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: 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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