Abstract TP362: Door to Needle Time Improves With Implementation of an Alteplase Alert Within the Existing Code Stroke Process in a Primary Stroke Center Emergency Department

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Tonia P Shelton ◽  
Leticia M Riley ◽  
Erin K Kibbey ◽  
Kristine J Heatley
Keyword(s):  
Emergency Department ◽  
Median Time ◽  
Action Plans ◽  
Frontline Staff ◽  
Charge Nurse ◽  
Primary Stroke Center ◽  
Consistent Manner ◽  
Primary Nurse ◽  
Stroke Center ◽  
Innovative Action

Background and Purpose: A Primary Stroke Center Emergency Department (ED) identified the need to decrease Door to Needle Time (DNT) for intravenous administration of Alteplase in order to align with stroke standards and provide optimal patient outcomes. Methods: A systematic review of the data collected since September 2014 demonstrated opportunities for improvement with our current Code Stroke process, consequently delaying DNT. Frontline staff identified a delay in the time from the physician’s order to initiation of Alteplase infusion. Based on the identified communication gaps between the physician and nursing staff, two innovative action plans were developed. An Alteplase Alert was implemented within the existing Code Stroke process. In addition to the facility-wide overhead Code Stroke initially placed upon patient arrival, an internal Alteplase Alert is now initiated within the ED once it is determined the patient is a candidate for Alteplase. Once the Alteplase Alert is initiated the charge nurse, an ED tech, and the designated Code Stroke nurse respond immediately to the patient’s bedside to assist the primary nurse in initiating the tasks associated with Alteplase administration. Secondly, a stroke Alteplase tool was designed to ensure continuity of care and team collaboration. Results: Data from January 2014 through August 2015 was used to establish the baseline. Prior to implementation, there were 2/17 (11.76%) patients with a DNT less than 60 minutes, with a median time of 84 minutes. After implementation, data from October 2015 through June 2016, demonstrated a decrease in DNT. There were 15/17 (88.23%) patients with DNT less than 60 minutes, with a median time of 51 minutes. Conclusions: Implementation of the innovative action plans including the Alteplase Alert and Stroke tool helped to accomplish a goal of improved DNT in an efficient and consistent manner. Application of the aforementioned plans led to immediate results. Over the last 10 months, the DNT has sustained a significant improvement.

Comparison of Code Stroke Response Times Between Emergency Department and Inpatient Settings in a Primary Stroke Center

2021 ◽  
Vol 11 (3-4) ◽  
pp. 47-53
Author(s):  
Catarina De Marchi Assuncao ◽  
Beth Chauncey Evers ◽  
Cassio Henrique Taques Martins ◽  
Kerri Remmel
Keyword(s):  
Emergency Department ◽  
Response Times ◽  
Primary Stroke Center ◽  
Inpatient Settings ◽  
Stroke Center

Abstract TP341: Nursing Impact on the Acute Stroke Team - Driving Practice in a Collaborative Environment

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Lauri Speirs
Keyword(s):  
Emergency Department ◽  
Acute Stroke ◽  
Endovascular Therapy ◽  
Golden Hour ◽  
Stroke Team ◽  
Primary Stroke Center ◽  
Response Team ◽  
Intense Training ◽  
Stroke Center ◽  
Time Frames

Background /Purpose: In 2005 a community hospital began the journey to Primary Stroke Center. One aspect was to develop a stroke response team. The acute stroke team must provide neurologist expertise at bedside, be cost neutral, compliment the workflow in the Emergency Department, and maximize the limited number of neurologists on staff. Stroke unit nurses were identified as neurological experts in the hospital. After intense training, Stroke Alert went live in October of 2007. The nurse led acute stroke team (AST) collaborated with the medical staff to increase the total volume of stroke patients receiving t-PA. With additional training, the nurse led team assisted in the identification and transfer of patients for endovascular therapy. Method: A group of 12 nurses were trained by the stroke medical director to complete a stroke assessment, then to communicate those findings to the neurologist on call and the Emergency Department physicians. The nurse responders and the Emergency Department nurses were trained to mix and calculate the doses for t-PA. In 2010 the nurse responders were educated on the criteria for endovascular therapy, including time frames, patient assessment, and key CT results. In 2011, the nurse responders were re-educated on the golden hour of stroke. Results: Since 2008, over 450 stroke alerts have been activated each year. The administration of t-PA increased from 4 patients in 2007 to 43 patients in 2011; an additional 9 patients were sent to another facility for endovascular therapy. In the first 6 months of 2012, over 50% of patients receive t-PA in less than 60 minutes and Gold plus from the AHA was achieved. Conclusion: Nurses can be a vital asset to the AST by providing neurological expertise, collaborating with physicians, and driving the stroke protocols.

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

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Deborah R Lee-Ekblad ◽  
Nan Meyers ◽  
Kelly Becker ◽  
Milind Chinoy ◽  
Brandon Lawrence ◽  
...  
Keyword(s):  
Emergency Department ◽  
Medical Center ◽  
Hospitalized Patients ◽  
Stroke Patients ◽  
Improvement Project ◽  
Early Management ◽  
Stroke Treatment ◽  
Primary Stroke Center ◽  
Stroke Center ◽  
Ischemic Attack

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

Abstract 3150: Partnering with Emergency Department Staff Educators Increases the Number of Notifications to the Acute Stroke Research Team

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Hannah Reimer ◽  
Suzanne DuRocher ◽  
Susan Galiczynski
Keyword(s):  
Emergency Department ◽  
Acute Stroke ◽  
Research Team ◽  
Clinical Staff ◽  
Treatment Area ◽  
Data Set ◽  
Research Personnel ◽  
Stroke Research ◽  
Primary Stroke Center ◽  
Stroke Center

Background: Preparation for the Joint Commission survey to determine Primary Stroke Center Certification requires extensive education of staff in all areas a stroke patient will be during their hospitalization. Research personnel in the Emergency Department (ED) often rely on clinical staff for notification of potential research participants. When present in the treatment area research personnel are notified in person or find potential participants by reviewing a patient’s chief complaint or admitting diagnosis. When outside the treatment area, particularly during times when on call from outside the hospital, the research staff is dependent on notification by clinical staff. Methods: During the survey preparation, ED staff was educated in care of ischemic and hemorrhagic stroke patients according to AHA/ASA guidelines. During the formal nursing education research personnel gave short presentations on currently enrolling acute stroke trials and gave instructions on how to reach the research team in the event that a potential study participant entered the ED. Quarterly research reports were given at the Emergency Medicine resident’s conference. Education was given to the nursing and medical staff from October 2010 through July 2011 when the survey took place. The database of the online paging system was reviewed for the time period April 2010 through July 2011. Test, demonstration, non-stroke study and calls from other institutions were deleted from the data set. The remaining calls were divided by the month in which they were placed. Results: The research team received on average 5 calls per month during the six months prior to the AHA/ASA education. During the education time the research team received on average 9.6 calls per month. Conclusion: Acute stroke research personnel increase the number of potential patient notifications by participating in ED staff education for the Primary Stroke Center Certification survey.

Abstract P828: Reducing and Sustaining "Door-To-Monitored Bed" Times in Patients Receiving Alteplase for Acute Stroke Symptoms

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Janet Leatherwood ◽  
Maureen Lall ◽  
Diane McGraw ◽  
Rita Richards ◽  
Fiona Smith
Keyword(s):  
Emergency Department ◽  
Change Management ◽  
Acute Stroke ◽  
Rapid Assessment ◽  
Stroke Care ◽  
Management Model ◽  
Quality Improvement Initiative ◽  
Process Change ◽  
Primary Stroke Center ◽  
Stroke Center

Background and Issues: Acute strokes are medical emergencies that require rapid assessment and treatment. Following treatments, focused and frequent monitoring is essential to quickly identify and mitigate any physiological deterioration. However, hospital capacity and decreased availability of monitored beds often causes delay in admission and prolonged stays in the emergency department and the potential increase in morbidity and mortality. Purpose: The purpose of this quality improvement initiative is to reduce the length of time from a patient presenting to the emergency department with acute stroke symptoms and treated with alteplase, to the time that the patient is being monitored utilizing “comprehensive specialized stroke care” level monitoring. This level of monitoring allows for the patient to be assessed closely and frequently to ensure the absence of physiological or neurological deterioration as well as for any adverse thrombolytic reaction. Methods: To improve the process of patient progression within the hospital, the care team utilized the ADKAR® Change Management Model. This model focuses on sponsoring awareness, promoting desire, providing knowledge, ensuring ability, and reinforcing changes. Each of these five components is critical to implement the proposed changes and ensure the longevity of the process changes. Results: Since the implementation of the process change, the Primary Stroke Center has experienced twenty-four months of mean “door-to-monitored bed” times below the 180 minute benchmark. In addition, the mean “door to monitored bed” time has decreased from 210 minutes in the three months preceding the process change (n=20), to 113 minutes during the twenty-four months following the change (n=150). Conclusions: During this process change, the Stroke Center successfully reduced the time between patient arrival and being in a monitored bed. The use of the ADKAR® Change Management Model is particularly advantageous in implementing a process change that is expected to be sustained into the future.

In-Hospital Stroke Care: A Six-Year Community-Based Primary Stroke Center Experience

2021 ◽  
pp. 194187442110070
Author(s):  
Felix Ejike Chukwudelunzu ◽  
Bart M Demaerschalk ◽  
Leonardo Fugoso ◽  
Emeka Amadi ◽  
Donn Dexter ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Hospital Mortality ◽  
Statistical Significance ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
Community Based ◽  
Chi Square ◽  
Stroke Team ◽  
Primary Stroke Center ◽  
Stroke Center

Background and purpose: In-hospital stroke-onset assessment and management present numerous challenges, especially in community hospitals. Comprehensive analysis of key stroke care metrics in community-based primary stroke centers is under-studied. Methods: Medical records were reviewed for patients admitted to a community hospital for non-cerebrovascular indications and for whom a stroke alert was activated between 2013 and 2019. Demographic, clinical, radiologic and laboratory information were collected for each incident stroke. Descriptive statistical analysis was employed. When applicable, Kruskal-Wallis and Chi-Square tests were used to compare median values and categorical data between pre-specified groups. Statistical significance was set at alpha = 0.05. Results: There were 192 patients with in-hospital stroke-alert activation; mean age (SD) was 71.0 years (15.0), 49.5% female. 51.6% (99/192) had in-hospital ischemic and hemorrhagic stroke. The most frequent mechanism of stroke was cardioembolism. Upon stroke activation, 45.8% had ischemic stroke while 40.1% had stroke mimics. Stroke team response time from activation was 26 minutes for all in-hospital activations. Intravenous thrombolysis was utilized in 8% of those with ischemic stroke; 3.4% were transferred for consideration of endovascular thrombectomy. In-hospital mortality was 17.7%, and the proportion of patients discharged to home was 34.4% for all activations. Conclusion: The in-hospital stroke mortality was high, and the proportions of patients who either received or were considered for acute intervention were low. Quality improvement targeting increased use of acute stroke intervention in eligible patients and reducing hospital mortality in this patient cohort is needed.

627 Strategies for Reducing Emergency Department Lengths of Stay for Admitted Pediatric Burn Patients

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S169-S169
Author(s):  
Lisa M Shostrand ◽  
Brett C Hartman ◽  
Belinda Frazee ◽  
Dawn Daniels ◽  
Madeline Zieger
Keyword(s):  
Emergency Department ◽  
Gap Analysis ◽  
Burn Patients ◽  
Improvement Project ◽  
Burn Trauma ◽  
Charge Nurse ◽  
Lengths Of Stay ◽  
Burn Unit ◽  
Set Up ◽  
Trauma Activation

Abstract Introduction Various strategies to reduce emergency department (ED) lengths of stay (LOS) for admitted pediatric burn patients may be employed as a quality improvement project. Decreasing ED LOS may promote patient outcomes and reduce morbidity. Initial discussions were brought forth during trauma and burn multidisciplinary peer review rounds in March 2019 and have persisted to present day. Methods Several strategies, such as preparation of the burn unit staff within one hour of patient arrival in ED, notification to the burn unit by the burn attending of an incoming pediatric burn patient, allowing the PICU charge nurses or advisors to assist with room set up and admissions, and creating a checklist to assist PICU nurses and advisors in helping prepare for anticipating inpatient admissions. These strategies were designed and enforced in March/April 2019. In addition to these action plans, trauma activation alerts were added in December 2019 to the burn charge nurse phone for pediatric burn trauma one and trauma alerts for more expedient notifications. Finally, communication efforts between ED and burn leadership teams were conducted in June 2020 to help with additional mitigating of ED LOS, such as discussing the appropriateness of specialty consults while in the ED. Results Initial ED LOS was reduced from 209 minutes in March 1019 to 150 minutes in June 2019. Increased trends were noted in early 2020, with a peak at 244 minutes in July 2020. Additional interventions, such as trauma activation alerts and ED/Burn team communications, did not provide sustainable long-term reductions. Conclusions Recent strategies to reduce overall ED LOS trends have been beneficial, but not consistent, in sustaining downward trends. Action to perform a gap analysis to discover persistent barriers and to introduce additional structure, such as a burn trauma one algorithm, may provide stability to this metric.

Effect of “drip-and-ship” and “drip-and-drive” on endovascular treatment of acute ischemic stroke with large vessel occlusion: a single-center retrospective study

2021 ◽  
pp. 028418512110068
Author(s):  
Yu Hang ◽  
Zhen Yu Jia ◽  
Lin Bo Zhao ◽  
Yue Zhou Cao ◽  
Huang Huang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Primary Stroke Center ◽  
Secondary Endpoints ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background Patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) were usually transferred from a primary stroke center (PSC) to a comprehensive stroke center (CSC) for endovascular treatment (drip-and-ship [DS]), while driving the doctor from a CSC to a PSC to perform a procedure is an alternative strategy (drip-and-drive [DD]). Purpose To compare the efficacy and prognosis of the two strategies. Material and Methods From February 2017 to June 2019, 62 patients with LVO received endovascular treatment via the DS and DD models and were retrospectively analyzed from the stroke alliance based on our CSC. Primary endpoint was door-to-reperfusion (DTR) time. Secondary endpoints included puncture-to-recanalization (PTR) time, modified Thrombolysis in Cerebral Infarction (mTICI) rates at the end of the procedure, and modified Rankin Scale (mRS) at 90 days. Results Forty-one patients received the DS strategy and 21 patients received the DD strategy. The DTR time was significantly longer in the DS group compared to the DD group (315.5 ± 83.8 min vs. 248.6 ± 80.0 min; P < 0.05), and PTR time was shorter (77.2 ± 35.9 min vs. 113.7 ± 69.7 min; P = 0.033) compared with the DD group. Successful recanalization (mTICI 2b/3) was achieved in 89% (36/41) of patients in the DS group and 86% (18/21) in the DD group ( P = 1.000). Favorable functional outcomes (mRS 0–2) were observed in 49% (20/41) of patients in the DS group and 71% (15/21) in the DD group at 90 days ( P = 0.089). Conclusion Compared with the DS strategy, the DD strategy showed more effective and a trend of better clinical outcomes for AIS patients with LVO.

scholarly journals COVID-19: Stroke Admissions, Emergency Department Visits, and Prevention Clinic Referrals

2020 ◽  
Vol 47 (5) ◽  
pp. 693-696 ◽  
Author(s):  
Maria Bres Bullrich ◽  
Sebastian Fridman ◽  
Jennifer L. Mandzia ◽  
Lauren M. Mai ◽  
Alexander Khaw ◽  
...  
Keyword(s):  
Emergency Department ◽  
Stroke Prevention ◽  
Stroke Unit ◽  
Emergency Department Visits ◽  
Related Factors ◽  
Hospital Policies ◽  
The Government ◽  
Stroke Center ◽  
The Impact ◽  
Prevention Clinic

Abstract:We assessed the impact of the coronavirus disease 19 (COVID-19) pandemic on code stroke activations in the emergency department, stroke unit admissions, and referrals to the stroke prevention clinic at London’s regional stroke center, serving a population of 1.8 million in Ontario, Canada. We found a 20% drop in the number of code strokes in 2020 compared to 2019, immediately after the first cases of COVID-19 were officially confirmed. There were no changes in the number of stroke admissions and there was a 22% decrease in the number of clinic referrals, only after the provincial lockdown. Our findings suggest that the decrease in code strokes was mainly driven by patient-related factors such as fear to be exposed to the SARS-CoV-2, while the reduction in clinic referrals was largely explained by hospital policies and the Government lockdown.

Strategies to Care for Patients Being Treated in the Emergency Department After Self-harm: Perspectives of Frontline Staff

2021 ◽  
Author(s):  
Gala True ◽  
Miranda Pollock ◽  
Cadence F. Bowden ◽  
Sara Wiesel Cullen ◽  
Abigail M. Ross ◽  
...  
Keyword(s):  
Emergency Department ◽  
Frontline Staff ◽  
Self Harm
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