Staff and Facility Utilization in Direct Patient Transfer to the Comprehensive Stroke Center: Testing a Real-Time Location System for Automatic Patient Pathway Characterization

Introduction: Starting reperfusion therapies as early as possible in acute ischemic strokes are of utmost importance to improve outcomes. The Comprehensive Stroke Centers (CSCs) can use surveys, shadowing personnel or perform journal analysis to improve logistics, which can be labor intensive, lack accuracy, and disturb the staff by requiring manual intervention. The aim of this study was to measure transport times, facility usage, and patient–staff colocalization with an automated real-time location system (RTLS).Patients and Methods: We tested IR detection of patient wristbands and staff badges in parallel with a period when the triage of stroke patients was changed from admission to the emergency room (ER) to direct admission to neuroradiology.Results: In total, 281 patients were enrolled. In 242/281 (86%) of cases, stroke patient logistics could be detected. Consistent patient–staff colocalizations were detected in 177/281 (63%) of cases. Bypassing the ER led to a significant decrease in median time neurologists spent with patients (from 15 to 9 min), but to an increase of the time nurses spent with patients (from 13 to 22 min; p = 0.036). Ischemic stroke patients used the most staff time (median 25 min) compared to hemorrhagic stroke patients (median 13 min) and stroke mimics (median 15 min).Discussion: Time spent with patients increased for nurses, but decreased for neurologists after direct triage to the CSC. While lower in-hospital transport times were detected, time spent in neuroradiology (CT room and waiting) remained unchanged.Conclusion: The RTLS could be used to measure the timestamps in stroke pathways and assist in staff allocation.

Direct Transfer to Angiosuite Triage Strategy for Patients Undergoing Mechanical Thrombectomy in a Rural Setting

BACKGROUND A direct admission to angiosuite (DAA) strategy in transfer patients with large vessel occlusion (LVO) is considered to decrease stroke time metrics and benefit functional outcomes. However, feasibility and effectiveness of DAA have not been established in rural settings. Fast door‐to‐reperfusion times and high‐quality reperfusion are key predictors of outcome in patients with LVO. To reduce treatment times in transferred patients with suspected LVO, we initiated a DAA triage protocol in 2017. METHODS We conducted a nested interventional cohort study of adult patients with anterior LVO from January 2015 to August 2019 transferred to our center from an outside hospital. Patients were divided into DAA for mechanical thrombectomy (MT) and patients directly admitted to the emergency department (DAED). DAED was subdivided into patients undergoing MT and patients who did not. Workflow times and clinical and radiographic outcomes were analyzed. RESULTS Forty‐five DAA patients and 241 DAED patients (DAED patients undergoing MT=134 patients and DAED patients not undergoing MT=107 patients) were identified. DAA patients had significantly shorter median door‐to‐arterial‐puncture times (15 versus 71 minutes) and puncture‐to‐recanalization times (27 versus 42.5 minutes). At discharge, DAA patients had a significant decrease in median admission National Institutes of Health Stroke Scale (NIHSS) score (ΔNIHSS score 10 versus 4; P =0.02), and higher rate of dramatic clinical improvement (ΔNIHSS score >10; 48.9% versus 23.5%; P <0.001). Both groups had comparable rates of functional independence (modified Rankin Scale; mRS 0–2; 36.1% versus 29.2%; P =0.52), and mortality at 90 days ( P =0.63). When mortality was excluded, DAA patients showed a significant proportion of excellent functional outcome (mRS 0–1; 50% versus 26%) before ( P =0.04) and after ( P =0.02) adjusting for confounders. CONCLUSIONS DAA is feasible and can safely reduce reperfusion times in transferred patients with LVO to MT centers in a rural setting. Reducing workflow times may impact the functional recovery of patients undergoing MT.

Drip-and-Ship for Thrombectomy Treatment in Patients With Acute Ischemic Stroke Leads to Inferior Clinical Outcomes in a Stroke Network Covering Vast Rural Areas Compared to Direct Admission to a Comprehensive Stroke Center

Introduction: Organizing regional stroke care considering thrombolysis as well as mechanical thrombectomy (MTE) remains challenging in light of a wide range of regional population distribution. To compare outcomes of patients in a stroke network covering vast rural areas in southwestern Germany who underwent MTE via direct admission to a single comprehensive stroke center [CSC; mothership (MS)] with those of patients transferred from primary stroke centers [PSCs; drip-and-ship (DS)], we undertook this analysis of consecutive stroke patients with MTE.Materials and Methods: Patients who underwent MTE at the CSC between January 2013 and December 2016 were included in the analysis. The primary outcome measure was 90-day functional independence [modified Rankin score (mRS) 0–2]. Secondary outcome measures included time from stroke onset to recanalization/end of MTE, angiographic outcomes, and mortality rates.Results: Three hundred and thirty-two consecutive patients were included (MS 222 and DS 110). Median age was 74 in both arms of the study, and there was no significant difference in baseline National Institutes of Health Stroke Scale scores (median MS 15 vs. 16 DS). Intravenous (IV) thrombolysis (IVT) rates differed significantly (55% MS vs. 70% DS, p = 0.008). Time from stroke onset to recanalization/end of MTE was 112 min shorter in the MS group (median 230 vs. 342 min, p &lt; 0.001). Successful recanalization [thrombolysis in cerebral infarction (TICI) 2b-3] was achieved in 72% of patients in the MS group and 73% in the DS group. There was a significant difference in 90-day functional independence (37% MS vs. 24% DS, p = 0.017), whereas no significant differences were observed for mortality rates at 90 days (MS 22% vs. DS 17%, p = 0.306).Discussion: Our data suggest that patients who had an acute ischemic stroke admitted directly to a CSC may have better 90-day outcomes than those transferred secondarily for thrombectomy from a PSC.

Abstract 1122‐000161: Clinical Factors Associated with rtPA Inclusion in Ischemic Stroke Patients with and without Heart Failure

Introduction : It is estimated that approximately 10–24% of acute ischemic stroke (AIS) patients have comorbid heart failure (HF). However, it is currently unknown if certain clinical risk factors associated with rtPA thrombolytic therapy differ based on HF diagnosis. The purpose of this study is to determine the clinical factors associated with rtPA inclusion in AIS patients with and without heart failure. Methods : Retrospective data for baseline clinical and demographic factors from January 2010 to January 2016 in a regional stroke center were analyzed. Of the 5,469 patients identified with AIS, 590 presented with heart failure while 4,879 did not. Odds ratios and 95% confidence intervals were used to determine which clinical factors were associated with rtPA inclusion. Results : Adjusted multivariate analysis demonstrated that within the AIS population, those without HF who received rtPA were more likely to be associated with Hispanic ethnicity (OR = 0.464, 95% CI, 0.247‐0.87, P = 0.017), coronary artery stenosis (OR = 0.55, 95% CI, 0.366‐0.83, P = 0.004), previous stroke (OR = 0.745, 95% CI, 0.609‐0.91, P = 0.004), previous TIA (OR = 1.447, 95% CI, 1.094‐1.91, P = 0.010), total cholesterol (OR = 1.487, 95% CI, 1.175‐1.88, P = 0.001), lipids (OR = 0.998, 95% CI, 0.996‐1, P = 0.038), serum creatinine (OR = 0.899, 95% CI, 0.854‐0.95, P<0.001), INR (OR = 0.825, 95% CI, 0.73‐0.93, P = 0.002), heart rate (OR = 0.13, 95% CI, 0.071‐0.24, P<0.001), and direct admission (OR = 2.87, 95% CI, 2.432‐3.39, P<0.001). AIS patients with HF who received rtPA were more likely to be associated with increasing age (OR = 0.982, 95% CI, 0.966‐1, P = 0.020), coronary artery disease (OR = 0.618, 95% CI, 0.391‐0.98, P = 0.0.040), INR (OR = 0.326, 95% CI, 0.129‐0.82, P = 0.018), and ambulatory improvement (OR = 1.69, 95% CI, 1.058‐2.7, P = 0.0.028). Conclusions : The results of this study demonstrate that within the AIS population, there are certain clinical risk factors that influence the likelihood of receiving rtPA in patients with and without HF. These findings provide further insight into AIS and HF and suggest the need for further research into the role the identified factors play in influencing clinical outcome.

Functional Outcome, Recanalization, and Hemorrhage Rates After Large Vessel Occlusion Stroke Treated With Tenecteplase Before Thrombectomy

ObjectiveTo investigate in routine care the efficacy and safety of IV thrombolysis (IVT) with tenecteplase prior to mechanical thrombectomy (MT) in patients with large vessel occlusion acute ischemic strokes (LVO-AIS), either secondarily transferred after IVT or directly admitted to a comprehensive stroke center (CSC).MethodsWe retrospectively analyzed clinical and procedural data of patients treated with 0.25 mg/kg tenecteplase within 270 minutes of LVO-AIS who underwent a brain angiography. The main outcome was 3-month functional independence (modified Rankin scale score ≤ 2). Recanalization (revised Treatment in Cerebral Ischemia score 2b-3), was evaluated before (pre-MT) and after MT (final).ResultsWe included 588 patients (median age 75 years [interquartile range (IQR) 61-84]; 315 women [54%]; median NIH Stroke Scale [NIHSS] score 16 [IQR 10-20]), of which 520 (88%) were secondarily transferred after IVT. Functional independence occurred in 47% (n = 269/570; 95%CI 43.0-51.4) of patients. Pre-MT recanalization occurred in 120 patients (20.4%; 95%CI 17.2-23.9), at a similar rate across treatment paradigms (direct admission, n = 14/68 [20.6%]; secondary transfer, n = 106/520 [20.4%]; p > .99) despite a shorter median IVT-to-puncture time in directly admitted patients (38 [IQR 23-55] vs 86 [IQR 70-110] minutes; p < .001). Final recanalization was achieved in 492 patients (83.7%; 95%CI 80.4-86.6). Symptomatic intracerebral hemorrhage occurred in 2.5% of patients (n = 14/567; 95%CI 1.4-4.1).ConclusionsTenecteplase before MT is safe, effective and achieves a fast recanalization in everyday practice in patients secondarily transferred or directly admitted to a CSC, in line with published results. These findings should encourage its wider use in bridging therapy.Classification of EvidenceThis study provides class IV evidence that tenecteplase within 270 minutes of LVO-AIS is increases the probability of functional independence.

TP9.2.17Developing Novel Referral Pathways in Emergency Surgery

Introduction In line with the principles of GIRFT and recognising the demand on the Emergency Department (ED) the Acute Surgical Unit (ASU) developed a direct admission pathway entitled ‘ASU Direct’ (ASUD). Nurse led ED triage with adherence to a referral proforma allows direct admission of suitable surgical patients eliminating medical ED review or discussion with the on-call Registrar. Aim Investigate the usefulness of the ASUD pathway and adherence to admission criteria. Method Two retrospective audits of ASUD referrals were completed and compared with concurrent traditional registrar referrals. Inter-departmental discussions occurred between audit cycles. Results Audit 1: 13 days, 150 cases (8 excluded). 75 (53%) referred via ASUD, 67 (47%) via surgical registrar. Sixteen ASUD cases (22%) breached pathway protocols including 3 young women referred without pregnancy tests. Seventeen (25%) cases referred via the Registrar fulfilled ASUD criteria. Documentation complete in 56% of ASUD cases. Audit 2: (3 weeks after feedback) - 10 days, 120 patients (25 excluded). Fifty one ASUD cases (54%) and 44 (46%) registrar referrals. 24% cases breached ASUD criteria, 7 registrar referrals (15%) appropriate for ASUD. ASUD documentation completed in 60% with 100% pregnancy status recorded. Conclusions Proportion of ASUD / registrar referrals remained constant but there were fewer missed opportunities for ASUD. Inappropriate ASUD admissions remained similar. While ASUD worked well for visible pathology, less-so for protocol-driven abdominal pain. Senior ‘front-door’ triage in ED might improve protocol compliance, helping to develop such pathways, observing GIRFT and avoid unnecessary transfer of patients (especially during the COVID pandemic).

FIGHT AGAINST SUPERBUGS IN A BURN CENTRE: ARE WE DOING ENOUGH

Objective: To determine the superbug infection in a burn centre, its impact on mortality/morbidity and to review all preventive/therapeutic steps taken to fight this menace. Study Design: Retrospective cross sectional study. Place and Duration of Study: Department of Burns & Plastic Surgery, Army Burn Centre, Combined Military Hospital Kharian, from Oct 2018 to Sep 2019. Methodology: A detailed retrospective audit of departmental data was carried out. Parameters like direct admission vs transferred patient, percentage of burns (Total Burn Surface Area-TBSA%), records of all burns related deaths and all culture/sensitivity reports were analysed using SPSS-20. As a standard practice in our unit blood, tracheal secretions and pus culture specimens of all patients are collected at the time of admission and then periodically fresh samples are taken every week or earlier when-ever required. Results: Out of 515 patients, 283 (54.95%) were children under the age of 12 years. The overall survival rate improved by 13.43% as compared to last year. Out of 584 bacteriology reports 396 (67.81%) were positive and 188 (32.19%) were negative. On culture 508 organisms were isolated, majority of which were Carbapenem Resistant Pseudomonas, Acinetobacter, Enterobacteriaceae and Methicillin resistant staphylococcus aureus. Conclusion: Multi drug resistant superbug infection is a worldwide menace. The best clinical practices, strict contact isolation, enhanced environmental cleaning and judicious use of appropriate antibiotics are the main strategies in this war. Need for newer more effective antibiotics cannot be overemphasized.