Abstract WP413: It’s a Draw! Nurse vs. Pharmacist Mixing tPA; Who’s Faster?

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Morgan Boyer
Keyword(s):  
Emergency Room ◽  
Median Time ◽  
Decision Time ◽  
Tissue Type ◽  
Community Hospitals ◽  
National Guidelines ◽  
Type Plasminogen Activator ◽  
Using Data ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: As a Comprehensive Stroke Center and a hub for telestroke stroke alert process is continual effort. Collaborating with spoke Stroke Coordinators is imperative to improving overall stroke alert process. A goal of national guidelines is to achieve a door to needle for administration of intravenous tissue-type plasminogen activator (tPA) of less than 60 minutes. A point of contention in the stroke alert process is the debate between Registered Nurse mixing versus pharmacy mixing of tPA. The question remains contentious in our telestroke community hospitals and therefore was analyzed. Methods: The telestroke network consists of 14 community hospitals of various bed sizes and stroke volume. Seven of the spokes use an Emergency Room nurse to mix tPA and the remaining seven use their pharmacy. Using data generated over 4 years from the telemedicine provider, the door to needle was assessed and compared. In addition, door to telestroke consultant decision to administer tPA was also analyzed. The average, minimum, maximum and median time in minutes was calculated for the door to needle and door to decision time points. Results: The average time for door to needle when nurses mix is 83 minutes versus an average door to needle time when pharmacy mixes is 93 minutes (p = 0.0398). The median time for nursing mixing is 81 minutes and pharmacy mixing is 89 minutes. The average door to consultant decision to administer tPA when nurses mix is 19 minutes compared to an average door to consultant decision to administer tPA when pharmacy mixes is 20 minutes (p = 0.5593). The fastest door to tPA administration is a spoke with a pharmacy mixing the drug at 23 minutes. Conclusion: The analysis of the telestroke network door to needle and door to consultant decision did not conclusively add evidence to a benefit of either the Emergency Room nurse or a Pharmacist mixing tPA. An effective and efficient stroke alert process demands a coordinated effort by all individuals. Not one role in the process makes the target achievable. Whether the Pharmacist or the bedside nurse prepares the drug, what makes it possible to achieve the target is the collaboration and understanding of everyone’s role.

Abstract TP281: Reducing Door-to-Needle Times in Acute Ischemic Stroke : Multidisciplinary Team-based Approach at a Single Center

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Nobuyuki Ohara ◽  
Junya Kobayashi ◽  
Toshiaki Goda ◽  
Takeshi Ikegami ◽  
Kotaro Watanabe ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Multidisciplinary Team ◽  
Treatment Time ◽  
Multivariable Analysis ◽  
Tissue Type ◽  
National Guidelines ◽  
Rapid Acquisition ◽  
Type Plasminogen Activator ◽  
Independent Ambulation

Background: The benefits of intravenous tissue-type plasminogen activator (tPA) in acute ischemic stroke are time dependent, and national guidelines recommend door-to-needle (DTN) time within 60 minutes. Several strategies have been reported to be associated with reducing DTN times. However, effectiveness of such strategies has not been fully evaluated. Methods: In 2014, we assembled a multidisciplinary team called ‘Acute Stroke Team (AST)’ aiming for improving outcomes of patients with acute ischemic stroke, especially by reducing onset-to-treatment time. A new protocol was implemented to minimize delays: AST staff prenotification, parallel process workflow, and rapid acquisition of laboratory testing and brain imaging. AST reviewed all intravenous tPA cases and discussed the points of improvement. AST also organized both public and in-hospital lectures, and simulation training course. We compared patients received intravenous tPA within 4.5 hours from the symptom onset at our institute in the pre AST (April 2011 - August 2014) and post AST (September 2014 - July 2016) period. Using univariate methods and multivariable logistic regression, we assessed the associated factors with favorable outcomes. Results: In the pre and post AST period, 46 and 36 patients were treated with intravenous tPA, respectively. Compared with pre AST period, the median (interquartile range) DTN times was reduced from 71 (63-95) minutes to 55 (49-71) minutes (p<0.01), and the percentage of patients with DTN times within 60 minutes were improved from 22% to 64% (P<0.001) in the post AST period. By multivariable analysis, shorter DTN times (OR 0.98, 95% CI 0.95-0.99, p=0.025), lower age (OR 0.90, 95% CI 0.85-0.96, p=0.001) and lower NIHSS on admission (OR 0.88, 95% CI 0.82-0.95, p=0.001) were independently associated with independent ambulation at hospital discharge. Conclusions: Multidisciplinary team-based approach reduced DTN times. Reducing DTN times was associated with improving patient outcomes. Future efforts should focus on sustainability and safety of this approach.

Abstract P136: Feasibility and Safety of an Expedited Emergency Department TIA Evaluation

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Anisha Garg ◽  
Ilavarasy Maran ◽  
Kelsey Vlieks ◽  
Kaile Neuschatz ◽  
Anna Coppola ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Emergency Room ◽  
Low Risk ◽  
Smoking History ◽  
Post Intervention ◽  
Abcd2 Score ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Ischemic Attack ◽  
Get With The Guidelines

Introduction: Transient ischemic attack (TIA) can portend impending stroke, but it is unclear whether a TIA evaluation necessitates inpatient admission. We assessed feasibility and safety of a TIA protocol in the emergency room for low-risk TIA patients. Methods: We studied low-risk TIA patients (ABCD2 score < 4, no significant vessel stenosis) before (January 2018-July 2019) and after (August 2019-March 2020) the implementation of an expedited, emergency room TIA protocol at a comprehensive stroke center. The pre-intervention cohort consisted of TIA patients in the institutional Get-With-The-Guidelines database who met pre-specified criteria ( Figure ) and were admitted. The post-intervention patients met the same criteria and underwent an expedited MRI with selected sequences. If the MRI showed no ischemia, patients were scheduled with rapid, outpatient stroke clinic follow-up and outpatient echocardiogram as indicated. We compared differences in outcomes of interest between the pre-and post-intervention cohorts including length of stay, radiographic and echocardiogram findings, and recurrent neurovascular events within 30 days. Results: In total, 120 TIA patients met criteria (71 pre-intervention, 49 patient post-intervention). Demographic and clinical characteristics were similar except the pre-intervention pathway had a higher proportion of patients with a smoking history and presenting symptom of aphasia and dysarthria. Median time from MRI order to completion was 2.3 hours in the post-intervention cohort. Median length of stay was 7.7 hours (IQR 5.2-9.7) in the post-intervention cohort compared to 28.8 hours (IQR 24.4-42.4) pre-intervention. There were no differences in neuroimaging or echocardiographic findings and 30-day re-presentation for stroke, TIA, or mortality. Conclusions: Our study demonstrates the feasibility and suggests safety of an expedited TIA protocol. Further study is needed to determine its generalizability.

Enhancement of Tissue-type Plasminogen Activator-induced Thrombolysis and Prevention of Reocclusion by Combination with a Humanized Anti-glycoprotein IIb/IIIa Monoclonal Antibody, YM337, in a Rhesus Monkey Model of Coronary Thrombosis

1998 ◽  
Vol 79 (03) ◽  
pp. 663-667 ◽  
Author(s):  
Kazuo Sato ◽  
Ken-ichi Suzuki ◽  
Yumiko Sakai ◽  
Yuta Taniuchi ◽  
Seiji Kaku ◽  
...  
Keyword(s):  
Monoclonal Antibody ◽  
Plasminogen Activator ◽  
Median Time ◽  
Bolus Injection ◽  
Coronary Thrombosis ◽  
Tissue Type ◽  
Clinical Value ◽  
Tissue Type Plasminogen Activator ◽  
Thrombosis Model ◽  
Type Plasminogen Activator

SummaryWe examined the effect of a humanized anti-glycoprotein IIb/IIIa monoclonal antibody, YM337, on thrombolysis with tissue-type plasminogen activator in a copper coil-induced coronary thrombosis model in rhesus monkeys. Fifty minutes after the formation of an occlusive thrombus, a test drug was administered by either i.v. bolus injection followed by continuous infusion (YM337, 0.25 mg/kg + 1.5 μg/kg/min) or i.v. bolus injection (aspirin, 17 mg/kg). Sixty minutes after induction of the occlusive thrombus, thrombolysis was initiated with tPA at a total dose of 0.5 mg/kg intravenously administered over 60 min, with 10% given as an initial bolus. The median time to reperfusion was significantly shortened by YM337 [saline, 60 min (n = 5); aspirin, 45 min (n = 5); YM337, 30 min (n = 5)]. The incidence of reocclusion was significantly decreased by YM337 (saline, 4/4; aspirin, 5/5; YM337, 1/5), and the median time to reocclusion was significantly prolonged by YM337 [saline, 30 min (n = 4); aspirin, 30 min (n = 5); YM337, 180 min (n = 5)]. YM337 significantly reduced the thrombus protein content at the end of experiment. ADP-induced platelet aggregation was completely inhibited by YM337. These results suggest that YM337 may be of clinical value as an adjunctive agent in thrombolytic therapy for patients with acute myocardial infarction.

scholarly journals Tenecteplase Improves Door‐to‐Needle Time in Real‐World Acute Stroke Treatment

2021 ◽  
Author(s):  
Jillian Hall ◽  
Jesse M. Thon ◽  
Mark Heslin ◽  
Lauren Thau ◽  
Terri Yeager ◽  
...  
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Process Improvement ◽  
Interquartile Range ◽  
Tissue Type ◽  
Independent Effect ◽  
Stroke Treatment ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Abstract BACKGROUND We report the interim results of a process improvement initiative at a comprehensive stroke center in which all tPA (tissue‐type plasminogen activator)–eligible patients were given tenecteplase for acute ischemic stroke. METHODS We retrospectively analyzed a prospectively maintained single‐center registry of consecutive patients with acute ischemic stroke treated at our comprehensive stroke center emergency department or transferred for further care. Patients treated with alteplase (tPA) before the process improvement initiative (October 2019–April 2020) were compared with those treated with tenecteplase (May 2020–July 2021). The primary efficacy outcome was the Target: Stroke Phase II recommendation of door‐to‐needle (DTN) time ≤45 minutes. Backward stepwise logistic regression was used to estimate an independent effect of tenecteplase against DTN time ≤45 minutes. Two contemporaneous, negative controls (time to first emergency department antibiotic for patients who presented with infectious symptoms and door‐to‐groin puncture for thrombectomy) were evaluated to confirm DTN time was unrelated to emergency department and other stroke treatment throughput. RESULTS Of the 113 included patients, 53 (47%) received tenecteplase. DTN time was significantly faster in patients treated with tenecteplase (median, 41 [interquartile range, 34–62] minutes versus 58 [interquartile range, 45–70] minutes; P <0.01), with no significant difference in symptomatic intracranial hemorrhage (2% versus 7%; P =0.37). Despite the higher proportion of tPA patients being transferred for care (with slower DTN time), tenecteplase remained independently predictive of DTN time ≤45 minutes (adjusted odds ratio, 3.96; 95% CI, 1.58–9.91). There was no difference in time to first emergency department antibiotic ( P >0.05) or door‐to‐puncture ( P >0.05) when similar periods were compared. CONCLUSIONS Tenecteplase was associated with faster DTN time when compared with tPA in those with acute ischemic stroke. This can likely be attributed to the ease of single bolus administration of tenecteplase.

Abstract TP286: Improving Core Measure Compliance in Stroke Chameleon Patients

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Michele Gribko ◽  
Ann Marie McLeod ◽  
Richard B Libman ◽  
Paul Wright ◽  
Jeffrey M Katz
Keyword(s):  
Statistical Significance ◽  
Altered Mental Status ◽  
Post Intervention ◽  
Vte Prophylaxis ◽  
Radiology Reports ◽  
Stroke Diagnosis ◽  
Stroke Education ◽  
Using Data ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: Patients presenting with altered mental status, syncope, and other non-localizing complaints may be subsequently diagnosed with minor ischemic or hemorrhagic strokes. These patients, termed stroke chameleons, are typically admitted to non-neurology units (NNUs) with a non-stroke diagnosis and are more likely to fall-out on stroke core measures (SCM). Early identification of these patients should improve SCM compliance and promote better care. Methods: A performance improvement initiative was implemented to elevate SCM compliance overall by targeting patients admitted to NNUs in a comprehensive stroke center. A nurse practitioner was dedicated to scan the electronic medical record for potential stroke chameleons on NNUs and review radiology reports to confirm a stroke diagnosis. A SCM checklist was utilized to reinforce SCM adherence with the patient’s providers and nurses. SCM compliance for 24 months pre and 12 months post intervention was compared using data entered into the Get With The Guideline-Stroke database. Results: Over the 3-year study period, 3,355 patients were discharged with a stroke diagnosis. Comparing pre to post intervention periods, 522/2129 (24.5%) vs. 401/1226 (32.7%) patients were admitted to NNUs. Distribution of pre- and post intervention stroke diagnoses were ischemic/TIA 381 (73.0%) vs. 319 (79.6%) and hemorrhagic 141 (27.0%) vs. 82 (20.4%). For NNU patients, the initiative had a statistically significant impact on stroke education documentation (45.5% pre vs. 67.0% post; p=0.0006). In addition, compliance improved for smoking cessation (77.8% to 81.2%), early antithrombotics (84.0% to 85.3%), VTE prophylaxis (90.8% to 94.7%), and discharge antithrombotic therapy (98.7% to 100%), although none were statistically significant. Conclusion: Dedicating resources to identify stroke chameleons early, and focusing compliance efforts on NNUs, significantly improved compliance with stroke education. Other SCM showed numerical improvements, but did not reach statistical significance. Especially in centers with high volumes of stroke chameleons, attention and efforts directed at this population raises the quality of care provided to all hospitalized stroke patients.

Abstract P438: A Reassessment of Hemoglobin and Hematoma Expansion in Intracerebral Hemorrhage

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Christoph Stretz ◽  
Brian C Mac Grory ◽  
Ali Mahta ◽  
SLEIMAN El JAMAL ◽  
Daniel C Sacchetti ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Hematoma Expansion ◽  
Multivariable Logistic Regression Analysis ◽  
Laboratory Markers ◽  
Increased Risk ◽  
Observational Cohort ◽  
Using Data ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Separate Cohort

Background: Prior studies identified an increased risk of hematoma expansion (HE) in patients with spontaneous intracerebral hemorrhage (ICH) and lower admission hemoglobin (Hgb) levels. We aimed to externally validate these findings in a separate cohort of ICH patients. Methods: We performed an observational cohort study on consecutive patients with ICH admitted to a Comprehensive Stroke Center over 2 years, using data from an institutional ICH registry. We excluded patients with secondary, non-spontaneous ICH etiologies, as well as patients who arrived >24 hours from symptom onset. Data on HE (defined as an increase of >33% or >6 mL) and 3-month outcomes were prospectively collected, while admission laboratory values were retrospectively abstracted. We compared admission Hgb, INR, and platelet count (Plt) between patients with and without HE, then determined associations between Hgb, HE, and unfavorable 3-month outcomes (modified Rankin Scale 4-6) after adjusting for established ICH predictors, any anticoagulant use, and laboratory markers of coagulopathy with multivariable logistic regression analysis. Results: Of 375 patients, mean age was 73.6 [SD 13.5], 50% (n=187) were male, 85% (n=317) were white, and 19% (n=71) had HE. Admission Hgb values were similar in patients with and without HE (mean [SD] 13.1 [1.8] g/dl vs. 13.1 [1.9] g/dl, p=0.98), as were INR values (median [IQR] 1.1 [1-1.3] vs. 1.1 [1.0-1.2], p=0.15), although patients with HE had modestly lower Plt (median [IQR] 181 [155-230] x 10 9 /l vs. 207 [170-253] x 10 9 /l, p=0.02). In our multivariable models, Hgb was not associated with HE (OR 0.97, 95% CI 0.83-1.12), but odds of unfavorable 3-month outcome increased with lower Hgb levels (OR 0.81 per 1 g/dL Hgb, 95% CI 0.68-0.96). Conclusion: Our study did not confirm prior associations between Hgb and HE, suggesting that if Hgb is implicated in HE, its effects are likely modest. However, Hgb may mediate outcomes in ICH patients via alternative mechanisms.

Abstract WP270: Outcomes of Telestroke tPA Patients Who Stay at Community Hospitals vs Transfer to a Comprehensive Stroke Center

Stroke ◽  
2018 ◽  
Vol 49 (Suppl_1) ◽  
Author(s):  
Nicole A Wysocki ◽  
Arvind Bambhroliya ◽  
Shima Bozorgui ◽  
Christy Ankrom ◽  
Alyssa Trevino ◽  
...  
Keyword(s):  
Community Hospitals ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Abstract P364: Use of the Electronic Alberta Stroke Program Early CT Score Software to Guide Treatment of Patients With Acute Ischemic Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Danielle L Weiss ◽  
Dennis Y Chuang ◽  
Ali Fadhil ◽  
Kelsey R Duncan ◽  
Alexa Weiss ◽  
...  
Keyword(s):  
Chart Review ◽  
Retrospective Chart Review ◽  
Community Hospitals ◽  
Ct Head ◽  
Logistic Regressions ◽  
Transferred Patients ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Contrast Ct ◽  
The Relationship

Introduction: Rapid recognition of large-vessel middle cerebral artery (lvMCA) stroke in patients with acute stroke symptoms is critical to guide thrombectomy and hemicraniectomy decisions. The Electronic Alberta Stroke Program Early CT Score (e-ASPECTS; Brainomix, LLC) is an automated, artificial intelligence software which quantifies acute ischemic volume (AIV) on CT head scans in the MCA territory. In this study, we investigate if e-ASPECTS-derived AIV could help guide treatment and predict outcomes for patients transferred from community hospitals. Hypothesis: E-ASPECTS can help identify patients that may benefit from thrombectomy or hemicraniectomy. Methods: We performed a retrospective chart review on patients age 18-90 transferred to our comprehensive stroke center (CSC) between 2013-2017. Non-contrast CT head scans performed at community hospitals prior to transfer were processed by e-ASPECTS to calculate AIV. Logistic regressions were used to test the relationship between AIV and eventual treatment (thrombectomy, hemicraniectomy). Results: 228 patient CT scans were analyzed by e-ASPECTS. In all transferred patients, higher AIV predicted patients with later confirmed lvMCA strokes (defined as an ICA or M1 occlusion; OR 1.03, CI 1.02-1.05, P<0.001). Higher AIV also trended toward thrombectomy but was not statistically significant (P=0.15). In the subgroup analysis of patients later confirmed to have lvMCA strokes, lower AIV was predictive for thrombectomy (OR 0.95, CI 0.92-0.97, P<0.001). Additionally, higher AIV predicted outcomes of malignant cerebral edema (MCE; OR 1.03, CI 1.02-1.05, P<0.001) and hemicraniectomy (OR 1.04, CI 1.00-1.07, P=0.03). Conclusions: Our study suggests that e-ASPECTS may be useful in identifying patients who would, or would not, benefit from transfer to a CSC from hospitals without thrombectomy or hemicraniectomy resources. Patients with stroke mimics or lvMCA strokes with large penumbras have lower AIVs, while patients with higher AIVs are at risk for MCE and may benefit from hemicraniectomy.

Abstract TP59: Rapid MR in Suspected Acute Stroke: Identifying Mimics That Can Avoid Admission

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Julie Bykowski ◽  
Nathan Gaines ◽  
Brett Meyer ◽  
Dawn Meyer ◽  
Thomas Hemmen ◽  
...  
Keyword(s):  
Mr Imaging ◽  
Acute Stroke ◽  
Median Time ◽  
Accurate Method ◽  
First Year ◽  
Imaging Data ◽  
Head Ct ◽  
Stroke Mimics ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: Diffusion weighted MR imaging (DWI) is the most accurate method to confirm or exclude acute ischemic stroke, however due to logistics is not widely used in the emergent setting. While many patients with stroke symptoms will get an MRI during their hospitalization, it may occur only after hours of care in the ER or after admission. Hypothesis: Providing emergent MR imaging in Stroke Code patients avoids unnecessary admission and associated costs for work-up of stroke mimics which otherwise would not be rapidly identified. Methods: IRB-approved retrospective review of the first year of expedited acute stroke MR imaging availability at a TJC Comprehensive Stroke Center. Imaging included immediate non-contrast head CT on arrival with CT Angiography at discretion of Stroke Code Leader. Emergent MR was then performed in patients without MRI contraindications who had unclear diagnosis, or to clarify extent of infarct. Demographic, clinical and imaging data were analyzed with time from triage to imaging, tPA decision, and discharge. Results: MRI was performed prospectively in 68/456 patients presenting with possible acute stroke symptoms from 7/1/2014-7/1/2015 (44 male, 26 female, age 60+/-15 years). Symptom onset was within 3 hours in 34 (49%), 3-6 hours in 12 (17%) and >6 hours or awoke with symptoms in 22 (31%); NIHSS of 4 or less in 40 (59%). Median time from arrival to completion of non-contrast head CT was 16 minutes; median time from CT imaging to completion of DWI was 39 minutes. Twenty-nine patients were discharged directly from the ER after MRI, with median ER stay of 5 hours, 15 minutes. Conclusions: Through multi-departmental collaboration, expediting MR imaging in the setting of acute stroke evaluation can avoid unnecessarily prolonged ER observation and admission in patients with stroke mimics.

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