Article Figures & Data
Figures
- Figure 1
Flowchart of the included study population. AIS, acute ischaemic stroke; ASCaM, Acute Stroke Care Map; tPA, tissue plasminogen activator.
- Figure 2
Greater Shenyang Acute Stroke Care Map. The geographical locations of all 20 participating hospitals are displayed. The inset image is the greater Shenyang map illustrating individual administrative divisions. The figure was modified from https://en.wikipedia.org/wiki/Shenyang under licensing of CC0 1.0 universal public domain dedication.
Tables
- Table 1
Strategies implemented among Shenyang ASCaM hospitals (with selected references)
Strategies Description References EMS prenotification Ambulance staff prenotifies hospital stroke neurologists regarding medical history and abnormalities. 10 27 28 39 Advanced ED preparation Preparation in advance of intravenous lines, catheters, infusion/infiltration pump, electrocardiographic monitoring or DSA suite if needed. * Dedicated stroke neurologists 24/7 availability Assign dedicated stroke fellows or at least neurology residents in ED with 24/7 availability, and neurointerventionists as conditioned. 11 Rapid stroke triage/notification Rapid stroke triage protocol and stroke team notification must be applied. 10 39 Staff accompany Thrombolysis-indicated patients must be accompanied by ED staffs (generally stroke nurses) all way through before the actual administration of intravenous tPA. * Immediate neuroimaging interpretation Brain imaging was read and interpreted by ED neurologist on the spot once yielded. 10 12 39 First-line neurologist decision Thrombolysis decision is made by the first-line neurologists and confirmed by stroke fellow by phone or in person. 10 First priority for thrombolysis indicated patients Hospital-wide first priority such as access to neuroimaging and laboratory facilities for thrombolysis-indicated patients must be strictly applied. 13 Stroke toolkits 24/7 availability Stroke toolkits including assessment scales, written inform and consent form and tPA are 24/7 available in ED. 10 39 Laboratory and neuroimaging in nearest location Laboratory and neuroimaging facilities were required to be renovated or relocated to the nearest possible location within the radius of ED. 10 12 27 40 *Strategies adapted to local healthcare system.
DSA, digital subtraction angiography; ED, emergency department; EMS, emergency medical services; tPA, tissue plasminogen activator.
- Table 2
Demographic and baseline characteristics of acute ischaemic stroke patients treated with tPA within 4.5 hours after onset
Pre-ASCaM
(N=189)ASCaM
(N=317)P value Age (year) N (n missed) 189 (0) 315 (2) Mean±SD 64.0±9.9 64.4±10.2 0.6408 Admission NIHSS N (n missed) 189 (0) 309(8) Mean±SD 8.2±6.2 7.5±5.3 0.1996 Age >80, n (%) 15 (7.9%) 12 (3.8%) 0.0445 Male, n (%) 131 (69.3%) 210 (66.5%) 0.5071 Previous stroke/TIA, n (%) 48 (25.4%) 77 (24.3%) 0.7801 Carotid stenosis, n (%) 78 (41.3%) 82 (25.9%) <0.001 HTN, n (%) 111 (58.7%) 202 (63.7%) 0.2634 DM, n (%) 53 (28.0%) 84 (26.5%) 0.7054 Dyslipidaemia, n (%) 122 (64.6%) 243 (76.7%) 0.0033 CAD/MI, n (%) 39 (20.6%) 64 (20.2%) 0.9041 AF/AFL, n (%) 21 (11.1%) 35 (11.0%) 0.9806 CHF, n (%) 5 (2.6%) 8 (2.5%) 0.9332 Prosthetic heart valve, n (%) 0 3 (0.9%) 0.2966 Seizure, n (%) 2 (1.1%) 0 0.1391 Peripheral vascular disease, n (%) 21 (11.1%) 39 (12.3%) 0.6883 Smoking, n (%) 89 (47.1%) 153 (48.4%) 0.7726 AF/AFL, atrial fibrillation/atrial flutter; ASCaM, Acute Stroke Care Map; CAD, coronary artery disease; CHF, congestive heart failure; DM, diabetes mellitus; HTN, hypertension; MI, myocardial infarction; NIHSS, National Institute of Health Stroke Scale; TIA, transient ischaemic attack.
- Table 3
Comparison of key performance measures and clinical outcomes, Pre-ASCaM versus ASCaM period
Pre-ASCaM
(N=189)ASCaM
(N=317)P value Unadjusted OR (95 % CI) or β P value Adjusted OR (95 % CI) or β P value tPA within 4.5 hours, % 54.5% (189/347) 65.4% (317/485) 0.0015 1.235 (1.08 to 1.41) 0.0015 1.724 (1.21 to 2.45)* 0.003* ODT (Mean±SD) 135.7±58.4 114.1±55.7 <0.001 −22.02922 <0.0001 −20.59164 0.0002 DNT (Mean±SD) 57.1±30.6 56.1±25.3 0.6838 −0.91595 0.7188 −0.24447 0.9260 ONT (Mean±SD) 195.6±59.3 169.2±58.1 <0.001 −26.74615 <0.0001 −24.89451 <0.0001 Favourable outcome (mRS ≤2), n (%) 151 (79.9%) 270 (85.2%) 0.1244 0.677 (0.422 to 1.087) 0.1064 0.761 (0.444 to 1.306) 0.3222 sICH, n (%) 6 (3.2%) 10 (3.2%) 0.9901 1.003 (0.359 to 2.806) 0.9950 In-hospital mortality 6 (3.2%) 8 (2.5%) 0.6659 1.262 (0.431 to 3.696) 0.6708 For multivariate analysis, data were adjusted for patient-level factors, including age, sex, medical history (including atrial fibrillation or atrial flutter, prosthetic heart valve, previous stroke or transient ischemic attack, coronary artery disease or prior myocardial infarction, carotid stenosis, peripheral vascular disease, hypertension, dyslipidaemia, seizure and current smoking), stroke severity (NIHSS score).
*Data were adjusted for the contribution of thrombolytic cases from every individual hospitals.
ASCaM, Acute Stroke Care Map; DNT, door-to-needle time; mRS, modified Rankin Scale; NIHSS, National Institute of Health Stroke Scale; ODT, onset-to-door time; ONT, onset-to-needle time; sICH, symptomatic intracerebral haemorrhage.
Supplementary data
