Verification of door-in-door-out time (DIDO time) at a core hospital in rural medical area without primary 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.

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Effect of “drip-and-ship” and “drip-and-drive” on endovascular treatment of acute ischemic stroke with large vessel occlusion: a single-center retrospective study

Acta Radiologica ◽

10.1177/02841851211006897 ◽

2021 ◽

pp. 028418512110068

Author(s):

Yu Hang ◽

Zhen Yu Jia ◽

Lin Bo Zhao ◽

Yue Zhou Cao ◽

Huang Huang ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Primary Stroke Center ◽

Secondary Endpoints ◽

Comprehensive Stroke Center ◽

Stroke Center

Background Patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) were usually transferred from a primary stroke center (PSC) to a comprehensive stroke center (CSC) for endovascular treatment (drip-and-ship [DS]), while driving the doctor from a CSC to a PSC to perform a procedure is an alternative strategy (drip-and-drive [DD]). Purpose To compare the efficacy and prognosis of the two strategies. Material and Methods From February 2017 to June 2019, 62 patients with LVO received endovascular treatment via the DS and DD models and were retrospectively analyzed from the stroke alliance based on our CSC. Primary endpoint was door-to-reperfusion (DTR) time. Secondary endpoints included puncture-to-recanalization (PTR) time, modified Thrombolysis in Cerebral Infarction (mTICI) rates at the end of the procedure, and modified Rankin Scale (mRS) at 90 days. Results Forty-one patients received the DS strategy and 21 patients received the DD strategy. The DTR time was significantly longer in the DS group compared to the DD group (315.5 ± 83.8 min vs. 248.6 ± 80.0 min; P < 0.05), and PTR time was shorter (77.2 ± 35.9 min vs. 113.7 ± 69.7 min; P = 0.033) compared with the DD group. Successful recanalization (mTICI 2b/3) was achieved in 89% (36/41) of patients in the DS group and 86% (18/21) in the DD group ( P = 1.000). Favorable functional outcomes (mRS 0–2) were observed in 49% (20/41) of patients in the DS group and 71% (15/21) in the DD group at 90 days ( P = 0.089). Conclusion Compared with the DS strategy, the DD strategy showed more effective and a trend of better clinical outcomes for AIS patients with LVO.

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How do treatment times impact on functional outcome in stroke patients undergoing thrombectomy in Germany? Results from the German Stroke Registry

International Journal of Stroke ◽

10.1177/1747493020985260 ◽

2021 ◽

pp. 174749302098526

Author(s):

Juliane Herm ◽

Ludwig Schlemm ◽

Eberhard Siebert ◽

Georg Bohner ◽

Anna C Alegiani ◽

...

Keyword(s):

Functional Outcome ◽

Odds Ratio ◽

Intravenous Thrombolysis ◽

Stroke Patients ◽

Poor Functional Outcome ◽

Stroke Registry ◽

Primary Stroke Center ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Center Time

Background Functional outcome post-stroke depends on time to recanalization. Effect of in-hospital delay may differ in patients directly admitted to a comprehensive stroke center and patients transferred via a primary stroke center. We analyzed the current door-to-groin time in Germany and explored its effect on functional outcome in a real-world setting. Methods Data were collected in 25 stroke centers in the German Stroke Registry-Endovascular Treatment a prospective, multicenter, observational registry study including stroke patients with large vessel occlusion. Functional outcome was assessed at three months by modified Rankin Scale. Association of door-to-groin time with outcome was calculated using binary logistic regression models. Results Out of 4340 patients, 56% were treated primarily in a comprehensive stroke center and 44% in a primary stroke center and then transferred to a comprehensive stroke center (“drip-and-ship” concept). Median onset-to-arrival at comprehensive stroke center time and door-to-groin time were 103 and 79 min in comprehensive stroke center patients and 225 and 44 min in primary stroke center patients. The odds ratio for poor functional outcome per hour of onset-to-arrival-at comprehensive stroke center time was 1.03 (95%CI 1.01–1.05) in comprehensive stroke center patients and 1.06 (95%CI 1.03–1.09) in primary stroke center patients. The odds ratio for poor functional outcome per hour of door-to-groin time was 1.30 (95%CI 1.16–1.46) in comprehensive stroke center patients and 1.04 (95%CI 0.89–1.21) in primary stroke center patients. Longer door-to-groin time in comprehensive stroke center patients was associated with admission on weekends (odds ratio 1.61; 95%CI 1.37–1.97) and during night time (odds ratio 1.52; 95%CI 1.27–1.82) and use of intravenous thrombolysis (odds ratio 1.28; 95%CI 1.08–1.50). Conclusion Door-to-groin time was especially relevant for outcome of comprehensive stroke center patients, whereas door-to-groin time was much shorter in primary stroke center patients. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03356392 . Unique identifier NCT03356392

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

Stroke ◽

10.1161/str.44.suppl_1.awp363 ◽

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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Abstract W P292: A Comparative Analysis of the Requirements for Certification of Stroke Programs, by Type and by Nationally Recognized Certifying Body

Stroke ◽

10.1161/str.45.suppl_1.wp292 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Stacey Lang

Keyword(s):

Selection Process ◽

Evaluation Process ◽

Program Leaders ◽

Primary Stroke Center ◽

Similarities And Differences ◽

Certification Organizations ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Core Measures ◽

Certification Requirements

Background and Purpose: There are currently three main, nationally recognized organizations that certify facilities as primary or comprehensive stroke centers. One of these organizations also offers a “Stroke Ready” designation. While each of these organizations share many of the same requirements, there are likewise many unique requirements between certifying bodies with respect to the certification requirements, process, performance, and on-going expectations. All should be considered when choosing a partner for certification by organizations that are committed to achieving an appropriate level of certification as determined by clinical capabilities. Differences in core measure requirements and definitions, data collection expectations and re-certification cycles among other factors are often overlooked when stroke program leaders are identifying the best certification partner for their particular organization. This poster will detail the similarities and differences among the various stroke program certifying organizations and present a detailed methodology to assist program leaders with the partner selection process. Methods: The three stroke program certifying organizations were examined for review cycles, levels of certification offered, requirements related to hospital certifications, and reportable core measures. Other factors such as cost, the actual certification process, and other considerations that may impact the successful achievement of certification within a particular organization were also reviewed. Results/Conclusion: While there are many similarities in the stroke center certification requirements and processes among the three certifying organizations, there are also significant differences. In order to ensure that the end product of a journey to certification will align with a hospital’s values, budget, and vision for the stroke program, an evaluation process in advance of certifying body selection is essential. Awareness of the similarities and differences among the stroke certification organizations can facilitate a hospital’s decision-making process for pursuit of certification as a stroke ready center, primary stroke center or comprehensive stroke center

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Abstract W P296: Establishing a Stroke Protocol Based on the Trauma Model

Stroke ◽

10.1161/str.45.suppl_1.wp296 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Mary Ann Blosky ◽

E. Andrew Raposo

Keyword(s):

Program Development ◽

Medical Center ◽

Clinical Signs ◽

The State ◽

Joint Commission ◽

High Performing ◽

Time Of Application ◽

Primary Stroke Center ◽

Stroke Center ◽

Trauma Model

Background and Purpose: In the summer of 2012, the state of Pennsylvania adopted legislation mandating EMS providers to deliver all patients with clinical signs of stroke to a certified stroke center for evaluation. In response to this change, development of a new stroke program began at a tertiary medical center located in the northeastern region of the state. The facility was a certified trauma center and also held various other disease specific certifications through the Joint Commission. This project sought to examine the needs of a newly developing primary stroke center within the context of a healthcare organization with numerous other specialized medical and surgical programs. Specifically, the investigators hoped to illustrate the similarities between stroke and other specialized services to demonstrate that many of the requirements of these programs are shared. Method: The site stroke clinical coordinator and system stroke program coordinator kept detailed records of all phases of stroke program development. As resource needs were identified, notation was made indicating whether or not those resources were already available in the hospital. By examining these records, the coordinators were able to identify how many of the resources needed to develop an effective stroke program were already present within the system. Results: Information was collected beginning at the inception of program development in 2012 through the time of application for Joint Commission Primary Stroke Center certification in August of 2013. During these 9 months, many of the needed resources were found to already exist in the facility, with most having been created or added as a result of the hospital’s trauma program development several years earlier. Conclusion: The hospital was able to develop a high performing stroke center with comparative ease due to the preexisting resources from the institution’s trauma program. It is the belief of the stroke team that these results could be easily duplicated in other facilities with trauma services that wish to expand into stroke specialization as well.

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Abstract WP455: Memorial Hermann Hospital System Stroke Coordinators: Working as One

Stroke ◽

10.1161/str.51.suppl_1.wp455 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Sandi G Shaw ◽

Isabel Gonzales ◽

Hari Indupuru ◽

Nicole Harrison ◽

Sean Savitz ◽

...

Keyword(s):

Best Practice ◽

Quality Care ◽

High Volume ◽

Work Load ◽

Joint Commission ◽

Large Hospital ◽

Hospital System ◽

Primary Stroke Center ◽

Stroke Center ◽

The Joint Commission

Background: Many hospital stroke programs fail to meet or maintain the certification requirements of The Joint Commission (TJC) as a Primary Stroke Center (PSC) or Comprehensive Stroke Center (CSC). The most common reason is the absence of a dedicated stroke program coordinator. There are opportunities for improvement to promote stroke coordinator growth and retention. Purpose: We created The Memorial Hermann Hospital System Stroke Coordinator Alliance to combine resources, reduce workload, and support stroke coordinators in order to promote adherence to best practice and maintain TJC stroke certification. Methods: The Memorial Hermann Hospital System Stroke Coordinator Alliance was developed in 2015. It includes 14 nurses who represent 11 acute care hospitals within a large hospital system in Houston (Figure1). Four of the hospitals are CSCs, five are PSCs, and two are not certified. Monthly meetings are conducted to create standardized access to resources, stroke coordinator orientation, education, medical power plans, process improvement, and data development. Coordinator work groups, a central email and shared drive, biweekly data meetings, and a buddy system were created to reduce work load, improve electronic communication, and streamline data review procedures. A partnership was created to onboard new coordinators and to prepare for mock and real time survey visits. In 2018 data abstraction was standardized across hospitals with use of a homegrown database Stroke Program Registry (REGIS). Results: Of the 14 Stroke Coordinators in place during fiscal years 2015 - 2019, retention was 100%. A total of 19 stroke surveys were completed and recognized as successful by The Joint Commission. A total of 17,148 stroke patients were received with PSC measures averaging greater than 95% and CSC measures above 90%. Conclusion: Implementing program development support for stroke coordinators improves retention and quality care in a high volume stroke system.

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Abstract 2623: Racial Disparities in Hospital Length of Stay among Native Hawaiians and other Pacific Islanders with Ischemic Stroke

Stroke ◽

10.1161/str.43.suppl_1.a2623 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Kazuma Nakagawa ◽

Matthew Koenig ◽

Todd Seto ◽

Susan Asai ◽

Cherylee Chang

Keyword(s):

Ischemic Stroke ◽

Length Of Stay ◽

Medical Center ◽

Parameter Estimate ◽

Hospital Length ◽

Pacific Islanders ◽

Native Hawaiians ◽

Hospital Length Of Stay ◽

Primary Stroke Center ◽

Stroke Center

Introduction: Native Hawaiians and other Pacific Islanders (NHPI) with ischemic stroke are younger and have more comorbidities compared to other major racial-ethnic groups. However, their impact on hospital length of stay (LOS) after ischemic stroke has not been studied. Hypothesis: We assessed the hypothesis that NHPI race is associated with a longer hospital LOS after ischemic stroke. Methods: Data from 2004 to 2010 were retrospectively obtained from the Get With the Guidelines-Stroke (GWTG-Stroke) database from The Queen’s Medical Center, the only primary stroke center for the state of Hawaii. Multivariable analyses were performed using a stepwise linear regression model to identify factors predictive of hospital LOS after ischemic stroke. Results: A total of 1921 patients hospitalized for ischemic stroke (NHPI 20%, Asians 53%, whites 24%, blacks 0.8%, others 2%) were studied. Univariate analyses showed that NHPI were younger (mean ages, NHPI 60±14 vs. Asians 72±14, p <0.0001; vs. whites 71±14, p <0.0001) and had higher prevalence of diabetes (NHPI 53% vs. Asians 67%, p <0.0001; vs. whites 22%, p <0.0001), hypertension (NHPI 82% vs. whites 22%, p <0.0001), prior stroke or TIA (NHPI 30% vs. Asians 23%, p =0.01), smoking (NHPI 19% vs. Asians 14%, p =0.01), dyslipidemia (NHPI 43% vs. whites 34%, p <0.01), and longer hospital LOS (NHPI 11±17 days vs. Asians 7±9 days, p <0.0001; whites 8±17 days, p <0.05). After adjusting for age, race, gender, and risk factors with predefined significance ( p <0.1), independent predictors for hospital LOS were NHPI race (parameter estimate, 2.67; 95% CI, 1.09 - 4.22, p =0.001), atrial fibrillation/atrial flutter (parameter estimate, 2.22; 95% CI, 0.53 - 3.90, p =0.01), and age (parameter estimate, -0.04; 95% CI, -0.09 - -0.002, p =0.04). Conclusions: Native Hawaiians and other Pacific Islanders with ischemic stroke have a longer hospital length of stay compared to Asians and whites. Further studies are needed to assess if other socioeconomic factors contribute to the observed differences.

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Abstract WP266: EMS/Hospital Combined Education Decreased Primary Stroke Center Bypass

Stroke ◽

10.1161/str.48.suppl_1.wp266 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Jason P Stopyra ◽

Myron Waddell ◽

Emily B Parks

Keyword(s):

North Carolina ◽

Quality Improvement ◽

Service Area ◽

Education Intervention ◽

Post Intervention ◽

Intervention Phase ◽

Primary Stroke Center ◽

Stroke Center ◽

The Impact

Introduction: Historically, community hospitals have had few options for meaningful treatment of patients presenting with acute stroke. As expertise grows in the administration of thrombolytics, primary stroke centers (PSC) fulfill an important role in the reduction of morbidity and mortality related to stroke. It is important for the PSC to partner with Emergency Medical Services (EMS) to change historical perceptions of the quality of PSC care. Education may improve teamwork and increase awareness of the PSC, thereby increasing their utilization in EMS disposition decisions. Objective: The objective of this study is to report the impact of an education intervention on PSC bypass decisions. Methods: The electronic patient care record database from a North Carolina county EMS system was queried as a quality improvement analysis from January 1, 2012 to February 28, 2016. This included 19 months prior to the education intervention, the year during the education intervention, and 19 months after the education intervention. All primary patient transports with Stroke/CVA, or suspected TIA as the primary or secondary impression were included. Interfacility transports were excluded. The recorded call location was determined to either be inside or outside the PSC service area. The hospital the patient was transported to was also recorded. Results: During the pre-intervention phase 222 patients were identified, 48 of which originated in the PSC service area. Of those 48 patients, 16 bypassed the PSC (33.3%). In the post-intervention phase, 94 of 269 total patients were in PSC service area. Only 12 bypasses occurred (12.8%) which is a reduction of 61.7% in PSC bypass compared to the pre-intervention phase. Conclusion: The period following a combined hospital/EMS educational intervention showed significant reduction in PSC bypass.

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