Primary Stroke Center Designation Research Articles

Trends in Telestroke Care Delivery

Telestroke provides access to vascular neurology expertise for hospitals lacking stroke coverage, and its use has risen rapidly in the past decade. We aim to characterize consultations, spoke behavior, and the relationship between spoke telestroke utilization (number of telestroke consults per year) and spoke alteplase treatment metrics in an academic telestroke network. We analyzed prospectively collected data on all telestroke consults from 2003 to 2018. Trends in network performance and spoke characteristics were analyzed using generalized estimating equations and Kendall τβ nonparametric tests as appropriate. Unadjusted and adjusted linear regression models determined associations between telestroke utilization and treatment metrics. The network included 2 hubs and 43 spokes with 12 803 consults performed during the study period. Network growth overall was +1.8 spokes per year, and median duration of spoke participation was 7.9 years. The numbers of consults and alteplase-treated patients increased annually, even after adjusting for the number of spokes in the network (P<0.01 for both). Although times from last seen well to spoke emergency department arrival and to consult request increased, door-to-needle time, time from teleconsult request to callback, and time from teleconsult to alteplase administration all decreased (all P<0.01). With time, the network included more spokes without a Primary Stroke Center designation. In adjusted analyses, for every 10 telestroke consults requested by a spoke, the spoke door-to-needle decreased by 1.8 minutes (P=0.02), number of patients treated with alteplase was an additional 1.7 (P<0.01), and the percent of eligible patients treated with alteplase increased by 8% (P=0.03). Telestroke network size and utilization increased over time. Increased use of teleconsults was associated with increased and timely use of alteplase. Over time, the delivery of timely emergency care has improved significantly among emergency departments participating in this telestroke network. Replication of these findings in other networks is warranted.

Abstract WP506: Looking for Themes to Improve Outcomes Through Team Debriefing

Background: Acute ischemic stroke (AIS) patients risk grave disability when treatment is delayed. The benchmark for door to needle (DTN) time for thrombolysis in AIS is less than 60 minutes; The American Stroke Association's (ASA) Target Stroke, Phase II (TSP II) sets a higher standard of less than 45 minutes. Emergency department caregivers at a 377 bed community hospital with primary stroke center designation were educated about the TSP II toolbox; however DTN times in 2016 were less than 60 minutes only 29% of the time with a mean time of 78 minutes, a medium time of 77 minutes and a range of 178 minutes. Purpose: Using a lean methodology approach we organized team debriefings to evaluate cases of time delay with the aim to develop strategies to improve outcome. Methods: As a process improvement project, an interprofessinal team was assembled to debrief and evaluate all patients receiving thrombolytic therapy. A comprehensive checklist was developed to include all of the critical components of care along with target benchmark timelines. Each data point was scrutinized to evaluate for possible time delays. The caregiver team was encouraged to objectively identify time delays and look for themes. Through root cause analysis, the most common theme identified was the performance of unnecessary tasks that could wait until after initiation of therapy. The other theme identified was delay in critical interventions such as timely lowering of blood pressure to prevent hemorrhage in patients undergoing thrombolysis. We engaged in coaching conversations among members of the team in an effort to promote better critical thinking and better patient outcomes. Results: From January, 2017 to August, 2018 there were 69 thrombolytic therapy cases The DTN rate of less than 60 minutes was 78%. Mean, median and mode times were 53,51 and 57 minutes respectively. The range was from 28-93 minutes. DTN in 45 minutes or less occurred at a rate of 30%. Conclusion: Improved outcome for exemplary professional practices can be afforded through a systematic approach to debrief about time sensitive treatments. Bringing team members together for a guided discussion designed to look for themes that lead to performance deficits will develop better patient outcomes.

Pharmacists' role in a hospital's initiative to become a certified primary stroke center.

Significant pharmacy department contributions to a medical center's efforts to attain certification as a primary stroke center (PSC) are described. As part of an initiative to improve outcomes in patients with stroke and earn the PSC designation, the pharmacy department of an 855-bed community teaching hospital participated in developing a multifaceted "Code Stroke" program. Pharmacists deployed in the emergency department (ED), intensive care units, and medical units are involved in all aspects of stroke care from admission to discharge. Pharmacists attend ED responses to Code Stroke alerts, assisting in patient evaluation and helping to ensure timely tissue plasminogen activator (t-PA) administration and prompt computed tomography scanning. Throughout the hospital stay of a patient with stroke, pharmacists are involved in verifying that applicable Joint Commission core measures are met. Once a patient with stroke is deemed ready for discharge, a transitions-of-care pharmacist ensures that the patient receives the assistance necessary to obtain newly prescribed medications and counseling to promote postdischarge compliance. Implementation of the Code Stroke program was associated with improvements in stroke care quality measures, including a reduction in the median time from hospital arrival to t-PA administration and improved core measure compliance. By participating in the implementation of a number of transformative initiatives, the pharmacy department played an important role in enabling the medical center to provide consistent, excellent care for all patients with stroke as it prepared for certification as a PSC.

Abstract 306: Regional Differences in Stroke Center Designation and Get with The Guidelines (GWTG-S) Participation and Performance: Results From The NorthEast Cerebrovascular Consortium (NECC)

Introduction: The NorthEast Cerebrovascular Consortium (NECC) was created in 2006 to unite health care providers, public health officials, legislators and advocacy organizations in an 8-state region to implement and assess a Stroke Systems of Care Model. Objectives: To examine differences in Primary Stroke Center (PSC) designation, participation in GWTG-S and performance of acute care hospitals (ACH) and critical access centers (CAC) in the NECC region compared to non-NECC regions. Methods: We compared percentages of ACHs/CACs with State versus National PSC Designation, GWTG-S participation and Performance Achievement award trends over time in the pre- (2005) and post- NECC (2006-13) time periods. State designation refers to states conducting designation themselves or a combination of their own designation/national designation (Joint Commission, DNV or HFAP). US census data regions were stratified as The NECC region (CT, MA, ME, NH, NJ, NY, RI, VT) vs. Non-NECC regions (PA, South, Midwest, West). ACH/CACs were obtained from CMS. GWTG-S data were used for GWTG-S participation and awards (silver or higher for &gt;1 year). Results: Over the study time period (2005-13) the ACH/CACs per year in The NECC and non-NECC regions were 433 + 10 and 4420 + 172. State PSC designation occurred in CT, MA, FL, MD, NJ, and NYS. OK State designation was excluded due to lack of data. In the NECC region, State PSC designation increased over time from 29.3% in 2005 to 63.2% in 2013, compared to 0.1% in 2005 to 3.6% in 2013 in non-NECC regions (both analyses p&lt;0.0001, Cochran Armitage Trend (CAT)). In the NECC region, National PSC designation increased over time from 2.8% in 2005 to 17.1% in 2013, compared to 35.5% in 2005 to 77.3% in 2013 in non-NECC regions (both analyses p&lt;0.0001, CAT). In the NECC region, GWTG-S participation increased over time from 21.2% in 2005 to 61.5% in 2013 compared to 9.2% in 2005 to 32.4% in 2013 in non-NECC regions (both analyses p&lt;0.0001, CAT), and GWTG-S awards increased over time in the NECC region from 0.5% in 2005 to 42.5% in 2013 compared to 0.1% in 2005 to 16.6% in 2013 in non-NECC regions (both analyses p&lt;0.0001, CAT). After adjusting for year, significantly more NECC ACH/CACs received State PSC designation and significantly more non-NECC ACH/CACs received National PSC designation (both analyses p&lt;0.0001, Cochran-Mantel-Haenszel (CMH)). Significantly more NECC ACH/CACs participated in GWTG-S and received GWTG-S awards than non-NECC ACH/CACs (both analyses p&lt;0.0001, CMH). Conclusions: There has been more rapid growth of State in lieu of National PSC certification, and participation and achievement in GWTG-S in the Northeast from 2006 through 2013 compared to other regions in the U.S. The NECC may compliment and enhance existing regulatory and advocacy initiatives. Further investigation is merited to evaluate the influence of regional networks and State versus National PSC designation.

Hospital and Demographic Characteristics Associated With Advanced Primary Stroke Center Designation

Despite evidence that primary stroke center (PSC) certification is associated with improvements in care and outcome, only a minority of hospitals have achieved this certification. We sought to determine hospital-based factors associated with achievement of PSC certification. We used the 2011 American Hospital Association survey and the 2010 national census for population and household data to identify potential hospital and demographic factors influencing certification as a PSC by the Joint Commission, Healthcare Facilities Accreditation Program, and DNV Healthcare. Of the 3696 hospitals to complete the survey, 3069 fulfilling study criteria included 908 PSC (31%) and 2161 non-PSC. Independent hospital characteristics associated with PSC certification were Joint Commission accreditation (odds ratio [OR], 3.5; 95% confidence interval [CI], 2.4-5.0), increasing size (per quartile in number of beds; OR, 2.5; 95% CI, 2.1-3.1) and inpatient neurological services (OR, 3.2; 95% CI, 2.4-4.6), number of households per zip code (per 1000 households; OR, 1.1; 95% CI, 1.0-1.2), increasing Hispanic population (by 10% increase; OR, 1.1; 95% CI, 1.0-1.2), and income per household (per $10 000; OR, 1.2; 95% CI, 1.1-1.3). Designation as a sole community provider (OR, 0.22; 0.10-0.47) or governmental hospital control (0.61; 0.44-0.84) was associated with noncertification. Less than 1 in 3 hospitals has achieved certification as an PSC. Potential areas of improvement include increasing certification of governmental-controlled hospitals.

Hospital variation in thrombolysis times among patients with acute ischemic stroke: the contributions of door-to-imaging time and imaging-to-needle time.

Given the limited time window available for treatment with tissue plasminogen activator (tPA) in patients with acute ischemic stroke, guidelines recommend door-to-imaging time (DIT) within 25 minutes of hospital arrival and door-to-needle (DTN) time within 60 minutes for patients with acute ischemic stroke. Despite improvements in DITs, DTN times for tPA treatment in patients with acute ischemic stroke remain suboptimal. To examine the contributions of DIT and imaging-to-needle (ITN) time to delays in timely delivery of tPA to patients with acute ischemic stroke and to assess between-hospital variation in DTN times. A cohort analysis of 1193 patients having acute ischemic stroke treated with intravenous tPA between January 2009 and December 2012. Multilevel linear regression models included random effects for 25 Michigan hospitals participating in the Paul Coverdell National Acute Stroke Registry. The primary outcome was a continuous measure of DTN time, in minutes, from emergency department arrival to thrombolytic delivery. The mean age was 68.1 years, the median National Institutes of Health Stroke Scale score was 11.0 (interquartile range, 6-17), 51.4% were female, and 37.5% were of nonwhite race/ethnicity.The mean (SD) DTN time was 82.9 (35.4) minutes, the mean (SD) DIT was 22.8 (15.9) minutes, and the mean (SD) ITN time was 60.1 (32.3) minutes. Most patients (68.4%) had DIT within 25 minutes, while 28.7% had DTN time within 60 minutes. Hospital variation accounted for 12.7% of variability in DTN times. Neither annual stroke volume nor primary stroke center designation was a significant predictor of shorter DTN time. Patient factors (age, sex, race/ethnicity, arrival mode, onset-to-arrival time, and stroke severity) explained 15.4% of the between-hospital variation in DTN times. After adjustment for patient-level factors, DIT explained 10.8% of the variation in hospital risk-adjusted DTN times, while ITN time explained 64.6%. Compared with DIT, ITN time is a much greater source of variability in hospital DTN times and is a more common contributor to delays in timely tPA therapy for acute ischemic stroke. More attention is needed to determine systems changes that can decrease ITN time for patients with acute ischemic stroke.

Abstract 17: Hospital Variation in Thrombolysis Times in Acute Ischemic Stroke Patients: the Contributions of Door-to-Imaging Time and Imaging-to-Needle Time

Background: Given the limited time window available for treatment with tPA in acute ischemic stroke patients, guidelines recommend door-to-imaging time within 25 minutes of hospital arrival and a door-to-needle time (DTN) within 60 minutes. Despite temporal improvements in door-to-image and DTN, tPA treatment times remain suboptimal. Objectives: To examine the contributions of door-to-image and imaging-to-needle times to delays in timely delivery of tPA to ischemic stroke patients, and to examine between-hospital variation in DTN. Methods: A cohort analysis of 1,193 ischemic stroke patients treated with intravenous tPA from 2009-2012 at 25 Michigan hospitals participating in the Paul Coverdell National Acute Stroke Registry. The primary outcome was DTN (time in minutes from emergency department arrival to tPA delivery). Multi-level linear regression models included hospital-specific random effects. Results: Mean patient age was 68 years, median NIHSS score was 11 (IQR 6-17), 51% were female, and 37% were nonwhite. Mean DTN was 82.9 ±35.4 minutes, mean door-to-imaging time was 22.8 ±15.9 minutes and mean imaging-to-needle time was 60.1 ±32.3 minutes. A majority of patients had door-to-imaging within 25 minutes (68.4%) but only a minority had DTN within 60 minutes (28.7%). At the patient level door-to-imaging time was only modestly correlated with DTN (r= 0.41), conversely image-to-needle time was strongly correlated with DTN (r= 0.89) (figure). In the multi-level model the hospital random effect accounted for only 12.7% of variability in door-to-needle time. Neither annual stroke volume nor primary stroke center designation was a significant predictor of better DTN. Patient factors (age, race, sex, arrival mode, onset-to-arrival time, and stroke severity) explained 15.4% of the between-hospital variation in DTN. After adjustment for patient factors, door-to-imaging time explained only 10.8% of the variation in hospital risk-adjusted DTN, while imaging-to-needle time explained 64.6%. Conclusion: Compared to door-to-imaging time, imaging-to-needle time was more closely correlated with DTN and a much greater contributor to variability in hospital door-to-needle times. More attention to systems changes that can decrease imaging-to-needle time for acute ischemic stroke patients is now needed.

Abstract W P289: Hyper Acute Stroke Nurse Initiative Improves Time to Initiation of Reperfusion Therapy

Background: Following Primary Stroke Center designation in 2008, several factors contributed to our hospital's influx of stroke patients. In 2010, the Emergency Medical System covering our county began diverting stroke patients to our facility. In 2011, our 400+ bed medical center became the only organization capable of providing endovascular treatments in the region. This catalyzed another surge of stroke patients transferred to our hospital from outside facilities. Nurses and physicians in the ED noted increased workloads in an attempt to deliver stroke care in a timely manner. In May 2013, the innovative Hyper Acute Stroke (HAS) nurse was created to meet the time sensitive needs of our expanding stroke population. Purpose: The purpose of this initiative is to show the addition of the HAS nurse would improve time to IV tPA and endovascular intervention in stroke care, as well as physician and nurse satisfaction. Methods: With strong administrative and medical support, the Stroke Program Director and 15 critical care neuroscience nurses formed the HAS team. Initial training for the HAS nurse comprised of NIHSS certification and enhancement of neuroscience knowledge. Orientation included training with the Stroke Program Director on inter-facility transfer processes, response to ED Code Strokes, and formation of stroke care algorithms. Upon training completion, daily rotation ensured 24/7 HAS nurse coverage. Pre and post HAS nurse performance measures for IV tPA door to needle (DTN) and door to endovascular intervention times were analyzed. Physician and nursing satisfaction was also surveyed pre- and post HAS nurse involvement. Results: Data refers to the 12 months pre HAS compared to data post HAS nurse. When comparing pre HAS to post HAS time periods, DTN decreased from an average of 82 minutes to 38 minutes, while door to endovascular intervention decreased from an average of 136 to 111 minutes. Physician and nurse satisfaction improved since the institution of the HAS nurse. Conclusions: In conclusion, when responding to Code Strokes or assisting with transfers requiring emergent endovascular intervention, HAS nurse involvement improved time to intervention, and physician/nurse satisfaction.

Abstract W P311: Demographic and Regional Characteristics Associated With Advanced Primary Stroke Center Designation

Background: Nationwide less than a third of eligible hospitals have achieved advanced certification in stroke, and there may be disparities affecting less affluent areas serving a higher proportion of minorities. We aimed to characterize demographic and regional factors associated with achievement of stroke center certification while controlling for hospital characteristics. Methods: We linked the 2011 American Hospital Association survey of hospital characteristics to the 2010 national census for population and household data by region. Emergency medical services stroke routing data was obtained from communication with state and county contact. Only hospitals with ≥ 25 beds and 24-hour emergency departments were evaluated. The Joint Commission, Healthcare Facilities Accreditation Program and DNV Healthcare websites were used to determine certification status of each hospital. We controlled for hospital bed size, teaching affiliation (AMA, ACGME), emergency department volume, rural designation, hospital type (governmental/for-profit/nonprofit), and trauma center designation in analysis. Results: Of the 3696 hospitals to complete the survey, the 3069 fulfilling study criteria included 908 PSC (31%) and 2161 non-PSC. In univariate analysis PSC hospitals were located in areas with greater population in immediate vicinity (29, 316 vs. 20,901, p&lt;0.0001), greater proportion of minorities (73% white, 16% black, 15% Hispanic vs. 80%/12%/11%, p&lt;0.0001), greater number of households per zip code (11,540 vs. 8050, p&lt;0.0001) and a higher regional mean income ($52,112 vs. $46,262, p&lt;0.0001) and higher home value ($234,000 vs. $170,000, p&lt;0.0001). More PSC hospitals were located in regions with preferential EMS routing of stroke (52% vs. 40%). While controlling for hospital-based factors, the demographic and regional factors independently associated with hospital PSC designation were number of households per zip code (per 1000 households OR 1.1, 95%CI 1.0-1.2), increasing Hispanic population (every 10% increase OR 1.1, 1.0-1.2), and income per household (per $10,000 OR 1.2, 1.1-1.3). Conclusions: Hospitals achieving PSC designation are located in more affluent and densely populated areas with higher population of Hispanic residents.

Abstract T MP54: Hospital Characteristics Associated with Advanced Primary Stroke Center Designation

Background: Organized stroke systems of care, including accreditation of hospitals as primary stroke centers (PSC), are meant to improve patient care and compliance with national guidelines. Nationwide, less than a third of eligible hospitals have achieved advanced certification in stroke. We aimed to characterize hospital factors associated with achievement of stroke center certification. Methods: We utilized the 2011 American Hospital Association survey to obtain data on hospital characteristics. Only hospitals with ≥ 25 beds and 24-hour emergency departments were evaluated. The Joint Commission (TJC), Healthcare Facilities Accreditation Program and DNV Healthcare websites were used to determine certification status of each hospital as a primary stroke center. All comprehensive SC were considered as PSC. Factors found to be associated with achievement of certification (P&lt;0.010) were evaluated by logistic regression to determine a final model of independent association. Results: Of the 3696 hospitals to complete the survey, 3069 fulfilled study criteria, including 908 PSC (31%) and 2161 non-PSC. PSC were larger (mean 354 vs. 136 beds), had busier EDs (56,000 vs. 24,000 visits/year), were more often affiliated with ACGME residency programs (43% vs. 14%), AMA medical schools (51% vs. 21%), TJC-accreditation (95% vs. 65%), inpatient neurological services (94% vs. 46%) and trauma centers (55% VS 38%); and were less likely to be governmental (Federal/State/County 10% vs. 26%) and designated sole community provider (1% vs 9%). Independent hospital characteristics associated with PSC certification were TJC accreditation (OR 3.5, 95%CI 2.4-5.0), sole community provider (OR 0.22, 0.10-0.47), hospital type (governmental vs. non 0.61, 0.44-0.84), increasing size (per quartile in number of beds OR 2.5, 2.1-3.1) and neurological services (OR 3.2, 2.4-4.6). Conclusions: PSC hospitals are larger non-governmental hospitals with availability of neurological services. Increasing the low numbers of governmental (i.e. County or State) hospital achievement of PSC may be a potential area of focus.

Are Acute Stroke-Ready Hospitals Ready?

See related article, p 3382. In 2005, an American Stroke Association Task Force report described the rationale and components of an integrated stroke system of care extending from primordial prevention through primary prevention, acute management, secondary prevention, and poststroke rehabilitation and recovery.1 The principle that optimal patient outcomes depend on the consistent implementation of care processes that are based on the best available evidence and that are facilitated by key organizational features was implicit in the approach.2 For acute stroke care, a 3-tiered system was envisioned composed of acute stroke–capable hospitals, having limited resources but possessing the means to deliver emergent stroke therapies; primary stroke center (PSC) hospitals, having the additional capacity to care for patients with stroke after the acute period; and comprehensive stroke center hospitals, having specialized resources and personnel to provide stroke treatment and rehabilitation that surpass those expected at PSCs.1 This tiered system of organization of hospitals was again endorsed in an updated American Heart Association/American Stroke Association policy statement.3 At the time of the original American Stroke Association 2005 Task Force report, in cooperation with the American Heart Association, the Joint Commission had already begun certifying PSC hospitals based on criteria developed by the Brain Attack Coalition (BAC).4 Started in December 2003, the PSC program has been embraced throughout the country, with >925 hospitals having been certified in 48 states as of July 2012 (http://www.jointcommission.org). The competitive healthcare marketplace in the United States has likely contributed to a hospital seeking PSC designation because there was little move to improve hospital-based stroke-related care organization in the years before the PSC program began.5 Several states have now developed their own stroke center certification programs as well. Joint Commission PSC certification involves rigorous biannual on-site reviews and regular reports on a …

Impact of Emergency Medical Services Stroke Routing Protocols on Primary Stroke Center Certification in California

Organized stroke systems of care include Primary Stroke Center (PSC) certification and preferential emergency medical services (EMS) routing of suspected patients with stroke to designated PSCs. Stroke EMS routing is not nationally governed; in California, routing is determined by county. EMS routing policies might provide an incentive for PSC accreditation. We evaluated the relationship between independent adoption of EMS routing protocols and PSC designation acquisition in California. Dates of PSC certification were obtained through The Joint Commissions Website and confirmatory calls to stroke coordinators. Starting date of county EMS PSC routing policies was obtained from county EMS agencies. We provide descriptive analysis of number of hospitals achieving PSC designation relative to implementation of EMS routing policies for all counties with PSCs. By June 2012, there were 131 California PSCs in 27 counties, and 22 of 58 counties had implemented EMS routing policies. The greatest number of PSCs was in Los Angeles (30) followed by San Diego (11), Orange (9), and Santa Clara (9) counties. Achievement of PSC designation occurred more frequently immediately before and after EMS routing: 51 PSCs (39%) within 1 year; 85 PSCs (65%) within 2 years. The yearly rate of eligible hospital conversion to PSC designation accelerated concurrent with EMS diversion policy adoption from 3.8% before to 16.2% during and decelerated afterward to 7.6%. Implementation of EMS routing policies may be an important factor driving PSC certification. National adoption of stroke routing policies may lead to more PSCs, positively impacting patient care.

Variable Impact of State Legislative Advocacy on Registry Participation and Regional Systems of Care Implementation

Regionalization, systems of care design, and quality improvement (QI) registry participation all promote the widespread dissemination of guideline-based evidence into actual practice. As a result, policy statements from the American Heart Association/American Stroke Association (AHA/ASA) advocate for the creation of regional systems of care for various time-critical diagnoses, including ST-elevation myocardial infarction (STEMI), out-of-hospital cardiac arrest resuscitation, and acute stroke.1–3 Creation of these regional networks requires multidisciplinary collaboration to implement 5 mutually reinforcing core elements4 that build each system: (1) Designation of certain hospitals with special treatment capabilities as Receiving Centers for STEMI, resuscitation, or stroke; (2) emergency medical services (EMS) destination protocols that allow for direct transport of certain patients identified by explicit triage criteria to a designated Receiving Center, thus allowing for bypass of closer hospitals if they lack the needed specialty service; (3) organized interhospital transfer and transport protocols to a Receiving Center for appropriate patients who initially self-present or are mistriaged to a Referral Hospital; (4) communication or telemedicine options to provide real-time expert consultation as needed from a Receiving Center to its associated Referral Hospitals or EMS providers; and (5) participation in a regional and/or national QI registry to track relevant process-of-care metrics and meaningful risk-adjusted clinical outcomes. Within each of the 50 states, unique challenges exist for stakeholders attempting to implement the 5 aforementioned core elements of regional or statewide systems of care. In particular, substantial variation exists with regard to the starting point for these initiatives. For example, some states already have sufficient regulatory authority within their EMS agency or state department of health (DOH) to regionalize care of time-critical diagnoses, whereas other states require new legislation to create coordinated systems. In October 2011, the Advocacy Coordinating Committee of the AHA convened a multispecialty task force to assess the …

Abstract WP350: Evolution of a Stroke Center Utilizing Systems Thinking and Collaborative Strategies

Background: As a large health system, positioned in the stroke belt, expansion was essential to meeting the growing demand for stroke care. The mission and vision was to meet the needs of stroke patients and become a recognized leader in stroke care in the South East. Stroke Center leadership established a strategic plan to gain organizational commitment to achieve this goal. Methods: In 2003, patients were cared for in a 6-bed stroke unit and a 30-bed acute care unit directed by Neurology. These beds became increasingly insufficient and care delivery fragmented. While still being able to meet patient needs and achieving Primary Stroke Center designation, the center lacked a comprehensive delivery model. Initial goals began with increasing capacity, volumes and streamlining care. Strong multidisciplinary partnership was crucial for change. To streamline care, Neurology and Neurosurgery partnered to create a NeuroCare Team (NCT) and aligned themselves under Surgery Services. The 8-bed Neurosurgery Intensive Care Unit expanded to a 16-bed Neuroscience Intensive Care Unit, the step-down converted to 18 stroke-capable beds, the 6-bed stroke unit dissolved and a 36-bed acute care unit designated stroke capable. All levels of care were now able to provide consistency by stroke trained nursing staff and physicians. With this increased capacity, the team implemented a new patient flow framework called ‘Open Access’. This concept required each member of the team to say ‘yes’ to stroke patient referrals, every patient, every time. The multidisciplinary team created a plan for bed availability to accommodate this vision. Results: Between 2009 and 2010, the center expanded capacity from 36 to 72 stroke-capable beds, with volumes increasing for outside hospital transfers by 100% in FY11. The Stroke Center was recognized by the American Heart Association’s Get With The Guidelines Bronze Achievement Award and by US News and World Report as a High Performing Hospital in 2012. Conclusions: Clinical collaboration, strategic leadership and organizational commitment can build a high quality, comprehensive and financially strong Stroke Center. Alignment of physician and nursing staff delivering stroke care is key to streamlining, consistency and quality of care.

State Primary Stroke Center Policies in the United States: Rural Health Issues

To explore the relationship between state primary stroke center (PSC) designation policy implementation and access to optimal stroke care for residents of rural areas. Primary data were collected during the period September 2008-August 2009. Following content analysis of state PSC policies, four case study states were selected for fieldwork, in part for state rural healthcare access challenges. Variables included the barriers and facilitators to PSC designation policy implementation. More than 100 semistructured stakeholder interviews were conducted by teams of researchers. Large-group meetings were also observed. Interview summaries were reviewed by stakeholders for accuracy and completeness. The consistent finding in all study states was that PSC designation and state policy implementation in rural areas are unlikely for a variety of reasons, including lack of financial resources for telemedicine, difficulty maintaining neurology coverage, and emergency departments unable to administer thrombolytics. Findings indicate recognition by states about the need for stroke-care public policy specific to telemedicine in rural areas. Although state PSC designation policies raise awareness of rural issues, designation policy alone cannot overcome the obstacle of rural access to optimal stroke care. States must be technology-ready, and providers need to embrace e-health and telemedicine to ensure coordination of care for stroke victims in rural areas. More important is that state policy makers should provide rules and regulations to encourage PSC hospitals to use telemedicine and "proxy credentialing" to support their affiliated rural facilities.

Abstract 3386: The “True Value” of the Primary Stroke Center Designation

Background: The “true value” to a community hospital of achieving the Joint Commission Primary Stroke Center (PSC) designation is unknown. On 8/26/2010 St. Rose Dominican Hospitals Siena Campus became Clark County, Nevada’s, ninth PSC. For 3 years prior to becoming a PSC our local fire company (Henderson, NV) bypassed our hospital so that suspected acute stroke patients could be taken to a PSC. Furthermore, on 1/1/2010 a County mandate was passed designating transport of patients with suspected acute stroke to a PSC. During the period August 1, 2007 to August 25, 2010 stroke patients were admitted to our hospital but we were restricted from receiving suspected acute strokes from pre-hospital providers. Our aim was to determine the true value to a community hospital of achieving the Joint Commission PSC designation in the first six months of operation. Methods: Using the Horizon Performance Management™ database we categorized inpatient admissions into stroke ICD-9-CM (Group 1), closely-stroke-related ICD-9-CM (Group 2), and loosely-stroke-related ICD-9-CM diagnoses (Group 3). Percent change in admissions alone and as a function of total inpatient admissions, and percent change in average contribution margin ($US) [net revenue - variable costs] for the three stroke and stroke-related categories were analyzed. We compared data for the 6-month epoch 9/1/2010 - 2/28/2011 to the average data from the same 6-month epochs in 2007-8, 2008-9, 2009-10. Results: 45%, 31%, and 21% increases in admissions were observed for Groups 1, 2, and 3, respectively. Admissions, as a percentage of total inpatient admissions, increased 5.97%, 0.64%, and 2.18% in Groups 1, 2, and 3, respectively. For Groups 1 &amp; 2 combined the increase was 3.55% and for all groups combined was 5.73%. The percent increase in average contribution margin was 90%, 22%, and 25% for Groups 1, 2, and 3, respectively. Conclusions: The present method was utilized to estimate the “true value” of the PSC designation to a community hospital. The present study indicates that stroke and stroke-related inpatient admissions increase, along with contribution margins, after PSC designation. Lesser increases in Groups 2 and 3 vs. Group 1 (stroke) likely represent the “halo effect”, reflecting an increase in admissions for conditions similar to stroke, but that are not stroke, transported to a hospital by virtue of being a PSC. Future analyses should focus on length of stay and outcome measures in community PSCs.

Neurohospitalists Reduce Length of Stay for Patients With Ischemic Stroke

Neurohospitalists may improve the efficiency and quality of care delivered to hospitalized patients with neurological disease. However, there is limited systematic data to support this hypothesis. The primary purpose of this study was to compare length of stay (LOS) for patients with ischemic stroke cared for by either neurohospitalists or community-based neurologists at a single institution. A retrospective chart review was performed for all patients with ischemic stroke discharged from St. Luke's Hospital in Jacksonville, Florida, between January 2006 and December 2007. The LOS for patients cared for by neurohospitalists was compared to the LOS for patients cared for by community neurologists. Compliance with Joint Commission inpatient stroke quality metrics was also compared. A total of 533 patients were discharged with a principal diagnosis of ischemic stroke over the 24-month study period. Neurohospitalists cared for 313 patients with mean (± SD) LOS of 4.9 (5.2) days (95% CI: 4.3-5.5 days), and community-based neurologists cared for 220 patients with a mean LOS of 6.5 (8.2) days (95% CI: 5.4-7.6 days). The mean LOS was significantly less for the neurohospitalists compared to the community-based neurologists (P = .005). Neurohospitalists achieved a higher compliance rate in 10 of 11 inpatient stroke quality metrics and achieved significantly higher compliance rate of smoking cessation education (P = .019). Neurohospitalists achieved significantly shorter LOS for patients with ischemic stroke compared to community-based neurologists. These data suggest that neurohospitalists can also improve compliance with quality metrics necessary for Joint Commission Primary Stroke Center designation.

Barriers and facilitators to implementing primary stroke center policy in the United States: results from 4 case study states.

We identified barriers and facilitators to the state-level implementation of primary stroke center (PSC) policies, which encourage the certification or designation of specialized stroke treatment facilities and may address concerns such as transportation bypass, telemedicine, and treatment protocols. We studied the experiences of 4 states (Florida, Massachusetts, New Mexico, and New York) selected from the 18 states that had enacted PSC policies or were actively considering doing so. We conducted semistructured interviews during fieldwork in each case study state. Our results showed that system fragmentation, gaps in human and financial resources, and complexity at the interorganizational and operational levels are common barriers and that policy champions, stakeholder support and communication, and operational adaptation are essential facilitators in the adoption and implementation of PSC policies. The identification of barriers and facilitators reveals the contextual elements that can help or hinder policy implementation and may be useful in informing policy formulation and implementation in other jurisdictions. Proactively identifying jurisdictional challenges and opportunities may help facilitate the policy process for PSC designation and allow jurisdictions to develop more effective stroke systems of care.

Hospital-Level Variation in Mortality and Rehospitalization for Medicare Beneficiaries With Acute Ischemic Stroke

stroke is the second leading cause of hospital admission among older adults in the United States. However, little is known regarding contemporary ischemic stroke mortality and rehospitalization rates for Medicare beneficiaries and how they vary by hospital. we analyzed outcome data from 91 134 Medicare fee-for-service beneficiaries treated at 625 Get With The Guidelines-Stroke hospitals between April 2003 and December 2006. Within each hospital, 30-day and 1-year death or all-cause readmission rates were calculated with and without risk adjustment. in this cohort, mean age was 79.3 years, 58% were female, and 82% were white. In-hospital, 30-day, and 1-year unadjusted mortality from admission were 6.1%, 14.1%, and 31.1%, respectively, for participating hospitals. The median hospital-level 30-day unadjusted death or readmission rate after discharge was 21.4% (10th to 90th 14.4% to 28.6%). The overall rate of death or rehospitalization within 1 year of hospital discharge was 61.9%. Risk-adjusted rates varied widely by hospital at each time point. There were no improvements in death or rehospitalization from 2003 to 2006. Hospital-level performance in risk-adjusted outcomes did not significantly differ by size or primary stroke center designation, but academic hospitals and those in the Northeast or West had slightly more favorable outcomes. nearly two thirds of the Medicare beneficiaries discharged after ischemic stroke died or were rehospitalized within 1 year, but hospital-level outcomes varied considerably. These findings underscore the need to better understand the patterns and causes of deaths and readmission after ischemic stroke and to develop strategies aimed at avoiding those that are preventable.

Primary Stroke Center Education for Nurses

Primary Stroke Center designation by the Joint Commission distinguishes those healthcare organizations with exemplary stroke prevention and management. However, meeting the Joint Commission's high-level excellence standards is challenging. This article provides nurse leaders with a stroke education template, based on Donabedian's quality model, which meets Primary Stroke Center nurse education requirements. The authors describe the structure, process, and outcomes of a stroke education program for nurses, recognized as Best-in-Practice in Connecticut, successfully implemented in a community hospital.