Introduction: Nurses and staff in Emergency Departments (ED) with low monthly case volumes have few opportunities to build confidence and solidify skills in acute stroke management. The Nursing-driven Acute Stroke Care (NAS-Care) study tested a workflow model with empowerment of ED bedside nurses, clear role assignments for team members, and standardized protocols including a predefined run sheet. Methods: Seven Texas hospitals participated in this prospective, multisite, baseline-controlled study as part of the Lone Star Stroke Research Consortium. After three months of blinded baseline data collection, the following interventions were implemented: NIHSS certification, nursing education including mock stroke codes, and a standardized flowsheet for code organization and documentation (run sheet). Participating nurses were surveyed before and after implementation of this process. Results: The study was completed at 6 hospitals, with 180 patients in the pre-intervention group and 267 in the post-intervention group. The study intervention was found to improve Door-to-ED provider and Door-to-CT metrics but not physician-dependent metrics, Door-to-Needle or Door-to-Provider times (Provencher et al, ISC 2020). Completed surveys were returned by 97 nurses (pre-intervention) and 57 nurses (post-intervention). There were significant increases in the following questions (10 point scale, p<.001): “I understand goals and processes of stroke code activation”, “stroke codes at my institution are completed efficiently”, and “stroke codes are nursing-driven.” In the post-intervention surveys, nurses reported that the NAS-Care protocol improved understanding (mean score 8.0 +/- 2.4 SD/10) and efficiency (8.2 +/- 2.4/10), and reported that they would recommend NAS-Care to be adopted at other institutions (8.8 +/- 2.1/10). Conclusion: Standardized nurse-driven stroke protocols improved self-assessed knowledge and confidence for nurses in EDs utilizing telestroke, in addition to gains in staff-dependent stroke metrics.
Previous studies have shown that faster Door to Needle (DTN) treatment times are associated with better outcomes for acute ischemic stroke patients. With the continued push for faster times, we aimed to determine if DTN treatment times in the 30- vs 45-minute time window yielded statistically significant differences in outcomes or complications. Data obtained from a multi-state stroke registry included acute ischemic stroke patients ≥18 years of age discharged between January 2017 and April 2020, and treated with IV alteplase with DTN times between 25-30 or 40-45 minutes. Outcomes were 90-day Modified Rankin Score (mRS) (0-2 vs 3-6), discharge disposition [home or inpatient rehabilitation facility (IRF) vs other location], complications (any treatment-related complication vs none), and hospital length of stay (LOS). Patients with a documented reason for delay or who received thrombectomy were excluded. Outcomes of patients with 25- to 30-minute DTN times were compared to those with 40- to 45-minute DTN times using generalized linear models and multiple linear regression, adjusting for admission NIHSS, age, gender, race/ethnicity, and medical history. Compared to the 20-25 minute group, patients treated in the 40-45 minute window had higher odds of a documented 90-day mRS of 3 or more (Adjusted Odds Ratio (AOR)=1.19, p=0.253, n=201 ) and treatment-related complication (AOR=1.35, p=0.569) and lower odds of discharge to home or IRF (AOR=0.846, p=0.359). There was little difference in LOS (β=-0.008, p=0.847). None of the outcomes reached statistical significance. Administering alteplase in the 25- to 30-minute window is safe and did not result in an increase in bleeding complications. Although faster treatment times trended toward better outcomes, there was no statistically significant difference between the 25-30 and 40-45 minute DTN treatment times.
Background: Reducing treatment time for ischemic stroke is crucial. In 2017, an urban Comprehensive Stroke Center (CSC) in the Pacific Northwest (PNW) initiated early activation of the interventional radiology team (Early-IR) based on first responder LAMS’ score of 4 or 5 to improve thrombectomy treatment times (door-to-arterial access times [DTAA]) for acute ischemic stroke patients. Policy efficacy has not been evaluated. Objectives: 1) Compare DTAA times and clinical outcomes pre vs post Early-IR initiation using a multi-state stroke registry. 2) Compare DTAA times and clinical outcomes between the PNW and other CSCs in the same multi-state stroke registry. Methods: Included ischemic stroke patients arrived via emergency medical services from 01/01/2015 to 03/30/2020 at PNW CSC and from 05/15/2017 to 03/31/2020 at five other CSCs. Mann-Whitney U test and multiple linear regression were used to compare DTAA among patients arriving Pre-Early IR vs Post-Early IR at PNW and then to compare PNW vs other CSCs during the Post-Early IR phase. Discharge disposition and ambulation were compared using Pearson’s chi-squared tests. Models were adjusted for admission NIHSS, age, gender, race, IV tPA treatment, comorbidities and medications at admission. Results: A total of 156 PNW patients were included in the primary analysis, 32.1 % (n=50) in the Pre- and 67.9% (n=106) in the Post-Early IR groups. Bivariate analyses showed DTAA was faster Post-Early IR (131 minutes vs 92 minutes, p<.001) and remained faster after adjusting for covariates (B=-.500, p <.001). Early IR did not significantly impact discharge disposition ( p =.620) or ambulation ( p =.995) (Table 1). Comparing the PNW to five other CSCs during the Post-Early IR period showed no significant difference in DTAA or secondary outcomes (Table 1). Conclusion: Early IR decreased thrombectomy treatment initiation times for ischemic stroke patients at the PNW CSC.
Introduction: Since 2015, endovascular thrombectomy (EVT) has been widely accepted as the standard of care for patients presenting proximal anterior circulation large vessel occlusion (LVO). However, patient selection for EVT remains uncertain in patients presenting with LVO and low NIHSS. Methods: Retrospective data from 37 hospitals within a large multi-hospital system stroke registry were analyzed and included patients age 18 or over, discharged between January 2016 and May 2020, with an admission NIHSS < 6, and who had a LVO visualized in the internal carotid artery or middle cerebral artery. Patients treated with EVT (with or without IV alteplase), IV alteplase alone, or best medical management (BMM) without IV alteplase or EVT were compared with regard to modified Rankin scale (mRS) at hospital discharge and hospital length of stay (LOS). Pearson’s chi-square square test and Mann-Whitney U test were conducted. Results: Discharge mRS analysis included 742 patients, 211 (28.4%) treated with EVT (with or without IV alteplase), 107 (14.4%) treated with IV alteplase alone, and 424 (57.2%) treated with BMM. A greater proportion of patients treated with IV alteplase alone (71.0%) had no or slight disability (mRS 0-2) compared to EVT (with or without IV alteplase) (51.7%), or BMM (52.6%) (p=.001). Analyses of LOS included 1,037 patients, 298 (28.7%) treated with EVT (with or without IV alteplase), 157 (15.1%) treated with IV alteplase alone, and 582 (56.1%) treated with BMM. Patients treated with IV alteplase alone had significantly shorter LOS (2.0 days, [Interquartile Range:3.0]) compared to EVT (with or without IV alteplase) (3.0 days [4.0]), or BMM (3.0 days [4.0]) (p<.001). Conclusion: Amongst this cohort of patients presenting with anterior circulation LVO and low NIHSS, better discharge outcomes were seen in patients treated with IV alteplase alone, compared to EVT (with or without IV alteplase) or BMM. The best treatment for this patient population remains unclear, and further research is needed.
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