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

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

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

Abstract WP435: Post Procedural Monitoring Tool Improves the Joint Commission Comprehensive Stroke Center Standard Compliance

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Denise Gaffney ◽  
Lorina Punsalang ◽  
Alvina Mkrtumyan ◽  
Raeesa Dhanji ◽  
David McCartney ◽  
...  
Keyword(s):  
Carotid Endarterectomy ◽  
Electronic Monitoring ◽  
Vital Signs ◽  
Joint Commission ◽  
Monitoring Tool ◽  
Post Intervention ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa ◽  
The Joint Commission

Background: The Joint Commission (TJC) Comprehensive Stroke Center standard requires monitoring of patients after IV tPA administration, diagnostic angiography, aneurysm coiling, carotid angioplasty and stenting, mechanical endovascular reperfusion (MER) and carotid endarterectomy. Meeting 100% compliance of the standard is challenging. In 2018, monitoring and documentation were among the TJC’s top ten cited survey findings. Purpose: To determine if an electronic tool can improve documentation compliance and reduce delays in monitoring of vital signs, and neurologic, pedal pulse and skin site assessments. Methods: The initiative was implemented in 2018 with the objective for all patients to have 100% of their post procedural monitoring completed. A documentation tool was created and introduced to nursing units via annual stroke education updates. The tool was added to an online nursing resource SharePoint website and application, which was accessible to all nurses within the hospital. The procedure end time was entered in the tool, which automatically calculated the documentation times. Data was compared 12 months pre and post intervention. Analysis and reporting of data were conducted monthly via the program’s quality oversight committee. Data was analyzed using T-Test. Results: In post-IV tPA patients, more patients had 100% complete documentation (79% post vs. 29% pre-implementation; p=0.006). For all post neuro-interventional radiology procedures, more patients had 100% complete documentation (68% post vs. 17% pre-implementation; p<0.001). For post carotid endarterectomy revascularization, there was a trend toward more patients with 100% complete documentation (83% vs 38%; p=0.07). Conclusion: Utilization of an electronic monitoring tool for post procedural documentation adherence can improve the percentage of patients who have 100% completed assessments and help meet the TJC standard.

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.

scholarly journals Institutional Incidence of Severe tPA-Induced Angioedema in Ischemic Cerebral Vascular Accidents

2018 ◽  
Vol 2018 ◽  
pp. 1-6
Author(s):  
Matthew Sczepanski ◽  
Paul Bozyk
Keyword(s):  
Length Of Stay ◽  
Ace Inhibitor ◽  
Upper Airway ◽  
Retrospective Chart Review ◽  
Time To Death ◽  
Tertiary Center ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Vascular Accidents ◽  
Cerebral Vascular

Introduction. Tissue plasminogen activator (tPA) is commonly used in ischemic cerebral vascular accidents (CVAs). tPA is generally well tolerated; however, orolingual angioedema is a well-documented adverse effect. Angioedema is generally mild, transient, and unilateral but can manifest as severe, life-threatening upper airway obstruction requiring intubation. Reported incidence for all severities ranges from one to five percent, whereas reported incidence of severe cases ranges from 0.18 to 1 percent of patients receiving tPA for ischemic CVA. Angiotensin-converting enzyme (ACE) inhibitors and middle cerebral artery distribution have been associated with a higher risk of developing angioedema. The aim of this study is to evaluate the incidence of severe tPA-induced angioedema and its effects on length of stay (LOS) and death. Methods. A retrospective chart review of patients receiving tPA for ischemic CVA from January 2014 through December 2016 was conducted at a large tertiary center with Comprehensive Stroke Center designation. Subjects were eighteen or older. Baseline demographics and clinical data were collected. Results. 147 patients were included with four developing severe angioedema due to tPA resulting in an incidence of 2.72%. All four were female. The median LOS was thirty days for patients with angioedema and twelve days for those without. The survival probability was higher in the angioedema group and mean time to death was twenty-two days in the angioedema group and twenty-one days in the nonangioedema group. Twenty-five patients died, one from the angioedema group. ACE inhibitor use was found to have an OR of 7.72. Conclusion. This study found a higher incidence of severe angioedema than that reported. Development of severe angioedema increased length of stay but was not shown to worsen outcomes in regards to death. Consistent with previous studies, ACE inhibitor use was associated with a higher risk of developing angioedema.

Abstract WP430: Implementation of Inpatient Stroke Champions Leads to Improved Inpatient Code Stroke Metrics

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Katherine V Lapsys ◽  
Jasmine Rochelle B Belmonte ◽  
Nathalie De La Pena-Gamboa ◽  
Raeesa Dhanji ◽  
Regina I Cuenca ◽  
...  
Keyword(s):  
Stroke Care ◽  
Final Diagnosis ◽  
Post Intervention ◽  
Specific Symptom ◽  
Delayed Treatment ◽  
Symptom Recognition ◽  
Number Of Patients ◽  
Inpatient Nursing ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: Stroke Champions (SC) are AHA recommended designated inpatient nurses that serve as expert resources for their units to ensure that evidence-based practices for stroke care are implemented. Inpatient Code Strokes (ICS) are difficult to recognize which results in delayed treatment. The purpose of this study is to determine if there was an improvement in inpatient acute stroke metrics with the addition of SC in the hospital. Methods: Over a 12-month period at a Comprehensive Stroke Center (CSC), 12 nurses in the inpatient stroke units were trained as SC. This training consisted of advanced education in CSC metrics, guidelines and required documentation. SC provided peer-to-peer education, served as expert resources, conducted comprehensive chart reviews, shift huddles, and “on the spot” feedback to nurses and physicians. The metrics were examined pre and post intervention and included: Symptom Recognition Time (SRT) to CT interpretation, SRT to tPA bolus time, and SRT to groin puncture. SRT is equivalent to Emergency Department door time for inpatient strokes. Statistical analysis was performed using T-test and the Mann-Whitney test. Results: There were 114 pre-SC and 101 post-SC ICS. There was a trend toward more patients being accurately diagnosed with a TIA or stroke (75.3% post vs. 65.8% pre-SC; p=0.06). The SRT to CT interpretation time for patients who received tPA improved from 43 to 35 mins. The number of patients treated with tPA increased from 10 to 17. SRT to tPA bolus time trended toward improvement from 57 to 42 mins (p=0.07). SRT to groin puncture time in patients who received both tPA and thrombectomy trended toward improvement from 81 vs. 65 mins (p=0.07). There were twice as many inpatient thrombectomy cases in post-SC (n=23) vs. pre-SC (n=12). Conclusion: The knowledge and expertise provided by SC resulted in a higher percentage of ICS having a final diagnosis of stroke. This demonstrates an increased accuracy of stroke specific symptom recognition by the inpatient nursing teams. There was improved SRT to tPA bolus and groin puncture time. This is the only study that shows implementation of the AHA recommended SC program improves inpatient code stroke recognition and treatment metrics.

Abstract TP377: Nurse Entered Stroke Order Sets Improve Emergency Department Metrics at a Comprehensive Stroke Center

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Tawnae C Griffith ◽  
Atul Gupta ◽  
Stacey Aggabao ◽  
Raeesa Dhanji ◽  
Denise Gaffney ◽  
...  
Keyword(s):  
Emergency Department ◽  
Stroke Care ◽  
Cardiac Monitoring ◽  
Post Intervention ◽  
Improvement Project ◽  
Order Sets ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Contrast Ct ◽  
Order Set

Introduction: The Joint Commission has established time sensitive metrics for stroke care in the Emergency Department (ED) including door to initial physician evaluation, door to lab and CT order placement, door to lab resulted and door to CT interpretation. Purpose: The purpose of this quality improvement project was to assess if nurse entered protocolized order sets for stroke patients would help to improve these metrics. Methods: A code stroke order set was initiated independently by nursing staff upon symptom recognition in the ED. The order set included CBC, electrolyte panel, BUN, creatinine, glucose, troponin, PT/INR, aPTT, non-contrast CT head, EKG, swallow screen and continuous cardiac monitoring. Data was collected for 3 months pre and post intervention. All ED nurses were trained on order set entry and their skills were validated. Data was analyzed using a T-Test. Results: 60 patient pre and 52 post-implementation were evaluated. Door to initial physician evaluation was faster (7 mins pre vs. 5 mins post; p=0.029). Door to lab order placement was faster (8 mins pre vs. 3 mins post; p=0.038). Door to CT ordered was faster (8 mins pre vs. 6 mins post; p<0.01). Door to labs resulted was faster (32 mins pre vs. 27 mins post; p=0.01). Door to CT interpretation was faster (19 mins pre vs. 18 mins post; p=0.04). Conclusion: Implementation of nurse entered order sets can improve ED metrics for door to initial physician evaluation, door to lab and CT order placement. This subsequently led to faster interpretation of the CT scan and lab results.

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

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

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

Abstract TP306: Risk of Stroke After ED Visits at Which No Diagnosis of TIA or Stroke was Recorded

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Marc Rosenman ◽  
Elissa Oh ◽  
Christopher T Richards ◽  
Norrina B Allen ◽  
Carmen Capo-Lugo ◽  
...  
Keyword(s):  
Preventive Treatment ◽  
High Volume ◽  
Missed Opportunities ◽  
Diagnostic Codes ◽  
Stroke Disability ◽  
Ed Visits ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Ischemic Attack ◽  
Future Work

Introduction: Unrecognized, high-risk conditions like transient ischemic attack (TIA) are missed opportunities to initiate timely preventive treatment to reduce the risk of subsequent stroke, disability, and death. Up to 50% of patients with a TIA may have a subsequent disabling stroke, many within 30 days. Hypothesis: Among patients with an Emergency Department (ED) visit at which no diagnosis of TIA or stroke was recorded, analysis of electronic health record (EHR) data can help predict risk of subsequent stroke. Methods: We performed a retrospective cohort study of EHR data (2011-2015) from a high-volume comprehensive stroke center with an annual ED volume of >85,000. Patients age 60-89 years who were discharged to home from the ED in <24 hours without ICD-9 diagnosis of TIA or stroke were included for analysis. If patients had >1 qualifying index visit during the study period, we used the first. For each patient we determined presence or absence during the ED visit of a head CT and/or any of these strings in the ED chief complaint (“Symptoms”): slur, speech, aphasia, confuse, word, difficult, comprehen, weak, clumsy, clumsiness, droop, paralysis, move, moving, face, or facial (but not “facial injury”). In four mutually-exclusive categories, CT (Yes/No) by Symptoms (Yes/No), we calculated rate of stroke in the 30, 90, and 365-day periods after discharge from the ED. Ischemic stroke ascertainment was based on diagnostic codes at subsequent ED or hospital visits. Results: Among 40,450 patients, mean age was 69 years, and 59% were women. Race was 57% white, 15% African-American, 23% other, and 4% unknown. Numbers of patients and rates of stroke by category are shown in the table. Conclusion: This simple approach established a clinically meaningful risk gradient across four groups. Present and future work to refine this model may contribute to comparative effectiveness research that evaluates management and triage strategies for patients across the stroke risk spectrum.

Abstract TP49: Acute Intracranial Stenting With Mechanical Thrombectomy Shows No Difference in Discharge Outcomes Compared With Mechanical Thrombectomy Alone

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Ameer E Hassan ◽  
Victor M Ringheanu ◽  
Wondwossen G Tekle ◽  
Laurie Preston ◽  
Adnan I Qureshi
Keyword(s):  
Length Of Stay ◽  
Mechanical Thrombectomy ◽  
Vessel Occlusion ◽  
Intracranial Stenting ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Discharge Outcomes ◽  
Poor Outcomes ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Proven Method

Background: Mechanical thrombectomy (MT) is a proven method of treating patients with acute ischemic stroke (AIS) from a large vessel occlusion. However, there has been controversy regarding the safety and efficacy of incorporating acute intracranial stenting in addition to standard MT especially after the WEAVE trial results which showed a significant increase in stroke and hemorrhage in patients receiving wingspan stenting within 7 days of index ischemic event. We compared the outcomes of all AIS patients treated with acute intracranial stenting + MT versus MT alone. Methods: Through the utilization of a prospectively collected endovascular database at a comprehensive stroke center between 2012-2019, variables such as demographics, co-morbid conditions, symptomatic intracerebral hemorrhage (ICH), mortality rate at discharge, and good/poor outcomes in regard to modified thrombolysis in cerebral infarction score (TICI) and modified Rankin Scale at discharge (mRS dc) were examined. The outcomes between patients receiving acute intracranial stenting + MT and patients that underwent MT alone were compared. Results: There were a total of 439 AIS patients who met criteria for the study (average age 70.38 ± 13.46 years; 45.6% were women). Analysis of 36 patients from the acute stenting + MT group (average age 66.72 ± 13.17 years; 30.6% were women), and 403 patients from the MT Alone group (average age 70.71 ± 13.45 years; 46.9% were women); see Table 1 for baseline characteristics and outcomes. Three patients (8.3%) in the acute stenting + MT group experienced ICH versus forty-four patients (10.9%) in the MT alone group (P=0.631); no significant increases were noted in length of stay (9.08 days vs 9.84 days; P=0.620) or good mRS scores at dc (P=0.636). Conclusion: Acute intracranial stenting in addition to MT was not associated with an increase in ICH rates, overall length of stay, or poor outcome upon discharge of patients. Prospective studies are recommended.

Abstract 86: Accuracy of Emergency Medical Services Dispatcher and Provider Recognition of Stroke in Clinical Practice

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Judy Jia ◽  
Michael Abboud ◽  
William Pajerowski ◽  
Michelle Guo ◽  
Guy David ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Emergency Medical Services ◽  
Stroke Care ◽  
Medical Services ◽  
Symptom Duration ◽  
Emergency Medical ◽  
Cerebrovascular Events ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Ischemic Attack

Objective: It is imperative that prehospital providers accurately recognize stroke. We assessed the sensitivity of stroke recognition by emergency medical services (EMS) in clinical practice in a major US city, and assessed variables associated with failure to recognize stroke. Methods: Data from the Philadelphia EMS system was linked with data from a single comprehensive stroke center to identify patients diagnosed with transient ischemic attack, ischemic stroke, or intracerebral hemorrhage by EMS dispatchers, EMS providers, or at hospital discharge between September 2009 and October 2012. Sensitivity and positive predictive value (PPV) were calculated. Multivariable logistic regression was used to identify variables associated with EMS recognition of stroke. Results: There were a total of 709 cases, 400 of which were cerebrovascular events (38% infarct, 10% ICH, and 8% TIA). Of these cases, 80 (20%) were not recognized by EMS dispatcher or EMS provider, 90 (23%) were recognized by dispatcher alone, 87 (22%) by EMS provider alone, and 143 (36%) by both. EMS providers recognized stroke with a sensitivity of 58%, PPV 69%. Dispatchers or EMS providers recognized stroke with a sensitivity of 80%, PPV 51%. In a multivariable model, EMS providers were more likely to miss a stroke when NIHSS was low (compared to NIHSS 10+, NIHSS 5-9 OR=1.6, 95% CI 0.9-3.0 & NIHSS<5 OR=4.6, 95% CI 2.7-7.9), when motor signs were absent (OR=2.4, 95% CI 1.5-3.9), and when symptom duration was > 270 minutes (OR=2.4, 95% CI 1.5-3.8). Medics correctly recognized 81% of stroke patients with NIHSS>4 and symptom duration <270 minutes, and dispatcher or EMS providers correctly recognized 90% of these patients. Conclusions: EMS recognized stroke with limited sensitivity, resulting in a high proportion of missed stroke cases. When added to the EMS provider impression, dispatcher impression meaningfully improves the sensitivity for recognizing stroke. Maximizing sensitivity is critical to prehospital interventions which may improve overall stroke care, such as transportation to designated stroke centers or EMS prenotification of receiving hospitals.

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