Abstract P117: Stroke-Nurse Triage: Effects on Time Metrics at a Regional Stroke Center

Introduction: Optimization of time metrics in the management of acute stroke is a priority. Nurses with special training in stroke management may contribute to enhanced delivery of care. This study analyzes the effects of initiating a nurse-led stroke triage program at a regional stroke center on time metrics of acute stroke. Methods: Registered nurses (RNs) who received specialized stroke training including NIHSS certification were designated to each presenting stroke code at our institution. The stroke RN was responsible for initial assessment, obtaining NIHSS, continued monitoring of the patient, and maintaining timely progression of care. Metrics including time from arrival to assessment by emergency department (ED) physician, assessment by a neurologist, head CT scan, the start of tissue plasminogen activator (tPA) administration, and puncture for mechanical thrombectomy were recorded. In retrospective review, stroke metrics 25 months prior to the start of the triage program (controls) and 23 months after the start of the program (cases) were analyzed. Results: 1,019 patients presented with symptoms of acute stroke during the study duration, with 293 presenting pre-program initiation and 796 presenting post-program initiation. No significant differences during this period were seen for primary outcomes of time from arrival to assessment by ED physician, CT scan, start of tPA administration, or groin puncture. A significant increase in time to assessment by a neurologist was observed (pre-program: 12.24 minutes, post-program: 17.42 minutes, p<0.001). There was no difference before or after the program in Modified Rankin Scale (mRS) scores at discharge. Conclusions: Implementation of the stroke-nurse triage program involved the delegation of tasks previously under the responsibility of ED physicians to the stroke nurses. This delegation did not negatively impact care as determined by the lack of significant difference pre- and post-program for the primary metrics of arrival to CT, arrival to tPA, and arrival to groin puncture. Incorporating specially trained stroke-nurses in acute stroke management may be an appropriate use of personnel without negatively impacting stroke care.

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Stroke care: initial data from a county-based bypass protocol for patients with acute stroke

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012476 ◽

2016 ◽

Vol 9 (7) ◽

pp. 631-635 ◽

Cited By ~ 45

Author(s):

Syed F Zaidi ◽

Julie Shawver ◽

Aixa Espinosa Morales ◽

Hisham Salahuddin ◽

Gretchen Tietjen ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Care ◽

Diagnostic Specificity ◽

Treatment Rate ◽

Systemic Thrombolysis ◽

Advanced Therapy ◽

Tissue Plasminogen ◽

Lucas County ◽

Comprehensive Stroke Center ◽

Stroke Center

BackgroundEarly identification and transfer of patients with acute stroke to a primary or comprehensive stroke center results in favorable outcomes.ObjectiveTo describe implementation and results of an emergency medical service (EMS)-driven stroke protocol in Lucas County, Ohio.MethodAll county EMS personnel (N=464) underwent training in the Rapid Arterial oCclusion Evaluation (RACE) score. The RACE Alert (RA) protocol, whereby patients with stroke and a RACE score ≥5 were taken to a facility that offered advanced therapy, was implemented in July 2015. During the 6-month study period, 109 RAs were activated. Time efficiencies, diagnostic accuracy, and mechanical thrombectomy (MT) outcomes were compared with standard ‘stroke-alert’ (N=142) patients from the preceding 6 months.ResultsAn increased treatment rate (25.6% vs 12.6%, p<0.05) and improved time efficiency (median door-to-CT 10 vs 28 min, p<0.05; door-to-needle 46 vs 75 min, p<0.05) of IV tissue plasminogen activator within the RA cohort was achieved. The rate of MT (20.1% vs 7.7%, p=0.06) increased and treatment times improved, including median arrival-to-puncture (68 vs 128 min, p=0.04) and arrival-to-recanalization times (101 vs 205 min, p=0.001) in favor of the RA cohort. A non-significant trend towards improved outcome (50% vs 36.4%, p=0.3) in the RA cohort was noted. The RA protocol also showed improved diagnostic specificity for ischemic stroke (52.3% vs 30.1%, p<0.05).ConclusionsOur results indicate that EMS adaptation of the RA protocol within Lucas County is feasible and effective for early triage and treatment of patients with stroke. Using this protocol, we can significantly improve treatment times for both systemic thrombolysis and MT.

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Abstract P141: Global Impact of Covid-19 Pandemic on Acute Stroke and Mechanical Thrombectomy - An International Survey

Stroke ◽

10.1161/str.52.suppl_1.p141 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Dileep R Yavagal ◽

Vasu Saini ◽

Violiza Inoa ◽

Hannah E Gardener ◽

Sheila O Martins ◽

...

Keyword(s):

Acute Stroke ◽

Mechanical Thrombectomy ◽

High Volume ◽

Stroke Care ◽

Acute Stroke Care ◽

Treatment Practices ◽

Global Impact ◽

Significant Difference ◽

The World ◽

The Impact

Introduction: The COVID-19 pandemic has strained the healthcare systems across the world but its impact on acute stroke care is just being elucidated. We hypothesized a major global impact of COVID-19 not only on stroke volumes but also on thrombectomy practice. Methods: A 19-item questionnaire survey aimed to identify the changes in stroke volumes and treatment practices seen during COVID-19 pandemic was designed using Qualtrics software. It was sent to stroke and neuro-interventional physicians around the world who are part of the executive committee of a global coalition, Mission Thrombectomy 2020 (MT2020) between April 5 th to May 15 th , 2020. Results: There were 113 responses across 25 countries. Globally there was a median 33% decrease in stroke admissions and a 25% decrease in mechanical thrombectomy (MT) procedures during COVID-19 pandemic compared to immediately preceding months (Figure 1A-B). This overall median decrease was despite a median increase in stroke volume in 4 European countries which diverted all stroke patients to only a few selected centers during the pandemic. The intubation policy during the pandemic for patients undergoing MT was highly variable across participating centers: 44% preferred intubating all patients, including 25% centers that changed their policy to preferred-intubation (PI) vs 27% centers that switched to preferred-conscious-sedation (PCS). There was no significant difference in rate of COVID-19 infection between PI vs PCS (p=0.6) or if intubation policy was changed in either direction (p=1). Low-volume (<10 stroke/month) compared with high-volume stroke centers (>20 strokes/month) are less likely to have neurointerventional suite specific written personal protective equipment protocols (74% vs 88%) and if present, these centers are more likely to report them to be inadequate (58% vs 92%). Conclusion: Our data provides a comprehensive snapshot of the impact on acute stroke care observed worldwide during the pandemic.

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Abstract 3446: Inpatient Code Stroke Protocol: A Quality Improvement and Knowledge Translation Strategy for a Challenging Scenario

Stroke ◽

10.1161/str.43.suppl_1.a3446 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Jacqueline D Willems ◽

Krsytyna Skrabka ◽

Roseane Nisenbaum ◽

Judith Barnaby ◽

Pawel Kostyrko ◽

...

Keyword(s):

Quality Improvement ◽

Acute Stroke ◽

Robust Regression ◽

Stroke Care ◽

Initial Assessment ◽

Stroke Severity ◽

Care Hospital ◽

Presenting Symptoms ◽

Number Of Patients ◽

Assessment And Treatment

Background: Stroke care faces a clinical challenge in treating inhospital strokes, which account for about 15% of all strokes. Prior studies showed an inequity in the assessment and treatment of inpatients who suffer a stroke versus out-of hospital. For example, inpatients have longer time to initial assessment, CT and are less likely (wait longer) to receive tissue plasminogen activator (t-PA). There is limited research evaluating the efficacy of inpatient code stroke protocols (ICSP) on access to and quality of hyper-acute stroke care. Objective: To evaluate the efficacy of the ICSP in a large tertiary care hospital. Methods: This prospective study evaluated a quality improvement strategy involving ICSP implementation at St Michael’s Hospital in 2009. The ICSP focuses on the identification of stroke symptoms and timely notification of most responsible physician, then leverages the Emergency Department code stroke process. A 3-month hospital-wide implementation period involved 60 min. education sessions with a minimum of 2 sessions per unit. Demographic factors, presenting symptoms, stroke severity, vascular risk factors as well as time of: symptoms onset, CT; and physician assessment were collected by chart abstraction after ethics approval. The primary outcomes was time from last seen normal (LSN) to CT scan. Secondary outcomes include time from LSN to initial assessment (IA), medical complications and number of patients receiving endovascular interventions or intravenous thrombolysis. The analysis was completed by comparing unadjusted and adjusted outcomes pre and post implementation of the ICSP. Descriptive statistics and robust regression was completed using SAS 9.0. Results: Overall, there were 245 inhospital strokes during the study period (152 pre and 93 post ICSP implementation). Mean age was 69.8 yrs, 60% were male. Most inpatient strokes occurred on cardiovascular services (42.9%). Main results summarized in table . There was no difference in the number of patients receiving thrombolysis or endovascular treatment. After adjustment for covariates, the ICS was associated with a significant reduction of 288 minutes (95%CI -566, -10) in time from LSN to CT. Similarly, there was significant reduction of 307 (95%CI -532, -82) in time from LSN to IA. Conclusions: Implementation of the ICSP resulted in improvements in the process indicators related to assessment and treatment of hyper-acute stroke. Similar quality improvement strategies can be implemented to ameliorate disparities between care for inpatients and outpatient presenting with an acute ischemic stroke.

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Abstract W P334: VA Healthcare System Responses to National Stroke Care Reorganization

Stroke ◽

10.1161/str.45.suppl_1.wp334 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Teresa M Damush ◽

Kristine K Miller ◽

Laurie Plue ◽

Arlene A Schmid ◽

Laura Myers ◽

...

Keyword(s):

Acute Stroke ◽

Nurse Managers ◽

Stroke Care ◽

Structured Interviews ◽

Acute Stroke Care ◽

Major Barrier ◽

Ongoing Work ◽

Final Sample ◽

Cross Training ◽

Stroke Center

Aims: In 2011, the VA released the Acute Ischemic Stroke (AIS) Directive which mandated reorganization of acute stroke care, including self-designation as Primary (P), Limited Hours (LH), or Supporting (S) stroke center. We conducted interviews across stroke centers to understand barriers and facilitators faced in response. Methods: The final sample included 38 (84% invited) facilities: 9 P, 24 LH, and 5 S facilities. In total, 107 persons were interviewed including ED Chiefs, Chiefs of Neurology, ED Nurse Managers/Nurses and other staff. Semi-structured interviews were based on the AIS Directive. Completed interviews were transcribed and analyzed using Nvivo 10. Results: Barriers reported were a lack of personnel assigned to coordinate the facility response to the directive. Data collection and lack of staff were likewise commonly reported as barriers. For thrombolysis measures, the low number of eligible Veterans was another major barrier. LH and S facilities reported some unique barriers: access to radiology and neurology services; EMS diverting stroke patients to nearby stroke centers, maintaining staff competency, and a lack of stroke clinical champions. Some solutions applied included cross training X-ray technicians to provide head CT coverage, developing stroke order sets and templates, and staff training. Larger facilities added a stroke code pager system and improved upon its use, and established ED nurses to become first alerts for an acute stroke patient. LH and S facilities also responded by attempting to secure additional services and by establishing formal transfer agreements to improve Veteran tPA access. Conclusions: The AIS Directive brought focused attention to reorganizing and improving stroke care across a range of facility types. Larger VA facilities tended to follow established practices for organizing stroke care, but the unique LH designation presented challenges to consistently organize systems. Since Veterans have financial interest in presenting to a VA facility, ongoing work to organize VA care and to improve access to thrombolysis at smaller VA facilities is needed. This protocol was supported by Genentech Inc. Protocol ML 28238, VA HSRD QUERI Rapid Response Project 11-374, and the VA Stroke QUERI Center.

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Abstract 1122‐000121: Integrated Geomapping Tool of Certified Stroke Centers in United States: A SVIN MT2020+ Committee Collaboration

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000121 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Evan Kolesnick ◽

Alfredo Munoz ◽

Kaiz Asif ◽

Santiago Ortega‐Gutierrez ◽

...

Keyword(s):

United States ◽

Acute Stroke ◽

Clinical Outcomes ◽

Healthcare Disparities ◽

Systems Of Care ◽

Stroke Care ◽

The United States ◽

Time Dependent ◽

Stroke Systems Of Care ◽

Stroke Center

Introduction : Stroke is a leading cause of morbidity, mortality and healthcare spending in the United States. Acute management of ischemic stroke is time‐dependent and evidence suggests improved clinical outcomes for patients treated at designated certified stroke centers. There is an increasing trend among hospitals to obtain certification as designated stroke centers. A common source or integrated tool providing both information and location of all available stroke centers in the US irrespective of the certifying organization is not readily available. The objective of our research is to generate a comprehensive and interactive electronic resource with combined data on all geographically‐coded certified stroke centers to assist in pre‐hospital triage and study healthcare disparities in stroke including availability and access to acute stroke care by location and population. Methods : Data on stroke center certification was primarily obtained from each of the three main certifying organizations: The Joint Commission (TJC), Det Norske Veritas (DNV) and Healthcare Facilities Accreditation Program (HFAP). Geographic mapping of all stroke center locations was performed using the ArcGIS Pro application. The most current data on stroke centers is presented in an interactive electronic format and the information is frequently updated to represent newly certified centers. Utility of the tool and its analytics are shown. Role of the tool in improving pre‐hospital triage in the stroke systems of care, studying healthcare disparities and implications for public health policy are discussed. Results : Aggregate data analysis at the time of submission revealed 1,806 total certified stroke centers. TJC‐certified stroke centers represent the majority with 106 Acute Stroke Ready (ASR), 1,040 Primary Stroke Centers (PSCs), 49 Thrombectomy Capable Centers (TSCs) and 197 Comprehensive Stroke Centers (CSCs). A total of 341 DNV‐certified programs including 36 ASRs, 162 PSCs, 16 PSC Plus (thrombectomy capable) and 127 CSCs were identified. HFAP‐certified centers (75) include 16 ASRs, 49 PSCs, 2 TSCs and 8 CSCs. A preliminary map of all TJC‐certified CSCs and TSCs is shown in the figure (1). Geospatial analysis reveals distinct areas with currently limited access to certified stroke centers and currently, access to certified stroke centers is extremely limited to non‐existent in fe States (for example: Idaho, Montana, Wyoming, New Mexico and South Dakota). Conclusions : Stroke treatment and clinical outcomes are time‐dependent and prompt assessment and triage by EMS directly to appropriate designated stroke centers is therefore critical. A readily available electronic platform providing location and treatment capability for all nearby certified centers will enhance regional stroke systems of care, including enabling more rapid inter‐hospital transfers for advanced intervention. Identifying geographic areas of limited access to treatment can also help improve policy and prioritize the creation of a more equitable and well‐distributed network of stroke care in the United States.

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Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018

International Journal of Stroke ◽

10.1177/1747493018786616 ◽

2018 ◽

Vol 13 (9) ◽

pp. 949-984 ◽

Cited By ~ 73

Author(s):

JM Boulanger ◽

MP Lindsay ◽

G Gubitz ◽

EE Smith ◽

G Stotts ◽

...

Keyword(s):

Emergency Department ◽

Ischemic Stroke ◽

Acute Stroke ◽

Transient Ischemic Attack ◽

Best Practice ◽

Stroke Care ◽

Stroke Management ◽

Practice Recommendations ◽

Prehospital Emergency ◽

Ischemic Attack

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider’s recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

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Abstract P855: Importance of Compliance in Dysphagia Screening in Acute Stroke Care

Stroke ◽

10.1161/str.52.suppl_1.p855 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Patty Noah ◽

Melanie Henderson ◽

Rebekah Heintz ◽

Russell Cerejo ◽

Christopher T Hackett ◽

...

Keyword(s):

Acute Stroke ◽

Aspiration Pneumonia ◽

Hemorrhagic Stroke ◽

Oral Intake ◽

Stroke Care ◽

Stroke Severity ◽

Stroke Patients ◽

Acute Stroke Care ◽

Chi Square ◽

Stroke Center

Introduction: Dysphagia occurs in up to two thirds of stroke patients and can lead to serious complications such as aspiration pneumonia, which is also linked to increased morbidity and mortality. Evidence-based guidelines recommend a bedside dysphagia assessment before oral intake in stroke patients regardless of initial stroke severity. Several studies have described registered nurses’ competency in terms of knowledge and skills regarding dysphagia screening. We aimed to examine the rate of aspiration pneumonia compared to the rate of dysphagia screening. Methods: A retrospective analysis of prospectively collected data at a single tertiary stroke center was carried out between January 2017 and June 2020. Data comparison was completed utilizing ICD-10 diagnosis codes to identify aspiration pneumonia in ischemic and hemorrhagic stroke patients. The data was reviewed to compare the compliance of a completed dysphagia screen prior to any oral intake to rate of aspiration pneumonia. Chi square tests were used to assess proportion differences in completed dysphagia screen and proportion of aspiration pneumonia diagnosis in the ischemic and hemorrhagic stroke patients. Results: We identified 3320 patient that met inclusion criteria. 67% were ischemic strokes, 22% were intracerebral hemorrhages and 11% were subarachnoid hemorrhages. Compliance with dysphagia screening decreased from 94.2% (n=1555/1650) in 2017-2018 to 74.0% (n=1236/1670) in 2019-2020, OR=0.17 (95%CI 0.14 - 0.22), p < 0.0001. Aspiration pneumonias increased from 58 (3.5%) in 2017-2018 to 77 (4.6%) in 2019-2020, but this difference was not statistically significant, OR=0.75 (95%CI 0.53 - 1.07), p = 0.11. Conclusion: We noted that the decrease in compliance with completing a dysphagia screen in patients with acute stroke prior to any oral intake was associated with a higher trend of aspiration pneumonia.

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Abstract T MP75: Facilities Available in Chinese Hospitals From China Stroke Research Network

Stroke ◽

10.1161/str.46.suppl_1.tmp75 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Chunjuan Wang ◽

Zixiao Li ◽

Yilong Wang ◽

Yong Jiang ◽

Xingquan Zhao ◽

...

Keyword(s):

Acute Stroke ◽

Mainland China ◽

Stroke Care ◽

Research Network ◽

Level Of Care ◽

Minimum Level ◽

Stroke Patients ◽

Stroke Research ◽

Primary Stroke Center ◽

Stroke Center

Background and Purpose: Stroke is the first leading cause of death in China and millions of patients were admitted to various levels of hospitals each year. However, it is unknown how many of these hospitals are able to provide an appropriate level of care for stroke patients since the certification program of comprehensive stroke center (CSC) and primary stroke center (PSC) has not been initiated in China. Method: In 2012, we selected all 554 hospitals that joined into the China Stroke Research Network (CSRN) to start a survey. These hospitals were from 31 provinces or municipalities, covered nearly the entire Mainland China. A six-page questionnaire was sent to each of them to obtain the stroke facility information. We used the same criteria and definitions for CSC, PSC, and minimum level for any hospital ward (AHW) admitting stroke patients with that of the European Stroke Facilities Survey. Results: For all the hospitals in CSRN, 521 (94.0%) returned the questionnaire, 20 (3.8%) met criteria for CSC, 179 (34.4%) for PSC, 64 (12.3%) for AHW, and 258 (49.5%) met none of them and provided a lower level of care. Hospitals meeting criteria for CSC, PSC, AHW, and none of them admitted 70 052 (8.8%), 334 834 (42.2%), 88 364 (11.1%), and 299 806 (37.8%) patients in the whole of last year. There was no 24-hour availability for brain CT scan in 4.3% of hospitals not meeting criteria for AHW, while neither stroke care map nor stroke pathway for patients admission in 81.0% of them. Conclusions: Less than two fifths of Chinese hospitals admitting acute stroke patients have optimal facilities, and nearly half even the minimum level is not available. Our study suggests that only one half acute stroke patients are treated in appropriate centers in China, facilities for hospitals admitting stroke patients should be enhanced and certification project of CSCs and PSCs may be a feasible choice.

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The role of cardiologists on the stroke unit

European Heart Journal Supplements ◽

10.1093/eurheartj/suaa160 ◽

2020 ◽

Vol 22 (Supplement_M) ◽

pp. M3-M12

Author(s):

Wolfram Doehner ◽

David Manuel Leistner ◽

Heinrich J Audebert ◽

Jan F Scheitz

Keyword(s):

Acute Stroke ◽

Stroke Unit ◽

Stroke Care ◽

Cardiovascular Complications ◽

Large Artery ◽

Stroke Management ◽

Acute Stroke Care ◽

Daily Work ◽

Cardiovascular Comorbidity ◽

Treatment And Prevention

Abstract Cardiologists need a better understanding of stroke and of cardiac implications in modern stroke management. Stroke is a leading disease in terms of mortality and disability in our society. Up to half of ischaemic strokes are directly related to cardiac and large artery diseases and cardiovascular risk factors are involved in most other strokes. Moreover, in an acute stroke direct central brain signals and a consecutive autonomic/vegetative imbalance may account for severe and life-threatening cardiovascular complications. The strong cerebro-cardiac link in acute stroke has recently been addressed as the stroke-heart syndrome that requires careful cardiovascular monitoring and immediate therapeutic measures. The regular involvement of cardiologic expertise in daily work on a stroke unit is therefore of high importance and a cornerstone of up-to-date comprehensive stroke care concepts. The main targets of the cardiologists’ contribution to acute stroke care can be categorized in three main areas (i) diagnostics workup of stroke aetiology, (ii) treatment and prevention of complications, and (iii) secondary prevention and sub-acute workup of cardiovascular comorbidity. All three aspects are by themselves highly relevant to support optimal acute management and to improve the short-term and long-term outcomes of patients. In this article, an overview is provided on these main targets of cardiologists’ contribution to acute stroke management.

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