Cerebral hemorrhages are a type of stroke causing bleeding in the brain from a ruptured brain vessel or an aneurysm. In the emergency department (ED), advanced practice nurses (APNs') play a pivotal role in identifying cerebral hemorrhages. Many APNs' lack the skills necessary to assess, diagnose, and manage this type of stroke. A delay in diagnosis of cerebral hemorrhages carries a high risk of morbidity and mortality and can lead to lifelong disability or death. The framework of this project is the Patricia Benner theory of novice-to-expert, which is a 5-step approach designed to strengthen nursing skills with the goal of developing nurses into experts in the neuroscience field. This project addressed whether a validated educational program for APNs' in the ED will increase knowledge to improve the assessment, diagnosis, and management of the cerebral hemorrhage stroke patient. A panel of experts were provided a comprehensive educational plan with multiple case scenarios. A 5-point Likert questionnaire was administered and a statistical analysis was performed. Results indicated the panel strongly agreed that the educational initiative increased APNs' knowledge and fostered a culture of change for APNs' in the ED. Potential implications of this educational module will be considered in satellite organizations impacting APNs' growth and improving patient care throughout the health system. The project determined that the significance of social change included increased APNs' knowledge and advanced professional growth, lowers mortality rates, and promotes an evidence-based quality improvement project.

Τα ΑΕΕ είναι η πρώτη αιτία αναπηρίας και η τρίτη αιτία θανάτου παγκοσμίως. Επίσης οι ασθενείς με ΑΕΕ είναι οι συχνότεροι χρήστες των υπηρεσιών υγείας. Παράλληλα, στη χώρα μας δαπανάται ετησίως το 10% του Ακαθάριστου Εγχώριου Προϊόντος (ΑΕΠ) για την υγεία σε σχέση με το μέσο όρο του 8,9% των χωρών του Οργανισμού Οικονομικής Συνεργασίας και Ανάπτυξης (ΟΟΣΑ). Στόχος της μελέτης είναι η οικονομική αξιολόγηση του ενδο-νοσοκομειακού κόστους ασθενών με οξύ ΑΕΕ στην Ελλάδα καθώς επίσης και ο προσδιορισμός ανεξάρτητων παραγόντων που επηρεάζουν το κόστος νοσηλείας. Καταγράφηκαν δημογραφικά και κλινικά χαρακτηριστικά σε 429 συνεχόμενους ασθενείς με οξύ ΑΕΕ (ισχαιμικό ή αιμορραγικό) που εισήχθησαν σε όλες τις κλινικές του Πανεπιστημιακού Γενικού Νοσοκομείου Πατρών για διάστημα 18 μηνών. Υπολογίσαμε το κόστος, για κάθε ασθενή ατομικά, από την ώρα της εισβολής του ΑΕΕ έως την έξοδό του από το νοσοκομείο. Το κόστος μετρήθηκε σε ευρώ (€) και σύμφωνα με τις πραγματικές δαπάνες του νοσοκομείου. Η μέση ηλικία των ασθενών ήταν 68.9 (±12.7) έτη και η διάρκεια νοσηλείας ήταν 10.9 (±7.9) ημέρες. Οι 345 ασθενείς (80%) είχαν ισχαιμικό ΑΕΕ και 84 (20%) είχαν πρωτοπαθή ενδοεγκεφαλική αιμορραγία. Το άμεσο ενδο-νοσοκομειακό κόστος νοσηλείας όλων των ασθενών με οξύ ΑΕΕ ανήλθε στα 1.551.445,00 € για μια συνολική διάρκεια νοσηλείας 4.674 ημερών (331,9 € ανά ημέρα νοσηλείας). Το μέσο ενδονοσοκομειακό κόστος ανά ασθενή με ΑΕΕ ήταν 3.624,9(±2695.4) €. Το 59% του συνολικού κόστους αποδόθηκε στο κόστος "κλίνης και προσωπικού", (6%) "προ εισαγωγής", (13%) "εργαστηριακό έλεγχο", (6%) "απεικονιστικό έλεγχο", (8%) "αποκλειστική νοσηλευτική φροντίδα", (7%) "φαρμακευτική αγωγή", (0.6%) "θεραπεία αποκατάστασης" και (0.7%) "διάφορα έξοδα". Τα αιμορραγικά ΑΕΕ είχαν σημαντικά μεγαλύτερο κόστος από τα ισχαιμικά ΑΕΕ (μέσο 5305.4 και 3.214,5 €, αντίστοιχα). Μεταξύ των υπότυπων των ισχαιμικών ΑΕΕ το συνολικό μέσο κόστος ήταν σημαντικά χαμηλότερο για τα "κενοτοπιώδη" έμφρακτα (2328.7±1100.2 €). Η διάρκεια νοσηλείας είχε υψηλή συσχέτιση με το συνολικό ενδο-νοσοκομειακό κόστος. Η πολυπαραγοντική γραμμική ανάλυση παλινδρόμησης έδειξε ότι το τμήμα εισαγωγής, η βαρύτητα του ΑΕΕ στην εισαγωγή, ο τύπος του ΑΕΕ και η κατάσταση εξόδου ήταν ανεξάρτητοι παράγοντες του κόστους. Αν επιθυμούμε τη συγκράτηση του νοσοκομειακού κόστους, θα πρέπει να ληφθούν υπόψη πολιτικές διοίκησης που στοχεύουν στη μείωση της διάρκειας νοσηλείας. / Stroke is the first cause of disability and the third cause of death worldwide. Moreover, in the western countries, the stroke patients are the most frequent users of all the health services and the hospital budgets. At the same time, 10% of the Gross Domestic Product (GDP) is annually spent on health in relation with the average 8.9% of the Organisation for Economic Co-operation and Development (OECD) countries. Aim of this study is the economic evaluation on the in-hospital cost of patients with an acute stroke in Greece and the identification of potential independent factors influencing this cost. Demographic and clinical data were recorded on 429 consecutive patients with an acute stroke (ischemic and hemorrhagic), admitted to the University General Hospital of Patras during a period of 18 months. We calculated the cost, individually for each patient, from the stroke onset until the discharge from the hospital. The cost was measured in euro (€), according to the real expenditure of hospital. Mean age was 68.9 (±12.7) years and length of stay (LOS) was 10.9 (±7.9) days. In all, 345 patients (80%) had an ischemic stroke and 84 (20%) had a primary intracerebral hemorrhage. The direct in-hospital cost of all stroke patients, 1.551.445,00 €, accounted for a total hospitalisation of 4.674 days (331.9 € per day in hospital). The mean in-hospital cost per patient was 3.624,9 (±2695.4) €. The 59% of the total cost concerns the cost of "bed and staff", (6%) "pre-hospital cost", (13%) "laboratory investigations", (6%) "imaging investigations", (8%) "supportive nursing", (7%) "medication", (0.6%) "rehabilitation therapy" and (0.7%) "other expenses". Hemorrhagic strokes were significantly more expensive than the ischemic strokes (mean 5305.4 (± 4204.8) € and 3214,5 (±1976.2) € respectively). Amongst ischemic stroke subtypes the mean total cost was significantly lower for lacunar strokes (2328.7 ± 1100.2 €). The length of stay was highly correlated with in-hospital total cost. Multivariate linear regression model showed that the admission ward, stroke severity on admission, stroke type and status discharge were independent predictors of cost. In order to withhold the hospital cost, policies of administration that aiming to the reduction of length of stay should be taken into consideration.

Background: Rare genetic mutations cause familial early-onset stroke disorders, known as “Mendelian strokes”. The broader relevance of rare mutations in unrelated young stroke patients is uncertain. We hypothesize that rare mutations in known and novel genes are important risk factors for stroke. Methods: Exome sequencing was used to characterize rare disruptive protein-altering mutations in 185 young cases and 185 matched controls from INTERSTROKE, a large and globally representative stroke study. The major objectives were: 1) to precisely define the role of known Mendelian stroke genes and 2) to discover novel gene and pathway associations. Results: A focused assessment of known Mendelian stroke genes revealed a significant contribution from NOTCH3, the causal gene for Cerebral Autosomal Dominant Arteriopathies with Subcortical Infarcts and Leucoencephalopathies (CADASIL). CADASIL mutations were identified in six cases and no controls (P=0.03). The clinical presentation of CADASIL mutation carriers deviated from known symptomatology, consisting of small-vessel ischemic strokes (SVIS) accompanied by secondary features including migraine and depression. A novel role for non-CADASIL NOTCH3 mutations in ICH was also elucidated (OR=2.86; 95% CI, 1.13 to 7.93, P=0.02). Such mutations were present in 22% of ICH cases and 8% of matching controls. An agnostic evaluation of all genes did not reveal any genome-wide significant associations. However, NOTCH3 was among the top ICH genes out of 13,706 tested, and many others were also biologically relevant, notably, AARS2 and NBEAL2. A protective association was identified for the renin angiotensin system (P=8.1x10-4), whereas type II diabetes mellitus was associated with increased risk (P=1.9x10-2). Conclusion: Rare mutations influence risk of early-onset stroke. CADASIL mutations play an important role in unrelated stroke patients. Beyond CADASIL, a novel role was uncovered for other NOTCH3 mutations as common and significant risk factors for ICH. Novel biologically relevant genes and pathways may also affect stroke susceptibility. / Thesis / Master of Science in Medical Sciences (MSMS)