and training. We will present a care strategy and pathway to address these three areas. Conclusion: Patients with dementia who are admitted to acute care hospitals may have better outcomes with attention to three elements of care. These three elements should form the basis for improvement efforts for these patients.Background:Intermountain Healthcare is the largest healthcare system in the Intermountain West, delivering care in 185 clinics and 22 hospitals across Utah and the surrounding regions. Queries of our electronic medical record indicated that prevalence of dementia was below expectations based on population-based estimates. Thus, we suspected underreporting of cognitive impairment and wide variation in clinical care. The Neurosciences Cognitive Care Development Team created a system-wide approach to diagnosing and treating mild cognitive impairment and dementia. Our aim was to determine whether a primary-care focused protocol would improve both the detection of cognitive impairment as well as the quality of care provided. Methods: The cognitive care team invited stakeholder participation from neurology, psychology, mental health, geriatrics, primary care, nursing, home care, hospice, care management, radiology, administration, patients, caregivers, and local community and governmental organizations. Our team was supported with a data manager, outcomes analyst, and technical writer. Data for analysis was retrieved from the Intermountain Enterprise Data Warehouse. We developed a standardized protocol to evaluate cognitive impairment, including how primary care providers screen for dementia at the Medicare annual wellness visit (AWV). A positive Mini-Cog at the AWV or physician, patient, or family concern about cognitive impairment prompt a diagnostic workup that includes focused history from the patient and a knowledgeable informant, objective cognitive exam (Montreal Cognitive Assessment), functional assessment, medication reconciliation, and screening for delirium. Guidance regarding diagnosis, neuroimaging, indications for specialty referral, and non-pharmacologic treatment for mild cognitive impairment and dementia, as well as pharmacologic treatment by specific diagnosis was provided as part of the protocol. We created tools to record results of screenings, assessments, and interventions in the electronic medical record such that pre-and post-implementation comparisons could be made. We disseminated the new protocol via trainings at the leadership, regional, and clinic levels. Adherence to the cognitive care protocol, increase in detection rate of dementia, and primary care provider satisfaction will be analyzed. Conclusions: By standardizing our primary care approach to cognitive disorders, we leveraged limited resources to improve cognitive care delivery to one third of patients aged 65 and older in Utah.
Introduction: The hyperdense MCA sign has been used as a marker of an underlying large vessel occlusion (LVO)/thrombus in the non-contrast head CT of acute stroke patients. However, due its low sensitivity, it has not been used routinely for definitive diagnosis of LVO. Furthermore, clinicians also have the ability to obtain further imaging with CT angiography to better visualize the vessels in most patients. However, this further imaging can take on average up to an additional 30 minutes due to delays in acquisition, patient cooperation, processing and image transmission time. We wanted to look for a simple sign on the early imaging (non-contrast HCT) to determine if we could activate the neuro interventional suite faster. Hypothesis: When present, the hyperdense MCA sign can accurately predict presence of a LVO and identify patients eligible for endovascular therapy sooner than vessel imaging. Methods: We retrospectively looked at all initial non-contrast head CTs for all consecutive stroke patients presenting to our facility in 2017 (n=86), with a last known well time (LKW) < 6 hours and NIHSS > 4, for the presence of a hyperdense MCA sign. We then reviewed subsequent imaging (CTA) to determine if LVO was actually present. Results: The hyperdense MCA sign was present in 17 (out of 86) cases, all of which had an LVO on CTA. The positive predictive value (PPV) was 100% indicating that there was a high probability that subjects with a positive hyperdense MCA sign will have a LVO. There were 12 cases with an LVO on CTA did not have a hyperdense MCA sign showing a sensitivity of 58.6%, thus the absence of a hyperdense MCA sign does not exclude LVO. Conclusion: Quick delivery of appropriate treatments for acute stroke patients have been linked to better outcomes. Given our analysis of cases with NIHSS > 4 and LKW < 6 hours, it seems that presence of a hyperdense MCA sign on the initial non-contrast HCT leads to a high level of certainty that an LVO is present. Perhaps this sign, in combination of LKW and NIHSS, can be used to activate the neuro interventional team while additional imaging is being obtained.
Introduction: Emergency Department (ED) Physicians typically consult with a specialist after pertinent results are gathered. In the case of acute stroke, delays in neurologist consultation equate to valuable time lost for treatment. When Telestroke went live in June 2015 at our 148-bed regional medical center, the physician norm was challenged because Telestroke protocol stipulates activation of the system before the CT scan. Despite education about the importance of calling early, ED physicians continued to activate Telestroke after gathering results. Hypothesis: Implementation of timely, structured feedback to ED physicians will change ED physician culture to reduce Door-to-Telestroke Activation (DTA) times. Methods: In February 2017, monthly feedback was initiated with ED physicians. Graphs showing current performance related to activation times were discussed, goals were reviewed, small improvements were acknowledged, and physicians were encouraged to share their successes. Using a prospective observational study design and a REDCap database, data from June 2015 to February 2017 were compared to data from March 2017 to July 2018. Results: From June 10, 2015 to July 18, 2018 Telestroke was activated 246 times in the ED. After the feedback initiation, the median DTA of 20 m (n=145) was significantly lower than the baseline median of 32 m (n=101, p<0.0001) and the percentage of activations prior to the CT scan rose significantly from 20% to 46% (p=0.0003). Also, Door-to-Needle (DTN) time decreased to a median of 48 m (n=27), compared to the baseline of 56 m (n=19, p=0.15) and the percentage of ischemic stroke patients treated with IV Alteplase increased to 17.7% from 13.4%. Median Door-to-CT (DTCT) remained unchanged at 17 m both pre and post intervention, demonstrating consistent ED processes. Conclusions: Timely ED physician feedback led to faster Door-to-Telestroke Activation times. While statistically insignificant, post intervention DTN times rose from a baseline of 63% (n=19) to 81% (n=27, p=0.29) which met the primary Target: Stroke Phase II goal to treat 75% of patients within 60 minutes. Faster activation resulted in faster treatment and ultimately improved chances of a better outcome.
Introduction: Beginning January 2014, a 245-bed Intermountain Healthcare primary stroke center was using a private Telestroke (SOC) service. On April 1, 2015, Intermountain implemented its own centralized, internal Telestroke service to provide coverage at this primary stroke center and five other hospitals. The Intermountain Telestroke service uses an internal telemedicine platform with employed physicians providing coverage. To clarify, the Intermountain system has a physician answer calls directly; the SOC model uses an intermediary before connecting to the physician. Hypothesis: Implementation of a centralized, internal Telestroke service will result in improved physician response and improved time to treatment compared to the private service. Methods: The Intermountain Healthcare enterprise data warehouse and SOC summary reports provided the data for this analysis. Wilcoxon-Mann-Whitney test was used to compare physician response time, DTN time, and door to CT time in patients treated during the 15-month SOC era to patients treated by the in house telestroke service. Results: From Jan 2014-Mar 2015, 27 patients received IV TPA at the facility, but only 2/27 had door to needle (DTN) time of <60m. The median DTN time in 2014 was 84 min and the median door to CT time was 18 min, strongly suggesting that the neurologist response time of this service was too long to meet AHA standards. Since implementing the Intermountain service, there has been a statistically significant improvement in DTN time. During the SOC time period, the median DTN time was 92.5 min (N = 35). After implementation, the Intermountain service provided a significantly lower median DTN time of 62.5 min (N=4; p = 0.03). The SOC median technician call-back time was 9.2 min (N=85), with an average physician video response time of 32 min (N=79). Intermountain median physician response time is 4 min (N=91). The door to CT time was not significantly different (Jan 2014-March 2015 was 18 min. vs Mar-May 2015, 14 min, N=31). Conclusions: The Intermountain Telestroke service outperformed SOC in response time and times to treatment. For healthcare systems that have the resources and expertise, an internal Telestroke service may result in faster times to treatment and better patient outcomes.
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