BackgroundThe extended time window for endovascular therapy in adult stroke represents an opportunity for stroke treatment in children for whom diagnosis may be delayed. However, selection criteria for pediatric thrombectomy has not been defined.MethodsWe performed a retrospective cohort study of patients aged <18 years presenting within 24 hours of acute large vessel occlusion. Patient consent was waived by our institutional IRB. Patient data derived from our institutional stroke database was compared between patients with good and poor outcome using Fisher’s exact test, t-test, or Mann-Whitney U-test.ResultsTwelve children were included: 8/12 (66.7%) were female, mean age 9.7±5.0 years, median National Institutes of Health Stroke Scale (NIHSS) 11.5 (IQR 10–14). Stroke etiology was cardioembolic in 75%, dissection in 16.7%, and cryptogenic in 8.3%. For 2/5 with perfusion imaging, Tmax >4 s appeared to better correlate with NIHSS. Nine patients (75%) were treated: seven underwent thrombectomy alone; one received IV alteplase and thrombectomy, and one received IV alteplase alone. Favorable outcome was achieved in 78% of treated patients versus 0% of untreated patients (P=0.018). All untreated patients had poor outcome, with death (n=2) or severe disability (n=1) at follow-up. Among treated patients, older children (12.8±2.9 vs 4.2±5.0 years, P=0.014) and children presenting as outpatient (100% vs 0%, P=0.028) appeared to have better outcomes.ConclusionsPerfusion imaging is feasible in pediatric stroke and may help identify salvageable tissue in extended time windows, though penumbral thresholds may differ from adult values. Further studies are needed to define criteria for thrombectomy in this unique population.
Background and Purpose: The transfer of patients with ischemic stroke from the intensive care unit (ICU) to noncritical care inpatient wards involves detailed information sharing between care teams. Our local transfer process was not standardized, leading to potential patient risk. We developed and evaluated an “ICU Transfer Checklist” to standardize communication between the neurocritical care team and the stroke ward team. Methods: Retrospective review of consecutive patients with ischemic stroke admitted to the neurocritical care unit who were transferred to the stroke ward was used to characterize transfer documentation. A multidisciplinary team developed and implemented an ICU Transfer Checklist that contained a synthesis of the patient’s clinical course, immediate “to-do” action items, and a system-based review of active medical problems. Postintervention checklist utilization was recorded for 8 months, and quality metrics for the postintervention cohort were compared to the preintervention cohort. Providers were surveyed pre- and postintervention to characterize perceived workflow and quality of care. Results: Patients before (n = 52) and after (n = 81) ICU Transfer Checklist implementation had similar demographic and clinical characteristics. In the postchecklist implementation period, the ICU Transfer Checklist was used in over 85% of patients and median hospital length of stay (LOS) decreased (8.6 days vs 5.4 days, P = .003), while ICU readmission rate remained low. The checklist was associated with improved perceptions of safety and decreased time needed to transfer patients. Conclusions: Use of the standardized ICU Transfer Checklist was associated with decreased hospital LOS and with improvements in providers’ perceptions of patient safety.
Introduction: Dysphagia is common after acute stroke. Variability in predicting who will require a gastrostomy tube (G-tube) prior to discharge can prolong length of hospital stay (LOS) and increase costs. Objectives: We propose a novel protocol to standardize speech therapy evaluation and G-tube recommendations among acute stroke patients with dysphagia to reduce LOS and costs. Methods: A cohort of acute stroke patients with dysphagia was identified through an administrative data set using ICD-10 codes for ischemic stroke and CPT codes for speech therapy evaluation, and if applicable, CPT code for G-tube placement. Patients with tracheostomy, comfort care orders, or discharge to hospice were excluded. A multidisciplinary team from speech therapy, neurology, and radiology applied quality improvement principles to design and implement a G-tube indicator score (Figure 1) to address variability in dysphagia evaluation. Median LOS and duration from initial speech therapy evaluation to final diet recommendation were compared between the pre- and post-intervention period. Cost savings were calculated using LOS and average daily institutional bed cost. Results: Between January 2016 to January 2017, 174/278 (62%) of acute stroke patients had dysphagia and 61/174 (35%) of these patients received G-tubes. Their median LOS was 21.7 days compared to 5 days for stroke patients without G-tube. In the post-implementation period from Feb-May 2017, 25/45 (55%) of acute stroke patients had dysphagia and 5/25 (20%) received G-tubes. Their median LOS was 16.4 days following the protocol implementation. This resulted in cost savings of $14,654 per G-tube patient. Conclusions: This novel G-tube indicator score standardized speech therapy evaluation and reduced LOS by more than 5 days among acute stroke patients requiring G-tube prior to discharge. Future studies will prospectively validate the score. Increased adoption would result in significant cost savings.
Background: With the advent of extended window EVT for acute stroke (AIS), interhospital transfer is increasingly frequent; with growing demand but static resources, stroke centers need to identify patients who are most likely to benefit from transfer, as not all transferred undergo intervention. In 2018 only 57% of AIS patients transferred to Stanford for EVT were taken to the cath lab, compared to 82% accepted after telestroke consultation. For non-telestroke transfers, review of imaging prior to acceptance isn’t required but is often available. We hypothesized that the ability to review imaging prior to acceptance would improve patient selection and correlate with an increased rate of EVT. Methods: We analyzed data from all AIS patients accepted for transfer with the intention of EVT in 2018. Pre-acceptance images were available via emails from facilities with RAPID software, scans sent through LifeImage, or via telestroke PACS. All patients had repeat imaging on arrival to SUH. Results: 75 of 131 patients underwent EVT (57.2%); 39.7% had pre-acceptance imaging. 65% of patients who had pre-acceptance imaging went for EVT vs 52% of those without (P=0.127). Average time from acceptance to arrival was 2h13m. 51.1% received IV tPA; tPA and time of transfer had no bearing on rate of EVT. Excluding patients who recanalized by arrival, 74% with pre-acceptance imaging went for EVT vs 59% without (P=0.113). Average infarct volume for those treated with EVT was 21.9mL vs 64.5mL in those with no EVT (p=0.04). Occlusion location included the internal carotid (31%); M1 (40%); M2 (11%); M3 (2%); and basilar (7%) arteries. Patients with ICA occlusions went for EVT most often (P<0.001). Of those who did not go for EVT, 18 of 56 (32%) were provided some form of higher level of care not available at the referring facility. Conclusions: Pre-acceptance imaging review was associated with a trend toward higher rates of EVT. Pre-acceptance imaging was not uniform, and utility of NCCT vs CTA vs CTP as well as assessment of collateral vessels will be presented. Telestroke evaluation may help address goals of care as well as clinical features that contribute to higher EVT rates in transfer patients.
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