Abstract T P298: A Comparison of Stroke Time Targets for In-Hospital Versus Emergency Department Ischemic Stroke Patients at a Primary Stroke Center

Introduction: Based on the 2013 Guidelines for Early Management of Patients With Acute Ischemic Attack, hospitals and emergency departments (ED) should develop efficient processes and protocols to manage stroke patients. The guidelines have several time targets for early stroke evaluation and treatment such as door to physician, door to CT initiation, door to CT interpretation, and door to drug. The goal of these time targets is to reduce morbidity and mortality associated with stroke. Hypothesis: We hypothesize that inpatient stroke evaluation and treatment is equivalent to patients presenting to the emergency department (ED) with stroke symptoms since the same stroke team responds to both inpatient stroke call downs and ED stroke call downs. This is to obtain initial data for a quality improvement project at Borgess Medical Center, Kalamazoo, MI. Methods: Between September 2010 and June 2013, all in-hospital stroke call down charts were retrospectively reviewed. For each month that there was an inpatient stroke call down, ED stroke call downs were retrospectively chart reviewed as well. There were 24 inpatient stroke call downs and 93 ER stroke call downs during this time period. Each chart was reviewed for time targets: door to physician, door to CT initiation, door to CT interpretation, and door to drug. Results: The hospitalized stroke patients experienced more delays in care than ED stroke patients. The inpatient target times are below recommended time targets. The average time to physician for inpatient stroke patients was 5 minutes as compared to the ED was 4.2 minutes. Time to CT initiation was 31.45 minutes for hospitalized patients as compared to 25.48 minutes for ED patients. CT interpretation was 52.83 minutes for inpatient strokes as compared to 47.21 minutes for ED stroke patients. Time to tPA was 122 minutes for hospitalized patients as compared to 94 minutes for ED stroke patients. Conclusion: Hospitalized patients developing stroke symptoms have delays in care as compared to patients that present to the emergency department with stroke symptoms. This may be due to emergency department patients getting preferential treatment for tests. Identifying these delays in care is important to improve stroke treatment for hospitalized patients.

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Abstract P854: Lean A3 Project in a Primary Stroke Center Results in Improved Dysphagia Screening Compliance for Stroke

Stroke ◽

10.1161/str.52.suppl_1.p854 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Melanie Henderson ◽

Susan Boesch ◽

Kristine Peyton ◽

Chris Hackett ◽

Patty Noah ◽

...

Keyword(s):

Oral Intake ◽

Stroke Patients ◽

Chi Square ◽

Improvement Project ◽

Charge Nurses ◽

Before And After ◽

Primary Stroke Center ◽

Stroke Center ◽

Risk Of Aspiration ◽

Get With The Guidelines

Introduction: Dysphagia is a common comorbidity after stroke linked to increased morbidity and mortality. Evidence-based guidelines recommend a bedside dysphagia screen before oral intake to reduce the risk of aspiration pneumonia in stroke patients. Prior studies have reviewed barriers to dysphagia screens being completed or documented timely on stroke patients before giving oral intake. Through Lean A3 process, we aimed to improve overall nursing documentation, including dysphagia screen, for stroke patients in the Emergency Department (ED) at an established Primary Stroke Center. Methods: The ED Charge Nurses and the Stroke Coordinator began an A3 project in May 2019 which focused on ED nurse documentation for stroke patients. Data included was 7 months prior to A3 implementation and 8 months post-implementation using Get With The Guidelines quality “Dysphagia Screen” measure. Lean A3 process involved changes to the computer system and re-education of nursing staff in July 2019 by the charge nurses and Stroke Coordinator. The post-A3 measurement period was between August 2019 and March 2020. Chi square tests were used to assess proportion differences in completed dysphagia screen and proportion of meeting or exceeding goal before and after the A3. Results: Overall compliance of patients screened for dysphagia was 87.3% (n = 379/434). After the A3 project, compliance for dysphagia screening was significantly higher than prior to the A3 implementation ((91.9% (n = 228/248) vs. 81.2% (n = 151/186), OR = 2.64 [95%CI 1.47-4.75], p < 0.001). In addition, the 90% goal for dysphagia screen compliance was achieved only 1 month of 7 (14.3%) prior to A3, but was achieved in 6 months of 8 post-A3 (75%), p = 0.04. Conclusion: In conclusion, we found that dysphagia screening documentation by ED nurses improved due to the Lean A3 process improvement project conducted in the ED.

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Abstract TP249: Hospital Transfer Cost Savings From Triaging Selected Stroke Patients Directly to the Comprehensive Stroke Centers (CSCs) Courtesy of the Mobile Stroke Treatment Unit (MSTU)

Stroke ◽

10.1161/str.48.suppl_1.tp249 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Atif Zafar ◽

Belinda Udeh ◽

Andrew Reimer ◽

Ramnath S Ramanathan ◽

Daniel Vela-Duarte ◽

...

Keyword(s):

Critical Care ◽

Critical Time ◽

Cost Savings ◽

The United States ◽

Generation Model ◽

Stroke Patients ◽

Treatment Unit ◽

Stroke Treatment ◽

Primary Stroke Center ◽

Stroke Center

Introduction: The Mobile Stroke Treatment Unit (MSTU) is a novel onsite pre-hospital treatment team with all basic infra-structure to diagnose, emergently treat and hence timely triage acute ischemic and hemorrhagic stroke patients to either the primary stroke center (PSCs) or comprehensive stroke centers (CSCs). Recent evidence supports outcome benefits in favor of intra-arterial therapy (IAT) in large vessel strokes and transfers to neuro-critical care units for managing large strokes. This has resulted in a surge in transfers to CSCs summing additional transfer costs for patients not initially presenting to a CSC. This is the first ever study in the United States that utilizes a basic cost generation model to measure the economic benefits of MSTU triage directly to the CSCs by-passing PSCs, for the those patients requiring higher-level care. Method: Mobile Stroke Treatment Unit database was used to identify patients that stroke neurologists triaged to CSCs. These included all acute ICH, IAT candidates and severe strokes with ICU needs. We calculated the average costs of a typical primary stroke center emergency room visit and the cost of a critical care transport, generating a cost savings model. Result: Fifty two patients who were evaluated by stroke neurologists in the mobile stroke unit from July 2014 to October 2015 were adjudged candidates for comprehensive stroke centers. Twenty four (46%) of these were intra-cerebral hemorrhage (ICH) confirmed on portable head CT while the other 28 (54%) presented with major strokes with possible IA thrombectomy candidacy or anticipated Neuro ICU needs due to stroke severity. Eleven ICH and 13 ischemic stroke patients (46%) of the 52 patients by-passed PSC to be taken directly to comprehensive stroke centers with a potential of saving millions of dollars in costs and critical time. Conclusion: Even in a city with dense presence of comprehensive stroke centers, a large cohort of patients by-passed primary stroke centers with a potential of saving millions of dollars in costs and critical time. Future goals include evaluating for difference in outcome in this group of patients that by-passed PSC courtesy MSTU. Additionally, this needs to be replicated in other counties and cities before policy changes are proposed.

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A Computer-Based Stroke Education Orientation Program for Nurses on a Designated Stroke Unit: A Program Development, Quality Improvement Project

10.28971/542017mm156 ◽

2017 ◽

Author(s):

Melanie Marco

Keyword(s):

Stroke Unit ◽

Stroke Patients ◽

Orientation Program ◽

Improvement Project ◽

Program Manager ◽

Stroke Team ◽

Primary Stroke Center ◽

Computer Based ◽

Stroke Education ◽

Stroke Center

<p>Evidence of improved outcomes for patients admitted to a dedicated stroke unit supports the need for specialized stroke education and protocols. The Joint Commission now requires all stroke patients be admitted to a PSC and receive care on a designated stroke unit. Care on the stroke unit is focused on preventing further debilitation, deterioration and reducing medical complications. Nurses working at a primary stroke center are required by TJC to have initial orientation stroke education and annual competency review to ensure stroke patients receive high quality, current care. The Joint Commission also requires core stroke team members receive at least eight hours of education annually, as determined by the stroke program manager. The stroke program manager determines composition of the stroke team in collaboration with hospital leadership and other stakeholders (Daniels, Johnson & Mackovjak, 2011). It is the responsibility of each primary stroke center to develop an education program for clinical staff.</p> <p>The purpose of this quality improvement project was to develop a computer-based stroke education orientation program for nurses on a recently designated stroke unit within a PSC facility.</p>

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Prolonged Emergency Department Length of Stay as a Predictor of Adverse Outcomes in Patients with Intracranial Hemorrhage

Journal of Critical Care Medicine ◽

10.1155/2015/526319 ◽

2015 ◽

Vol 2015 ◽

pp. 1-5 ◽

Cited By ~ 5

Author(s):

Erica M. Jones ◽

Amelia K. Boehme ◽

Aimee Aysenne ◽

Tiffany Chang ◽

Karen C. Albright ◽

...

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Adverse Outcome ◽

Independent Predictor ◽

Adverse Outcomes ◽

Stroke Patients ◽

Significant Independent Predictor ◽

Prolonged Length ◽

Stroke Center ◽

Shift Change

Objectives. Extended time in the emergency department (ED) has been related to adverse outcomes among stroke patients. We examined the associations of ED nursing shift change (SC) and length of stay in the ED with outcomes in patients with intracerebral hemorrhage (ICH). Methods. Data were collected on all spontaneous ICH patients admitted to our stroke center from 7/1/08–6/30/12. Outcomes (frequency of pneumonia, modified Rankin Scale (mRS) score at discharge, NIHSS score at discharge, and mortality rate) were compared based on shift change experience and length of stay (LOS) dichotomized at 5 hours after arrival. Results. Of the 162 patients included, 60 (37.0%) were present in the ED during a SC. The frequency of pneumonia was similar in the two groups. Exposure to an ED SC was not a significant independent predictor of any outcome. LOS in the ED ≥5 hours was a significant independent predictor of discharge mRS 4–6 (OR 3.638, 95% CI 1.531–8.645, and P = 0.0034) and discharge NIHSS (OR 3.049, 95% CI 1.491–6.236, and P = 0.0023) but not death. Conclusions. Our study found no association between nursing SC and adverse outcome in patients with ICH but confirms the prior finding of worsened outcome after prolonged length of stay in the ED.

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How do treatment times impact on functional outcome in stroke patients undergoing thrombectomy in Germany? Results from the German Stroke Registry

International Journal of Stroke ◽

10.1177/1747493020985260 ◽

2021 ◽

pp. 174749302098526

Author(s):

Juliane Herm ◽

Ludwig Schlemm ◽

Eberhard Siebert ◽

Georg Bohner ◽

Anna C Alegiani ◽

...

Keyword(s):

Functional Outcome ◽

Odds Ratio ◽

Intravenous Thrombolysis ◽

Stroke Patients ◽

Poor Functional Outcome ◽

Stroke Registry ◽

Primary Stroke Center ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Center Time

Background Functional outcome post-stroke depends on time to recanalization. Effect of in-hospital delay may differ in patients directly admitted to a comprehensive stroke center and patients transferred via a primary stroke center. We analyzed the current door-to-groin time in Germany and explored its effect on functional outcome in a real-world setting. Methods Data were collected in 25 stroke centers in the German Stroke Registry-Endovascular Treatment a prospective, multicenter, observational registry study including stroke patients with large vessel occlusion. Functional outcome was assessed at three months by modified Rankin Scale. Association of door-to-groin time with outcome was calculated using binary logistic regression models. Results Out of 4340 patients, 56% were treated primarily in a comprehensive stroke center and 44% in a primary stroke center and then transferred to a comprehensive stroke center (“drip-and-ship” concept). Median onset-to-arrival at comprehensive stroke center time and door-to-groin time were 103 and 79 min in comprehensive stroke center patients and 225 and 44 min in primary stroke center patients. The odds ratio for poor functional outcome per hour of onset-to-arrival-at comprehensive stroke center time was 1.03 (95%CI 1.01–1.05) in comprehensive stroke center patients and 1.06 (95%CI 1.03–1.09) in primary stroke center patients. The odds ratio for poor functional outcome per hour of door-to-groin time was 1.30 (95%CI 1.16–1.46) in comprehensive stroke center patients and 1.04 (95%CI 0.89–1.21) in primary stroke center patients. Longer door-to-groin time in comprehensive stroke center patients was associated with admission on weekends (odds ratio 1.61; 95%CI 1.37–1.97) and during night time (odds ratio 1.52; 95%CI 1.27–1.82) and use of intravenous thrombolysis (odds ratio 1.28; 95%CI 1.08–1.50). Conclusion Door-to-groin time was especially relevant for outcome of comprehensive stroke center patients, whereas door-to-groin time was much shorter in primary stroke center patients. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03356392 . Unique identifier NCT03356392

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Abstract WP363: Journey of a Five-Hospital System to Primary Stroke Center Certification

Stroke ◽

10.1161/str.44.suppl_1.awp363 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Deb Motz ◽

Dicky Huey ◽

Tracy Moore ◽

Byron Freemyer ◽

Tommye Austin

Keyword(s):

Administrative Support ◽

Medical Center ◽

Academic Medical Center ◽

Stroke Care ◽

Multidisciplinary Teams ◽

Hospital System ◽

Order Sets ◽

Primary Stroke Center ◽

Stroke Center ◽

Evidenced Based

Background: In 2008, a city with a population of over one million people had no organized stroke care or Certified Primary Stroke Centers. Patients presenting with stroke symptoms had inconsistent neurology coverage and little or no access to rtPA. The purpose is to describe steps taken for five acute-care hospitals (with one CMS provider number) to become Primary Stroke Certified. Methods: The journey began with administrative support and a commitment to provide the resources for a successful program. To oversee development, a Medical Director and Stroke Coordinator were appointed. To bridge the gap in available specialty physicians, partnerships were formed with a telemedicine group to provide emergency treatment and an academic medical center to augment the neurology and neuro-surgical coverage. Multidisciplinary teams met monthly in each facility. Representatives from each team formed a regional committee and an education council was created to share best practices and assure consistency across the system. Evidenced based order sets were developed using clinical practice guidelines. The Medical Executive Committee at each facility and ultimately the Medical Executive Board endorsed the order sets and mandated their use. Each facility chose the appropriate unit to cohort the stroke patients which encouraged expertise in care. Results: This journey resulted in a high functioning system of care. Baptist Health System became Joint Commission Certified in all five locations (May 2009). We were awarded the Get with the Guidelines Bronze Award (September 2010), the Silver Plus Award (July 2011) and the Gold Plus Award (July 2012). In addition, we were the first in Texas to achieve the Target Stroke Honor Roll (Q3 2011) and have maintained this status for eight consecutive quarters. Conclusion: In conclusion, administrative support is imperative to the success of a stroke program. Leadership, partnerships, committees, councils and staff involvement from the start drove the team to a successful certification process with outstanding outcomes. The stroke committees continue to meet monthly to analyze performance measures, identify opportunities for improvement and execute action plans.

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Abstract W P296: Establishing a Stroke Protocol Based on the Trauma Model

Stroke ◽

10.1161/str.45.suppl_1.wp296 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Mary Ann Blosky ◽

E. Andrew Raposo

Keyword(s):

Program Development ◽

Medical Center ◽

Clinical Signs ◽

The State ◽

Joint Commission ◽

High Performing ◽

Time Of Application ◽

Primary Stroke Center ◽

Stroke Center ◽

Trauma Model

Background and Purpose: In the summer of 2012, the state of Pennsylvania adopted legislation mandating EMS providers to deliver all patients with clinical signs of stroke to a certified stroke center for evaluation. In response to this change, development of a new stroke program began at a tertiary medical center located in the northeastern region of the state. The facility was a certified trauma center and also held various other disease specific certifications through the Joint Commission. This project sought to examine the needs of a newly developing primary stroke center within the context of a healthcare organization with numerous other specialized medical and surgical programs. Specifically, the investigators hoped to illustrate the similarities between stroke and other specialized services to demonstrate that many of the requirements of these programs are shared. Method: The site stroke clinical coordinator and system stroke program coordinator kept detailed records of all phases of stroke program development. As resource needs were identified, notation was made indicating whether or not those resources were already available in the hospital. By examining these records, the coordinators were able to identify how many of the resources needed to develop an effective stroke program were already present within the system. Results: Information was collected beginning at the inception of program development in 2012 through the time of application for Joint Commission Primary Stroke Center certification in August of 2013. During these 9 months, many of the needed resources were found to already exist in the facility, with most having been created or added as a result of the hospital’s trauma program development several years earlier. Conclusion: The hospital was able to develop a high performing stroke center with comparative ease due to the preexisting resources from the institution’s trauma program. It is the belief of the stroke team that these results could be easily duplicated in other facilities with trauma services that wish to expand into stroke specialization as well.

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Abstract W P340: Emergency Department Nurses Collaborate With Long Term Care Facilities for Stroke Patients

Stroke ◽

10.1161/str.46.suppl_1.wp340 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Jamie L Strom

Keyword(s):

Emergency Department ◽

Long Term Care ◽

Stroke Patients ◽

Term Care ◽

Stroke Treatment ◽

Emergency Department Nurses ◽

Senior Services ◽

To Receive ◽

Education Initiative

Background and Purpose: Stroke treatment is often delayed before patients reach the emergency department (ED). Some patients arrive in time to receive medication that can reverse new stroke symptoms. Some are not as fortunate. They are either admitted to the palliative unit, or discharged only to live with their new disabilities possibly for the rest of their lives. In 2013, nurses observed many long term care (LTC) patients were not getting to the ED in time to receive tPA (tissue plasminogen activator), a medication used to reverse stroke symptoms. The purpose of this process improvement was to increase the number of LTC patients with stroke symptoms arriving in the ED within the tPA window. Methods: To determine how many patients from nursing homes were missing the tPA window, data from the ED’s records was abstracted from the month of June 2013. The sample size was all patients who presented with possible stroke symptoms, and who were also from LTC facilities. Surprisingly, 100% of LTC patients presenting with stroke symptoms missed the tPA window. With the support of ED leadership, we decided to raise awareness about the tPA window in the LTC facilities. No evidence existed from ED’s related to LTC patients and the tPA window. Approximately 1,000 unused stroke pamphlets were collected. A PowerPoint presentation based on AHA guidelines was used. A lecture occurred at the community’s senior services meeting, and many LTC administrators were willing to adopt this education initiative at their facilities. ED staff became involved and helped conduct the in-services. In exchange for their volunteering, they received credit to help with career ladders at their hospital. Results: The number of possible stroke patients from LTC facilities getting to the ED within eight hours of the last time seen normal (LTSN) has increased from 0% in June 2013, to 25% in March 2014. Conclusions: Stroke education teams of ED nurses showed improvement in LTC patients arriving in the ED within the tPA window. In conclusion, it is encouraged that other ED staff volunteer to teach in LTC facilities in their own communities, in assisting their stroke patients as well.

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Abstract 2623: Racial Disparities in Hospital Length of Stay among Native Hawaiians and other Pacific Islanders with Ischemic Stroke

Stroke ◽

10.1161/str.43.suppl_1.a2623 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Kazuma Nakagawa ◽

Matthew Koenig ◽

Todd Seto ◽

Susan Asai ◽

Cherylee Chang

Keyword(s):

Ischemic Stroke ◽

Length Of Stay ◽

Medical Center ◽

Parameter Estimate ◽

Hospital Length ◽

Pacific Islanders ◽

Native Hawaiians ◽

Hospital Length Of Stay ◽

Primary Stroke Center ◽

Stroke Center

Introduction: Native Hawaiians and other Pacific Islanders (NHPI) with ischemic stroke are younger and have more comorbidities compared to other major racial-ethnic groups. However, their impact on hospital length of stay (LOS) after ischemic stroke has not been studied. Hypothesis: We assessed the hypothesis that NHPI race is associated with a longer hospital LOS after ischemic stroke. Methods: Data from 2004 to 2010 were retrospectively obtained from the Get With the Guidelines-Stroke (GWTG-Stroke) database from The Queen’s Medical Center, the only primary stroke center for the state of Hawaii. Multivariable analyses were performed using a stepwise linear regression model to identify factors predictive of hospital LOS after ischemic stroke. Results: A total of 1921 patients hospitalized for ischemic stroke (NHPI 20%, Asians 53%, whites 24%, blacks 0.8%, others 2%) were studied. Univariate analyses showed that NHPI were younger (mean ages, NHPI 60±14 vs. Asians 72±14, p <0.0001; vs. whites 71±14, p <0.0001) and had higher prevalence of diabetes (NHPI 53% vs. Asians 67%, p <0.0001; vs. whites 22%, p <0.0001), hypertension (NHPI 82% vs. whites 22%, p <0.0001), prior stroke or TIA (NHPI 30% vs. Asians 23%, p =0.01), smoking (NHPI 19% vs. Asians 14%, p =0.01), dyslipidemia (NHPI 43% vs. whites 34%, p <0.01), and longer hospital LOS (NHPI 11±17 days vs. Asians 7±9 days, p <0.0001; whites 8±17 days, p <0.05). After adjusting for age, race, gender, and risk factors with predefined significance ( p <0.1), independent predictors for hospital LOS were NHPI race (parameter estimate, 2.67; 95% CI, 1.09 - 4.22, p =0.001), atrial fibrillation/atrial flutter (parameter estimate, 2.22; 95% CI, 0.53 - 3.90, p =0.01), and age (parameter estimate, -0.04; 95% CI, -0.09 - -0.002, p =0.04). Conclusions: Native Hawaiians and other Pacific Islanders with ischemic stroke have a longer hospital length of stay compared to Asians and whites. Further studies are needed to assess if other socioeconomic factors contribute to the observed differences.

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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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