Abstract WP399: Reduced Cost and Decreased Length of Stay Associated with Acute Ischemic Stroke Care Provided by Nurse Practitioners: A Single Primary Stroke Center Experience

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Leah Roering ◽  
Michelle Peterson ◽  
Muhammad Shah Miran ◽  
Melissa Freese ◽  
Kenneth Shea ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Length Of Stay ◽  
Acute Ischemic Stroke ◽  
Nurse Practitioners ◽  
Acute Care Hospital ◽  
Stroke Care ◽  
Care Hospital ◽  
Medical Provider ◽  
The Mean ◽  
Stroke Center

Background: Nurse practitioner (NP) have a wider role in modern stroke centers providing quality evidence based care to patients in both in and outpatient settings for acute ischemic stroke (AIS) and transient ischemic attack (TIA) patients. We studied the outcome measures, length of stay (LOS) and cost before and after implementation of nurse practitioners as the primary medical provider in a community based stroke center. Methods: St Cloud hospital is acute care hospital with dedicated stroke service responsible for workup and management of all patients admitted with AIS and TIA. From March 2014-March 2015, all patients were primarily managed by stroke neurologists with or without support of NP, representing physician driven arm. From June 2015-March 2016 all non-critical patients were managed primarily by NP, representing the NP driven arm of care. For this analysis, we excluded all patients with subarachnoid hemorrhage or intracerebral hemorrhage. Using ICD codes, we abstracted LOS and hospitalization cost for all patients, and compared between two arms. Results: A total of 822 patients were included in physician arm and 336 in NP arm. The mean age was 72±14 years for both arms, and 54.4% were male in physician arm and 57.4% were male in NP arm. The mean total LOS for the physician arm was 3.1 ±3.3 days while 2.9±3.6 for NP arm (p=0.6). The total cost for physician arm was $11,286.70 ±$10,920.90 while the NP arm was $10,277.30± $10,142.30 (p=0.1). Conclusion: There is a trend towards lower cost and length of stay with implementation of NP as primary stroke provider for patients admitted with acute ischemic stroke.

Abstract 5: Do Stroke Centers Reduce Mortality for Patients with Acute Ischemic Stroke? An Instrumental Variable Analysis

2011 ◽  
Vol 4 (suppl_1) ◽  
Author(s):  
Ying Xian ◽  
Robert G Holloway ◽  
Katia Noyes ◽  
Manish N Shah ◽  
Bruce Friedman
Keyword(s):  
New York ◽  
Ischemic Stroke ◽  
Hospital Mortality ◽  
Acute Ischemic Stroke ◽  
New York State ◽  
Selection Effect ◽  
Stroke Care ◽  
Instrumental Variable Analysis ◽  
All Cause Mortality ◽  
Stroke Center

Background: Although the establishment of stroke centers based on the Brain Attack Coalition recommendations has great potential to improve quality of stroke care, little is known about whether stroke centers improve health outcomes such as mortality. Methods: Using 2005-2006 New York State Statewide Planning and Research Cooperative System data, we identified 32,783 hospitalized patients age 18+ with a principal diagnosis of acute ischemic stroke (ICD-9 433.x1, 434.x1 and 436). We compared in-hospital mortality and up to one year all-cause mortality between New York State Designated Stroke Centers and non-stroke center hospitals. Because patients were not randomly assigned to hospitals, stroke centers might treat different types of patients than other hospitals (a selection effect). We used a “natural randomization” approach, instrumental variable analysis (differential distance was the instrument), to control for this selection effect. To determine whether the mortality difference was specific to stroke care, we repeated the analysis using a different group of patients with gastrointestinal (GI) hemorrhage (N=53,077). Results: Of the 32,783 stroke patients, nearly 50% (16,258) were admitted to stroke centers. Stroke centers had lower unadjusted in-hospital mortality and 30-, 90-, 180-, and 365-day all-cause mortality than non-stroke centers (7.0% vs. 7.8%, 10.0% vs. 12.6%, 14.6% vs. 17.5%, 18.0% vs. 21.0%, 22.4% vs. 26.2%, respectively). After adjusting for patient and hospital characteristics, comorbidities, and the patient selection effect, stroke centers were associated with significantly lower all-cause mortality. The adjusted differences were -2.6%, -2.7%, -1.8%, and -2.3% for 30-, 90-, 180- and 365-day mortality (all p<0.05). The adjusted difference in in-hospital mortality was -0.8% but was not statistically significant. In a specificity analysis of patients with GI hemorrhage, stroke centers had slightly higher mortality. Conclusions: Hospitals that are Designated Stroke Centers had lower mortality for acute ischemic stroke than non-stroke center hospitals. The mortality benefit was specific to stroke and was not observed for GI hemorrhage. Providing stroke centers nationwide has the potential to reduce mortality.

Abstract P188: Transfer Time From Spoke ER Arrival to CSC Arrival in a Hub-Spoke Transfer Model of Thrombolysis for Acute Ischemic Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Vivien H Lee ◽  
Paul A Segerstrom ◽  
Ciarán J Powers ◽  
Sharon Heaton ◽  
Shahid M Nimjee ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Univariate Analysis ◽  
Transfer Model ◽  
Transfer Time ◽  
Intravenous Tissue Plasminogen Activator ◽  
The Mean ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Er Status

Introduction: Acute ischemic stroke (AIS) patients who present to a spoke Emergency Room (ER) and require transfer to a comprehensive stroke center (CSC) hub face potential delays Methods: We performed a retrospective review of 269 suspected AIS patients who received intravenous tissue plasminogen activator (tPA) from July 2016 to October 2017 in our academic telestroke network. During this period, nearly all tPA patients were transferred to the CSC hub. Data was collected on patient demographics, National Institutes of Health Stroke Scale (NIHSS), door to needle time (DTN), and distance to CSC. ER-to-CSC was defined as the time from patient arrival at Spoke ER to arrival at CSC. Top volume ER status was assigned to the 4 Spoke ERs with the highest volume of tPA. Results: Among 269 AIS patients who received tPA at spoke ERs, the mean age was 65.4 years (range, 21 to 95), 49% were female, and 91.8% were white. The initial median NIHSS was 6 (range, 0 to 30) and the mean DTN was 73.1 minutes (range, 14 to 234). The mean distance from Spoke ER to CSC was 55.2 miles (range 5.8 to 125) and the mean ER-to-CSC was 2.6 hours (range 0.62 to 6.3) (Figure 1). In univariate analysis, the following factors were significantly associated with ER-to-CSC: distance (p < 0.0001), DTN (p < 0.0001), NIHSS (p 0.0007), and top volume ER status (p 0.0034). Patient sex, age, race, SBP, weight, initial NIHSS, daytime shift, and weekend status were not significantly associated with ER-to-CSC. Significant variables from the univariate analysis were included in multivariate linear regression model in which DTN (P < 0.0001), distance (P < 0.0001), and NIHSS (P 0.024) association with ER-to-CSC remained significant. Conclusions: In our series of AIS tPA patients transferred to CSC, the mean time from spoke ER arrival to CSC arrival was 2.6 hours. Factors associated with CSC arrival time include markers of ER performance (DTN), severity (NIHSS), and distance. Further study is warranted to improve transfer time in AIS.

Abstract P145: Outcomes of an EMR-Enabled Acute Ischemic Stroke Care Path in a Primary Stroke Center

Circulation ◽  
2019 ◽  
Vol 139 (Suppl_1) ◽  
Author(s):  
Aaron Dunn ◽  
Selena Pasadyn ◽  
Francis May ◽  
Dolora Wisco
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Stroke Care ◽  
Primary Stroke Center ◽  
Stroke Center ◽  
Care Path

scholarly journals Mandatory Neuroendovascular Evolution: Meeting the New Demands

2018 ◽  
Vol 8 (1) ◽  
pp. 69-82
Author(s):  
Mohammad El-Ghanem ◽  
Francisco E. Gomez ◽  
Prateeka Koul ◽  
Rolla Nuoman ◽  
Justin G. Santarelli ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Symptom Onset ◽  
Mechanical Thrombectomy ◽  
Stroke Care ◽  
Endovascular Intervention ◽  
Stroke Patients ◽  
Hub And Spoke ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: Traditionally, patients undergoing acute ischemic strokes were candidates for mechanical thrombectomy if they were within the 6-h window from onset of symptoms. This timeframe would exclude many patient populations, such as wake-up strokes. However, the most recent clinical trials, DAWN and DEFUSE3, have expanded the window of endovascular treatment for acute ischemic stroke patients to within 24 h from symptom onset. This expanded window increases the number of potential candidates for endovascular intervention for emergent large vessel occlusions and raises the question of how to efficiently screen and triage this increase of patients. Summary: Abbreviated pre-hospital stroke scales can be used to guide EMS personnel in quickly deciding if a patient is undergoing a stroke. Telestroke networks connect remote hospitals to stroke specialists to improve the transportation time of the patient to a comprehensive stroke center for the appropriate level of care. Mobile stroke units, mobile interventional units, and helistroke reverse the traditional hub-and-spoke model by bringing imaging, tPA, and expertise to the patient. Smartphone applications and social media aid in educating patients and the public regarding acute and long-term stroke care. Key Messages: The DAWN and DEFUSE3 trials have expanded the treatment window for certain acute ischemic stroke patients with mechanical thrombectomy and subsequently have increased the number of potential candidates for endovascular intervention. This expansion brings patient screening and triaging to greater importance, as reducing the time from symptom onset to decision-to-treat and groin puncture can better stroke patient outcomes. Several strategies have been employed to address this issue by reducing the time of symptom onset to decision-to-treat time.

scholarly journals Delayed presentation of acute ischemic strokes during the COVID-19 crisis

2020 ◽  
Vol 12 (7) ◽  
pp. 639-642 ◽  
Author(s):  
Clemens M Schirmer ◽  
Andrew J Ringer ◽  
Adam S Arthur ◽  
Mandy J Binning ◽  
W Christopher Fox ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Public Awareness ◽  
Public Life ◽  
Baseline Period ◽  
Delayed Presentation ◽  
Stroke Patients ◽  
The Us ◽  
The Mean ◽  
Stroke Center

BackgroundThe COVID-19 pandemic has disrupted established care paths worldwide. Patient awareness of the pandemic and executive limitations imposed on public life have changed the perception of when to seek care for acute conditions in some cases. We sought to study whether there is a delay in presentation for acute ischemic stroke patients in the first month of the pandemic in the US.MethodsThe interval between last-known-well (LKW) time and presentation of 710 consecutive patients presenting with acute ischemic strokes to 12 stroke centers across the US were extracted from a prospectively maintained quality database. We analyzed the timing and severity of the presentation in the baseline period from February to March 2019 and compared results with the timeframe of February and March 2020.ResultsThere were 320 patients in the 2-month baseline period in 2019, there was a marked decrease in patients from February to March of 2020 (227 patients in February, and 163 patients in March). There was no difference in the severity of the presentation between groups and no difference in age between the baseline and the COVID period. The mean interval from LKW to the presentation was significantly longer in the COVID period (603±1035 min) compared with the baseline period (442±435 min, P<0.02).ConclusionWe present data supporting an association between public awareness and limitations imposed on public life during the COVID-19 pandemic in the US and a delay in presentation for acute ischemic stroke patients to a stroke center.

Abstract 3251: Relationship Between tPA and Factor VIII Levels in Patients with Acute Ischemic Stroke

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Tiffany R Chang ◽  
Karen C Albright ◽  
Rebecca Kruse-Jarres ◽  
Cindy Lessinger ◽  
Amelia K Boehme ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Factor Viii ◽  
Acute Ischemic Stroke ◽  
Surrogate Marker ◽  
Factor Viii Level ◽  
Before And After ◽  
Viii Level ◽  
The Mean ◽  
Stroke Center ◽  
Iv Tpa

Background: Factor VIII levels may be screened as part of a hypercoagulable work-up in patients with ischemic stroke. However, it is unknown how treatment with IV tPA may affect these levels during the acute phase of ischemic stroke. Methods: From our prospective registry, we identified patients who presented with acute ischemic stroke to our stroke center between July 2008 and April 2011 and determined if factor VIII levels had been measured during the acute hospitalization. We compared mean factor VIII levels using independent sample t test in patients not treated with IV tPA to post-tPA treatment levels using independent samples t tests. Results: Of the 72 patients who had factor VIII levels checked during admission, 25 (34.7%) received IV tPA. The mean factor VIII level was observed to be lower in patients who were treated with tPA (140.8 vs 180.5, p=0.048). Patients who experienced averted stroke (36%, 9/25) had significantly lower mean factor VIII level than patients who completed infarction on diffusion-weighted MRI (64%, 16/25) (132.7 vs 175.2, p=0.002). Of patients with post-tPA factor VIII levels, the mean factor VIII level of those whose samples were drawn within 24 hours of tPA were not different than the mean factor VIII level of those whose samples were drawn more than 24 hours after tPA (p=0.784). Conclusion: Our observations found that factor VIII levels were lower in both patients treated with IV tPA and in patients with averted stroke. As factor VIII levels were drawn after thrombolytic therapy was administered, this raises the question of whether tPA lowers factor VIII levels or if factor VIII can serve as a potential surrogate marker for recanalization. Prospective studies examining factor VIII levels (1) before and after treatment with IV tPA and (2) in comparison to recanalization are needed to clarify this interesting observation.

Risk of Aneurysm Rupture After Thrombolysis in Patients With Acute Ischemic Stroke and Unruptured Intracranial Aneurysms

Neurology ◽  
2021 ◽  
Vol 97 (18) ◽  
pp. e1790-e1798
Author(s):  
Jyri Juhani Virta ◽  
Daniel Strbian ◽  
Jukka Putaala ◽  
Miikka Korja
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Aneurysms ◽  
Aneurysm Rupture ◽  
Radiology Reports ◽  
Stroke Study ◽  
Unruptured Intracranial Aneurysms ◽  
The Mean ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background and ObjectivesUnruptured intracranial aneurysms (UIAs) are considered to be a relative contraindication for IV thrombolysis (IVT) in acute ischemic stroke (AIS). Currently, however, data are limited on the risk of UIA rupture after IVT. Our objective was to assess whether IVT for AIS can lead to a UIA rupture and intracranial hemorrhages (ICHs) in patients with unruptured UIAs.MethodsThis was a prospective cohort study of consecutive patients treated in a comprehensive stroke center between 2005 and 2019. We assessed radiology reports and records at the Finnish Care Register for Health Care to identify patients with UIAs among all patients with AIS treated with IVT at the center. We analyzed patient angiograms for aneurysm characteristics and other brain imaging studies for ICHs after IVT. The main outcome was in-hospital ICHs attributable to a UIA rupture after IVT. Secondary outcomes were in-hospital symptomatic ICHs (European-Australian Cooperative Acute Stroke Study [ECASS-2] criteria, i.e., NIH Stroke Scale score increase ≥4 points) and any in-hospital ICHs.ResultsA total of 3,953 patients were treated with IVT during the 15-year study period. One hundred thirty-two (3.3%) of the 3,953 patients with AIS had a total of 155 UIAs (141 saccular and 14 fusiform). The mean diameter of UIAs was 4.7 ± 3.8 mm, with 18.7% being ≥7 mm and 9.7% ≥10 mm in diameter. None of the 141 saccular UIAs ruptured after IVT. Three patients (2.3%, 95% confidence interval [CI] 0.6%–5.8%) with large fusiform basilar artery UIAs had a fatal rupture at 27 hours, 43 hours, and 19 days after IVT. All 3 were administered anticoagulation treatments after IVT, and anticoagulation took effect during the UIA rupture. Any ICHs and symptomatic ICHs were detected in 18.9% (95% CI 12.9%–26.2%) and 8.3% (95% CI 4.4%–13.8%) of all patients with AIS, respectively.DiscussionIVT appears to be safe in patients with AIS with saccular UIAs, including larges UIAs (≥10 mm). Anticoagulation after AIS in patients with large fusiform posterior circulation UIAs may increase the risk of aneurysm rupture.

scholarly journals Stroke Care in the First Affiliated Hospital of Chengdu Medical College during the COVID-19 Outbreak

2020 ◽  
pp. 1-6
Author(s):  
Li-Li Zhang ◽  
Yi-Jia Guo ◽  
Ya-Peng Lin ◽  
Ren-Zhong Hu ◽  
Jian-Ping Yu ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Public Awareness ◽  
Stroke Care ◽  
Significant Drop ◽  
Remote Areas ◽  
Medical College ◽  
Stroke Group ◽  
The Mean ◽  
Stroke Education ◽  
Stroke Center

Coronavirus disease-2019 (COVID-19) has become a pandemic disease globally. The First Affiliated Hospital of Chengdu Medical College has adopted telestroke to make stroke care accessible in remote areas. During the period January 2020 to March 2020, there was no COVID-19 case reported in our stroke center. A significant reduction of stroke admission was observed between the ischemic stroke group (235 vs. 588 cases) and the intracerebral hemorrhage group (136 vs. 150 cases) when compared with the same period last year (<i>p</i> &#x3c; 0.001). The mean door-to-needle time (DNT) and door-to-puncture time (DPT) was 62 and 124 min, respectively. Compared to the same period last year, a significant change was observed in DNT (62 ± 12 vs. 47 ± 8 min, <i>p</i> = 0.019) but not in DPT (124 ± 58 vs. 135 ± 23 min, <i>p</i> = 0.682). A total of 46 telestroke consultations were received from network hospitals. Telestroke management in the central hospital was performed on 17 patients. Of them, 3 (17.6%) patients had brain hernia and died in hospital and 8 (47.1%) patients were able to ambulation at discharge and had a modified Rankin Scale of 0–2 at 3 months. The COVID-19 pandemic impacted stroke care significantly in our hospital, including prehospital and in-hospital settings, resulting in a significant drop in acute ischemic stroke admissions and a delay in DNT. The construction of a telestroke network enabled us to extend health-care resources and make stroke care accessible in remote areas. Stroke education and public awareness should be reinforced during the COVID-19 pandemic.

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