Effect of a 72 Hour Stroke Care Bundle on Early Outcomes after Acute Stroke: A Non Randomised Controlled Study

<div><p>Background</p><p>Integrated care pathways (ICP) in stroke management are increasingly being implemented to improve outcomes of acute stroke patients. We evaluated the effect of implementing a 72 hour stroke care bundle on early outcomes among patients admitted within seven days post stroke to the national referral hospital in Uganda.</p><p>Methods</p><p>In a one year non-randomised controlled study, 127 stroke patients who had ‘usual care’ (control group) were compared to 127 stroke patients who received selected elements from an ICP (intervention group). Patients were consecutively enrolled (controls first, intervention group second) into each group over 5 month periods and followed to 30-days post stroke. Incidence outcomes (mortality and functional ability) were compared using chi square test and adjusted for potential confounders. Kaplan Meier survival estimates and log rank test for comparison were used for time to death analysis for all strokes and by stroke severity categories. Secondary outcomes were in-hospital mortality, median survival time and median length of hospital stay.</p><p>Results</p><p>Mortality within 7 days was higher in the intervention group compared to controls (RR 13.1, 95% CI 3.3–52.9). There was no difference in 30-day mortality between the two groups (RR 1.2, 95% CI 0.5–2.6). There was better 30-day survival in patients with severe stroke in the intervention group compared to controls (P = 0.018). The median survival time was 30 days (IQR 29–30 days) in the control group and 30 days (IQR 7–30 days) in the intervention group. In the intervention group, 41patients (32.3%) died in hospital compared to 23 (18.1%) in controls (P < 0.001). The median length of hospital stay was 8 days (IQR 5–12 days) in the controls and 4 days (IQR 2–7 days) in the intervention group. There was no difference in functional outcomes between the groups (RR 0.9, 95% CI 0.4–2.2).</p><p>Conclusions</p><p>While implementing elements of a stroke-focused ICP in a Ugandan national referral hospital appeared to have little overall benefit in mortality and functioning, patients with severe stroke may benefit on selected outcomes. More research is needed to better understand how and when stroke protocols should be implemented in sub-Saharan African settings.</p><p>Trial Registration</p><p>Pan African Clinical Trials Registry <a href="http://www.pactr.org/ATMWeb/appmanager/atm/atmregistry?_nfpb=true&_windowLabel=BasicSearchUpdateController_1&BasicSearchUpdateController_1_actionOverride=%2Fpageflows%2Ftrial%2FbasicSearchUpdate%2FviewTrail&BasicSearchUpdateController_1id=1272" target="_blank">PACTR201510001272347</a></p></div

Additional file 2: Table S2. of Determinants of hypertension in a young adult Ugandan population in epidemiological transition—the MEPI-CVD survey

Factors associated with hypertension among adults (age 18–40 years) in Wakiso district, Central Uganda. (PDF 175 kb

Additional file 1: Table S1. of Determinants of hypertension in a young adult Ugandan population in epidemiological transition—the MEPI-CVD survey

Additional baseline characteristics of the survey population in Wakiso district, Central Uganda. (PDF 153 kb

Kaplan Meier survival curves by stroke severity category comparing survival of patients in the control group and the intervention group.

<p>(A) shows Kaplan Meier curves comparing survival of participants with mild stroke in the control and intervention groups. (B) shows Kaplan Meier curves comparing survival of participants with moderate stroke in the control and intervention groups. (C) shows Kaplan Meier curves comparing survival of participants with severe stroke in the control and intervention groups. (D) shows Kaplan Meier curves comparing survival of participants with very severe stroke in the control and intervention groups. The p values were obtained from the log rank tests.</p

Elements of the stroke care bundle versus ‘usual care’ for patients presenting to the Accident and Emergency unit with acute stroke.

<p>Elements of the stroke care bundle versus ‘usual care’ for patients presenting to the Accident and Emergency unit with acute stroke.</p

Consort flow diagram.

<p>Consort flow diagram.</p

shows Kaplan Meier survival curves comparing survival of all participants in the control group and intervention group.

<p>shows Kaplan Meier survival curves comparing survival of all participants in the control group and intervention group.</p

Clinical and laboratory characteristics of the study patients.

<p>Clinical and laboratory characteristics of the study patients.</p

The Modified Early Warning Score.

<p>This table shows the vital sign parameters comprising the Modified Early Warning Score. Adapted from Subbe et al, 2001 [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0151408#pone.0151408.ref012" target="_blank">12</a>].</p

Baseline characteristics of enrolled patients.

<p>* Baseline characteristics of 452 study patients are presented here, as collected at the time of enrollment. Attendants are family and friends of patients who stay with them in hospital to provide them with food, personal care, and transport. They are also responsible for obtaining all prescribed medications and test results.</p