Justus-Liebig-University of Giessen Dpt. of Neurology

Stroke Management

in Germany

Dr. Jens AllendoerferDpt. of Neurology

University Hospital of Gießen(Head: Prof. Dr. M. Kaps)

Bloodletting

Justus-Liebig-University of Giessen Dpt. of Neurology

built in 1890

In the early 90s:Development of the german stroke unit concept and implementation in stroke care, supported by the public health system

100 years later…>150 stroke unitsin the states of Germany

Since 1995Prospective data collection for quality assurance anddevelopment of marker of quality in stroke care*

*Heuschmann et al, Stroke 2006;37;2573-2551

Stroke Unit in GermanyCentral reading

• Blood pressure• Heart rate• ECG with automated

arrhythmia detection• Oxygen saturation• Breathing rate• Temperature

Equipment• Monitor• Oxygen• Suction devices

Optimized management of care with a Stroke Unit

MinutenMinuten1010 2020 3030 4040

Neurologist on dutyAnamnesis, clinical status, Lab(EKG, Ultrasound)

CCT or DWI MRI

(CTAngio, DSA,Xray)

Stroke TEAM treatmentBasic therapyMonitoringfurther diagnostics

rtPA

Emergency medical service gives basic information by call

Emergency dpt. CCT or MRI Stroke Unit

Advantages of a Stroke Unit

Admission as early as possible

Organisation of emergency medical service

Specialized staff

Fast diagnosis

Modern treatment strategies

Short hospital stay

Early physio- and speechtherapy

Early Rehabilitation

Admission• demographic data• Time of stroke, of admission• clinical scales like NIHSS & mRS before admission• dependency statusHospital inpatient stay• diagnostic procedures• medical treatment & additional procedures• complications• duration of symptoms• Stroke classification according to TOAST • Findings of MRI and CT scan

End of inpatient treatment• secondary prophylaxis (antiplatelets, statins…)• diagnosis according to ICD-10• clinical scales like NIHSS, mRS, Barthel Index• rehabilitation status (discharge or appointment for rehab.)

Sanctions in case of incomplete documentation

• Data were compared with ICD data of the health insurance• If the rate of QA documentation is below 80% a reduction of

payment follows• These mechanisms provides a nearly complete

documentation of stroke patients

Scientific evaluation

A data core set of all QA documentations in the different states of germany is given to the ADSR (German Stroke Register Study Group) for further evaluation

21.350 stroke patients (2006 in Hesse)

male

female

Mean age 73.3y

Age

Hospital arrival after stroke

Risk factors

0

10

20

30

40

50

60

70

80

TIA Stroke AF DM Hypertension smoker others

89% of all patients have at least one risk factor

% o

f p

atie

nts

in history

Diagnostic in acute stroke

0 5000 10000 15000 20000

CCT

MRI

MRA

Duplex extra

TCD/TCCS

TTE/TEE

all

<3h

>3h

Diagnoses in Stroke

Infarction 61%

TIA

ICH

5%

unk

Early treatment in acute stroke

0 2000 4000 6000 8000 10000 12000

AP

Hep high

Hep low

Lysis iv

(only patients with cerebral infarction, n=13129)

78%

16%

65%

3,5%

Thrombolysis in acute stroke

local (i. a.)

i.v.

all

0 100 200 300 400 500

Thrombolysis

(pat. with cerebral infarction arrived within 3h, n=2402)

rate of 19,3%

End of hospital treatment

Length of stay: 9,5 days (mean)

Treatment on the Stroke Unit: 3,9 days (mean)

(n=21.350)

Home 50% Inpatient Rehabilitation 29% Nursing home 6% died in hospital 6%

Discharge

Useful data or waste?

1. Jauss M, Allendoerfer J, Stolz E, Schutz HJ, Misselwitz B. Treatment results of stroke patients aged >80 years receiving intravenous rt-PA. Cerebrovasc Dis 2007;24(2-3):305-6.

2. Foerch C, Misselwitz B, Humpich M, Steinmetz H, Neumann-Haefelin T, Sitzer M. Sex disparity in the access of elderly patients to acute stroke care. Stroke 2007;38(7):2123-6.

3. Foerch C, Misselwitz B, Sitzer M, Berger K, Steinmetz H, Neumann-Haefelin T. Difference in recognition of right and left hemispheric stroke. Lancet 2005;366(9483):392-3.

4. Sitzer M, Foerch C, Neumann-Haefelin T, Steinmetz H, Misselwitz B, Kugler C, Back T. Transient ischaemic attack preceding anterior circulation infarction is independently associated with favourable outcome. J Neurol Neurosurg Psychiatry 2004;75(4):659-60.

5. Suenkeler IH, Nowak M, Misselwitz B, Kugler C, Schreiber W, Oertel WH, Back T. Timecourse of health-related quality of life as determined 3, 6 and 12 months after stroke. Relationship to neurological deficit, disability and depression. J Neurol 2002;249(9):1160-7.

And some more papers by the ADSR were supported by the stroke registry of Hesse (Heuschmann et. al….Stroke 2003, JAMA 2004, Arch Int Med 2004, Stroke 2006, )