Abstract 99: Geographic Access to Acute Stroke Care in the United States

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Opeolu Adeoye ◽  
Brendan G Carr ◽  
Karen C Albright ◽  
Catherine Wolff ◽  
Michael Mullen ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Response Times ◽  
Demographic Data ◽  
Stroke Care ◽  
The United States ◽  
Fee For Service ◽  
Acute Stroke Care ◽  
Geographic Access ◽  
The Us ◽  
Iv Tpa

Background: Only 5% of ischemic stroke (IS) patients receive IV tPA and less than 1% receive endovascular therapy (ET). Prior work has described access to Primary Stroke Centers (PSC). We describe access of the US population to all facilities that provide IV tPA or ET for IS. Methods: We used US demographic data and IV tPA and ET rates in the 2011 Medicare Provider and Analysis Review (MEDPAR), a claims-based dataset that contains fee-for-service Medicare-eligible inpatient hospital discharges in the US. ICD-9 codes 433.xx, 434.xx and 436 identified IS cases. ICD-9 code 99.10 defined IV tPA treatment. Among IS cases, hospitals that gave any IV tPA were considered IV capable. ET was defined by ICD-9 code 39.74. Hospitals that performed any ET in IS cases were considered endovascular capable. PSCs were defined as hospitals certified as such by the Joint Commission in 2010. We estimated ambulance response times using arc-GIS’s network analyst and helicopter transport times using validated models. Population access to care was determined by summing the population contained within travelsheds that could reach capable hospitals within 60minutes. Results: Of 370351 IS primary diagnosis discharges, 14926 (4%) received IV tPA and 1889 (0.5%) had ET. By ground, 81% percent of the US population had access to IV capable hospitals within 60minutes, 66% had access to PSCs and 56% had access to ET capable hospitals. By air, 97% percent had access to IV capable hospitals within 60minutes, 91% had access to PSCs and 85% had access to ET hospitals. The Figure shows 60 (yellow) and 120 minute (green) access to IV rt-PA capable hospitals. Conclusion: Most of the US population has geographic access to acute stroke care, but treatment rates remain extremely low. Given our definitions of capability, actual access may be less than described. To optimize US stroke care systems and increase the use of acute therapies, pre- and inhospital interventions to overcome barriers in access to acute stroke care are needed.

scholarly journals Geographic Access to Acute Stroke Care in the United States

Stroke ◽  
2014 ◽  
Vol 45 (10) ◽  
pp. 3019-3024 ◽  
Author(s):  
Opeolu Adeoye ◽  
Karen C. Albright ◽  
Brendan G. Carr ◽  
Catherine Wolff ◽  
Micheal T. Mullen ◽  
...  
Keyword(s):  
United States ◽  
Acute Stroke ◽  
Stroke Care ◽  
The United States ◽  
Acute Stroke Care ◽  
Geographic Access

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

Stroke ◽  
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.

Abstract P278: Improving Stroke Systems of Care in Nebraska

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Marco A Gonzalez Castellon ◽  
James A BOBENHOUSE ◽  
David Franco ◽  
Beth L Malina ◽  
Mindy Cook ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Rural Areas ◽  
Systems Of Care ◽  
Stroke Care ◽  
The United States ◽  
Advisory Council ◽  
Management Tool ◽  
Acute Stroke Care ◽  
Stroke Systems Of Care ◽  
Get With The Guidelines

Introduction: Stroke is a leading cause of disability in the United States. Disparities in stroke care between metropolitan and rural areas have long been recognized. Access to high-level timely stroke expertise improves outcomes, but in rural areas this is limited by sparse availability of stroke specialists. Since 2006, the Nebraska Stroke Advisory Council, a statewide coalition of stroke experts and stakeholders, began implementing strategies to improve stroke care. In 2016, the Nebraska legislature approved Bill 722, mandating the development of stroke systems of care. In 2018, the AHA and the Helmsley Charitable Trust launched Mission: Lifeline Stroke, a coordinated 3-year program to enhance stroke systems of care in Nebraska. Purpose: To assess advances in acute stroke care in Nebraska after implementing a statewide stroke system of care focused on rural areas. Methods: The Council joined with AHA to expand public and professional stroke education offerings including workshops, conferences, and EMS trainings. They developed state specific treatment guidelines and created educational reinforcement materials. From 2016 to 2019 Get With The Guidelines® (GWTG) was used for stroke data collection and quality improvement in Nebraska. GWTG participating hospitals expanded from 7 to 40 sites (21 critical access). Results: The number of stroke and Transient Ischemic Attack cases reported more than doubled from 2016 to 2019 (1848 to 3987 cases). The door to CT initiated in < 25 minutes improved by 13%. IV alteplase therapy gains included: utilization increased from 8.7% to 11.3%; median door to drug time reduced from 54 to 42 minutes; and door to drug within 60 minutes of arrival increased from 67% to 80.4%.The number of alteplase monitored patients doubled and mechanical thrombectomy cases increased from 77 in 2017 to 138 in 2019. Conclusion: Implementation of strategies in Nebraska, with an emphasis on rural critical access hospitals, led to significant improvements in acute stroke care. This work represents the authors’ independent analysis of local or multicenter data gathered using the AHA Get With The Guidelines® Patient Management Tool but is not an analysis of the national GWTG dataset and does not represent findings from the AHA GWTG National Program

Abstract WP433: Factor Associated With Significant Delay in Acute Stroke Triage Process

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Mananchaya Kongmuangpuk ◽  
Usanee Fongsri ◽  
Rojana Pakdeewongse ◽  
Roongnapa Sinlapadeelerdkul ◽  
Waitayaporn Pengtong ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Fast Track ◽  
Demographic Data ◽  
Stroke Care ◽  
Chief Complaint ◽  
Acute Stroke Care ◽  
Multivariable Logistic Regression Model ◽  
Factors Associated ◽  
Presenting Symptoms ◽  
Initial Symptoms

Background: Benefit of revascularization in acute ischemic stroke declines over time. Any delay in acute stroke care contributes to poor treatment outcome. We aimed to identify factors associated with the delay in the process of acute stroke triage. Methods: All patients presented at the emergency room at the Siriraj Hospital, Mahidol University, Thailand under stroke fast track protocol (ASFP) from January 2015 to March 2017 were reviewed. Demographic data, stroke subtypes, time measures, initial NIHSS were recorded. Delay in triage was defined as either door to first physician > 10 minutes or door to activate stroke fast track > 15 minutes. Multivariable logistic regression model were performed to identify independent variables associated with triage delay. Results: A total of 1,000 patients were enrolled under ASFP with a mean age of 63.5+15.3 years and 53.9% were male. Triage delay was found in 11.2%. Factors associated with a delay in stroke triage were inaccurate presenting symptom(s) OR17.69 (95% CI 10.86, 28.82), dizziness and dysphagia as an initial presentation OR 3.26 (95% CI 1.64, 6.48) and OR 8.02 (95% CI 1.31, 49.28) respectively and uncertain chief complaint OR 3.35 (95% CI 1.56, 7.19). Conclusion: Unclear chief complaint, dizziness and vertigo as an initial symptoms and inaccurate presenting symptoms significantly associated with the delay in acute stroke triage in an emergency department. Further research is needed to clarify if strategic questioning could help nurses and ER physicians in reducing this delay.

Abstract 3379: Benefiting the Community; The Impact of Joining a Regional Stroke Network

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Nancy D Papesh ◽  
James Gebel
Keyword(s):  
Acute Stroke ◽  
Care Center ◽  
Tertiary Care ◽  
Cleveland Clinic ◽  
Stroke Care ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
Stroke Treatment ◽  
The Impact ◽  
Iv Tpa

Background: The Cleveland Clinic Health System (CCHS) consists of a large tertiary care center and 10 regional hospitals. It is organized both clinically and administratively into multispecialty organ based Institutes rather than departments. The CCHS re-introduced a regional initiative to standardize stroke care in 2008. Medina Hospital is a 118-bed community hospital in rural North-eastern Ohio, where there is a high stroke burden and previously minimal IV tPA use. Medina Hospital joined the CCHS Stroke Network in November 2009. Hypothesis: We hypothesized that after joining the formally organized stroke CCHS system of care, the proportion of stroke patients receiving IV tPA and the timeliness of administration of acute thrombolytic therapy would both significantly increase. Methods: Data was analyzed from our prospective participation in the Get with the Guidelines-Stroke and the Ohio Coverdell Stroke Registries. Baseline data regarding quality, outcomes and stroke performance measures were reviewed. CCHS initially supported acute stroke care in early 2010 with a telemedicine cart and then introduced 24/7 emergency, on-site, CCHS neurologist, acute stroke call coverage in late 2010. Standardized CCHS stroke care pathways and order sets were also introduced in 2010. The proportion of stroke patients treated with IV tPA in 2010 and 2011 (post- joining CCHS) was compared to 2009 (2-sided Fisher’s exact test), and door-to-needle times were compared from 2010 to 2011 (unpaired t-test). Results: IV tPA treatment utilization increased from 0/69 patients (0%) in 2009 to 9/67 patients (11.8%) in 2010 [exact p=.0033] and 11/46 (19.3%) in the first 7 months of 2011 [exact p=.0001]. Door-to-needle times improved from a mean of 81.4 (95%CI 66.4 to 96.4) minutes in 2010 to 61.7 (95% CI 52.7 to 70.8) minutes in 2011 (p=.0158). Conclusions: Participation in an organized formal collaborative regional hospital stroke treatment network resulted in dramatic improvements from zero IV tPA utilization to greatly exceeding the national benchmark averages for both percentage treatment with IV tPA and door-to-needle time in a rural area where patients previously had minimal access to acute stroke expertise.

Abstract NS8: The Effects of Introducing a Nurse Practitioner Stroke Champion into the Emergency Department

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Lindsay Olson-Mack ◽  
Jacqueline Reardon ◽  
Elton Hedden ◽  
Rowena Carino ◽  
Cynthia VanWyk ◽  
...  
Keyword(s):  
Emergency Department ◽  
Acute Stroke ◽  
Nurse Practitioner ◽  
Treatment Effectiveness ◽  
Stroke Care ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
Assessment And Treatment ◽  
Iv Tpa

Background and Purpose: Emergency Department (ED) physicians often manage acute stroke patients without Neurology support at the bedside. Without guidance, they are left to rapidly assess, diagnose and treat acute stroke patients with minimal follow up on treatment effectiveness and patient outcomes. We hypothesized that introducing a Nurse Practitioner (NP) as Stroke Champion into an ED that did not have access to in-house Neurology would drive awareness of acute stroke care, and positively change practice to decrease door to needle times. Methods: The NP started in the 24-bed ED in June 2012. The average daily census of the ED for 2012 was 135 patients per day, and from January to June 2012, ED physicians initiated 46 stroke codes. Although Neurologists were available via telephone, ED physicians were left to accurately assess and initiate stroke codes, determine eligibility, and order IV tPA. In collaboration with the Stroke Medical Director, the Stroke NP conducted multiple education sessions regarding timing metrics in acute stroke care and door to tPA goals with ED clinicians, radiology, lab and pharmacy departments. Data was shared with stakeholders monthly to drive performance improvement initiatives. Results: Rapid improvements were made in all metrics. Mean time to CT first image improved by 19.3 minutes (37.3 to 18.0 minutes) in 6 months, and to 14.7 minutes in 1 year. CT result mean turn-around-time decreased by 19 minutes (from 54.0 to 29.1 minutes) in the first 6 months, and by 22.6 minutes (from 54.0 to 26.0 minutes) at 12 months. Likewise, laboratory result turn-around-times dramatically decreased by a mean of 15.9 minutes (54.4 to 38.5 minutes) over 6 months, and by a mean of 23 minutes (54.4 to 31.0 minutes) within 12 months. IV tPA treatment rates increased from 5% to 14.4% of all ischemic strokes. Door to IV tPA treatment times decreased by a mean of 33.9 minutes (104.5 to 70.6 minutes) in 6 months, and by 46.8 minutes (from 104.5 to 57.7 minutes) within the year. Conclusions: Introducing an NP into the ED to serve as Stroke Champion can provide added support to improve care of acute stroke patients by expediting assessment and treatment.

Abstract TP244: A Successful Statewide Initiative to Designate Hospital as Remote Treatment Stroke Centers

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Shelley Nichols ◽  
Debbie Camp ◽  
McCord Smith ◽  
Chris Threlkeld ◽  
James Lugtu ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Systems Of Care ◽  
Standard Of Care ◽  
Stroke Care ◽  
Acute Stroke Care ◽  
Stroke Registry ◽  
Remote Treatment ◽  
Stroke Systems Of Care ◽  
Stroke Center ◽  
Iv Tpa

Background: As treatment of acute ischemic stroke (AIS) with IV tPA has become standard of care, smaller hospitals with limited resources have struggled to conform to consensus guidelines. To fill this practice gap, stroke systems of care were developed to support smaller, often rural, hospitals in providing standard stroke care to the patients they serve. Methods: As a result of legislative support from the Coverdell-Murphy Act, the Georgia Coverdell Acute Stroke Registry (GCASR) in collaboration with the Georgia Office of EMS (GA OEMS), the Georgia Hospital Association (GHA), and other state partners, developed a method for designating hospitals as Remote Treatment Stroke Centers (RTSC). The primary focus of performance improvement was treatment with IV tPA in eligible patients. Data collection and process change were used to improve the following quality indicators: percentage of eligible AIS patients treated with IV tPA and number of stroke alert notifications. Hospitals were required to partner with an accredited stroke center and use telemedicine to support the decision for administering IV tPA. GA OEMS was charged with reviewing and surveying individual hospitals applying for RTSC status. The GCASR served as the central repository to facilitate data sharing and benchmarking across hospitals. An inter-hospital transfer tool was created for EMS providers, adopted by GA OEMS, and disseminated throughout the state to guide management of patients receiving IV tPA who required transfer from a RTSC to an accredited stroke center. Results: Starting in 2014, pertinent information was distributed and assistance provided to the 24 RTSC eligible GCASR hospitals. At present, 4 hospitals have achieved designation; 1 hospital is pending survey; and several are considering application. In 2012-13 the now 4 RTSC hospitals gave IV tPA to 8 patients. In 2014-15 as these hospitals sought and achieved designation, this number rose to 24. During this same period, stroke alerts increased from 76 to 308. Conclusion: A state-based public health stroke initiative is effective in facilitating the designation of RTSC and thereby improving the delivery of acute stroke care in underserved areas.

Abstract WP273: Evolution of a U.S. County System for Acute Comprehensive Stroke Care

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Radoslav I Raychev ◽  
Dana Stradling ◽  
David M Brown ◽  
Joey R Gee ◽  
David L Lombardi ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Systems Of Care ◽  
Early Recognition ◽  
Stroke Care ◽  
Reperfusion Therapy ◽  
Acute Stroke Care ◽  
Vessel Occlusion ◽  
Transfer Rates ◽  
Over Time ◽  
Iv Tpa

Introduction: In an effort to maximize provision of acute stroke therapies, the Emergency Medical Services (EMS) in Orange County, CA (6 th most populous U.S. county) established a system of care whereby patients with suspected acute stroke are taken to hub sites with endovascular treatment (EVT) capability or to spoke hospitals. Patients at spokes with acute ischemic stroke (AIS) and suspected large vessel occlusion (LVO) are transferred by EMS to hubs. Here we examined the relationship between stroke features, hospital transfers, and mortality; and their change over time. Methods: All patients during 2013-2015 were included for whom 911 was called within 7 hours of onset, and EMS personnel declared “acute stroke" at end of initial evaluation. Results: A total of 6,188 patients (mean age 72) had suspected stroke, of which 54.9% were AIS and 19.4% hemorrhagic stroke. Across all patients, transfer rates into hub sites increased over time (OR 1.12 per 3-months, p<0.0001) and differed by diagnosis (p<0.0001), with transfer in 12.0% of hemorrhages (n=122) but only 3.5% of AIS (n=101). Among patients with AIS only, transfer rates into a hub site increased over time (OR 1.08, p<0.0001), spiking mid-2015. Acute reperfusion therapy was given to 28.3% (20.9% IV tPA only, 3.6% IA therapy only, 3.8% IV tPA+IA), but its usage was unrelated to transfer status, and only 11% of all transferred AIS patients received EVT. Across all patients, mortality during acute hospitalization was 8.2% and did not differ by transfer status, but did differ by diagnosis (p<0.0001): 23.6% of hemorrhages vs. 5.4% of AIS. Over time, mortality decreased only among patients with AIS (OR 0.95, p=0.03). Conclusions: There were several favorable features of this acute stroke care system, including that 28.3% of AIS patients received reperfusion therapy and that mortality decreased over time. However, while transfer to EVT-ready sites increased, rates of IA therapy were low. Continued efforts to optimize acute stroke systems of care should be tailored toward increasing EVT by early recognition of LVO and timely triage to hub facilities.

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