Clinical routines and structural resources for performing transoesophageal echocardiography on German stroke units.

Abstract

Background: Transoesophageal echocardiography (TOE) is essential for identifying cardiac sources of embolism in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA). As randomized controlled trials are missing, recommendations regarding echocardiography after stroke remain vague, and clinical routines and structural resources for performing TOE on stroke units may differ. We here examined structural conditions for performing TOE on certified stroke units in Germany, and evaluated factors that may influence the decision to perform TOEs.

Methods: In this prospective exploratory cross-sectional survey, a standardized anonymous questionnaire was sent to all clinical leads of certified stroke units in Germany, supported by the German Stroke Society. The questionnaire focused on (a) on general characteristics of stroke units and logistics of TOE examinations and (b) local indication for performing TOEs, with a focus on factors that may influence this decision.

Results: Data from 248 SUs (stroke units) were included into the analysis (response rate 71.1%). The reported median TOE rate was 23.0% (IQR 18-34). Lower TOE rates were related to increasing numbers of stroke patients (p = 0.048). Most TOEs were performed within 24-48 h after the request (49.6%). Longer waiting times for TOE were associated with level of certification (p < 0.001) and higher numbers of stroke patients (p = 0.002). The presence of a stroke unit cardiologist did not result into shorter waiting times (p = 0.238). In total, 23.8% of the responding stroke units do not have a standardized operating procedure (SOP) for indicating TOE. Though 50% of leads considered quantitative requirements for indicating TOEs, within certain clinical contexts and situations, our findings revealed a broad consensus among stroke unit leads concerning TOE indications.

Conclusions: Despite limitations, our study provides valuable insights into performing TOE in hospitalized German stroke patients. This may facilitate the optimized use of TOE in hospitals and represent a first step towards the development of future guidelines and SOPs, in particular in the context of limited resources.