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

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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The impact of tele-neurologists on acute stroke care at an advanced primary stroke centre

Journal of Telemedicine and Telecare ◽

10.1177/1357633x20921039 ◽

2020 ◽

pp. 1357633X2092103

Author(s):

Scott Gutovitz ◽

Jonathan Leggett ◽

Leslie Hart ◽

Samuel M Leaman ◽

Heather James ◽

...

Keyword(s):

Acute Stroke ◽

Mechanical Thrombectomy ◽

Stroke Care ◽

Final Diagnosis ◽

Stroke Patients ◽

Acute Stroke Care ◽

Care Guidelines ◽

Stroke Center ◽

The Impact ◽

Stroke Centre

Introduction We evaluated the impact of tele-neurologists on the time to initiating acute stroke care versus traditional bedside neurologists at an advanced stroke center. Methods This observational study evaluated time to treatment for acute stroke patients at a single hospital, certified as an advanced primary stroke centre, with thrombectomy capabilities. Consecutive stroke alert patients between 1 March, 2016 and 31 March, 2018 were divided into two groups based on their neurology consultation service (bedside neurology: 1 March, 2016–28 February, 2017; tele-neurology: 1 April, 2017–31 March, 2018). Door-to-tPA time and door-to-IR time for mechanical thrombectomy were compared between the two groups. Results Nine hundred and fifty-nine stroke patients met the inclusion criteria (436 bedside neurology, 523 tele-neurology patients). There were no significant differences in sex, age, or stroke final diagnosis between groups ( p > 0.05). 85 bedside neurology patients received tPA and 35 had mechanical thrombectomy, 84 and 44 for the tele-neurology group respectively. Door-to-tPA time (median (IQR)) was significantly higher among tele-neurology (64 min (51.5–83.5)) than bedside neurology patients (45 min (34–69); p < 0.0001). There was no difference in door-to-IR times (mean ± SD) between bedside neurology (87.2 ± 33.3 min) and tele-neurology (90.4 ± 33.4 min; p = 0.67). Discussion At this facility, our tele-neurology services vendor was associated with a statistically significant delay in tPA administration compared with bedside neurologists. There was no difference in door-to-IR times. Delays in tPA administration make it harder to meet acute stroke care guidelines and could worsen patient outcomes.

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Abstract W P212: The Effect Of Pre-hospital Notification On Time To Head Ct, Stroke Specialist Arrival, And Tpa Administration For Hispanic Patients With Acute Stroke

Stroke ◽

10.1161/str.46.suppl_1.wp212 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Jonathan McCoy ◽

Ralph Fader ◽

Colleen Donovan ◽

Robert Eisenstein ◽

Pamela Ohman-Strickland ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Care ◽

Independent Effect ◽

Stroke Severity ◽

Stroke Patients ◽

Head Ct ◽

Logistic Regression Models ◽

Hispanic Patients ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: Hispanics have an increased incidence of ischemic stroke but may be less likely to use Emergency Medical Services (EMS) for stroke care. Objective: To examine disparities in pre-hospital triage and emergent evaluation of Hispanic stroke patients. We hypothesized that Hispanic stroke patients with pre-hospital notification experience less delay in emergent evaluation but the reduction may not be as pronounced as general stroke patients. Methods: Retrospective cohort study of all emergency department patients alerted as Brain Attack (BAT) between January 1, 2009 and August 31, 2012, at an urban comprehensive stroke center. We collected demographics, co-morbidities, and stroke severity from a quality assurance database. Outcome variables included EMS utilization, pre-hospital BAT activation, head CT timing & tissue plasminogen activator (TPA) timing. Effects of ethnicity and pre-hospital notification on evaluation and treatment times were measured using multivariate logistic regression models. The study was IRB approved. Results: During the study period, 832(64 Hispanic) patients were alerted as Brain Attacks. Hispanic patients were younger 56±17 vs. 68±16 years (p<0.0001), had trends for less EMS utilization (walk-in 35% vs. 22%) and lower NIHSS 9.3±4.3 vs. 12.8±8.3 (p=0.06), but did not differ in comorbidities. Patients with pre-hospital notification had significantly shorter times to stroke specialist arrival, door to head CT, and door to TPA irrespective of ethnicity. However, ethnicity did have independent effect on time to TPA administration. Please see Table 1. Conclusion: Pre-hospital notification is associated with faster stroke evaluation and treatment, including among Hispanic patients with acute stroke. Further study is needed to examine if outreach to increase EMS utilization will decrease disparities in this population.

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Bottlenecks in the Acute Stroke Care System during the COVID-19 Pandemic in Catalonia

Cerebrovascular Diseases ◽

10.1159/000516309 ◽

2021 ◽

pp. 1-9

Author(s):

Anna Ramos-Pachón ◽

Álvaro García-Tornel ◽

Mònica Millán ◽

Marc Ribó ◽

Sergi Amaro ◽

...

Keyword(s):

Acute Stroke ◽

Functional Outcome ◽

Stroke Care ◽

Care Quality ◽

Point Of View ◽

Stroke Severity ◽

Acute Stroke Care ◽

Vessel Occlusion ◽

Prehospital Delays ◽

The Impact

Introduction: The COVID-19 pandemic resulted in significant healthcare reorganizations, potentially striking standard medical care. We investigated the impact of the COVID-19 pandemic on acute stroke care quality and clinical outcomes to detect healthcare system’s bottlenecks from a territorial point of view. Methods: Crossed-data analysis between a prospective nation-based mandatory registry of acute stroke, Emergency Medical System (EMS) records, and daily incidence of COVID-19 in Catalonia (Spain). We included all stroke code activations during the pandemic (March 15–May 2, 2020) and an immediate prepandemic period (January 26–March 14, 2020). Primary outcomes were stroke code activations and reperfusion therapies in both periods. Secondary outcomes included clinical characteristics, workflow metrics, differences across types of stroke centers, correlation analysis between weekly EMS alerts, COVID-19 cases, and workflow metrics, and impact on mortality and clinical outcome at 90 days. Results: Stroke code activations decreased by 22% and reperfusion therapies dropped by 29% during the pandemic period, with no differences in age, stroke severity, or large vessel occlusion. Calls to EMS were handled 42 min later, and time from onset to hospital arrival increased by 53 min, with significant correlations between weekly COVID-19 cases and more EMS calls (rho = 0.81), less stroke code activations (rho = −0.37), and longer prehospital delays (rho = 0.25). Telestroke centers were afflicted with higher reductions in stroke code activations, reperfusion treatments, referrals to endovascular centers, and increased delays to thrombolytics. The independent odds of death increased (OR 1.6 [1.05–2.4], p 0.03) and good functional outcome decreased (mRS ≤2 at 90 days: OR 0.6 [0.4–0.9], p 0.015) during the pandemic period. Conclusion: During the COVID-19 pandemic, Catalonia’s stroke system’s weakest points were the delay to EMS alert and a decline of stroke code activations, reperfusion treatments, and interhospital transfers, mostly at local centers. Patients suffering an acute stroke during the pandemic period had higher odds of poor functional outcome and death. The complete stroke care system’s analysis is crucial to allocate resources appropriately.

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Abstract 2903: Nutritional Access of Dysphagic Patients 3 Months after Onset of Acute Stroke -From Database of 5,000 Patients in a Single Stroke Center-

Stroke ◽

10.1161/str.43.suppl_1.a2903 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Makoto Nakajima ◽

Yuichiro Inatomi ◽

Toshiro Yonehara ◽

Yoichiro Hashimoto ◽

Teruyuki Hirano

Keyword(s):

Acute Stroke ◽

Chronic Phase ◽

Oral Intake ◽

Continuous Variables ◽

Operating Characteristics ◽

Stroke Patients ◽

Nihss Score ◽

Swallowing Dysfunction ◽

Stroke Center ◽

Dysphagic Patients

Background and purpose: Prediction of swallowing function in dysphagic patients with acute stroke is indispensable for discussing percutaneous endoscopic gastrostomy (PEG) placement. We performed a retrospective study using database of a large number of acute ischemic stroke patients to clarify predictors for acquisition of oral intake in chronic phase. Methods: A total 4,972 consecutive acute stroke patients were admitted to our stroke center during 8.5 years; a questionnaire was sent to all the survivors after 3 months of onset. We investigated nutritional access after 3 months of onset in 588 patients who could not eat orally 10 days after admission, and analyzed predictive factors for their acquisition of oral intake. Continuous variables were dichotomized to identify the most sensitive predictors; the cutoff values were investigated by receiver operating characteristics curve analysis. Results: Out of 588 dysphagic patients, 75 died during the 3 months, and 143 (28%) of the residual 513 achieved oral intake after 3 months. In logistic-regression models, age ≤80 years, absence of hyperlipidemia, absence of atrial fibrillation, modified Rankin Scale score 0 before onset, and low National Institutes of Health Stroke Scale (NIHSS) score independently predicted oral intake 3 months after onset. From two different model analyses, NIHSS score ≤17 on day 10 (OR 3.63, 95% CI 2.37-5.56) was found to be a stronger predictor for oral intake than NIHSS score ≤17 on admission (OR 2.34, 95% CI 1.52-3.59). At 3 months, 17/143 (12%) patients with oral intake were living at home, while only 1/370 (0.3%) patients without oral intake were. Conclusion: A quarter of dysphagic patients with acute stroke obtained oral intake 3 months after onset. Clinicians should be cautious about PEG placement for stroke patients with severe dysphagia who were independent prior to the stroke, aged ≤80 years, and show NIHSS score ≤17 on day 10, because their swallowing dysfunction may improve in a few months.

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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 P184: Effect of Acute Stroke Care Hospital Networks in Korea

Stroke ◽

10.1161/str.52.suppl_1.p184 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Jihoon Kang ◽

Seong Eun Kim ◽

Hyunjoo Song ◽

Hee-joon Bae

Keyword(s):

Network Analysis ◽

Acute Stroke ◽

Stroke Care ◽

The Other ◽

Care Hospital ◽

Initial Visit ◽

Analysis Method ◽

Stroke Patients ◽

Acute Stroke Care ◽

Hospital Networks

Purpose: Stroke patients generally transport stroke patients either to nearest stroke hospital with secondary transfers or to hub hospitals in selective cases. This study aimed to determine the stroke community of close networks and to evaluate their role for the access the endovascular treatment (EVT). Methods: Using the nationwide acute stroke hospital (ASH) surveillance data assessed the major quality indicators of all stroke patients of South Korea, triage information both initial visit and secondary interhospital transfers were extracted according to the hospitals. Based on them, stroke community with dense linkages were partitioned using the network-based Louvain algorithm. The hierarchical model estimated the function of stroke community for the EVT. Results: For 6-month surveying period, 19113 subjects admitted to the 246 ASHs. Of them, 1831 (9.6%) were transferred from 763 adjacent facilities not ASH, while 1283 (6.7%) from the other ASHs. The algorithm determined the 113 stroke communities where composed median 7 hospitals (2 ASHs and 5 adjacent facilities) and treated about 30 subjects per month. Most of communities formed the spindle shape with higher centralization index and located within 150 Km (Figure). Stroke communities significantly affected 11% of EVT after adjustments. Conclusions: Network analysis method effectively contoured the high centralizing stroke communities and helped the functions on the EVT accessibility.

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Abstract 20: Acute Stroke Care and Thrombolysis at Critical Access Hospitals in Illinois

Stroke ◽

10.1161/str.44.suppl_1.a20 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Shyam Prabhakaran ◽

Robin Hamann ◽

Kathleen O’Neill ◽

Michelle Gardner ◽

Peggy Jones

Keyword(s):

Quality Improvement ◽

Acute Stroke ◽

Stroke Care ◽

The United States ◽

Critical Access Hospitals ◽

Stroke Patients ◽

Acute Stroke Care ◽

Improvement Program ◽

Discharge Disposition ◽

Intravenous Tissue Plasminogen Activator

Background: Critical access hospitals (CAH) are the first point of stroke care in many rural regions of the United States (US). The Illinois Critical Access Hospital Network (ICAHN), a network of 51 CAH in Illinois, began a quality improvement program to address acute stroke care in 2009. We evaluated the performance on several metrics in acute stroke care at CAH between 2009 and 2011. Methods: Currently, 28 of 51 CAHs in Illinois currently participate in the American Heart Association’s Get With The Guidelines - Stroke (GWTG-S) registry for quality improvement. The GWTG-S registry captured elements including demographics, diagnosis, times of arrival, imaging completion, and intravenous tissue plasminogen activator (IV tPA) administration, and final discharge disposition. We analyzed the change in percent of stroke patients receiving tPA, door-to-needle (DTN) time, and proportion of total stroke patients admitted versus transferred to another facility over the 3 years. Fisher’s exact and Mann-Whitney tests were used as appropriate. Results: In the baseline assessment (2009), there were 111 strokes from 8 sites which grew to 12 sites and 305 strokes in year 1 (2010) and 14 sites and 328 strokes in year 3 (2011). The rate of tPA use for ischemic stroke was 2.2% in 2009, 4.0% in 2010, and 6.2% in 2011 (P=0.20). EMS arrival (41.1%), EMS pre-notification (82.6%), door-to-CT times (median 35 minutes; 34.6% < 25 minutes), and DTN times (average 93 minutes; 13.3% DTN time < 60 minutes) were not different over time. The rate of transfer from CAH to another hospital (51.3%) was constant. Every patient that received tPA except 1 (96.9%) was transferred (drip-ship) for post-tPA care. Conclusions: Improving acute stroke care at CAHs is feasible and represents a significant opportunity to increase tPA utilization in rural areas. As stroke systems develop, it is vital that CAHs be included in quality improvement efforts. The ICAHN stroke collaborative provided the opportunity to coordinate resources, share best practices, participate in targeted educational programming, and utilize data for performance improvement through the funded GWTG-S registry.

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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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Abstract 352: Early Data From an Implementation Science Study Suggests the Need for Identification and Adoption of Best Practices to Improve the Timeliness of Stroke Treatment

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/hcq.13.suppl_1.352 ◽

2020 ◽

Vol 13 (Suppl_1) ◽

Author(s):

Lisa M Monk

Keyword(s):

Best Practices ◽

Acute Stroke ◽

Care Delivery ◽

Stroke Care ◽

Early Data ◽

Screening Tools ◽

Stroke Severity ◽

Ct Scanner ◽

Acute Stroke Care ◽

Stroke Treatment

There is a disconnect from discovery of best treatment options and application into clinical practice in a timely manner. The I M plementation of best Pr actices f O r acute stroke care-de v eloping and optimizing regional systems of Stroke Care (IMPROVE Stroke Care) goal is to develop a regional integrated stroke system that identifies, classifies, and treats patients with acute ischemic stroke more rapidly and effectively with reperfusion therapy. These improvements in acute stroke care delivery are expected to result in lower mortality, fewer recurrent strokes, and improved long term functional outcomes. Recent discoveries in stroke care and advancement in technology extends the window for both TPA administration and mechanical thombectomy. The challenge of implementing these latest advances are difficult considering the ability of hospitals to implement the original American Heart Association (AHA) Systems of Stroke Care recommendations. Early data from this project shows that the challenges continue to exist in recommendations that have been in place as early as 2005. EMS is not utilizing pre-hospital stroke screening tools, only 5% of the time, stroke severity tools, only 7% of the time, lytic checklists, 0% of the time, destination decision changed due to severity score, 0% of the time, and pre-notifying emergency rooms, only 63% of the time. Emergency departments door to CT <45 minutes, only 55% of the time, Lytic given in CT scanner, only 35% of the time, Door to lytic therapy< 45 minutes, 77% of the time, Door to Groin puncture, 81% of the time, and Door to TICI Flow 2c/3 flow <90 minutes, 39% of the time. The Systems of Stroke Care have recommendations that will improve time to treatment and outcomes for patients. This project is working to provide tools, guidance, data, and feedback to improve application of these recommendations and identify best practices and solutions to barriers.

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