E.02 Streamlining hyperacute stroke management at Royal University Hospital

Background: The Saskatoon stroke program participated in the ESCAPE trial looking at rapid endovascular revascularization for large vessel occlusion. Improvements were necessary to meet the timelines mandates in ESCAPE and to comply with Canadian Best Practice Guidelines. Methods: Retrospective chart review and prospective gathering of key metrics was performed using REDCap (Research Electronic Data Capture) software. Changes adapted from Canadian Best Practice Recommendations for Stroke Care, the ESCAPE protocol, and the Calgary stroke program HASTE project were implemented. Results: Changes implemented included increasing ambulance bypass window to 12 hours, FAST stroke assessment, emergency department pre-notification and registration, stroke alert protocol, team swarm of the patient, administration of tPA in the computed tomography (CT) room, and rapid access to the endovascular suite. Total number of patients between the years 2012 and 2014 was 287, and of those, 93 received tPA. Door-to-CT times decreased from 40 minutes to 21 minutes from 2012 to 2014; and Door-to-Needle (tPA) decreased from 62 minutes to 46 minutes from 2012 to 2014. Conclusions: By following Canadian best practice recommendations for stroke care, the ESCAPE protocol, and adaptation of Calgary stroke program HASTE project, our stroke program implemented changes to reduce treatment times for patients experiencing stroke in our province.

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Abstract 3500: Implementing Best Practice Recommendations to Address Urinary Incontinence after Stroke

Stroke ◽

10.1161/str.43.suppl_1.a3500 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Sarah Donaldson ◽

Erik Leci ◽

Matthew Meyer ◽

Shannon Janzen ◽

Norine Foley ◽

...

Keyword(s):

Urinary Incontinence ◽

Clinical Practice ◽

Best Practice ◽

Stroke Care ◽

Intermittent Catheterization ◽

Bladder Training ◽

Rehabilitation Unit ◽

Practice Recommendations ◽

Number Of Patients ◽

Training Protocol

Background and Purpose: Urinary incontinence following stroke is known to have a detrimental effect on rehabilitation progress, resulting in a slower rate of recovery and less functional independence at discharge. Canadian Best Practice Recommendations for Stroke Care (2010) and the American Stroke Association Clinical Practice Guidelines (2005) recommend that a bladder training program, including timed and prompted toileting on a consistent schedule, be implemented in patients who are incontinent of urine following a stroke. Canadian Best Practice Recommendations for Stroke Care (2010) further recommend intermittent catheterization as an intervention to address urinary incontinence. The aim of the present study was to assess the extent to which the Canadian guidelines are being incorporated into clinical practice. Methods: A retrospective chart review was conducted for consecutive stroke admissions to a neuro-rehabilitation unit in Ontario, Canada over a period of six months. Charts were reviewed for the occurrence of urinary incontinence, whether intermittent catheterization was performed, any mention of bladder training and the documentation of a bladder training protocol. Results: One hundred and four charts were reviewed, after excluding four patients that could not be assessed for urinary incontinence due to other medical conditions. Thirty-three patients were reported to be incontinent of urine during their stay in the rehabilitation unit. Intermittent catheterization was performed for 11 patients (33.3%) with urinary incontinence. Bladder training was indicated as a therapy that was used in the rehabilitation of 16 patients (48.5%). However, a formal bladder training protocol followed by the nursing staff was only documented in 5 patients (15.2%). Conclusions: The rehabilitation of urinary incontinence following stroke is an important issue, with a substantial number of patients failing to receive the recommended therapy. There is a need to develop strategies to promote the application of best-practice recommendations to address urinary incontinence.

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Toward a more effective approach to stroke: Canadian Best Practice Recommendations for Stroke Care

Canadian Medical Association Journal ◽

10.1503/cmaj.071253 ◽

2008 ◽

Vol 178 (11) ◽

pp. 1418-1425 ◽

Cited By ~ 98

Author(s):

P. Lindsay ◽

M. Bayley ◽

A. McDonald ◽

I. D. Graham ◽

G. Warner ◽

...

Keyword(s):

Best Practice ◽

Stroke Care ◽

Practice Recommendations

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Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018

International Journal of Stroke ◽

10.1177/1747493018786616 ◽

2018 ◽

Vol 13 (9) ◽

pp. 949-984 ◽

Cited By ~ 73

Author(s):

JM Boulanger ◽

MP Lindsay ◽

G Gubitz ◽

EE Smith ◽

G Stotts ◽

...

Keyword(s):

Emergency Department ◽

Ischemic Stroke ◽

Acute Stroke ◽

Transient Ischemic Attack ◽

Best Practice ◽

Stroke Care ◽

Stroke Management ◽

Practice Recommendations ◽

Prehospital Emergency ◽

Ischemic Attack

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider’s recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

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Epidemiological Surveillance of the Impact of the COVID-19 Pandemic on Stroke Care Using Artificial Intelligence

Stroke ◽

10.1161/strokeaha.120.031960 ◽

2021 ◽

Author(s):

Raul G. Nogueira ◽

Jason M. Davies ◽

Rishi Gupta ◽

Ameer E. Hassan ◽

Thomas Devlin ◽

...

Keyword(s):

Artificial Intelligence ◽

Acute Stroke ◽

Systems Of Care ◽

Ct Perfusion ◽

Stroke Care ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Number Of Patients ◽

The Impact

Background and Purpose: The degree to which the coronavirus disease 2019 (COVID-19) pandemic has affected systems of care, in particular, those for time-sensitive conditions such as stroke, remains poorly quantified. We sought to evaluate the impact of COVID-19 in the overall screening for acute stroke utilizing a commercial clinical artificial intelligence platform. Methods: Data were derived from the Viz Platform, an artificial intelligence application designed to optimize the workflow of patients with acute stroke. Neuroimaging data on suspected patients with stroke across 97 hospitals in 20 US states were collected in real time and retrospectively analyzed with the number of patients undergoing imaging screening serving as a surrogate for the amount of stroke care. The main outcome measures were the number of computed tomography (CT) angiography, CT perfusion, large vessel occlusions (defined according to the automated software detection), and severe strokes on CT perfusion (defined as those with hypoperfusion volumes >70 mL) normalized as number of patients per day per hospital. Data from the prepandemic (November 4, 2019 to February 29, 2020) and pandemic (March 1 to May 10, 2020) periods were compared at national and state levels. Correlations were made between the inter-period changes in imaging screening, stroke hospitalizations, and thrombectomy procedures using state-specific sampling. Results: A total of 23 223 patients were included. The incidence of large vessel occlusion on CT angiography and severe strokes on CT perfusion were 11.2% (n=2602) and 14.7% (n=1229/8328), respectively. There were significant declines in the overall number of CT angiographies (−22.8%; 1.39–1.07 patients/day per hospital, P <0.001) and CT perfusion (−26.1%; 0.50–0.37 patients/day per hospital, P <0.001) as well as in the incidence of large vessel occlusion (−17.1%; 0.15–0.13 patients/day per hospital, P <0.001) and severe strokes on CT perfusion (−16.7%; 0.12–0.10 patients/day per hospital, P <0.005). The sampled cohort showed similar declines in the rates of large vessel occlusions versus thrombectomy (18.8% versus 19.5%, P =0.9) and comprehensive stroke center hospitalizations (18.8% versus 11.0%, P =0.4). Conclusions: A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This analysis underscores the broader application of artificial intelligence neuroimaging platforms for the real-time monitoring of stroke systems of care.

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Abstract P539: Comparison of Transradial Artery versus Transfemoral Artery Access for Solumbra Technique in Mechanical Thrombectomy

Stroke ◽

10.1161/str.52.suppl_1.p539 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Taha Nisar ◽

Jimmy Patel ◽

Muhammad Z Memon ◽

Amit Singla ◽

Priyank Khandelwal

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Arrival Time ◽

Mechanical Thrombectomy ◽

Retrospective Chart Review ◽

Functional Independence ◽

Binary Logistic Regression Analysis ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Number Of Patients

Introduction: Solumbra technique involves the simultaneous use of stent-retriever and large-bore aspiration for clot retrieval in mechanical thrombectomy (MT). We aim to compare various time parameters in patients who undergo MT via solumbra technique via transradial artery (TRA) approach vs. transfemoral artery (TRF) approach. Methods: We performed a retrospective chart review of patients who underwent MT via solumbra technique for anterior circulation large vessel occlusion at a comprehensive stroke center from 7/2014 to 5/2020. We compared time to recanalization parameters, score of TICI≥2b, and functional independence (3-month mRS≤2) in patients who underwent MT via TRA vs.TRF approach via the solumbra technique. A binary logistic regression analysis was performed, controlling for age, sex, pre-treatment-NIHSS, type of anesthesia (general vs.moderate), laterality, and clot location [proximal (internal carotid or M1 segment of the middle cerebral artery) vs.distal (M2 or M3 segment of the middle cerebral artery)]. Results: A total of 98 patients met our inclusion criteria. The mean age was 63.59±14.40 years. 18 (18.37%) patients underwent MT through transradial approach. In our cohort, there was a significant association of TRA with shorter angio suite arrival-time to puncture-time (22.12±9.92mins vs.28.83±12.26mins; OR, 0.94; 95% CI, 0.88-1; P 0.026), but not with puncture-time to recanalization-time (84.34±61.34mins vs.63.73±35.29mins; OR, 1.01; 95% CI, 1-1.03; P 0.085), angio suite arrival-time to recanalization-time (103.12±51.29mins vs.93.42±39.08mins; OR, 1.01; 95% CI, 1-1.02; P 0.524), number of passes to recanalization (1.78±1.36 vs.1.68±1.05; OR, 1.03; 95% CI, 0.66-1.63 ; P 0.899), number of patients with TICI≥2b (83.34% vs.91.25%; OR, 0.68; 95% CI, 0.14-3.4; P 0.633), and functional independence (66.67% vs.78.75%; OR, 0.49; 95% CI, 0.13-1.86; P 0.292), when compared to TRF approach for MT using solumbra technique. Conclusion: Our study demonstrates a significant association between TRA approach with shorter angio suite arrival-time to puncture-time but not with overall time to recanalization, number of patients with TICI≥2b, and functional independence, when compared to TRF approach for MT using solumbra technique.

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Adherence to Canadian Best Practice Recommendations for Stroke Care: Assessment and Management of Poststroke Depression in an Ontario Rehabilitation Facility

Topics in Stroke Rehabilitation ◽

10.1310/tsr1902-132 ◽

2012 ◽

Vol 19 (2) ◽

pp. 132-140 ◽

Cited By ~ 12

Author(s):

Katherine Salter ◽

J. Andrew McClure ◽

Hannah Mahon ◽

Norine Foley ◽

Robert Teasell

Keyword(s):

Best Practice ◽

Stroke Care ◽

Poststroke Depression ◽

Practice Recommendations ◽

Rehabilitation Facility ◽

Care Assessment

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Best practice guidelines for stroke in Cameroon: An innovative and participatory knowledge translation project

African Journal of Disability ◽

10.4102/ajod.v3i1.92 ◽

2014 ◽

Vol 3 (1) ◽

Cited By ~ 1

Author(s):

Lynn Cockburn ◽

Timothy N. Fanfon ◽

Alexa Bramall ◽

Eta M. Ngole ◽

Pius Kuwoh ◽

...

Keyword(s):

Patient Outcomes ◽

Practice Guidelines ◽

Stroke Rehabilitation ◽

Best Practice ◽

Guideline Development ◽

Front Line ◽

African Countries ◽

Practice Recommendations ◽

Best Practice Guidelines ◽

Successes And Challenges

Background: Although the adherence to stroke guidelines in high-income countries has been shown to be associated with improved patient outcomes, the research, development and implementation of rehabilitation related guidelines in African countries is lacking.Objectives: The purpose of this article is to describe how a group of front-line practitioners collaborated with academics and students to develop best practice guidelines (BPG) for the management and rehabilitation of stroke in adult patients in Cameroon.Method: A working group was established and adapted internationally recognised processes for the development of best practice guidelines. The group determined the scope of the guidelines, documented current practices, and critically appraised evidence to develop guidelines relevant to the Cameroon context.Results: The primary result of this project is best practice guidelines which provided an overview of the provision of stroke rehabilitation services in the region, and made 83 practice recommendations to improve these services. We also report on the successes and challenges encountered during the process, and the working group’s recommendations aimed at encouraging others to consider similar projects.Conclusion: This project demonstrated that there is interest and capacity for improving stroke rehabilitation practices and for stroke guideline development in Africa.

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Abstract TP391: Working Within a Stroke System of Care to Decrease Door to Transfer Times From Spoke to Hub

Stroke ◽

10.1161/str.47.suppl_1.tp391 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Michelle Whaley ◽

Alissa Dell ◽

Melissa Chase ◽

Melissa Mooney ◽

Jill Hulbert ◽

...

Keyword(s):

Acute Stroke ◽

Best Practice ◽

Retrospective Chart Review ◽

Nurse Leaders ◽

Study Objective ◽

Team Members ◽

Imaging Results ◽

Number Of Patients ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: Best practice recommends that hospitals treating acute stroke patients have protocols in place to ensure rapid transfer to an advanced facility for a higher level of care, if needed. Our system of hospitals consists of five primary stroke centers (PSC) and one comprehensive stroke center (CSC) in a major metropolitan area. PSCs utilize telemedicine for acute stroke decision-making and patients are transferred to the CSC for consideration of advanced treatments when deemed appropriate by the care team. Purpose: Our study objective was to streamline processes at our PSCs to decrease the door to transport time (DTT) to the CSC. Methods: Stroke coordinators from the six sister hospitals meet quarterly to collaborate and share best practices in patient care. Our team of nurse leaders determined potential strategies to eliminate wasted time in the transfer process. Team members went back to their home facilities with the goal of generating buy-in from individual caregivers to decrease the time to transport out to the CSC. An overall attitude of urgency was encouraged during meetings with stroke councils and providers. Preliminary imaging results were used to guide decision to transfer, rather than waiting for final results. Some hospitals chose to notify the flight team of potential transport earlier in the emergency department stay, while others are still in the process of affecting change. We collected data on transferred patients with a diagnosis of acute stroke between the dates of 2/1/15-7/31/15 (n=23) and compared against the same time period in 2014 (n=11). Results: A total of 34 patients were included in our retrospective chart review. The number of patients transferred for consideration of additional acute treatment increased from 11 in 2014 to 23 during the study period in 2015. When examining patients who transferred and actually received endovascular treatment for acute stroke (n=8 in 2014 versus n=11 in 2015), the mean DTT decreased from 84 minutes in 2014, to 77 minutes in 2015. We also noted that patient transfers were faster during day time hours when compared to night. Conclusions: A system-wide, collaborative approach between PSCs and CSCs can decrease DTT when nurse leaders and providers streamline processes.

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