Alteplase administration for acute ischemic stroke (AIS) in ER - a 5-year review

ER visits for AIS grown in last 10 years by 25% Ongoing effort by AHA/ASA to improve access to care with early stroke recognition and awareness Time is brain; rate of thrombolysis with alteplase (ALT) should increase with better EMS systems, awareness, and educatio

Improving Door-to-Groin Time for Stroke-Alert Patients Arriving at TJUH

Introduction: Due to the large number of endovascular-eligible acute ischemic stroke patients, the urgent nature of effective stroke treatment protocols has become increasingly recognized at TJUH. Due to the hospital’s unique situation with two city blocks between the ER and endovascular lab, in-hospital factors remain a significant reason for the delay of treatment. Objective: The purpose was to conduct a quality-assurance trial to determine whether standardizing imaging modalities for inpatient and ER stroke-alert patients at our institution would improve door-to-puncture times. Methods: After implementation of the new stroke alert protocol, data were prospectively collected for six months for two groups of patients: patients transferred from the ER for possible large vessel occlusions (LVO) who underwent thrombectomy and patients who were transferred for possible LVO but deemed not a candidate for thrombectomy. Retrospective comparison data were obtained from 2015 to 2017 for the same six-month period to account for seasonal variability. Results: The co-primary outcomes were door-to-groin puncture time (DTG) time and door-to-door (ER to endovascular lab (DTD)) time. Average DTD times for 2015, 2016 and 2017 were 114, 129 and 145 minutes and the average DTG times were 263, 207, and 165 minutes, respectively. Discussion: After enactment of the new algorithm, our DTG time decreased to 103 minutes and the DTD time decreased to 107 minutes. Therefore, the emphasis on quality improvement regarding the stroke alert algorithm decreased DTG time for acute stroke patients with large vessel occlusion undergoing mechanical thrombectomy

Antithrombotic Choice and Timing in Patients Presenting with Symptomatic Hemorrhagic Conversion of Ischemic Stroke

The primary aim of this research project is to determine the optimal time for antithrombotic agent initiation post ischemic stroke without resulting hemorrhagic conversion. We hypothesize that not only is hemorrhagic conversion risk often inaccurately estimated, but also that antiplatelet agents and anticoagulants may pose similar risk of hemorrhagic conversion, particularly when initiated seven days post ischemic stroke. This risk potentially outweighs their protective effects against recurrent stroke. We are in the process of identifying patients with hemorrhagic conversion of ischemic stroke at Thomas Jefferson University Hospital and will analyze the type and timing of antithrombotic agents. Additional risk factors studied include mechanism and location of stroke, infarct volume, atrial fibrillation, LDL levels, statin therapy, chronic diseases, and substance abuse. We will perform a multivariate analysis to evaluate for associations among the risk factors. Due to unexpectedly lower rates of patients with hemorrhagic conversion and difficulties obtaining data due to coding variability, we do not currently have sufficient data for a full analysis (N=50). Interesting trends seen in the data include that 22 out of our 50 patients bled on aspirin monotherapy. However, there is a need for more patient data to begin drawing statistically significant conclusions. Once data collection is completed, we anticipate identifying specific antithrombotic therapies and timing of therapies that have strong associations with hemorrhagic conversion. This will help to develop evidence-based guidelines for management of acute ischemic stroke treatment at a large comprehensive stroke center with diverse patient population

Early Follow-Up Phone Calls to Reduce 30-Day Readmissions For Stroke Patients Discharged to Home

Patients admitted to the acute stroke unit with minor neurologic deficits are frequently discharged directly to home rather than to a rehabilitation center. Data from our tertiary care comprehensive stroke center has shown that in a 7-month period, 37% of patients admitted to the stroke unit were discharged home versus discharged to rehab or other location. Our average 30-day readmission rate for home discharges is 5.14%. More than 30% of these readmitted patients had been discharged on a Thursday or Friday on their index admission. When discharged home, patients typically are tasked with several responsibilities including but not limited to medication management, organizing follow-up appointments, monitoring blood pressure, and coordinating home services. In addition to recovering mentally and physically from stroke, these tasks can lead to additional burden particularly on weekends when access to care may be limited. We hypothesize that those who are discharged home on a Thursday or Friday are at higher risk for readmission and predict that scripted phone calls to these patients over the weekend could result in reduction in readmissions

Updates in Stroke Diagnosis, Management, and Prevention

Topics Covered Background Diagnosis Acute ischemic stroke management update TIA/Minor stroke Secondary stroke prevention Intracranial stenosis Dissection Cryptogenic stroke Intracerebral hemorrhage Outpatient stroke car

Safety, Efficiency, and Efficacy of Protocolized Contrast-Enhanced Imaging in Acute Stroke Evaluation.

BACKGROUND AND PURPOSE: Computed tomography angiography and perfusion studies have increasingly become a part of acute stroke evaluation. However, the volume, benefit, and scope of need for imaging is sometimes debated. PURPOSE: This study evaluated the safety, efficiency, and efficacy of changes to the acute stroke evaluation protocol at our academic institution. Previously, contrast-enhanced imaging was opt-in and ordered upon suspicion of large vessel occlusion. This was subsequently transitioned to one where contrast-enhanced imaging was automatically ordered for all patients with opt-out of imaging if felt appropriate. METHODS: We performed a retrospective, case-control study that included patients evaluated for acute stroke management before and after the protocol change. Six hundred forty-seven patients met criteria for study involvement, of which 258 were in the preprotocol and 389 in the postprotocol group. RESULTS: There was no significant difference in rate of acute kidney injury and no delay in door-to-needle time. There was significant improvement in door-to-groin puncture times (49.9 minutes) for typical cases and increase in monthly rate of endovascular therapy (EVT). CONCLUSION: Protocolization of contrast-enhanced imaging for acute stroke evaluation proved safe with respect to renal function, did not delay door-to-needle time, improved door-to-groin puncture time, and lead to higher rates of EVT

Improving Medical and Endovascular Management for Acute Ischemic Stroke Through Multidisciplinary Education and Simulation

Primary goals: Reduce door to treatment times (both DTN and DTP) to meet and exceed existing guidelines metrics. Educate residents about acute stroke management, including national guidelines and new institutional protocols to improve efficiency during stroke alerts.https://jdc.jefferson.edu/patientsafetyposters/1097/thumbnail.jp

Improving ED Door to Puncture Times for Endovascular Thrombectomy in Acute Ischemic Stroke

Objectives Optimize the management of patients presenting to TJUH with AIS who are candidates for ET. Enable continued process improvement through improved data collection methods and identification of new process metrics.https://jdc.jefferson.edu/patientsafetyposters/1145/thumbnail.jp

Process Improvement for Endovascular Thrombectomy in Patients Presenting with Acute Ischemic Stroke

Aims Critically evaluate the existing stroke activation and ET protocols for compliance with new 2018 metrics and guidelines. Review DTP times under the existing protocol to assess for potential inefficiencies or gaps in care delivery, specifically addressing differences between processes at JHN compared to ED/Gibbon. Make changes to the existing stroke alert protocol to better reflect current guidelines, streamline care, and ultimately improve process metrics (DTP times). Establish a system for recursive continuous analysis of AIS patients to identify protocol gaps, inefficiencies and areas for further intervention.https://jdc.jefferson.edu/patientsafetyposters/1096/thumbnail.jp