps included impact on patient conveyance, patient outcomes and cost-effectiveness. (2) Clinician views. Usability - relied on stable Wi-Fi and audio-visual signals, and back-up processes for when signals failed. Clinicians described training as important for confidence in using prehospital video triage services, noting potential for 'refresher' courses and joint training events. Ambulance clinicians preferred more active training, as used in North Central London. Acceptability - most clinicians felt that prehospital video triage improved on previous processes and wanted it to continue or expand. Ambulance clinicians reported increased confidence in decisions. Stroke clinicians found doing assessments alongside their standard duties a source of pressure. Safety - clinical leaders monitored and managed potential patient safety issues;clinicians felt strongly that services were safe. Implementation - several factors enabled prehospital video triage at a system level (e.g. COVID-19) and more locally (e.g. facilitative governance, receptive clinicians). Clinical leaders reached across and beyond their organisations to engage clinicians, senior managers and the wider system. (3) Impact on safety and quality: we found no evidence of increased times from symptom onset to arrival at services or of stroke clinical interventions reducing in studied areas. We found several significant improvements relative to the rest of England (possibly resulting from other service changes). LIMITATIONS: We could not interview patients and carers. Ambulance data had no historic or regional comparators. Stroke audit data were not at patient level. Several safety issues were not collected routinely. Our survey used a convenience sample. CONCLUSIONS: Prehospital video triage was perceived as usable, acceptable and safe in both areas. FUTURE RESEARCH: Qualitative research with patients, carers and other stakeholders and quantitative analysis of patient-level data on care delivery, outcomes and cost-effectiveness, using national controls. Focus on sustainability and roll-out of services. STUDY REGISTRATION: This study is registered as PROSPERO CRD42021254209. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research;Vol. 10, No. 26. See the NIHR Journals Library website for further project information.
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Background and aims: To observe how the Covid-19 pandemic affected trends in referrals to our tertiary hyperacute stroke unit (HASU). Methods: Referrals from emergency departments in hospitals within our sector were made electronically using the online 'Refer-A-Patient' system. We reviewed 150 referrals made post-Covid, from 16th March 2020 (when Covid restrictions were first introduced in the UK) until June 2020. These were compared with 150 referrals made pre-Covid, between March and June in 2019. Results: The patients in the pre-Covid referral cohort were significantly older on average than the post-Covid referral cohort (p=0.0476);there were more referrals under the age of 50, and fewer over the age of 80, post-Covid. We accepted significantly fewer patients for transfer post-Covid compared with pre-Covid (21% vs. 43% respectively, p=0.0001). The percentage of cases with a confirmed stroke diagnosis post-transfer was marginally higher post-Covid than pre-Covid (69% vs. 59% respectively, p=0.2443). Importantly, of the patients not accepted for transfer post-Covid, none had a subsequent stroke diagnosis. Conclusions: The Covid-19 pandemic seems to have led to a more selective approach in accepting referrals for transfer. This in turn appears to have reduced our stroke mimic rate. This poses an argument that there are benefits in being more selective. Video triage is an emerging tool, which can be used in emergency departments to aid the accuracy of selection for transfer and warrants further evaluation.
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Background: In 2020, North Central (NC) London and East Kent introduced prehospital video triage, where stroke and ambulance clinicians used videoconferencing to assess suspected stroke patients on scene. The aim was to reduce conveyance of non-stroke patients to stroke services and reduce transmission of Covid-19. Methods: Rapid, mixed-method evaluation of prehospital video triage in NC London and East Kent (July 2020-September 2021), drawing on: • Interviews with ambulance and stroke clinicians (n=27);observations (n=12);documents (n=23);• Survey of ambulance clinicians (n=233) in NC London and East Kent. • Descriptive statistical analysis of local ambulance conveyance data (n=1,400;April-September 2020). • Difference-in-differences regression analysis of team-level national audit data, to understand changes in delivery of clinical interventions in NC London and East Kent relative to the rest of England (n=137,650;2018-2020). Results: Interview and survey data suggested clinicians perceived prehospital video triage as usable, safe, and preferable to 'business-as-usual'. Several interrelated factors influenced implementation, including impetus of Covid-19, facilitative local governance, receptive professional values, engaging clinical leadership, active training approaches, and stable audiovisual signal;stroke clinician capacity was a potential risk to sustainability. Neither area saw increased time from symptom onset to arrival at services, while delivery of clinical interventions either remained unchanged or improved significantly, relative to the rest of England. Conclusions: Prehospital video triage in NC London and East Kent was perceived as usable, acceptable, and safe;it was associated with some significant improvements in secondary care processes. Key influences included national and local context, characteristics of triage services, and implementation approaches.
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Background and aims: As the Omicron variant emerged and became prevalent within the UK, an increased risk of nosocomial COVID-19 infection presented itself in this busy London Stroke Unit. This posed particular risk to the Acute Stroke Unit patients some of whom had been inpatients for up to five months and therefore missed the opportunity for vaccination under the nationwide scheme, or who had not taken up the vaccine when offered in the past. An improvement project was undertaken to provide inpatient vaccination to these vulnerable patients. Results: Of the 18 patients admitted to the unit at the beginning of December 2021, 60% had not received the full complement of COVID vaccinations. 22% of patients had not received any doses of COVID vaccination. 7 patients were identified for vaccination in the first round. 3 others would have been eligible but unfortunately tested positive prior to the first vaccination date. Informed consent was gained from those patients with capacity (40%). Next of kin were informed for the remaining patients, with a best interest decision made to proceed. The vaccination status of patients is to be reviewed in weekly Multidisciplinary Team Meetings. Conclusions: Assessment of COVID vaccination status for long term patients will play a key role in the prevention of nosocomial infection in Stroke patients and should be undertaken where possible.
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Background and Aims: As a consequence of the COVID-19 pandemic prehospital video assessment (PHVA) of possible stroke was commenced by University College London Hospital and London Ambulance Service. We compared the accuracy of this assessment tool against conventional screening with FAST. Methods: We examined the accuracy of PHVA from May 2020 to April 2021, together with final diagnoses, timings for treatment provided and ambulance crew primary assessment (FAST status) wherever this was recorded. Results: Of 1300 patients triaged, 600 (46%) were sent to HASU, 570 (44%) were AE diverts and 65 (5%) were sent to their local TIA clinic. 40 patients (3%) were returned to their LAS pathway and missing data was noted for 25 patients (2%). From 426 patients where FAST status was recorded, diagnosis of likely stroke/TIA was correct in 89% (278) of PHVA versus 55% (173) of FAST assessed cases. Correct identification of non-stroke was correct in 84% (96) of PHVA versus 65% (75) of FAST assessed cases. A positive predictive value of 93% (PHVA) versus 59% (FAST) and negative predictive value 96% (PHVA) versus 84% (FAST) is noted. 46 thrombolysis and 12 thrombectomy cases with median treatment time before and during PHVA of 35 minutes (Interquartile range (IQR)-26) vs 33 (IQR-15) and 136 (IQR-87) vs 125 (IQR-49) minutes respectively, were noted. Conclusions: PHVA has been validated further, showing superior accuracy to the existing FAST assessment and may improve hyperacute treatment times and their variance.
Subject(s)
COVID-19 , Stroke , Biomarkers , Humans , Lung , Pandemics , Prognosis , SARS-CoV-2 , Stroke/diagnostic imaging , Stroke/epidemiologyABSTRACT
BACKGROUND AND PURPOSE: Diagnosis of coronavirus disease 2019 (COVID-19) relies on clinical features and reverse-transcriptase polymerase chain reaction testing, but the sensitivity is limited. Carotid CTA is a routine acute stroke investigation and includes the lung apices. We evaluated CTA as a potential COVID-19 diagnostic imaging biomarker. MATERIALS AND METHODS: This was a multicenter, retrospective study (n = 225) including CTAs of patients with suspected acute stroke from 3 hyperacute stroke units (March-April 2020). We evaluated the reliability and accuracy of candidate diagnostic imaging biomarkers. Demographics, clinical features, and risk factors for COVID-19 and stroke were analyzed using univariate and multivariate statistics. RESULTS: Apical ground-glass opacification was present in 22.2% (50/225) of patients. Ground-glass opacification had high interrater reliability (Fleiss κ = 0.81; 95% CI, 0.68-0.95) and, compared with reverse-transcriptase polymerase chain reaction, had good diagnostic performance (sensitivity, 75% [95% CI, 56-87]; specificity, 81% [95% CI, 71-88]; OR = 11.65 [95% CI, 4.14-32.78]; P < .001) on multivariate analysis. In contrast, all other contemporaneous demographic, clinical, and imaging features available at CTA were not diagnostic for COVID-19. The presence of apical ground-glass opacification was an independent predictor of increased 30-day mortality (18.0% versus 5.7%, P = .017; hazard ratio = 3.51; 95% CI, 1.42-8.66; P = .006). CONCLUSIONS: We identified a simple, reliable, and accurate COVID-19 diagnostic and prognostic imaging biomarker obtained from CTA lung apices: the presence or absence of ground-glass opacification. Our findings have important implications in the management of patients presenting with suspected stroke through early identification of COVID-19 and the subsequent limitation of disease transmission.