Implementation of Stroke Pathways to Reduce Length of Stay, Cost, Readmissions, and Mortality

Introduction: Acute stroke is a major contributor to healthcare costs. In 2012, es-timated direct costs associated with stroke was $71B, which is projected to double to$184B by 2030. As healthcare evolves and reimbursements decrease, cost control in disease specific populations is critical. In January 2017, length of stay (LOS) peaked at 5.25 days, as did variable and total cost/case. In fiscal year 2017 the 30-day readmission rate was 9% and the mortality rate was 12%. Compliance with stroke ad-mission order sets was at 55%. Methods: A multidisciplinary committee was formed in February 2017 to develop standardized, evidence-based clinical pathways for three populations: Ischemic stroke (IS) treated with IV tPA, TIA/IS without IV tPA, and intracerebral hemorrhage. The team met biweekly to standardize clinical pathways, decrease time to follow-up imaging, focus on physician order set utilization, and control costs. A comprehensive education program for all clinical staff was completed; official implementation of the pathways was in November 2017. Pathways are discussed in stroke multidisciplinary rounds and rapid discharge rounds daily to ensure compliance and identify opportunities for improvement. We reviewed a retrospective financial report of all in-hospital cases coded as MS-DRG 61-69 from 12/2017 through 11/2018 and compared it the 1/2017 report. Results: A total of 83 cases where available for 1/2017 and of 1623 for 1/2017 through 11/2018. There was a reduced LOS by 10% (4.74 days), reduced variable cost/case by 24% ($5,958), reduced total cost/case by 23$13,790), reduced the 30-d re-admission rate to 6%, and reduced the mortality rate to 7%. Case mix index was 6% higher at 1.2753 (vs. 1.2055 previously). Order set compliance improved to 91% (Table). Discussion: Standardization of stroke clinical pathways led to improved order set compliance, almost ¼ reduction in variable and total costs per case, shortened LOS, and reduced mortality and readmission rates

A Real World Experience of the FAST-ED Based Pre-Hospital Stroke Triage System to Detect Large Vessel Occlusions

Introduction: In March 2017, the Fire Officers Association of Miami-Dade employed the Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale to better identify large vessel occlusion (LVO) strokes. Individuals with a score≥4 bypass other centers for a comprehensive stroke center, whereas those with a score ≥6 also have the interventional team activated from the field. The FAST-ED scale was developed using a retrospective cohort of ischemic strokes and TIAs. There have been no prospective, real world examples on the performance of this tool when used in the field by emergency personnel. Methods: Stroke alert cases brought to our center byFOAMD during March 2017-August 2018 were analyzed. We used the FAST-ED score documented on the EMS run sheet and examined the incidence of LVOs and treatment rates for applicable cases. Cases without FAST-ED scores were excluded. Results: A total of 686 patients met criteria. Of these, 354 (52%) had ischemic stroke, and 135 (20%) had a LVO. Of all LVOs, 39% had score of ≥6, whereas 72% had a score of ≥4. Out of all stroke alerts with a FAST-ED score ≥4, 97 (31%) had a LVO and 72 (23%) were treated with mechanical reperfusion (MR). Of all stroke alerts with a score ≥6, 53 (38%) had a LVO and 43 (31%) were treated endovascularly. The endovascular team was activated from the field on 92 cases with a score ≥6 during off hours, but only 30 (33%) had MR. Discussion: In a real world experience of the FAST-ED score being completed in the field, the detection of LVOs was much lower than in the initial report. Almost 1/3 of cases with a score of ≥4 and more than 1/3 with ≥6 had a LVO, and most of those cases were treated endovascularly. Only 1/3 of field activations led to an endovascular procedure

A Real World Experience of the FAST-ED Based Pre-Hospital Stroke Triage System to Detect Large Vessel Occlusions

Introduction: In March 2017, the Fire Officers Association of Miami-Dade employed the Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale to better identify large vessel occlusion (LVO) strokes. Individuals with a score≥4 bypass other centers for a comprehensive stroke center, whereas those with a score ≥6 also have the interventional team activated from the field. The FAST-ED scale was developed using a retrospective cohort of ischemic strokes and TIAs. There have been no prospective, real world examples on the performance of this tool when used in the field by emergency personnel. Methods: Stroke alert cases brought to our center byFOAMD during March 2017-August 2018 were analyzed. We used the FAST-ED score documented on the EMS run sheet and examined the incidence of LVOs and treatment rates for applicable cases. Cases without FAST-ED scores were excluded. Results: A total of 686 patients met criteria. Of these, 354 (52%) had ischemic stroke, and 135 (20%) had a LVO. Of all LVOs, 39% had score of ≥6, whereas 72% had a score of ≥4. Out of all stroke alerts with a FAST-ED score ≥4, 97 (31%) had a LVO and 72 (23%) were treated with mechanical reperfusion (MR). Of all stroke alerts with a score ≥6, 53 (38%) had a LVO and 43 (31%) were treated endovascularly. The endovascular team was activated from the field on 92 cases with a score ≥6 during off hours, but only 30 (33%) had MR. Discussion: In a real world experience of the FAST-ED score being completed in the field, the detection of LVOs was much lower than in the initial report. Almost 1/3 of cases with a score of ≥4 and more than 1/3 with ≥6 had a LVO, and most of those cases were treated endovascularly. Only 1/3 of field activations led to an endovascular procedure