Abstract TP310: Overcoming Barriers to Reduce Door to Needle Times in Acute Ischemic Stroke Patients: Field to CT

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Spozhmy Panezai ◽  
Florence Chukwuneke ◽  
Audrey Arango ◽  
Jaskiran Brar ◽  
Joshua Daniel ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Patient Outcomes ◽  
Patient Characteristics ◽  
Adverse Outcomes ◽  
Ct Scanner ◽  
Stroke Patients ◽  
Stroke Team ◽  
Presentation Time ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: Time lost is brain lost. The ASA’s Target Stroke strategies were reviewed to improve Door to CT (DTCT) and Door to Needle (DTN) times. Taking acute stroke patients direct from triage to the CT scanner can reduce thrombolysis treatment times, which may improve patient outcomes. In April 2015, the JFK Comprehensive Stroke Center introduced a Direct to CT policy for acute stroke patients who are assessed to be acute by the JFK EMS service. Method: We performed a prospective pilot study comparing door-to-CT times (DTCT) and door-to-needle (DTN) times pre- and post-implementation of Direct to CT policy, and analyzed patient characteristics, Emergency Department (ED) presentation time, adverse effects, protocol violations and patient outcomes. Delays in treatment, enablers and barriers to treatment were also examined. The purpose was to look at feasibility and maintenance of quality when applied to a larger subset of patients. Results: There was no statistical difference in demographics or clinical factors in patients who presented pre- (2013, 2014, n= 621) or post- Direct to CT (April 20-June 20, 2015 n=22). However, a reduction in mean DTCT times (21 mins vs. 8.7 mins, p<.0001) and DTN times (55 mins vs. 19 mins, p<.0001) was seen. There was no increase in adverse outcomes (7% vs. 0%) in patients taken Direct to CT. There was no difference in patient outcomes, however the current study size is small. Numerous barriers to Direct to CT were identified at the pre-hospital, ED, CT and stroke team levels. These issues included ED resources, hospital geography and space, and stroke team decision making. Some of these concerns are ongoing and will take time and effort to overcome. Strengths noted were the EMS capability of pre-hospital Intravenous line establishment, blood draws, and EKG performance as well as IV tPA initiation in the CT area. Conclusions: Taking patients Direct to CT has significantly reduced time to evaluation, DTCT, and DTN and further improvements may be achieved through resolution of identified barriers.

Abstract W P177: Direct to CT: Overcoming Barriers to Reduce Door to Needle times in Acute Stroke Patients

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Skye Coote ◽  
Tanya Frost ◽  
Shaloo Singhal ◽  
Chris Bladin ◽  
Amanda Gilligan
Keyword(s):  
Acute Stroke ◽  
Patient Outcomes ◽  
Patient Characteristics ◽  
Adverse Outcomes ◽  
Ct Scanner ◽  
Stroke Patients ◽  
Stroke Team ◽  
Presentation Time ◽  
A Prospective Study ◽  
Improve Patient

Background: Taking acute stroke patients direct from triage to the CT scanner can reduce thrombolysis treatment times, which can improve patient outcomes. In May 2013, Box Hill Hospital introduced a Direct to CT policy for acute stroke patients who are called through as a Code Stroke by the ambulance service within business hours (8am-4.30pm) Monday to Friday. Method: We performed a prospective study comparing door-to-CT times (DTCT) and door-to-needle (DTN) times pre- and post-implementation of Direct to CT, and examined patient characteristics, Emergency Department (ED) presentation time, adverse effects, protocol violations and patient outcomes. Delays in treatment, enablers and barriers to treatment were also examined. Results: There was no statistical difference in demographics or clinical factors in patients who presented pre- (January-April, n=21) or post- Direct to CT (May-July, n=29). However, a reduction in median DTCT times (27 mins vs. 16 mins, p=0.01) and DTN times (97 mins vs. 52 mins, p<0.001) was seen. There was no increase in thrombolysed mimics (4.8% vs. 3.4%, p=0.82), protocol violations (9.5% vs. 0%, p=0.17) or adverse outcomes (33% vs. 35%, p=0.93) in patients taken Direct to CT. There was no difference in patient outcomes, however the current study size is small. Numerous barriers to Direct to CT were identified within four categories: pre-hospital, ED, CT and the stroke team, and issues included: lack of paramedic intravenous cannulation, ED resources, and stroke team indecisions; some of which are ongoing and are taking considerable time and efforts to overcome. Conclusions: Taking patients Direct to CT has significantly reduced time to treatment and further improvements may be achieved through resolution of identified barriers.

scholarly journals Effect of heparin on recanalization in acute stroke patients with intra-arterial thrombi

2015 ◽  
Vol 7 (2) ◽  
Author(s):  
Bijal K. Mehta ◽  
Haris Kamal ◽  
Aaron McMurtray ◽  
Mohammed Shafie ◽  
Ping Li
Keyword(s):  
Acute Stroke ◽  
Cerebral Artery ◽  
Demographic Data ◽  
Patient Characteristics ◽  
Stroke Patients ◽  
Intraluminal Thrombus ◽  
Heparin Infusion ◽  
Intravenous Heparin ◽  
Stroke Center ◽  
Infusion Protocol

Anticoagulant use, such as heparin, is usually contraindicated in acute stroke patients. We present a study of patients, who were treated with intravenous heparin after a stroke that were also found to have an intraluminal thrombus. Prior studies imply that recanalization is achieved with heparin; however heparin should only prevent thrombus propagation. Therefore it is unclear whether and how IV heparin can achieve recanalization of intraluminal thrombi in acute stroke patients. A retrospective review of all acute stroke patients from a single stroke center who received a therapeutic IV heparin infusion from 5/2006 to 9/2011 were included in the study. We compared patients who had complete/partial recanalization and/or improved flow versus those that did not, with both these groups on a standard intravenous heparin infusion protocol. Demographic data was compared between the groups. Average partial thromboplastin time (PTT) during heparin infusion, time between computed tomography angiographies (CTAs), time from stroke onset to receiving IV heparin, and vessel occluded were also compared between groups. Forty-one patients (19 female, 22 male) were included in the study with a total of 55 vessels (either carotid, middle cerebral artery, anterior cerebral artery, posterior cerebral artery/posterior circulation) having intraluminal thrombi; 31 patients had 41 vessels with either partial or complete recanalization of effected vessels, while 10 patients had 14 vessels that did not have at least one vessel recanalize while on heparin. Using t-test we noted that the average PTT between the vessels that had partial/complete recanalization group (61.74) and non-recanalization group (66.30) was not statistical significantly different (P=0.37).The average time in days on heparin between vascular imaging studies (CTA/conventional angiogram) in the group of vessels with partial/complete recanalization (7.12 days) and the ones with no change (6.11 days) was not significantly different between the two groups (P=0.59). Patient’s vessels receiving heparin for &lt;24 hours <em>versus</em> those &gt;24 hours did not significantly differ either (P=0.17). This study compares patient characteristics associated with recanalization of intraluminal thrombi in acute stroke patients on heparin. Recanalization of intraluminal thrombi are not associated with average PTT or duration on heparin.

Primary to comprehensive stroke center transfers: Appropriateness, not futility

2018 ◽  
Vol 13 (6) ◽  
pp. 550-553 ◽  
Author(s):  
Mayank Goyal ◽  
Bijoy K Menon ◽  
Alexis T Wilson ◽  
Mohammed A Almekhlafi ◽  
Ryan McTaggart ◽  
...  
Keyword(s):  
Decision Making ◽  
Endovascular Treatment ◽  
Patient Outcomes ◽  
Stroke Patients ◽  
Endovascular Thrombectomy ◽  
Nuanced Understanding ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Post Hoc ◽  
Transfer Decisions

Background and purpose Ischemic stroke patients must be transferred to comprehensive stroke centers for endovascular treatment, but this transfer can be interpreted post hoc as “futile” if patients do not ultimately undergo the procedure or have a poor outcome. We posit that transfer decisions must instead be evaluated in terms of appropriateness at the time of decision-making. Methods We propose a classification schema for Appropriateness of Transfer for Endovascular Thrombectomy based on patient, logistic, and center characteristics. Results The classification outline characteristics of patients that are 1. Appropriate for transfer for endovascular treatment; 2. Inappropriate for transfer; and 3. Appropriate for transfer for higher level of care. Conclusions Appropriate transfer decisions for endovascular treatment are significant for patient outcomes. A more nuanced understanding of transfer decision-making and a classification for such transfers can help minimize inappropriate transfers in acute stroke.

Abstract WP279: Concordance of Paramedic and Hospital Documented Last Known Well Times for EMS Transported Acute Ischemic Stroke Patients

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Lucas Ramirez ◽  
Nichole Bosson ◽  
Marianne Gausche-Hill ◽  
Jeffery L Saver ◽  
Sid Starkman ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Patient Characteristics ◽  
Final Diagnosis ◽  
Multivariate Regression Analysis ◽  
Stroke Patients ◽  
Hospital Arrival ◽  
Median Difference ◽  
Suspected Stroke ◽  
Stroke Center

Background: Last known well time (LKWT) is increasingly used by EMS systems to identify acute stroke patients appropriate for direct routing to Stroke Centers. However, determining LKWT in the field is challenging, as patients may be aphasic, witnesses may not be available on scene, and rapid departure from the scene is desirable. Objective: To characterize the concordance and degree of discordance between prehospital-determined LKWT and final LKWT documented at the hospital. Methods: This is a retrospective analysis of consecutive patients with positive prehospital stroke screens transported to an approved stroke center in a large metropolitan system from January 2011 to December 2014. Data was abstracted from the regional EMS Agency stroke database. Patients with missing prehospital or hospital documentation of LKWT were excluded. The percent concordance and the median difference were calculated for prehospital versus final hospital documented LKWT. The effect of patient characteristics on discordance was also explored via multivariate regression analysis. Result: Among the 9,810 patients transported for suspected stroke, the median age was 75 (Interquartile range [IQR] 62-85) years, 53% were women, 67% White, 11% Asian, 9% Black and 27% Hispanic. The median NIHSS was 11 (IQR 4 to 20). 83% had a cerebrovascular final diagnosis, ischemic stroke (IS) being the most common (n=5160, 53%), whereas 17% had a non-stroke-related diagnosis. There were 6873 patients missing either prehospital or hospital documentation of LKWT leaving 9810 patients for the analysis. Prehospital and hospital documented LKWTs were exactly equal in 42% of patients (36% for IS), within 15 minutes in 53% (48% for IS), within 1 hour in 66% (63% in IS) and within 2 hours in 70% (68% in IS). The median difference in LKWT between documented prehospital and hospital values was 0 minutes (IQR -6 to 18). The degree of discordance in LKWT did not vary with patient sex, race, or Hispanic ethnicity. Conclusions: Paramedic-documented LKWT was within 15 minutes of the final hospital documented LKWT in just over half of acute stroke EMS transports and within 1 hour in two-thirds.. As accurate LKWT determination in the field is challenging, time of symptom onset should be confirmed after hospital arrival.

Abstract T MP86: A Prospective Study of the Effect of Dehydration on Stroke Severity and Short Term Outcome

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Mona N Bahouth ◽  
Argye Hillis ◽  
Rebecca Gottesman
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Urine Specific Gravity ◽  
Stroke Severity ◽  
Lesion Volume ◽  
Stroke Patients ◽  
Short Term ◽  
Term Outcome ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: Many ischemic stroke patients present to the hospital in a state of dehydration. We hypothesized that patients who were dehydrated at the time of acute stroke would have more severe stroke and worse short term outcomes. Methods: We enrolled consecutive ischemic stroke patients within 12 hours from their last normal neurological exam at a single academic health system. Patients with renal failure or who were unable to undergo MRI were excluded. Surrogate markers for dehydration were defined as BUN/Creatinine ratio >15 and urine specific gravity >1.010. Stroke severity was determined based on clinical examination (NIHSS score) and lesion volume measured on diffusion weighted MRI. The primary outcome of interest was change in NIHSS from admission to discharge. Results: We surveyed 383 ischemic stroke admissions to our comprehensive stroke center. Of these, 168 met inclusion criteria with 126/168 (75%) having complete laboratory and MRI data. 44% of our patients were dehydrated at the time of admission, with no difference in demographics between the dehydrated and hydrated groups. Baseline NIHSS (6.7 vs 7.3; p=0.63) and lesion volumes (12 vs 16; p=0.48) were similar in the two groups. 42% of dehydrated patients were in the worst short term quartile of NIHSS change, as compared with 17% of the hydrated group (p=0.02). Dehydration remained a significant predictor of having the worst NIHSS change, after adjustment for age, initial NIHSS, lesion volume, and admission glucose (OR=4.34, 95% CI 1.75-10.76). Conclusions: Nearly half of acute stroke patients admitted to the hospital are dehydrated by surrogate laboratory markers. Acute stroke patients with markers of dehydration demonstrate greater worsening in NIHSS scores as compared with hydrated patients, independent of infarct size. Results suggest an opportunity for an inexpensive and globally available treatment to optimize functional outcomes of the stroke patient.

Abstract TP401: Impact of Vital Signs and Neurological Assessments After Alteplase for Acute Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Scott Drake ◽  
Swetha Renati ◽  
Karen Packer Wilson ◽  
Nicholas Hilker ◽  
Nicole Slye ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Patient Outcomes ◽  
Retrospective Review ◽  
Vital Signs ◽  
Full Compliance ◽  
Institutional Review ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Get With The Guidelines ◽  
The Impact

Background: Vital signs and neurologic assessments are currently performed using the schedule utilized during the clinical trials which led to the approval of alteplase for acute stroke. These assessments can be disruptive to patients and represent a considerable staffing and infrastructural demand. While the goal of this approach is to improve outcomes by rapidly detecting actionable changes, its impact has been questioned. Despite its widespread use there has been limited systematic review regarding its influence on outcomes. Purpose: This project’s aim was to determine the impact of these assessments by conducting a retrospective review at our large, urban, comprehensive stroke center. We sought to evaluate the rate of compliance with established guidelines, and assess its correlation with patient outcomes. Methods: This retrospective review of patients receiving alteplase for acute stroke was approved by our institutional review board. A total of 130 patients were identified during 2018. Data was collected from the electronic medical record and The Get with the Guidelines database. Results: Our institutional guideline includes a total of 36 vital signs and 24 neurological assessments during first 24-hours after alteplase administration, for a total of 60 assessments. 63% of patients had full compliance with all 60 assessments. The discharge modified Rankin scale (mRS) for those with full compliance was 2.35 versus 2.31 for patients without 100% compliance (p>0.05; NS). There was less compliance with vital signs compared to neurological assessments (73.8% versus 76.9%). Conclusions: The majority of patients were complaint with all assessments however a notable portion missed at least one assessment, occurring more frequently with vital signs. Full compliance with all assessments was not associated with improved mRS.

Abstract W P212: The Effect Of Pre-hospital Notification On Time To Head Ct, Stroke Specialist Arrival, And Tpa Administration For Hispanic Patients With Acute Stroke

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Jonathan McCoy ◽  
Ralph Fader ◽  
Colleen Donovan ◽  
Robert Eisenstein ◽  
Pamela Ohman-Strickland ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Stroke Care ◽  
Independent Effect ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Head Ct ◽  
Logistic Regression Models ◽  
Hispanic Patients ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: Hispanics have an increased incidence of ischemic stroke but may be less likely to use Emergency Medical Services (EMS) for stroke care. Objective: To examine disparities in pre-hospital triage and emergent evaluation of Hispanic stroke patients. We hypothesized that Hispanic stroke patients with pre-hospital notification experience less delay in emergent evaluation but the reduction may not be as pronounced as general stroke patients. Methods: Retrospective cohort study of all emergency department patients alerted as Brain Attack (BAT) between January 1, 2009 and August 31, 2012, at an urban comprehensive stroke center. We collected demographics, co-morbidities, and stroke severity from a quality assurance database. Outcome variables included EMS utilization, pre-hospital BAT activation, head CT timing & tissue plasminogen activator (TPA) timing. Effects of ethnicity and pre-hospital notification on evaluation and treatment times were measured using multivariate logistic regression models. The study was IRB approved. Results: During the study period, 832(64 Hispanic) patients were alerted as Brain Attacks. Hispanic patients were younger 56±17 vs. 68±16 years (p<0.0001), had trends for less EMS utilization (walk-in 35% vs. 22%) and lower NIHSS 9.3±4.3 vs. 12.8±8.3 (p=0.06), but did not differ in comorbidities. Patients with pre-hospital notification had significantly shorter times to stroke specialist arrival, door to head CT, and door to TPA irrespective of ethnicity. However, ethnicity did have independent effect on time to TPA administration. Please see Table 1. Conclusion: Pre-hospital notification is associated with faster stroke evaluation and treatment, including among Hispanic patients with acute stroke. Further study is needed to examine if outreach to increase EMS utilization will decrease disparities in this population.

scholarly journals In-Hospital Intravenous Thrombolysis Offers No Benefit in Mechanical Thrombectomy in Optimized Tertiary Stroke Center Setting

2020 ◽  
Author(s):  
Juha-Pekka Pienimäki ◽  
Jyrki Ollikainen ◽  
Niko Sillanpää ◽  
Sara Protto
Keyword(s):  
Clinical Outcome ◽  
Acute Stroke ◽  
Mechanical Thrombectomy ◽  
Clinical Laboratory ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Ordinal Logistic Regression Analysis ◽  
Stroke Center

Abstract Purpose Mechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO. Materials and Methods We collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis. Results Fifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients. Conclusions MT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients.

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

2015 ◽  
Vol 2015 ◽  
pp. 1-5 ◽  
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.

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

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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