A Bundle of Acute Stroke Care

National standards for high-quality stroke care improves patient outcomes and compliment revascularization treatments, which are applicable to approximately 10-15% worldwide. Stroke unit care is the most effective interventions targeting all patients with stroke. Access to and quality of a multidisciplinary stroke unit care at admission varies within and between countries where patients with stroke may be admitted to either stroke units or emergency departments without specific stroke unit care. The studies in this PhD investigated 1) if high-quality of stroke unit care associated with lower long-term all-cause mortality, 2) if it was feasible to implement a specialized stroke nurse in the emergency department as part of a frontline stroke unit, 3) if the location of a specialized stroke nurse in the emergency department improved fulfilment of national quality indicators, that reflected multidisciplinary stroke unit care. The methodologies applied were registry-based analysis using national databases combined with retrospective observational studies. The retrospective observational studies identified how to implement a specialized stroke nurse in the emergency department and how it affected fulfillment of process performance measures. In all three studies, data supported the importance of high adherence to process performance measures and that adherence improved fulfilment of process performance measures if a specialized stroke nurse was extended from the stroke unit to the emergency department. In
Study I, timely fulfilment of mandatory nationally recommended process performance measures was associated with improved long-term survival. Patient with fulfillment of all process performance measures demonstrated a 10% lower 10-years all-cause mortality compared with those with less than 49% fulfilment showing a dose-response relationship. Although beneficial, all-cause mortality among patient with complete fulfilment remained 19% higher than of the general Danish population, while all-cause mortality was 40% higher when fulfilment was below 49%. Study II showed that it was feasible to locate a specialized stroke nurse in the emergency department, but the implementation did not lower 30-days or long-term all-cause mortality. However, during the presence of a specialized stroke nurse in the emergency department adherence to process performance measures improved for mobilization, bladder scan, and dysphagia screening. In Study III, locating the specialized stroke nurse in the emergency department significantly increased fulfilment of national process performance measures compared with the period before and after the nurse’s reassignment to the stroke units. Most notably were the process performance measures of mobilization, dysphagia screening, and transfer to a stroke unit fulfilled. The improvements were not sustained after the SNN returned to the stroke unit. These findings 8
highlight the importance of adherence to specific process performance measures and the importance of having a specialized stroke nurse as part of a frontline stroke unit.