Abstract TP360: Triage Nursing Intervention Improves Stroke Treatment Rate and Times for Walk-In Strokes

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Nayive Quezada ◽  
Ron Burke ◽  
Yaima Miro Gonzalez ◽  
Maygret Ramirez ◽  
Ivis C Gonzalez ◽  
...  
Keyword(s):  
Rapid Assessment ◽  
Community Outreach ◽  
Nursing Intervention ◽  
Treatment Rate ◽  
Stroke Treatment ◽  
Response Team ◽  
Emergency Department Triage ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
One Year

Introduction: Our comprehensive stroke center provides community outreach and stroke education to patients, caregivers, and community members on the importance of calling 911 in the event of a stroke. However, approximately 1/3 of our center’s stroke alerts are walk-ins. With a walk-in stroke, rapid assessment is essential because the stroke response team has no information compared to information that otherwise would be provided by EMS. As such, our center developed a rapid assessment by the emergency triage nurse or technician, who can then activate a stroke alert. Methods: The change to rapid stroke assessment and stroke alert activation by triage nurses and technicians (rather than waiting for an emergency physician to assess and activate a stroke alert) was made in March 2018. Cases from one year prior to the intervention were compared to cases from the year after implementation. Differences in turnaround times (door to stroke alert activation, door to needle [DTN]) were calculated. Results: In the period before implementation, there were 1200 stroke alerts, of which 420 arrived via triage (35%). Median door to stroke alert was 0 min. Of those who arrived through triage, 8 received IV alteplase (8/420=2%). For those patients, median DTN was 39 min. In contrast, after implementation, there were 1401 stroke alerts, of which 342 arrived via triage (24%). Median door to stroke alert was 2 min. Of those, 15 received IV alteplase (15/342=4%), with a median DTN of 32 min. Discussion: A nursing driven initiative at Emergency Department triage was effective at improving stroke treatment rate and decreasing DTN for IV alteplase for walk-in stroke patients.

Abstract WP467: Challenging the National and Regional Targets and Achieving Door-to-Needle in 25 Minutes or Less at a Comprehensive Stroke Center

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Cynthia Sinogui ◽  
Hillary Mitchell ◽  
Anna Moiseyenko ◽  
Leslie Keear ◽  
Maraget Smith ◽  
...  
Keyword(s):  
Rapid Assessment ◽  
Baseline Data ◽  
Process Data ◽  
Treatment Target ◽  
Treatment Targets ◽  
Assessment And Treatment ◽  
Visual Aid ◽  
Local Facility ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: The American Heart/ American Stroke Association (AHA/ASA) established national 60 and 45-minute alteplase treatment targets ensure timely administration of alteplase in patients with acute ischemic stroke (AIS). To challenge the 21 facilities of our integrated health system, our organization established a treatment target of 30-minutes or less. To raise the bar further, our local facility set a treatment target of 25-minutes or less. Purpose: To streamline and standardize rapid assessment and treatment for AIS patients receiving alteplase in 25-minutes or less at a CSC. Methods: Baseline data and process timeline were reviewed, and the workflow was evaluated using real-time observations conducted by front-line staff. Staff, physicians, and former patients involved in cases that met the 30-minute target were interviewed. Several Plan-Do-Study-Act cycles were performed. An interdisciplinary subcommittee meets weekly to review cases for compliance and evaluation for process sustainability. An in-depth review is conducted for all cases outside the 25-minute treatment target. AHA/ASA exclusion criteria are allowed. Results: Baseline data was reviewed yielding 18% compliance to the target of 25-minute or less (3/16). Changes were implemented in April 2018. Between April 2018 and July 2019 of the 107 cases treated, 55% of cases were within 25-minutes, 81% within 30-minutes, 85% with 45-minutes, and 95% in 60-minutes. Keys to decreasing times were use of timer, a designated timekeeper, announcement of time increments, and revisions of the process. Data and other graphics were posted in the Stroke Alert vestibule as a visual aid for staff. Collaboration between departments was integral in driving change. Conclusion: Challenging national and organizational treatment targets and revising workflows were effective ways to sustain alteplase treatments times of 25-minutes or less.

Abstract WP429: A Nurse Driven Acute Stroke Alert Process Improves Treatment Times and Treatment Rates

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Daniel D'Amour ◽  
Jayme Strauss ◽  
Amy K Starosciak
Keyword(s):  
Treatment Time ◽  
Treatment Decision ◽  
Treatment Rate ◽  
Treatment Decision Making ◽  
National Rate ◽  
Number Of Patients ◽  
Stroke Team ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Positive Effect

Introduction: Treatment time has gained sufficient popularity because it is now well-known that “Time is Brain”. Treatment rates, however, lag behind in importance even though more lives can be saved by treating more often. Our TJC Comprehensive Stroke Center has a nurse-led stroke alert process that focuses on multiple, rapid, parallel steps to reduce DTN for IV alteplase. The Baptist Emergency Stroke Team (BEST) responders are highly-trained and skilled nurses that assess, coordinate, and initiate processes to ensure the best times. We identified that our treatment rate was lower than the national rate for certified CSCs, so the BEST responders used a stepwise process to develop their own interventions to improve rates. Methods: First, the BEST responders started tracking our monthly rate. Next, they set a rate goal, and then brainstormed how to influence treatment decision-making. The BEST team initiated a monthly PI meeting that focused on the importance of treating disability rather than an NIHSS score. Then the team scripted and rehearsed critical conversations to have providers that advocated specifically for treating disability. The team adopted the motto, “Treat Disability, Not Numbers”. Results Conclusions: Our CSC observed a small decrease in median DTN but double the treatment rate after the BEST responder intervention. In comparison, these statistics did not change at the national CSC level. The sICH rate was reduced from Period A to C, meaning that increased treatment rate did not lead to increased hemorrhagic rate. Nursing initiatives can have a substantial positive effect on increasing the number of patients treated with IV alteplase for acute ischemic stroke.

Abstract TP317: Utility and Cost of Inpatient Thrombophilia Testing in Ischemic Stroke Patients Aged 18-60

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Effrosyni Apostolidou ◽  
Priya Khatri ◽  
Eric Thomas ◽  
Sean Savitz ◽  
Alicia Zha
Keyword(s):  
Ischemic Stroke ◽  
Cryptogenic Stroke ◽  
Inpatient Setting ◽  
Initial Hospital ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
One Year ◽  
Care Costs ◽  
Fvl Mutation

Introduction: Patients (pts) <60 years with ischemic stroke (IS) are commonly tested for thrombophilias (TP) due to the perception that there could be underlying hypercoagulable states. However, inherited TPs are largely not a risk factor for IS; and testing for acquired TPs in an acute inpatient setting may yield erroneous results that increase health care costs. We reviewed the frequency and cost of TP testing at our institution as part of a plan-do-study act cycle for improving the utilization of inpatient TP testing in young pts after IS. Methods: We performed a retrospective review of 18-60 year old pts admitted for IS to our comprehensive stroke center between 11/2016 and 7/2018. Pts discharged with a stroke etiology not attributed to large vessel (LV), small vessel (SV), or cardioembolic (CE) origin and the initial hospital TP testing monitored. Pts seen subsequently in clinic or later admissions in our system were monitored. Results: Of 1,162 pts, 104 without diagnosed LV/SV/CE etiologies were identified. At least one TP test was performed in 82 (79%) pts (Table 1). In 70 pts testing was done in the initial 24 hrs of hospitalization. One test abnormality was seen in 42 (51%) pts but anticoagulation was initiated in only one 1 patient at discharge. Forty-seven (45%) pts were followed in our outpatient clinic, with a mean follow up of 5 (0.2 – 24) months. TP was confirmed in 3 pts in clinic – two with heterozygous FVL mutation and one with known homozygous FVL mutation. The total charges of the initial inpatient testing is estimated to be as high as $222,150 for 82 patients. Conclusion: Frequent inpatient TP testing in young pts with cryptogenic stroke does not change management and can be costly to the hospital. Based on these results, we created a practice guideline to improve utilization of TP testing starting January 2019. A one year analysis of the effectiveness, safety, and cost for these changes is ongoing.

Abstract TP373: Classification of sICH in Stroke Center Hospitals: Reliability in Question

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Victoria Swatzell ◽  
Fern Cudlip ◽  
Andrei V Alexandrov ◽  
Anne W Alexandrov
Keyword(s):  
Pay For Performance ◽  
Reperfusion Therapy ◽  
Hemorrhagic Transformation ◽  
Quality Data ◽  
Treatment Rate ◽  
Team Members ◽  
Common Definition ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Contrast Ct

Background: Measuring sICH is an important accountability of Stroke Centers. Since the NINDS rt-PA Study, the sICH definition has changed as knowledge of reperfusion-associated hemorrhagic transformation has grown. We aimed to determine what sICH definition was used by Stroke Centers and how this impacts sICH rates. Methods: Stroke Centers were invited to participate in a survey with the option to complete it via SurveyMonkey TM or by mail. Instructions to adhere to the sICH definition adopted in policies/procedures were provided, and to ask for clarification from Stroke Team members if needed. Data were assembled in SPSS, and analyzed using descriptive statistics and Student t-tests. Results: 229 responses were received representing 84% of U.S. states and the District of Columbia; 31% represented academic medical centers and 69% community hospitals. 64% of respondees were responsible for collecting the stroke quality data that supports certification. Overall tPA treatment rate for the sample was 8.7% + 6.4 (median 7%), with an overall reported sICH rate of 9.5% + 16.4 (median 5%). Official definitions supported sICH for 86% of responding hospitals, however the most common definition (48%) reported was, “any hemorrhage on non-contrast CT or MRI in combination with any clinical deterioration.” Only 17% identified the definition for sICH adopted by TJC for Comprehensive Stroke Center reporting. Among those that adhered to the TJC definition, sICH rates were significantly lower at 3%+2.3 (median 3%; t=4.7; mean difference = 7.7%; p<.0001, 95% CI 4.4-10.95), compared to 10.6%+17.5 (median 6%). Conclusions: Our study documents a significant need for education and inter-rater reliability monitoring of the use of sICH classification after intravenous tPA to ensure accuracy in local quality improvement processes, as well as the validity of data submitted to national stroke registries. Additionally, because sICH associated with reperfusion therapy is a new measure undergoing testing by TJC that could ultimately be tied to future pay-for-performance and public reporting, consensus on its definition as well as reliable sICH classification will be essential to future Stroke Center evaluation.

Abstract TP394: Inpatient Onset Stroke Protocols in the Era of Value Based Medicine: Can We Remove Effectively Process Inefficiencies?

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Maryika I Gibson ◽  
Beth Susemiehl
Keyword(s):  
Cost Estimation ◽  
Rapid Response Team ◽  
Stroke Care ◽  
Quality Metrics ◽  
Trauma Patients ◽  
Hospital Inpatient ◽  
Response Team ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Based Medicine

Introduction: The American Stroke Association guidelines (2018) extension of the window for stroke interventions created an opportunity for quality improvement (QI) efforts in a sub-population designated as In-hospital (Inpatient) strokes (IHS). The new focus on salvageable tissue allows qualified IHS to receive effective reperfusion interventions. To improve outcomes in this population, hospitals are designing protocols and QI initiatives specific to IHS. Methods: An analysis of the implementation of a Code Stroke Rapid Response Team (RRT) process in a Primary (PSC) and a Comprehensive Stroke Center (CSC) was performed. We utilized descriptive statistics and cost estimation of centralizing the care of IHS on dedicated units. Results: CSC patients had a lower treatment -OR=0.17 CI 95%, and a higher mimics rate -OR= 3.03 95% CI compared to PSC. Cost of intra-hospital transfers was estimated at $5,000 to $8,000. Most of IHS occurred in cardiothoracic and trauma patients. While overall quality metrics improved -symptom discovery to CT 47% under 25 min, discovery to assessment 90% under 10 min, in the CSC the intra-hospital transfers contributed to added expenditures. The false-positive calls documented multiple contraindications to acute interventions. Conclusions: When implementing QI programs, hospitals should balance available resources, patients population specifics, and desired outcomes. Creating one-size-fits-all protocols can lead to multiple wastes in complex organizations. In the era of Value-Based Medicine and declining reimbursements, adopting flexible organization-specific and clinically oriented pathways and aligning treatment goals of multi-specialty teams will address the needs of IHS. Utilization of tools specific to early detection of IHS and further studies with a systematic collection, evaluation, and analysis of data is needed. Fostering efficient and consistent team communication and processes that balance quality metrics and fiscal responsibilities based on hospital structural and functional differences should become the next step in designing Code Stroke protocols. Real-World Evidence from sharing results will lead to an improvement in inpatient stroke care and patients’ outcomes- a mission long overdue.

Abstract TP289: Code Neuro-Intervention a New Necessity: Reality of Shifting Stroke Care Paradigm

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Laura Suhan ◽  
Spozhmy Panezai ◽  
Jaskiran Brar ◽  
Audrey Z Arango ◽  
Anna Pullicino ◽  
...  
Keyword(s):  
Stroke Care ◽  
Work Hours ◽  
Stroke Treatment ◽  
Angiography Suite ◽  
Stroke Team ◽  
Cross Training ◽  
Code Process ◽  
Time Parameters ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: Various strategies have been implemented to reduce acute stroke treatment times. A unique code process pathway was designed at our hospital specifically to be activated by the stroke team for the purpose of rapidly assembling the Neurointerventional team. Methods: Code Neurointervention (NI), was designed and tested from January 2014 to April 2014 for all the patients who presented with ischemic strokes to our community based, university affiliated comprehensive stroke center. We retrospectively analyzed all patients who had Code NI called from May 1, 2014 to April 30, 2015 and compared them to patients who underwent acute endovascular treatment the prior year (Non Code NI). The following parameters were compared: decision to recanalization and door to recanalization times. Further analysis was done to compare patients presenting during business hours (Monday-Friday 8am-5pm) and off hours using GraphPad QuickCalcs Web site. Results: There were 28 Code NI; 14 were called during work hours and 14 during off hours. The previous year 25 patients underwent acute endovascular intervention; 12 during work hours and 13 during off hours. Mean decision to recanalization time was 106 (Code NI) vs 115 minutes (Non Code NI) (p<0.0.6) during work hours and 154 (Code NI) vs 139 minutes (Non Code NI) (p<0.37) during off hours. Mean door to recanalization time was 169 (Code NI) vs 173 minutes (Non Code NI) (p<0.85) during work hours and 252 (Code NI) vs 243minutes (Non Code NI) (p< 0.75) during off hours. Subset analysis of time parameters for patients in Code NI group showed mean decision to recanalization times of 106 minutes during work hours vs 154 minutes off work hours (p<0.004). Mean door to recanalization times were 169 minutes vs 251 minutes (p<0.0003), respectively. Conclusion: Institution of Code NI significantly improved intervention time parameters during work hours as compared to off hours. Rapid assembly of the neurointervention team, rapid availability of imaging and angiography suite likely contribute to these differences. Further initiatives, such as improving neurointervention staff availability during off hours or cross training other staff can further improve acute intervention time parameters.

Abstract 3531: Clinical Outcomes Following Endovascular Stroke Treatment Facilitated via Telestroke Evaluation

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Stacie Demel ◽  
Amin Aghaebrahim ◽  
Vivek Reddy ◽  
Maxim Hammer ◽  
Lori Massaro ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Clinical Outcomes ◽  
Medical Center ◽  
Mortality Rates ◽  
Favorable Outcome ◽  
Multivariate Logistic Regression Model ◽  
Small Community ◽  
Stroke Treatment ◽  
Comprehensive Stroke Center ◽  
Stroke Center

BACKGROUND: Most stroke patients present to small community hospitals without established stroke pathways or interventional stroke treatment capability. The advent of 2 way audiovisual telestroke systems gives such patients the opportunity to be assessed rapidly by stroke neurologists. Patients who are not candidates for systemic IV tPA or have failed thrombolytic treatment can be identified and transferred to a comprehensive stroke center for potential endovascular treatment. We compared the clinical outcomes of patients undergoing endovascular stroke treatment at University of Pittsburgh Medical Center triaged either through telestroke or non-telestroke means. METHODS: Prospective data including demographics, co-morbidities, baseline Alberta Stroke Program Early CT (ASPECT) and National Institute of Health Stroke Scale (NIHSS) score, intervention modality (pharmacological, mechanical or both), time to treatment, clinical outcome, and hemorrhage and mortality rates were compared. Favorable outcome was defined as modified rankin score (mRS) of 2 or less. RESULTS: Between 3/2007 and 5/2011, thirty four patients underwent endovascular stroke treatment following telestroke evaluation versus 354 patients who were triaged through other means. Baseline characteristics were similar between the groups. Time to endovascular treatment (595 vs. 767 minutes; p = 0.5), pretreatment with systemic tPA (51.6 vs. 56.9%, p=0.6), recanalization (TIMI ≥ 2; 91.2% vs. 84.8%; p = 0.31), favorable outcome (modified rankin score ≤ 2; 50% vs. 40.4%; p = 0.29) and mortality rates (28.1% vs. 34.9%, p=0.44) were comparable. Multivariate logistic regression model identified young age (OR 0.91, CI 0.88-0.95, p<0.01), successful recanalization (OR 3.3, CI 1.8-6.2, p<0.01), and baseline ASPECT score (OR 6.5, CI 2.4-17.4, p<0.01) as predictors of favorable outcome. CONCLUSION: The results of this study suggest that telestroke guided endovascular stroke treatment is feasible and the outcomes are similar to those patients who were triaged by traditional means. Future randomized studies which specifically compare triage via telemedicine vs. telephone or direct emergency department presentation are needed to substantiate these findings.

Abstract P149: Regional Transfer Protocols Can Improve Transfer Times and Reduce Length of Stay for Thrombectomy Candidates Seen on Telestroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Michele M Joseph ◽  
Amanda L Jagolino-Cole ◽  
Alyssa D Trevino ◽  
Liang Zhu ◽  
Alicia M Zha ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Emergency Rooms ◽  
Stroke Patients ◽  
Arrival Times ◽  
Time Periods ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
One Year ◽  
The Impact ◽  
Transfer Times

Introduction: Our telestroke (TS) network instituted a regional transfer protocol (RTP) that allows for stroke patients in need of higher level of care to be pre-accepted and transferred to the nearest appropriate comprehensive stroke center (CSC). We studied the impact of the RTP on resource utilization and time metrics in patients transferred for evaluation of intra-arterial thrombectomy (IAT). Before the RTP, all potential IAT patients were transferred to one central CSC. After the RTP was initiated, the network had the capability to transfer to two additional CSCs within the same health system that are strategically located in the Houston area. Methods: We identified patients evaluated via TS in spoke emergency rooms that were subsequently transferred for IAT evaluation from 1/1/2016 to 12/31/2017 - one year prior and one year after the RTP. Baseline demographic characteristics, transfer and IAT metrics, and outcomes were compared for the two time periods. Results: Of 220 patients, 102 patients were transferred pre-RTP, and 120 were transferred to the three CSCs post-RTP. There were no significant differences in baseline characteristics, except fewer patients received tPA post-RTP (Table 1). In total, 30 patients (29%) pre-RTP and 42 patients (35%) post-RTP underwent IAT (p=0.38). Post-RTP, there was a trend toward faster travel times (median 40 vs 32 minutes, p=.07) and transfer initiation times to hub arrival times (median 109 vs 100.5 minutes, p=0.09). Door to groin puncture times were not statistically different between the two time periods. Post-RTP patients had a significantly shorter length of stay (median 6 vs 5 days, p=0.03). Conclusions: Regional transfer protocols can potentially help reduce transfer times and length of stay for stroke patients at CSCs that were initially seen by TS at community hospitals; however, larger sample size is needed to study its impact on other IAT-related metrics and clinical outcomes.

Use of computed tomography perfusion for acute stroke in routine clinical practice: Complex scenarios, mimics, and artifacts

2018 ◽  
Vol 13 (5) ◽  
pp. 469-472 ◽  
Author(s):  
Carlos Garcia-Esperon ◽  
Andrew Bivard ◽  
Christopher Levi ◽  
Mark Parsons
Keyword(s):  
Computed Tomography ◽  
Acute Stroke ◽  
Treatment Decision ◽  
Added Value ◽  
Stroke Treatment ◽  
Computed Tomography Perfusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Weighted Sequences ◽  
Perfusion Maps

Background Computed tomography perfusion is becoming widely accepted and used in acute stroke treatment. Computed tomography perfusion provides pathophysiological information needed in the acute decision making. Moreover, computed tomography perfusion shows excellent correlation with diffusion-weighted imaging and perfusion-weighted sequences to evaluate core and penumbra volumes. Multimodal computed tomography perfusion has practical advantages over magnetic resonance imaging, including availability, accessibility, and speed. Nevertheless, it bears some limitations, as the limited accuracy for small ischemic lesions or brainstem ischemia. Interpretation of the computed tomography perfusion maps can sometimes be difficult. The stroke neurologist faces complex or atypical cases of cerebral ischemia and stroke mimics, and needs to decide whether the “lesions” on computed tomography perfusion are real or artifact. Aims The purpose of this review is, based on clinical cases from a comprehensive stroke center, to describe the added value that computed tomography perfusion can provide to the stroke physician in the acute phase before a treatment decision is made.

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