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.

Abstract W P334: VA Healthcare System Responses to National Stroke Care Reorganization

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Teresa M Damush ◽  
Kristine K Miller ◽  
Laurie Plue ◽  
Arlene A Schmid ◽  
Laura Myers ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Nurse Managers ◽  
Stroke Care ◽  
Structured Interviews ◽  
Acute Stroke Care ◽  
Major Barrier ◽  
Ongoing Work ◽  
Final Sample ◽  
Cross Training ◽  
Stroke Center

Aims: In 2011, the VA released the Acute Ischemic Stroke (AIS) Directive which mandated reorganization of acute stroke care, including self-designation as Primary (P), Limited Hours (LH), or Supporting (S) stroke center. We conducted interviews across stroke centers to understand barriers and facilitators faced in response. Methods: The final sample included 38 (84% invited) facilities: 9 P, 24 LH, and 5 S facilities. In total, 107 persons were interviewed including ED Chiefs, Chiefs of Neurology, ED Nurse Managers/Nurses and other staff. Semi-structured interviews were based on the AIS Directive. Completed interviews were transcribed and analyzed using Nvivo 10. Results: Barriers reported were a lack of personnel assigned to coordinate the facility response to the directive. Data collection and lack of staff were likewise commonly reported as barriers. For thrombolysis measures, the low number of eligible Veterans was another major barrier. LH and S facilities reported some unique barriers: access to radiology and neurology services; EMS diverting stroke patients to nearby stroke centers, maintaining staff competency, and a lack of stroke clinical champions. Some solutions applied included cross training X-ray technicians to provide head CT coverage, developing stroke order sets and templates, and staff training. Larger facilities added a stroke code pager system and improved upon its use, and established ED nurses to become first alerts for an acute stroke patient. LH and S facilities also responded by attempting to secure additional services and by establishing formal transfer agreements to improve Veteran tPA access. Conclusions: The AIS Directive brought focused attention to reorganizing and improving stroke care across a range of facility types. Larger VA facilities tended to follow established practices for organizing stroke care, but the unique LH designation presented challenges to consistently organize systems. Since Veterans have financial interest in presenting to a VA facility, ongoing work to organize VA care and to improve access to thrombolysis at smaller VA facilities is needed. This protocol was supported by Genentech Inc. Protocol ML 28238, VA HSRD QUERI Rapid Response Project 11-374, and the VA Stroke QUERI Center.

Abstract TP256: mStroke: "Mobile Stroke" - Improving Acute Stroke Care With Smartphone Technology

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Benjamin Y Andrew ◽  
Colleen M Stack ◽  
Julian P Yang ◽  
Jodi A Dodds
Keyword(s):  
Acute Stroke ◽  
Real Time ◽  
Care Coordination ◽  
Stroke Care ◽  
Time Of Day ◽  
Care Process ◽  
Acute Stroke Care ◽  
Nihss Score ◽  
Medical Centers ◽  
Smartphone Technology

Introduction: The use of mobile electronic care coordination via smartphone technology is a novel approach aimed at increasing efficiency in acute stroke care. One such platform, StopStroke© (Pulsara Inc., Bozeman, MT), serves to coordinate personnel (EMS, nurses, physicians) during stroke codes with real-time digital alerts. This study was designed to examine post-implementation data from multiple medical centers utilizing the StopStroke© application, and to evaluate the effect of method of arrival to ED and time of presentation on these results. Methods: A retrospective analysis of all acute stroke codes using StopStroke© from 3/2013 – 5/2016 at 12 medical centers was performed. Preliminary unadjusted comparison of clinical metrics (door-to-needle time [DTN], door-to-CT time [DTC], and rate of goal DTN) was performed between subgroups based on both method of arrival (EMS vs. other arrival to ED) and time of day. Effects were then adjusted for confounding variables (age, sex, NIHSS score) in multiple linear and logistic regression models. Results: The final dataset included 2589 unique cases. Patients arriving by EMS were older (median age 67 vs. 64, P < 0.0001), had more severe strokes (median NIHSS score 8 vs. 4, P < 0.0001), and were more likely to receive tPA (20% vs. 12%, P < 0.0001) than those arriving to ED via alternative method. After adjustment for age, sex, NIHSS score and case time, patients arriving via EMS had shorter DTC (6.1 min shorter, 95% CI [2, 10.3]) and DTN (12.8 min shorter, 95% CI [4.6, 21]) and were more likely to meet goal DTN (OR 1.83, 95% CI [1.1, 3]). Adjusted analysis also showed longer DTC (7.7 min longer, 95% CI [2.4, 13]) and DTN (21.1 min longer, 95% CI [9.3, 33]), and reduced rate of goal DTN (OR 0.3, 95% CI [0.15, 0.61]) in cases occurring from 1200-1800 when compared to those occurring from 0000-0600. Conclusions: By incorporating real-time pre-hospital data obtained via smartphone technology, this analysis provides unique insight into acute stroke codes. Additionally, mobile electronic stroke care coordination is a promising method for more efficient and efficacious acute stroke care. Furthermore, early activation of a mobile coordination platform in the field appears to promote a more expedited and successful care process.

Abstract P855: Importance of Compliance in Dysphagia Screening in Acute Stroke Care

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Patty Noah ◽  
Melanie Henderson ◽  
Rebekah Heintz ◽  
Russell Cerejo ◽  
Christopher T Hackett ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Aspiration Pneumonia ◽  
Hemorrhagic Stroke ◽  
Oral Intake ◽  
Stroke Care ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
Chi Square ◽  
Stroke Center

Introduction: Dysphagia occurs in up to two thirds of stroke patients and can lead to serious complications such as aspiration pneumonia, which is also linked to increased morbidity and mortality. Evidence-based guidelines recommend a bedside dysphagia assessment before oral intake in stroke patients regardless of initial stroke severity. Several studies have described registered nurses’ competency in terms of knowledge and skills regarding dysphagia screening. We aimed to examine the rate of aspiration pneumonia compared to the rate of dysphagia screening. Methods: A retrospective analysis of prospectively collected data at a single tertiary stroke center was carried out between January 2017 and June 2020. Data comparison was completed utilizing ICD-10 diagnosis codes to identify aspiration pneumonia in ischemic and hemorrhagic stroke patients. The data was reviewed to compare the compliance of a completed dysphagia screen prior to any oral intake to rate of aspiration pneumonia. Chi square tests were used to assess proportion differences in completed dysphagia screen and proportion of aspiration pneumonia diagnosis in the ischemic and hemorrhagic stroke patients. Results: We identified 3320 patient that met inclusion criteria. 67% were ischemic strokes, 22% were intracerebral hemorrhages and 11% were subarachnoid hemorrhages. Compliance with dysphagia screening decreased from 94.2% (n=1555/1650) in 2017-2018 to 74.0% (n=1236/1670) in 2019-2020, OR=0.17 (95%CI 0.14 - 0.22), p < 0.0001. Aspiration pneumonias increased from 58 (3.5%) in 2017-2018 to 77 (4.6%) in 2019-2020, but this difference was not statistically significant, OR=0.75 (95%CI 0.53 - 1.07), p = 0.11. Conclusion: We noted that the decrease in compliance with completing a dysphagia screen in patients with acute stroke prior to any oral intake was associated with a higher trend of aspiration pneumonia.

Abstract TMP86: Telestroke Improves Guideline-Based Comprehensive Stroke Care: The TELECAST Trial

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Christopher D Streib ◽  
Oladi Bentho ◽  
Kathryn Bard ◽  
Eric Jaton ◽  
Sarah Engkjer ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Stroke Care ◽  
Composite Score ◽  
Stroke Recurrence ◽  
Acute Stroke Care ◽  
Specialist Service ◽  
Stroke Treatment ◽  
Chi Squared ◽  
Secondary Outcomes ◽  
The Impact

Introduction: Limited access to stroke specialist expertise produces disparities in inpatient stroke treatment. The impact of telestroke on the remote delivery of guideline-based inpatient stroke care is yet to be comprehensively studied. The TELECAST trial (NCT03672890) prospectively examined the impact of a 24-7 telestroke specialist service dedicated to inpatient acute stroke care spanning admission to discharge. Methods: AHA stroke guidelines were used to derive outcome metrics in the following acute stroke inpatient care categories: diagnostic stroke evaluation (DSE), secondary stroke prevention (SSP), health screening and evaluation (HSE), and stroke education (SE). Adherence to AHA guidelines for stroke inpatients pre-telestroke (July 1, 2016-June 30, 2018) and post-telestroke intervention (July 1, 2018-June 30, 2019) were studied. The primary outcome was a composite score of all guideline-based stroke care. Secondary outcomes consisted of subcategory composite scores in DSE, SSP, HSE, and SE. Chi-squared tests were utilized to assess primary and secondary outcomes. Statistical analysis was performed using STATA 15.0. Results: Following institution of a comprehensive inpatient telestroke service, overall adherence to guideline-based metrics improved (composite score: 85% vs 94%, p<0.01) as did adherence to DSE guidelines (subgroup score: 90 vs 95%, p<0.01). SSP, HSE, and SE subgroup scores were not significantly different. See Table 1. Conclusion: The implementation of a 24-7 inpatient telestroke service improved adherence to AHA guidelines for inpatient acute stroke care. Dedicated inpatient telestroke specialist coverage may improve inpatient stroke care and reduce stroke recurrence in hospitals without access to stroke specialists.

Ten Years of Improving Acute Stroke Management in a Metropolitan Area: A Population-Based Quantification of Quality Indicators

2021 ◽  
pp. 1-11
Author(s):  
Anna Alegiani ◽  
Michael Rosenkranz ◽  
Leonie Schmitz ◽  
Susanne Lezius ◽  
Günter Seidel ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Quality Indicators ◽  
Metropolitan Area ◽  
Stroke Care ◽  
Care Quality ◽  
Acute Stroke Care ◽  
Stroke Units ◽  
Stroke Treatment ◽  
Acute Stroke Treatment ◽  
Over Time

<b><i>Background and Purpose:</i></b> Rapid access to acute stroke treatment improves clinical outcomes in patients with ischemic stroke. We aimed to shorten the time to admission and to acute stroke treatment for patients with acute stroke in the Hamburg metropolitan area by collaborative multilevel measures involving all hospitals with stroke units, the Emergency Medical Services (EMS), and health-care authorities. <b><i>Methods:</i></b> In 2007, an area-wide stroke care quality project was initiated. The project included mandatory admission of all stroke patients in Hamburg exclusively to hospitals with stroke units, harmonized acute treatment algorithms among all hospitals, repeated training of the EMS staff, a multimedia educational campaign, and a mandatory stroke care quality monitoring system based on structured data assessment and quality indicators for procedural measures. We analyzed data of all patients with acute stroke who received inhospital treatment in the city of Hamburg during the evaluation period from the quality assurance database data and evaluated trends of key quality indicators over time. <b><i>Results:</i></b> From 2007 to 2016, a total of 83,395 patients with acute stroke were registered. During this period, the proportion of patients admitted within ≤3 h from symptom onset increased over time from 27.8% in 2007 to 35.2% in 2016 (<i>p</i> &#x3c; 0.001). The proportion of patients who received rapid thrombolysis (within ≤30 min after admission) increased from 7.7 to 54.1% (<i>p</i> &#x3c; 0.001). <b><i>Conclusions:</i></b> Collaborative stroke care quality projects are suitable and effective to improve acute stroke care.

Abstract 352: Early Data From an Implementation Science Study Suggests the Need for Identification and Adoption of Best Practices to Improve the Timeliness of Stroke Treatment

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Lisa M Monk
Keyword(s):  
Best Practices ◽  
Acute Stroke ◽  
Care Delivery ◽  
Stroke Care ◽  
Early Data ◽  
Screening Tools ◽  
Stroke Severity ◽  
Ct Scanner ◽  
Acute Stroke Care ◽  
Stroke Treatment

There is a disconnect from discovery of best treatment options and application into clinical practice in a timely manner. The I M plementation of best Pr actices f O r acute stroke care-de v eloping and optimizing regional systems of Stroke Care (IMPROVE Stroke Care) goal is to develop a regional integrated stroke system that identifies, classifies, and treats patients with acute ischemic stroke more rapidly and effectively with reperfusion therapy. These improvements in acute stroke care delivery are expected to result in lower mortality, fewer recurrent strokes, and improved long term functional outcomes. Recent discoveries in stroke care and advancement in technology extends the window for both TPA administration and mechanical thombectomy. The challenge of implementing these latest advances are difficult considering the ability of hospitals to implement the original American Heart Association (AHA) Systems of Stroke Care recommendations. Early data from this project shows that the challenges continue to exist in recommendations that have been in place as early as 2005. EMS is not utilizing pre-hospital stroke screening tools, only 5% of the time, stroke severity tools, only 7% of the time, lytic checklists, 0% of the time, destination decision changed due to severity score, 0% of the time, and pre-notifying emergency rooms, only 63% of the time. Emergency departments door to CT <45 minutes, only 55% of the time, Lytic given in CT scanner, only 35% of the time, Door to lytic therapy< 45 minutes, 77% of the time, Door to Groin puncture, 81% of the time, and Door to TICI Flow 2c/3 flow <90 minutes, 39% of the time. The Systems of Stroke Care have recommendations that will improve time to treatment and outcomes for patients. This project is working to provide tools, guidance, data, and feedback to improve application of these recommendations and identify best practices and solutions to barriers.

JCAHO Stroke Center Certification as a Strategy for a Statewide System of Acute Stroke Care in North Carolina

2007 ◽  
Vol 14 (5 Supplement 1) ◽  
pp. S31-S32
Author(s):  
A. Asimos ◽  
S. Huston ◽  
L. Mettam ◽  
D. Enright
Keyword(s):  
North Carolina ◽  
Acute Stroke ◽  
Stroke Care ◽  
Acute Stroke Care ◽  
Stroke Center

Abstract TMP8: Predictors of Large Vessel Occlusion in Kaiser Stroke EXPRESS Program

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jeffrey G Klingman ◽  
Anne C Kim ◽  
Meghan Hatfield ◽  
Benjamin Wilson ◽  
Lauren Klingman ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Patient Characteristics ◽  
Stroke Care ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Acute Stroke Care ◽  
Kaiser Permanente ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Improved Outcomes

Background: In 2015, trials showed that rapid endovascular stroke treatment (EST) of qualified patients with large vessel occlusion (LVO) resulted in improved outcomes over treatment with IV tPA alone. In 2015, Kaiser Permanente Northern California (KPNC) redesigned its acute stroke care work flow for its 21 stroke centers, which included expedited IV t-pa treatment, rapid CTA investigation, expedited transfer of appropriate patients for EST. We assessed for predictors of LVO post-implementation. Methods: The KPNC Stroke EXPRESS program was live in all centers by January 2016. Using clinical data for 1/1/16 - 7/10/16, we evaluated the frequency and locations of LVO, and patient characteristics of those with LVO. Multivariate logistic regression was used to examine whether age, gender, race, or an NIHSS ≥ 8 are predictors of LVO. Results: There were 2,204 tele-stroke alert cases from the ED. Among 993 (39.3%) that proceeded as likely acute stroke, 812 (81.8%) were evaluated with CTA. Out of those who had a CTA, 152 (18.7%) were found to have LVO as followed: 27 (17.8%) ICA, 87 (57.2%) M1, 24 (15.8%) M2, 6 (4.0%) basilar, 5 (3.3%) PCA, and 3 (2.0%) vertebral. Of those with LVO, 97 (63.8%) were treated with EST. Patients with LVO had a higher median NIHSS (15 vs. 5 in those without LVO). Neglect (27% vs. 7%) and gaze deviation (16% vs. 1%) were more likely to be seen among those with LVO and treated with EST compared to those without LVO. In multivariate analysis, age (OR=1.02, 95% CI 1.00 - 1.03, p=0.01) and NIHSS ≥8 (OR = 4.99, 95% CI 3.32- 7.49, p < 0.001) were associated with LVO. PPV for NIHSS ≥8 was 75.7%. Conclusions: In our large multi-ethnic population of acute stroke patients, a relatively small percentage (19%) was found to have LVO and only a subset qualified for EST. Predictors of LVO included NIHSS ≥8, increasing age, and presence of neglect and gaze preference. Given the low numbers of patients brought in for acute stroke treatment who ended up with a LVO requiring EST, further research is needed to assess a given system’s ability to rapidly evaluate and transfer as appropriate for EST rather than paramedic based diversion.

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.

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