Abstract 2317: A Multidisciplinary Team Approach to Improving Laboratory Results and Thrombolytic Treatment in Acute Code Stroke Patients.

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Debbie Tay ◽  
Connie Boyd ◽  
Andrew Imbus ◽  
Arbi Ohanian ◽  
Jessica Graves ◽  
...  
Keyword(s):  
Los Angeles ◽  
Acute Stroke ◽  
Median Time ◽  
Stroke Care ◽  
Lean Six Sigma ◽  
Phase Iii ◽  
Team Approach ◽  
Medical Systems ◽  
Acute Stroke Care ◽  
The Past

Despite improvement in acute stroke care, stroke remains the third major cause of death and leading cause of disability nationwide. An increase in the number of certified Primary Stroke Centers (PSC) over the past years has been credited for the improvement. Los Angeles County proactively implemented the Approved Stroke Center Network in which Emergency Medical Systems may passes non-certified PCS for acute stroke treatments. Our hospital’s journey towards building a stroke program began in early 2008, and in 2009 a CODE STROKE algorithm was implemented. Over the past two years, the team has strived to continuously improve ‘door to needle’ times. Opportunity to improve door-to-lab results was recognized so we sought to investigate and identify barrier(s)/reason(s) for delays. Methods The LEAN Six Sigma team guided our multidisciplinary committee for identifying contributing delays. A review of the clinical pathway from the patient’s arrival time (door) and activation of Code Stroke are time-stamped at every step. Phase I identified delays with phlebotomist transit times. The laboratory management addressed this issue by reinforcing the need to expedite the specimen collection, transit time and processing. Some improvement was noted in the door-to-lab results time but significant delays remained a problem. Phase II incorporated lab draws being performed prior to the patient going for their CT scan. Phase III involves utilization of an iStat unit within the emergency department for analysis of a CHEM 8 panel. Results Analysis of data initially showed door-to-lab results had a median time of 52 minutes, with 38% having results within 45 minutes. Ten patients received tPA within median times of 66 minutes, with 53% receiving tPA within 60 minutes. In 2010 action plans initiated yielded significant improvements with door-to-lab results median times of 44 minutes, 64% having lab results within 45 minutes. Twenty one patients received tPA within a median time of 55 minutes, and 70% having received tPA within 60 minutes. Conclusion The multidisciplinary stroke team identified barriers and implemented process changes yielding improvements in door-to-lab results that in turn resulted in overall improvements in tPA treatment times. Data collection and process evaluation continue.

Abstract W MP104: Quality of Acute Stroke Care at Primary Stroke Centers Before and After Certification in Comparison to Never-Certified Hospitals

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Nerses Sanossian ◽  
May A Kim-Tenser ◽  
David S Liebeskind ◽  
Justina Breen ◽  
Scott Hamilton ◽  
...  
Keyword(s):  
Los Angeles ◽  
Acute Stroke ◽  
Stroke Care ◽  
Care Quality ◽  
Acute Stroke Care ◽  
Phase 3 ◽  
Before And After ◽  
Beneficial Impact ◽  
Mean Time

Background: Primary Stroke Centers (PSC) provide better acute stroke care than non-PSC hospitals, including faster times to imaging and lytic treatment, and higher rates of lytic delivery. Nationwide less than 1 in 3 hospital has achieved this designation. We aimed to determine the extent to which the better performance at PSC is driven by improvements within hospitals after PSC designation versus better baseline hospital care among facilities seeking PSC certification. Methods: From 2005 to 2012, the NIH Field Administration of Stroke Therapy -Magnesium (FAST-MAG) Phase 3 clinical trial enrolled subjects with likely stroke within 2 hours of onset in a study of prehospital start of a neuroprotective agent. Subjects were routed to 59 community and academic centers in Los Angeles and Orange Counties. Of the original 59 centers, 39 eventually achieved PSC status during the study period. Each subject was classified as enrolled at a PSC before certification (pre-PSC), at a PSC post certification (post-PSC), or at a hospital that never achieved PSC (non-PSC). Results: Of 1700 cases, 529 (31%) were enrolled at pre-PSC, 856 (50%) at post-PSC, and 315 (19%) at non-PSC hospitals. Mean time in minutes from ED arrival to first scan was 33 minutes at post-PSC, 47 minutes at pre-PSC and 49 at non-PSCs [p<0.001 by Mann-Whitney]. Among cases of cerebral ischemia (CI) [N=1223], rates of TPA utilization were 43% at post-PSC, 27% at pre-PSC and 28% at non-PSC hospitals [p<0.001 by X2]. Time in minutes from ED arrival to thrombolysis in treated cases was 71 at post-PSC, 98 at pre-PSC, and 95 at non-PSC hospitals [p<0.001 by Mann-Whitney]. Hospitals that achieved PSC showed improvements in pre-PSC and post-PSC performance on door to imaging time, from 47 to 33 minutes [p=0.014]; percent TPA use in CI, from 27% to 43% [p<0.001], and reduced door-to-needle times, from 98 to 71 minutes [p=0.003]. There was no difference in time to imaging [47 vs. 49 minutes], time to thrombolysis [98 vs. 95 minutes] and percent TPA use [27% vs. 28%] between pre-PSC hospitals and non-PSC hospitals. Conclusions: Better performance of Primary Stroke Centers on acute care quality metrics is primarily driven by a beneficial impact of the PSC-certification process, and not better performance prior to seeking PSC status.

Abstract WP248: Methods to Achieving a 9-minute Door to TPA Time

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Deepak S Nair ◽  
Arun Talkad ◽  
Clayton McNeil ◽  
Jan Jahnel ◽  
Teresa Swanson-Devlin ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Stroke Care ◽  
Time Of Day ◽  
National Average ◽  
Acute Stroke Care ◽  
Stroke Treatment ◽  
The Past ◽  
Stroke Center

Introduction Despite guidelines recommending “door to needle times” (DTN) of ≤60 minutes and the Target: Stroke program, the national average for stroke treatment is 79 minutes. We present the factors that have reduced DTN in our Stroke Center. Methods We retrospectively identified all patients who received IV rt-PA using our acute stroke code database, from 2007 to 2012. The patients were organized by their DTN into four groups: <20min, 20-39min, 40-59min, and ≥60min. Median NIHSS scores were calculated, along with median DTN per group and annually. We also specified median lab times, the source of the stroke code (EMS or ED), and time of day for the code. Results There were 180 patients that received IV rt-PA: 7 patients in <20min, 49 in 20-39min, 52 in 40-59min, and 72 in ≥60min. Median DTN was 14min, 30min, 46.5min, and 76min, respectively, with the overall fastest DTN being 9 minutes. Median NIHSS scores were 7, 12, 13, and 8, respectively. EMS initiated the code in 100% of the <20min cases, 45% in 20-39min, 44% in 40-59min, and 40% in ≥60min. Eighty-six percent of the <20min cases arrived during the day, as did 84% of the 20-39min, 65% of the 40-59min, and 42% of the ≥60min cases. When rt-PA was given before labs were resulted, the median DTN was 30min; otherwise, the median DTN was 54min. All cases with <20min DTN presented after May 2011, when the first such case occurred. The median DTN was 65.5min in 2007, 51min in 2008, 61min in 2009, 59.5min in 2010, 47min in 2011, and 35min in 2012. Conclusions Our experience suggests that the “Target: Stroke” strategies (EMS initiation of stroke codes, rapid triage, rt-PA before labs) can significantly reduce the time to thrombolysis. However, our significant improvement over the past two years followed a singular 13-minute DTN, which demonstrated that teamwork and passion for acute stroke care can catalyze the consistent delivery of efficient stroke treatment.

DHOW2 score leads to significant improvement in acute stroke care management emergency department: a prospective analysis

2019 ◽  
Vol 5 (4) ◽  
pp. 127-134
Author(s):  
Naveed Akhtar ◽  
Abdul Salam ◽  
Paula Bourke ◽  
Saadat Kamran ◽  
Zain Bhutta ◽  
...  
Keyword(s):  
Emergency Department ◽  
Acute Stroke ◽  
Phase Ii ◽  
Stroke Care ◽  
Phase Iii ◽  
Medical Complications ◽  
Acute Stroke Care ◽  
Early Admission ◽  
Patients At Risk ◽  
Risk Patients

BackgroundDelays in transfer of patients from emergency department (ED) to stroke ward increases medical complications. We evaluate if a new risk-score ‘DHOW2’ (dysphagia, hemiplegia, observation-required, wet (incontinence) and weight) will identify high-risk patients and whether expedited admission of ‘high-DHOW2’ score patients to SW will result in fewer complications.MethodsThe DHOW2 score was designed to determine risk of complications following acute stroke. Phase I (279 patients) tested rates of complications with increasing DHOW2. Phase II (1091 patients), evaluated if early admission to the SW of high-DHOW2 patients will lead to fewer complications. Phase III (1257 patients) monitored implementation of the DHOW2 following completion of the study.FindingsMedical complications increased with higher-DHOW2 scores during all three phases; 0%–0.8% with DHOW2 of ≤3, 3.1%–6.5% with DHOW2 of 4–5 and 10.9%–14.1% with DHOW2 of ≥6 (p=<0.001). In phase II, more high-DHOW2 patients were admitted expeditiously to the SW from ED resulting in fewer complications, and fewer deaths. The odds of medical complications with DHOW2 of ≥6 was 36.8–58.3 compared with DHOW2 of ≤3. Expedited SW admission of ‘high-DHOW2 patients’ to within 8 hours reduced the development of complications to odds of 19.18–30.17 (p<0.001).InterpretationsThe DHOW2 score detects patients at risk of AS related medical complications. It is easy to implement in busy EDs where nurses can use the score to identify such patients. The risk stratification by DHOW2 and early transfer of high-scoring patients to SW is associated with significantly fewer complications.

Abstract TMP55: Understanding Cultural and Knowledge Barriers to Acute Stroke Care in the Filipino American Community

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Antonio L Moya ◽  
Vincent Grospe ◽  
Julia Brock ◽  
Linh Nhat-Doan Vo ◽  
Eric Cheng ◽  
...  
Keyword(s):  
Social Media ◽  
Los Angeles ◽  
Focus Groups ◽  
Acute Stroke ◽  
Stroke Risk ◽  
Stroke Care ◽  
The Philippines ◽  
Lessons Learned ◽  
Community Leaders ◽  
Acute Stroke Care

Introduction: Filipino Americans (FilAms) in Los Angeles make up the largest Filipino community outside of the Philippines and 2nd largest Asian subgroup in L.A. County. FilAms also have higher rates of stroke, high blood pressure, and diabetes not only compared to other Asian subgroups but also to African American and Latino communities. Little is known about FilAm knowledge and cultural barriers in accessing acute stroke care. Methods: Using a qualitative descriptive design, we studied knowledge, attitudes, and health behaviors of the L.A. FilAm community with regard to acute stroke care by conducting 5 focus groups of 5-7 people each and 6 semi-structured interviews with key community leaders. Participants were recruited through L.A. FilAm community organizations. Focus groups were organized as follows: 1st: elderly community members at high stroke risk; 2 nd : spouses of those at high stroke risk; 3 rd : paid caregivers of those with stroke risk; 4 th : unpaid caregivers of those with stroke risk; 5 th : young FilAms with family members with stroke risk. Six individual interviews were with elderly FilAms identified as exceptionally healthy by community leaders. We conducted thematic analysis, coding for themes on barriers to acute stroke care. Results: Two key themes have emerged: 1) spiritualistic fatalism and the belief that God is in control of all outcomes despite an individual’s will and 2) fear of calling 911, specifically linked to shame in being perceived as unhealthy by neighbors, fear of deportation among undocumented FilAms, and fear of high ambulance cost. Elderly participants perceived social media as one of the most effective ways to widely engage FilAms on stroke. Conclusion: Beliefs related to spiritualistic fatalism as well as fear of calling 911 are powerful barriers to acute stroke care among FilAms. The results can inform a culturally-relevant intervention for the community using social media, the Internet, and Filipino television programs to encourage FilAms to obtain acute stroke care. Data collected is currently being integrated into a FilAm stroke media tool. Lessons learned from this project will also be used to create stroke education for other U.S. Asian Pacific Islander communities.

scholarly journals Current state of acute stroke care in Southeast Asian countries

2018 ◽  
Vol 25 (3) ◽  
pp. 291-296
Author(s):  
Justin Christopher Ng ◽  
Anchalee Churojana ◽  
Sirintara Pongpech ◽  
Luu Dang Vu ◽  
Cindy Sadikin ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Endovascular Therapy ◽  
Stroke Care ◽  
Southeast Asian ◽  
Asian Countries ◽  
Acute Stroke Care ◽  
The Past ◽  
Current State ◽  
Care Systems ◽  
Southeast Asian Countries

Acute stroke care systems in Southeast Asian countries are at various stages of development, with disparate treatment availability and practice in terms of intravenous thrombolysis and endovascular therapy. With the advent of successful endovascular therapy stroke trials over the past decade, the pressure to revise and advance acute stroke management has greatly intensified. Southeast Asian patients exhibit unique stroke features, such as increased susceptibility to intracranial atherosclerosis and higher prevalence of intracranial haemorrhage, likely secondary to modified vascular risk factors from differing dietary and lifestyle habits. Accordingly, the practice of acute endovascular stroke interventions needs to take into account these considerations. Acute stroke care systems in Southeast Asia also face a unique challenge of huge stroke burden against a background of ageing population, differing political landscape and healthcare systems in these countries. Building on existing published data, further complemented by multi-national interaction and collaboration over the past few years, the current state of acute stroke care systems with existing endovascular therapy services in Southeast Asian countries are consolidated and analysed in this review. The challenges facing acute stroke care strategies in this region are discussed.

Description of a novel telemedicine-enabled comprehensive system of care: drip and ship plus drip and keep within a system of stroke care delivery

2016 ◽  
Vol 23 (3) ◽  
pp. 428-436
Author(s):  
Patricia Commiskey ◽  
Arash Afshinnik ◽  
Elizabeth Cothren ◽  
Toby Gropen ◽  
Ifeanyi Iwuchukwu ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Care Delivery ◽  
Medical Center ◽  
Stroke Care ◽  
Tissue Type ◽  
Team Approach ◽  
Care Needs ◽  
Acute Stroke Care ◽  
Time Sensitivity ◽  
Comprehensive Stroke Center

United States (US) and worldwide telestroke programs frequently focus only on emergency room hyper-acute stroke management. This article describes a comprehensive, telemedicine-enabled, stroke care delivery system that combines “drip and ship” and “drip and keep” models with a comprehensive stroke center primary hub at Ochsner Medical Center in New Orleans, advanced stroke-capable regional hubs, and geographically-aligned, “stroke-ready” spokes. The primary hub provides vascular neurology expertise via telemedicine and monitors care for patients remaining at regional hubs and spokes using a multidisciplinary team approach. By 2014, primary hub telestroke consults grew to ≈1000/year with 16 min average door to consult initiation and 20 min to completion, and 29% of ischemic stroke patients received recombinant tissue-type plasminogen activator (rtPA), increasing 275%. Most patients remained in hospitals close to home, but neurointensive care and interventional procedures were common reasons for primary hub transfer. Given the time sensitivity and expert consultation needed for complex acute stroke care delivery paradigms, telestroke programs are effective for fulfilling unmet care needs. Combining drip and ship and drip and keep management allows more patients to stay “local,” limiting primary hub transfer unless more advanced services are required. Post admission telestroke management at spokes increases personnel efficiency and can positively impact stroke outcomes.

scholarly journals Bottlenecks in the Acute Stroke Care System during the COVID-19 Pandemic in Catalonia

2021 ◽  
pp. 1-9
Author(s):  
Anna Ramos-Pachón ◽  
Álvaro García-Tornel ◽  
Mònica Millán ◽  
Marc Ribó ◽  
Sergi Amaro ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Functional Outcome ◽  
Stroke Care ◽  
Care Quality ◽  
Point Of View ◽  
Stroke Severity ◽  
Acute Stroke Care ◽  
Vessel Occlusion ◽  
Prehospital Delays ◽  
The Impact

<b><i>Introduction:</i></b> The COVID-19 pandemic resulted in significant healthcare reorganizations, potentially striking standard medical care. We investigated the impact of the COVID-19 pandemic on acute stroke care quality and clinical outcomes to detect healthcare system’s bottlenecks from a territorial point of view. <b><i>Methods:</i></b> Crossed-data analysis between a prospective nation-based mandatory registry of acute stroke, Emergency Medical System (EMS) records, and daily incidence of COVID-19 in Catalonia (Spain). We included all stroke code activations during the pandemic (March 15–May 2, 2020) and an immediate prepandemic period (January 26–March 14, 2020). Primary outcomes were stroke code activations and reperfusion therapies in both periods. Secondary outcomes included clinical characteristics, workflow metrics, differences across types of stroke centers, correlation analysis between weekly EMS alerts, COVID-19 cases, and workflow metrics, and impact on mortality and clinical outcome at 90 days. <b><i>Results:</i></b> Stroke code activations decreased by 22% and reperfusion therapies dropped by 29% during the pandemic period, with no differences in age, stroke severity, or large vessel occlusion. Calls to EMS were handled 42 min later, and time from onset to hospital arrival increased by 53 min, with significant correlations between weekly COVID-19 cases and more EMS calls (rho = 0.81), less stroke code activations (rho = −0.37), and longer prehospital delays (rho = 0.25). Telestroke centers were afflicted with higher reductions in stroke code activations, reperfusion treatments, referrals to endovascular centers, and increased delays to thrombolytics. The independent odds of death increased (OR 1.6 [1.05–2.4], <i>p</i> 0.03) and good functional outcome decreased (mRS ≤2 at 90 days: OR 0.6 [0.4–0.9], <i>p</i> 0.015) during the pandemic period. <b><i>Conclusion:</i></b> During the COVID-19 pandemic, Catalonia’s stroke system’s weakest points were the delay to EMS alert and a decline of stroke code activations, reperfusion treatments, and interhospital transfers, mostly at local centers. Patients suffering an acute stroke during the pandemic period had higher odds of poor functional outcome and death. The complete stroke care system’s analysis is crucial to allocate resources appropriately.

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