Abstract 3150: Partnering with Emergency Department Staff Educators Increases the Number of Notifications to the Acute Stroke Research Team

Background: Preparation for the Joint Commission survey to determine Primary Stroke Center Certification requires extensive education of staff in all areas a stroke patient will be during their hospitalization. Research personnel in the Emergency Department (ED) often rely on clinical staff for notification of potential research participants. When present in the treatment area research personnel are notified in person or find potential participants by reviewing a patient’s chief complaint or admitting diagnosis. When outside the treatment area, particularly during times when on call from outside the hospital, the research staff is dependent on notification by clinical staff. Methods: During the survey preparation, ED staff was educated in care of ischemic and hemorrhagic stroke patients according to AHA/ASA guidelines. During the formal nursing education research personnel gave short presentations on currently enrolling acute stroke trials and gave instructions on how to reach the research team in the event that a potential study participant entered the ED. Quarterly research reports were given at the Emergency Medicine resident’s conference. Education was given to the nursing and medical staff from October 2010 through July 2011 when the survey took place. The database of the online paging system was reviewed for the time period April 2010 through July 2011. Test, demonstration, non-stroke study and calls from other institutions were deleted from the data set. The remaining calls were divided by the month in which they were placed. Results: The research team received on average 5 calls per month during the six months prior to the AHA/ASA education. During the education time the research team received on average 9.6 calls per month. Conclusion: Acute stroke research personnel increase the number of potential patient notifications by participating in ED staff education for the Primary Stroke Center Certification survey.

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Abstract T MP75: Facilities Available in Chinese Hospitals From China Stroke Research Network

Stroke ◽

10.1161/str.46.suppl_1.tmp75 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Chunjuan Wang ◽

Zixiao Li ◽

Yilong Wang ◽

Yong Jiang ◽

Xingquan Zhao ◽

...

Keyword(s):

Acute Stroke ◽

Mainland China ◽

Stroke Care ◽

Research Network ◽

Level Of Care ◽

Minimum Level ◽

Stroke Patients ◽

Stroke Research ◽

Primary Stroke Center ◽

Stroke Center

Background and Purpose: Stroke is the first leading cause of death in China and millions of patients were admitted to various levels of hospitals each year. However, it is unknown how many of these hospitals are able to provide an appropriate level of care for stroke patients since the certification program of comprehensive stroke center (CSC) and primary stroke center (PSC) has not been initiated in China. Method: In 2012, we selected all 554 hospitals that joined into the China Stroke Research Network (CSRN) to start a survey. These hospitals were from 31 provinces or municipalities, covered nearly the entire Mainland China. A six-page questionnaire was sent to each of them to obtain the stroke facility information. We used the same criteria and definitions for CSC, PSC, and minimum level for any hospital ward (AHW) admitting stroke patients with that of the European Stroke Facilities Survey. Results: For all the hospitals in CSRN, 521 (94.0%) returned the questionnaire, 20 (3.8%) met criteria for CSC, 179 (34.4%) for PSC, 64 (12.3%) for AHW, and 258 (49.5%) met none of them and provided a lower level of care. Hospitals meeting criteria for CSC, PSC, AHW, and none of them admitted 70 052 (8.8%), 334 834 (42.2%), 88 364 (11.1%), and 299 806 (37.8%) patients in the whole of last year. There was no 24-hour availability for brain CT scan in 4.3% of hospitals not meeting criteria for AHW, while neither stroke care map nor stroke pathway for patients admission in 81.0% of them. Conclusions: Less than two fifths of Chinese hospitals admitting acute stroke patients have optimal facilities, and nearly half even the minimum level is not available. Our study suggests that only one half acute stroke patients are treated in appropriate centers in China, facilities for hospitals admitting stroke patients should be enhanced and certification project of CSCs and PSCs may be a feasible choice.

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Abstract TP341: Nursing Impact on the Acute Stroke Team - Driving Practice in a Collaborative Environment

Stroke ◽

10.1161/str.44.suppl_1.atp341 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Lauri Speirs

Keyword(s):

Emergency Department ◽

Acute Stroke ◽

Endovascular Therapy ◽

Golden Hour ◽

Stroke Team ◽

Primary Stroke Center ◽

Response Team ◽

Intense Training ◽

Stroke Center ◽

Time Frames

Background /Purpose: In 2005 a community hospital began the journey to Primary Stroke Center. One aspect was to develop a stroke response team. The acute stroke team must provide neurologist expertise at bedside, be cost neutral, compliment the workflow in the Emergency Department, and maximize the limited number of neurologists on staff. Stroke unit nurses were identified as neurological experts in the hospital. After intense training, Stroke Alert went live in October of 2007. The nurse led acute stroke team (AST) collaborated with the medical staff to increase the total volume of stroke patients receiving t-PA. With additional training, the nurse led team assisted in the identification and transfer of patients for endovascular therapy. Method: A group of 12 nurses were trained by the stroke medical director to complete a stroke assessment, then to communicate those findings to the neurologist on call and the Emergency Department physicians. The nurse responders and the Emergency Department nurses were trained to mix and calculate the doses for t-PA. In 2010 the nurse responders were educated on the criteria for endovascular therapy, including time frames, patient assessment, and key CT results. In 2011, the nurse responders were re-educated on the golden hour of stroke. Results: Since 2008, over 450 stroke alerts have been activated each year. The administration of t-PA increased from 4 patients in 2007 to 43 patients in 2011; an additional 9 patients were sent to another facility for endovascular therapy. In the first 6 months of 2012, over 50% of patients receive t-PA in less than 60 minutes and Gold plus from the AHA was achieved. Conclusion: Nurses can be a vital asset to the AST by providing neurological expertise, collaborating with physicians, and driving the stroke protocols.

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Abstract P828: Reducing and Sustaining "Door-To-Monitored Bed" Times in Patients Receiving Alteplase for Acute Stroke Symptoms

Stroke ◽

10.1161/str.52.suppl_1.p828 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Janet Leatherwood ◽

Maureen Lall ◽

Diane McGraw ◽

Rita Richards ◽

Fiona Smith

Keyword(s):

Emergency Department ◽

Change Management ◽

Acute Stroke ◽

Rapid Assessment ◽

Stroke Care ◽

Management Model ◽

Quality Improvement Initiative ◽

Process Change ◽

Primary Stroke Center ◽

Stroke Center

Background and Issues: Acute strokes are medical emergencies that require rapid assessment and treatment. Following treatments, focused and frequent monitoring is essential to quickly identify and mitigate any physiological deterioration. However, hospital capacity and decreased availability of monitored beds often causes delay in admission and prolonged stays in the emergency department and the potential increase in morbidity and mortality. Purpose: The purpose of this quality improvement initiative is to reduce the length of time from a patient presenting to the emergency department with acute stroke symptoms and treated with alteplase, to the time that the patient is being monitored utilizing “comprehensive specialized stroke care” level monitoring. This level of monitoring allows for the patient to be assessed closely and frequently to ensure the absence of physiological or neurological deterioration as well as for any adverse thrombolytic reaction. Methods: To improve the process of patient progression within the hospital, the care team utilized the ADKAR® Change Management Model. This model focuses on sponsoring awareness, promoting desire, providing knowledge, ensuring ability, and reinforcing changes. Each of these five components is critical to implement the proposed changes and ensure the longevity of the process changes. Results: Since the implementation of the process change, the Primary Stroke Center has experienced twenty-four months of mean “door-to-monitored bed” times below the 180 minute benchmark. In addition, the mean “door to monitored bed” time has decreased from 210 minutes in the three months preceding the process change (n=20), to 113 minutes during the twenty-four months following the change (n=150). Conclusions: During this process change, the Stroke Center successfully reduced the time between patient arrival and being in a monitored bed. The use of the ADKAR® Change Management Model is particularly advantageous in implementing a process change that is expected to be sustained into the future.

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Emergency Medical Services Support for Acute Ischemic Stroke Patients Receiving Thrombolysis at a Primary Stroke Center

Journal of brain disease ◽

10.4137/jcnsd.s2221 ◽

2009 ◽

Vol 1 ◽

pp. JCNSD.S2221

Author(s):

Byron R. Spencer ◽

Omar M. Khan ◽

Bentley J. Bobrow ◽

Bart M. Demaerschalk

Keyword(s):

Decision Making ◽

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Stroke Onset ◽

Stroke Patients ◽

Emergency Medical ◽

Field Assessment ◽

Primary Stroke Center ◽

Stroke Center

Background Emergency Medical Services (EMS) is a vital link in the overall chain of stroke survival. A Primary Stroke Center (PSC) relies heavily on the 9-1-1 response system along with the ability of EMS personnel to accurately diagnose acute stroke. Other critical elements include identifying time of symptom onset, providing pre-hospital care, selecting a destination PSC, and communicating estimated time of arrival (ETA). Purpose Our purpose was to evaluate the EMS component of thrombolysed acute ischemic stroke patient care at our PSC. Methods In a retrospective manner we retrieved electronic copies of the EMS incident reports for every thrombolysed ischemic stroke patient treated at our PSC from September 2001 to August 2005. The following data elements were extracted: location of victim, EMS agency, times of dispatch, scene, departure, emergency department (ED) arrival, recordings of time of stroke onset, blood pressure (BP), heart rate (HR), cardiac rhythm, blood glucose (BG), Glasgow Coma Scale (GCS), Cincinnati Stroke Scale (CSS) elements, emergency medical personnel field assessment, and transport decision making. Results Eighty acute ischemic stroke patients received thrombolysis during the study interval. Eighty-one percent arrived by EMS. Two EMS agencies transported to our PSC. Mean dispatch-to-scene time was 6 min, on-scene time was 16 min, transport time was 10 min. Stroke onset time was recorded in 68%, BP, HR, and cardiac rhythm each in 100%, BG in 81%, GCS in 100%, CSS in 100%, and acute stroke diagnosis was made in 88%. Various diagnostic terms were employed: cerebrovascular accident in 40%, unilateral weakness or numbness in 20%, loss of consciousness in 16%, stroke in 8%, other stroke terms in 4%. In 87% of incident reports there was documentation of decision-making to transport to the nearest PSC in conjunction with pre-notification. Conclusion The EMS component of thrombolysed acute ischemic stroke patients care at our PSC appeared to be very good overall. Diagnostic accuracy was excellent, field assessment, decision-making, and transport times were very good. There was still room for improvement in documentation of stroke onset and in employment of a common term for acute stroke.

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Abstract WMP3: Direct Transfer to Angio-suite to Reduce Door-to-puncture Time in Thrombectomy for Acute Stroke

Stroke ◽

10.1161/str.48.suppl_1.wmp3 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Marc Ribo ◽

Alejandro Tomasello ◽

Sandra Boned ◽

Pilar Coscojuela ◽

Jesus Juega ◽

...

Keyword(s):

Acute Stroke ◽

Control Group ◽

Direct Transfer ◽

Stroke Patients ◽

Primary Stroke Center ◽

Femoral Puncture ◽

Procedural Time ◽

Baseline Characteristics ◽

Stroke Center ◽

Race 4

Background: We aim to evaluate the feasibility and safety of a direct transfer to the angio-suite protocol for acute stroke patients candidates for endovascular treatment (EVT). Methods: Starting June 2016, patients with pre-hospital stroke code activation (RACE≥4) admitted within 4.5h from symptoms-onset were directly transferred on admission to angio-suite (DTA) bypassing the emergency room. After Xpert-CT in the angio-suite for parenchymal evaluation, femoral puncture and EVT were performed as usual. Patients following DTA were compared to all patients with same admission criteria treated with EVT in the previous 2 years (control group, CG). Results: Of the 16 patients that followed DTA, 1 (6%) showed an intracranial hemorrhage (ICH) on Xpert-CT and 15 underwent EVT, representing 50% of EVT admitted within 4.5h or 34% of all EVT performed in the study period. 56% of DTA patients had previous neuroimaging at a primary stroke center, 44% were primary admissions with no previous neuroimaging. Baseline characteristics including age (71 Vs 72 years; p=0.71) and admission NIHSS (18.5 Vs 18;p=0.68) were comparable. Median time from admission to groin puncture was significantly shorter in DTA patients (15 minutes IQR:13-19 Vs 65 IQR:45-10;p<0.01). Rate of no treatable occlusion on initial angiogram was 13.3% in DTA Vs 2.4% in CG (p=0.17). Procedural time (36 Vs 55 minutes;p=0.034) was shorter in the DTA group, while recanalization (TICI 2b-3: 86% Vs 81%;p=0.24) and symptomatic ICH rates(6.7% Vs 6.6%;p=0.98) and 24h NIHSS (10 Vs 10.5; p=0.81) were comparable. The total time from admission to recanalization was significantly shorter when DTA was applied (median 52 Vs 123;p<0.01). Conclusion: In a subgroup of acute stroke patients presenting in the early window, direct transfer and triage in the angio-suite seems feasible, safe and achieves a significant reduction in hospital workflow times.

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Abstract W P286: Assessing Wisconsin Hospitals’ Capacity to Treat Acute Stroke

Stroke ◽

10.1161/str.46.suppl_1.wp286 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Julie E Baumann

Keyword(s):

Acute Stroke ◽

Technical Assistance ◽

Systems Of Care ◽

Stroke Care ◽

Self Report ◽

The Status ◽

Primary Stroke Center ◽

Stroke Systems Of Care ◽

Stroke Center ◽

Reported Data

Introduction: Establishing regional stroke systems of care can improve timely treatment and survival, and reduce disability and related healthcare costs for persons experiencing acute stroke. A well-functioning stroke system requires seamless coordination between EMS, hospitals and certified stroke centers. Of 127 non-specialty hospitals in Wisconsin, 2% are comprehensive stroke centers and 24% have achieved primary stroke center certification. However, little is known about other hospitals’ capacity to treat acute stroke. The Wisconsin Stroke Coalition (WSC) wanted to better understand the need to improve stroke care capacity among hospitals not certified to treat stroke. The hypothesis was that few non-stroke certified hospitals in Wisconsin have all the criteria in place to treat acute stroke. Methods: WSC developed a short survey based on the Brain Attack Coalition’s recommendations for an acute stroke-ready hospital (ASRH). The tool included a user-friendly checklist that captured the status of each recommendation; in place currently or within six months; could be developed with assistance; or no plan to develop. WSC distributed the survey to 88 non-specialty, non-stroke certified hospitals and requested that each self-report their level of stroke care. Results: Fifty-nine percent of hospitals responded to the survey. Among respondents, 5% reported having all recommendations in place within six months, 53% reported having some of the recommendations in place and 1% reported no plan to develop any of the recommendations. While only a few had implemented every recommendation, the majority either had in place or were receptive to adopting individual suggestions. Nearly half of respondents reported having telestroke in place (either by phone, with video, or both). Conclusions: According to self-reported data, non-specialty, non-stroke certified hospitals in Wisconsin appear well-positioned or receptive to developing basic recommendations for acute stroke-ready hospitals. WSC plans to disseminate findings to Wisconsin hospitals and gather further information about technical assistance that would improve their level of stroke care and coordination with EMS.

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Abstract TP362: Door to Needle Time Improves With Implementation of an Alteplase Alert Within the Existing Code Stroke Process in a Primary Stroke Center Emergency Department

Stroke ◽

10.1161/str.48.suppl_1.tp362 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Tonia P Shelton ◽

Leticia M Riley ◽

Erin K Kibbey ◽

Kristine J Heatley

Keyword(s):

Emergency Department ◽

Median Time ◽

Action Plans ◽

Frontline Staff ◽

Charge Nurse ◽

Primary Stroke Center ◽

Consistent Manner ◽

Primary Nurse ◽

Stroke Center ◽

Innovative Action

Background and Purpose: A Primary Stroke Center Emergency Department (ED) identified the need to decrease Door to Needle Time (DNT) for intravenous administration of Alteplase in order to align with stroke standards and provide optimal patient outcomes. Methods: A systematic review of the data collected since September 2014 demonstrated opportunities for improvement with our current Code Stroke process, consequently delaying DNT. Frontline staff identified a delay in the time from the physician’s order to initiation of Alteplase infusion. Based on the identified communication gaps between the physician and nursing staff, two innovative action plans were developed. An Alteplase Alert was implemented within the existing Code Stroke process. In addition to the facility-wide overhead Code Stroke initially placed upon patient arrival, an internal Alteplase Alert is now initiated within the ED once it is determined the patient is a candidate for Alteplase. Once the Alteplase Alert is initiated the charge nurse, an ED tech, and the designated Code Stroke nurse respond immediately to the patient’s bedside to assist the primary nurse in initiating the tasks associated with Alteplase administration. Secondly, a stroke Alteplase tool was designed to ensure continuity of care and team collaboration. Results: Data from January 2014 through August 2015 was used to establish the baseline. Prior to implementation, there were 2/17 (11.76%) patients with a DNT less than 60 minutes, with a median time of 84 minutes. After implementation, data from October 2015 through June 2016, demonstrated a decrease in DNT. There were 15/17 (88.23%) patients with DNT less than 60 minutes, with a median time of 51 minutes. Conclusions: Implementation of the innovative action plans including the Alteplase Alert and Stroke tool helped to accomplish a goal of improved DNT in an efficient and consistent manner. Application of the aforementioned plans led to immediate results. Over the last 10 months, the DNT has sustained a significant improvement.

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Does primary stroke center certification change ED diagnosis, utilization, and disposition of patients with acute stroke?

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2011.08.015 ◽

2012 ◽

Vol 30 (7) ◽

pp. 1152-1162 ◽

Cited By ~ 8

Author(s):

Dustin W. Ballard ◽

Mary E. Reed ◽

Jie Huang ◽

Barbara J. Kramer ◽

John Hsu ◽

...

Keyword(s):

Acute Stroke ◽

Primary Stroke Center ◽

Stroke Center

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Abstract NS26: Pre-hospital Stroke Evaluation Using Expanded Stroke Screening Tools

Stroke ◽

10.1161/str.46.suppl_1.ns26 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Theresa Hamm ◽

Brian Helland

Keyword(s):

Acute Stroke ◽

Chart Review ◽

Recognition Rate ◽

Retrospective Chart Review ◽

Accurate Method ◽

Posterior Circulation ◽

Screening Tools ◽

Anterior Circulation ◽

Primary Stroke Center ◽

Stroke Center

Background and Purpose: The Cincinnati Pre-Hospital Stroke scale is a quick and accurate method for identifying stroke in the EMS setting. In 1999, Kothari et. al. demonstrated that the Cincinnati Pre-Hospital Stroke Scale (CPSS) identified 87% of acute anterior circulation strokes. We hypothesize that adding additional criteria from the NIH Stroke Scale to the CPSS will increase EMS providers’ ability to recognize stroke syndromes beyond anterior circulation strokes in the EMS setting. In Iowa, current EMS protocols use the CPSS for field stroke examinations as a minimum standard. The addition of additional elements from the NIH Stroke Scale that specifically evaluate posterior circulation should improve stroke recognition in the field. The Miami Emergency Neurological Deficit exam (MEND) specifically meets these criteria: it is based on the CPSS, and adds elements of the NIHSS that evaluate posterior circulation. This should allow EMS providers to triage and transport more patients to a primary stroke center. Methods: A retrospective chart review was done within a 22 month period at a Joint Commission Certified Primary Stroke Center. Only patients with confirmed diagnosis of stroke were included; TIA and all other diagnoses were excluded. Patient symptoms were listed and the exam criteria for both the CPSS and MEND were applied. The vascular distribution of stroke for each patient was evaluated to confirm results. Results: 732 patients presented in the 22 month period. 468 (64%) were identified using CPSS criteria.644 (88%) were identified using MEND criteria. This results in an increase of 176 (24%) patients who would have been recognized as experiencing an acute stroke using the MEND exam. Conclusion: Use of an expanded stroke exam by EMS providers will result in a higher recognition rate for anterior and posterior circulation acute stroke.

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