Stroke Code Activation Research Articles

Extended delays in recognition of stroke symptoms and stroke code activation for in-hospital strokes: The DELAY study.

Extended delays in recognition of stroke symptoms and stroke code activation for in-hospital strokes: The DELAY study.

Optimizing Acute Ischemic Stroke Care: Evaluating Emergency Stroke Code Activation and Thrombolytic Therapy in East Azerbaijan Province

Background: Stroke remains a significant global health challenge, contributing to mortality and disability burdens. Optimizing stroke care involves understanding the complexities of in-hospital management, especially in regions like East Azerbaijan Province, where stroke incidence is high. Objectives: This study evaluates the effectiveness of Emergency Stroke Code (ESC) activation and thrombolytic therapy in acute ischemic stroke care at Imam Reza Hospital, Tabriz, a referral center. Methods: A cross-sectional study was carried out between April 2021 and March 2022, including patients with activated ESC or receiving thrombolysis at Imam Reza Hospital, Tabriz. Data on patient demographics, risk factors, time intervals, thrombolysis administration, adverse events, and outcomes were collected and analyzed using SPSS software. Results: Among 748 acute stroke patients, 165 received thrombolysis, with 117 having ESC activation. The main reasons for not administering tissue plasminogen activator (tPA) in patients with ESC code activation included mild symptoms (23.6%), exceeding thrombolysis time (14.8%), and hemorrhagic stroke (10.4%). Pre-hospital ESC activation significantly reduced time intervals from hospital arrival to CT-scan and tPA injection (P < 0.001). The incidence of intracranial hemorrhage was 6.7% overall, with rare systemic bleeding (0.6%). Pre-hospital notification did not show significant changes in the National Institutes of Health Stroke Scale (NIHSS) or Modified Rankin Scale (MRS) scores. Conclusions: While ESC activation streamlines in-hospital processes, it alone may not improve clinical outcomes without efficient out-of-hospital systems. Pre-hospital communication systems like ESC can aid in reducing in-hospital processing time for thrombolysis but must be coupled with efforts to enhance early diagnosis and efficient dispatch systems to optimize stroke care.

Prehospital stroke detection scales: A head-to-head comparison of 7 scales in patients with suspected stroke.

Several prehospital scales have been designed to aid paramedics in identifying stroke patients in the ambulance setting. However, external validation and comparison of these scales are largely lacking. To compare all published prehospital stroke detection scales in a large cohort of unselected stroke code patients. We conducted a systematic literature search to identify all stroke detection scales. Scales were reconstructed with prehospital acquired data from two observational cohort studies: the Leiden Prehospital Stroke Study (LPSS) and PREhospital triage of patients with suspected STrOke (PRESTO) study. These included stroke code patients from four ambulance regions in the Netherlands, including 15 hospitals and serving four million people. For each scale, we calculated the accuracy, sensitivity and specificity for a diagnosis of stroke (ischemic, hemorrhagic or TIA). Moreover, we assessed the proportion of stroke patients who received reperfusion treatment with intravenous thrombolysis or endovascular thrombectomy that would have been missed by each scale. We identified 14 scales, of which seven (CPSS, FAST, LAPSS, MASS, MedPACS, OPSS, and sNIHSS-EMS) could be reconstructed. Of 3317 included stroke code patients, 2240 (67.5%) had a stroke (1528 ischemic, 242 hemorrhagic, 470 TIA) and 1077 (32.5%) a stroke mimic. Of ischemic stroke patients, 715 (46.8%) received reperfusion treatment. Accuracies ranged from 0.60 (LAPSS) to 0.66 (MedPACS, OPSS and sNIHSS-EMS), sensitivities from 66% (LAPSS) to 84% (MedPACS and sNIHSS-EMS), and specificities from 28% (sNIHSS-EMS) to 49% (LAPSS). MedPACS, OPSS and sNIHSS-EMS missed the fewest reperfusion-treated patients (10.3-11.2%), whereas LAPSS missed the most (25.5%). Prehospital stroke detection scales generally exhibited high sensitivity but low specificity. While LAPSS performed poorest, MedPACS, sNIHSS-EMS and OPSS demonstrated the highest accuracy and missed the fewest reperfusion-treated stroke patients. Use of the most accurate scale could reduce unnecessary stroke code activations for patients with a stroke mimic by almost a third, but at the cost of missing 16% of strokes and 10% of patients who received reperfusion treatment.

Workflow and Short-Term Functional Outcomes in Simultaneous Acute Code Stroke Activation and Stroke Reperfusion Therapy.

The burden of simultaneous acute code stroke activation (ACSA) is not known. We aim to assess the effect of simultaneous ACSA on workflow metrics and home time at 90 days in patients undergoing reperfusion therapies in the emergency department. Simultaneous ACSA was defined as code activation within 60 min of the arrival of any patient receiving intravenous thrombolysis, within 150 min of the arrival of any patient receiving endovascular thrombectomy, within 45 min of the arrival of any patient receiving no reperfusion therapies (based on mean local door-to-needle and door-to-puncture times). Simultaneous ACSA was further graded as 1, 2 and 3. We assessed workflow metrics as door-to-CT (DTC) time, in minutes, and functional outcome as home time at 90 days. A total of 2605 patients were assessed as ACSA at a mean ± SD activations of 130.8 ± 17.1/month and 859 (33%) were simultaneous. Among all ACSA, 545 (20.9%) underwent acute reperfusion therapy with a mean age of 70.6 ± 14.2 years, 45.9% (n = 254) were female with a median (IQR) NIHSS of 13 (8-18). A total of 220 (40.4%) patients underwent simultaneous treatments. The median DTC time, in minutes, was prolonged in grade 3 simultaneous ACSA (18 (13, 28)) compared to non-simultaneous ACSA (15 (11, 21) β = 0.23, p < 0.0001). There was no difference in the median home time at 90 days between the simultaneous (58, 0-84.5 days) and non-simultaneous (54, 0-85 days) patients. Simultaneous ACSA is frequent in patients receiving acute reperfusion therapies. An optimal workflow in high-volume centers may help mitigate the clinical and system burden associated with simultaneity.

Stroke Imaging Performance Assessment at a Community-based Hospital

Introduction: An efficient stroke program plays a crucial role in timely diagnosis and management of acute stroke cases. Our hospital has endorsed performance targets for critical steps in the stroke activation and management pathway. This is a quality improvement initiative aimed to identify bottleneck events within the current code stroke pathway that led to delays in image acquisition/interpretation and challenge the achievement of set benchmark times. Methods: We constructed a process map outlining key steps in the code stroke pathway relevant to image acquisition and interpretation, aligning with the stroke target benchmark times. A total of 241 stroke cases documented between 1/1/2022 and 6/1/2022 were reviewed. Activity timestamp was utilized to calculate various time intervals and assess compliance with the specified benchmark times set by our institution’s stroke program. Results: Arrival to stroke activation was the most frequently missed benchmark (miss rate of 45.8%) with wide ranging arrival to code stroke activation time (mean of 18.9±22.2 minutes). The next frequently missed benchmarks were arrival to noncontrast head computed tomography (NCT) read time (miss rate of 25.4%), and arrival to first CT angiogram (CTA) slice acquisition time (miss rate of 21.1%), both set at under 45 minutes. The fourth frequently missed benchmark was observed in order to CTA read time, where 19.0% of cases missed the goal time of under 60 minutes; this benchmark encompasses the time interval between the first NCT slice to the subsequent first CTA slice, a variable time interval under the radiology department’s control that averaged 9.1±18.6 minutes. Conclusions: Although arrival to NCT read time and arrival to first CTA slice acquisition times were among the greatest missed time benchmarks, these were likely secondary to inconsistencies in arrival to code stroke activation time. One of the time intervals in the fourth frequently missed benchmark of order to CTA read time was under departmental control. Addressing and enhancing the consistency of this specific time interval could potentially contribute to an overall improvement in the time interval from ordering the CTA to the CTA being read.

P.025 Accuracy of code stroke activations: a tale of two comprehensive stroke centres

Background: We evaluated the accuracy of code strokes activations at two comprehensive stroke centres in Toronto, Canada. Methods: We conducted a multi-centre, retrospective cohort study of all adult patients seen as code stroke in emergency rooms (ER) of two comprehensive stroke centres (CSC) in Toronto, Canada between January 1, 2022 and Dec 31, 2022. We included cases where the code stroke was activated in the field by paramedics and where it was activated in the ER by a physician. We reported off-criteria code stroke activations as the proportion of code stroke activations that did not meet all criteria for activation, and described the criteria that were not met. Results: A total of 677 (61.9% paramedic) code strokes were seen at CSC1 and 439 (80.6% paramedic) at CSC2. At CSC1, 21.2% paramedic-activated and 38.6% ER-activated were off-criteria, and at CSC2, 14.2% paramedic-activated and 48.1% ER-activated code stroke were off-criteria. Most of these were due to incorrect assessment of the last seen normal time. Conclusions: One in five code strokes did not meet criteria for activation. Improving the accuracy of paramedic and ER assessment of last seen normal time may be an avenue to reduce off-criteria code stroke activations.

Prospective Validation of Glial Fibrillary Acidic Protein, d ‐Dimer, and Clinical Scales for Acute Large‐Vessel Occlusion Ischemic Stroke Detection

Background Large‐vessel occlusion (LVO) ischemic stroke is responsible for significant morbidity and mortality. We have previously described a novel tool for acute LVO detection that combines blood‐based biomarkers (glial fibrillary acidic protein and d ‐dimer) with stroke severity scales to achieve high accuracy. Accordingly, the present study sought to prospectively validate cutoff values that we had previously established for biomarkers and scales. Methods The TIME (Testing for Identification Markers of Stroke) trial was designed as a prospective observational diagnostic accuracy study. All ambulance‐identified stroke code activations &lt;18 hours from symptom onset were recruited at Brandon Regional Hospital (Brandon, FL) between May 2021 and August 2022. Previously determined cutoff concentrations of plasma glial fibrillary acidic protein (213 pg/mL) and d ‐dimer (600 ng/mL) were used in combination with prehospital stroke scales to detect LVO. We compared rates of LVO detection against a reference standard using computed tomography/magnetic resonance angiography. Results A total of 382 patients with suspected stroke were recruited. The final cohort was composed of 323 patients with suspected stroke with the following distribution: LVO ischemic stroke (n = 29, 9%), non‐LVO ischemic stroke (n = 48, 15%), hemorrhagic stroke (n = 13, 4%), transient ischemic attack (n = 12, 3.9%), and stroke mimics (n = 220, 68.1%). Combining blood‐based biomarkers (glial fibrillary acidic protein and d ‐dimer) with the scale field assessment stroke triage for emergency destination yielded the best performance for LVO detection, with specificity of 94% and sensitivity of 71%. Performance was found to be higher in a subanalysis focusing on patients presenting &lt;6 hours from symptom onset, with 93% specificity and 81% sensitivity. Critically, application of the biomarker and stroke scale algorithms ruled out all patients with hemorrhage. Conclusion The present work prospectively validated the potential utility of previously defined glial fibrillary acidic protein and d ‐dimer cutoff levels (ie, 213 pg/mL and 600 ng/mL, respectively), demonstrating their value for discrimination of LVO stroke from differential diagnoses during code stroke workups. (ClinicalTrials.gov number, NCT04292600.)

Impact of Local Tailoring on Acute Stroke Care in 21 Disparate Emergency Departments: A Prospective Stepped Wedge Type III Hybrid Effectiveness-Implementation Study.

Faster delivery of tPA (tissue-type plasminogen activator) results in better health outcomes for eligible patients with stroke. Standardization of stroke protocols in emergency departments (EDs) has been difficult, especially in nonstroke centers. We measured the effectiveness of a centrally led implementation strategy with local site tailoring to sustain adherence to an acute stroke protocol to improve door-to-needle (DTN) times across disparate EDs in a multihospital health system. Prospective, type III hybrid effectiveness-implementation cohort study measuring performance at 21 EDs in Utah and Idaho (stroke centers [4]/nonstroke centers [17]) from January 2018 to February 2020 using a nonrandomized stepped-wedge design, monthly repeated site measures and multilevel hierarchical modeling. Each site received the implementation strategies in 1 of 6 steps providing control and intervention data. Co-primary outcomes were percentage of DTN times ≤60 minutes and median DTN time. Secondary outcomes included percentage of door-to-activation of neurological consult times ≤10 minutes and clinical effectiveness outcomes. Results were stratified between stroke and nonstroke centers. A total of 855 474 ED patient encounters occurred with 5325 code stroke activations (median age, 69 [IQR, 56-79] years; 51.8% female patients]. Percentage of door-to-activation times ≤10 minutes increased from 47.5% to 59.9% (adjusted odds ratio, 1.93 [95% CI, 1.40-2.67]). A total of 615 patients received tPA of ≤3 hours from symptom onset (median age, 71 [IQR, 58-80] years; 49.6% female patients). The percentage of DTN times ≤60 minutes increased from 72.5% to 86.1% (adjusted odds ratio, 3.38, [95% CI, 1.47-7.78]; stroke centers (77.4%-90.0%); nonstroke centers [59.3%-72.1%]). Median DTN time declined from 46 to 38 minutes (adjusted median difference, -9.68 [95% CI, -17.17 to -2.20]; stroke centers [41-35 minutes]; nonstroke centers [55-52 minutes]). No differences were observed in clinical effectiveness outcomes. A centrally led implementation strategy with local site tailoring led to faster delivery of tPA across disparate EDs in a multihospital system with no change in clinical effectiveness outcomes including rates of complication. Disparities in performance persisted between stroke and nonstroke centers.

Ischemic Stroke in the Cardiac Surgery Intensive Care Unit: A Quality Improvement Study

ObjectiveTo investigate the frequency of stroke and code stroke activation, and the factors influencing code stroke management in postoperative cardiac surgical patients. DesignA retrospective quality improvement study conducted between January 1st, 2016, and December 31st, 2021. SettingCardiac Surgery Recovery Unit (CSRU) at London Health Sciences Centre (LHSC) in London, Ontario, Canada. ParticipantsPost-cardiac surgery patients aged 18 years or older who developed ischemic stroke during their admission to the CSRU. InterventionsNo specific interventions were administered as part of this study. “Code Stroke" activation mobilizes a specialized team. The objectives include assessment by a physician within 10 minutes, obtaining neuroimaging and interpretation within 45 minutes, and commencement of treatment within 60 minutes. Measurements and Main ResultsThe incidence rate of stroke in the CSRU was 1.3%, and 34% of these cases had code stroke activated. The last known well time was 11 +/- 8 hours. The most common reasons for not activating code stroke were not meeting both timing and clinical criteria. The average time to Computed Tomography (CT) scan was 36 +/- 22 minutes. Among patients who had code stroke activated, 24% had large vessel occlusion (LVO), and 67% of those with LVO had an established stroke on their initial CT. ConclusionCode stroke was activated in only one-third of patients who experienced a stroke following cardiac surgery. Additionally, out of those who had code stroke activated, only one-fourth were diagnosed with LVO. Among those with LVO, two-thirds were found to have a well-established stroke on non-contrast CT scans and were deemed ineligible for intervention.

Analysis of real-time data gathered using a mobile application from patients treated after code stroke activation in Alicante

IntroductionManagement of code stroke (CS) is complex, and the collection of information for subsequent evaluation is crucial. We present data obtained using a mobile application on the management of CS between 2020 and 2021 at the Hospital General Universitario Dr. Balmis (HGUB), a tertiary-level hospital that is the reference centre for endovascular treatment (EVT) in the province of Alicante. Material and methodsWe conducted a prospective, observational study of all patients attended after CS activation at the HGUB in 1 year. Data were collected using a specifically designed mobile application (CODICT). We present a descriptive analysis of patients' baseline characteristics, call flow, acute phase care, treatment rates, and mortality and functional outcomes at discharge and at 3 months in patients receiving EVT. ResultsA total of 1018 CS activations were recorded. Revascularisation treatment (intravenous fibrinolytic treatment [IVT], EVT, or EVT+IVT) was performed in 252 patients (24.75%), of whom 177 (17.38%) received EVT, amounting to a mean rate of 9.43 per 100 000 population. By healthcare district, the lowest rate was 3.16 and the highest was 16.40. A total of 49.32% of patients receiving EVT presented favourable functional status (mRS≤2) at 90 days. ConclusionThe data collected during IC care can be traced in real time through mobile applications. The potential of this approach is demonstrated by the volume of data collected during 1 year. These data show considerable disparities in access to EVT in the province of Alicante, which could be suggested as an area for improvement.

Are we missing an opportunity? Prehospital delay in patients with acute ischemic stroke and known atrial fibrillation

Introduction and ObjectivesThe follow-up of patients with atrial fibrillation (AF) presents an opportunity to alert patients and their families on how to recognize and act in the event of stroke. Our aim was to compare stroke recognition-to-door time and prehospital stroke code activation in patients with known AF (KAF) and AF detected after stroke (AFDAS). MethodsWe performed a retrospective cohort study of consecutive patients receiving acute recanalization treatment for acute ischemic stroke between January 2016 and August 2022, with AF as a potential stroke cause. Patients were divided into KAF and AFDAS, and stroke recognition-to-door time and prehospital stroke code activation were compared. In the KAF subgroup, we assessed whether the use of preadmission anticoagulation was associated with the studied prehospital parameters. ResultsWe included 438 patients, 290 female (66.2%), mean age 79.3±9.4 years. In total, 238 patients had KAF (54.3%) and 200 (45.7%) had AFDAS. Of those with KAF, 114 (48.1%) were pretreated with anticoagulation. Patients with KAF and AFDAS had no differences in stroke recognition-to-door time (74.0 [55.0–101.0] vs. 78.0 [60.0–112.0] min; p=0.097) or prehospital stroke code activation [148 (64.6%) vs. 128 (65.3%); p=0.965]. In the KAF subgroup, preadmission anticoagulation did not influence stroke recognition-to-door time or mode of hospital admission. ConclusionStroke recognition-to-door time and prehospital stroke code activation were similar between patients with known or newly diagnosed AF. Preadmission anticoagulation treatment also did not affect the studied parameters. Our findings highlight a missed opportunity to promote stroke knowledge in patients followed due to AF.

Abstract TP119: Predicting Posterior Circulation Stroke During Emergency Triage: Dizzy-7 Project

Introduction: “Stroke code” activation is a uniform process to summon healthcare stakeholders to orchestrate the rapid sequential steps for urgent management in patients with possible stroke. Acute dizziness, a common emergency department (ED) presentation, frequently leads to stroke code activation; however, cancellation rates remain high and process improvement strategies are warranted. Methods: We analyzed stroke identification accuracy, cancellation rates, and clinical characteristics in patients presenting with an acute vestibular syndrome to inform process improvement strategies for stroke code activation. We developed an ED triage diagnostic algorithm termed, “Dizzy-7”, based on evidence incorporating key history and physical examination elements derived in patients with acute posterior circulation ischemia. Subsequent analyses were performed on algorithmic utilization and its ability to predict stroke. Results: 1599 patients presented with acute dizziness over a 4-month period (2022-2023). Stroke code activation occurred in nearly one in four (366/1599) these presentations. 20% (319/1599) were ultimately diagnosed with stroke and of these, 49% (319/366) were identified following stroke code activation. The Dizzy-7 algorithm was used infrequently (4%) among all acute dizziness presentations. Of the 65 cases that incorporated the algorithm, 16 resultant stroke code activations occurred with 1 confirmed diagnosis (6%). We analyzed stroke alert cancellation and found an increased frequency in cancellation for those without use of the protocol at 22% (77/350) compared to those who did use it at 6% (1/16). Discussion: Accurate and reliable identification of acute ischemic stroke among patients presenting with acute dizziness remains complex. Implementation of a triage diagnostic algorithm based on contemporary evidence was infrequently implemented. Process improvement efforts targeted at greater algorithmic use, interprofessional collaboration, and education may improve stroke code utilization efficiency. Although based on limited sample size, a trend towards reduced stroke code cancellation rates were seen throughout the pilot Dizzy-7 algorithm use.

Abstract HUP5: Patient and Hospital Characteristics Associated With Disparities in Acute Stroke Treatment in Community and Academic Hospitals

Introduction: Expedited transportation, identification, and coordination of care are essential drivers of optimal outcomes in the management of acute ischemic stroke (AIS), but systemic biases and barriers may affect these processes. We assessed patient- and hospital-level factors that may be associated with differences in prehospital and emergency department care processes for patients with AIS at academic medical centers (AMC) and those at community hospitals (CH). Methods: We retrospectively collected data from the electronic health record at an academic medical center (Tufts Medical Center) for adults age ≥ 18 hospitalized with AIS between 1/1/2018-12/31/2020, including patients who presented directly to the AMC versus patients transferred from a CH for further care. We performed multivariate analyses to assess predictors of emergency medical service (EMS) use, stroke code activation, door-to-CT time, and door-to-needle time across all patients and in each group. Results: 542 patients were included. AMC patients identifying as Asian (OR 0.25, 95% CI 0.13-0.47) and Hispanic (OR 0.19, 95% CI 0.05-0.72) and CH patients identifying as Black (OR 0.17, 95% CI 0.17-0.62) were less likely to use EMS compared to white patients. Patients with non-English primary language were less likely to use EMS (OR 0.38, 95% CI 0.23-0.63) compared to English-speaking patients in all hospitals. CH patients identifying as Hispanic were less likely to have stroke code activation (OR 0.24, 95% CI 0.05-0.86) compared to white patients. There were no differences in median door-to-CT or door-to-needle times between CH and AMC patients. In analyses including all patients, Asian race was associated with longer door-to-CT time (OR 1.25, 95% CI 1.03-1.49), and female sex was associated with longer door-to-needle time (OR 1.23, 95% CI 1.03-1.43). Conclusion: There are multiple potential sources of disparity in prehospital and hospital-based hyperacute care for patients with AIS including sex, race, ethnicity, and non-English primary language. These may represent opportunities for community outreach on EMS use, interventions to address systemic racism among healthcare providers, and interventions to alleviate language barriers.

Abstract WP45: A Collaborative Approach to Improving Inpatient Stroke Code Time Target Metrics

Much effort and education has been placed on pre-hospital and emergency departments to recognize signs and symptoms of acute stroke and time metrics such as door-to-CT, door-to-needle, and door-to-device. For admitted patients with acute onset of stroke symptoms, our data analysis identified a gap in the timeliness of stroke code activation upon symptoms discovery and subsequent delays in CT initiation and treatment. We evaluated our current process and implemented action plans to enhance the current inpatient stroke code process through focused education and training of staff to improve their recognition of acute stroke, timely activation of stroke code and improved CT initiation and treatment times. In 2021, several cardiology pilot units were selected and neuroscience nurse specialists conducted staff education which focused on recognition of stroke signs and symptoms, code activation criteria and response time targets. A resource binder and checklist were created to guide staff in putting together pertinent elements for communication and documentation. Data was collected on stroke code response times and individual feedback was provided. The group meets quarterly to evaluate progress, discuss opportunities for improvement and highlight best practices and outcomes. The checklist was a useful tool in reminding staff of pertinent information to communicate to the stroke team although form completion is not consistent. In 2021-2022, 54% of stroke codes were called within 10 minutes of symptoms discovery. CTH initiation time within 25 minutes of symptoms discovery was achieved in 16.2% of patients. Data analysis showed an opportunity to improve documentation of symptoms discovery time which were missing in 13.8% of cases. This collaborative approach with the pilot units has increased awareness and focus to the inpatient stroke code process. Opportunities exist to improve time target achievements in CTH initiation, treatment, and documentation of symptoms discovery time. Communication between the stroke team and the patient’s primary team has been identified as an essential factor for continued improvement along with on-going staff education.

Abstract TP58: Stroke Recognition Task Force: Increasing Early Activation of Inpatient Stroke Codes

Background: 1 in 5 strokes occur in the hospital. Patients with in-hospital stroke have increased vascular risk factors, delayed time to recognition, and increased mortality compared to patients with community-onset stroke. All staff should be able to recognize and initiate management of patients with a suspected acute stroke. Purpose The goals of this project were to increase early activation of inpatient stroke codes and confidence levels related to the recognition of stroke and management of patients during a code. Methods: An education program, providing unit specific information, was provided to each inpatient unit at an academic medical center. A survey was created for learners to take before and after the education session; including questions regarding symptom recognition, how to activate a stroke code, and tasks required following activation. Additional questions included self-assessment of the learner’s confidence level in different aspects of stroke care, including stroke recognition and management. To assess time to activation, data related to inpatient stroke code activations was analyzed pre- and post-intervention. Data included symptom discovery and stroke team activation time gathered from the electronic medical record. Results: Data from 119 codes was reviewed. Prior to intervention, only 50% of inpatient stroke codes were activated within 10 minutes of symptom discovery. Following intervention, 75% of inpatient stroke codes were activated within 10 minutes of symptom discovery. There were 61 pre-session survey responses and 39 post-session. Before the session, 56.1% of participants were slightly or moderately confident in identifying stroke, but after the session, 80.5% of participants were very or extremely confident in identifying stroke. Before the session, 81.8% of participants did not feel comfortable managing a patient during a code, but after the session, 95% of participants felt comfortable. Conclusion: An education session for hospital staff can increase knowledge and confidence level in the recognition of stroke and their management of patients. This curriculum has potential to be used nationally to reduce delays to diagnosis, increase usage of acute therapies and reduce mortality associated with in-hospital stroke.

Abstract WP38: Nurse-Driven Emergency Evaluation Improves Timely Acute Stroke Response

Background: Stroke is associated with high rates of death and disability; prompt and effective interventions are imperative. Depending on emergency department (ED) physicians to initiate stroke codes may delay critical time targets, especially for patients arriving by private vehicle (POV). This study examines existing stroke care protocols in the ED of a Comprehensive Stroke Center and evaluates a new nurse-driven acute stroke response protocol. Purpose: The primary goal of this initiative was to improve outcomes for patients arriving by POV, by reducing triage delays and accelerating time-sensitive acute stroke interventions. Methods: This retrospective study implemented a nurse-led stroke activation process, in lieu of the conventional physician-led method. Nurses received comprehensive training in intervention goals and identification of stroke symptoms and last known-well times. The nurse-led model targeted patients presenting to the ED with a minimum of 2 stroke symptoms within 6 hours of symptom onset—an assessment tool, incorporating the FAST algorithm (Face, Arm, Speech, Time) and key National Institutes of Health Stroke Scale (NIHSS) exam components, enhanced symptom specificity. Critical intervention times were evaluated for improvement. Results: ED POV arrival patients with acute stroke symptoms were studied from 11/7/21-7/31/23; the nurse-driven process was implemented on 11/7/22. Pre-intervention review included 247 patients with 216 patients in the post-intervention review. Median door-to-activation times fell from 17 to 10 minutes, door-to-CT from 24 to 19 minutes, and door-to-needle times from 49 to 43.5 minutes. Median NIHSS scores in tPA-treated patients were compared pre- and post-intervention. In the physician-led group, initial median NIHSS scores were 6, reducing to 1 at discharge. The nurse-led group showed an initial median NIHSS score of 5, also reducing to 1 at discharge. Conclusions: The nurse-driven method effectively shortened critical time metrics in the stroke code process, while maintaining optimal patient outcomes. A paradigm shift towards ED triage nurse-led stroke code activation for acute stroke may lead to higher quality acute stroke care.

Abstract TP64: Nursing Led Intervention Improves Thrombolytic Administration Time by Optimizing Emergency Department Code Stroke Pathways

Background: Timely efficient thrombolytic administration has been associated with better clinical outcome in acute ischemic stroke patients. Shortening the time from arrival to code stroke activation can lead to faster thrombolytic administration. Methods: Door to code stroke activation and door to needle times were calculated in consecutive code strokes in the emergency department (ED) from 1/2021-11/2021 Pre and 12/2021-12/2022 Post implementation of “Triage to CT” pathway. Our previous code stroke processes included initial evaluation by the triage nurse, followed by rooming and transferring the patient from triage to the ED room, and then to the CT suite. To improve our process, a staging area was set up where a gurney was placed adjacent to the triage area. This allows rapid assessment and activation of the code stroke protocol. ED staff were educated on sending the patient directly to CT after activation of code stroke by the triage physician. This process eliminates the need to room the patient prior to CT scan. Result: Median Door to Code stroke activation time was significantly lowered after the implementation of “Triage to CT” pathway (17 min to 11 min, respectively, p&lt;0.0001) Conclusion: In our study, “Triage to CT” pathway significantly shortened door to code stroke activation. Optimization of an emergency code stroke process by taking the patient straight to CT suite from the triage area decreases door to code stroke activation time and ultimately door to needle time.

Regionalization of stroke systems of care in the stroke belt states: The IMPROVE stroke care quality improvement program

Despite guidelines and strong evidence supporting intravenous thrombolysis and endovascular thrombectomy for acute stroke, access to these interventions remains a challenge. The objective of the IMPROVE stroke care program was to accelerate acute stroke care delivery by implementing best practices and improving the regional systems of care within comprehensive stroke networks. The IMPROVE Stroke Care program was a prospective quality improvement program based on established models used in acute coronary care. Nine hub hospitals (comprehensive stroke centers), 52 regional/community referral hospitals (spokes), and over 100 emergency medical service agencies participated. Through 6 regional meetings, 49 best practices were chosen for improvement by the participating sites. Over 2 years, progress was tracked and discussed weekly and performance reviews were disseminated quarterly. Data were collected on 21,647 stroke code activations of which 8,502 (39.3%) activations had a final diagnosis of stroke. There were 7,226 (85.0%) ischemic strokes, and thrombolytic therapy was administered 2,814 times (38.9%). There was significant overall improvement in the proportion that received lytic therapy within 45 minutes (baseline of 44.6%-60.4%). The hubs were more frequently achieving this at baseline, but both site types improved. A total of 1,455 (17.1%) thrombectomies were included in the data of which 401 (27.6%) were transferred from a spoke. There was no clinically significant change in door-to-groin times for hub-presenting thrombectomy patients, however, significant improvement occurred for transferred cases, 46 minutes (interquartile range [IQR] 36, 115.5) at baseline to 27 minutes (IQR 10, 59). The IMPROVE program approach was successful at improving the delivery of thrombolytic intervention across the consortium at both spoke and hub sites through collaborative efforts to operationalize guideline-based care through iterative sharing of performance and best practices for implementation. Our approach allowed identification of both opportunities for improvement and operational best practices providing guidance on how best to create a regional stroke care network and operationalize the published acute stroke care guidelines.

A smartphone pupillometry tool for detection of acute large vessel occlusion

ObjectivesPupillary light reflex (PLR) parameters can be used as quantitative biomarkers of neurological function. Since digital infrared pupillometry is expensive, we sought to examine alterations in PLR parameters using a smartphone quantitative pupillometry platform in subjects with acute ischemic stroke (AIS). Materials and methodsPatients were enrolled if they presented to the emergency department as a stroke code activation and had evidence of a large vessel occlusion (LVO) on computed tomography angiography. Controls were enrolled from hospital staff. A smartphone pupillometer was used in AIS patients with LVO pre-mechanical thrombectomy, immediately post-thrombectomy, and at 24 h post-thrombectomy. Clinical and demographic data were collected, along with the proprietary Neurological Pupil index (NPi) score from the NPi-200 digital infrared pupillometer. PLR parameters were compared using mean differences. The absolute and non-absolute inter-eye difference in each parameter for each subject were also analyzed by measuring 1 - (R:L) to determine alteration in the equilibrium between subject pupils. The NPi was analyzed for mean differences between cohorts. ResultsHealthy controls (n = 132) and AIS patients (n = 31) were enrolled. Significant differences were observed in PLR parameters for healthy subjects when compared to pre-thrombectomy subjects in both mean and absolute inter-eye differences after post hoc Bonferroni correction. The proprietary NPi score was not significantly different for all groups and comparisons. ConclusionsSignificant alterations in the PLR were observed in AIS patients with LVO before thrombectomy, indicating the potential use of smartphone pupillometry for detection of LVO.

Prediction of large vessel occlusion for ischaemic stroke by the Van scale

ABSTRACT Background: Rapid and accurate detection of stroke by paramedics or emergency clinicians at the time of first contact is crucial for timely initiation of appropriate treatment. Several stroke recognition scales have been developed to support the initial triage Identification of emergent large vessel occlusion (ELVO) stroke has become increasingly important with the recent publications of favorable acute stroke thrombectomy trials. Multiple screening tools exist but the length of the examination and the false positive rate range from good to adequate. A screening tool was designed and tested in the emergency department using nurse responders without a scoring system. Methods: Suspected stroke patients admitted by ambulance paramedics directly to an acute stroke unit through a rapid ambulance protocol were examined by a neurologist or admitting stroke physician. The vision, aphasia, and neglect (VAN) screening tool was designed to quickly assess functional neurovascular anatomy, which was used as an LVO screen for all stroke patients. Results: There were 162 consecutive code stroke activations during the pilot study. 60 (37%) of the patients were VAN positive and 128 (79%) had a National Institutes of Health Stroke Scale (NIHSS) score of ≥ 6. NIHSS &gt; 6 was more sensitive (100% vs 93% for VAN) but VAN was more specific (90% vs 74% for NIHSS ≥ 6). Similarly, VAN had 83% positive predictive value while NIHSS ≥ 6 had only a 42% positive predictive value. No patient that was NIHSS &lt; 6 had an LVO (100% negative predictive value), there were 4 patients with VAN negative who had LVO (97% negative predictive value). However, VAN had 91% specificity versus 32% for NIHSS. Conclusions: VAN assessment performed well in identifying patients with LVO. Keywords: Stroke, VAN, NIHSS, Large vessel occlusion.