Abstract WP460: Stroke Awareness is a 911: Stroke Team and EMS Collaboration for Stroke Education

Background: Accurate pre-hospital recognition of acute stroke is essential, but current training of EMS providers varies across agencies. We created targeted classes specifically for prehospital providers to increase their knowledge of stroke symptoms, emphasizing posterior circulating artery stroke (PCA) symptoms, with the goal to increase awareness of neurological emergencies and enhance patient destination decisions. Purpose: To enhance prehospital providers’ stroke knowledge, improve provider confidence levels of symptom identification and to help guide the prehospital providers with their stroke patient destination decision-making. Implementation process: Our stroke team collaborated with Beverly Hills Fire Department (BHFD). We created three educational modules using recorded stroke-specific paramedic calls that involved BHFD paramedics and Cedars-Sinai Mobile Intensive Care nurses. 77 EMS providers total attended the three classes. Each educational module outlined pathophysiology of stroke and reviewed treatment provided and final disposition of each case. Pre- and post-class knowledge assessment and evaluation Likert-scale surveys were distributed to each class participant. These surveys were collected and tallied. Results: Of 63 pre-class survey respondents, 25% felt definitely adequately trained and 54% felt somewhat adequately trained to recognize an acute ischemic neurologic event and felt somewhat likely to designate a patient as a Stroke Center candidate if their chief complaints coincided with PCA symptoms. Of 40 post-class survey respondents, 75% indicated that the class definitely augmented their previous training in recognizing an acute ischemic neurologic event, and 83% would very likely designate a patient as a Stroke Center candidate if their chief complaints coincided with PCA symptoms. Using Chi-square analysis, the improvement is stroke symptom confidence was statistically significant (p<0.01). Conclusions: The post-class surveys showed a substantial and statistically significant increase in the confidence levels of recognizing PCA symptoms in the field. Further studies will measure persistence of knowledge gained over time and extension of the educational modules to other agencies.

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

Stroke ◽

10.1161/str.51.suppl_1.wp439 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Betty Robertson ◽

Denise Levesque ◽

Nicole Wolber ◽

Nili Steiner ◽

Nancy Nunez ◽

...

Keyword(s):

Clinical Trials ◽

Anticoagulation Therapy ◽

Training Session ◽

Stroke Care ◽

Patient Identification ◽

Stroke Team ◽

Expert Nurses ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Patient Enrollment

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 W P359: Stroke Symptom Identification: Using a Modified ROSIER SCALE at Emergency Room Triage

Stroke ◽

10.1161/str.46.suppl_1.wp359 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Deborah Bergman ◽

Keyword(s):

Emergency Room ◽

Team Member ◽

Assessment Tool ◽

Stroke Patients ◽

Hospital Emergency ◽

Roles And Responsibilities ◽

Stroke Symptom ◽

Stroke Team ◽

Hospital Emergency Room ◽

Stroke Center

Background and Issues: Stroke patients can arrive to the emergency room via Emergency Medical Services (EMS) or ambulatory at triage. Processes are already in place to identify stroke patients in the field such as the Cincinnati Pre-hospital Stroke Scale used by the Emergency Management Services (EMS) and early notification to the hospital emergency room staff. Data showed that approximately 68% of stroke patients at this stroke center arrived by or were brought to the hospital by self, family, or coworkers and not by EMS. Our main goal was to improve the process for recognizing stroke symptoms for patients who do not arrive by EMS and minimize delays to activating the Stroke Code Team Page in the triage area. Methods: The first step was to identify the barriers or delays that nurses had with initiating a stroke code alert. Stroke code activations were delayed because of uncertainty of who should call it and some nurses did not feel confident in their decision to activate the stroke code alert without consulting the emergency room physician. It was determined that the nurse would feel more empowered if there was more clarity to their roles and responsibilities during the assessment phase and there was an assessment tool available to guide them to the decision to activate the stroke team page. A modified version of the “Recognition of Stroke in the Emergency Room” (ROSIER) scale was implemented for the nurses to evaluate a patient that presents with stroke like symptoms. In addition to clarify their roles a workflow chart was deployed to show each team member their specific roles and responsibilities during this process. Results: Prior to the implementation of the ROSIER scale at triage the activation of stroke codes at triage were inconsistent. After education of the ED nurses and implementation of the ROSIER SCALE at triage there was a significant increase in the activations of stroke codes by ED nurses and a decrease in the time from triage to stroke team activation. Conclusions: Using an assessment tool like the ROSIER Scale in addition to clarifying the roles and responsibilities of the team can reduce delays to identifying acute stroke symptoms in patients at a busy emergency room triage area and improve opportunities for timely interventions.

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Abstract T P260: Confirmation: The Target Stroke Best Practice Strategies Work

Stroke ◽

10.1161/str.46.suppl_1.tp260 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Nojan Valadi ◽

Alexis Thomas

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Process Improvement ◽

Best Practice ◽

Stroke Patients ◽

High Performers ◽

Process Implementation ◽

Honor Roll ◽

Stroke Team ◽

Stroke Center

Background: A recent national push for optimizing stroke center performance led by the efforts of AHA/ASA to recognize high performers with the Target Stroke Honor Roll recognition have focused on achieving expedited treatment for stroke with door-to-needle (DTN) time of ≤60 minutes.Our organization recognized the need to optimize our performance and set an initial goal of achieving DTN time of ≤60 minutes in greater than 50% of our patients. The Target Stroke Initiative by the AHA/ASA identified 10 key strategies for best practice associated with reducing DTN times. Our organization adopted and implemented all of these strategies over a 30-day period. Methods: The Target Stroke best practice strategies were implemented over a 30-day period, and the Stroke Team worked collaboratively to identify other weaknesses needing to be addressed. DTN times ≤60 minutes from the 12 months prior to process improvement implementation were compared with the first 2 months post implementation. Results: There were 345 ischemic stroke patients treated at our facility during the 12 month period prior to the process implementation, with a total of 14 patients (1.12 per month) treated with tPA. The percentage of patients treated with tPA was 4%, and the percentage of patients treated with DTN ≤60 minutes was 0%. Over the two months following process implementation, 68 ischemic stroke patients were treated at our facility, with 11 patients treated with tPA (5.5 per month). The percentage of stroke patients treated with tPA was 16%, with 70% of patients treated with DTN ≤60 minutes. Conclusion: This study serves as confirmation that collaboration and implementation of the 10 key strategies for best practice as outlined by the Target Stroke Initiative, coupled with changes to identified areas of weakness, can improve and expedite the care of patients with acute ischemic stroke. This can substantially improve DTN times, as well as the overall number and percentage of patients that receive thrombolysis with a hopeful impact on their outcome as well as Target Stroke Honor Roll recognition for the facility. In conclusion, we recommend implementation of these best practice strategies to other facilities.

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Abstract TP389: Collaborative Approach to Improving Tele Stroke Call Back Times

Stroke ◽

10.1161/str.51.suppl_1.tp389 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Annette Clements ◽

Jennifer M Smith ◽

Benjamin K Morrow ◽

Ahutosh Jadhav

Keyword(s):

Call Center ◽

Time Window ◽

Phone Call ◽

Hub And Spoke ◽

Time Flow ◽

Physician Contact ◽

Stroke Team ◽

Timely Access ◽

Direct Cell ◽

Stroke Center

Background/Purpose: Emergency stroke evaluation requires rapid access to stroke experts for treatment decisions and advice, in many community settings this is facilitated through a hub and spoke telemedicine relationship. Since widespread adoption of the expanded endovascular time window, volume of calls to a single large academic hub stroke center have drastically increased and it was identified that there was a delay in achieving rapid connection to the hub sites which may result in delayed tPA evaluations. We sought to implement a focused process review to improve timely access to the hub stroke team. Methods: Leadership from the hub and spoke hospitals collaboratively reviewed and implemented steps to improve the time from spoke call out to hub call back for acute stroke. Interventions included: 1) Establishing a goal of less than 10 minutes for physician contact on all cases, 2) Revising spoke protocol to call out immediately following CT instead of after CT read, 3) Development of a stroke call out log that is shared between sites, 4) Hub hospital revised protocol to have cases within tPA time window bypass phone call and go directly to camera, 5) Exchange of direct cell phone numbers for follow-up questions on existing patients, 6) Weekly calls to discuss any video case time delays and time flow review, 7) development of a hub hospital call center escalation process for when the primary call physician has multiple calls coming in. Results: Data we analyzed through retrospective review of a prospectively collected database over a five month period. Results are displayed in the table 1. Conclusions: Improved process flow times within tele-stroke networks may be achieved through a focused collaborative relationship between hub and spoke hospitals with transparency of data and open discussion about barriers to achieving desired results.

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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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Gender differences in time from arrival to stroke team activation in patients presenting with acute stroke symptoms

10.22514/sv.2021.051 ◽

2021 ◽

Keyword(s):

Acute Stroke ◽

Proportional Hazards ◽

Gender Disparity ◽

Cox Proportional Hazards ◽

Activation Time ◽

National Guidelines ◽

Logistic Regression Models ◽

Patient Gender ◽

Stroke Team ◽

Stroke Center

Background and Purpose: Women are more likely to experience delays in evaluation and treatment for acute stroke. As national guidelines increasingly emphasize the importance of rapid stroke intervention, it is important to further investigate this gender disparity. We sought to evaluate whether door-to-stroke activation time varied by patient gender among patients for whom stroke team activation occurred in the emergency department (ED). Methods: This was a retrospective analysis of a prospectively collected registry of all patients for whom the stroke team was activated in the ED of an urban, academic, regional stroke center over 1 year. Our primary outcome was door to stroke activation time (DTA), with the primary predictor of interest being patient gender. We assessed for differences in DTA using multivariable Cox proportional hazards and logistic regression models. Results: There were 211 patient encounters included in the study, 117 women and 94 males. Median DTA was 8 minutes longer for women, and women were less likely to have DTA ≤ 15 minutes (odds ratio 0.26 [95% confidence interval 0.12 to 0.58]). Conclusion: A gender disparity existed in door to activation time for women presenting with suspected acute stroke, even when controlling for a variety of factors. These results provide evidence that gender may impact initial management of stroke patients.

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Abstract TP349: Advanced Practice Registered Nurses Provide Cost-effective, Quality Stroke Care

Stroke ◽

10.1161/str.44.suppl_1.atp349 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Brenda Jones ◽

Katherine Taylor ◽

Joyce Dorssom

Keyword(s):

Registered Nurses ◽

Cost Effective ◽

Stroke Care ◽

Advanced Practice ◽

Stroke Population ◽

Stroke Team ◽

Physical Form ◽

Advanced Practice Registered Nurses ◽

Stroke Center ◽

Evidenced Based

Background: Our institution is a nationally known stroke center. The number of stroke patients treated yearly grew from 235 in 2000 to 917 in 2011. We are challenged to provide clinically excellent, ground breaking care in a fiscally responsible manner to this growing population. Purpose: To meet this challenge our institution utilizes Advanced Practice Registered Nurses (APRNs) to improve and streamline stroke care. Methods: An APRN was part of the stroke team at the inception and continues as Coordinator. In 2008 the team implemented an additional APRN role to provide acute inpatient care to stroke and general Neurology patients. There are now 3 Board Certified APRNs who meet Certified Stroke Center requirements and fill this role. Their backgrounds are Emergency Medicine, Intensive Care, and Internal Medicine, and they are Certified Neurology Registered Nurses. They work collaboratively with the Neurologists in 12 hour shifts, 7 days a week. The APRNs complete History and Physicals, participate in research, provide education, assist with acute strokes and perform patient rounds.They address patient and staff concerns, and maintain collaborative care with other disciplines. Results: APRN collaboration assures continuous patient monitoring and allows physicians to address more acute issues. The Interval Summary dictation improves accurate coding of patient visits, assists in documenting core stroke measures, and provides current follow up to referring facilities. The APRNs designed and utilize a Neuroscience History and Physical form, which provides uniform and streamlined documentation. Their productivity logs show during June of 2012, a completion of 139 new consults, 169 routine follow ups, and monitoring of 97 ICU patients. This is in addition to dictation and multiple workplace demands. The Neurologists requested additional APRN coverage and are favorable of collaborative practice. Conclusion: In conclusion, the organized, streamlined, evidenced- based APRN care results in cost effectiveness meeting the challenges of the growing stroke population. Future plans for the APRN role include continued efficient care, educational efforts, preceptors for APRN students and residents, and participation in the hospital APRN Council.

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