Stroke Center Designation Research Articles

A Multidisciplinary Approach to Increase Dysphagia Compliance in Stroke Patients.

BACKGROUND: The objective was to optimize conditions that increase dysphagia compliance after stroke-a measure recognized by The Joint Commission in designating institutions as primary or comprehensive stroke centers and by the American Heart Association that promotes stroke treatment adherence and bestows achievement and quality awards. Failure to meet stroke measures, including medication documentation, may produce poor patient outcomes that directly affect consumer confidence and choice of treatment facility. Stroke patient care requires multidisciplinary team collaboration to manage multiple factors; variations in practice create fallouts that need correction, the absence of which jeopardizes standards for maintaining stroke center designation. PURPOSE: Aims were to determine the nature of dysphagia fallouts in our quaternary academic teaching hospital, assess multidisciplinary workflows and barriers to success, and develop strategies to enhance dysphagia compliance. DESCRIPTION: We used a multidisciplinary approach using James Reason's Swiss cheese model to examine compliance. The clinical nurse specialist interviewed physicians, advanced practice providers, pharmacists, speech-language pathologists (SLPs), nurses, and informaticists to ascertain discipline-specific success barriers, targeting top issues for each discipline to develop solutions. Unit educators unified their dysphagia reduction strategies; physicians, pharmacists, and informaticists collaborated to clarify standardized medication route orders and to increase electronic health record swallow screen visibility to multidisciplinary users; and SLPs adjusted workflow and documentation. EVALUATION: Outcomes included reinforcing correct nursing charting, pharmacy oral-to-feeding tube conversion order revision, optimization of delivery and awareness of medication routes, electronic health record system enhancements, and SLPs aligning documentation with nursing medication administration. The multidisciplinary approach proved successful and increased dysphagia compliance by 9.6% ( P = .001). These outcomes contributed to a successful The Joint Commission survey, redesignation as a comprehensive stroke center, and American Heart Association Gold Plus achievement award.

Addressing Disparities in Acute Stroke Management and Prognosis.

There are now abundant data demonstrating disparities in acute stroke management and prognosis; however, interventions to reduce these disparities remain limited. This special report aims to provide a critical review of the current landscape of disparities in acute stroke care and highlight opportunities to use implementation science to reduce disparities throughout the early care continuum. In the prehospital setting, stroke symptom recognition campaigns that have been successful in reducing prehospital delays used a multilevel approach to education, including mass media, culturally tailored community education, and professional education. The mobile stroke unit is an organizational intervention that has the potential to provide more equitable access to timely thrombolysis and thrombectomy treatments. In the hospital setting, interventions to address implicit biases among health care providers in acute stroke care decision-making are urgently needed as part of a multifaceted approach to advance stroke equity. Implementing stroke systems of care interventions, such as evidence-based stroke care protocols at designated stroke centers, can have a broader public health impact and may help reduce geographic, racial, and ethnic disparities in stroke care, although further research is needed. The long-term impact of disparities in acute stroke care cannot be underestimated. The consistent trend of longer time to treatment for Black and Hispanic people experiencing stroke has direct implications on long-term disability and independence after stroke. A learning health system model may help expedite the translation of evidence-based interventions into clinical practice to reduce disparities in stroke care.

Heterogeneity of State Stroke Center Certification and Designation Processes.

Stroke centers are critical for the timely diagnosis and treatment of acute stroke and have been associated with improved treatment and outcomes; however, variability exists in the definitions and processes used to certify and designate these centers. Our study categorizes state stroke center certification and designation processes and provides examples of state processes across the United States, specifically in states with independent designation processes that do not rely on national certification. In this cross-sectional study from September 2022 to April 2023, we used peer-reviewed literature, primary source documents from states, and communication with state officials in all 50 states to capture each state's process for stroke center certification and designation. We categorized this information and outlined examples of processes in each category. Our cross-sectional study of state-level stroke center certification and designation processes across states reveals significant heterogeneity in the terminology used to describe state processes and the processes themselves. We identify 3 main categories of state processes: No State Certification or Designation Process (category A; n=12), State Designation Reliant on National Certification Only (category B; n=24), and State Has Option for Self-Certification or Independent Designation (category C; n=14). Furthermore, we describe 3 subcategories of self-certification or independent state designation processes: State Relies on Self-Certification or Independent Designation for Acute Stroke Ready Hospital or Equivalent (category C1; n=3), State Has Hybrid Model for Acute Stroke Ready Hospital or Equivalent (category C2; n=5), and State Has Hybrid Model for Primary Stroke Center and Above (category C3; n=6). Our study found significant heterogeneity in state-level processes. A better understanding of how these differences may impact the rigor of each process and clinical performance of stroke centers is worthy of further investigation.

Abstract TMP20: Mapping the Expansion of the Minnesota Stroke System of Care

Objectives: Stroke is the fifth leading cause of death in Minnesota (MN) and in the United States. The state of MN a has a unique geographical layout with many healthcare facilities located in rural areas. In 2013 legislation was passed authorizing the Minnesota Department of Health to designate hospitals as Acute Stroke Ready Hospitals, Primary Stroke Centers, and Comprehensive Stroke Centers. When a hospital joins the MN Stroke System they maintain vital infrastructure, expertise, and care processes to provide high quality stroke care in accordance with evidence-based guidelines. We used geographic information systems (GIS) methods to visualize the growth and expansion of the Minnesota Stroke System and quantify its reach to Minnesotans across the state over a 10-year period. Methods: Using the Network Analyst extension of ESRI ArcGIS Desktop 10.8.2, 30- and 60- minute drive time service areas were calculated around each designated hospital in 2013, 2017 and 2023. Census block groups were identified where the mean center of population fell within the 30-minute drive time areas and the populations of those block groups were summed. A percentage was calculated using the total Minnesota population as the denominator. Results: In 2013, only 66% of Minnesota’s population lived within 30 minutes of a designated stroke center and 80% lived within a 60-minute drive time. Stroke designated hospitals (19) were largely concentrated in metropolitan areas, leaving many rural Minnesotans without ready access to stroke centers. After the first cycle in 2017, or three-year period post statute, drive time status increased to 90% of the population living within 30 minutes of a designated stroke system hospital and 98% living within a 60- minute drive time. As of 2023, 94% of Minnesotans now live within a 30-minute drive of a designated Stroke System Hospital and 99% live within a 60-minute drive time. Conclusions: Stroke statute was the catalyst for improving stroke care access in MN. The voluntary system of care expanded rapidly from 19 initial hospitals to 119 over a 10-year period. This progress means more than 1.9 million additional Minnesotans now have better access to emergency stroke care.

Abstract TP69: Development of System-Wide Stroke-Specific Nursing Education for a Hospital System

Background: Stroke nursing education is a requirement for Stroke Center designation. Providing eight hours of stroke-specific education to hundreds of nurses annually can be challenging for any medical institution. Purpose: The purpose of our project was to improve the quality of stroke nursing education for a seven-hospital system in New York City and to reach a larger audience of nurses by creating a learning environment that is strong, evidence-based, engaging and interactive. Methods: We recruited stroke neurologists, nurse practitioners, and experienced stroke nurses to provide lectures during monthly stroke education days. The eight-hour curriculum was designed by stroke program directors and stroke coordinators. Topics included acute stroke management, imaging, stroke complications, NIHSS review, post-stroke rehab, swallow screen, and stroke trivia. At least two presenters were recruited for each topic to ensure coverage. We used a zoom platform to provide stroke education. We assessed nurses’ performance during the educational process. Lectures were interactive with multiple-choice questions, polling and trivia, and allowed nurses to engage and ask questions. Educational days were offered monthly, and the schedule was posted for the entire year on the system-wide educational platform. We continued to improve the quality and delivery of the content based on nurses’ feedback. Results: Following initiation of this program, monthly education days via a virtual platform allowed us to reach a wider nursing audience across the system and to achieve consistency and quality of stroke nursing education. Over 2,000 nurses took part in our educational days during years of 2020-2023. Based on 1575 nurses’ reviews and feedback, the ability to interact with the presenters, ask questions, and the interactive content delivered by stroke experts were most appreciated.: Conclusions: Virtual technology and our nurse-oriented stroke curriculum allowed us to reach a wider audience of nurses. Assigning designated topic-specific partner-lecturers ensured coverage in case of an unexpected event. This method allows nurse educators to provide system-wide evidence-based interactive nursing education by specialty experts and emphasize material in real time.

84 An Overview of State Stroke Center Designation Processes in the United States

84 An Overview of State Stroke Center Designation Processes in the United States

The Relationship Between Hospital Stroke Center Designation and TVT Reported Stroke: The Michigan TAVR Experience

BackgroundThe 30-day rate of stroke after transcatheter aortic valve replacement (TAVR) has been suggested as a hospital quality metric. Thirty-day stroke rates for nonsurgical, high, and moderate-risk TAVR trials were 3.4% to 6.1%, whereas those in the national Transcatheter Valve Therapy (TVT) Registry for the same patient population were much lower. Hospital comprehensive stroke center (CSC) is the highest designation for integrated acute stroke recognition, management, and care. ObjectivesUsing Michigan TVT data, we assessed whether in-hospital post-TAVR stroke rates varied between CSC and non-CSC institutions. MethodsTVT data submitted from the 22 Michigan Transcatheter Aortic Valve Replacement Collaborative participating institutions between January 1, 2016, and June 30, 2019, were included (N = 6,231). Bayesian hierarchical regression models accounting for patient clinical characteristics and hospital clustering were fitted to assess the association between hospital CSC accreditation and in-hospital post-TAVR stroke. Adjusted ORs and 95% credible intervals were estimated. The University of Michigan Institutional Review Board has waived the need for the approval of studies based on the data collected by the Blue Cross Blue Shield of Michigan Cardiovascular Consortium registry. ResultsThere were 3,882 (62.3%) patients at 9 CSC sites and 2,349 (37.7%) patients at 13 non-CSC sites. CSC sites had significantly higher rates of in-hospital post-TAVR stroke (CSC: 2.65% vs non-CSC: 1.15%; P < 0.001). After adjustment, patients who underwent TAVR at a CSC hospital had a significantly higher risk of in-hospital stroke (adjusted OR: 2.21; 95% CI: 1.03-4.62). However, CSC designation was not significantly associated with other important post-TAVR clinical outcomes including 30-day mortality. ConclusionsReported Michigan Transcatheter Aortic Valve Replacement Collaborative TVT stroke rates were significantly higher at sites with Joint Hospital Commission stroke designation status; however, other reported important clinical outcomes did not differ significantly based on this designation. CSC designation is a possible factor in stroke rate detection differences between TAVR institutions and might be a factor in the observed differences in stroke rates between TAVR trials and those reported in TVT. In addition, these data suggest that comparison between hospitals based on post-TAVR stroke rates is potentially problematic.

Early Mobilization Post Acute Stroke Thrombolysis and/or Thrombectomy Survey.

We sought to determine mobilization practices following emergency stroke therapy in centers across the United States. We surveyed hospitals in the NIH StrokeNet regarding mobilization practices following acute stroke thrombolysis and/or thrombectomy. An anonymous survey was sent out to all StrokeNet sites Survey questions included stroke center designation, location of admission, whether a formal bed rest protocol was in place, minimum bed rest period required, which person first mobilized the patient. 48 centers responded to the survey including 45 Comprehensive Stroke Centers and 3 Primary Stroke Centers. Most patients were admitted to a neuro-intensive care unit (54%), others to a general medical/surgical ICU, stroke ward, or combination. 60% of respondents indicated that a formal bed rest policy was in place. Minimum bed rest requirements after thrombolysis alone ranged from 0 to 24hours (35% with a 24-hour bed rest protocol, 19% with no minimum, 13% with a 12-hour minimum, 4% with an 8-hour minimum, 4% with a 6-hour minimum, and 6% with a variable rest period). Similar variations were reported in patients undergoing thrombectomy with ranges from 0 to 24hours bed rest. First mobilization was by a nurse 52% of the time and by a physical therapist 48% of the time. Mobilization practices following emergency ischemic stroke reperfusion treatments vary significantly across stroke centers. Mobilization of patients is performed primarily by nurses and therapists. Further study regarding an optimal approach for mobilization following acute ischemic stroke thrombolysis and/or thrombectomy is warranted.

Cincinnati Prehospital Stroke Scale Implementation of an Urban County Severity-Based Stroke Triage Protocol: Impact and Outcomes on a Comprehensive Stroke Center

Background and purposeScreening scales are recommended to assist field-based triage of acute stroke patients to designated stroke centers. Cincinnati prehospital stroke scale (CPSS) is a commonly used prehospital stroke screening tool and has been validated to identify large vessel occlusion (LVO). This study addresses the impact of county-based CPSS implementation to triage suspected LVO patients to a comprehensive stroke center (CSC). Materials and methodsDekalb County in Atlanta, Georgia, implemented CPSS-based protocol with score of 3 and last seen normal time < 24 h mandating transfer to the nearest CSC if the added bypass time was <15 min. Frequency of stroke codes, LVO, IV-tPA use, and thrombectomy treatment were compared six months before and after protocol change (November 1, 2020). ResultsDuring the study period, 907 stroke patients presented to the CSC by EMS, including 289 (32%) with CPSS score 3. There was an increase in monthly ischemic stroke volume (pre-16 ± 2 vs.19 ± 3 p = 0.03), LVO (pre-4.3 ± 1.7 vs. post-7.0 ± 2.4; p = 0.03), EVT (pre-15% vs. post-30%; p = 0.001), without significant increase in stroke mimic volume or delay in mean time from last seen normal to IV-tPA (pre-165 ± 66, post-158 ± 49 min; p = 0.35). CPSS score 3 was associated with increased likelihood of LVO diagnosis (OR 8.5, 95% CI 5.0-14.4; p = 0.001) and decreased the likelihood of stroke mimics (OR 0.66, 95% CI 0.50-0.88; p = 0.004). ConclusionCPSS is a quick, easy to implement, and reliable prehospital severity scale for EMS to triage LVO to CSC without delaying IV-tPA treatment or significantly increasing stroke mimics.

Lessons Learned From the Historical Trends on Thrombolysis Use for Acute Ischemic Stroke Among Medicare Beneficiaries in the United States.

BackgroundThe most recent time trends on intravenous thrombolysis (IVT) utilization for acute ischemic stroke was reported in 2011 using the Get with the Guidelines. Our objectives are to assess and validate the change in IVT utilization through 2014 in a national sample of Medicare beneficiaries and to examine the effect of patient, stroke center designation, and geography on IVT utilization.MethodsWe built a comprehensive national stroke registry by combining patient-level, stroke center status, and geographical characteristics, using multiple data sources. Using multiple national administrative databases from 2007 to 2014, we generated a mixed-effect logistic regression model to characterize the independent associations of patient, hospital, and geographical characteristics with IVT in 2014.ResultsUse of IVT increased consistently from 2.8% in 2007 to 7.7% in 2014, P < 0.001. Between group differences persisted, with lower odds of use in patients who were ≥86 years (aOR 0.74, 95% CI 0.65–0.83), Black (aOR 0.73, 95% CI 0.61–0.87), or treated at a rural hospital (aOR 0.88, 95% CI 0.77–1.00). Higher odds of use were observed in patients who arrived by ambulance (aOR 2.67, 95% CI 2.38–3.00), were treated at a hospital certified as a stroke center (aOR 1.96, 95% CI 1.68–2.29), or were treated at hospitals located in the most socioeconomically advantaged areas (aOR 1.27, 95% CI 1.05–1.54).ConclusionsBetween 2007 and 2014, the frequency of IVT for patients with acute ischemic stroke increased substantially, though differences persisted in the form of less frequent treatment associated with certain characteristics. These findings can inform ongoing efforts to optimize the delivery of IVT to all AIS patients nationwide.

An inventory of stroke centers in the United States.

ObjectivesStroke centers are essential for the optimal care of patients with acute stroke. However, there is no universally applied standard for stroke center certification/designation and no unified list of confirmed US stroke centers. Multiple national organizations, and some state governments, certify/designate hospitals as stroke centers of various levels, but discrepancies exist between these systems. We aimed to create a unified, easily accessible, national stroke center database.MethodsLists of confirmed stroke centers were obtained from national certifying bodies (The Joint Commission [TJC], Det Norske Veritas, and Healthcare Facilities Accreditation Program) and each state government. Lists were reconciled to a common standard based on TJC requirements and incorporated into the 2018 National Emergency Department Inventory–USA database, which includes all emergency departments (EDs).ResultsAmong 5533 US EDs, we confirmed 2446 (44%) as stroke centers, including 297 Comprehensive Stroke Centers, 14 Thrombectomy‐capable Stroke Centers, 1459 Primary Stroke Centers, and 678 Acute Stroke Ready Hospitals. Compared with EDs without stroke centers, EDs with stroke centers had higher annual visit volumes, were more often academic, and were more often located in hospitals that had trauma or burn centers.ConclusionWe report the consolidation of multiple stroke center designation groups with varying criteria into a unified list of all confirmed US stroke centers linked to a comprehensive, national ED database. This data set will be valuable for future stroke systems research and improving access to emergency stroke care for patients. These data have the potential to further optimize the emergency care of patients with stroke.

Impact of Telestroke Implementation on Emergency Department Transfer Rate.

Telestroke networks are associated with improved outcomes from acute ischemic stroke (AIS) and facilitate greater access to care, particularly in underserved regions. These networks also have the potential to influence patient disposition through avoiding unnecessary interhospital transfers. This study examines the effect of implementation of the VA National Telestroke Program (NTSP) on interhospital transfer among Veterans. We analyzed patients with AIS presenting to the emergency departments of 21 VA hospitals before and after telestroke implementation. Transfer rates were determined through review of administrative data and chart review and patient and facility-level characteristics were collected to identify predictors of transfer. Comparisons were made using t test, Wilcoxon rank sum, and χ 2 analysis. Multivariable logistic regression with sensitivity analysis was conducted to assess the influence of telestroke implementation on transfer rates. We analyzed 3,488 stroke encounters (1,056 pre-NTSP and 2,432 post-NTSP). Following implementation, we observed an absolute 14.4% decrease in transfers across all levels of stroke center designation. Younger age, higher stroke severity, and shorter duration from symptom onset were associated with transfer. At the facility level, hospitals with lower annual stroke volume were more likely to transfer; 1 hospital saw an increase in transfer rates following implementation. After adjusting for patient and facility characteristics, the implementation of VA NTSP resulted in a nearly 60% reduction in odds of transfer (odds ratio 0.39 [0.19, 0.77]). In addition to improving treatment in acute stroke, telestroke networks have the potential to positively affect the efficiency of interhospital networks through disposition optimization and the avoidance of unnecessary transfers.

Abstract WMP88: Endovascular Therapy For Large Vessel Occlusion Stroke With Low NIH Stroke Scale: A Population-Level Assessment

Introduction: There is increasing interest in endovascular therapy (EVT) for patients with large vessel occlusion (LVO) acute ischemic stroke (AIS) presenting with low NIH Stroke Scale. Here, we assess the prevalence of LVO with low NIHSS and real-world trends in utilization of EVT in this population. Methods: We performed a cross-sectional study using the Texas Public Use Data File, which captures all inpatient admissions in the state from non-federal hospitals (10/01/2016-06/30/2020). AIS cases were defined as hospitalizations to acute care hospitals with a primary diagnosis of AIS using ICD-10-CM codes I63.x and NIHSS was determined using ICD-10-CM codes R29.700- R29.742. Low NIHSS was defined as &lt;6 and high NIHSS as ≥ 6. LVO was determined by ICD-10-CM codes and EVT was determined by ICD-10 procedure codes. Comprehensive stroke center (CSC) designation was determined by Texas Department of Health Services published listings. Results: Among 61,524 AIS cases, patients with low NIHSS accounted for 63% and were more likely to be younger, male and white than those with high NIHSS. LVO was twice as prevalent among high NIHSS AIS (52% vs 24% p&lt;0.001) but 44% of LVOs presented with low NIHSS. EVT rates were much lower in low NIHSS LVOs compared to high NIHSS LVOs (4% vs 27%, p&lt;0.001). EVT rates in LVOs increased during the study period (0.4% per quarter, 95% CI 0.3-0.6%, p&lt;0.001), as well in low NIHSS LVOs (0.2% per quarter, 95% CI 0.1-0.3%, p=0.001). These findings, however, were only seen in CSC-certified hospitals, for both high NIHSS LVOs (1.0% per quarter, 95% CI 0.7-1.3%, p&lt;0.001) and low NIHSS LVOs (0.3% per quarter, 95% CI 0.06-0.4%, p=0.010) but not seen in non-CSC hospitals. Conclusions: In this large state-level cohort, nearly one-quarter of low NIHSS patients were found to have LVO, and increasing trends in EVT use were observed in this group. The effectiveness and safety of EVT in low NIHSS LVOs need to be further evaluated in real world clinical settings.

Abstract WP42: FAST Implementation Of An Urban County Severity-based Stroke Triage Protocol: Impact And Outcomes On A Comprehensive Stroke Center

Background: Severity scales are recommended to assist field-based triage of acute stroke patients to designated stroke centers however require additional EMS education and performance. The Cincinnati prehospital stroke scale (CPSS) is a commonly used pre-hospital stroke screen and has been validated as a severity scale to identify large vessel occlusion (LVO). This study objective is to determine the impact of a county-based implementation of CPSS as a stroke severity scale to directly triage selected patients to a comprehensive stroke center (CSC). Methods: Dekalb County, Georgia in Atlanta implemented a CPSS-based triage protocol with a score of 3 and last seen normal (LSN) time &lt; 24 hours mandating transfer to the nearest CSC if added time was &lt;15 minutes. We compared patients presenting by EMS to the CSC six months before and after the protocol change (November 1, 2020) including frequencies of stroke alerts, diagnoses, LVO, IV tPA use, thrombectomy treatment and LSN time to treatment. Results: During the study period, 802 suspected acute stroke patients presented to the CSC by EMS including 95 (12%) with a FAST score of 3. There was a significant increase in monthly EMS stroke alerts with the protocol implementation (Pre- 43 ± 5.6, Post- 54 ± 5.9; p=0.005). Overall, 325 (41%) patients had a final diagnosis of stroke or TIA, including 228 (28%) with ischemic stroke. There was a significant increase in ischemic stroke patients presenting with LVO (Pre- 26%, Post- 36%; p=0.01) and the monthly rate of mechanical thrombectomy (Pre- 2.0 ± 2.0, Post- 5.5 ± 2.4; p= 0.005) but no difference in tPA administration rate. LSN to tPA median times were similar (Pre- 2.8 ± 1.1, Post- 2.6 ± 0.87 hours; p=0.66) though LSN to groin puncture median times increased (Pre- 3.2, Post- 7.1 hours; p=0.04). CPSS score of 3 was associated with the final diagnosis of ischemic stroke, IV tPA administration and presence of LVO (p=&lt;0.001). Conclusion: County-based implementation of a CPSS score of 3 is a quick, easy and effective approach to triage suspected stroke patients to a thrombectomy-capable center that identifies stroke patients with LVO and increases thrombectomy treatment rates without delays in tPA treatment.

Abstract WP121: Early Mobilization Post Acute Stroke Thrombolysis And/or Thrombectomy (EMPATHY) Survey

Background: Traditionally, bed rest after emergency ischemic stroke treatments has been defined as 24 hours hours. The scientific basis for this timeline has not been established and practices may vary. We sought to determine bed rest practices following emergency stroke therapy in centers across the United States. Methods: We surveyed hospitals in the StrokeNet system regarding bed rest practices following acute stroke thrombolysis and/or thrombectomy. An anonymous survey (SurveyMonkey®) was sent out by the central coordinating center to all StrokeNet participating centers across the United States. Survey questions included stroke center designation, location of admission, whether a formal bed rest protocol was in place, minimum bed rest period required, which person first mobilized the patient, average duration of bed rest, which factors would alter duration of bed rest. Results: 48 centers responded to the survey including 45 Comprehensive Stroke Centers and 3 Primary Stroke Centers. Most patients were admitted to a neuro-intensive care unit (69%), and others to a general medical/surgical ICU or stroke ward. 60% of respondents indicated that a formal bed rest policy was in place. Minimum bed rest requirements after thrombolysis alone ranged from 0-24 hours (43% with a 24 hour bed rest protocol, 20% with no minimum, 15% with a 12 hour minimum, 5% with an 8 hour minimum, 5% with a 6 hour minimum, and 12% with an indeterminate response). Similar variations were reported in patients undergoing thrombectomy with ranges from 0-24 hours bed rest. First mobilization was by a nurse 52% of the time and by a physical therapist 48% of the time. Actual mobilizations ranged from 0-36 hours after treatment. The most common factors that altered bed rest duration were: hemodynamic factors (&gt; 90% of respondents depending on the scenario) and NIHSS score (&gt; 65% depending on the scenario). Conclusion: Bed rest practices following emergency ischemic stroke treatment vary significantly across stroke centers. Mobilization of patients is performed primarily by nurses and therapists. Major factors that influence bed rest duration include hemodynamic factors and NIHSS score. Further study regarding an optimal approach for bed rest is warranted.

Abstract 1122‐000121: Integrated Geomapping Tool of Certified Stroke Centers in United States: A SVIN MT2020+ Committee Collaboration

Introduction : Stroke is a leading cause of morbidity, mortality and healthcare spending in the United States. Acute management of ischemic stroke is time‐dependent and evidence suggests improved clinical outcomes for patients treated at designated certified stroke centers. There is an increasing trend among hospitals to obtain certification as designated stroke centers. A common source or integrated tool providing both information and location of all available stroke centers in the US irrespective of the certifying organization is not readily available. The objective of our research is to generate a comprehensive and interactive electronic resource with combined data on all geographically‐coded certified stroke centers to assist in pre‐hospital triage and study healthcare disparities in stroke including availability and access to acute stroke care by location and population. Methods : Data on stroke center certification was primarily obtained from each of the three main certifying organizations: The Joint Commission (TJC), Det Norske Veritas (DNV) and Healthcare Facilities Accreditation Program (HFAP). Geographic mapping of all stroke center locations was performed using the ArcGIS Pro application. The most current data on stroke centers is presented in an interactive electronic format and the information is frequently updated to represent newly certified centers. Utility of the tool and its analytics are shown. Role of the tool in improving pre‐hospital triage in the stroke systems of care, studying healthcare disparities and implications for public health policy are discussed. Results : Aggregate data analysis at the time of submission revealed 1,806 total certified stroke centers. TJC‐certified stroke centers represent the majority with 106 Acute Stroke Ready (ASR), 1,040 Primary Stroke Centers (PSCs), 49 Thrombectomy Capable Centers (TSCs) and 197 Comprehensive Stroke Centers (CSCs). A total of 341 DNV‐certified programs including 36 ASRs, 162 PSCs, 16 PSC Plus (thrombectomy capable) and 127 CSCs were identified. HFAP‐certified centers (75) include 16 ASRs, 49 PSCs, 2 TSCs and 8 CSCs. A preliminary map of all TJC‐certified CSCs and TSCs is shown in the figure (1). Geospatial analysis reveals distinct areas with currently limited access to certified stroke centers and currently, access to certified stroke centers is extremely limited to non‐existent in fe States (for example: Idaho, Montana, Wyoming, New Mexico and South Dakota). Conclusions : Stroke treatment and clinical outcomes are time‐dependent and prompt assessment and triage by EMS directly to appropriate designated stroke centers is therefore critical. A readily available electronic platform providing location and treatment capability for all nearby certified centers will enhance regional stroke systems of care, including enabling more rapid inter‐hospital transfers for advanced intervention. Identifying geographic areas of limited access to treatment can also help improve policy and prioritize the creation of a more equitable and well‐distributed network of stroke care in the United States.

Abstract P155: The Network Effect on Inter-Facility Transfers Among Regional Stroke Certified Hospitals

Introduction and Purpose: Timely inter-facility transfer of thrombectomy-eligible patients is a mainstay of Stroke Systems of Care. We investigated transfer patterns among stroke certified hospitals in the Dallas-Fort Worth Metroplex (19 counties, 9,286 sq mi, &gt;7.7 million people), by hospital network and stroke center status. Methods: In Feb 2020, all 44 North Central Texas Trauma Regional Advisory Council (NCTTRAC) hospitals identified network status, stroke designation and geographic location. Stroke Assessment and Large Vessel Occlusion (LVO) screening tool use was evaluated. The distance between the sending and receiving facility was calculated using GPS coordinates. If the closest Comprehensive Stroke Center (CSC) was not used, the average distance between the selected and the closest CSC was geospatially mapped via R statistical analysis software (Vienna, Austria) gmapsdistance package. Results: Of the 44 facilities, 6 were Acute Stroke Ready Hospitals (ASRHs), 27 were Primary Stroke Centers (PSCs), 11 were CSCs (Fig 1). Seventy-seven percent (n=34) were part of four hospital networks. All facilities used stroke assessment tools; 57% completed LVO screening. Seventeen percent of ASRHs (n=1) and 56% of PSCs (n=15) conducted inter-facility transfers. Sixty percent of non-network facilities transferred to the closest CSC. Of the remaining 40%, the average distance between the closest and the selected CSC was 1.5 miles (min max 0.2-2.9). Seventeen percent of network facilities transferred to the closest CSC. Among the remaining 83%, the average distance between the closest and the selected CSC was 4.1 miles (min-max 1-8). Conclusions: Non-network facility status increased the likelihood of transfer to the closest Comprehensive Stroke Center. Transfer distance variability among network facilities may contribute to delays in reperfusion therapy. Figure 1 . Transfer Patterns (in Blue) of Dallas Fort-Worth Metroplex Hospitals by Stroke Center Designation

Inactivated Four-Factor Prothrombin Complex Concentrate Dosing Practices for Reversal of Warfarin-Related Intracranial Hemorrhage

Inactivated four-factor prothrombin complex concentrate (I4F-PCC, Kcentra®) has become an important agent for the urgent or emergent reversal of bleeding associated with vitamin K antagonists such as warfarin. There is recognized inter-institutional variability with the use of I4F-PCC, especially as it relates to dosing practices. We sought to characterize variations in I4F-PCC dosing practices and their impact on patient outcomes and describe overall real-world clinical practice surrounding I4F-PCC utilization in the context of the management of warfarin-related intracranial hemorrhage (ICH). This is a multicenter retrospective pragmatic registry study of adult patients admitted at a participating study site between January 1, 2014, and December 31, 2015, who received I4F-PCC for reversal of warfarin-related ICH. Practices around warfarin-related ICH reversal in context of I4F-PCC utilization are described, including repeat I4F-PCC dosing, adjunctive reversal agents, and dose rounding policies (i.e., rounding doses to nearest vial size vs preparing exact/unrounded doses). All research was approved by local human investigation committees at each institution. Seventeen institutions contributed data on 528 patients to this registry. These institutions were primarily urban centers (74%), located in the southeast USA (47%), with Level 1 Trauma designation (79%), and with Comprehensive Stroke Center designation (74%). Most patients included in the study had sustained a non-traumatic ICH (68%), had a median admission GCS of 14 (IQR 7-15), and were receiving warfarin for atrial fibrillation (57.4%). There was substantial time latency between baseline INR and I4F-PCC (median 2.4h, IQR 1.4-4.5h). Most patients received adjunctive reversal agents, including vitamin K (89.5%) and fresh frozen plasma (FFP) (31.9%). A smaller proportion (6.0%) of patients received repeat I4F-PCC dosing. The median ICU length of stay (LOS) was 3days (IQR 2-7days), median hospital LOS was 6days (IQR 3-12days), and overall mortality rate was 28.8%. For institutions rounding doses to the nearest vial size, the first post-I4F-PCC dose INR was statistically but not clinically significantly lower than for institutions without vial size dose rounding, with comparable degrees of INR reduction from baseline. No differences were observed between dose rounding cohorts in adverse effects, ICU or hospital LOS, modified Rankin score at discharge, or mortality rates. Most patients received single doses of I4F-PCC, with adjunctive reversal agents and rounding doses to vial size. The time difference from baseline INR to factor product administration is a potential opportunity for process improvement in the management of warfarin-related ICH.

Provincial Door-to-Needle Improvement Initiative Results in Improved Patient Outcomes Across an Entire Population.

Improving door-to-needle times (DNTs) for thrombolysis of acute ischemic stroke patients improves outcomes, but participation in DNT improvement initiatives has been mostly limited to larger, academic medical centers with an existing interest in stroke quality improvement. It is not known whether quality improvement initiatives can improve DNT at a population level, including smaller community hospitals. This study aims to determine the effect of a provincial improvement collaborative intervention on improvement of DNT and patient outcomes. A pre post cohort study was conducted over 10 years in the Canadian province of Alberta with 17 designated stroke centers. All ischemic stroke patients who received thrombolysis in the Canadian province of Alberta were included in the study. The quality improvement intervention was an improvement collaborative that involved creation of interdisciplinary teams from each stroke center, participation in 3 workshops and closing celebration, site visits, webinars, and data audit and feedback. Two thousand four hundred eighty-eight ischemic stroke patients received thrombolysis in the pre- and postintervention periods (630 in the post period). The mean age was 71 years (SD, 14.6 years), and 46% were women. DNTs were reduced from a median of 70.0 minutes (interquartile range, 51-93) to 39.0 minutes (interquartile range, 27-58) for patients treated per guideline (P<0.0001). The percentage of patients discharged home from acute care increased from 45.6% to 59.5% (P<0.0001); the median 90-day home time increased from 43.3 days (interquartile range, 27.3-55.8) to 53.6 days (interquartile range, 36.8-64.6) (P=0.0015); and the in-hospital mortality decreased from 14.5% to 10.5% (P=0.0990). The improvement collaborative was likely the key contributing factor in reducing DNTs and improving outcomes for ischemic stroke patients across Alberta.

A Retrospective Comparison of 3-Factor Prothrombin Complex Concentrate Products for Warfarin Reversal.

Current guidelines suggest that 3-factor prothrombin complex concentrate is a possible alternative to 4-factor products for the emergent reversal of bleeding secondary to warfarin. While multiple observational studies have evaluated various forms of 3-factor prothrombin complex concentrate individually, no study has compared the efficacy of the 2 products. The purpose of this study is to compare the efficacy and safety of Bebulin™ and Profilnine™ for the emergent reversal of warfarin-associated major bleeding. We conducted a retrospective cohort study of patients receiving both Bebulin™ and Profilnine™ at an urban, academic medical center with comprehensive stroke center designation and a neurosurgical center of excellence. All patients were treated at a single center that utilized a fixed, weight-based dosing protocol. The primary outcome was the percentage of patients in each group achieving a goal international normalization ratio of 1.4 or less. There was a significant difference in goal international normalization ratio achieved favoring Bebulin™ (85.5% vs 27.3%; P < .001) over Profilnine™. Median dose per kilogram of actual body weight was the same between the groups. When we assessed results by baseline™ international normalization ratio subgroup, more patients in the Bebulin™ group achieved goal when baseline values were 6 or less. No thrombotic events were documented in either group. We found that patients treated with Bebulin™ experienced significantly higher rates of successful international normalization ratio reversal when compared to those who received Profilnine™. Further research is needed to determine the comparative efficacy between the 2 agents.