Rapid Decline in Telestroke Consults in the Setting of COVID-19.

Background and Purpose: As coronavirus disease 2019 (COVID-19) continues to be a global pandemic, there is a growing body of evidence suggesting that incidence of diseases that require emergent care, particularly myocardial infarction and ischemic stroke, has declined rapidly. The objective of this study is to quantify our experience of telestroke (TS) consults at a large tertiary comprehensive stroke center during the COVID-19 pandemic. Methods: We retrospectively reviewed TS consults of patients presenting to our neuroscience network. Those with a confirmed diagnosis of acute ischemic stroke or transient ischemia attack were included. Data were compared from April 1, 2019, to June 30, 2020, which include consults prepandemic and during the crisis. Results: A total of 1,982 TS consults were provided in 1 year. Prepandemic, the mean monthly consults were 148. In April 2020, only 59 patients were seen (49% decline). Mobile stroke unit consults decreased by 72% in the same month. The 30-day moving average of patients seen per day was between five and six prepandemic declined to between two and three in April, and then began to uptrend during May. The mean percentage of patients receiving intravenous tissue plasminogen activator was 16% from April 2019 to March 2020 and increased to 31% in April 2020. The mean percentage of patients receiving endovascular therapy was 10% from April 2019 to March 2020 and increased to 19% in April 2020. Conclusions: At our large tertiary comprehensive stroke center, we observed a significant and rapid decline in TS consults during the COVID-19 pandemic. We cannot be certain of the reasons for the decline, but a fear of contracting coronavirus, social distancing, and isolation likely played a major role. Further research must be done to elucidate the etiology of this decline

A Systems Thinking Approach to Redesigning the Patient Experience to Reduce 30 Day Hospital Readmission

INTRODUCTION The cost of medical care is spiraling out of control, and one of the many reasons is lack of preventative care, poor communication to the patient and primary caregiver(s) both in an inpatient and outpatient setting. There are potentially many reasons for this cost escalation, one of the drivers of this cost is 30 day readmission after a hospitalization and this is what was examined in this analysis. The purpose of this paper in particular is to share what has been learned using a systems thinking approach to hospital readmissions and the patient experience. It is critical to understand the problems that occurred in the past. In addition, we will explain the methodology utilized and bring awareness to the iterative process. We will also demonstrate a suggested redesigned model

Stroke Centers of Excellence in the United States: Certification, Access and Outcomes

Introduction: Stroke is a leading cause of morbidity, mortality and healthcare costs in the United States. Evidence suggests that certified stroke centers have improved patient outcomes relative to non-certified hospitals. Our study explains the process, associated cost, quality and geographic proclivities of different certifying organizations. Methods: Data was collected from published literature, information on certifying organizations’ websites and through direct communication with representatives of The Joint Commission (TJC), Det Norske Veritas and Germanischer Lloyd (DNV-GL), and Healthcare Facilities Accreditation Program (HFAP). Geographic mapping of thrombectomy capable centers and comprehensive stroke centers was performed with the ArcGIS online tool. Results: Among the three certifying organizations, standards for recognition as acute, primary, thrombectomy capable and comprehensive stroke centers are not standardized. At the time of this review, there were 1406 TJC-certified stroke centers, 241 DNV-GL certified stroke centers and 66 HFAP-certified stroke centers in the United States. Cost for certification was similar with price scaled by complexity of capabilities. Quality metrics revealed a significantly higher rate of tPA administration and shorter door-to-needle time for TJC and DNV-GL centers than HFAP. All primary stroke centers exhibited improved in-hospital, 30-day and 1-year mortality when compared to non-stroke centers. Discussion: Despite lack of standardization of criteria between organizations, certification provides a mechanism for ensuring hospitals deliver higher standards of stroke care. Understanding variations in quality and scope of different organizations enables targeting of at-risk regions to maximize access and availability of care

Readmission Risk Assessment Tool for Stroke Patients

Introduction: Strokes are one of the leading causes of morbidity and mortality in the world and its cost of management has vastly increased; an effective prediction tool that utilizes artificial intelligence to lower the rate of stroke-related readmissions has the potential to lower healthcare costs and increase the quality of provider care. We hypothesize that machine learning techniques are superior to traditional statistics when determining the likelihood of 30-day readmission for Jefferson’s stroke patients. Methods: Jefferson’s existing data on stroke patients were cleaned, aggregated, and prepared to be split into train and test sets. Using the train sets, machine learning (ML) models such as Random Forest, Support Vector Machines, and Neural Networks were trained to assess the risk of readmission. Each model’s accuracy and precision were captured in the form of confusion matrices, AUCs, and more to reveal the most superior ML method in assessing this risk. These results were then compared to the readmission risk determined by traditional statistics. Results: After training the ML models, the test sets were inputted to determine how accurately they could predict a stroke patient’s chance of readmission with new data. Traditional statistics (in the form of logistic regression) showed an accuracy of 84%. The ML methods utilized resulted in the following accuracies: Random Forest at 95.50%, SVM at 94.79%, and Neural Networks at 95.40%. Discussion: This study not only demonstrates that machine learning methods are superior to traditional statistics in regard to determining the 30-day readmission risks for Jefferson stroke patients, but it also shows that the Random Forest model is the most accurate in doing so. The potential implications of this tool are large; its use can be seen at both the patient and the hospital levels by improving costs for the patient and the hospital as well as improving stroke education and care

Letter: Thrombotic Neurovascular Disease in COVID-19 Patients.

Although the respiratory system is the primary target of the coronavirus, studies have demonstrated a strong tropism to the central nervous system (CNS).1,2 The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infects cells by binding to the angiotensin-converting enzyme 2 (ACE2) receptor. This receptor is also found in the CNS and plays a crucial role in autoregulating cerebral perfusion pressure.3,4 Additionally, epidemiological data demonstrated increased mortality due to cardiovascular and cerebrovascular diseases during flu pandemics due to a hypercoagulable state.5,6 The triad of neuroinvasion of SARS-CoV-2, induction of hypercoagulable state,5-9 and the inhibition of ACE2 blocking the formation of Angiotensin (1-7) serve as the pathophysiology for neurovascular insults.3,4 We present a case series of coronavirus disease 2019 (COVID-19) patients from 2 health systems developing cerebrovascular insult

Epidemiology of a large telestroke cohort in the Delaware valley

•Telestroke network has been shown to increase the frequency of tPA usage.•Telestroke network could help decrease the need for transfer.•A decrease in transfer rate may result in economical benefit for the network.•NIHSS and tPA administration at onset predicted transfer.•It is necessary to increase the public awareness regarding stroke symptoms. The American Heart Association/American Stroke Association has recently endorsed telestroke. Telestroke has enhanced stroke diagnosis, increased tPA administration and improved long-term outcomes. However, many of the publication on telemedicine so far have been review articles. We investigated the epidemiological features of telestroke patients and evaluated the difference between the transferred and non-transferred cohorts. We collected data on telestroke consultation, between January 2012 and June 2013, regarding patient's age, gender, diagnosis, NIHSS, onset-to-spoke time (OTS), tPA administration and transfer status. Further data was obtained on transferred patients regarding discharge and endovascular interventions. The means of age, NIHSS and OTS time were the following: 67.59 years, 7.65 and 11.28h respectively. The proportion of transferred patients was 12.04% (280/2324); lower than what was previously reported. The overall rate of IV tPA administration was 11.98%. Transferred patients had a significantly higher NIHSS mean (10.93 vs. 6.73; P<0.001), and were more likely to have received IV-tPA at onset (25.57 vs. 9.67; P<0.001). The age, gender proportion, stroke mimic proportion, and the mean of OTS did not differ between the two-groups (0.49 vs. 0.31; P=0.38). A logistic regression showed that NIHSS (OR=1.06, P<0.001) and tPA administration at onset (OR=2.78, P<0.001) predict the transfer. Of the transferred patients, 4.5% received endovascular intervention. The mortality rate of transferred patients was 12.9%. Other outcomes were the following: 52% discharge to rehabilitation facilities, 29% discharge to home, and 8% discharge to long-term nursing facilities. Telestroke network is increasing the frequency of tPA usage in acute ischemic stroke and may decrease the need for transfer. Our aim was to optimize the stroke therapy to shorten the hospital stay and to increase the discharge home. This allows a better functional outcome and an additional benefit of cost-saving for the hospitals

Comparison of Stroke Cohorts Cared for by Two Different Specialties in a Practice-Based Tele-Stroke Population

Conclusion Telemedicine is allowing for more patients suffering from AIS to receive care by dedicated stroke physicians including neurovascular surgeons. Our study does not find any difference in outcome between neurologists, who have traditionally managed stroke care, and neurosurgeons. Although ischemic stroke is a matter of multidisciplinary management, these surgeons are appropriately knowledgeable to prescribing IVrt-PA and concurrently performing MT in a highly-specialized stroke unit.https://jdc.jefferson.edu/neurosurgeryposters/1012/thumbnail.jp

Pennsylvania comprehensive stroke center collaborative: Statement on the recently updated IV rt-PA prescriber information for acute ischemic stroke.

OBJECTIVE: Recently, the FDA guidelines regarding the eligibility of patients with acute ischemic stroke to receive IV rt-PA have been modified and are not in complete accord with the latest AHA/ASA guidelines. The resultant differences may result in discrepancies in patient selection for intravenous thrombolysis. METHODS: Several comprehensive stroke centers in the state of Pennsylvania have undertaken a collaborative effort to clarify and unify our own recommendations regarding how to reconcile these different guidelines. RESULTS: Seizure at onset of stroke, small previous strokes that are subacute or chronic, multilobar infarct involving more than one third of the middle cerebral artery territory on CT scan, hypoglycemia, minor or rapidly improving symptoms should not be considered as contraindications for intravenous thrombolysis. It is recommended to follow the AHA/ASA guidelines regarding blood pressure management and bleeding diathesis. Patients receiving factor Xa inhibitors and direct thrombin inhibitors within the preceding 48h should be excluded from receiving IV rt-PA. CT angiography is effective in identifying candidates for endovascular therapy. Consultation with and/or transfer to a comprehensive stroke center should be an option where indicated. Patients should receive IV rt-PA up to 4.5h after the onset of stroke. CONCLUSIONS: The process of identifying patients who will benefit the most from IV rt-PA is still evolving. Considering the rapidity with which patients need to be evaluated and treated, it remains imperative that systems of care adopt protocols to quickly gather the necessary data and have access to expert consultation as necessary to facilitate best practices