Abstract WP439: "You Gotta Troll to Enroll!" Nurses Actively Scouting Patients for Clinical Trials

Problem/ Background: Evidence- based practice is the cornerstone in delivery of stroke care to optimize outcomes for patients. Research is the foundation to build and advance clinical practice. As a Comprehensive Stroke Center, we are charged with participating in IRB approved research. In 2016 the SUCCEED trial was stopped here as a result of low enrollment. The stroke nurses were not directly involved in that trial. In 2017, the stroke nurses partnered with our physicians and began the ARAMIS trial. This is a multicenter study of acute stroke patients taking anticoagulation therapy prior to admission and suffering a stroke. We recognized the need for our stroke nurses to collaborate, participate and use their expertise in identifying appropriate research patients for this study. Quality Question: Will tasking Stroke Nurses with identifying patients improve the enrollment of patients in ARAMIS trial? Methods: Stroke nurses attended an ARAMIS training session for physicians. Included in the meeting was review of inclusion/exclusion criteria for patient enrollment. A group e-mail was created for all participating in the study to help identify potential patients. When a patient was discovered an email was sent to the group alerting those responsible for obtaining consent for the study and data collection for the registry. Results: After one trial was ended due to low enrollment, the new ARAMIS trial opened. The stroke team nurses took the lead on identifying patients. Reviewing retrospective data starting in November 2017 until March 2019, 56 patients were enrolled in Aramis. Stroke nurses identified 43 patients (77%), Neurology fellows 10 (18%) and Faculty physicians 3 (5%). Conclusion: When including expert nurses in the patient identification process, the nurse plays a pivotal role in identifying appropriate patient for the MDs to enroll, thus, increasing enrollment in clinical trials. While additional tracking and trending needs to take place as new trails open, this trial makes clear the need for nurse involvement in identifying appropriate patients.

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

Stroke ◽

10.1161/str.51.suppl_1.wp281 ◽

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.

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

Stroke ◽

10.1161/str.48.suppl_1.tp289 ◽

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.

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Abstract WP334: Standardized Language Reduces Symptom Discovery to CT Times: “Code Stroke - Inpatient”

Stroke ◽

10.1161/str.48.suppl_1.wp334 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Kailey L Cox ◽

Elizabeth Baraban

Keyword(s):

Evaluation Process ◽

Rapid Response Team ◽

Stroke Care ◽

Inpatient Setting ◽

Standard Language ◽

High Performing ◽

Stroke Team ◽

Response Team ◽

Comprehensive Stroke Center ◽

Stroke Center

Introduction: Inpatient stroke represents up to 17% of all strokes and should receive the same timely care as patients arriving to the ER, especially in a Joint Commission Certified Comprehensive Stroke Center (CSC). However, evidence suggests there is greater in-hospital delay in evaluation and treatment of inpatient strokes compared with stroke patients in the ER. To reduce symptom discovery to CT time, we implemented standardized language and a single pager for inpatient stroke alerts in a CSC hospital. Hypothesis: Using standard language to activate the stroke team and a one-call system will reduce symptom discovery to CT times for patients with stroke in the inpatient setting. Methods: A baseline evaluation revealed a lack of standard language for activating the stroke team (e.g. “Activate Stroke Team”, “Acute Stroke”, “Stroke Consult”, “Internal Alert”) and that the Rapid Response Team (RRT) nurse had to call multiple people to initiate the stroke evaluation process. Key stakeholders formed a workgroup and implemented a hospital-wide education initiative that included the use of standardized language for inpatient activation of the stroke team (“Code Stroke - Inpatient”) and the creation of a pager group with all responders (Stroke MD, RRT nurse, Transport, CT tech, Pharmacy, IV therapy, Chaplain, and NCCU Charge RN). Symptom discovery time to CT was measured pre- (January 2015-February 2016) and post-implementation (March 2016-August 2016). Data were reported as mean ± standard deviation and median [interquartile range], and results were analyzed using an unpaired t-test. Results: Implementation of standardized language and a single pager reduced the symptom discovery to CT times from 260 ± 421.9 minutes (median = 98 [59,277], n=22) pre-implementation to 39.8 ± 16.5 minutes (median = 36.0 [28, 47], n=20) post-implementation. Conclusion: A multidisciplinary approach is essential to improving symptom discovery to CT times for inpatient strokes; even high performing CSC’s may lack timely care for this population. Continued research is needed to understand successful methods for equalizing the disparity of stroke care in the ER versus inpatient units.

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

The Neurohospitalist ◽

10.1177/19418744211007001 ◽

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.

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Coronavirus disease 2019 is threatening stroke care systems: a real-world study

BMC Health Services Research ◽

10.1186/s12913-021-06297-4 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Jiawei Xin ◽

Xuanyu Huang ◽

Changyun Liu ◽

Yun Huang

Keyword(s):

Real World ◽

Mainland China ◽

Stroke Care ◽

Hospital Length ◽

Real World Data ◽

Care Systems ◽

Long Term Prognosis ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Medical Burden

Abstract Background Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, the stroke care systems have been seriously affected because of social restrictions and other reasons. As the pandemic continues to spread globally, it is of great significance to understand how COVID-19 affects the stroke care systems in mainland China. Methods We retrospectively studied the real-world data of one comprehensive stroke center in mainland China from January to February 2020 and compared it with the data collected during the same period in 2019. We analyzed DTN time, onset-to-door time, severity, effects after treatment, the hospital length of stays, costs of hospitalization, etc., and the correlation between medical burden and prognosis of acute ischemic stroke (AIS) patients. Results The COVID-19 pandemic was most severe in mainland China in January and February 2020. During the pandemic, there were no differences in pre-hospital or in-hospital workflow metrics (all p>0.05), while the degree of neurological deficit on admission and at discharge, the effects after treatment, and the long-term prognosis were all worse (all p<0.05). The severity and prognosis of AIS patients were positively correlated with the hospital length of stays and total costs of hospitalization (all p<0.05). Conclusions COVID-19 pandemic is threatening the stroke care systems. Measures must be taken to minimize the collateral damage caused by COVID-19.

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Impact of RapidAI mobile application on treatment times in patients with large vessel occlusion

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017365 ◽

2021 ◽

pp. neurintsurg-2021-017365

Author(s):

Mais Al-Kawaz ◽

Christopher Primiani ◽

Victor Urrutia ◽

Ferdinand Hui

Keyword(s):

Mobile Application ◽

Secondary Analysis ◽

Multiple Linear Regression Model ◽

Stroke Care ◽

Mobile App ◽

Large Vessel ◽

Vessel Occlusion ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Adjusted Model

BackgroundCurrent efforts to reduce door to groin puncture time (DGPT) aim to optimize clinical outcomes in stroke patients with large vessel occlusions (LVOs). The RapidAI mobile application (Rapid Mobile App) provides quick access to perfusion and vessel imaging in patients with LVOs. We hypothesize that utilization of RapidAI mobile application can significantly reduce treatment times in stroke care by accelerating the process of mobilizing stroke clinicians and interventionalists.MethodsWe analyzed patients presenting with LVOs between June 2019 and October 2020. Thirty-one patients were treated between June 2019 and March 2020 (pre-app group). Thirty-three patients presented between March 2020 and October 2020 (post-app group). Mann–Whitney U test and Kruskal–Wallis tests were used to examine variables that are not normally distributed. In a secondary analysis we analyzed interhospital time metrics between primary stroke centers and our comprehensive stroke center.ResultsBaseline demographic and vascular risk factors were similar in both groups. Use of Rapid Mobile App resulted in 33 min reduction in DGPT (P=0.02), 35 min reduction in door to first pass time (P=0.02), and 37 min reduction in door to recanalization time (P=0.02) in univariate analyses when compared with patients treated pre-app. In a multiple linear regression model, utilization of Rapid Mobile App significantly predicted shorter DGPT (P=0.002). In an adjusted model, National Institutes of Health Stroke Scale (NIHSS) 24 hours after procedure and at discharge were significantly lower in the post-app group (P=0.03). Time of transfer between primary and comprehensive stroke center was comparable in both groups (P=0.26).ConclusionIn patients with LVOs, the implementation of the RapidAI mobile application was independently associated with reductions in intrahospital treatment times.

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

Stroke ◽

10.1161/str.51.suppl_1.wp429 ◽

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.

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Detection of Large Vessel Occlusion Stroke in the Prehospital Setting

Stroke ◽

10.1161/strokeaha.120.033053 ◽

2021 ◽

Author(s):

Laura C.C. van Meenen ◽

Maritta N. van Stigt ◽

Arjen Siegers ◽

Martin D. Smeekes ◽

Joffry A.F. van Grondelle ◽

...

Keyword(s):

Diagnostic Accuracy ◽

Stroke Care ◽

Prehospital Setting ◽

Large Vessel ◽

Large Vessel Occlusion ◽

User Friendliness ◽

Vessel Occlusion ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Good Diagnostic Accuracy

A reliable and fast instrument for prehospital detection of large vessel occlusion (LVO) stroke would be a game-changer in stroke care, because it would enable direct transportation of LVO stroke patients to the nearest comprehensive stroke center for endovascular treatment. This strategy would substantially improve treatment times and thus clinical outcomes of patients. Here, we outline our view on the requirements of an effective prehospital LVO detection method, namely: high diagnostic accuracy; fast application and interpretation; user-friendliness; compactness; and low costs. We argue that existing methods for prehospital LVO detection, including clinical scales, mobile stroke units and transcranial Doppler, do not fulfill all criteria, hindering broad implementation of these methods. Instead, electroencephalography may be suitable for prehospital LVO detection since in-hospital studies have shown that quantification of hypoxia-induced changes in the electroencephalography signal have good diagnostic accuracy for LVO stroke. Although performing electroencephalography measurements in the prehospital setting comes with challenges, solutions for fast and simple application of this method are available. Currently, the feasibility and diagnostic accuracy of electroencephalography in the prehospital setting are being investigated in clinical trials.

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Impact of COVID-19 Pandemic on the Incidence, Prehospital Evaluation, and Presentation of Ischemic Stroke at a Nonurban Comprehensive Stroke Center

Stroke Research and Treatment ◽

10.1155/2021/6624231 ◽

2021 ◽

Vol 2021 ◽

pp. 1-5

Author(s):

Cesar Velasco ◽

Brandon Wattai ◽

Scott Buchle ◽

Alicia Richardson ◽

Varun Padmanaban ◽

...

Keyword(s):

Urban Areas ◽

Stroke Care ◽

Final Diagnosis ◽

Medical Attention ◽

Presenting Symptoms ◽

Number Of Patients ◽

Community Transmission ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

The Impact

Introduction. Many reports have described a decrease in the numbers of patients seeking medical attention for typical emergencies during the COVID-19 pandemic. These reports primarily relate to urban areas with widespread community transmission. The impact of COVID-19 on nonurban areas with minimal community transmission is less well understood. Methods. Using a prospectively maintained prehospital quality improvement database, we reviewed our hospital EMS transports with a diagnosis of stroke from January to April 2019 (baseline) and January to April 2020 (pandemic). We compared the volume of patients, transport/presentation times, severity of presenting symptoms, and final diagnosis. Results. In January, February, March, and April 2019, 10, 11, 17, and 19 patients, respectively, were transported in comparison to 19, 14, 10, and 8 during the same months in 2020. From January through April 2019, there was a 53% increase in transports, compared to a 42% decrease during the same months in 2020, constituting significantly different trend-line slopes (3.30; 95% CI 0.48–6.12 versus -3.70; 95% CI -5.76–-1.64, p = 0.001 ). Patient demographics, comorbidities, and symptom severity were mostly similar over the two time periods, and the number of patients with a final diagnosis of stroke was also similar. However, the median interval from EMS dispatch to ED arrival for patients with a final diagnosis of stroke was significantly longer in January to April 2020 ( 50 ± 11.7 min ) compared to the same time period in 2019 ( 42 ± 8.2 min , p = 0.01 ). Discussion/Conclusion. Our data indicate a decrease in patient transport volumes and longer intervals to EMS activation for suspected stroke care. These results suggest that even in a nonurban location without widespread community transmission, patients may be delaying or avoiding care for severe illnesses such as stroke. Clinicians and public health officials should not ignore the potential impact of pandemic-like illnesses even in areas of relatively low disease prevalence.

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Abstract TP303: Real-world Eligibility for Revascularization in Acute Stroke: A 12 Year Single Center Statistics

Stroke ◽

10.1161/str.47.suppl_1.tp303 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Peter Vanacker ◽

Dimitris Lambrou ◽

Ashraf Eskandari ◽

Patrik Michel

Keyword(s):

Time Windows ◽

Standard Of Care ◽

Stroke Care ◽

Regional Level ◽

Effective Number ◽

Single Center ◽

Resource Needs ◽

Liberal Approach ◽

Comprehensive Stroke Center ◽

Stroke Center

Aims: Endovascular treatment (EVT) for acute ischemic stroke (AIS) is the new standard of care for well selected, large vessel occlusive strokes. Hypothesis: We aimed to determine the frequency of patients potentially eligible for IV thrombolysis (IVT) and EVT based on the latest AHA/ASA guidelines. Methods: Data from a prespecified consecutive AIS registry (ASTRAL, 2003-2014) of a single comprehensive stroke center were examined. All AIS admitted <24hours and sufficient data to determine EVT-eligibility according to AHA/ASA guidelines (class I and IIa recommendations) on IVT and EVT were selected. Another set of more liberal criteria from different EVT trials and clinical practice was also tested. Time windows for EVT-eligibility was 4.5h (allowing for a door-to-groin delay ≤90min) and for IVT 3.5h (door-to-needle delay ≤60min). Results: A total of 2’704 AIS were included, of whom 26.8% were secondary transferrals. Proportion of IVT-eligible patients was 12.4% for all AIS, and 24.6% and 36.2% for patient arriving <24h and 6h respectively. Frequency of EVT-eligibility differed between the AHA/ASA guideline and the more liberal approach: 2.9% vs. 4.9% of all AIS and 10.5% vs. 17.7% of all patients arriving <6hours. These numbers are in line with the effective number of EVT applied in 2013 (15%) and 2014 (12%). Conclusions: Of patients arriving within 6h at a comprehensive stroke center, 10.5% are EVT eligible according to AHA/ASA criteria, nearly double (17.7%) with more liberal criteria, and again double for IV thrombolysis (36.2%). These figures may be useful for planning resource needs of stroke care on a regional level.

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