Abstract TP259: Accuracy of EMS Identification of Acute Strokes Eligible for tPA Treatment in Kaiser Stroke EXPRESS Program

Background: Field-based diversion for potential stroke patients who may qualify for endovascular stroke therapy (EST) has been proposed more widely in 2015. In 2015, Kaiser Permanente Northern California (KPNC) redesigned its acute stroke care work flow for all its 21 stroke centers, which included rapid evaluation of all stroke alerts by a stroke neurologist via teleneurology. We investigated the accuracy of EMS-activated stroke alerts. Methods: From 1/1/16 to 7/10/16, all acute strokes presenting to an ED between 7 AM and midnight were assessed upon arrival by a teleneurologist. We reviewed all telestroke cases to determine the frequency of tPA given, cancelled stroke alerts, and the reasons for not treating with IV t-PA, particularly among ambulance arrivals. Multivariate logistic regression was used to assess age, gender, race, Kaiser membership, and mode of ED arrival as predictors of stroke alert cancellation. Results: There were 2192 stroke alerts activated. Of these, 1332 (60.7%) arrived by EMS and 860 (39.2%) by non-EMS transport. Of patients arriving by EMS, 651 (48.9%) were cancelled and deemed ineligible for IV t-PA. Most common reasons for cancellation were: last time known well (LTKW) out of range (23%), stroke mimic (33%), symptom resolution (19%), new data regarding goals of care (2%), and other (22.5%). The remaining 681 (51.1%) ambulance arrivals were potential candidates for IV tPA. Subsequently, 334 (50.4%) of them received tPA. Reasons for tPA not given included subsequent resolution of symptoms, concerning CT findings (such as bleed), INR>1.7 in patients on warfarin, further information clarifying time of onset. Among those who arrived by EMS and received IV t-PA, all had CTA and 103 (30.8%) were found to have a large vessel occlusion and 74 (71.8%) underwent EST. In multivariate analysis for all cancelled stroke alerts, arrival by non-EMS transport (OR=1.74, 95% CI 1.44-2.10, p<0.001) was more likely to be cancelled. Conclusions: Close to half of EMS-activated stroke alerts were cancelled upon initial assessment. Only 5% of patients initially identified by EMS as having a potential acute stroke ultimately underwent EST. Better determination of LTKW and stroke symptoms would improve the accuracy of EMS-initiated stroke alerts.

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Abstract TMP8: Predictors of Large Vessel Occlusion in Kaiser Stroke EXPRESS Program

Stroke ◽

10.1161/str.48.suppl_1.tmp8 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Jeffrey G Klingman ◽

Anne C Kim ◽

Meghan Hatfield ◽

Benjamin Wilson ◽

Lauren Klingman ◽

...

Keyword(s):

Acute Stroke ◽

Patient Characteristics ◽

Stroke Care ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Acute Stroke Care ◽

Kaiser Permanente ◽

Vessel Occlusion ◽

Stroke Treatment ◽

Improved Outcomes

Background: In 2015, trials showed that rapid endovascular stroke treatment (EST) of qualified patients with large vessel occlusion (LVO) resulted in improved outcomes over treatment with IV tPA alone. In 2015, Kaiser Permanente Northern California (KPNC) redesigned its acute stroke care work flow for its 21 stroke centers, which included expedited IV t-pa treatment, rapid CTA investigation, expedited transfer of appropriate patients for EST. We assessed for predictors of LVO post-implementation. Methods: The KPNC Stroke EXPRESS program was live in all centers by January 2016. Using clinical data for 1/1/16 - 7/10/16, we evaluated the frequency and locations of LVO, and patient characteristics of those with LVO. Multivariate logistic regression was used to examine whether age, gender, race, or an NIHSS ≥ 8 are predictors of LVO. Results: There were 2,204 tele-stroke alert cases from the ED. Among 993 (39.3%) that proceeded as likely acute stroke, 812 (81.8%) were evaluated with CTA. Out of those who had a CTA, 152 (18.7%) were found to have LVO as followed: 27 (17.8%) ICA, 87 (57.2%) M1, 24 (15.8%) M2, 6 (4.0%) basilar, 5 (3.3%) PCA, and 3 (2.0%) vertebral. Of those with LVO, 97 (63.8%) were treated with EST. Patients with LVO had a higher median NIHSS (15 vs. 5 in those without LVO). Neglect (27% vs. 7%) and gaze deviation (16% vs. 1%) were more likely to be seen among those with LVO and treated with EST compared to those without LVO. In multivariate analysis, age (OR=1.02, 95% CI 1.00 - 1.03, p=0.01) and NIHSS ≥8 (OR = 4.99, 95% CI 3.32- 7.49, p < 0.001) were associated with LVO. PPV for NIHSS ≥8 was 75.7%. Conclusions: In our large multi-ethnic population of acute stroke patients, a relatively small percentage (19%) was found to have LVO and only a subset qualified for EST. Predictors of LVO included NIHSS ≥8, increasing age, and presence of neglect and gaze preference. Given the low numbers of patients brought in for acute stroke treatment who ended up with a LVO requiring EST, further research is needed to assess a given system’s ability to rapidly evaluate and transfer as appropriate for EST rather than paramedic based diversion.

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CT perfusion: stroke, seizure or both?

BMJ Case Reports ◽

10.1136/bcr-2021-245723 ◽

2021 ◽

Vol 14 (12) ◽

pp. e245723

Author(s):

Elizebath Davies ◽

Fathalla Elnagi ◽

Thomas Smith

Keyword(s):

Acute Stroke ◽

Small Vessel Disease ◽

Ct Perfusion ◽

Stroke Care ◽

Large Vessel ◽

Arterial Calcification ◽

Acute Stroke Care ◽

Vessel Occlusion ◽

History Of ◽

Stroke Mimic

An 88-year-old male with a history of hypertension, ischaemic heart disease and Bell’s palsy presented with symptoms and signs of an acute ischaemic stroke. National Institutes of Health Stroke Scale (NIHSS) was 19 at presentation, indicative of potential large vessel occlusion. The initial CT scan revealed evidence of small vessel disease and arterial calcification. As there were no contraindications, he received thrombolytic treatment. CT angiography and CT perfusion imaging were performed in preparation for possible thrombectomy. There was no evidence of a large vessel thrombus, and changes on CT perfusion were suggestive of seizure activity, with relative hyperperfusion on the cerebral hemisphere of interest. Post thrombolysis, his NIHSS was 5. An MR scan revealed evidence of bilateral thalamic infarcts. After a period of rehabilitation, he was discharged home and independently mobile but with cognitive impairment.Acute stroke care increasingly uses multimodal imaging to confirm the clinical diagnosis and help optimise initial emergency management. Such imaging is useful in determining whether the presentation is a vascular event or stroke mimic. Moreover, seizures complicate and mimic acute strokes, which can lead to therapeutic uncertainty. This case highlights the increasingly sophisticated investigation of patients presenting with suspected acute stroke, with the attendant need for accurate interpretation by experienced clinicians.

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Bottlenecks in the Acute Stroke Care System during the COVID-19 Pandemic in Catalonia

Cerebrovascular Diseases ◽

10.1159/000516309 ◽

2021 ◽

pp. 1-9

Author(s):

Anna Ramos-Pachón ◽

Álvaro García-Tornel ◽

Mònica Millán ◽

Marc Ribó ◽

Sergi Amaro ◽

...

Keyword(s):

Acute Stroke ◽

Functional Outcome ◽

Stroke Care ◽

Care Quality ◽

Point Of View ◽

Stroke Severity ◽

Acute Stroke Care ◽

Vessel Occlusion ◽

Prehospital Delays ◽

The Impact

Introduction: The COVID-19 pandemic resulted in significant healthcare reorganizations, potentially striking standard medical care. We investigated the impact of the COVID-19 pandemic on acute stroke care quality and clinical outcomes to detect healthcare system’s bottlenecks from a territorial point of view. Methods: Crossed-data analysis between a prospective nation-based mandatory registry of acute stroke, Emergency Medical System (EMS) records, and daily incidence of COVID-19 in Catalonia (Spain). We included all stroke code activations during the pandemic (March 15–May 2, 2020) and an immediate prepandemic period (January 26–March 14, 2020). Primary outcomes were stroke code activations and reperfusion therapies in both periods. Secondary outcomes included clinical characteristics, workflow metrics, differences across types of stroke centers, correlation analysis between weekly EMS alerts, COVID-19 cases, and workflow metrics, and impact on mortality and clinical outcome at 90 days. Results: Stroke code activations decreased by 22% and reperfusion therapies dropped by 29% during the pandemic period, with no differences in age, stroke severity, or large vessel occlusion. Calls to EMS were handled 42 min later, and time from onset to hospital arrival increased by 53 min, with significant correlations between weekly COVID-19 cases and more EMS calls (rho = 0.81), less stroke code activations (rho = −0.37), and longer prehospital delays (rho = 0.25). Telestroke centers were afflicted with higher reductions in stroke code activations, reperfusion treatments, referrals to endovascular centers, and increased delays to thrombolytics. The independent odds of death increased (OR 1.6 [1.05–2.4], p 0.03) and good functional outcome decreased (mRS ≤2 at 90 days: OR 0.6 [0.4–0.9], p 0.015) during the pandemic period. Conclusion: During the COVID-19 pandemic, Catalonia’s stroke system’s weakest points were the delay to EMS alert and a decline of stroke code activations, reperfusion treatments, and interhospital transfers, mostly at local centers. Patients suffering an acute stroke during the pandemic period had higher odds of poor functional outcome and death. The complete stroke care system’s analysis is crucial to allocate resources appropriately.

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Global Epidemiology of Stroke and Access to Acute Ischemic Stroke Interventions

Neurology ◽

10.1212/wnl.0000000000012781 ◽

2021 ◽

Vol 97 (20 Supplement 2) ◽

pp. S6-S16

Author(s):

Vasu Saini ◽

Luis Guada ◽

Dileep R. Yavagal

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Randomized Clinical Trials ◽

Time Window ◽

Systems Of Care ◽

Stroke Care ◽

Acute Stroke Care ◽

Vessel Occlusion ◽

Global Epidemiology

Purpose of the ReviewTo provide an up-to-date review of the incidence of stroke and large vessel occlusion (LVO) around the globe, as well as the eligibility and access to IV thrombolysis (IVT) and mechanical thrombectomy (MT) worldwide.Recent FindingsRandomized clinical trials have established MT with or without IVT as the usual care for patients with LVO stroke for up to 24 hours from symptom onset. Eligibility for IVT has extended beyond 4.5 hours based on permissible imaging criteria. With these advances in the last 5 years, there has been a notable increase in the population of patients eligible for acute stroke interventions. However, access to acute stroke care and utilization of MT or IVT is lagging in these patients.SummaryStroke is the second leading cause of both disability and death worldwide, with the highest burden of the disease shared by low- and middle-income countries. In 2016, there were 13.7 million new incident strokes globally; ≈87% of these were ischemic strokes and by conservative estimation about 10%–20% of these account for LVO. Fewer than 5% of patients with acute ischemic stroke received IVT globally in the eligible therapeutic time window and fewer than 100,000 MTs were performed worldwide in 2016. This highlights the large gap among eligible patients and the low utilization rates of these advances across the globe. Multiple global initiatives are underway to investigate interventions to improve systems of care and bridge this gap.

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Ongoing Improvement in Acute Ischemic Stroke Therapy Per Concurrent Guidelines and Easily Implementable Quality Improvement Protocol

Neuroscience and Neurological Surgery ◽

10.31579/2578-8868/184 ◽

2021 ◽

Vol 8 (6) ◽

pp. 01-09

Author(s):

Wengui Yu

Keyword(s):

Quality Improvement ◽

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Stroke Care ◽

Linear Regression Models ◽

Stroke Therapy ◽

Acute Stroke Care ◽

Stroke Registry ◽

Intravenous Tissue Plasminogen Activator

Background: Despite proven efficacy of intravenous tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT) in acute ischemic stroke, there has been slow administration of these therapies in the real world practice. We examined the ongoing quality improvement in acute stroke care at our comprehensive stroke center. Methods: Consecutive patients with acute ischemic stroke from 2013 to 2018 were studied. Patients were managed using Code Stroke algorithm per concurrent AHA guidelines and a simple quality improvement protocol implemented in 2015. Demographics and clinical data were collected from Get-With-The-Guideline-Stroke registry and electronic medical records. Patients were divided into 3 groups per admission and implementation date of quality improvement initiatives. Quality measures, including rates of intravenous tPA and EVT, door-to-needle (DTN) time, and door-to-puncture (DTP) time, were analyzed with general mean linear regression models and Jonckheere-Terpstra test. Results: Of the 1,369 eligible patients presenting within 24 hours of symptom onset or wakeup stroke, the rate of intravenous tPA was 20%, 30% and 22%, respectively, in 2013-2014, 2015-2016, and 2017-2018. In contrast, EVT rate was 9%, 14% and 15%, respectively. Based on Jonckheere-Terpstra test, there was significant ongoing improvement in the median DTN time (57, 45, 39 minutes; p < 0.001) and DTP time (172, 130, 114 minutes; p =0.009) during the 3 time periods, with DTN time ≤ 60 and ≤45 minutes in 80% and 63% patients, respectively, in 2017-2018. Conclusions: Getting with the guidelines and simple quality improvement initiatives are associated with satisfactory rates of acute stroke therapy and ongoing improvement in door to treatment times.

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

Stroke ◽

10.1161/str.48.suppl_1.wp273 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Radoslav I Raychev ◽

Dana Stradling ◽

David M Brown ◽

Joey R Gee ◽

David L Lombardi ◽

...

Keyword(s):

Acute Stroke ◽

Systems Of Care ◽

Early Recognition ◽

Stroke Care ◽

Reperfusion Therapy ◽

Acute Stroke Care ◽

Vessel Occlusion ◽

Transfer Rates ◽

Over Time ◽

Iv Tpa

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

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The COAST stroke advance directive

Neurology Clinical Practice ◽

10.1212/cpj.0000000000000549 ◽

2018 ◽

Vol 8 (6) ◽

pp. 521-526 ◽

Cited By ~ 1

Author(s):

Kevin McGehrin ◽

Ilana Spokoyny ◽

Brett C. Meyer ◽

Kunal Agrawal

Keyword(s):

Acute Stroke ◽

Advance Directive ◽

Patient Autonomy ◽

Stroke Care ◽

Time Constraints ◽

Stroke Therapy ◽

Acute Stroke Care ◽

Medical Decisions ◽

Language And Cognition ◽

Acute Stroke Therapy

Within the field of neurology, there has been limited discussion of how to best respect patient autonomy in patients presenting with an acute stroke, who often have impairments in language and cognition. In addition to performing a detailed neurologic examination and providing a thorough timeline of their current presentation and medical history, these patients and their families are then asked to quickly make critical medical decisions regarding acute stroke therapies (thrombolysis and endovascular therapy). These discussions are often limited by time constraints and inadequate opportunities for patient education regarding acute stroke care. This article discusses some of the challenges of preserving patient autonomy in patients presenting with acute stroke and the advent of a stroke advance directive (Coordinating Options for Acute Stroke Therapy [COAST]) aimed to overcome these obstacles.

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Stroke Intervention: Geographic Disparities in Acute Stroke Care and the Role of Interventional Cardiology

EMJ Interventional Cardiology ◽

10.33590/emjintcardiol/20-00009 ◽

2020 ◽

Keyword(s):

Acute Stroke ◽

Case Series ◽

Intravenous Thrombolysis ◽

Interventional Cardiology ◽

Stroke Care ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Acute Stroke Care ◽

Vessel Occlusion ◽

Geographic Disparities

Stroke is the second-leading cause of death and a major cause of disability worldwide. The majority of strokes are ischaemic, and effective therapy to achieve reperfusion includes intravenous thrombolysis and, for proximal large vessel occlusion strokes, endovascular mechanical thrombectomy (MT). There has been a paradigm shift in acute stroke care, driven by a series of randomised controlled trials demonstrating that timely reperfusion with MT results in superior outcomes compared to intravenous thrombolysis in patients with large vessel occlusion strokes. There are significant geographic disparities in delivering acute stroke care because of the maldistribution of neurointerventional specialists. There are now several case series demonstrating the feasibility and safety of first medical contact MT by carotid stent-capable interventional cardiologists and noninvasive neurologists working on stroke teams, which is a solution to the uneven distribution of neurointerventionalists and allows stroke interventions to be delivered in local communities.

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Support of New Triage Protocol among Acute Stroke Care Providers

Interventional Neurology ◽

10.1159/000486459 ◽

2018 ◽

Vol 7 (5) ◽

pp. 241-245

Author(s):

Haitham M. Hussein ◽

David C. Anderson

Keyword(s):

Acute Stroke ◽

Online Survey ◽

Medical Service ◽

Stroke Care ◽

Care Providers ◽

Large Vessel Occlusion ◽

Acute Stroke Care ◽

Vessel Occlusion ◽

Triage Protocol ◽

Almost All

Objective: We conducted an online survey to gauge the acceptance of sending acute stroke patients with suspected large vessel occlusion (LVO) directly to an endovascular-capable hospital (ECH) even if that means bypassing a closer alteplase-capable hospital (ACH) without endovascular capability. Methods: The survey was composed of two cases of acute stroke, one with cortical symptoms suggestive of LVO and the other without. In each case, responders were asked to choose between triaging to a closer ACH or an ECH that is further away and to provide an opinion regarding the maximum extra travel time they would tolerate if they chose the ECH. The survey was sent electronically to national groups of neurologists, emergency department (ED) physicians, emergency medical service (EMS) directors, and stroke coordinators. Results: There were 320 responders from 44 states, most of them with 10 years or more of experience. Most of the responders, 72.5%, chose ECH for the LVO case, while 56% chose ACH for the non-LVO case. There were marked differences in responses by specialty: neurology strongly supported ECH for LVO and strongly supported ACH for non-LVO, most ED and EMS chose ECH for both cases, and stroke coordinators were the least supportive of bypassing ACH. Almost all groups agreed on 30 min as the acceptable extra transfer time to ECH. Conclusion: Among the survey responders, there is a broad acceptance of the idea of bypassing ACH and going straight to ECH when LVO is suspected; however, there is less agreement on triaging patients with non-LVO stroke.

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

Stroke ◽

10.1161/str.51.suppl_1.tp250 ◽

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.

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