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Background: Intravenous thrombolytic therapy (IVT) with tissue plasminogen activator for acute ischemic stroke is underutilized in many parts of the world. Randomized trials to test the effectiveness of thrombolysis implementation strategies are limited. Methods and Results: This study aimed to test the effectiveness of a multicomponent, multidisciplinary tissue plasminogen activator implementation package in increasing the proportion of thrombolyzed cases while maintaining accepted benchmarks for low rates of intracranial hemorrhage and high rates of functional outcomes at 3 months. A cluster randomized controlled trial of 20 hospitals in the early stages of thrombolysis implementation across 3 Australian states was undertaken. Monitoring of IVT rates during the baseline period allowed hospitals (the unit of randomization) to be grouped into 3 baseline IVT strata—very low rates (0% to ≤4.0%); low rates (>4.0% to ≤10.0%); and moderate rates (>10.0%). Hospitals were randomized to an implementation package (experimental group) or usual care (control group) using a 1:1 ratio. The 16-month intervention was based on behavioral theory and analysis of the steps, roles, and barriers to rapid assessment for thrombolysis eligibility and involved comprehensive strategies addressing individual and system-level change. The primary outcome was the difference in tissue plasminogen activator proportions between the 2 groups postintervention. The absolute difference in postintervention IVT rates between intervention and control hospitals adjusted for baseline IVT rate and stratum was not significant (primary outcome rate difference=1.1% (95% CI −1.5% to 3.7%; P=0.38). Rates of intracranial hemorrhage remained below international benchmarks. Conclusions: The implementation package resulted in no significant change in tissue plasminogen activator implementation, suggesting that ongoing support is needed to sustain initial modifications in behavior. Clinical Trial Registration: URL: ww

AIMS: Penumbral selection is best-evidence practice for thrombectomy in the 6-24 hour window. Moreover, it helps to identify the best responders to thrombolysis. Multimodal computed tomography (mCT) at the primary centre-including noncontrast CT, CT perfusion, and CT angiography-may enhance reperfusion therapy decision-making. We developed a network with five spoke primary stroke sites and assessed safety, feasibility, and influence of mCT in rural hospitals on decision-making for thrombolysis. METHODS: Consecutive patients assessed via telemedicine from April 2013 to June 2018. Clinical outcomes were measured, and decision-making compared using theoretical models for reperfusion therapy applied without mCT guidance. Symptomatic intracranial hemorrhage (sICH) was assessed according to Safe Implementation of Treatments in Stroke Thrombolysis Registry criteria. RESULTS: A total of 334 patients were assessed, 240 received mCT, 58 were thrombolysed (24.2%). The mean age of thrombolysed patients was 70 years, median baseline National Institutes of Health Stroke Scale was 10 (IQR 7-18) and 23 (39.7%) had a large vessel occlusion. 1.7% had sICH and 3.5% parenchymal hematoma. Three months poststroke, 55% were independent, compared with 70% in the non-thrombolysed group. CONCLUSION: Implementation of CTP in rural centers was feasible and led to high thrombolysis rates with low rates of sICH.

Background Urinary incontinence has negative effects for patients and health systems. In recent Stroke Foundation audits, nationally 35% of acute and 41% of rehabilitation inpatients had urinary incontinence, but only half had associated management plans. Aim To determine if broader implementation (multiple Health Districts, across phases of care) of our previously-piloted multidisciplinary Structured urinary Continence Assessment and Management Plan (SCAMP) interventions (including clinically-applicable tools, processes and education; audit and feedback) improves inpatient post-stroke urinary incontinence assessment, diagnosis and management. Methods Design: before- and after-implementation study at six acute stroke/ medical units, two comprehensive stroke and six rehabilitation services in three New South Wales Local Health Districts.Primary outcome: change in the proportion of incontinent patients who have a continence management plan.Secondary outcomes: change in the proportion of patients who have a urinary continence assessment, documented incontinence diagnosis and receive continence education. We will also determine the intervention effect on clinician knowledge, skills and confidence, and potential cost-effectiveness (hospital perspective).Data collection: medical record audits, clinician questionnaires and site-specific teams identifying local barriers and enablers to continence management. Data will be collected for 3 months before and after the 7-month implementation period. Sustainability will be evaluated 16 months after implementation commences.Results Ethics is approved. Before-implementation data collection commenced January 2019. The project will be completed by July 2020. Discussion Our SCAMP interventions can potentially operationalise high-level concepts outlined in Australian stroke guidelines into effective clinical care across hospitals a

Background and Aims:Urinary incontinence is a common, costly but often overlooked stroke complication. We aim to determine if implementing our SCAMP intervention (includes previously-piloted clinically-applicable tools and processes and education, audit and feedback) improves urinary incontinence assessment and management for in-hospital patients following stroke. Methods:Design: pragmatic, before- and after-implementation study at six acute stroke/ medical units, two comprehensive stroke and six rehabilitation services in NSW, Australia. Primary outcome: change in the proportion of incontinent patients who have a continence management plan. Secondary outcomes: change in the proportion of patients who have a urinary continence assessment, recorded diagnosis of incontinence type/s, and receive continence education. We will also determine the intervention effect on clinician knowledge, skills and confidence, and the potential cost-effectiveness from a hospital perspective. Data collection: medical record audits, clinician questionnaires and site-specific teams identifying local barriers and enablers to continence management. Data will be collected for 3 months before and after the 7-month implementation period. To assess sustainability, outcomes will again be measured 16 months after implementation commences. Fifteen consecutive medical record audits (incontinent patients) per site per month will provide >80% power to detect a 20% absolute increase (from before intervention) in the proportion of incontinent patients with an incontinence plan (type 1 error rate of 5%). Results:Ethics has been approved. Before-implementation data collection is underway. The project will be completed by July 2020. Conclusions:We will translate high-level concepts outlined in clinical guidelines into effective and efficient continence care. SCAMP has the potential to be read

Background: Stroke is a leading cause of death and disability internationally. One of the three effective interventions in the acute phase of stroke care is thrombolytic therapy with tissue plasminogen activator (tPA), if given within 4.5 hours of onset to appropriate cases of ischaemic stroke.Objectives: To test the effectiveness of a multi-component multidisciplinary collaborative approach compared to usual care as a strategy for increasing thrombolysis rates for all stroke patients at intervention hospitals, while maintaining accepted benchmarks for low rates of intracranial haemorrhage and high rates of functional outcomes for both groups at three months.Methods and design: A cluster randomised controlled trial of 20 hospitals across 3 Australian states with 2 groups: multi- component multidisciplinary collaborative intervention as the experimental group and usual care as the control group. The intervention is based on behavioural theory and analysis of the steps, roles and barriers relating to rapid assessment for thrombolysis eligibility; it involves a comprehensive range of strategies addressing individual-level and system-level change at each site. The primary outcome is the difference in tPA rates between the two groups post-intervention. The secondary outcome is the proportion of tPA treated patients in both groups with good functional outcomes (modified Rankin Score (mRS <2) and the proportion with intracranial haemorrhage (mRS ≥2), compared to international benchmarks.Discussion: TIPS will trial a comprehensive, multi-component and multidisciplinary collaborative approach to improving thrombolysis rates at multiple sites. The trial has the potential to identify methods for optimal care which can be implemented for stroke patients during the acute phase. Study findings will include barriers and solutions to effective thrombolysis implementation and trial outcomes will be published whether significant or not.Trial registration: Australian New Zealand Clini