Reducing Readmission Rates By Improving Transitions Of Care For Stroke Patients In The Pre-Covid And Covid Eras

Introduction: Acute cerebrovascular disease ranks among the top causes of 30-day readmissions. Studies have shown that enhancing and streamlining transitions of care (TOC) for patients can improve readmission rates for many conditions. Our research explores the impact of in-person and telemedicine TOC stroke clinic on readmission rates at an urban comprehensive stroke center. Methods: Participants were identified by ICD-10 diagnoses corresponding with stroke or transient ischemic attack at Thomas Jefferson University Hospital (TJUH). Starting in January of 2019, an in-person TOC clinic visit with a vascular neurologist or nurse practitioner was automatically scheduled within 1-3 weeks for patients discharged to home. When coronavirus precautions began, these visits transitioned to telemedicine. Follow-up telephone surveys assessing self-efficacy, confidence and perceived value of TOC clinic were administered. Readmission statistics were collected from the TJUH electronic health record. Preliminary data analysis was performed in SPSS. Results: 208 individuals (113 in-person, 95 telemedicine) seen in TOC clinic were included in preliminary analysis. The 30-day all-cause readmission rate was 5.8% (12 patients). Of these readmissions, 2 were seen in the clinic (2.1%), and 10 were evaluated via telemedicine (8.8%). Chi Square revealed a between group difference (X2 = 4.318, p = 0.038). Participants in both the in-person group (u = 8.421, SD = 1.835) and telemedicine group (u = 8.100, SD = 1.875) considered TOC a valuable experience. Analysis of perceived TOC value did not differ between groups (t = 0.654, p = 0.515). Discussion: Stroke readmissions represent a significant source of morbidity, mortality and healthcare spending in the United States. Overall, there were fewer readmissions among TJUH TOC clinic patients compared to institutional and national 30-day stroke readmission rates. Understanding the relative impact of an in-person and telemedicine TOC stroke clinic will provide valuable information as healthcare systems navigate the post-COVID era

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

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

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

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

Case Report Diagnostic Challenges of Cryptococcus neoformans in an Immunocompetent Individual Masquerading as Chronic Hydrocephalus

Cryptococcus neoformans can cause disseminated meningoencephalitis and evade immunosurveillance with expression of a major virulence factor, the polysaccharide capsule. Direct diagnostic assays often rely on the presence of the cryptococcal glucuronoxylomannan capsular antigen (CrAg) or visualization of the capsule. Strain specific phenotypic traits and environmental conditions influence differences in expression that can thereby compromise detection and timely diagnosis. Immunocompetent hosts may manifest clinical signs and symptoms indolently, often expanding the differential and delaying appropriate treatment and diagnosis. We describe a 63-year-old man who presented with a progressive four-year history of ambulatory dysfunction, headache, and communicating hydrocephalus. Serial lumbar punctures (LPs) revealed elevated protein (153-300 mg/dL), hypoglycorrhachia (19-47 mg/dL), lymphocytic pleocytosis (89-95% lymphocyte, WBC 67-303 mg/dL, and RBC 34-108 mg/dL), and normal opening pressure (13-16 cm H 2 O). Two different cerebrospinal fluid (CSF) CrAg assays were negative. A large volume CSF fungal culture grew unencapsulated C. neoformans. He was initiated on induction therapy with amphotericin B plus flucytosine and consolidation/maintenance therapy with flucytosine, but he died following discharge due to complications. Elevated levels of CSF Th1 cytokines and decreased IL6 may have affected the virulence and detection of the pathogen

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