Abstract TP369: EMS and ED Feedback Tool: Improving Metrics and Patient Outcome

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Angelia F Russell ◽  
Matthew E Tilem ◽  
Barbara V Voetsch
Keyword(s):  
Patient Outcome ◽  
Emergency Department ◽  
Stroke Patient ◽  
Stroke Care ◽  
Time Of Arrival ◽  
Modified Rankin Scale ◽  
Discharge Diagnosis ◽  
Cat Scan ◽  
Free Care ◽  
Patient’S Outcome

Background: Prompt recognition by emergency medical services (EMS) and emergency department (ED) triage is paramount in the treatment and survival of the stroke patient. We hypothesized that providing prompt feedback to EMS and ED on stroke care may improve EMS and hospital metrics and raise the hospital’s defect free care. Objective: To determine if the feedback provided to EMS and ED would improve the metrics and patient outcome. Method: A retrospective analysis comparing the percent of patients met the metrics prior to and after initiation of the feedback tools. Feedback forms were developed May 2015, education provided on forms Jun 2015, and implemented Jul 2015. Feedback was provided on all patients called in as a SA, BA on arrival, and/or patients with a discharge diagnosis of stroke. Results: Comparing the first six months prior to the feedback tool (127 BA in ED and 31 EMS SA) with the six months after (173 BA in the ED and 79 EMS SA) the Get with the Guideline (GWTG) timeline goals in the ED improved (Time of Arrival (TOA) to MD, goal 10 minutes, May 2015 35% to Dec 2015 100%; TOA to Neurology Consult, goal 15 minutes, May 2015 65% to Dec 2015 82%; TOA to Cat Scan (CT), goal 25 minutes, May 2015 41% to Dec 2015 79%; TOA to CT read, goal 45 minutes, May 2015 12% to Dec 2015 71%; TOA to t-PA, goal 60 minutes, May 2015 0% to Dec 2015 80%; CT ordered as a stroke, May 2015 21% to Dec 2015 84%; dysphagia screening prior to by mouth, May 2015 29% to Dec 93%) and the number of stroke alerts increased (pre-notification rates Q1/Q2 26.3%; Q3/Q4 56.8%). The hospital’s stroke defect free care in Q1/Q2 (77.3%) increased in Q1/Q2 2016 (97.2%). With the improvements in the EMS, ED, and hospital metrics, length of stay (LOS) decreased (Q1/Q2 5.77 days to Q3/Q4 5.05 days) and more patients were discharged with a lower modified Rankin Scale (mRS) (Q1/Q2 mRS 0-3 33%; Q3/Q4 mRS 0-3 48%). Conclusion: The EMS and ED metrics improved and continue to improve despite a growing and thriving neurology service. By providing the stroke care feedback, EMS and ED developed a more vested interested in the patient’s outcome. Based on the response from the EMS and ED staff on the stroke feedback tools, it is the most expedient and efficient way to communicate and continually educate on the care of the stroke patient both pre-hospital and in hospital.

Abstract W P269: Collaboration in the Emergency Department Improves Stroke Care

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Julie M Fussner ◽  
Kiefah Awadallah
Keyword(s):  
Emergency Department ◽  
Stroke Patient ◽  
Stroke Care ◽  
Ct Scanner ◽  
Patient Room ◽  
University Hospitals ◽  
Charge Nurse ◽  
Prioritization Process ◽  
Hand Off ◽  
Telephone Calls

Introduction: The purpose of this project is to improve the timeliness of stroke care at University Hospitals Comprehensive Stroke and Cerebrovascular Center (UHCSCC). Several projects were implemented in the Emergency Department (ED): Brain Attack (BAT) Lab Turnaround, ED Medic Role Revision, Standardized Handoff Tool and Dedicated Stroke Patient Room. Methods: First, the BAT lab project addressed the need to expedite lab results since there was no prioritization of specimens. Working with a multidisciplinary team including the ED Lab Quality committee, a new process was developed for the BAT labs using a colored requisition. Second, the ED Medic role was identified to assist with communication of incoming transfers At UHCSCC communication of all patients arriving by EMS or transfers from other facilities is directed through the UH Transfer Center. With an average of 150 patients arriving per day, this requires 8.1 hours of telephone calls placed to the ED charge nurse a month. Third, documentation of the handoff from transporting personnel was written inconsistently in multiple locations. A standardized hand off form was implemented for the nurse to obtain consistent and readily available information to provide efficient care for the stroke patient. Finally, when a new ED was built in 2011, a dedicated stroke room was designed with an attaching CT scanner to further improve the time of diagnosis for the stroke patient. Results: With the new prioritization process for lab specimens, the turnaround times dramatically improved. Average result times decreased by 23 minutes for CBC, 47 minutes for BMP and 35 minutes for PT/ INR. The Medic role revision decreased the telephone calls placed to the ED charge nurse by 5.5 hours a month to allow more time spent assisting with patient care. Handoff documentation improved from 33% to 90% compliance. Finally, in the new ED with the stroke room attached to the CT scanner, the average time from arrival to CT completion decreased from average of 32 to 20 minutes. Conclusions: The implementation of the BAT Lab Turnaround, ED Medic Role Revision, Standardized Handoff Tool and Dedicated Stroke Patient Room projects have all demonstrated that collaboration between the ED and other disciplines has improved the stroke care provided.

Syncope and Presyncope as a Presenting Symptom or Discharge Diagnosis in the Emergency Department: An Administrative Data Validation Study

2017 ◽  
Vol 33 (12) ◽  
pp. 1729-1732
Author(s):  
John A. Staples ◽  
Cristian Vadeanu ◽  
Bobby Gu ◽  
Shannon Erdelyi ◽  
Herbert Chan ◽  
...  
Keyword(s):  
Emergency Department ◽  
Administrative Data ◽  
Validation Study ◽  
Discharge Diagnosis ◽  
Data Validation

scholarly journals Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018

2018 ◽  
Vol 13 (9) ◽  
pp. 949-984 ◽  
Author(s):  
JM Boulanger ◽  
MP Lindsay ◽  
G Gubitz ◽  
EE Smith ◽  
G Stotts ◽  
...  
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Transient Ischemic Attack ◽  
Best Practice ◽  
Stroke Care ◽  
Stroke Management ◽  
Practice Recommendations ◽  
Prehospital Emergency ◽  
Ischemic Attack

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider’s recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

scholarly journals Interfacility transfers for US ischemic stroke and TIA, 2006–2014

Neurology ◽  
2018 ◽  
Vol 90 (18) ◽  
pp. e1561-e1569 ◽  
Author(s):  
Benjamin P. George ◽  
Sara J. Doyle ◽  
George P. Albert ◽  
Ania Busza ◽  
Robert G. Holloway ◽  
...  
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Stroke Care ◽  
Hospital Level ◽  
Transfer Rates ◽  
The Us ◽  
Ed Visits ◽  
Low Volume

ObjectiveTo investigate changes in emergency department (ED) transfers for ischemic stroke (IS) and TIA.MethodsWe performed a retrospective observational study using the US Nationwide Emergency Department Sample to identify changes in interfacility ED transfers for IS and TIA from the perspective of the transferring ED (2006–2014). We calculated nationwide transfer rates and individual ED transfer rates for IS/TIA by diagnosis and hospital characteristics. Hospital-level fractional logistic regression examined changes in transfer rates over time.ResultsThe population-estimated number of transfers for IS/TIA increased from 22,576 patient visits in 2006 to 54,485 patient visits in 2014 (p trend < 0.001). The rate of IS/TIA transfer increased from 3.4 (95% confidence interval [CI] 3.0–3.8) in 2006 to 7.6 (95% CI 7.2–7.9) in 2014 per 100 ED visits. Among individual EDs, mean transfer rates for IS/TIA increased from 8.2 per 100 ED visits (median 2.0, interquartile range [IQR] 0–10.2) to 19.4 per 100 ED visits (median 8.1, IQR 1.1–33.3) (2006–2014) (p trend < 0.001). Transfers were more common among IS. Transfer rates were greatest among rural (adjusted odds ratio [AOR] 3.05, 95% CI 2.56–3.64) vs urban/teaching and low-volume EDs (AOR 7.49, 95% CI 6.58–8.53, 1st vs 4th quartile). The adjusted odds of transfer for IS/TIA increased threefold (2006–2014).ConclusionsInterfacility ED transfers for IS/TIA more than doubled from 2006 to 2014. Further work should determine the necessity of IS/TIA transfers and seek to optimize the US stroke care system.

Abstract WP280: Use of Strategies to Improve Door-to-Needle Times with Tissue Plasminogen Activator in Acute Ischemic Stroke by US Hospitals: Findings from the Target: Stroke Survey

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Gregg C Fonarow ◽  
Eric E Smith ◽  
Xin Zhao ◽  
Eric D Peterson ◽  
Ying Xian ◽  
...  
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Stroke Care ◽  
Ct Scanner ◽  
Critical Pathways ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen

Background: The benefits of intravenous tissue-plasminogen activator (tPA) in acute ischemic stroke are time-dependent and several strategies have been reported to be associated with more rapid door-to-needle (DTN) times. However, the extent to which hospitals are utilizing these strategies has not been well studied. Methods: We surveyed 304 hospitals joining Target: Stroke regarding their baseline use of strategies to reduce door-to-needle times in the 1/2008-2/2010 timeframe (prior to the initiation of Target: Stroke). The survey was developed based on literature review and expert consensus for strategies identified as being associated with shorter DTN times and further refined after pilot testing. Categorical responses are reported as frequencies. Results: Hospitals participating in the survey were 50% academic, median 163 (IQR 106-247) ischemic stroke admissions per year, median 10 (IQR 6-17) tPA treated patients per year, and had median 79 minute (IQR 71-89) DTN times. By survey, 214 of 304 hospitals (70%) reported initiating or revising strategies to reduce DTN times in the prior 2 years. Reported use of the different strategies varied in frequency, with use of ischemic stroke critical pathways, CT scanner located in the Emergency Department, and tPA being stored in the Emergency Department being the strategies least frequently employed (Table). As part of Target: Stroke participation, 279 of 304 hospitals (91.5%) indicated they planned to have a dedicated team focused on reducing DTN times. Conclusions: While most US hospitals participating in this survey report use of the strategies to improve the timeliness of tPA administration for acute ischemic stroke, significant variation exists. Further research is needed to understand which of these strategies are most effective in improving acute ischemic stroke care.

Abstract TP251: It’s All in the Wrist - Integrating EMS, Telestroke and Stroke Registry Data Systems

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Aliza T Brown ◽  
David Vrudny ◽  
Tammie Marshall ◽  
Sanjeeva Onteddu ◽  
Martin Radvany ◽  
...  
Keyword(s):  
Stroke Patient ◽  
Stroke Care ◽  
Data Systems ◽  
Medical Systems ◽  
Educational Training ◽  
Band Placement ◽  
Discharge Data ◽  
Stroke Registry ◽  
Positive Screen ◽  
Get With The Guidelines

Background: States without a recognized directive for stroke care and transport risk the ability to monitor, assess and review stroke patient movement from first medical contact (FMC) to delivery/and/or transfer to hospitals. We are seeking to determine a new tracking program’s efficacy from emergency medical systems (EMS) to telestroke sites and other receiving hospitals utilizing Get-With-The-Guidelines (GWTG) in data reporting. Hypothesis: We hypothesized that all three entities (EMS, telestroke sites and other hospitals) would record suspected and positive strokes into their electronic databases and integrate the process into their standard of practice, protocols and guidelines. Methods: Statewide EMS agencies, receiving hospitals in the Arkansas Stroke Registry and telestroke sites received educational training about placing blue wristbands on all suspected strokes. Stroke bands were to be placed on all patients arriving via EMS or privately owned vehicle. The bands contained a unique number sequence for recording in both EMS and hospital GWTG electronic databases. We retrospectively reviewed all prospectively collected data from January 1, 2019 to May 31, 2019 for wristband placement by the EMS systems and determined the percentage match to hospital emergency department (ED) discharge data using the GWTG data and telestroke data. Results: From the five months of retrospective analysis of prospectively collected data for 5 months showed, 4,668 strokes were seen in hospitals complying with GWTG. Forty-two% of the positive strokes in hospital (EDs) had stroke bands placed. Of these 8.4% had matching stroke wristband numbers to the EMS database. The telestroke system reported 636 consultations with 95% band placement, 39% placed by EMS. Matching telestroke band ID’s to EMS records was 37%. Wristbands placed by EMS were associated with positive screen tests, pre-notification and shortened Door to CT time (p < 0.0021). Conclusions: Wrist-bands were associated with improved EMS response and provided informed response to hospital care teams. For consistent tracking of positive stroke patient data from FMC to discharge both prehospital and hospital, systems must undergo additional training followed by surveys to determine informed training.

Abstract TP227: Outcomes of a Regionalized Stroke Care System

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Denisse Sequeira ◽  
Christian Martin-Gill ◽  
Gregory Lowry ◽  
Marcus Robinson ◽  
Hinnah Siddiqui ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Functional Outcome ◽  
Stroke Care ◽  
Discharge Diagnosis ◽  
Hospital Data ◽  
Exact Test ◽  
Endovascular Interventions ◽  
Good Functional Outcome ◽  
Suspected Stroke ◽  
Iv Tpa

Introduction: Strokes are one of the leading causes of death and disability. Time-sensitive therapies are available including IV-TPA and endovascular therapies which require rapid and effective triage. Endovascular therapies are available at comprehensive stroke centers (CSC). We evaluated if there was any improvement in outcomes for patients who are transported directly to a CSC. Hypothesis: Patients that receive acute interventions for stroke have improved outcomes when transferred directly to CSC as compared to transport to a PSC and then transferred to a interventional facility. Methods: A retrospective cohort study of 5,188 patients transported from January 2012 to December 2013 with an EMS provider impression of suspected stroke via both air and ground transport. Of these, data was complete for 1,196 patients with a confirmed discharge diagnosis of ischemic stroke. Pre-hospital data was abstracted from EMS charts. Ischemic strokes were identified by final hospital discharge diagnosis and good functional status was defined as a modified Rankin scale <3 at discharge. Categorical outcomes were tested using Fishers Exact Test and Ordinal outcomes using the Mann Whitney Test. Results: For those with complete data mortality was 10% (CI 8.3-11.7) in this cohort with good functional outcomes in 37% (CI 34.3-39.7) of patients. IV- TPA was administered to 293 (24%) and endovascular interventions were performed in 167 (14%). There were 739 (63%) inter-facility transfers and 442 (37%) received directly from the scene. Transport to the CSC occurred by air in 798 (67%) cases as compared to 398 (33%) by ground. Mortality and good functional outcome did not differ between patients transferred and those taken directly to the CSC. Among patients receiving either TPA or endovascular therapy, direct transport to the CSC is associated with good functional outcome (Fisher’s exact= 0.041) but not with mortality. Conclusions: Among patients with a diagnosis of ischemic stroke presenting to a CSC, there is no difference in mortality and good functional outcome as a function of transfer from the scene or transfer from another facility. However, among those who received tPA or endovascular intervention good functional outcome was associated with direct presentation to the CSC.

Abstract WP281: Pharmacists Improve Door to Needle Times in the Emergency Department

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Kevin Phan ◽  
Megan Degener
Keyword(s):  
Emergency Department ◽  
Cerebral Perfusion ◽  
Stroke Care ◽  
Time Frame ◽  
Safe Delivery ◽  
Team Meetings ◽  
Stroke Team ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
The Impact

Background: An estimated two million brain cells die every minute cerebral perfusion is impaired. The best outcomes for acute ischemic strokes are achieved by decreasing the time from emergency department (ED) arrival to thrombolytic therapy. Alteplase, a high risk medication, was dosed and prepared in the pharmacy. This contributed to prolonged door to needle (DTN) times. Purpose: To describe the impact of pharmacist interventions on DTN times in the ED. Methods: All patients who received alteplase for acute ischemic stroke from January 2012 to April 2019 were reviewed. In November 2012, the ED pharmacy program began with a dedicated ED pharmacist for 8 hours a day and expanded to 13 hours a day in September 2014. During those hours alteplase was prepared at bedside in the ED. In November 2015, all pharmacists were trained on the ED code stroke process. Monthly case reviews and DTN times were reported to the stroke coordinators starting January 2017. Alteplase preparation and administration in the computed tomography (CT) room started April 2017. Following comprehensive stroke center certification, routine stroke competency exams were administered to pharmacists in 2018. In 2019, pharmacists started reporting DTN times at neuroscience core team meetings. Results: During this time frame, a total of 407 patients received alteplase. Average DTN times decreased from a baseline of 130.9 minutes to 45.3 minutes. Interventions that resulted in the largest decrease in average DTN times were the expanded ED service hours (34.6 minutes) and pharmacist preparation of alteplase in the CT room (21.9 minutes). Conclusions: Pharmacists directly impacted stroke care in the ED by decreasing DTN times. Presence of a pharmacist in the ED enabled fast and safe delivery of alteplase by ensuring accurate dosing and preparation. Pharmacists also performed rapid medication reconciliation and expedited antihypertensive therapies. In conclusion, having pharmacists as part of the stroke team is a model that could be adopted by hospitals to enhance stroke care.

scholarly journals Triaging the triage: reducing waiting time to triage in the emergency department at a tertiary care hospital in New Delhi, India

2019 ◽  
Vol 36 (9) ◽  
pp. 558-563
Author(s):  
Akshay Kumar ◽  
Dheeneshbabu Lakshminarayanan ◽  
Nitesh Joshi ◽  
Sonali Vaid ◽  
Sanjeev Bhoi ◽  
...  
Keyword(s):  
Emergency Department ◽  
Waiting Time ◽  
Tertiary Care ◽  
Time Of Arrival ◽  
New Delhi ◽  
Care Hospital ◽  
Senior Leadership ◽  
Frontline Staff ◽  
Patient Load ◽  
Hot Weather

BackgroundProlonged wait times prior to triage outside the emergency department (ED) were a major problem at our institution, compromising patient safety. Patients often waited for hours outside the ED in hot weather leading to exhaustion and clinical deterioration. The aim was to decrease the median waiting time to triage from 50 min outside ED for patients to <30 min over a 4-month period.MethodsA quality improvement (QI) team was formed. Data on waiting time to triage were collected between 12 pm and 1 pm. Data were collected by hospital attendants and recorded manually. T1 was noted as a time of arrival outside the ED, and T2 was noted as the time of first medical contact. The QI team used plan–do–study–act cycles to test solutions. Change ideas to address these gaps were tested during May and June 2018. Change ideas were focused on improving the knowledge and skills of staff posted in triage and reducing turnover of triage staff. Data were analysed using run chart rules.ResultsWithin 6 weeks, the waiting time to triage reduced to <30 min (median, 12 min; IQR, 11 min) and this improvement was sustained for the next 8 weeks despite an increase in patient load.ConclusionThe authors demonstrated that people new to QI could use improvement methods to address a specific problem. It was the commitment of the frontline staff, with the active support of senior leadership in the department that helped this effort succeed.

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