Impact of COVID-19 on Acute Stroke Presentation at a Comprehensive Stroke Center

Background and purpose: Blood-based biomarkers could enable early and cost-effective diagnostics for acute stroke patients in the prehospital setting to support early initiation of treatments. However, large prehospital sample sets required for biomarker discovery and validation are missing, and the feasibility of large-scale blood sampling by emergency medical services (EMS) has not been determined. We set out to establish extensive prehospital blood sampling of thrombolysis candidates in the catchment area of our comprehensive stroke center, with a 1.5 million population base. Methods: EMS personnel were trained to collect prehospital blood samples using a cannula-adapter technique. Time delays, sample quality and performance bottlenecks were investigated between May 20, 2013 and May 19, 2014. Results: Prehospital blood sampling and study recruitment were successfully performed in 430 thrombolysis candidates, of which 55.3% were admitted outside office hours. The median (interquartile range) emergency call to prehospital sample time was 33 minutes (25-41), and the median time from reported symptom onset or wake-up to prehospital sample was 53 minutes (38-85; n=394). Prehospital sampling was performed 31 minutes (25-42) earlier than admission blood sampling, and 37 minutes (30-47) earlier than admission neuroimaging. Quality control data from 25 participating EMS units indicated a 4-minute increase in median transport time (from arrival on-scene to hospital door) for study patients compared to patients of the preceding year. The hemolysis rate in serum and plasma samples was 6.5% and 9.3% for EMS samples, and 0.7% and 1.6% for admission samples collected with venipuncture. Conclusions: Prehospital biomarker sampling is feasible in standard EMS units and provides a median timesaving of over 30 minutes to obtain first blood samples. Large biobanks of prehospital blood samples will facilitate development of ultra-acute stroke biomarkers.

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Stroke Simulation Improves Acute Stroke Management: A Systems-Based Practice Experience

Journal of Graduate Medical Education ◽

10.4300/jgme-d-17-00167.1 ◽

2018 ◽

Vol 10 (1) ◽

pp. 57-62 ◽

Cited By ~ 9

Author(s):

Tapan Mehta ◽

Sara Strauss ◽

Dawn Beland ◽

Gilbert Fortunato ◽

Ilene Staff ◽

...

Keyword(s):

Blood Pressure ◽

Medical Education ◽

Acute Stroke ◽

Simulation Training ◽

Stroke Registry ◽

Practice Experience ◽

Intravenous Tissue Plasminogen Activator ◽

Simulation Based ◽

Comprehensive Stroke Center ◽

Stroke Center

ABSTRACT Background Literature on the effectiveness of simulation-based medical education programs for caring for acute ischemic stroke (AIS) patients is limited. Objective To improve coordination and door-to-needle (DTN) time for AIS care, we implemented a stroke simulation training program for neurology residents and nursing staff in a comprehensive stroke center. Methods Acute stroke simulation training was implemented for first-year neurology residents in July 2011. Simulations were standardized using trained live actors, who portrayed stroke vignettes in the presence of a board-certified vascular neurologist. A debriefing of each resident's performance followed the training. The hospital stroke registry was also used for retrospective analysis. The study population was defined as all patients treated with intravenous tissue plasminogen activator for AIS between October 2008 and September 2014. Results We identified 448 patients meeting inclusion criteria. Simulation training independently predicted reduction in DTN time by 9.64 minutes (95% confidence interval [CI] –15.28 to –4.01, P = .001) after controlling for age, night/day shift, work week versus weekend, and blood pressure at presentation (> 185/110). Systolic blood pressure higher than 185 was associated with a 14.28-minute increase in DTN time (95% CI 3.36–25.19, P = .011). Other covariates were not associated with any significant change in DTN time. Conclusions Integration of simulation based-medical education for AIS was associated with a 9.64-minute reduction in DTN time.

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Prehospital Stroke Triage

Neurology ◽

10.1212/wnl.0000000000012792 ◽

2021 ◽

Vol 97 (20 Supplement 2) ◽

pp. S25-S33

Author(s):

Anna Ramos ◽

Waldo R. Guerrero ◽

Natalia Pérez de la Ossa

Keyword(s):

Acute Stroke ◽

Randomized Clinical Trials ◽

Vessel Occlusion ◽

Novel Technologies ◽

Maximum Benefit ◽

Prehospital Management ◽

Prehospital Triage ◽

Clinical Tools ◽

Comprehensive Stroke Center ◽

Stroke Center

Purpose of the ReviewThis article reviews prehospital organization in the treatment of acute stroke. Rapid access to an endovascular therapy (EVT) capable center and prehospital assessment of large vessel occlusion (LVO) are 2 important challenges in acute stroke therapy. This article emphasizes the use of transfer protocols to assure the prompt access of patients with an LVO to a comprehensive stroke center where EVT can be offered. Available prehospital clinical tools and novel technologies to identify LVO are also discussed. Moreover, different routing paradigms like first attention at a local stroke center (“drip and ship”), direct transfer of the patient to an endovascular center (“mothership”), transfer of the neurointerventional team to a local primary center (“drip and drive”), mobile stroke units, and prehospital management communication tools all aimed to improve connection and coordination between care levels are reviewed.Recent FindingsLocal observational data and mathematical models suggest that implementing triage tools and bypass protocols may be an efficient solution. Ongoing randomized clinical trials comparing drip and ship vs mothership will elucidate which is the more effective routing protocol.SummaryPrehospital organization is critical in realizing maximum benefit from available therapies in acute stroke. The optimal transfer protocols directed to accelerate EVT are under study, and more accurate prehospital triage tools are needed. To improve care in the prehospital setting, efficient tools based on patient factors, local geography, and hospital capability are needed. These tools would optimally lead to individualized real-time decision-making.

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Letter by Morelli et al Regarding Article, “Acute Stroke Care Is at Risk in the Era of COVID-19: Experience at a Comprehensive Stroke Center in Barcelona”

Stroke ◽

10.1161/strokeaha.120.031124 ◽

2020 ◽

Vol 51 (11) ◽

Author(s):

Nicola Morelli ◽

Paolo Immovilli ◽

Donata Guidetti

Keyword(s):

At Risk ◽

Acute Stroke ◽

Stroke Care ◽

Acute Stroke Care ◽

Comprehensive Stroke Center ◽

Stroke Center

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Abstract TP391: Working Within a Stroke System of Care to Decrease Door to Transfer Times From Spoke to Hub

Stroke ◽

10.1161/str.47.suppl_1.tp391 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Michelle Whaley ◽

Alissa Dell ◽

Melissa Chase ◽

Melissa Mooney ◽

Jill Hulbert ◽

...

Keyword(s):

Acute Stroke ◽

Best Practice ◽

Retrospective Chart Review ◽

Nurse Leaders ◽

Study Objective ◽

Team Members ◽

Imaging Results ◽

Number Of Patients ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: Best practice recommends that hospitals treating acute stroke patients have protocols in place to ensure rapid transfer to an advanced facility for a higher level of care, if needed. Our system of hospitals consists of five primary stroke centers (PSC) and one comprehensive stroke center (CSC) in a major metropolitan area. PSCs utilize telemedicine for acute stroke decision-making and patients are transferred to the CSC for consideration of advanced treatments when deemed appropriate by the care team. Purpose: Our study objective was to streamline processes at our PSCs to decrease the door to transport time (DTT) to the CSC. Methods: Stroke coordinators from the six sister hospitals meet quarterly to collaborate and share best practices in patient care. Our team of nurse leaders determined potential strategies to eliminate wasted time in the transfer process. Team members went back to their home facilities with the goal of generating buy-in from individual caregivers to decrease the time to transport out to the CSC. An overall attitude of urgency was encouraged during meetings with stroke councils and providers. Preliminary imaging results were used to guide decision to transfer, rather than waiting for final results. Some hospitals chose to notify the flight team of potential transport earlier in the emergency department stay, while others are still in the process of affecting change. We collected data on transferred patients with a diagnosis of acute stroke between the dates of 2/1/15-7/31/15 (n=23) and compared against the same time period in 2014 (n=11). Results: A total of 34 patients were included in our retrospective chart review. The number of patients transferred for consideration of additional acute treatment increased from 11 in 2014 to 23 during the study period in 2015. When examining patients who transferred and actually received endovascular treatment for acute stroke (n=8 in 2014 versus n=11 in 2015), the mean DTT decreased from 84 minutes in 2014, to 77 minutes in 2015. We also noted that patient transfers were faster during day time hours when compared to night. Conclusions: A system-wide, collaborative approach between PSCs and CSCs can decrease DTT when nurse leaders and providers streamline processes.

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Use of computed tomography perfusion for acute stroke in routine clinical practice: Complex scenarios, mimics, and artifacts

International Journal of Stroke ◽

10.1177/1747493018765493 ◽

2018 ◽

Vol 13 (5) ◽

pp. 469-472 ◽

Cited By ~ 4

Author(s):

Carlos Garcia-Esperon ◽

Andrew Bivard ◽

Christopher Levi ◽

Mark Parsons

Keyword(s):

Computed Tomography ◽

Acute Stroke ◽

Treatment Decision ◽

Added Value ◽

Stroke Treatment ◽

Computed Tomography Perfusion ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Weighted Sequences ◽

Perfusion Maps

Background Computed tomography perfusion is becoming widely accepted and used in acute stroke treatment. Computed tomography perfusion provides pathophysiological information needed in the acute decision making. Moreover, computed tomography perfusion shows excellent correlation with diffusion-weighted imaging and perfusion-weighted sequences to evaluate core and penumbra volumes. Multimodal computed tomography perfusion has practical advantages over magnetic resonance imaging, including availability, accessibility, and speed. Nevertheless, it bears some limitations, as the limited accuracy for small ischemic lesions or brainstem ischemia. Interpretation of the computed tomography perfusion maps can sometimes be difficult. The stroke neurologist faces complex or atypical cases of cerebral ischemia and stroke mimics, and needs to decide whether the “lesions” on computed tomography perfusion are real or artifact. Aims The purpose of this review is, based on clinical cases from a comprehensive stroke center, to describe the added value that computed tomography perfusion can provide to the stroke physician in the acute phase before a treatment decision is made.

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Risk Assessment of the Door‐In‐Door‐Out Process at Primary Stroke Centers for Patients With Acute Stroke Requiring Transfer to Comprehensive Stroke Centers

Journal of the American Heart Association ◽

10.1161/jaha.121.021803 ◽

2021 ◽

Vol 10 (18) ◽

Author(s):

Jane L. Holl ◽

Rebeca Khorzad ◽

Rebecca Zobel ◽

Amy Barnard ◽

Maureen Hillman ◽

...

Keyword(s):

Computed Tomography ◽

Risk Assessment ◽

Acute Stroke ◽

Failure Modes ◽

Learning Collaborative ◽

Vessel Occlusion ◽

Solution Design ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Criticality Analysis

Background Patients with acute stroke at non‐ or primary stroke centers (PSCs) are transferred to comprehensive stroke centers for advanced treatments that reduce disability but experience significant delays in treatment and increased adjusted mortality. This study reports the results of a proactive, systematic, risk assessment of the door‐in‐door‐out process and its application to solution design. Methods and Results A learning collaborative (clinicians, patients, and caregivers) at 2 PSCs and 3 comprehensive stroke centers in Chicago, Illinois participated in a failure modes, effects, and criticality analysis to identify steps in the process; failures of each step, underlying causes; and to characterize each failure’s frequency, impact, and safeguards using standardized scores to calculate risk priority and criticality numbers for ranking. Targets for solution design were selected among the highest‐ranked failures. The failure modes, effects, and criticality analysis process map and risk table were completed during in‐person and virtual sessions. Failure to detect severe stroke/large‐vessel occlusion on arrival at the PSC is the highest‐ranked failure and can lead to a 45‐minute door‐in‐door‐out delay caused by failure to obtain a head computed tomography and computed tomography angiogram together. Lower risk failures include communication problems and delays within the PSC team and across the PSC comprehensive stroke center and paramedic teams. Seven solution prototypes were iteratively designed and address 4 of the 10 highest‐ranked failures. Conclusions The failure modes, effects, and criticality analysis identified and characterized previously unrecognized failures of the door‐in‐door‐out process. Use of a risk‐informed approach for solution design is novel for stroke and should mitigate or eliminate the failures.

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Abstract TP310: Overcoming Barriers to Reduce Door to Needle Times in Acute Ischemic Stroke Patients: Field to CT

Stroke ◽

10.1161/str.47.suppl_1.tp310 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Spozhmy Panezai ◽

Florence Chukwuneke ◽

Audrey Arango ◽

Jaskiran Brar ◽

Joshua Daniel ◽

...

Keyword(s):

Acute Stroke ◽

Patient Outcomes ◽

Patient Characteristics ◽

Adverse Outcomes ◽

Ct Scanner ◽

Stroke Patients ◽

Stroke Team ◽

Presentation Time ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: Time lost is brain lost. The ASA’s Target Stroke strategies were reviewed to improve Door to CT (DTCT) and Door to Needle (DTN) times. Taking acute stroke patients direct from triage to the CT scanner can reduce thrombolysis treatment times, which may improve patient outcomes. In April 2015, the JFK Comprehensive Stroke Center introduced a Direct to CT policy for acute stroke patients who are assessed to be acute by the JFK EMS service. Method: We performed a prospective pilot study comparing door-to-CT times (DTCT) and door-to-needle (DTN) times pre- and post-implementation of Direct to CT policy, and analyzed patient characteristics, Emergency Department (ED) presentation time, adverse effects, protocol violations and patient outcomes. Delays in treatment, enablers and barriers to treatment were also examined. The purpose was to look at feasibility and maintenance of quality when applied to a larger subset of patients. Results: There was no statistical difference in demographics or clinical factors in patients who presented pre- (2013, 2014, n= 621) or post- Direct to CT (April 20-June 20, 2015 n=22). However, a reduction in mean DTCT times (21 mins vs. 8.7 mins, p<.0001) and DTN times (55 mins vs. 19 mins, p<.0001) was seen. There was no increase in adverse outcomes (7% vs. 0%) in patients taken Direct to CT. There was no difference in patient outcomes, however the current study size is small. Numerous barriers to Direct to CT were identified at the pre-hospital, ED, CT and stroke team levels. These issues included ED resources, hospital geography and space, and stroke team decision making. Some of these concerns are ongoing and will take time and effort to overcome. Strengths noted were the EMS capability of pre-hospital Intravenous line establishment, blood draws, and EKG performance as well as IV tPA initiation in the CT area. Conclusions: Taking patients Direct to CT has significantly reduced time to evaluation, DTCT, and DTN and further improvements may be achieved through resolution of identified barriers.

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Abstract P32: Advanced Practice Provider-Based Acute Stroke Protocol Performs Well Compared to a Resident-Based Protocol

Stroke ◽

10.1161/str.52.suppl_1.p32 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Noah Grose ◽

Cassandra Forrest ◽

Sharon Heaton ◽

Vivien Lee

Keyword(s):

Acute Stroke ◽

Nurse Practitioners ◽

Final Diagnosis ◽

Reperfusion Therapy ◽

National Institutes Of Health ◽

Advanced Practice ◽

Intravenous Tissue Plasminogen Activator ◽

The Hours ◽

Comprehensive Stroke Center ◽

Stroke Center

Introduction: The administration of intravenous tissue plasminogen activator (IVtPA) for acute ischemic stroke (AIS) is typically done by neurology resident physicians at academic stroke centers. We sought to compare the performance of an advanced practice provider (APP)-based IVtPA protocol to a resident-based protocol. Methods: We performed a retrospective review of Emergency Room (ER) acute stroke codes from January 1, 2018 to January 1, 2019 that received AIS reperfusion therapy, including IVtPA or mechanical thrombectomy (MT). Inpatient AIS were excluded. During this timeframe, 5 acute stroke-trained nurse practitioners covered the daytime shifts for acute stroke codes on a rotating basis (during the hours of 7:00 am -4:00 pm, Monday through Friday). The neurology residents continued to cover all other stroke code shifts. We collected data on baseline demographics, initial National Institutes of Health Stroke Scale (NIHSS), door to needle (DTN) time, and door to groin puncture (DTG) time. Statistical analyses were performed using JMP software package (version 14). All tests were 2-sided, and a P value was considered significant at <0.05. Results: Among 322 AIS case who received acute reperfusion therapy, 133 (41.4%) received IVtPA, 200 (62.3%) received MT, and 11 (3.4%) received both. Among the 133 IVtPA patients, there was no difference in age (62.2 vs 59.9, p 0.56) or mean initial NIHSS (7.7 vs 8.2, p 0.75) when comparing the APP-based protocol to the resident-based protocol group, but patients seen by the APP were more likely to be male (78.3 vs 42.7%, p 0.0015). Compared to the resident-based protocol, the APP-based protocol had faster mean DTN times (38.9 vs 54.7 minutes, p 0.0374) and were more likely to have final diagnosis of stroke (95.7% vs 70%, p 0.0034). Among the 200 MT patients, the DTG time showed a trend for faster times for the APP-based protocol, although this was not significant (60.5 vs 76.5, p 0.0083). Conclusion: At our academic comprehensive stroke center, APP driven acute stroke code protocols perform as well as resident-based protocols in terms of time to reperfusion therapy.

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