scholarly journals Reduction in stroke patients’ referral to the ED in the COVID-19 era: A four-year comparative study

2020 ◽  
Author(s):  
Saban Mor ◽  
Reznik Anna ◽  
Shachar Tal ◽  
Sivan-Hoffmann Roten
Keyword(s):  
Hospital Death ◽  
Access To Health Services ◽  
Social Distancing ◽  
Access To Health ◽  
Number Of Patients ◽  
Negative Effect ◽  
Diagnosis Rate ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Difficult Times

AbstractIntroductionCurrent reports indicate that the increased use of social distancing for preventive COID-19 distribution may have a negative effect on patients who suffering from acute medical conditions.AimWe examined the effect of social distancing on acute ischemic stroke (AIS) patients’ referral to the emergency department (ED)MethodA retrospective archive study was conducted between January 2017 and April 2020 in a comprehensive stroke center. We compare the number of neurologic consultations, time from symptoms onset to ED arrival, patients diagnosis with AIS, number of patients receiving treatment (tPA, endovascular thrombectomy (EVT) or combine) and in-hospital death.ResultsThe analysis included a total of 14,626 neurological consultations from the years 2017 to 2020. A significant decrease of 58.6% was noted during the months of January-April of the year 2020 compared to the parallel period of 2017. Percent of final AIS diagnosis for the year of 2020 represent 24.8% of suspected cases, with the highest diagnosis rate demarcated for the year of 2019 with 25.6% of confirmed patients. The most remarkable increase was noted in EVT performance through the examined years (2017, n=21; 2018, n=32; 2019, n=42; 2020, n=47).ConclusionCOVID-19 pandemic resulted in routing constraints on health care system resources that were dedicated for treating COVID-19 patients.The healthcare system must develop and offer complementary solutions that will enable access to health services even during these difficult times.

Abstract 3313: Outcomes of “Drip-and-Ship” Paradigm Among Patients with Acute Ischemic Stroke. Results of a State Wide Study

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Saqib A Chaudhry ◽  
Gustavo J Rodriguez ◽  
M. Fareed K Suri ◽  
Adnan I Qureshi
Keyword(s):  
Ischemic Stroke ◽  
Recombinant Tissue Plasminogen Activator ◽  
Population Based ◽  
Primary Diagnosis ◽  
Hospital Charges ◽  
Stroke Patients ◽  
Frequency Distributions ◽  
Number Of Patients ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: “Drip-and-ship” denotes patients in whom intravenous (IV) recombinant tissue plasminogen activator (rt-PA) is initiated at the emergency department (ED) of a community hospital, followed by transfer within 24 hours to a comprehensive stroke center. Although drip-and-ship paradigm has the potential to increase the number of patients who receive IV rt-PA, comparative outcomes have not been assessed at a population based level. Methods: State-wide estimates of thrombolysis, associated in-hospital outcomes and mortality were obtained from 2008-2009 Minnesota Hospital Association (MHA) data. Patient numbers and frequency distributions were calculated for state-wide sample of patients hospitalized with a primary diagnosis of ischemic stroke. Patients outcomes were analyzed after stratification into patients treated with IV rt-PA through primary ED arrival or drip-and-ship paradigm. Results: Of the 21,024 admissions, 602 (2.86%) received IV rt-PA either through primary ED arrival (n=473) or drip-and-ship paradigm (n=129). The rates of secondary intracerebral or subarachnoid hemorrhage were higher in patients treated with IV rt-PA through primary ED arrival compared with those treated with drip-and-ship paradigm (8.5% versus 3.1, p=0.038). The in-hospital mortality rate was similar among ischemic stroke patients receiving IV rt-PA through primary ED arrival or drip-and-ship paradigm (5.9% versus 7.0%). The mean hospital charges were $65,669 for primary ED arrival and $47,850 for drip-and-ship treated patients (p<0.001). Conclusions: The results of drip-and-ship paradigm compare favorably with IV rt-PA treatment through primary ED arrival in this state-wide study.

Abstract WP429: A Nurse Driven Acute Stroke Alert Process Improves Treatment Times and Treatment Rates

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Daniel D'Amour ◽  
Jayme Strauss ◽  
Amy K Starosciak
Keyword(s):  
Treatment Time ◽  
Treatment Decision ◽  
Treatment Rate ◽  
Treatment Decision Making ◽  
National Rate ◽  
Number Of Patients ◽  
Stroke Team ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Positive Effect

Introduction: Treatment time has gained sufficient popularity because it is now well-known that “Time is Brain”. Treatment rates, however, lag behind in importance even though more lives can be saved by treating more often. Our TJC Comprehensive Stroke Center has a nurse-led stroke alert process that focuses on multiple, rapid, parallel steps to reduce DTN for IV alteplase. The Baptist Emergency Stroke Team (BEST) responders are highly-trained and skilled nurses that assess, coordinate, and initiate processes to ensure the best times. We identified that our treatment rate was lower than the national rate for certified CSCs, so the BEST responders used a stepwise process to develop their own interventions to improve rates. Methods: First, the BEST responders started tracking our monthly rate. Next, they set a rate goal, and then brainstormed how to influence treatment decision-making. The BEST team initiated a monthly PI meeting that focused on the importance of treating disability rather than an NIHSS score. Then the team scripted and rehearsed critical conversations to have providers that advocated specifically for treating disability. The team adopted the motto, “Treat Disability, Not Numbers”. Results Conclusions: Our CSC observed a small decrease in median DTN but double the treatment rate after the BEST responder intervention. In comparison, these statistics did not change at the national CSC level. The sICH rate was reduced from Period A to C, meaning that increased treatment rate did not lead to increased hemorrhagic rate. Nursing initiatives can have a substantial positive effect on increasing the number of patients treated with IV alteplase for acute ischemic stroke.

scholarly journals Impact of COVID-19 Pandemic on the Incidence, Prehospital Evaluation, and Presentation of Ischemic Stroke at a Nonurban Comprehensive Stroke Center

2021 ◽  
Vol 2021 ◽  
pp. 1-5
Author(s):  
Cesar Velasco ◽  
Brandon Wattai ◽  
Scott Buchle ◽  
Alicia Richardson ◽  
Varun Padmanaban ◽  
...  
Keyword(s):  
Urban Areas ◽  
Stroke Care ◽  
Final Diagnosis ◽  
Medical Attention ◽  
Presenting Symptoms ◽  
Number Of Patients ◽  
Community Transmission ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
The Impact

Introduction. Many reports have described a decrease in the numbers of patients seeking medical attention for typical emergencies during the COVID-19 pandemic. These reports primarily relate to urban areas with widespread community transmission. The impact of COVID-19 on nonurban areas with minimal community transmission is less well understood. Methods. Using a prospectively maintained prehospital quality improvement database, we reviewed our hospital EMS transports with a diagnosis of stroke from January to April 2019 (baseline) and January to April 2020 (pandemic). We compared the volume of patients, transport/presentation times, severity of presenting symptoms, and final diagnosis. Results. In January, February, March, and April 2019, 10, 11, 17, and 19 patients, respectively, were transported in comparison to 19, 14, 10, and 8 during the same months in 2020. From January through April 2019, there was a 53% increase in transports, compared to a 42% decrease during the same months in 2020, constituting significantly different trend-line slopes (3.30; 95% CI 0.48–6.12 versus -3.70; 95% CI -5.76–-1.64, p = 0.001 ). Patient demographics, comorbidities, and symptom severity were mostly similar over the two time periods, and the number of patients with a final diagnosis of stroke was also similar. However, the median interval from EMS dispatch to ED arrival for patients with a final diagnosis of stroke was significantly longer in January to April 2020 ( 50 ± 11.7   min ) compared to the same time period in 2019 ( 42 ± 8.2   min , p = 0.01 ). Discussion/Conclusion. Our data indicate a decrease in patient transport volumes and longer intervals to EMS activation for suspected stroke care. These results suggest that even in a nonurban location without widespread community transmission, patients may be delaying or avoiding care for severe illnesses such as stroke. Clinicians and public health officials should not ignore the potential impact of pandemic-like illnesses even in areas of relatively low disease prevalence.

Abstract P263: Do Different Sites of Vessel Occlusion Dictate the Need for Intubation Prior to Endovascular Treatment and Have an Effect on Outcome?

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Ameer E Hassan ◽  
Victor M Ringheanu ◽  
Raul G Nogueira ◽  
Laurie Preston ◽  
Adnan I Qureshi ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Functional Independence ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Number Of Patients ◽  
Baseline Characteristics ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Proven Method ◽  
Morbid Conditions

Introduction: Endovascular treatment (EVT) is a widely proven method to treat patients diagnosed with intracranial large vessel occlusion. In order to ensure patients safety prior to and during EVT, preprocedural intubation has been adopted in many centers as a means for airway protection and immobilization. However, the correlation between site of vessel occlusion, need for intubation, and outcomes, has not yet been established. Methods: Through the utilization of a prospectively collected database at a comprehensive stroke center between 2012-2020, demographics, co-morbid conditions, intracerebral hemorrhage, mortality rate, and functional independence outcomes were examined. The outcomes and sites of occlusion between patients receiving mechanical thrombectomy (MT) treated while intubated versus those treated under conscious sedation (CS) were compared. Results: Out of 625 patients treated with MT, a total of 218 (34.9%) were treated while intubated (average age 70.3 ± 13.7, 37.2% women), and 407 (65.1%) were treated while under CS (average age 70.3 ± 13.7, 47.7% women); see Table 1 for baseline characteristics and outcomes. A higher number of patients requiring intubation had an occlusion in the basilar versus those only requiring CS. No differences were noted in regard to the proportion of patients receiving intubation or CS when treated for RMCA, LMCA, or internal carotid artery occlusions. Conclusion: Intubation + MT was associated with significantly worsened outcomes in regard to recanalization rates, functional outcome, and mortality. In anterior circulation strokes, intubation in RMCA patients were found to have poorer clinical outcome. Higher rates of intubation were also found to be needed in patients with basilar occlusions. Further research is required to determine whether site of occlusion dictates the need for intubation, and whether intubation allows for favorable outcome between R and LMCA occlusions.

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

Stroke ◽  
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.

Abstract WP430: Implementation of Inpatient Stroke Champions Leads to Improved Inpatient Code Stroke Metrics

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Katherine V Lapsys ◽  
Jasmine Rochelle B Belmonte ◽  
Nathalie De La Pena-Gamboa ◽  
Raeesa Dhanji ◽  
Regina I Cuenca ◽  
...  
Keyword(s):  
Stroke Care ◽  
Final Diagnosis ◽  
Post Intervention ◽  
Specific Symptom ◽  
Delayed Treatment ◽  
Symptom Recognition ◽  
Number Of Patients ◽  
Inpatient Nursing ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: Stroke Champions (SC) are AHA recommended designated inpatient nurses that serve as expert resources for their units to ensure that evidence-based practices for stroke care are implemented. Inpatient Code Strokes (ICS) are difficult to recognize which results in delayed treatment. The purpose of this study is to determine if there was an improvement in inpatient acute stroke metrics with the addition of SC in the hospital. Methods: Over a 12-month period at a Comprehensive Stroke Center (CSC), 12 nurses in the inpatient stroke units were trained as SC. This training consisted of advanced education in CSC metrics, guidelines and required documentation. SC provided peer-to-peer education, served as expert resources, conducted comprehensive chart reviews, shift huddles, and “on the spot” feedback to nurses and physicians. The metrics were examined pre and post intervention and included: Symptom Recognition Time (SRT) to CT interpretation, SRT to tPA bolus time, and SRT to groin puncture. SRT is equivalent to Emergency Department door time for inpatient strokes. Statistical analysis was performed using T-test and the Mann-Whitney test. Results: There were 114 pre-SC and 101 post-SC ICS. There was a trend toward more patients being accurately diagnosed with a TIA or stroke (75.3% post vs. 65.8% pre-SC; p=0.06). The SRT to CT interpretation time for patients who received tPA improved from 43 to 35 mins. The number of patients treated with tPA increased from 10 to 17. SRT to tPA bolus time trended toward improvement from 57 to 42 mins (p=0.07). SRT to groin puncture time in patients who received both tPA and thrombectomy trended toward improvement from 81 vs. 65 mins (p=0.07). There were twice as many inpatient thrombectomy cases in post-SC (n=23) vs. pre-SC (n=12). Conclusion: The knowledge and expertise provided by SC resulted in a higher percentage of ICS having a final diagnosis of stroke. This demonstrates an increased accuracy of stroke specific symptom recognition by the inpatient nursing teams. There was improved SRT to tPA bolus and groin puncture time. This is the only study that shows implementation of the AHA recommended SC program improves inpatient code stroke recognition and treatment metrics.

scholarly journals Early Experience With Tenecteplase at a Comprehensive Stroke Center

2021 ◽  
pp. 10.1212/CPJ.0000000000001096
Author(s):  
Spozhmy Panezai ◽  
Ilya Dubinsky ◽  
Sindhu Sahito ◽  
Nancy Gadallah ◽  
Laura Suhan ◽  
...  
Keyword(s):  
Thrombolytic Agent ◽  
Clinical Pathways ◽  
Clinical Decision ◽  
Successful Implementation ◽  
Stroke Patients ◽  
Decision Algorithm ◽  
Number Of Patients ◽  
New Process ◽  
Comprehensive Stroke Center ◽  
Stroke Center

AbstractPurposeof review: Tenecteplase has been studied and recommended as an alternative thrombolytic agent in acute stroke patients. A brief review of clinical trials and guidelines pertinent to our clinical decision algorithm is described. This is followed by operational steps that were made to create and implement a clinical pathway based on available evidence in which tenecteplase is used in select stroke patients at our comprehensive stroke center.Recent findings:A number of patients have been treated at our center with IV tenecteplase. A case is presented to illustrate the successful implementation of this new process.Summary:Development of our protocol is discussed in detail in order to enable other centers to create their own clinical pathways for thrombolytic treatment of acute ischemic stroke using tenecteplase.

Abstract 32: Intravenous Tpa Delays Door-to-puncture Time in Acute Ischemic Stroke With Large Vessel Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Kunakorn Atchaneeyasakul ◽  
Shashvat Desai ◽  
Jay Dolia ◽  
Kavit Shah ◽  
Merritt Brown ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Empirical Studies ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Negative Effect ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Background: The current 2018 AHA/ASA Guidelines for early stroke management recommend use of IV tPA in all eligible acute ischemic stroke patients within 4.5 hours of onset while being considered for mechanical thrombectomy (MT). Whether or not tPA administration is beneficial prior to thrombectomy is still an ongoing debate. Potential delay of MT initiation due to tPA start is a major concern but has not been well-delineated in empirical studies. Methods: In a prospective large volume comprehensive stroke center registry, we analyzed all patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO) treated with thrombectomy between 2012-2017, who arrived directly from field to ED within 4.5h of last known well. Patients without contraindication to IV-tPA are given bolus dose in the scanner suite and the remainder of the 1h infusion en route to and in the angio-suite to prevent delay. Results: Among 777 thrombectomy patients identified in the database, 237 arrived directly within 4.5 hours from onset, including 65.8% (156) not treated with IV-tPA and 34.2% (81) receiving IV-tPA, both well-matched in age and NIHSS. Overall, the door-to-needle (DTN) time was 40m (IQR31-56), surpassing the Target Stroke national targets (60m and 45m) active during the study period. However, median door-to-puncture (DTP) time was 22m longer in the IV-tPA group, 74 vs 52m (p<0.001). IV-tPA was not independently associated with better recanalization rate (TICI 2B-3 95.9% vs 92.9%) or functional independent outcome (modified Rankin score 0-2) at 90 days, 37.3% vs 39.4%. Conclusion: IV-tPA administration in AIS-LVO was associated with delayed door-to-puncture times in a comprehensive stroke center with efficient DTN times surpassing advanced national targets, without change in recanalization rate or outcomes. Randomized trials are needed to determine the net positive, neutral, or negative effect of IV-tPA in this population.

Abstract 194: Impact of Primary Stroke Centers On a Comprehensive Stroke Center

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Karen C Albright ◽  
Amelia Boehme ◽  
William Hicks ◽  
Woody Bursaw ◽  
Michael Mullen ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Ischemic Stroke ◽  
Clinical Information ◽  
Patient Characteristics ◽  
Large Artery ◽  
Chi Square ◽  
Number Of Patients ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Houston Area

Introduction: The creation of primary stroke centers (PSCs) accredited by The Joint Commission (TJC) has increased access of care to a higher number of patients with acute ischemic stroke (AIS) in greater metropolitan areas. However, PSCs in many regions of the US do not conduct clinical trials in acute stroke. We hypothesized that creation of PSCs in the greater Houston area has led to changes in the demographics of our stroke admissions. Methods: Consecutive patients admitted to the UT Houston stroke team from 1/1/2005-12/30/2010 were screened. Records were reviewed for demographic and clinical information. Patient characteristics were compared among years using Chi-square and Kruskal-Wallis. Results: Over the 5 year period, 6,036 patients were admitted to our stroke service. The number of admissions increased from 674 in 2005 to 1,234 in 2010. Transfers from outside hospitals trended up from 24.6% (n=166) of all admissions in 2005 to 41.8% (n=516) in 2010. With the increase in transfers, the number of ICH transfer cases has increased over the past 5 years ( Fig ). Among all ischemic strokes, the percent of large artery occlusions (LAOs) presenting within 6-hrs from symptom onset fell from 34.3% (69/201) in 2005 to 16.4% (45/274) in 2010. Minor strokes (NIHSS 0-5) have increased from 37.4% (141/377) in 2005 to 42.5% (239/562). Overall, IV t-PA treatment rates remained unchanged, ranging from 29.7% to 37.0% from 2005 to 2010 (p=.490). Among AIS patients presenting within 6-hrs, study enrollment fell from 41.8% (84/201) in 2005 to 26.3% (72/274) in 2010. Figure 1 shows the changing demographics of our admissions plotted against the number of hospitals that have attained TJC PSC accreditation. Conclusion: As PSCs have arisen in the greater Houston area, we have seen a shift in the demographics of our stroke admissions including an escalating number of transfer patients. Among ischemic stroke patients, the number of LAOs has been decreasing overtime and the number of mild strokes has been increasing. These results are likely due, in part, to the transport of patients by EMS to the nearest PSCs who then preferentially request transfer of ICH cases to comprehensive stroke centers (CSCs). Consequently, the number of patients enrolled into clinical trials (the majority of which have been based on ischemic stroke and LAOs) has substantially decreased at our center. PSCs should be encouraged by accreditation committees to work with CSCs and participate in clinical research. To that end, PSCs may need investments in staff and resources to conduct clinical trials testing new stroke therapies.

Abstract P159: Patients Transferred Within a Telestroke Network for Large Vessel Occlusion

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Sujan T Reddy ◽  
Sean I Savitz ◽  
Elliott Friedman ◽  
Octavio Arevalo ◽  
Jing Zhang ◽  
...  
Keyword(s):  
Vascular Imaging ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Rapid Acquisition ◽  
Number Of Patients ◽  
Ct Brain ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: In a telestroke network, patients at a referring hospital (RH) with large vessel occlusion (LVO) are transferred to a comprehensive stroke center (CSC) for endovascular thrombectomy (EVT). However, a significant number of patients do not ultimately undergo thrombectomy after CSC arrival. Methods: Within a 17 hospital telestroke network, we retrospectively analyzed patients with suspected or confirmed LVO transferred to a CSC and characterized the reasons why these patients did not undergo EVT based on the 2019 AHA guidelines. Results: Of 400 patients transferred to our hub, 68 (17%) were based on vascular imaging at RH. Time from RH arrival to neuroimaging was significantly longer in patients that underwent both CT & CTA brain and neck compared to only CT brain (53 vs. 13 minutes, p <0.05). Accuracy of anterior circulation LVO (ACLVO) detection based on clinical suspicion was 62% (205 of 332 patients). Among 234 ACLVO patients (Table 1), overall 175 (74%) [early window group: 123 (73%) patients and late window group: 52 (80%) patients] met at least one EVT ineligibility criterion. The reasons for EVT ineligibility varied from large core infarct (aspects <6 or core volume >70cc on perfusion imaging in late window), low NIHSS (<6), distal occlusion, and poor baseline mRS (>1) (Table 2). Conclusion: Instituting rapid acquisition and interpretation of vascular imaging at referring hospitals for LVO detection and establishing benchmarks for door to vascular imaging is urgently needed for referring hospitals. Table 1: Study flowchart

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