Abstract TP414: Support from a Comprehensive Stroke Center Improves Door to tPA Times at Primary Stroke Centers

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Julie M Fussner ◽  
Kelly Montgomery ◽  
Tinatin Gumberidze ◽  
Erin Supan
Keyword(s):  
Gap Analysis ◽  
Heart Association ◽  
Measure Data ◽  
Quality Improvement Initiative ◽  
University Hospitals ◽  
Stroke Registry ◽  
National Quality ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
System Average

Target Stroke, a national quality improvement initiative of the American Heart Association /American Stroke Association (AHA/ASA) to improve the timeliness of administration of intravenous (IV) tissue plasminogen activator (tPA) to eligible stroke patients, was launched in 2010. The door-to-needle time goal is 60 minutes (mins) from hospital arrival. Earlier administration of IV t-PA is associated with greater functional recovery. Since 2009 University Hospitals Comprehensive Stroke and Cerebrovascular Center (UHCSCC) has meet quarterly with its 7 system community hospitals to share stroke core measure data, review clinical practice guidelines and address new system initiatives for the care of the stroke patient. The purpose of this project is to demonstrate how a comprehensive stroke center (CSC) can assist a primary stroke center (PSC) to improve their door to tPA treatment times. In 2010 to support the primary stroke centers, the UHCSCC developed standardized stroke education for nurses including an online course for tPA. In 2014 an additional online interactive module was created to assist nurses in programing the Alaris IV pump to improve their speed. In 2013 the quarterly system meetings started to include door to CT and door to tPA data with discussions about best practices and challenges. The AHA Target Stroke campaign recommendations and evidenced-based strategies were reviewed and a gap analysis at each hospital was completed to identify opportunities. Throughout 2012-2013 the stroke coordinator at UHCSCC led monthly conference calls with the community stroke coordinators. Since 2014 the stroke operations manager visits each community hospital monthly to work with the stroke coordinator and their teams reviewing TPA cases. Finally, a formal feedback took was developed and is sent to the PSC to provide patient outcomes and opportunities on all TPA cases that are transferred to the CSC. The AHA Get With The Guidelines stroke registry is used to monitor compliance. In 2012 the University Hospitals Health System average door to tPA in 60 mins was only 41%. January - June 2015, the system average has improved 86%. Community primary stroke centers benefit from the comprehensive stroke center interventions and support to improve door to tPA in 60 mins.

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

Abstract WMP88: Shorter Door-to-Needle Times of Intravenous Alteplase Improve “Efficiency” of Care and Moderately Affect “Quality” of Care: Study Based on a Large Comprehensive Stroke Center

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Suja S Rajan ◽  
Jessica N Wise ◽  
Marquita Decker-palmer ◽  
Thanh Dao ◽  
Cynthia Salem ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Clinical Outcomes ◽  
Heart Association ◽  
P Value ◽  
Regression Analyses ◽  
Inpatient Mortality ◽  
Care Outcomes ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: The American Heart Association (AHA) recently raised the bar on timely treatment of acute ischemic stroke (AIS) with intravenous (IV) alteplase, by recommending door-to-needle times of 30 minutes or less for 50% or more of the AIS patients. Our study looks at the effectiveness of this new standard, by examining the effect of varying door-to-needle times on efficiency and quality of care, and clinical outcomes. Methods: Our study examined 762 AIS patients treated with IV alteplase in a large academic health system from 2015-2018, and compared their outcomes after treatment within 30, 45 and 60 minutes of arrival. The outcomes compared were: 1) Efficiency of care outcome - Length of stay (LOS); 2) Quality of care outcomes - Inpatient mortality and Disability at discharge; 3) Clinical outcomes - Discharge and 90-day modified Rankin Scale (mRS), and Post-alteplase (24 hr) NIH Stroke Scale (NIHSS). Adjusted logistic and linear regression analyses were used, after controlling for baseline patient socio-demographic and clinical characteristics. Results: Based on the adjusted regression analyses (Table 1), being treated within 30 minutes of arrival reduced the average LOS by 1.3 days (p-value: 0.02), but did not affect the quality of care outcomes. Similarly, being treated within 45 minutes of arrival reduced LOS by 0.9 days (p-value: 0.04). Being treated within 60 minutes of arrival did not affect LOS, but reduced the odds of inpatient mortality by 68% (p-value: 0.00), and disability at discharge by 29% (p-value: 0.08). Being treated within 30 minutes of arrival was associated with better mRS and NIHSS scores as compared with being treated within 45 or 60 minutes. Conclusion: Quicker IV alteplase treatment significantly improved efficiency of care and clinical outcomes. Quality of care outcomes did not improve beyond the 60 minute door-to-needle threshold. This study provides evidence supporting AHA’s new recommendation of 30 minutes or less door-to-needle time.

scholarly journals Stroke Simulation Improves Acute Stroke Management: A Systems-Based Practice Experience

2018 ◽  
Vol 10 (1) ◽  
pp. 57-62 ◽  
Author(s):  
Tapan Mehta ◽  
Sara Strauss ◽  
Dawn Beland ◽  
Gilbert Fortunato ◽  
Ilene Staff ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Medical Education ◽  
Acute Stroke ◽  
Simulation Training ◽  
Stroke Registry ◽  
Practice Experience ◽  
Intravenous Tissue Plasminogen Activator ◽  
Simulation Based ◽  
Comprehensive Stroke Center ◽  
Stroke Center

ABSTRACT Background  Literature on the effectiveness of simulation-based medical education programs for caring for acute ischemic stroke (AIS) patients is limited. Objective  To improve coordination and door-to-needle (DTN) time for AIS care, we implemented a stroke simulation training program for neurology residents and nursing staff in a comprehensive stroke center. Methods  Acute stroke simulation training was implemented for first-year neurology residents in July 2011. Simulations were standardized using trained live actors, who portrayed stroke vignettes in the presence of a board-certified vascular neurologist. A debriefing of each resident's performance followed the training. The hospital stroke registry was also used for retrospective analysis. The study population was defined as all patients treated with intravenous tissue plasminogen activator for AIS between October 2008 and September 2014. Results  We identified 448 patients meeting inclusion criteria. Simulation training independently predicted reduction in DTN time by 9.64 minutes (95% confidence interval [CI] –15.28 to –4.01, P = .001) after controlling for age, night/day shift, work week versus weekend, and blood pressure at presentation (> 185/110). Systolic blood pressure higher than 185 was associated with a 14.28-minute increase in DTN time (95% CI 3.36–25.19, P = .011). Other covariates were not associated with any significant change in DTN time. Conclusions  Integration of simulation based-medical education for AIS was associated with a 9.64-minute reduction in DTN time.

Abstract MP20: The Effect of the Covid-19 Pandemic on Stroke Code Time Metrics at an Academic, Comprehensive Stroke Center

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Dawn M Meyer ◽  
Benjamin Shifflett ◽  
Reza Bavarsad Shahripour ◽  
Tamra Ranasinghe ◽  
Dolores Torres ◽  
...  
Keyword(s):  
Arrival Time ◽  
Treatment Decision ◽  
Stroke Care ◽  
Demographic Variables ◽  
Hospital Arrival ◽  
Stroke Registry ◽  
Treatment Administration ◽  
Race Ethnicity ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: The COVID-19 pandemic forced immediate changes to stroke code protocols to maintain safety of patients and providers. We hypothesize that stroke code time metrics were significantly longer in the peri-COVID stroke code activations compared to pre-COVID activations. Methods: We analyzed data from an IRB-approved, prospectively collected stroke registry at a large academic, comprehensive stroke center (CSC). We included all patients that presented as stroke code activations from June 2009-August 2020, excluding spoke telestroke and in-house codes. Pre-COVID was defined as June 1, 2009-March 11, 2020 and peri-COVID March 12, 2020 to August 11, 2020. The pre-pandemic stroke code protocol began June 2009. We assessed The Joint Commission stroke code time metrics between groups. Demographic variables of baseline NIHSS, sex, race/ethnicity, age, smoking, pertinent past medical history, arrival mode, and baseline glucose were assessed. A t-test was used to compare stroke code time metrics in minutes. All analyses were done unadjusted. Results: We assessed 813 pre and 328 peri-COVID stroke code activations. Baseline demographics were significant only for an increased number of Hispanics in the pre-COVID group (22.9% vs 11.1%, p<0.001). Onset to hospital arrival time was significantly longer in the peri-COVID compared to pre-COVID group (244 vs 110 min, p<0.001). Onset to stroke code activation was significantly longer in the peri-COVID compared to pre-COVID group (243.8 vs 116.8 min, p<0.009). Time from arrival to treatment decision was significantly decreased in the peri-COVID group (29.9 vs 39.6 min, p=0.04). Time from arrival to CT scan completed (p=0.37), arrival to treatment administration (p=0.06), and onset to treatment administration (p=0.48) were not significantly different between groups. Conclusion: The COVID-19 pandemic significantly impacted the volume and demographic of stroke patients seeking emergency care. This data supports the trend of patients delaying emergent stroke care. This academic, CSC developed and implemented a COVID-19 stroke code protocol within days of a statewide lockdown. The use of telestroke in this peri-pandemic protocol may have accounted for the significant decrease in time to treatment decision.

Abstract P689: Do Cyclic Patterns of Stroke Code Activation Occur in a Comprehensive Stroke Center?

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Edward Labin ◽  
Dawn M Meyer ◽  
Benjamin Shifflett ◽  
Brett C Meyer ◽  
Royya F Modir
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Circadian Rhythm ◽  
Time Of Day ◽  
Stroke Registry ◽  
Changing Practice ◽  
Cyclic Patterns ◽  
Chi Squared ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: The effects of circadian rhythm on stroke can include increases in morning heart rate, blood pressure, catecholamines, platelet aggregation, and hypercoagulability and might correlate with higher numbers of morning strokes. We assessed time of day and frequency of stroke code activation for a potential role of circadian rhythm in stroke risk. Methods: A retrospective analysis of prospectively collected data from an IRB approved stroke registry, from July 2004 to July 2020, was performed. Codes were included where stroke codes were activated with last known well (LKW) <6 hours to limit the effect of wake-up strokes and equalize changing practice patterns over time. Subjects were divided into four epochs based on code activation: Night (00:00-05:59), Morning (06:00-11:59), Afternoon (12:00-17:59), and Evening (18:00-23:59). Confirmed diagnosis of stroke, baseline blood pressure (SBP & DBP), heart rate (HR), and PTT were compared. Chi squared was used to compare categorical data and t test for continuous. Results: A total of 5,366 subjects were identified. Stroke code activations differed across epochs (Night n=312, 5.81%; Morning n=1439, 26.82%; Afternoon n=2207, 41.13%; Evening n=1408, 26.24%: p<0.0001). In the subset analysis of true strokes, activations also differed across epochs (Night n=125, 5.26%; Morning n= 831, 34.95%; Afternoon n=934, 39.28%; Evening n=488, 20.52%: p<0.0001). Overall, SBP was different with Evening highest and Morning lowest (x 151.6, x 148.2;p=0.01). Overall DBP showed Night highest and Afternoon lowest (x 83.9, x 81;p=0.002). Heart rate showed Night highest and Morning lowest (x 84.9, x 81.6;p=0.002). Conclusions: This study found that most stroke code activations occur in Afternoons at this CSC. This may be due to patient level characteristics, bystander availability, or other factors. Future studies should assess multi-center data and include other circadian rhythm biomarkers.

Eligibility for late endovascular treatment using DAWN, DEFUSE-3, and more liberal selection criteria in a stroke center

2019 ◽  
Vol 12 (9) ◽  
pp. 842-847 ◽  
Author(s):  
Stefania Nannoni ◽  
Davide Strambo ◽  
Gaia Sirimarco ◽  
Michael Amiguet ◽  
Peter Vanacker ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Selection Criteria ◽  
Time Window ◽  
Real Life ◽  
Good Health ◽  
Late Time ◽  
Vessel Occlusion ◽  
Stroke Registry ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background and purposeThe real-life application of DAWN and DEFUSE-3 trials has been poorly investigated. We aimed to identify the proportion of patients with acute ischemic stroke (AIS) eligible for late endovascular treatment (EVT) in our stroke center based on trial and more liberal selection criteria.MethodsAll consecutive patients in our stroke registry (2003–2017) admitted within 5–23 hours of last proof of good health were selected if they had complete clinical and radiological datasets. We calculated the proportion of patients eligible for late EVT according to trial (DAWN and/or DEFUSE-3) and more liberal clinical/imaging mismatch criteria (including lower admission National Institutes of Health Stroke Scale score and Alberta Stroke Program Early CT Score for core estimation).ResultsOf 1705 patients with AIS admitted to our comprehensive stroke center in the late time window, we identified 925 patients with complete clinical and radiological data. Among them, the proportions of late EVT eligibility were 2.5% (n=23) with DAWN, 5.1% (n=47) with DEFUSE-3, and 11.1% (n=103) with more liberal criteria. Considering late-arriving patients with large vessel occlusion (n=221), the percentages of eligible patients were 10.4%, 21.3%, and 46.6%, respectively. A favorable outcome was observed at comparable rates in treated patients selected by trial or liberal criteria (67% vs 58%, p=0.49).ConclusionsIn a long-term stroke registry, the proportion of late EVT eligibility varied greatly according to selection criteria and referral pattern. Among late-arriving patients referred to our comprehensive stroke center, we found 5.6% eligible according to trial (DAWN/DEFUSE-3) and 11.1% according to liberal criteria. These data indicate that late EVT could be offered to a larger population of patients if more liberal criteria are applied.

Abstract TP220: Is Fibrinogen a Reliable Lab to Follow in Acute Ischemic Stoke After Thrombolysis

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Deepak Gulati ◽  
Muhammad Nasir ◽  
Dharti Dua ◽  
Michel Torbey
Keyword(s):  
Reference Range ◽  
Fibrinogen Level ◽  
Heart Association ◽  
Bleeding Complications ◽  
Hematoma Expansion ◽  
Normal Reference Range ◽  
Single Center Experience ◽  
The Mean ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: American Heart Association suggests empirical therapies (cryoprecipitate, FFP and platelets) for post-IVtpa hemorrhage but acknowledges the lack of evidence to support any specific therapy. Different institutions have developed care pathways for post-IVtpa sICH involving frequent fibrinogen level checks. During thrombolysis, circulating fibrinogen is decreased, and thus rapid administration of cryoprecipitate is recommended. A marker of fibrinogen of <100-150 mg/dL has been traditionally used as a cutoff to suggest effective thrombolysis or administration of cryoprecipitate or to assess the risk of bleeding complications. Monitoring of fibrinogen level has been used to guide the reversal therapy in the setting of post-IVtpa hemorrhage. This practice is not fully addressed in the literature. Purpose: To determine the significance of fibrinogen level in relation to thrombolysis in acute ischemic stroke (AIS) based on our single center experience. Methods: We retrospectively reviewed fibrinogen levels in two groups of patients with AIS who presented to our comprehensive stroke center. First group included 50 patients who received IVtpa including two patients w/ post-IVtpa sICH and second group included 50 patients with AIS who could not receive IVtpa due to contraindication. Fibrinogen level was checked in immediate post-IVtpa period usually within 2hr of IVtpa or 6hr from onset. Results: The mean fibrinogen level in first group with patients with AIS who received IVtpa is 321.65 mg/dl with range from 102 to 533 mg/dl. Normal reference range is 220-410mg/dl. The mean fibrinogen level in second group without IVtpa is 376mg/dl with range from 124 to 583mg/dl. The fibrinogen level in two patients with post-IVtpa sICH was 216 and 282 mg/dl. Conclusions: No significant correlation is found between fibrinogen level (<100mg/dl) and IVtpa use. We also found no significant change in fibrinogen level in patients with post-IVtpa sICH even though there are only two cases included so far. Above finding suggests that we should focus our research on mechanism other than decrease fibrinogen level to be an underlying cause of post-IVtpa hemorrhage in order to develop agent for better reversal and to prevent continued hematoma expansion.

Abstract TP396: Strategies for Successful Stroke Survey

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Claranne Mathiesen ◽  
Erin M Conahan
Keyword(s):  
Gap Analysis ◽  
Care Delivery ◽  
Team Development ◽  
Use Of Resources ◽  
Quality And Outcomes ◽  
Initial Survey ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Time And Energy ◽  
Disease Specific

Background: Comprehensive Stroke Center (CSC) certification has been available since 2012. Over 100 hospitals have completed this rigorous advanced disease specific certification. Stroke certification occurs every two years and can be resource intensive for hospitals. No matter how experienced a center is, preparation of the extended team takes considerable time and energy. Issue: Stroke Centers operate in a dynamic healthcare environment, continuously undergoing series of changes that impact care delivery across the continuum. In theory, survey preparation is an on-going process. In reality people get comfortable once certified and return to previous workflows with less attention to detail. Current literature focuses on improved quality and outcomes that result from disease specific certification. There is a limited amount of published literature regarding stroke survey preparation activities, and available publications are over ten years old. Purpose: The purpose of this presentation is to formally contribute successful survey strategies to the experience of the stroke community. Method: Various aspects of preparation, including team development, standards and clinical practice guidelines review, the role of data, and methods to prepare staff will be discussed. In addition the use of resources, the value of pre-survey consultation to provide external gap analysis, and equitable distribution of preparation activities will be explored. Result: Thorough survey preparation has led to an initial survey and two recertifications with a total of 11 RFIs. Multidisciplinary teamwork requires ongoing commitment to assure adoption of standards and continued engagement to ensure all involved areas are ready to actively participate in the on-site review process. Conclusion: More research and publication is needed to assist stroke centers to prepare for a successful stroke survey. As CSC’s mature expectations are increased to grow the way programs meet the needs of presenting stroke patients and develop the professional team. By comparing and sharing strategies, comprehensive stroke programs can share experiences that lead to decreased stress and improved confidence at the time of on-site certification visit

Abstract WP142: Intravenous Tissue Plasminogen Activator for Patients with Mild and Rapidly Improving Ischemic Strokes and Large Vessel Occlusions: Examining In-hospital Outcomes

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jeffrey Wagner ◽  
Constance McGraw ◽  
Kathryn McCarthy ◽  
Judd Jensen ◽  
Alessandro Orlando ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Heart Association ◽  
Patient Characteristics ◽  
Large Vessel ◽  
Stroke Severity ◽  
Vessel Occlusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Increased Risk ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: Upon hospital arrival, patients with mild or rapidly improving acute ischemic strokes (AIS) are frequently not treated with IV-tPA. Recent guidelines from the American Heart Association report that diagnosis on imaging of large vessel occlusion (LVO) despite mild stroke severity leads to increased risk of poorer outcomes. The objective of our study was to examine outcomes following tPA in this AIS population. Methods: The study included all AIS patients with an admission NIHSS ≤7 and diagnosis of a LVO on imaging from a single comprehensive stroke center between 2010-2016. Patients were excluded due to missing contraindications to tPA or with a symptom to arrival time of >4.5 hours (n=234). We compared patients who received tPA to those who received no treatment because of mild or rapidly improving symptoms. Outcomes were sICH, improvement in NIHSS score, discharge mRS ≤2, and in-hospital mortality. Patient characteristics were compared univariately, and step-wise logistic regression was used to adjust for confounding variables. Entry criterion was P=0.2 and exit criterion was P=0.07. Results: There were 76 patients with an AIS diagnosis of LVO. Of these patients, 39 (51%) were treated with tPA and 37 (49%) were not treated. Overall, the median (IQR) age was 72 (61-82.5). Patients treated with tPA had a median admission NIHSS of 5 (3-6), and a larger proportion were male (77%) and smokers (4%). Patients without tPA treatment had a median NIHSS of 2 (1-3), and a larger proportion had hypertension (49%). All outcomes were not significantly different between groups after adjustment (Table 1). There were no patients with sICH. Conclusions: Our study suggests that tPA in mild LVO patients does not introduce additional risk in terms of sICH, in-hospital mortality, change in NIHSS, or discharge mRS. Further justification for withholding tPA in this group should be based on 90-day mRS scores, in order to better understand long-term functional outcomes.

Sign in / Sign up

Export Citation Format

Share Document