CODE STROKE ALERT—Concept and Development of a Novel Open-Source Platform to Streamline Acute Stroke Management

If you want this in your hospital YOU will need to initiate. Your hospital has no person assigned to read and implement research.  Why should they? The status quo is good enough. If 10% full recovery  and 12% tPA full recovery aren't good enough, why aren't stroke survivors complaining and filing lawsuits? Maybe because they have been bamboozled into accepting that fucking tyranny of low expectations provided by your stroke medical professionals.

CODE STROKE ALERT—Concept and Development of a Novel Open-Source Platform to Streamline Acute Stroke Management

• ¹Neurointerventional Service – Department of Radiology, Monash Health, Clayton, VIC, Australia
• ²Deloitte, Sydney, NSW, Australia
• ³School of Medicine, Monash University, Clayton, VIC, Australia
• ⁴Department of Neurology, Monash Health, Clayton, VIC, Australia
• ⁵Neurointerventional Service – Department of Radiology, Austin Health, Melbourne, VIC, Australia
• ⁶School of Medicine, Deakin University, Waurn Ponds, VIC, Australia
• ⁷Alcohol Beverages Australia, Sydney, NSW, Australia
• ⁸Department of Engineering, Monash University, Clayton, VIC, Australia
• ⁹South Australian Health and Medical Research Institute, Adelaide, SA, Australia
• ¹⁰Department of Radiology, Northern Health, Epping, VIC, Australia
• ¹¹Department of Neurology, Austin Health, Heidelberg, VIC, Australia
• ¹²School of Medicine, The University of Melbourne, Parkville, VIC, Australia
• ¹³Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia

Introduction: Effective, time-critical intervention in acute stroke is crucial to mitigate mortality rate and morbidity, but delivery of reperfusion treatments is often hampered by pre-, in-, or inter-hospital system level delays. Disjointed, repetitive, and inefficient communication is a consistent contributor to avoidable treatment delay. In the era of rapid reperfusion therapy for ischemic stroke, there is a need for a communication system to synchronize the flow of clinical information across the entire stroke journey.

Material/Methods: A multi-disciplinary development team designed an electronic communications platform, integrated between web browsers and a mobile application, to link all relevant members of the stroke treatment pathway. The platform uses tiered notifications, geotagging, incorporates multiple clinical score calculators, and is compliant with security regulations. The system safely saves relevant information for audit and research.

Results: Code Stroke Alert is a platform that can be accessed by emergency medical services (EMS) and hospital staff, coordinating the flow of information during acute stroke care, reducing duplication, and error in clinical information handover. Electronic data logs provide an auditable trail of relevant quality improvement metrics, facilitating quality improvement, and research.

Discussion: Code Stroke Alert will be freely available to health networks globally. The open-source nature of the software offers valuable potential for future development of plug-ins and add-ons, based on individual institutional needs. Prospective, multi-site implementation, and measurement of clinical impact are underway.

Introduction

Gold standard treatment of acute ischemic stroke relies on timely reperfusion of ischemic cerebral tissue. The two primary methods of reperfusion are thrombolysis using intravenous tissue plasminogen activator (IV tPA) and mechanical thrombectomy. These therapies have been proven to be effective in several randomized clinical trials and meta-analyses (1–3). With rapid reperfusion therapy, up to 70% of patients may have good neurological recovery (4).

Mechanical thrombectomy is superior to IV tPA for acute ischaemic stroke due to large vessel occlusion (LVO). In multiple recent trials, the effect of time to reperfusion with mechanical thrombectomy was directly proportional to patient outcome (5–7). It is estimated that every 1-min reduction in the interval between stroke onset and start of mechanical thrombectomy results in an additional week of healthy living (8).

A comprehensive stroke service is necessarily complex, involving medical professionals across multiple disciplines and departments. Such an intricate system is prone to inefficiencies related to delayed dissemination of information, communication duplication, and error as well as the need for consensus decision making among stroke specialists and neuro-interventionalists (NI). The time critical nature of cerebral reperfusion is a compelling motivation to optimize communication systems, allowing for synchronization and improved coordination of clinical information (9).

To address this need, we aimed to develop a novel, open-source, multi-platform communication application, named “Code Stroke Alert,” that facilitates efficient multi-cast, tiered communication during the hyperacute management stages of an ischaemic stroke.

Stroke Pathway and Barriers to Timely Reperfusion

The basic pathway of communication in a stroke patient is outlined in Figure 1. Most strokes occur in the community and rely on initial recognition by the patient or a family member with subsequent first medical contact with local emergency medical services (EMS). Pre-hospital triage and care varies based on locality but generally involves a basic assessment by trained paramedics and transfer to a local stroke centre. The emergency department (ED) then alerts the radiology and stroke staff of the impending stroke (in most hospitals this is achieved through a group page). Much of the communication to this point is one-way, with limited ability to provide confirmation by any party, nor detailed clinical information.

FIGURE 1

Figure 1. Flowchart of communication pathway in a stroke case.

On arrival to hospital, multiple processes happen quickly and simultaneously. The stroke patient will be reassessed in detail by ED nurses, physicians, and the stroke team, whilst simultaneous handover is provided by the paramedics. Throughout this period, there is constant communication between all parties and senior clinical decision makers within the team. Following clinical assessment, the patient will proceed to neuroimaging with computed tomography (CT). Based on imaging findings in correlation with clinical assessment, a treatment decision will then be made. If the decision is for mechanical thrombectomy, activation of the angiography lab and anesthetics team must occur immediately, with broader notification (stroke unit and admission logistics) shortly after commencement of the procedure.

There are a number of points in this complex process which are vulnerable to delay (Table 1). The initial recognition by community members is the first and there are concerted efforts being made to improve health literacy to address this issue. Once EMS have been contacted there is a triage and dispatch process and then time spent in assessment and information gathering. A decision has to be made regarding destination, followed by transport time to the target hospital. Within the hospital environment there is a further complex succession of medical assessment, imaging acquisition, decision-making and treatment, and in some cases, transfer to a mechanical thrombectomy-capable service may be required.

TABLE 1

Table 1. Potential systemic barriers to timely reperfusion therapy.

Up to 40 different health care professionals may be involved in this entire process for an individual stroke presentation. This includes, but is not limited to, paramedic staff, ambulance staff, emergency staff, stroke physicians, stroke nurses, radiologists, radiographers, radiology nurses, NI, anesthetics staff, orderlies, junior medical staff, and administrative staff.

Reliable and efficient communication is a necessity in such a scenario, but most hospitals currently rely on paging systems or paper information sheets with multiple handovers and a sequential dissemination of information. This can lead to communication duplication, information loss, security concerns and, ultimately, time delays. The bold text delays presented in Table 1 highlight points at which we hypothesized that a dedicated, electronic information gathering and distribution program could accelerate the pathway of a stroke patient.

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