Abstract P828: Reducing and Sustaining "Door-To-Monitored Bed" Times in Patients Receiving Alteplase for Acute Stroke Symptoms

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Janet Leatherwood ◽  
Maureen Lall ◽  
Diane McGraw ◽  
Rita Richards ◽  
Fiona Smith
Keyword(s):  
Emergency Department ◽  
Change Management ◽  
Acute Stroke ◽  
Rapid Assessment ◽  
Stroke Care ◽  
Management Model ◽  
Quality Improvement Initiative ◽  
Process Change ◽  
Primary Stroke Center ◽  
Stroke Center

Background and Issues: Acute strokes are medical emergencies that require rapid assessment and treatment. Following treatments, focused and frequent monitoring is essential to quickly identify and mitigate any physiological deterioration. However, hospital capacity and decreased availability of monitored beds often causes delay in admission and prolonged stays in the emergency department and the potential increase in morbidity and mortality. Purpose: The purpose of this quality improvement initiative is to reduce the length of time from a patient presenting to the emergency department with acute stroke symptoms and treated with alteplase, to the time that the patient is being monitored utilizing “comprehensive specialized stroke care” level monitoring. This level of monitoring allows for the patient to be assessed closely and frequently to ensure the absence of physiological or neurological deterioration as well as for any adverse thrombolytic reaction. Methods: To improve the process of patient progression within the hospital, the care team utilized the ADKAR® Change Management Model. This model focuses on sponsoring awareness, promoting desire, providing knowledge, ensuring ability, and reinforcing changes. Each of these five components is critical to implement the proposed changes and ensure the longevity of the process changes. Results: Since the implementation of the process change, the Primary Stroke Center has experienced twenty-four months of mean “door-to-monitored bed” times below the 180 minute benchmark. In addition, the mean “door to monitored bed” time has decreased from 210 minutes in the three months preceding the process change (n=20), to 113 minutes during the twenty-four months following the change (n=150). Conclusions: During this process change, the Stroke Center successfully reduced the time between patient arrival and being in a monitored bed. The use of the ADKAR® Change Management Model is particularly advantageous in implementing a process change that is expected to be sustained into the future.

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

Stroke ◽  
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.

Abstract W P286: Assessing Wisconsin Hospitals’ Capacity to Treat Acute Stroke

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Julie E Baumann
Keyword(s):  
Acute Stroke ◽  
Technical Assistance ◽  
Systems Of Care ◽  
Stroke Care ◽  
Self Report ◽  
The Status ◽  
Primary Stroke Center ◽  
Stroke Systems Of Care ◽  
Stroke Center ◽  
Reported Data

Introduction: Establishing regional stroke systems of care can improve timely treatment and survival, and reduce disability and related healthcare costs for persons experiencing acute stroke. A well-functioning stroke system requires seamless coordination between EMS, hospitals and certified stroke centers. Of 127 non-specialty hospitals in Wisconsin, 2% are comprehensive stroke centers and 24% have achieved primary stroke center certification. However, little is known about other hospitals’ capacity to treat acute stroke. The Wisconsin Stroke Coalition (WSC) wanted to better understand the need to improve stroke care capacity among hospitals not certified to treat stroke. The hypothesis was that few non-stroke certified hospitals in Wisconsin have all the criteria in place to treat acute stroke. Methods: WSC developed a short survey based on the Brain Attack Coalition’s recommendations for an acute stroke-ready hospital (ASRH). The tool included a user-friendly checklist that captured the status of each recommendation; in place currently or within six months; could be developed with assistance; or no plan to develop. WSC distributed the survey to 88 non-specialty, non-stroke certified hospitals and requested that each self-report their level of stroke care. Results: Fifty-nine percent of hospitals responded to the survey. Among respondents, 5% reported having all recommendations in place within six months, 53% reported having some of the recommendations in place and 1% reported no plan to develop any of the recommendations. While only a few had implemented every recommendation, the majority either had in place or were receptive to adopting individual suggestions. Nearly half of respondents reported having telestroke in place (either by phone, with video, or both). Conclusions: According to self-reported data, non-specialty, non-stroke certified hospitals in Wisconsin appear well-positioned or receptive to developing basic recommendations for acute stroke-ready hospitals. WSC plans to disseminate findings to Wisconsin hospitals and gather further information about technical assistance that would improve their level of stroke care and coordination with EMS.

Abstract TP341: Nursing Impact on the Acute Stroke Team - Driving Practice in a Collaborative Environment

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Lauri Speirs
Keyword(s):  
Emergency Department ◽  
Acute Stroke ◽  
Endovascular Therapy ◽  
Golden Hour ◽  
Stroke Team ◽  
Primary Stroke Center ◽  
Response Team ◽  
Intense Training ◽  
Stroke Center ◽  
Time Frames

Background /Purpose: In 2005 a community hospital began the journey to Primary Stroke Center. One aspect was to develop a stroke response team. The acute stroke team must provide neurologist expertise at bedside, be cost neutral, compliment the workflow in the Emergency Department, and maximize the limited number of neurologists on staff. Stroke unit nurses were identified as neurological experts in the hospital. After intense training, Stroke Alert went live in October of 2007. The nurse led acute stroke team (AST) collaborated with the medical staff to increase the total volume of stroke patients receiving t-PA. With additional training, the nurse led team assisted in the identification and transfer of patients for endovascular therapy. Method: A group of 12 nurses were trained by the stroke medical director to complete a stroke assessment, then to communicate those findings to the neurologist on call and the Emergency Department physicians. The nurse responders and the Emergency Department nurses were trained to mix and calculate the doses for t-PA. In 2010 the nurse responders were educated on the criteria for endovascular therapy, including time frames, patient assessment, and key CT results. In 2011, the nurse responders were re-educated on the golden hour of stroke. Results: Since 2008, over 450 stroke alerts have been activated each year. The administration of t-PA increased from 4 patients in 2007 to 43 patients in 2011; an additional 9 patients were sent to another facility for endovascular therapy. In the first 6 months of 2012, over 50% of patients receive t-PA in less than 60 minutes and Gold plus from the AHA was achieved. Conclusion: Nurses can be a vital asset to the AST by providing neurological expertise, collaborating with physicians, and driving the stroke protocols.

Abstract 3150: Partnering with Emergency Department Staff Educators Increases the Number of Notifications to the Acute Stroke Research Team

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Hannah Reimer ◽  
Suzanne DuRocher ◽  
Susan Galiczynski
Keyword(s):  
Emergency Department ◽  
Acute Stroke ◽  
Research Team ◽  
Clinical Staff ◽  
Treatment Area ◽  
Data Set ◽  
Research Personnel ◽  
Stroke Research ◽  
Primary Stroke Center ◽  
Stroke Center

Background: Preparation for the Joint Commission survey to determine Primary Stroke Center Certification requires extensive education of staff in all areas a stroke patient will be during their hospitalization. Research personnel in the Emergency Department (ED) often rely on clinical staff for notification of potential research participants. When present in the treatment area research personnel are notified in person or find potential participants by reviewing a patient’s chief complaint or admitting diagnosis. When outside the treatment area, particularly during times when on call from outside the hospital, the research staff is dependent on notification by clinical staff. Methods: During the survey preparation, ED staff was educated in care of ischemic and hemorrhagic stroke patients according to AHA/ASA guidelines. During the formal nursing education research personnel gave short presentations on currently enrolling acute stroke trials and gave instructions on how to reach the research team in the event that a potential study participant entered the ED. Quarterly research reports were given at the Emergency Medicine resident’s conference. Education was given to the nursing and medical staff from October 2010 through July 2011 when the survey took place. The database of the online paging system was reviewed for the time period April 2010 through July 2011. Test, demonstration, non-stroke study and calls from other institutions were deleted from the data set. The remaining calls were divided by the month in which they were placed. Results: The research team received on average 5 calls per month during the six months prior to the AHA/ASA education. During the education time the research team received on average 9.6 calls per month. Conclusion: Acute stroke research personnel increase the number of potential patient notifications by participating in ED staff education for the Primary Stroke Center Certification survey.

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

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.

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

Stroke ◽  
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.

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

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Evan Kolesnick ◽  
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.

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

2018 ◽  
Vol 13 (9) ◽  
pp. 949-984 ◽  
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.

Abstract WP363: Journey of a Five-Hospital System to Primary Stroke Center Certification

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Deb Motz ◽  
Dicky Huey ◽  
Tracy Moore ◽  
Byron Freemyer ◽  
Tommye Austin
Keyword(s):  
Administrative Support ◽  
Medical Center ◽  
Academic Medical Center ◽  
Stroke Care ◽  
Multidisciplinary Teams ◽  
Hospital System ◽  
Order Sets ◽  
Primary Stroke Center ◽  
Stroke Center ◽  
Evidenced Based

Background: In 2008, a city with a population of over one million people had no organized stroke care or Certified Primary Stroke Centers. Patients presenting with stroke symptoms had inconsistent neurology coverage and little or no access to rtPA. The purpose is to describe steps taken for five acute-care hospitals (with one CMS provider number) to become Primary Stroke Certified. Methods: The journey began with administrative support and a commitment to provide the resources for a successful program. To oversee development, a Medical Director and Stroke Coordinator were appointed. To bridge the gap in available specialty physicians, partnerships were formed with a telemedicine group to provide emergency treatment and an academic medical center to augment the neurology and neuro-surgical coverage. Multidisciplinary teams met monthly in each facility. Representatives from each team formed a regional committee and an education council was created to share best practices and assure consistency across the system. Evidenced based order sets were developed using clinical practice guidelines. The Medical Executive Committee at each facility and ultimately the Medical Executive Board endorsed the order sets and mandated their use. Each facility chose the appropriate unit to cohort the stroke patients which encouraged expertise in care. Results: This journey resulted in a high functioning system of care. Baptist Health System became Joint Commission Certified in all five locations (May 2009). We were awarded the Get with the Guidelines Bronze Award (September 2010), the Silver Plus Award (July 2011) and the Gold Plus Award (July 2012). In addition, we were the first in Texas to achieve the Target Stroke Honor Roll (Q3 2011) and have maintained this status for eight consecutive quarters. Conclusion: In conclusion, administrative support is imperative to the success of a stroke program. Leadership, partnerships, committees, councils and staff involvement from the start drove the team to a successful certification process with outstanding outcomes. The stroke committees continue to meet monthly to analyze performance measures, identify opportunities for improvement and execute action plans.

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