Geographic Modeling to Quantify the Impact of Primary and Comprehensive Stroke Center Destination Policies

Introduction. Many reports have described a decrease in the numbers of patients seeking medical attention for typical emergencies during the COVID-19 pandemic. These reports primarily relate to urban areas with widespread community transmission. The impact of COVID-19 on nonurban areas with minimal community transmission is less well understood. Methods. Using a prospectively maintained prehospital quality improvement database, we reviewed our hospital EMS transports with a diagnosis of stroke from January to April 2019 (baseline) and January to April 2020 (pandemic). We compared the volume of patients, transport/presentation times, severity of presenting symptoms, and final diagnosis. Results. In January, February, March, and April 2019, 10, 11, 17, and 19 patients, respectively, were transported in comparison to 19, 14, 10, and 8 during the same months in 2020. From January through April 2019, there was a 53% increase in transports, compared to a 42% decrease during the same months in 2020, constituting significantly different trend-line slopes (3.30; 95% CI 0.48–6.12 versus -3.70; 95% CI -5.76–-1.64, p = 0.001 ). Patient demographics, comorbidities, and symptom severity were mostly similar over the two time periods, and the number of patients with a final diagnosis of stroke was also similar. However, the median interval from EMS dispatch to ED arrival for patients with a final diagnosis of stroke was significantly longer in January to April 2020 ( 50 ± 11.7 min ) compared to the same time period in 2019 ( 42 ± 8.2 min , p = 0.01 ). Discussion/Conclusion. Our data indicate a decrease in patient transport volumes and longer intervals to EMS activation for suspected stroke care. These results suggest that even in a nonurban location without widespread community transmission, patients may be delaying or avoiding care for severe illnesses such as stroke. Clinicians and public health officials should not ignore the potential impact of pandemic-like illnesses even in areas of relatively low disease prevalence.

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Abstract TP310: Effect of an Extended Treatment Window on Transfer Times in Patients With Stroke

Stroke ◽

10.1161/str.51.suppl_1.tp310 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Dawn K Beland ◽

Ilene Staff ◽

Jenna Beckwith ◽

Amre Nouh

Keyword(s):

Decision Making ◽

Process Of Care ◽

Patient Demographics ◽

Complex Decision Making ◽

Complex Decision ◽

Stroke Type ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

The Impact ◽

Transfer Times

STK-OP-1 examines transfer times for patients going to a higher level of care. Known as door in, door out or DIDO, certified stroke centers are required to report times for both ischemic and hemorrhagic stroke patients transferred to a Primary or Comprehensive Stroke Center (CSC). Purpose: Barriers to time-sensitive transfer and complex decision making are common. As a result, Hartford Healthcare (HHC) began a QI initiative to measure DIDO times while introducing advanced CTP imaging and treatment in the extended window, April 2018. This project evaluates the impact on DIDO. Methods: This multi-center QI project evaluated data pre and post implementation for stroke transfers to the CSC. Pre-implementation was May 2017 to April 2018, post-implementation May 2018 to March 2019. Patient and process of care data abstracted from Epic was entered into Excel. The main analysis compared median DIDO times using Wilcoxon Ranked Sum. Results: Data were collected on hospital, stroke type/severity and treatments administered; patient demographics, and key timing variables of door in/door out, EMS and CT. While there is no universal criterion for DIDO, 60 minutes is often the ultimate goal with 90 or 120 minutes as intermediate goals. Pre and post implementation median DIDO times for all hospitals were 117 and 139 minutes (p = 0.02), for HHC hospitals 115 and 137 minutes (p = 0.027) and for non-HHC hospitals 118 and 140.5 minutes (p = 0.423). Of the pre-implementation group, 7.8% had CTP imaging prior to transfer compared with 9.3% post. Extended times post-implementation include factors such as complex decision making, patient eligibility or hospital capacity issues. A new transfer algorithm was implemented April 2019. Future analyses will correlate DIDO with patient, stroke and treatment categories to better define delays and barriers. Relevance: A JC directive to CSCs are to develop supportive relationships with referring hospitals to facilitate efficient care. As decision making becomes more complex, the process for transfer needs to improve. DIDO goals need to be realistic to prevent secondary imaging at the CSC, i.e. the tradeoff for an extra 15 or 20 minutes should translate into shorter door to puncture times. Reducing the time to treatment may help improve patient outcomes.

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Abstract WP281: Pharmacists Improve Door to Needle Times in the Emergency Department

Stroke ◽

10.1161/str.51.suppl_1.wp281 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Kevin Phan ◽

Megan Degener

Keyword(s):

Emergency Department ◽

Cerebral Perfusion ◽

Stroke Care ◽

Time Frame ◽

Safe Delivery ◽

Team Meetings ◽

Stroke Team ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

The Impact

Background: An estimated two million brain cells die every minute cerebral perfusion is impaired. The best outcomes for acute ischemic strokes are achieved by decreasing the time from emergency department (ED) arrival to thrombolytic therapy. Alteplase, a high risk medication, was dosed and prepared in the pharmacy. This contributed to prolonged door to needle (DTN) times. Purpose: To describe the impact of pharmacist interventions on DTN times in the ED. Methods: All patients who received alteplase for acute ischemic stroke from January 2012 to April 2019 were reviewed. In November 2012, the ED pharmacy program began with a dedicated ED pharmacist for 8 hours a day and expanded to 13 hours a day in September 2014. During those hours alteplase was prepared at bedside in the ED. In November 2015, all pharmacists were trained on the ED code stroke process. Monthly case reviews and DTN times were reported to the stroke coordinators starting January 2017. Alteplase preparation and administration in the computed tomography (CT) room started April 2017. Following comprehensive stroke center certification, routine stroke competency exams were administered to pharmacists in 2018. In 2019, pharmacists started reporting DTN times at neuroscience core team meetings. Results: During this time frame, a total of 407 patients received alteplase. Average DTN times decreased from a baseline of 130.9 minutes to 45.3 minutes. Interventions that resulted in the largest decrease in average DTN times were the expanded ED service hours (34.6 minutes) and pharmacist preparation of alteplase in the CT room (21.9 minutes). Conclusions: Pharmacists directly impacted stroke care in the ED by decreasing DTN times. Presence of a pharmacist in the ED enabled fast and safe delivery of alteplase by ensuring accurate dosing and preparation. Pharmacists also performed rapid medication reconciliation and expedited antihypertensive therapies. In conclusion, having pharmacists as part of the stroke team is a model that could be adopted by hospitals to enhance stroke care.

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Abstract P149: Regional Transfer Protocols Can Improve Transfer Times and Reduce Length of Stay for Thrombectomy Candidates Seen on Telestroke

Stroke ◽

10.1161/str.52.suppl_1.p149 ◽

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.

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Abstract P562: The Safety Of Mechanical Thrombectomy In Nonagenarians In A Majority Hispanic Population

Stroke ◽

10.1161/str.52.suppl_1.p562 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Nura Salhadar ◽

WONDWOSSEN TEKLE ◽

Amrou Sarraj ◽

Ameer E Hassan

Keyword(s):

Primary Outcome ◽

Mechanical Thrombectomy ◽

Statistical Significance ◽

Hispanic Population ◽

Vessel Occlusion ◽

Border Communities ◽

Baseline Characteristics ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

The Impact

Background and objective: Elderly patients were underrepresented in RCTs that proved the efficacy and safety of mechanical thrombectomy (MT) in acute ischemic strokes (AIS) due to large vessel occlusion (LVO). Additionally, the impact of race and socio-economics in AIS outcomes is well-reported. We sought to assess MT clinical outcomes in Hispanic Octogenarians and Nonagenarians that reside in underserved border communities. Methods: A retrospective cohort study from a prospectively collected comprehensive stroke center database was conducted. The primary outcome was discharge (mRS 0-2). Secondary outcomes were NIHSS improvement ≥4 points at discharge, sICH, mortality and length of stay (LOS). A two-tailed t-test assessed statistical significance between the two groups. Results: Of 202 included patients, 172 (85%) were octogenarians and 30 nonagenarians (17%). Nonagenarians had higher rates of females (80% vs 59%; p<0.05), similar rates of Hispanics (57% vs. 63%, p-xx) and a trend towards higher NIHS (20 vs. 17, P=0.09). Other baseline characteristics were similar (Table 1). Time last known well to arrival to MT center and to recanalization were longer in octogenarians, all other time metrics did not differ. Nonagenarians had numerically lower favorable outcomes at discharge (7% vs. 16%, p=0.11) as compared to octogenarians. Rates of clinical improvement on NIHSS were similar (27% vs. 23%, p=0.74). Mortality (23% vs. 28%, p=0.63) and sICH (7% vs 4%, p=0.46), octogenarians and nonagenarians, respectively. Octogenarians trended towards longer LOS (10 vs 6 days, p=0.05). Conclusions: Both groups had lower favorable good outcome rates than MT outcomes reported in RCTs. Nonagenarians had numerically lower favorable outcomes but mortality and sICH were similar. Further studies are warranted to further assess the impact of age and socioeconomics on MT outcomes.

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Abstract WP401: What Goes Around Comes Around: The Impact of Adding the Stroke Coordinator to Daily Rounds

Stroke ◽

10.1161/str.48.suppl_1.wp401 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Suzanne Stone ◽

Amanda Dirickson

Keyword(s):

Quality Care ◽

Depression Screening ◽

Advanced Practice ◽

Prospective Data ◽

Program Manager ◽

Multidisciplinary Rounds ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

The Impact

Background: Multidisciplinary rounds have classically consisted of the attending, advanced practice providers, residents and fellows. For most large comprehensive stroke centers (CSC), the stroke coordinator role is not intimately engaged in these teaching rounds thus disconnected from the team during focused discussions on care management. In order to advance the quality and comprehensiveness of patient care the stroke coordinator was added to clinical rounds. Purpose: We propose allocating dedicated time to the stroke coordinator role for daily morning rounds with the stroke neurologist and team to increase compliance with quality care measures. Method: Following the core and care team measures required for certification of a comprehensive Stroke Center, the stroke program manager selected three targets for improvement from the provider team and collected retrospective and prospective data for comparison once implementing the role change. Baseline patient data (collected the year prior to initiation of the stroke coordinator at rounds, was compared to patient safety and quality variables after initiation of rounds. Results: The action of provider intervention triggered by scoring threshold in depression screening improved a yearly mean of 52% to 82%. The documentation of rTPA compliance went from a mean of 0% to 94%, The timely documentation of NIHSS as a severity score in acute ischemic stroke rose from a mean of 90% to 93% Conclusions: Each of the metrics reflect Improvement over time. During rounds the coordinator would actively discuss gaps in care including documentation of eligibility for TPA, team action on patients with high scores on depression screening and timely documentation of NIHSS. In addition, the stroke coordinator reflected feeling more like a team member and not an "outsider looking in". It can further be hypothesized that the team remained very receptive to suggestions in the care of stroke patients, as the stroke coordinator was well known to them and available for questions and discussion each day. The closer role of stroke coordinator is still ongoing due to its success.

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Abstract TP379: The Impact of a Nurse Navigator-Centered Discharge Plan on Care Transitions for Patients Discharged From a Comprehensive Stroke Center

Stroke ◽

10.1161/str.51.suppl_1.tp379 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Frances Jaime ◽

Cristina Carillo-Gutierrez ◽

Kim Smith ◽

Marwah Elsehety ◽

Peri Smith ◽

...

Keyword(s):

Clinical Symptoms ◽

Care Transition ◽

Discharge Process ◽

Stroke Patients ◽

Post Discharge ◽

Home Discharge ◽

Nurse Navigator ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

The Impact

Background: An effective care transition plan at the time of a stroke discharge impacts risk factor control, readmissions, and patient satisfaction. In our Comprehensive Stroke Center (CSC), we assigned a registered nurse to be our Stroke Nurse Navigator (SNN). The SNN meets with patients and caregivers prior to discharge to address care transition needs and answers the Stroke Nurse Helpline to provide assistance after discharge. Purpose: To assess the impact of the SNN in meeting care transition needs of patients discharged home from a CSC Methods: Stroke patients in our CSC are called within 72 hours after home discharge, and a standard questionnaire is used to assess satisfaction with the discharge process. We compared post-discharge callback data from stroke patients during a 6-month period before (1/1/18 to 6/30/18) and after (7/1/18 to 12/31/18) designation of the SNN. Results: Among 413 stroke patients who completed questionnaires, 207 were pre-SNN and 206 were post-SNN, representing 55% and 47% of home discharges respectively. There was a 46% decrease in all concerns: 74% in non-clinical concerns, 70% in complaints about hospital experience, and 45% in reported early admissions (Table 1). There were fewer reported concerns about activity restrictions and assistive devices (100% decrease), outpatient therapy (76% decrease), prescriptions (75% decrease), outpatient testing (60% decrease), and other discharge information (29%). There were more concerns related to clinical symptoms after hospitalization (36% increase), establishing care with primary provider or neurologist (36% increase), and understanding home medications. Conclusion: SNNs may play a role in meeting care transition needs of stroke patients by providing assistance before and early after a home discharge. SNNs may foster heightened awareness among stroke patients and caregivers about following through on recommended post-hospital care for better recovery outcomes.

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Abstract TP368: The Impact of Hospital Based Specialist Physicians Conducting Post-Discharge Follow-Up Phone Calls at a Comprehensive Stroke Center

Stroke ◽

10.1161/str.51.suppl_1.tp368 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Cynthia Sinogui ◽

Yogesh Nandan ◽

Amber Jennings ◽

Pat Zrelak

Keyword(s):

Acute Care ◽

Nursing Facilities ◽

Post Discharge ◽

Skilled Nursing ◽

Secure Messaging ◽

Phone Calls ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

The Impact

Background: As a Comprehensive Stroke Center (CSC), The Joint Commission requires post-discharge follow-up phone calls to be conducted within 7 days of discharge for all complex stroke patients. Purpose: To develop and sustain a feasible approach for Hospital Based Specialist (HBS) physicians to conduct follow-up phone calls within 7 days. Methods: A baseline evaluation of all post-discharge phone calls was conducted. It was determined that patients were receiving several phone calls already, therefore the team did not want to add an additional call to meet compliance. HBS calls were realigned to include a stroke-specific focus, reinforcing stroke education and secondary prevention. Calls were made within 7 days by the discharging physician. All stroke patient types discharged with a stroke diagnosis were contacted regardless of severity. Patients discharged to skilled nursing facilities, board and care, acute rehabilitation or other acute care hospitals were excluded. A templated note was developed to ensure all stroke-specific components were covered. All HBS physicians were trained. Telephone interactions occurred between the patient, family member, and/or caregiver. Those unable to be reached but had messages left or secure messaging sent were counted as compliant. Reminders were sent out to physicians to improve call compliance. Tracking occurred weekly for call compliance and note template utilization. Results: Between January 2018 and May 2019, 612 patients discharged home from the acute care setting. Of those, 55% (334) were contacted. Of those, 73% had the templated note documented. Several hurdles were encountered along the way, but utilization of the templated note and physician reminders improved compliance. Conclusion: Post-discharge follow-up phone calls initiated by HBS physicians and utilization of a templated note are a feasible means of meeting and sustaining the CSC requirement.

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Abstract TP401: Impact of Vital Signs and Neurological Assessments After Alteplase for Acute Stroke

Stroke ◽

10.1161/str.51.suppl_1.tp401 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Scott Drake ◽

Swetha Renati ◽

Karen Packer Wilson ◽

Nicholas Hilker ◽

Nicole Slye ◽

...

Keyword(s):

Acute Stroke ◽

Patient Outcomes ◽

Retrospective Review ◽

Vital Signs ◽

Full Compliance ◽

Institutional Review ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Get With The Guidelines ◽

The Impact

Background: Vital signs and neurologic assessments are currently performed using the schedule utilized during the clinical trials which led to the approval of alteplase for acute stroke. These assessments can be disruptive to patients and represent a considerable staffing and infrastructural demand. While the goal of this approach is to improve outcomes by rapidly detecting actionable changes, its impact has been questioned. Despite its widespread use there has been limited systematic review regarding its influence on outcomes. Purpose: This project’s aim was to determine the impact of these assessments by conducting a retrospective review at our large, urban, comprehensive stroke center. We sought to evaluate the rate of compliance with established guidelines, and assess its correlation with patient outcomes. Methods: This retrospective review of patients receiving alteplase for acute stroke was approved by our institutional review board. A total of 130 patients were identified during 2018. Data was collected from the electronic medical record and The Get with the Guidelines database. Results: Our institutional guideline includes a total of 36 vital signs and 24 neurological assessments during first 24-hours after alteplase administration, for a total of 60 assessments. 63% of patients had full compliance with all 60 assessments. The discharge modified Rankin scale (mRS) for those with full compliance was 2.35 versus 2.31 for patients without 100% compliance (p>0.05; NS). There was less compliance with vital signs compared to neurological assessments (73.8% versus 76.9%). Conclusions: The majority of patients were complaint with all assessments however a notable portion missed at least one assessment, occurring more frequently with vital signs. Full compliance with all assessments was not associated with improved mRS.

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Operationalization of the Transition to Comfort Measures Only in the Neurocritical Care Unit: A Quality Improvement Project

American Journal of Hospice and Palliative Medicine® ◽

10.1177/1049909118790069 ◽

2018 ◽

Vol 36 (1) ◽

pp. 38-44

Author(s):

Abhijit Lele ◽

Chong Cheever ◽

Larry Healey ◽

Kellie Hurley ◽

Louis J. Kim ◽

...

Keyword(s):

Quality Improvement ◽

Neurocritical Care ◽

Quality Improvement Project ◽

Smooth Transition ◽

Missed Opportunities ◽

Improvement Project ◽

Interdisciplinary Health Care Teams ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

The Impact

Introduction: Transition to comfort measures only (CMO) is common in the neurocritical care unit, and close communication between interdisciplinary health-care teams is vital to a smooth transition. We developed and implemented a CMO huddle in an effort to reduce inconsistencies during the process of CMO transition. Methods: The CMO huddle was a multiphase quality improvement project in a neurocritical care unit of a level-1 trauma and comprehensive stroke center. Interdisciplinary critical care clinicians engaged in a huddle during CMO processes and participated in a pre- and postimplementation survey to examine the impact of CMO huddle on communication, missed opportunities, and improvement in knowledge. Results: Since the CMO implementation, a total of 131 patients underwent CMO transitions. After implementation of an interdisciplinary CMO huddle, 64.3% of neurocritical care nurses reported that they felt included and involved in CMO process compared to 28% before implementation ( P = .003); 87.9% of all neurocritical care clinicians reported that they felt comfortable participating in CMO discussions compared to 69.8% before ( P < .001); 57.4% of all neurocritical care clinicians reported that the CMO huddle improved communication among neurocritical care clinicians, 51.9% reported reduction in missed opportunities during CMO process, and 21.7% reported witnessing less-than-ideal CMO process compared to 80% before ( P < .001). Conclusions: Implementation of a multidisciplinary huddle in the neuro–intensive care unit before transition to CMO may improve clinician’s experience of the end-of-life process through enhanced nursing inclusion and involvement and organized communication with the neurocritical care team.

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