Abstract WMP62: Achieving Ultra-Fast Door-to-Needle Times With a “Treat-in-CT” Acute Stroke Protocol

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Andria L Ford ◽  
Jennifer A Williams ◽  
Brian Hoff ◽  
David Curfman ◽  
Rebecca Wiesehan ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Lean Manufacturing ◽  
Treatment Time ◽  
Point Of Care ◽  
Patient Flow ◽  
Vital Signs ◽  
Ct Scanner ◽  
Rapid Improvement ◽  
Ct Protocol ◽  
Before And After

Background: Ultra-early thrombolysis [onset-to-treatment time (OTT) < 90 min], leads to better clinical outcomes. We utilized lean manufacturing principles to re-choreograph patient flow such that tPA was delivered in the CT scanner rather than moving the patient to a separate treatment room. We tested the efficiency and safety of a “Treat-in-CT” protocol comparing metrics and outcomes before and after implementation. Methods: In July 2014, a LEAN rapid improvement event was conducted to design a “Treat-in-CT” stroke protocol. Several changes included: (1) Vital signs monitors and point of care glucose and INR were placed near the scanner. (2) Computer monitors were placed in the scanner to allow for rapid charting and order entry. (3) Local EMS crews, physicians, nursing staff, and CT technicians were trained on parallel work-flow in the scanner. The “Treat-in-CT” protocol went live 10/1/2014. We directly compared the “Pre” and “Post” Treat-in-CT epochs (1/2013-9/2014 and 10/2014-8/2015, respectively) with regard to baseline variables, metrics, and outcomes. Non-parametric statistics were used with p<0.05 required for significance. Results: In the Pre- and Post-Treat-in-CT epochs, 139 and 74 patients were treated with IV tPA, respectively. Baseline variables were similar between the two epochs. Median door-to-needle time was lower in the Post-Treat-in-CT epoch: 38 min pre vs. 29 min post (p=0.002) with a trend towards lower OTT: 131 min pre vs. 100 min post (p=0.07). To ensure that efficiency did not impact safety, favorable discharge location (87% pre vs. 81% post, p=0.3), symptomatic hemorrhage rate (2.9% pre vs. 1.5% post, p=1.0), stroke mimic rate, and 90 day mRS were compared and did not differ. Conclusions: The AHA Target: Stroke-Phase II guidelines recommend administration of tPA bolus while in the CT scanner. A “Treat-in-CT” acute stroke protocol using efficient choreography and parallel processing expedited tPA delivery without compromising safety.

Abstract 104: Golden Hour-Thrombolysis by Starting Treatment Before Hospital Arrival the Pre-Hospital Acute Neurological Treatment and Optimization of Medical Care in Stroke Study (PHANTOM-S)

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Martin Ebinger ◽  
Matthias Wendt ◽  
Michal Rozanski ◽  
Benjamin Winter ◽  
Carolin Waldschmidt ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Treatment Time ◽  
Point Of Care ◽  
Intravenous Thrombolysis ◽  
Conventional Care ◽  
Ct Scanner ◽  
Term Outcome ◽  
Golden Hour ◽  
Stroke Study ◽  
A Prospective Study

Objective: The effectiveness of intravenous thrombolysis in acute ischemic stroke is time dependent. The effects are likely to be highest if onset-to-treatment time (OTT) is < 60 minutes, the so called Golden-Hour. Starting thrombolysis in a specialized ambulance with a CT-scanner plus point-of-care laboratory reduced time from emergency call to treatment in the prospective controlled PHANTOM-S study. We evaluated the rate and effectiveness of Golden-Hour thrombolysis. Methods: The stroke emergency mobile (STEMO) is staffed with a neurologist trained in emergency medicine, a paramedic and a technician. The effects of the STEMO implementation were evaluated in a prospective study comparing weeks with and without STEMO-availability. STEMO was deployed when the dispatchers suspected an acute stroke during emergency calls. If STEMO was not available (in operation or maintenance), patients received conventional care. OTT-intervals were dichotomized in either ≤60 (Golden-Hour) or > 60 minutes as well as categorized in 10-minute intervals from 0 to 270 minutes for graphical description. Results: Overall, thrombolysis rates in ischemic stroke were 33% (200/614) when STEMO was deployed and 22% (330/1497) in conventional care (p<0.001). The proportion of Golden-Hour treatments (from all thrombolysis) was 6-fold higher after STEMO deployment (31.0%; n= 62 versus 4.9%; n=16; p<0.01). Compared to patients with longer OTT patients with Golden-Hour thrombolysis had no higher risks for 7- or 90-day mortality (adjusted ORs: 0.38, 95%-CI: 0.09-1.70 and 0.69, 95%-CI: 0.32-1.53) but were more likely to be discharged at home (adjusted OR: 1.93 95%CI: 1.09-3.41; p=0.024). Conclusion: STEMO increased the percentage of patients treated within the Golden-Hour. This entailed no risk to patients’ safety and was associated with better short-term outcome.

Abstract TP75: Safety and Outcome of Thrombolysis in Acute Stroke with Prolonged Onset-to-Treatment Times and Low National Institute of Health Stroke Scale Scores. Report on Experience in China, First 1000 Patients of 3300 Treated

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Pei-Lan Zhang ◽  
Jin-Huan Wang ◽  
Yu-Xin Wang ◽  
Yan Chen ◽  
Chen-Hao Zhang ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Treatment Time ◽  
Significant Risk ◽  
Stroke Patients ◽  
Data Set ◽  
Scale Scores ◽  
Before And After ◽  
Metropolitan Hospital ◽  
Mri Scans ◽  
Efficacy Of Treatment

Introduction: Stroke in China is the leading cause of death. We report on a collaboration between a large metropolitan hospital in China, Tianjin Huanhu Hospital, and Inova Fairfax and Inova Alexandria Stroke Programs presenting data on the first 1000 (of more than 3300 treated since 2012) patients treated with IV-rtPA. The safety and efficacy of treatment with rtPA between 4.5-6 hours after onset is unclear. Similarly there is little data on outcome of patients treated with rtPA with normal or low NIHSS. Methods: Patients were treated with thrombolysis between late 2012 and fall of 2014. Patients had MRI scans at 24 hours. Patients had NIHSS scores before and after treatment, and modified Rankin Scores (mRS) at 90 days after treatment. Results: See Chart. Conclusions: 1) IV-rtPA can be given safely between 4.5-6 hours without significant risk of sICH and worsening outcomes. 2) Higher NIHSS before thrombolysis was correlated with poorer outcomes. 3) There was no significant correlation between onset to treatment time up to 6 hours and outcome. 4) Outcome was excellent (mRS 0-1) in 72% treated 0-3 hours, 74% 3-4.5 hours and remarkably 85% 4.5-6 hours. The data set includes many patients who were asymptomatic or nearly so prior to treatment. This will need to be more fully evaluated in the remainder (2300) of this cohort of more than 3300 treated patients. Comment: This cohort represents one of the largest series of acute stroke patients treated with IV-rtPA > 4.5 hours after onset. It also reveals outcome of treatment in patients with low NIHSS treated at various intervals after last know well.

scholarly journals THE EFFECT OF A BOARDING RESTRICTION PROTOCOL ON EMERGENCY DEPARTMENT CROWDING

2021 ◽  
Author(s):  
Ji Hwan Lee ◽  
Ji Hoon Kim ◽  
Incheol Park ◽  
Hyun Sim Lee ◽  
Joon Min Park ◽  
...  
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Primary Outcome ◽  
Treatment Time ◽  
Patient Flow ◽  
Hospital Beds ◽  
Before And After ◽  
Day Of The Week ◽  
Ed Crowding ◽  
Post Period

ABSTRACT Background Access block due to a lack of hospital beds causes emergency department (ED) crowding. We initiated the boarding restriction protocol that limits ED length of stay (LOS) for patients awaiting hospitalization to 24 hours from arrival. This study aimed to determine the effect of the protocol on ED crowding. Method This was a pre-post comparative study to compare ED crowding before and after protocol implementation. The primary outcome was the red stage fraction with more than 71 occupying patients in the ED (severe crowding level). LOS in the ED, treatment time and boarding time were compared. Additionally, the pattern of boarding patients staying in the ED according to the day of the week was confirmed. Results Analysis of the number of occupying patients in the ED, measured at 10-minute intervals, indicated a decrease from 65.0 (51.0-79.0) to 55.0 (43.0-65.0) in the pre- and post-periods, respectively (p<0.0001). The red stage fraction decreased from 38.9% to 15.1% of the pre- and post-periods, respectively (p<0.0001). The proportion beyond the goal of this protocol of 24 hours decreased from 7.6% to 4.0% (p<0.0001). The ED LOS of all patients was similar: 238.2 (134.0-465.2) and 238.3 (136.9-451.2) minutes in the pre- and post-periods, respectively. In admitted patients, ED LOS decreased from 770.7 (421.4-1587.1) to 630.2 (398.0-1156.8) minutes (p<0.0001); treatment time increased from 319.6 (198.5-482.8) to 344.7 (213.4-519.5) minutes (p<0.0001); and boarding time decreased from 298.9 (109.5-1149.0) to 204.1 (98.7-545.7) minutes (p<0.0001). In the pre-period, boarding patients accumulated in the ED on weekdays, with the accumulation resolved on Fridays; this pattern was alleviated in the post-period. Conclusions The protocol effectively resolved excessive ED crowding by alleviating the accumulation of boarding patients in the ED on weekdays. Additional studies should be conducted on changes this protocol brings to patient flow hospital-wide.

Abstract TP250: Reducing Treatment Time in Acute Ischemic Stroke by Utilizing a Kaizen Model

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Mohamad Fayad ◽  
Jussie` Lima ◽  
Dawn Beland ◽  
Ilene Staff ◽  
Lincoln Abbott ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Treatment Time ◽  
Stroke Care ◽  
Work Flow ◽  
Workflow Model ◽  
Ct Scanner ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
Flow Process ◽  
Improvement Project

Introduction: Treating patients suspect of acute stroke requires efficient multidisciplinary teamwork in order to provide appropriate care. Several “Lean Management” methods have been applied in a variety of healthcare settings. Kaizen, meaning “improvement” in Japanese is a tool which emphasizes empowerment of employees on creating value streams to identify and reduce wastes, synchronize work flow processes, manage variability, and devise communication and sustainability plans. We report on the use of this methodology to improve our acute stroke care metrics. Objective: To optimize the management of the acute stroke patient flow process from the emergency department ED to destination therapy by applying the Kaizen methods. Methodes: This is a quality improvement project designed to evaluate the efficiency of the new workflow model for acute stroke that was put into place June 2018 at Hartford Hospital. A 5 day event spent involving all stakeholders from patient registration to destination treatment (IV or mechanical thrombolytic therapy) were conducted. During this event, a time work flow process for the management of suspected stroke patients was identified and an appropriate plan was formulated to reduce times. The following parameters were utilized: Door to CT scanner time (DTCT), Door to drug (IV-tPA) (DTD), and Door to mechanical thrombectomy puncture time (DTP). We included all stroke patients presenting to the ED and treated at our institution 6 months prior and post implementation. A non-parametric analysis was utilized. Results: A total of 135 patients were included in this analysis, 60 prior and 75 post Kaizen. Improvement across all parameters was observed post Kaizen with an average reduction time of DTCT 5 min, DTD 5min, and DTP 22min. The median times pre-Kaizen were; DCT 14min IQR 6-27, DTD 55min IQR 43.5-77.5, and DTP 128min IQR 88-151. The median times post-Kaizen were; DTCT 9min IQR 6-23, DTD 50.5min IQR 37-64, and DTP 106 min IQR 83.5-141.5. Conclusion: By utilizing the Kaizen, we identified numerous opportunities to reduce variability, standardize workflow processes, and ultimately reduce all parameter times. As time is brain, reducing pretreatment times favorably impacts patients’ outcomes and reduces morbidity in stroke.

Abstract TP311: Multidisciplinary Stroke Simulation: Novel Team Based Approach to Decrease Door-to-Needle Times

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Christopher A Mutch ◽  
Zachary Threlkeld ◽  
Sara Cole ◽  
Christine Martin ◽  
Benjamin Kozak ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Ct Perfusion ◽  
Stroke Care ◽  
Simulated Patients ◽  
Ct Scanner ◽  
Acute Stroke Care ◽  
Before And After ◽  
Care Guidelines ◽  
Multidisciplinary Simulation ◽  
The Impact

Introduction: In acute stroke, time equals brain. Minimizing time to treatment maximizes eligibility and effectiveness of fibrinolytics. Timely treatment of acute stroke requires precise coordination of a multidisciplinary team ranging from first responders to neurointerventionalists. Simulation-based learning allows participants to hone their skills and make mistakes in a controlled environment. To our knowledge, the impact of multidisciplinary stroke simulation has not been reported in literature. Here we describe our initial experience implementing such a simulation. Hypothesis: Participation in stroke simulation will improve knowledge of acute stroke care guidelines and decrease door-to-needle time. Methods: Neurology, emergency medicine and radiology trainees, EMTs, nurses, medical students, technologists, and pharmacists took part in the evaluation and treatment of simulated patients with stroke symptoms in actual clinical settings from ambulance to ED to CT scanner to IR suite. Neurology and neuroradiology faculty debriefed participants following simulations. Questions on stroke care (derived from the 2013 AHA/ASA guideline and 2015 update) were sent to likely participants before and after the simulation; those who completed pre/post quizzes and the simulation were included in analysis. Results: Survey response rate was 86%. All participants had improved scores on the post-simulation quiz, scoring an average of 19% higher, 95% CI [8%, 29%]. For example, correct responses that IV tPA is not contraindicated prior to endovascular therapy improved from 64 to 100% after the simulation; responses correctly identifying the appearance of ischemic penumbra on CT perfusion imaging increased from 27 to 73%. Nearly all (92%) respondents would recommend the simulation to their peers. Conclusions: Simulation of acute stroke scenarios improves participants’ knowledge of acute stroke management guidelines and may improve door-to-needle time. We present a novel framework for multidisciplinary simulation, which could be implemented at other institutions. Further evaluation of simulation effect on door-to-needle time is ongoing.

Abstract 64: Feasibility and safety on intravenous tissue Plasminogen Activator in the Pre-Hospital Acute Neurological Therapy and Optimization of Medical Care in Stroke Patients - Study (PHANTOM-S) Results of the Phantom-S pilot study

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Joachim E Weber ◽  
Martin Ebinger ◽  
Michal Rozanski ◽  
Carolin Waldschmidt ◽  
Matthias Wendt ◽  
...  
Keyword(s):  
Pilot Study ◽  
Acute Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Treatment Time ◽  
Hospital Setting ◽  
Ct Scanner ◽  
Time To Treatment ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen

Background: Beneficial effects of intravenous tissue Plasminogen Activator (tPA) in acute ischemic stroke (AIS) are strongly time-dependent. In PHANTOM-S, we use a specialized stroke ambulance equipped with a CT-scanner and point-of-care laboratory in order to shorten time-to-treatment. We report feasibility and safety of the 3-months pilot phase. Methods: The ambulance (staffed by a neurologist, paramedic and technician) is deployed by the dispatch center when the emergency call algorithm yields a suspected acute stroke. The pilot study was restricted to patients able to give informed consent. Preliminary Results: Between February 8 and April 30, 2011, the ambulance was deployed 208 times. Specific medical management was provided for 108 patients. 54 patients (50%) had a stroke while 31 (29%) had other neurological and 23 (21%) non-neurological diseases. 24 (48%) (median-NIHSS: 8; mean-age: 75±12) of 50 patients with AIS ambulance diagnosis received tPA (23 in the pre-hospital setting and one patient after admission for CT dysfunction). One of the tPA treated patients had a final non-stroke diagnosis (sepsis). Mean alarm-to-treatment time of pre-hospital tPA application was 58 minutes (62 minutes including the in-hospital tPA-application) compared to 98 minutes in 50 consecutive patients treated with tPA in Charité hospitals in 2010. Two (8%) of the tPA patients suffered a symptomatic intracranial hemorrhage and one patient (4%) died in-hospital. Technical failures comprised one CT dysfunction and two delayed CT-image transmissions Conclusions: Pre-hospital acute stroke management including tPA-application is feasible and the results suggest a significant shortening of time-to-treatment without obvious safety concerns. Final data will be presented at the ISC.

Prehospital Computed Tomography Angiography in Acute Stroke Management

2017 ◽  
Vol 44 (5-6) ◽  
pp. 338-343 ◽  
Author(s):  
Michael Kettner ◽  
Stefan Alexander Helwig ◽  
Andreas Ragoschke-Schumm ◽  
Lenka Schwindling ◽  
Safwan Roumia ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Acute Stroke ◽  
Point Of Care ◽  
Vascular Pathology ◽  
Ct Scanner ◽  
Vessel Occlusion ◽  
Spot Sign ◽  
Specialized Treatment ◽  
Mobile Stroke Unit ◽  
Prehospital Management

Background: An ambulance equipped with a computed tomography (CT) scanner, a point-of-care laboratory, and telemedicine capabilities (mobile stroke unit [MSU]) has been shown to enable the delivery of thrombolysis to stroke patients directly at the emergency site, thereby significantly decreasing time to treatment. However, work-up in an MSU that includes CT angiography (CTA) may also potentially facilitate triage of patients directly to the appropriate target hospital and specialized treatment, according to their individual vascular pathology. Methods: Our institution manages a program investigating the prehospital management of patients with suspicion of acute stroke. Here, we report a range of scenarios in which prehospital CTA could be relevant in triaging patients to the appropriate target hospital and to the individually required treatment. Results: Prehospital CTA by use of an MSU allowed to detect large vessel occlusion of the middle cerebral artery in one patient with ischemic stroke and occlusion of the basilar artery in another, thereby allowing rational triage to comprehensive stroke centers for immediate intra-arterial treatment. In complementary cases, prehospital imaging not only allowed diagnosis of parenchymal hemorrhage with a spot sign indicating ongoing bleeding in one patient and of subarachnoid hemorrhage in another but also clarified the underlying vascular pathology, which was relevant for subsequent triage decisions. Conclusion: Defining the vascular pathology by CTA directly at the emergency site may be beneficial in triaging patients with various cerebrovascular diseases to the most appropriate target hospital and specialized treatment.

A Point of Care Lateral Flow Assay for Rapid and Colorimetric Detection of Interleukin 6 and Perspectives in Bedside Diagnostics

2020 ◽  
Author(s):  
Carla Eiras
Keyword(s):  
Interleukin 6 ◽  
Limit Of Detection ◽  
Inflammatory Diseases ◽  
Point Of Care ◽  
Colorimetric Detection ◽  
Lateral Flow ◽  
Lateral Flow Assay ◽  
Aggregation Assay ◽  
Before And After ◽  
Bedside Diagnosis

Interleukin-6 (IL-6) is a multifunctional cytokine and high bloodstream levels of which have been associated with severe inflammatory diseases, such as dengue fever, sepsis, various cancers, and visceral leishmaniasis (VL). Rapid tests for the quantification of IL-6 would be of great assistance for the bedside diagnosis and treatment of diseases such as VL. We have developed a lateral flow assay (LFA) for rapid and colorimetric IL-6 detection, consisting of anti-IL-6 antibodies conjugated to gold nanoparticles (AuNPs). The optimal concentration of anti-IL-6 used in the conjugate was determined to be 800.0 μg/mL, based on an aggregation assay using LFA. A linear relationship between IL-6 standard concentration and color intensity was observed after 20 min, with a linear range between 1.25 ng/mL and 9,000 ng/mL. The limit of detection for this method was estimated a t0.38 ng/mL. The concentration of IL-6 in five patients with severe VL was measured using LFA, and the results were consistent with those obtained using the cytometric bead array (CBA) method. A thorough analysis of the LFA membranes’ surface morphology, before and after sample contact, was performed using atomic force microscopy (AFM).The prototype described here is still being tested and improved, but this LFA will undoubtedly be of great help in the clinical quantification of IL-6.

A Point of Care Lateral Flow Assay for Rapid and Colorimetric Detection of Interleukin 6 and Perspectives in Bedside Diagnostics

2020 ◽  
Author(s):  
Carla Eiras
Keyword(s):  
Interleukin 6 ◽  
Limit Of Detection ◽  
Inflammatory Diseases ◽  
Point Of Care ◽  
Colorimetric Detection ◽  
Lateral Flow ◽  
Lateral Flow Assay ◽  
Aggregation Assay ◽  
Before And After ◽  
Bedside Diagnosis

Interleukin-6 (IL-6) is a multifunctional cytokine and high bloodstream levels of which have been associated with severe inflammatory diseases, such as dengue fever, sepsis, various cancers, and visceral leishmaniasis (VL). Rapid tests for the quantification of IL-6 would be of great assistance for the bedside diagnosis and treatment of diseases such as VL. We have developed a lateral flow assay (LFA) for rapid and colorimetric IL-6 detection, consisting of anti-IL-6 antibodies conjugated to gold nanoparticles (AuNPs). The optimal concentration of anti-IL-6 used in the conjugate was determined to be 800.0 μg/mL, based on an aggregation assay using LFA. A linear relationship between IL-6 standard concentration and color intensity was observed after 20 min, with a linear range between 1.25 ng/mL and 9,000 ng/mL. The limit of detection for this method was estimated at a t0.38 ng/mL. The concentration of IL-6 in five patients with severe VL was measured using LFA, and the results were consistent with those obtained using the cytometric bead array (CBA) method. A thorough analysis of the LFA membranes’ surface morphology, before and after sample contact, was performed using atomic force microscopy (AFM). The prototype described here is still being tested and improved, but this LFA will undoubtedly be of great help in the clinical quantification of IL-6.

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