Process improvement methodologies uncover unexpected gaps in stroke care

Background The diagnosis and treatment of acute stroke requires timed and coordinated effort across multiple clinical teams. Purpose To analyze the frequency and temporal distribution of emergent stroke evaluations (ESEs) to identify potential contributory workflow factors that may delay the initiation and subsequent evaluation of emergency department stroke patients. Material and Methods A total of 719 sentinel ESEs with concurrent neuroimaging were identified over a 22-month retrospective time period. Frequency data were tabulated and odds ratios calculated. Results Of all ESEs, 5% occur between 01:00 and 07:00. ESEs were most frequent during the late morning and early afternoon hours (10:00–14:00). Unexpectedly, there was a statistically significant decline in the frequency of ESEs that occur at the 14:00 time point. Conclusion Temporal analysis of ESEs in the emergency department allowed us to identify an unexpected decrease in ESEs and through process improvement methodologies (Lean and Six Sigma) and identify potential workflow elements contributing to this observation.

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Abstract P816: Nurse-Driven Rapid Covid-19 Testing in Emergency Department Stroke Patients

Stroke ◽

10.1161/str.52.suppl_1.p816 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Stacey Aggabao ◽

Tawnae Thorsen ◽

Atul Gupta ◽

Raeesa Dhanji ◽

Denise Gaffney ◽

...

Keyword(s):

Emergency Department ◽

Personal Protective Equipment ◽

Stroke Care ◽

Protective Equipment ◽

Rapid Evaluation ◽

Ct Scanner ◽

Stroke Patients ◽

Specimen Collection ◽

Normal Code

Introduction: The COVID-19 pandemic presents obstacles to time sensitive emergencies, such as stroke care. In acute strokes, knowing the COVID-19 status may help to preserve personal protective equipment (PPE) in patients in whom a thrombectomy may be indicated and helps to decrease unnecessary exposure. This study aims to demonstrate that rapid evaluation of a patient’s COVID-19 status is feasible without delaying treatment times. Methods: An intradisciplinary team was convened to create a workflow for rapid COVID-19 testing. The Abbott Rapid® COVID-19 swab kit and assay were stocked in the ED Pyxis, utilizing the narcotic count feature to ensure all swabs were accounted. Upon activation of Code Stroke, the ED RN donned PPE and swabbed the patient’s naso-oral pharynx. The collected swab was labeled, placed in a bio-hazard bag, sanitized and handed to a second RN outside of the room. The specimen was taken to a pre-alerted lab technician who prepped the assay after hearing the code stroke. After specimen collection, the patient followed the normal code stroke pathway and was taken to the CT scanner. Metrics were analyzed for the pre COVID-19 (January through April) and during active COVID-19 (May through July) periods. Results: There were 136 code strokes from January thru July 2020. 81 were during pre-COVID vs. 55 during active-COVID. 47 of 55 (96%) were swabbed, 2 (4%) of whom were positive. There was no difference between pre-COVID and active-COVID door to CT initiated time (16 mins [IQR 13-24] vs. 22 mins [IQR 13-25] p=0.75), door to CT resulted time (21 mins [IQR 15-26]) vs. 23 mins [IQR 16-29] p=0.63). 18 patients received tPA pre-COVID and 5 during active-COVID with no difference in DTN (pre: 37.5 mins [IQR 30-43] vs. active: 28 mins {IQR 26-41] p=0.37). Door to CT initiated was faster for those who had their COVID swab performed pre-CT (14 mins [IQR 11.5-16.5] p=0.034) vs. post-CT (20 mins [IQR 17-28]). Likewise, door to CT resulted was also faster pre-CT: 24 mins [IQR 19-32] vs. post-CT: 17 mins [IQR 15-23] (p=0.04). Conclusion: The COVID-19 rapid swab code stroke process was feasible and did not delay treatment times.

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Abstract NS8: The Effects of Introducing a Nurse Practitioner Stroke Champion into the Emergency Department

Stroke ◽

10.1161/str.45.suppl_1.ns8 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Lindsay Olson-Mack ◽

Jacqueline Reardon ◽

Elton Hedden ◽

Rowena Carino ◽

Cynthia VanWyk ◽

...

Keyword(s):

Emergency Department ◽

Acute Stroke ◽

Nurse Practitioner ◽

Treatment Effectiveness ◽

Stroke Care ◽

Stroke Patients ◽

Acute Stroke Care ◽

Assessment And Treatment ◽

Iv Tpa

Background and Purpose: Emergency Department (ED) physicians often manage acute stroke patients without Neurology support at the bedside. Without guidance, they are left to rapidly assess, diagnose and treat acute stroke patients with minimal follow up on treatment effectiveness and patient outcomes. We hypothesized that introducing a Nurse Practitioner (NP) as Stroke Champion into an ED that did not have access to in-house Neurology would drive awareness of acute stroke care, and positively change practice to decrease door to needle times. Methods: The NP started in the 24-bed ED in June 2012. The average daily census of the ED for 2012 was 135 patients per day, and from January to June 2012, ED physicians initiated 46 stroke codes. Although Neurologists were available via telephone, ED physicians were left to accurately assess and initiate stroke codes, determine eligibility, and order IV tPA. In collaboration with the Stroke Medical Director, the Stroke NP conducted multiple education sessions regarding timing metrics in acute stroke care and door to tPA goals with ED clinicians, radiology, lab and pharmacy departments. Data was shared with stakeholders monthly to drive performance improvement initiatives. Results: Rapid improvements were made in all metrics. Mean time to CT first image improved by 19.3 minutes (37.3 to 18.0 minutes) in 6 months, and to 14.7 minutes in 1 year. CT result mean turn-around-time decreased by 19 minutes (from 54.0 to 29.1 minutes) in the first 6 months, and by 22.6 minutes (from 54.0 to 26.0 minutes) at 12 months. Likewise, laboratory result turn-around-times dramatically decreased by a mean of 15.9 minutes (54.4 to 38.5 minutes) over 6 months, and by a mean of 23 minutes (54.4 to 31.0 minutes) within 12 months. IV tPA treatment rates increased from 5% to 14.4% of all ischemic strokes. Door to IV tPA treatment times decreased by a mean of 33.9 minutes (104.5 to 70.6 minutes) in 6 months, and by 46.8 minutes (from 104.5 to 57.7 minutes) within the year. Conclusions: Introducing an NP into the ED to serve as Stroke Champion can provide added support to improve care of acute stroke patients by expediting assessment and treatment.

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Abstract 3651: Reducing Incidence of Hospital Acquired Pneumonia After Acute Stroke Through Implementation Of Simple Bedside Swallow Assessment

Stroke ◽

10.1161/str.43.suppl_1.a3651 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Catherine J Videtto ◽

Mary Jane Finnegan

Keyword(s):

Emergency Department ◽

High Risk ◽

Acute Stroke ◽

Stroke Care ◽

Nursing Interventions ◽

Stroke Patients ◽

Increased Risk ◽

Hospital Acquired Pneumonia ◽

Hospital Acquired ◽

Simple Bedside

The incidence of hospital-acquired pneumonia (HAP) has been estimated to occur in acute stroke patients with rates reported as high as approximately 10 - 25%. Mechanical ventilation, multiple infarct locations, dysphagia and abnormal chest x-ray findings all contribute to increased risk for dysphagia and ultimately development of pneumonia. Because fatality rates of 20 - 45% have been reported in HAP, stroke care nurses are urged to comply with guidelines recommending implementation of simple bedside swallow assessments to identify high risk patients and institute appropriate nursing interventions to avoid development of the potentially fatal complication of stroke related pneumonia. A retrospective review of 493 patients admitted to the stroke service of a community hospital was performed to determine incidence of hospital acquired pneumonia in acute stroke patients. The sample of patients were admitted through the emergency department and depending on the severity of stroke, were admitted to either an ICU or step-down unit bed. The simple bedside swallow screen was completed by an emergency department nurse. The patient was not allowed anything by mouth until the assessment was completed. If the assessment revealed the patient had a competent level of cognition, ability to adequately handle secretion in a sitting position, and maintain a venous pulse oxygenation of greater than 94%, the patient was asked to swallow three sequential one ounce medicine cups of water. If coughing, choking, drooling, or oxygen desaturation was assessed, the patient was maintained nothing by mouth until a formal swallow evaluation was completed by a speech therapist. During the period of 1/1/09 - 7/30/11, this hospital’s annual incidence of HAP in the post stroke patient was found to be significantly less than nationally published incidence. The diagnosis of HAP was based upon Center for Disease Control Guidelines for Hospital-Acquired Pneumonia. The patients reported as developing HAP met the criteria of having a primary discharge of stroke and a secondary discharge diagnosis of hospital acquired pneumonia. This community hospital’s mean incidence of hospital acquired pneumonia over the total 31 month study period was 3.6%. A simple bedside swallow screen performed by competent emergency department nurses to detect swallowing difficulty quickly and accurately in stroke patients prior to administering anything by mouth, has achieved the goal of identifying patients at high risk for dysphagia and avoiding the potential complication of hospital acquired pneumonia.

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Why Stroke Patients Don’t Receive T-PA? An Analysis of Patient Eligibility: Implications for Improving Clinical Impact by Increasing Future Treatment Numbers

Stroke ◽

10.1161/str.32.suppl_1.372-d ◽

2001 ◽

Vol 32 (suppl_1) ◽

pp. 372-372

Author(s):

Philip A Barber ◽

Jinijin Zhang ◽

Andrew M Demchuk ◽

Michael D Hill ◽

Andrea Cole-Haskayne ◽

...

Keyword(s):

Emergency Department ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Stroke Care ◽

Stroke Patients ◽

Acute Stroke Care ◽

Stroke Registry ◽

Specific Protocol ◽

Stroke Type ◽

Ischemic Attack

P183 Background T-PA is an effective treatment of acute ischemic stroke within 3 hours. However, the success of t-PA on reducing disability is dependent on it being accessible to more patients. We identified the reasons why patients with ischemic stroke did not receive intravenous t-PA and assessed the community impact of the therapy in a large North American city. Methods Consecutive patients with acute ischemic stroke were identified in a prospective stroke registry at a teaching hospital between October 1996 and December 1999. Additional patients with ischemic stroke admitted to one of three other hospitals during the study period were identified. The Oxford Community Stroke Program Classification was used to record stroke type. Results Of 2165 stroke patients presenting to the emergency department 1179 (54.5%) were diagnosed with ischemic stroke, 31.7% with intracranial hemorrhage, and 13.8 % with transient ischemic attack. 84/339 (29%) patients were admitted within 3 hours of stroke received intravenous t-PA. The major reasons for exclusion for stroke patients presenting within 3 hours were mild stroke (20%), clinical improvement (18.6%), and specific protocol exclusions (11.5%). Delay in presentation to emergency department excluded 840/1179 (71%). 1817 ischemic stroke patients were admitted to Calgary hospitals during the study period of which 4.6% received intravenous t-PA. Generalization of the Calgary experience to other Canadian communities suggests the benefit from t-PA for ischemic stroke may be substantial with an additional 460 independent survivors per annum. Conclusion The effectiveness of t-PA can be improved by understanding why patients are excluded from its use. The eligibility of patients for t-PA must increase by promoting health education programs and by developing organized acute stroke care infrastructure within the community.

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Evaluation of Stroke in the Emergency Department

Acute Stroke Management in the First 24 Hours ◽

10.1093/med/9780190856519.003.0005 ◽

2018 ◽

pp. 78-96

Author(s):

Robert Sawyer ◽

Edward C. Jauch

Keyword(s):

Emergency Department ◽

Acute Stroke ◽

Systems Of Care ◽

Supportive Therapy ◽

Stroke Care ◽

Stroke Patients ◽

Endovascular Thrombectomy ◽

Intravenous Alteplase ◽

Get With The Guidelines ◽

Therapy Quality

Acute stroke remains a challenge due to the myriad of presentations and the narrow therapeutic windows for reperfusion therapies. This chapter reviews the Emergency Department (ED) initial evaluation and treatment of stroke, recognition of potential stroke patients, and ED-based systems of care to optimize stroke care for the various forms of stroke encountered in the ED. The chapter also covers therapy options, including intravenous alteplase, endovascular thrombectomy, and supportive therapy. Quality assurance and feedback is addressed through Get with the Guidelines-Stroke. Common scenarios and pitfalls that are frequently encountered when evaluating patients with acute stroke in the ED are discussed.

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Emergency department telemedicine consults decrease time to interpret computed tomography of the head in a multi-network cohort

Journal of Telemedicine and Telecare ◽

10.1177/1357633x19877746 ◽

2019 ◽

pp. 1357633X1987774 ◽

Cited By ~ 2

Author(s):

Morgan B Swanson ◽

Aspen C Miller ◽

Marcia M Ward ◽

Fred Ullrich ◽

Kimberly AS Merchant ◽

...

Keyword(s):

Computed Tomography ◽

Emergency Department ◽

Rural Areas ◽

Stroke Care ◽

Stroke Patients ◽

Process Outcomes ◽

Telemedicine Consultation ◽

Interaction Term ◽

The Impact ◽

Improve Access

Introduction Telemedicine can improve access to emergency stroke care in rural areas, but the benefit of telemedicine across different types and models of telemedicine networks is unknown. The objectives of this study were to (a) identify the impact of telemedicine on emergency department (ED) stroke care, (b) identify if telemedicine impact varied by network and (c) describe the variation in process outcomes by telemedicine across EDs. Methods A prospective cohort study identified stroke patients in four telemedicine networks between November 2015 and December 2017. Primary exposure was telemedicine consultation during ED evaluation. Outcomes included: (a) interpretation of computed tomography (CT) of the head within 45 minutes and (b) time to administer tissue plasminogen activator (tPA). An interaction term tested for differences in telemedicine effect on stroke care by network and hospital. Results Of the 932 stroke subjects, 36% received telemedicine consults. For subjects with a last known well time within two hours of ED arrival (27.9%), recommended CT interpretation within 45 minutes was met for 66.8%. Telemedicine was associated with higher odds of timely head CT interpretation (adjusted odds ratio = 3.03; 95% confidence interval (CI) 1.69–5.46). The magnitude of the association between telemedicine and time to interpret a CT of the head differed between telemedicine networks (interaction term p = 0.033). Among eligible patients, telemedicine was associated with faster time to administer tPA (adjusted hazard ratio = 1.81; 95% CI 1.31–2.50). Discussion Telemedicine consultation during the ED encounter decreased the time to interpret at CT of the head among stroke patients, with differing magnitudes of benefit across telemedicine networks. The effect of heterogeneity of telestroke affects across different networks should be explored in future analyses.

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Spatial and Temporal Analysis of Microplasma Light Emission

MRS Proceedings ◽

10.1557/opl.2012.968 ◽

2012 ◽

Vol 1469 ◽

Author(s):

M. Blajan ◽

H. Fukunaga ◽

K. Shimizu

Keyword(s):

Light Emission ◽

Temporal Distribution ◽

Temporal Analysis ◽

Active Species ◽

Spectroscopy Analysis ◽

Propagation Of Light ◽

Time Period ◽

Spatial And Temporal Analysis ◽

Excited Species ◽

Discharge Gap

ABSTRACTEmission spectroscopy analysis was used to study the microplasma phenomena. The microplasma discharge in Ar, N2/Ar and O2/Ar was analyzed in the discharge gap area and spatial distribution of active species was measured also outside the electrodes. Spatial and temporal distribution showed the propagation of light emission from anode towards cathode within a time period of 190 ns. The measurement of OH peak at 308.9 nm proved the existence of this excited species 1 mm outside the electrodes area.

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Tendencias del cambio climático en la Demarcación Hidrográfica de Manabí

Revista de Investigaciones en Energía Medio Ambiente y Tecnología RIEMAT ISSN 2588-0721 ◽

10.33936/riemat.v3i1.1414 ◽

2018 ◽

Vol 3 (1) ◽

pp. 1

Author(s):

Campos Cedeño Antonio Fermín ◽

Mendoza Álava Junior Orlando

Keyword(s):

El Niño ◽

El Nino ◽

Technical Information ◽

Temporal Distribution ◽

Temporal Analysis ◽

Botanical Garden ◽

Monthly Precipitation ◽

Water Network ◽

Monthly Distribution ◽

Index Terms

Abstract— The Manabí Hydrographic Demarcation (DHM) is characterized as the only one that does not receive input from Andes Mountains, therefore, its water network is fed exclusively by the rainfall that occurs in the rainy season and that the warm current of El Niño plays a fundamental role in its production. In order to have technical information, important for the planning, control and development of the water resources of the DHM, in this research is made a temporal analysis of the monthly precipitation for 55 years, period 1963-2017. The National Institute of Hydrology and Meteorology of Ecuador (INAMHI) in station M005, located in the Botanical Garden of the Technical University of Manabí (Universidad Técnica de Manabí) in Portoviejo, obtained these records. An analysis is made of the monthly and annual patterns, establishing that the El Niño events that occurred in 1983, 1997 and 1998, have set guidelines for the change in rainwater production at the intensity and temporal distribution levels, increasing the months of drought, while the levels of rainfall increase, concentrating in fewer months, basically in February and March. This is a situation that increases the water deficit especially when there is not enough infrastructure of hydraulic works for the storage and regulation of runoff. Index Terms— Hydrology, rainfall, monthly distribution, annually distribution, climate change, El Niño phenomenon

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New Perspectives in Stroke Management: Old Issues and New Pathways

Brain Sciences ◽

10.3390/brainsci11060767 ◽

2021 ◽

Vol 11 (6) ◽

pp. 767

Author(s):

Fabio Pilato ◽

Rosalinda Calandrelli ◽

Fioravante Capone ◽

Michele Alessiani ◽

Mario Ferrante ◽

...

Keyword(s):

Time Window ◽

Enhanced Recovery ◽

Current Knowledge ◽

Oral Anticoagulants ◽

Chronic Phase ◽

Stroke Care ◽

New Drugs ◽

Stroke Patients ◽

Social Burden ◽

Novel Approaches

Stroke is a leading cause of disability and death worldwide and social burden is huge in terms of disabilities, mortality and healthcare costs. Recently, in an acute stroke setting, renewed interest in disease-modifying therapies and novel approaches has led to enhanced recovery and the reduction of long-term disabilities of patients who suffered a stroke. In the last few years, the basic principle “time is brain” was overcome and better results came through the implementation of novel neuroimaging tools in acute clinical practice, allowing one to extend acute treatments to patients who were previously excluded on the basis of only a temporal selection. Recent studies about thrombectomy have allowed the time window to be extended up to 24 h after symptoms onset using advanced neuroradiological tools, such as computer tomography perfusion (CTP) and magnetic resonance imaging (MRI) to select stroke patients. Moreover, a more effective acute management of stroke patients in dedicated wards (stroke units) and the use of new drugs for stroke prevention, such as novel oral anticoagulants (NOACs) for atrial fibrillation, have allowed for significant clinical improvements. In this editorial paper, we summarize the current knowledge about the main stroke-related advances and perspectives and their relevance in stroke care, highlighting recent developments in the definition, management, treatment, and prevention of acute and chronic complications of stroke. Then, we present some papers published in the Special Issue “Clinical Research on Ischemic Stroke: Novel Approaches in Acute and Chronic Phase”.

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Modeling Population Spatial-Temporal Distribution Using Taxis Origin and Destination Data

Sustainability ◽

10.3390/su13073727 ◽

2021 ◽

Vol 13 (7) ◽

pp. 3727

Author(s):

Fatema Rahimi ◽

Abolghasem Sadeghi-Niaraki ◽

Mostafa Ghodousi ◽

Soo-Mi Choi

Keyword(s):

Regression Analysis ◽

Mean Squared Error ◽

Population Distribution ◽

Temporal Distribution ◽

Coefficient Of Determination ◽

Temporal Modeling ◽

Location Data ◽

Time Period ◽

Proposed Model

During dangerous circumstances, knowledge about population distribution is essential for urban infrastructure architecture, policy-making, and urban planning with the best Spatial-temporal resolution. The spatial-temporal modeling of the population distribution of the case study was investigated in the present study. In this regard, the number of generated trips and absorbed trips using the taxis pick-up and drop-off location data was calculated first, and the census population was then allocated to each neighborhood. Finally, the Spatial-temporal distribution of the population was calculated using the developed model. In order to evaluate the model, a regression analysis between the census population and the predicted population for the time period between 21:00 to 23:00 was used. Based on the calculation of the number of generated and the absorbed trips, it showed a different spatial distribution for different hours in one day. The spatial pattern of the population distribution during the day was different from the population distribution during the night. The coefficient of determination of the regression analysis for the model (R2) was 0.9998, and the mean squared error was 10.78. The regression analysis showed that the model works well for the nighttime population at the neighborhood level, so the proposed model will be suitable for the day time population.

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