Abstract 267: Improving Inpatient Stroke Care by Implementing Stroke Units Across Health Systems Using an Improvement Collaborative Approach

Background: Stroke units, defined as a geographic location where stroke patients are cared for by an interdisciplinary team, hold the strongest evidence in reduced mortality and disability for stroke patients. However, according to the 2011 Canadian Stroke Network’s National Stroke Audit, only 23% of stroke patients in Canada were admitted to a Stroke Unit with the Canadian province of British Columbia (BC) lagging at only 4%. The objective of this quality improvement initiative was to increase the number of stroke units and to improve existing stroke units; additionally, we aimed to improve adherence to best practice acute stroke care. Methods: Using the Institute for Healthcare Improvement’s Breakthrough Series Collaborative methodology, a stroke unit Improvement Collaborative was run from January 2013 to December 2013 by Stroke Services BC, a program of the Provincial Health Services Authority in BC. Faculty members were recruited from BC and the Calgary Stroke Program in the province of Alberta. The collaborative had 4 Learning Sessions, a closing workshop, and bi-weekly webinars. Teams followed a structured 7-step framework: understanding current volumes; securing space; establishing the team; ensuring clinical best practice; creating processes for team communication; ensuring patient engagement; and establishing quality improvement mechanisms. Pre and post self-reports of care were collected through electronic polling at Learning Session 2 in February 2013 (pre, n=78) and at the Closing Celebration in December 2013 (post, n=66) using a 4-point Likert scale. There were 20 questions based on best practice. Results: Eleven teams enrolled representing 17 hospitals in BC and a hospital in Saskatoon in the province of Saskatchewan. Teams were either working at the hospital or health region level. There were a total of 75 new stroke beds created in BC, and 12 beds recommended for Saskatoon. Furthermore, the results from the e-voting on best practice showed statistically significant improvement in the following areas: admission to a stroke unit (p=0.005); assessment by an interdisciplinary team within 48 hours of admission (p=0.002); use of standardized valid tools (p=0.002); swallowing screen within 24 hours (p<0.001); core interprofessional team on the stroke unit (p<0.001); care to prevent secondary complication (p<0.001); management of serum lipid levels (p=0.017); patient education (p<0.001); and team education (p=0.02). Conclusions: This inter-provincial Quality Improvement Collaborative was successful in implementing and improving stroke units, and in improving best practice care of inpatient stroke patients. Critical success factors include the engagement of faculty from high-performing centers even if they exist outside the jurisdiction where improvement is sought, and the use of the 7-step framework for implementing stroke units.

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Abstract 20: Acute Stroke Care and Thrombolysis at Critical Access Hospitals in Illinois

Stroke ◽

10.1161/str.44.suppl_1.a20 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Shyam Prabhakaran ◽

Robin Hamann ◽

Kathleen O’Neill ◽

Michelle Gardner ◽

Peggy Jones

Keyword(s):

Quality Improvement ◽

Acute Stroke ◽

Stroke Care ◽

The United States ◽

Critical Access Hospitals ◽

Stroke Patients ◽

Acute Stroke Care ◽

Improvement Program ◽

Discharge Disposition ◽

Intravenous Tissue Plasminogen Activator

Background: Critical access hospitals (CAH) are the first point of stroke care in many rural regions of the United States (US). The Illinois Critical Access Hospital Network (ICAHN), a network of 51 CAH in Illinois, began a quality improvement program to address acute stroke care in 2009. We evaluated the performance on several metrics in acute stroke care at CAH between 2009 and 2011. Methods: Currently, 28 of 51 CAHs in Illinois currently participate in the American Heart Association’s Get With The Guidelines - Stroke (GWTG-S) registry for quality improvement. The GWTG-S registry captured elements including demographics, diagnosis, times of arrival, imaging completion, and intravenous tissue plasminogen activator (IV tPA) administration, and final discharge disposition. We analyzed the change in percent of stroke patients receiving tPA, door-to-needle (DTN) time, and proportion of total stroke patients admitted versus transferred to another facility over the 3 years. Fisher’s exact and Mann-Whitney tests were used as appropriate. Results: In the baseline assessment (2009), there were 111 strokes from 8 sites which grew to 12 sites and 305 strokes in year 1 (2010) and 14 sites and 328 strokes in year 3 (2011). The rate of tPA use for ischemic stroke was 2.2% in 2009, 4.0% in 2010, and 6.2% in 2011 (P=0.20). EMS arrival (41.1%), EMS pre-notification (82.6%), door-to-CT times (median 35 minutes; 34.6% < 25 minutes), and DTN times (average 93 minutes; 13.3% DTN time < 60 minutes) were not different over time. The rate of transfer from CAH to another hospital (51.3%) was constant. Every patient that received tPA except 1 (96.9%) was transferred (drip-ship) for post-tPA care. Conclusions: Improving acute stroke care at CAHs is feasible and represents a significant opportunity to increase tPA utilization in rural areas. As stroke systems develop, it is vital that CAHs be included in quality improvement efforts. The ICAHN stroke collaborative provided the opportunity to coordinate resources, share best practices, participate in targeted educational programming, and utilize data for performance improvement through the funded GWTG-S registry.

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Abstract TP345: Improving Door to Drug Times for Ischemic Stroke Patients Using a Team Approach

Stroke ◽

10.1161/str.44.suppl_1.atp345 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Denise Sorenson ◽

Alyson Flood

Keyword(s):

Ischemic Stroke ◽

Best Practice ◽

Stroke Care ◽

Team Approach ◽

Stroke Patients ◽

Acute Stroke Care ◽

Stakeholder Collaboration ◽

Team Members ◽

Team Meetings ◽

Team Motivation

Background and Purpose: Decreasing door to drug times for ischemic stroke patients has been proven to optimize preservation of brain tissue, resulting in better functional outcomes. In prior years, the stroke team focus was to meet or exceed the 50% goal for the Joint Commission measure; patients arriving within 2 hours of last known well receive alteplase within 180 minutes. In the fall of 2011, the Neuroscience Medical Director challenged the team to meet target stroke goals and achieve the gold standard of excellence. Methods: Guided by the Plan Do Study Act model and principles of shared governance, the team refocused efforts to enhance stakeholder collaboration, educate, and provide monthly evaluation of door to door times. Code Stroke pathways were revised to improve efficiency, and inclusion / exclusion criteria were revised. The team is presented with state and national benchmark best practice data on an ongoing basis. Individual alteplase case feedback sheets are sent to all involved providers and departments, who are encouraged to provide input into the process. All alteplase cases are reviewed during team meetings, and outcomes are shared. Role modeling, physician engagement, positive feedback to team members and celebration of successes instill team motivation and confidence. In June, the program hosted an inaugural Stroke Symposium, where national speakers shared the ‘state of the science’, validating the rationale for improving processes for acute stroke care. Results: In the first 6 months of 2012, the median door to drug time was reduced by 48% to 55 minutes from 104 minutes in 2011. In the same time period, 10 of 15 patients had alteplase administered in < 60 minutes, versus 2 of 25 in 2011. Conclusions: Significant improvements in stroke care can be gained by establishing a cohesive team with a shared goal of excellence. Strong leadership, the ability of staff on all levels to be partners in decision making, information sharing, education and recognition are keys to success. Future challenges include ensuring the processes are sustainable, and maintaining team motivation to continue to find opportunities to reduce door to drug times.

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Abstract T P206: An Executable Graphical Model for In Silico Prototyping of Processes for Acute Stroke Care

Stroke ◽

10.1161/str.46.suppl_1.tp206 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

David Norris ◽

Drew G Levy

Keyword(s):

Quality Improvement ◽

Acute Stroke ◽

In Silico ◽

Graphical Model ◽

Systems Of Care ◽

Stroke Care ◽

Care Process ◽

Quality Improvement Initiative ◽

Acute Stroke Care ◽

Neurologic Outcomes

Background: Strong evidence shows neurologic outcomes in acute ischemic stroke (AIS) worsen with delay from symptom onset to thrombolytic therapy. Yet this onset-to-treatment (OTT) time has not decreased in most systems of care over the past decade. Even the in-hospital, “door-to-needle” (DTN) component of this delay is unimproved, notwithstanding exceptions in institutions where innovative quality improvement efforts have borne fruit. Objective: Provide a basis for visualizing, communicating, and simulating stroke care system configuration and performance to facilitate the quality improvement efforts necessary for reducing DTN and OTT times in AIS. Methods: We developed an executable, graphical model of acute stroke care, employing the hierarchical colored Petri net (CPN) formalism. The top level of the hierarchy sets the epidemiologic context, including demographics and background processes like stroke prevention and onset. At deeper levels, we elaborate time-critical processes that contribute to OTT: stroke recognition, EMS activation and transport, and many emergency department (ED) processes. Key ED innovations described in the literature were modeled: EMS prenotification, a direct-to-imaging transport strategy, process parallelism, and telestroke capability. Results: Our CPN model has provided a platform for detailed, realistic prototyping and simulation of acute stroke care processes. The performance characteristics of process configurations with multiple, interacting innovations were evaluated and compared. Conclusions: In silico care process prototyping permits evaluation of proposed innovations in simulated settings. Using an intensively graphical simulation modeling methodology adds value by promoting “visual consensus” regarding care process structure and function, among stakeholders in a quality improvement initiative.

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Abstract 115: Current Status of Acute Stroke Management in Korea: A Nationwide Report Based on 19,608 Patients Treated in 216 Hospitals

Stroke ◽

10.1161/str.51.suppl_1.115 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Jun Yup Kim ◽

Keon-Joo Lee ◽

Jihoon Kang ◽

Beom Joon Kim ◽

Seong-Eun Kim ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Unit ◽

National Level ◽

Stroke Care ◽

Current Status ◽

Endovascular Coiling ◽

Stroke Management ◽

Acute Stroke Care ◽

Survey Period ◽

Stroke Units

Introduction: There have been few reports on status of acute stroke management at a national level worldwide, and none in Korea. This study is aimed to describe the current status and disparities of acute stroke management in Korea. Methods: Data from 5th (2013) and 6th (2014) national surveys for assessing quality of acute stroke care were used. Patients with principal diagnosis codes indicating subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), ischemic stroke (IS), who were admitted via emergency rooms within 7 days of onset at hospitals treating 10 or more stroke cases during the each 3-month survey period were selected. Results: A total of 19,608 stroke cases (age, 67.7±13.5years; female, 45%; IS, 76%; ICH, 15%; SAH, 9%) treated in 216 hospitals were analyzed. Thirty-one percent of hospitals had stroke units and 41% of stroke cases were treated at hospitals without stroke units. In IS, IV thrombolysis (IVT) and endovascular treatment (EVT) rates were 10.7% and 3.6%, respectively. Thirty-nine percent of IVT and fifty-two percent of EVT cases were performed in hospitals with annual volume of <25 IVT and <15 EVT. Centralization of EVT showed disparities by region (Figure). Carotid endarterectomy, carotid artery stenting, decompressive, bypass surgery was conducted in 0.2%, 1.4%, 1.0%, 0.2% of IS cases; decompressive surgery was done in 28.1% of ICH cases; surgical clipping, endovascular coiling was done in 17.2%, 14.3% of SAH cases, respectively. There were noticeable regional disparities in various interventions, use of ambulance, arrival time and provision of stroke unit service. Conclusions: This study is the first report on the status of acute stroke care in Korea on a national level. Large number of recanalization therapies were performed in low-volume-hospitals. Expansion of stroke unit service, stroke center certification or accreditation, and connections between stroke centers and EMS are highly recommended.

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Stroke units: research in practice

10.1093/med/9780199689644.003.0013 ◽

2015 ◽

Author(s):

Lalit Kalra

Keyword(s):

Stroke Unit ◽

Stroke Care ◽

Evidence Base ◽

Multidisciplinary Teams ◽

Stroke Patients ◽

Stroke Units ◽

Key Points ◽

Stroke Unit Care ◽

Rehabilitation Needs ◽

Therapy Sessions

Key points• Stroke units are the cornerstone of quality stroke care.• The benefits of stroke unit care are supported by a very strong evidence base• In 2007 the National Stroke Strategy mandated that all stroke patients should have prompt access to stroke unit care.• Despite policy and guidelines, only 62% stroke patients were treated on specialist stroke units in 2010.• Patients spend long periods of inactivity on stroke units; multidisciplinary teams need to encourage rehabilitation activities outside therapy sessions.• Rehabilitation needs to be family- and carer-oriented to prepare patients for life after discharge.

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Variation in quality of acute stroke care by day and time of admission: prospective cohort study of weekday and weekend centralised hyperacute stroke unit care and non-centralised services

BMJ Open ◽

10.1136/bmjopen-2018-025366 ◽

2019 ◽

Vol 9 (11) ◽

pp. e025366 ◽

Cited By ~ 1

Author(s):

Mariya Melnychuk ◽

Stephen Morris ◽

Georgia Black ◽

Angus I G Ramsay ◽

Jeannie Eng ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Unit ◽

Performance Standards ◽

Stroke Care ◽

Acute Stroke Care ◽

P Values ◽

Stroke Units ◽

Hyperacute Stroke ◽

Time Of Admission

ObjectiveTo investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units compared with the rest of England.DesignProspective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme.SettingAcute stroke services in London hyperacute stroke units and the rest of England.Participants68 239 patients with a primary diagnosis of stroke admitted between January and December 2014.InterventionsHub-and-spoke model for care of suspected acute stroke patients in London with performance standards designed to deliver uniform access to high-quality hyperacute stroke unit care across the week.Main outcome measures16 indicators of quality of acute stroke care, mortality at 3 days after admission to the hospital, disability at the end of the inpatient spell, length of stay.ResultsThere was no variation in quality of care by day and time of admission to the hospital across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor was there variation in 3-day mortality or disability at hospital discharge (all p values>0.05). Other quality of care measures significantly varied by day and time of admission across the week in London (all p values<0.01). In the rest of England there was variation in all measures by day and time of admission across the week (all p values<0.01), except for mortality at 3 days (p value>0.05).ConclusionsThe London hyperacute stroke unit model achieved performance standards for ‘front door’ stroke care across the week. The same benefits were not achieved by other models of care in the rest of England. There was no weekend effect for mortality in London or the rest of the England. Other aspects of care were not constant across the week in London hyperacute stroke units, indicating some performance standards were perceived to be more important than others.

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Abstract 2197: Telestroke: Optimizing Access to Emergency Interventions in Acute Stroke Care

Stroke ◽

10.1161/str.43.suppl_1.a2197 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Rayetta Johnson

Keyword(s):

Quality Improvement ◽

Acute Stroke ◽

Health Care Providers ◽

Positive Impact ◽

Medical Center ◽

Stroke Care ◽

Nurse Specialist ◽

Care Providers ◽

Acute Stroke Care ◽

Evidenced Based

Background and Issues: The burden of stroke in North Carolina is one of the highest in the nation (approximately 28,000 stroke hospitalizations from 2003-2007). The number and high costs of stroke have made it incumbent to improve the numbers of patients receiving effective treatment. There are two major barriers for treatment of acute stroke: time and access. The utilization of telestroke in community hospitals aids in decreasing these barriers by providing immediate access to a stroke neurologist. In order for telestroke to be successful, awareness and education regarding acute stroke care must be provided for health care providers as well as the communities. Thus, the development of a telestroke system requires nursing and medical expertise. The Primary Stroke Center Team at Wake Forest Baptist Medical Center in Winston-Salem, N.C. implemented a telestroke network system (Intouch's Health's RP-7 Robotic system) in January of 2010 to provide 24/7 access to the medical center's acute stroke experts and the latest advancements in stroke interventions. There are eight hospitals in the network at the present time. Methods: Our team identified that many of the network hospital's staff are not experienced in taking care of a stroke patient and that a “roadmap” is useful to guide them in these steps.The stroke nurse specialist developed a quality improvement plan for the network hospitals which included: an evidence-based algorithm for patient care; stroke education, in particular, neurological assessment and tPA administration classes for the ED staff; quarterly meetings to provide outcome and feedback data with each network hospital; stroke awareness events for the community. Mock telestroke consults were also performed prior to “going live” with telestroke for each of the network hospitals. Of utmost importance is the early involvement and education of the EMS system in the respective county of the network hospital. The buy-in of EMS was found to be a key component in the success of the network. Finally, attention to customized quality improvement efforts for each of the facilities are required to accomplish integration into the telestroke network. Results: The data has been analyzed, and thus far, a 24% rate of tPA administration has been seen with our network hospitals (an increase from the 3.6% national average). Comparisons between each of the eight network hospitals' rates of administration of tPA prior to and after joining the network show a trend of increase (10%-40%). The effectiveness of the algorithm has also been explored by analysis of feedback and initial results have shown a positive impact. Conclusion: A combination of improving access to stroke neurologists in conjunction with a focus on improving the level of care via evidenced based stroke care teaching and implementation of algorithms at a network hospital is required for implementing and building a successful telestroke network.

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Abstract T P259: What Should Really be Happening to Our Stroke Patients Post-Acute Care?: A System Best Practice Model for Inpatient Rehab

Stroke ◽

10.1161/str.45.suppl_1.tp259 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Shelley Sharp ◽

Elizabeth Linkewich ◽

Jacqueline Willems ◽

Nicola Tahair ◽

Charissa Levy ◽

...

Keyword(s):

Acute Care ◽

Stroke Unit ◽

Best Practice ◽

Patient Flow ◽

System Capacity ◽

Stroke Patients ◽

Practice Model ◽

Term Care ◽

Stroke Unit Care ◽

The Right

Background: A regional Stroke Report Card identified poor performance on system efficiency, effectiveness, and integration of stroke best practice. This engaged regional funders and 17 organizations (11 acute, 6 rehab) to collaborate in stroke system planning. The focus included stroke unit care and access to timely and appropriate rehabilitation, including increased access for severe stroke. Changes in acute care, including pre-hospital, have facilitated access to stroke unit care in the city. A model of patient flow from acute care was needed to understand other system capacity needs. Purpose: To use best practice and benchmarks to delineate post-acute patient flow and facilitate alignment of resources for inpatient rehabilitation. Methods: Administrative data from national reporting and local rehab referral system databases were used to review current system usage from acute care. A model of proportional distribution of cases from acute, specifically to inpatient rehab, was established using provincial benchmarks, evidence informed targets, and organization market share of total inpatient rehab system capacity. Iterative discussions were required to confirm the organizations’ commitment to stroke best practice. New volume and case mix changes were applied to determine capacity and resource planning needs across organizations. Results: The best practice model, approved by all stakeholders, proposes 40% of stroke patients discharged alive from acute care should access inpatient, 13% outpatient rehabilitation and 6% to Complex Continuing Care and Long Term Care. Current practice is 26%, <5% and 13% respectively. A projected volume increase of 278 patients is distributed across 5/6 rehab providers. This results in a total proportional system shift from 20% (n=160) to 41.5% (n =446) of severe patients receiving access to high intensity rehab. A reduction in the overall proportion of moderate and mild stroke patients from 65% (519) to 49.5% (n=534) and 15% (n=119) to 9% (n=96) respectively. Conclusion: Significant investment/redistribution of resources within the system is required to support patient flow and provide care in the right place at the right time. System funder support is critical to create a quality of care (best practice) system.

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Abstract P184: Effect of Acute Stroke Care Hospital Networks in Korea

Stroke ◽

10.1161/str.52.suppl_1.p184 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Jihoon Kang ◽

Seong Eun Kim ◽

Hyunjoo Song ◽

Hee-joon Bae

Keyword(s):

Network Analysis ◽

Acute Stroke ◽

Stroke Care ◽

The Other ◽

Care Hospital ◽

Initial Visit ◽

Analysis Method ◽

Stroke Patients ◽

Acute Stroke Care ◽

Hospital Networks

Purpose: Stroke patients generally transport stroke patients either to nearest stroke hospital with secondary transfers or to hub hospitals in selective cases. This study aimed to determine the stroke community of close networks and to evaluate their role for the access the endovascular treatment (EVT). Methods: Using the nationwide acute stroke hospital (ASH) surveillance data assessed the major quality indicators of all stroke patients of South Korea, triage information both initial visit and secondary interhospital transfers were extracted according to the hospitals. Based on them, stroke community with dense linkages were partitioned using the network-based Louvain algorithm. The hierarchical model estimated the function of stroke community for the EVT. Results: For 6-month surveying period, 19113 subjects admitted to the 246 ASHs. Of them, 1831 (9.6%) were transferred from 763 adjacent facilities not ASH, while 1283 (6.7%) from the other ASHs. The algorithm determined the 113 stroke communities where composed median 7 hospitals (2 ASHs and 5 adjacent facilities) and treated about 30 subjects per month. Most of communities formed the spindle shape with higher centralization index and located within 150 Km (Figure). Stroke communities significantly affected 11% of EVT after adjustments. Conclusions: Network analysis method effectively contoured the high centralizing stroke communities and helped the functions on the EVT accessibility.

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Abstract T P188: Equivalency in Intravenous Thrombolytic Treatment Rates Between Primary Stroke Centers and Non-Primary Stroke Centers Through the Use of Telestroke

Stroke ◽

10.1161/str.45.suppl_1.tp188 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Archit Bhatt ◽

Elizabeth Barban ◽

Leslie Corless ◽

Tamela Stuchiner ◽

Amit Kansara

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Symptom Onset ◽

Stroke Care ◽

Bivariate Analysis ◽

Stroke Patients ◽

Acute Stroke Care ◽

Stroke Registry ◽

Patient Arrival ◽

History Of

Background: Research has shown that subjects evaluated at (Primary Stroke Centers) PSCs are more likely to receive rt–PA than those evaluated at non–PSCs. It is unknown if telestroke evaluation affects rt-PA rates at non-PSCs. We hypothesized that with a robust telestroke system rt-TPA rates among PSCs and non-PSCs are not significantly different. Methods and Results: Data were obtained from the Providence Stroke Registry from January 2010 to December 2012. We identified ischemic stroke patients (n=3307) who received care in Oregon and Southwest Washington, which include 2 PSCs and 14 non-PSCs. Intravenous rt–PA was administered to 7.3% (n=242) of ischemic patients overall, 8.4% (n=79) at non–PSCs and 6.9% (n=163) at PSCs (p=.135). Stroke neurologists evaluated 5.2 % (n=172) of all ischemic stroke patients (n=3307) were evaluated via telestroke robot. Our analysis included AIS (Acute Ischemic Stroke) patients, those presenting within 4.5 hours of symptom onset. We identified 1070 AIS discharges from 16 hospitals of which 77.9 % (n=833) were at PSCs and 22.1 % (n=237) non-PSCs. For acute ischemic stroke patients (AIS) patients, those presenting within 4.5 hours of symptom onset, 22.1% (n=237) received rt-PA; 21.5% (n=74) presented at non–PSCs and 23.7% (n=163) presented at PSCs. Among AIS, bivariate analysis showed significant differences in treatment rates by race, age, NIHSS at admit, previous stroke or TIA, PVD, use of robot, smoking and time from patient arrival to CT completed. Using multiple logistic regression adjusting for these variables, treatment was significantly related to admit NIHSS (AOR=1.67, p<.001), history of stroke (AOR=.323, p<.001), TIA (AOR=.303, p=.01) and PVD (AOR=.176, p=.02), time to CT (.971, p<.001), and use of robot (7.76, p<.001). PSC designation was not significantly related to treatment (p=.06). Conclusions: Through the use of a robust telestroke system, there are no significant differences in the TPA treatment rates between non-PSC and PSC facilities. Telestroke systems can ensure stroke patients access to acute stroke care at non-PSC hospitals.

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