Stroke Care Teams Research Articles

The Montreal Cognitive Assessment detects cognitive deficits that go unnoticed during clinical observation in the acute phase after stroke

ABSTRACT Background Detecting cognitive impairments early after stroke is essential for appropriate referrals. Although recommended in stroke guidelines, early cognitive screening is not always implemented. We assessed whether the Montreal Cognitive Assessment (MoCA) adds diagnostic value compared to clinical observation alone. In addition, discharge destinations for stroke patients with and without cognitive deficits detected with the screening tool or the treatment team were explored. Methods Forty-four stroke patients were screened with the MoCA during stroke unit admission. Their charts were studied for cognitive impairments reported by the stroke care team, who were blinded to screening scores. Proportions of detected cognitive deficits were compared between screening (score <26) and patient charts. Discharge destination distribution (home vs. rehabilitation) was explored. Results The proportion of cognitively impaired patients indicated by the MoCA (84%) and reported in patients’ charts (25%) differed significantly (p < 0.001). The distribution of discharge destination did not suggest an association with the detection of cognitive deficits by the treatment team or the cognitive screening. Conclusions The MoCA detects more cognitive deficits than clinical impression alone, emphasizing the importance of standard screening for cognitive impairments in acute stroke patients. Ultimately, systematic screening may enhance discharge planning and improve long-term outcomes.

Post Stroke Visual Impairment: Interdisciplinary Collaborative Program – Canadian Perspective

ABSTRACT Post-stroke visual impairment (PSVI) affects more than 60% of the people who have a stroke but visual function is not routinely assessed in most stroke units. Recent high-quality research in this field has produced evidence-based assessment and management practices for PSVI. Orthoptists have integrated into the stroke care team in the United Kingdom (UK) to provide this valuable service. This paper outlines the development and implementation of the first known orthoptic PSVI service in North America. A pilot program was developed between the Ophthalmology, Neurology, and Physical Medicine and Rehabilitation Departments in Saskatoon, Saskatchewan, Canada. A new referral pathway was established to refer stroke patients with PSVI directly to an orthoptist with specialization in PSVI. Clinical findings from the first year of operation are reported. One hundred and seven visual deficits were suspected by the referring service. Visual field deficits were the most commonly reported PSVI. Diplopia was the most commonly reported oculomotor deficit in this cohort, and visual neglect/inattention was the most common visual perceptual deficit reported. Reading issues were the most commonly reported functional issues. Following assessment by an orthoptist, 45 additional visual deficits were identified and addressed. Stroke patients require assessment and treatment for PSVI. Orthoptists are perfectly suited to PSVI assessment and management. There is an opportunity to increase orthoptists’ scope of practice in North America to ensure stroke patients receive specialized vision assessment and treatment.

Practice patterns, role and impact of advanced practice nurses in stroke care: A mixed-methods systematic review.

To undertake a systematic review of the practice patterns and roles of advanced practice nurses (APNs) in inpatient and outpatient stroke-care services; and to evaluate the impact of APN-led inpatient and outpatient stroke-care services on clinical and patient-reported outcomes. A mixed-methods systematic review. A systematic search was conducted across six electronic databases for primary studies. Data were synthesised using a convergent integrated approach. DATA SOURCES (INCLUDE SEARCH DATES) *FOR REVIEWS ONLY: A systematic search was conducted across PubMed, CINAHL, Cochrane Library, Embase, PsycInfo and ProQuest Dissertations & Theses Global, for primary studies published between the inception of the databases and 3 November 2022. Findings based on the 18 included primary studies indicate that the APNs' roles have been implemented across the continuum of stroke care, including pre-intervention care, inpatient care and post-discharge care. Practicing at an advanced level, the APNs engaged in clinical, operational and educational undertakings across services and disciplines. Positive clinical and patient-reported outcomes have been attributed to their practice. The review highlights the critical role of APNs in improving stroke care, especially in the pre-intervention phase. Their clinical expertise, patient-centered approach and collaboration can transform stroke care. Integrating APNs into stroke care teams is essential for better management and outcomes in light of the increasing stroke burden. Healthcare institutions should integrate APNs to enhance pre-intervention stroke care, improve diagnostic accuracy and expedite treatment. APNs can prioritise patient-centric care, including assessments, coordination and education. Medication reconciliation, timely rehabilitation referrals and lifestyle modifications for secondary stroke prevention are crucial. Implementing advanced practice nursing frameworks ensures successful APN integration, leading to improved stroke care and better patient outcomes in response to the growing stroke burden. What problem did the study address? Poor clarity of the role of advanced practice nurses among patients, physicians, healthcare professionals, health policymakers and nurses. What were the main findings? Advanced practice nurses practise across the continuum of stroke care, mainly in pre-intervention care which takes place before initiating treatment, inpatient care and post-discharge care. The implementation of the advanced practice nurse role in stroke care has contributed positively to clinical and patient-reported outcomes. Where and on whom will the research have an impact? Insights from the review are envisioned to inform healthcare policymakers and leaders in the implementation and evaluation of the APN role in stroke care. Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. No Patient or Public Contribution. TRIAL AND PROTOCOL REGISTRATION: https://figshare.com/ndownloader/files/41606781; Registered on Open Science Framework osf.io/dav8j.

P.060 Teamwork makes dreamwork: a stroke of genius

Background: Interprofessional collaboration is at the center of much of our work as Neurologists, yet often Medical Education inadequately prepares students for the complexities of interdisciplinary practice. Authentic, meaningful Interprofessional Education (IPE) requires consideration in involement of all individuals involved in interprofessional health care (IPHC) (Holbrook, 2013). Methods: We have collected authentic stories of acute stroke care through interviews with patients and other health care professionals on the acute stroke care team. Drawing on these narratives, we have crafted a multimedia story combining film, photography, and art. Results: This case will be integrated into Western University’s Undergraduate Medical Education curriculum but is intended to be a valuable tool for teaching IPE competencies in all IPE contexts. All media will be available thorugh Western Libaries open access Health Education Media Library. Main learning outcomes include improved recognition of HCP roles and the vital and diverse contributions of each team member. Conclusions: Drawing on the experiences of real stroke patients, families, and all other HCPs, we have crafted a rich educational case portraying the complexity of IPHC that will allow learners to reflect on the complex roles of health professoinals in a successful interprofessional team.

Abstract WP34: Collaboration Between Acute Care Hospitals And Rehabilitation Hospitals Reduces 30-day Readmission And Mortality After Ischemic Stroke Hospital Discharge

Background: To improve transitions of care from an acute hospital to an acute rehabilitation hospital, monthly multidisciplinary case review meetings among these hospitals' staff were implemented in 2020. This study aimed to determine whether this effort improved the outcomes of stroke patients. Methods: Monthly online meetings among the acute stroke care team and 3 rehabilitation hospital team leaders were implemented in a large healthcare system. The goal of these meetings was to review all readmissions in-depth, promote communication, and establish best practice protocols to reduce adverse events. We compared patient outcomes before (2018-2019, n=360) and after (2020-2021, n=264) the intervention using multivariate logistic regression models. The primary outcomes were all-cause mortality and readmission within 30 days after acute hospital discharge. Secondary outcomes were 30-day mortality, readmission, and ED visits. The models were adjusted for patient demographics, comorbidities, stroke severity assessed with the National Institute of Health Stroke Scale (NIHSS), and hospital stroke certification status. Results: The median patient age was 70 (interquartile range [IQR]: 60;79), and 297 (48%) were females. The patients in the post-intervention period had longer hospital stays (median 6 vs. 5 days, p&lt;.0001) and higher median NIHSS scores (6 vs. 4, p=0.03). The intervention was associated with lower 30-day all-cause mortality and readmission (12% vs. 22%, Adjusted odds ratio [aOR], 0.562; 95% confidence interval [CI], 0.344-0.920). Readmissions alone were reduced (11% vs. 22%, aOR, 0.557; 95% CI, 0.338-0.918). No significant associations between the intervention and mortality (aOR, 1.00; 95% CI, 0.21-4.85) or ED visits (aOR, 0.86; 95% CI, 0.52-1.40) were found. Conclusion: The multidisciplinary case review meetings among neurology and rehabilitation staff may greatly reduce 30-day hospital readmissions and mortality after acute stroke hospital discharge.

AC-ABAC: Attribute-based access control for electronic medical records during acute care

Acute care demands fast response and procedures from the healthcare professionals involved in the emergency. The availability of electronic medical records (EMR) enables acute care teams to access patient data promptly, which is critical for proper treatment. The EMR contains sensitive data, so proper access control is a necessity. However, acute care situations entail the introduction of dynamic authorisation techniques that are able to swiftly grant access to the acute care teams during the treatment and that at the same time can revoke it as soon as the treatment is over. In this work, our contributions are threefold. First, we propose a step-by-step methodology that defines dynamic and fine-grained access control in acute care incidents. Then, we applied this methodology with the Amsterdam University Medical Center acute stroke care teams, resulting in a new model coined ’Acute Care Attribute-Based Access Control (AC-ABAC)’. AC-ABAC implements access control policies that take into account contextual attributes for dynamically sharing patient data with the appropriate healthcare professionals during the life cycle of acute care. Finally, we evaluate the performance and show the feasibility and correctness of AC-ABAC through a prototype implementation of the model and simulation of patient data requests in various scenarios. The results show that the most complex policy evaluation takes on average 194.89 ms, which is considered worthwhile when compared to the added value to the system’s security and the acute care process.

Abstract TP32: From Stroke Code To Stroke Clinic; The Emerging Role Of The Stroke Nurse Navigator

Background: With numerous stroke centers across the US now caring for complex stroke patients, the role of the stroke nurse navigator has catapulted to be one of the critical elements of a successful stroke program. Our hospital developed an innovative model that addresses the transitions of care after stroke and describes the unique nurse navigator model for stroke patients and families. Methods: Under a triple aim mission statement to support patients and families throughout the care continuum, five practice domains were identified spanning the patient’s stroke journey - see table 1. For each domain, expected experiences were described and best practices were outlined. Results: Our hospital supported hiring stroke nurse navigators to develop best practices as a complementary role to the stroke care teams during each phase of the patient’s hospitalization to promote a seamless from stroke code to stroke clinic. After discharge, the navigators aligned with acute and subacute rehabilitation teams, visiting nurse agencies, and with patients and caregivers at home. In addition to clinical care, the navigators participated in quality improvement projects, regulatory readiness for certification, and community outreach programs - see Table 2. Discussion: The stroke nurse navigator, as a critical member of the stroke program, is uniquely positioned to optimize the transitions of care for patients and families recovering from stroke. This evolving model of acute and recovery stroke care identifies the practice domains and outlines the navigator practice responsibilities that compliments the medical care along the stroke recovery care continuum.Table 1. Table 2.

Abstract WMP33: Longitudinal Use Of The American Stroke Association Time Tracker Tool To Reduce Door To Needle And Door To Device Times In Stroke

Introduction: The faster IV Alteplase and mechanical thrombectomy is initiated in acute ischemic stroke, the better the outcome. Delays can significantly impact times to treatment. A mechanism to communicate time targets to code stroke teams can play an important role in providing knowledge about time sensitive metrics. The utilization of the ASA Stroke Time Tracker tool was created to improve communication in a timely manner to stroke teams providing acute treatment. The emphasis is on the education of time targets to improve door to treatment times. Hypothesis: To explore whether the use of the American Stroke Association Time Tracker tool as a communication instrument is associated with improved DTN and DTD times in both direct and transfer patients. Methods: In March 2020 the application of the ASA time tracker tool was introduced. A retrospective review revealed that DTN times improved from 58.7% to 71.6 % for those receiving t-PA within 45 minutes or less during the period the tool was in use. To explore whether timely feedback using the Time Tracker tool was associated with improved DTD times, mechanical thrombectomy data including DTD was collected and communicated to stroke care teams in April 2021. Compilation of time sensitive metrics in the evaluation of DTN times continued through Q2 2021. A retrospective analysis was conducted. Results: For those who received IV Alteplase, the percentage of patients treated within 30 minutes continued to improve, 21.1% (Q3 2020) vs. 35.7% (Q2 2021). The percentage of patients treated within 45 minutes also improved from 71.8% (Q3 2020) to 80.0% (Q2 2021). In patients who received endovascular therapy during Quarter 3 2020, 56.1% met the advanced therapy AHA Elite Plus criteria of DTD within 60 minutes (transfer patients) OR within 90 minutes (direct admit). This improved to 73.1% patients in Quarter 2 2021, during the use of the tool. Conclusions: There is an association between use of the ASA Time Tracker tool and improved DTN and DTD times. Further study should include continued use of the tool to confirm an association between direct communication with Code Stroke teams and improved treatment times.

Abstract 1122‐000033: Automated Detection of Intracerebral Hemorrhage Using Artificial Intelligence: Pilot Deployment of Viz ICH

Introduction : Stroke is a major cause of morbidity and mortality. Hemorrhagic strokes are often more severe and associated with higher mortality when compared to ischemic stroke and account for approximately 13% of all strokes. Initial care for patients with intracerebral hemorrhage (ICH) is in part guided by neuroimaging findings. Non‐contrast computed tomography (NCCT) is often the first imaging obtained in the work up of the acute stroke patient given its diagnostic accuracy for hemorrhage, ubiquity, low cost, and short scan time. Immediate evaluation of imaging by stroke experts, such as neurologists, neurosurgeons, and radiologists, is essential. Artificial intelligence tools can help to expedite image assessment and careteam coordination thereby accelerating time to treatment. In this study, we report on the use of Viz ICH, an AI‐enhanced ICH detection platform, to identify ICH on initial CT and coordinate emergent care in an urban health system with an ICH Center. Methods : All consecutive stroke codes presenting with ICH from May 2019 to August 2019 were eligible for analysis. Non‐contrast CT (NCCT) was conducted for each patient and submitted to the Viz ICH in a prospective fashion. An automated volumetric analysis of these NCCTs was conducted by Viz ICH and assessment was conducted for potential ICH. If suspected ICH was detected, Viz ICH sent an automated prompt to the stroke care team for review. CT impressions provided by radiologists served as the clinical reference standard test and Viz ICH output served as the index test. Diagnostic accuracy tests were then performed. Results : A total of 682 patients were analyzed for ICH, out of which 28 patients were positive for intracerebral hemorrhage (ICH) (4%) and 654 were negative for hemorrhage (96%) based on radiology impressions. Viz ICH was able to correctly identify hemorrhages in 25/28 patients and non‐hemorrhages in 650/654 patients. Overall, the software had high diagnostic accuracy with 89.3% sensitivity, 99.4% specificity, and an overall accuracy of 99.0%. The software also had a positive predictive value of 86.2%, a negative predictive value of 99.5%, a positive likelihood ratio of 145.98, and a negative likelihood ratio of 0.108. Conclusions : Viz ICH is an AI‐enhanced platform that may help in the diagnosis and detection of ICH, with a sensitivity of 89.3 and a specificity of 99.4% in this preliminary study. Though future validation studies with a larger cohort of patients positive for each type of hemorrhage must be conducted for true diagnostic accuracy data, Viz ICH has the potential to be an adjunct tool to streamline ICH triage, reduce treatment delays, and improve outcomes of patients presenting with ICH.

Abstract 50: Virtual Care via Mobile Application Using a Patient Electronic Health Record Portal is Feasible and Increases Stroke Patient Engagement - A Pilot Study

Introduction: Improving patient engagement in post-acute stroke cohort is challenging. Additional tools are necessary to help patients take an active role their health. Care Companion is an interactive patient engagement tool embedded within a patient’s EHR portal that can provide disease-specific education, symptom monitoring, medication reminders and patient self-reported outcomes. The application was created for patients within the existing Stroke Care Model who are followed for 90 days post-acute. As the first organization to pilot EPIC Care Companion for acute stroke patients, we aimed to evaluate the feasibility of a mobile application and its impact on patient engagement. Methods: We developed stroke specific content for Care Companion including automated alert parameters. Patients were selected based on co-morbidities, willingness and ability to participate and access to a mobile device. Individualized content was electronically sent to the patient via mobile device notifications at predetermined intervals. Patients responded to questionnaires, and input individualized data including blood pressure readings, exercise logs, glucose levels, and nicotine consumption. Patients were able to contact all members of the care team and request assistance to manage risk factors. Participants completed a Likert scale impact survey at day 90. We compared total number of patient-nurse navigator interactions between Care Companion users versus non-users with a t-test. Results: Since January 2020, 406 patients were enrolled in the Stroke Care Model and completed 90 days of follow up. We enrolled 39 patients in the pilot. Patient reported impact surveys were returned in 25 out of 39 patients (64% response rate). Most patients reported that it was easy to enroll in Care Companion (100%) and complete assigned tasks (96%). Patients found the educational content useful (91%) and made lifestyle changes based on the information (90%). Patients enrolled in Care Companion had significantly more interactions with their care team compared to non-enrolled patients (6.6 ± 4.6 vs 3.1 ± 1.9), p&lt;.0001. Conclusion: Implementation of Stroke Care Companion was feasible and increased patient engagement with the stroke care team.

Expanding the stroke team to include interventional cardiology.

Team-based care has been emphasized as a strategy to improve and optimize outcomes for broad groups of patients who have presented with often complex medical conditions including large vessel cerebral occlusion. Although neurointerventionalists from different specialties perform mechanical embolectomy, which has become the standard of care for large vessel cerebral occlusion, these specialties are limited by relatively low numbers typically concentrated in a small number of sites. In this single center experience, approximately 50 patients with large vessel stroke were transferred out of an emergency room to other centers despite the availability of an experienced cardiologist with extensive carotid experience. Such transfer strategies typically result in delays in receiving reperfusion and, therefore, may decrease the success rates and substantial improvement that can be obtained by patients in this setting. Trained interventional cardiologists in centers with limited 24/7/365 coverage could achieve rapid revascularization and reperfusion saving lives. In order to accommodate the need for treating these patients, carotid stent trained cardiologists should enter the arena, learn mechanical embolectomy, and be supported by their colleagues from other disciplines on acute stroke care teams.

The Cost Effectiveness of Mobile Stroke Unit in the United States

Research ObjectiveIschemic stroke accounts for 87% of all strokes and is a leading cause of morbidity and mortality in the United States. Timely administration of thrombolysis (rtPA) and proper supportive care are essential to recovery of IS patients. Recent data show that compared to standard ambulances, use of Mobile Stroke Units (MSUs)—ambulances equipped with telemedicine, a stroke care team, and radiologic assistance—significantly shorten the time to rtPA administration, potentially increasing likelihood of recovery. However, it is unknown whether these health benefits are substantial to offset the high incremental costs of operating and deploying MSUs. This study assessed the cost‐effectiveness care of ischemic stroke patients via MSUs compared to care via standard ambulances, using the U.S. health care sector’s perspective.Study DesignWe developed a Markov‐based decision‐tree model to track the annual transitions of individuals in a representative cohort of 1000 U.S. ischemic stroke patients across four health states (no disability, minor disability, major disability, and death), over a lifetime horizon and under two treatment scenarios: treatment via MSU vs treatment via standard ambulance. The model was parameterized using probabilities of stroke severity, likelihood of rtPA administration, and health state transition probabilities, as well as the total annual costs and disability‐adjusted life years (DALYs) associated with each health state. All parameter values were derived from the published literature. All costs were converted to year 2018 U.S. dollars. Total discounted costs, DALYs, incremental costs, DALYs averted, and incremental cost‐effectiveness ratio (ICER) of care via MSU, relative to care standard ambulance, were calculated. A probabilistic sensitivity analysis with 1000 iterations of the model was conducted to account for uncertainty in the model’s parameter values.Population StudiedPopulation consisted of a representative cohort of 1000 ischemic stroke patients 18 years and older, living in the United States.Principal FindingsPreliminary base case results show that relative to care via standard ambulances, care via MSUs averted 651 discounted DALYs (87 406 vs 88 057 DALYs, respectively) at an additional discounted cost of $11 million ($195 million vs $184 million, respectively). Assuming an average U.S. willingness‐to‐pay threshold of $150 000 per DALY averted, our results demonstrate that treatment of ischemic stroke via MSU is highly cost‐effective compared to care via standard ambulance, resulting in $17 498 per DALY averted. The probability sensitivity analysis showed that the ICER was robust to uncertainty in parameter values, with 85% of simulated values being cost‐effective at the willingness‐to‐pay threshold of $150 000/DALY averted.ConclusionsResults suggest that from a U.S. health care sector’s perspective, care via MSU is a highly cost‐effective approach for improving health outcomes after ischemic stroke compared to care via standard ambulance.Implications for Policy or PracticeMobile Stroke Units can significantly reduce time from alarm to thrombolysis administration in ischemic stroke patients. Our preliminary findings support the adoption of care via MSU as a cost‐effective approach for improving health outcomes in ischemic stroke patients.

Knowledge of the Egyptian emergency physicians about the use of rt-PA in acute ischemic stroke

BackgroundThe administration of recombinant tissue plasminogen activator (rt-PA) has increased the focus on acute ischemic stroke (AIS) as an emergency condition. The emergency physicians have to rapidly recognize the patients who are candidates for rt-PA and refer them to the specialized stroke team within the proper time window. The knowledge of the emergency physicians about the benefit and the drawbacks of this therapy is crucial and it affects their attitudes towards its use.ObjectiveTo apply a survey on the Egyptian emergency physicians aiming to investigate their knowledge about the use rt-PA therapy in AIS.MethodologyA self-administered questionnaire was sent to the emergency physicians who are working in three Egyptian governorates.ResultsOut of 120 emergency physicians, the total knowledge of the study group was good with a score of 7 ± 1.8/11. Most of the participants mentioned the correct answers (over 50%) for all items except for one question regarding the blood glucose control before the use of rt-PA. Significant positive correlation was noted between the knowledge score and the age.ConclusionsThe surveyed emergency physicians had a good knowledge about the use of rt-PA in AIS, yet, this knowledge is mainly theoretical. Therefore, tutorials, clinical training, and active engagement in the stroke care team are warranted to improve their clinical practice.

Abstract WP456: Using An Electronic Dashboard To Improve Communication On Stroke Core Measure Compliance

Background and Purpose: Several years ago, an excel spreadsheet was created to improve real time communication about stroke core measure compliance to all the inpatient units. This daily spreadsheet was sent to the nursing leadership to be shared with the nurse or MD to ensure the stroke orders were carried out and patient education provided. The process to review each chart daily for compliance with the core measures, enter it into the spreadsheet, send it to the nursing leadership daily took approximately 3 hours or more a day. This was not an efficient use of time. We decided to create an electronic dashboard that would extract all of the stroke core measure information from the electronic patient record automatically, eliminating manual abstraction, thus making the process more efficient while allowing effective communication throughout the organization. Methods: Our IT department, working alongside our Stroke Care Team, developed data extraction processes pertinent to Stroke Core Measures to allow for an hourly extraction into a Tableau dashboard. This software allows for logic to be applied to the various elements to evaluate the successful completion of each core measure for patients currently admitted to our institution for Stroke-related diagnoses and conditions. Results: The key stake holders for each unit review the dashboard which is refreshed hourly to identify areas that have not met the measure. After the review, the leadership implements a plan to improve attainment for these measures. The dashboard has also allowed for correction of documentation in real time but has limitations because it depends on the data within the electronic medical record and the programing to extract that data. The team communicates with our IT department to correct the issues with the data displayed in tableau. Conclusions: The tableau dashboard is an effective and efficient tool providing a snapshot of the current attainment of the primary and comprehensive stroke core measures. The implementation of this dashboard has increased awareness of the stroke core measure compliance and has improved communication among the clinical staff.

Variations in hospital resource use across stroke care teams in England, Wales and Northern Ireland: a retrospective observational study

ObjectiveTo identify the main drivers of inpatient stroke care resource use, estimate the influence of stroke teams on the length of stay (LoS) of its patients and analyse the variation...

Abstract WMP16: Artificial Intelligence Detection of Cerebrovascular Large Vessel Occlusion - Nine Month, 650 Patient Evaluation of the Diagnostic Accuracy and Performance of the Viz.ai LVO Algorithm

Introduction: Prompt and accurate identification of Large Vessel Occlusion (LVO) for Acute Ischemic Stroke (AIS) by CTA is essential for optimal endovascular reperfusion therapy. The Viz.ai algorithm (Viz LVO) was developed to process head and neck CTAs using a convolutional neural network artificial intelligence platform to identify anterior circulation LVOs from the ICA-T to the sylvian MCA M1 segments. We evaluated the diagnostic accuracy and notification time of Viz LVO compared with our institutional standard of care. Methods: Consecutively acquired CTAs performed for suspected AIS between 3/1/2016 and 11/30/2017 were identified for inclusion. No studies were excluded from analysis to reflect our institutional prevalence of anterior circulation LVOs. The CTAs were evaluated by the Viz-AI-Algorithm® v4.1.2. The processing time and automated LVO detection were recorded. These were compared against the radiology report, the radiologist to stroke care team time-to-notification, as well as an independent review of all studies by a neuroradiologist for secondary findings that may influence the accuracy of Viz LVO. Results: Analysis of 650 CTAs performed for AIS was conducted for 650 patients. The mean patient age was 66 (SD 15), 51% were female, and 30% of all studies were positive for anterior circulation LVO. Viz.ai demonstrated a sensitivity of 82%, specificity of 94%, PPV of 77%, and NPV of 95%. There were 31 false positives (16 due to intracranial atherosclerosis) and 23 false negatives reported by Viz.ai. Forty one cases were not processed due to metal artifact, inadequate contrast, motion artifact, or excess z-spacing variability. The mean processing time for Viz.ai was 5 minutes with a maximum of 8 minutes for all studies. The mean clinical standard-of-care notification time at our institution was 32 minutes with a maximum of 116 minutes. Conclusion: To the best of our knowledge, this is the first AI-algorithm for detecting intracranial LVOs. Viz LVO has demonstrated impressive performance for accurate identification and timely notification of proximal intracranial LVOs. Future endeavors to optimize detection of LVO in poor quality CTAs, despite anatomic variations such as tortuosity, and of the MCA-M2 are ongoing.

Abstract MP058: Racial and Gender Differences in Acute Ischemic Stroke Pre-hospital Documentation: Last Known Well, Pre-alert Notification and Stroke Severity, Paul Coverdell National Acute Stroke Program, 2012-2015

Stroke is the fifth leading cause of death in the United States and a major cause of adult disability. Documentation of stroke-related factors that occur before arrival to the hospital or immediately upon arrival may be critical in determining patient eligibility for life-saving measures, including receipt of thrombolytic therapy (e.g., alteplase) and other neurointerventional treatment. There is a need to describe differences in documentation of pre-hospital measures, in order to improve overall stroke patient care. De-identified data for 216,129 stroke patients were reported by hospital personnel during the 2012-2015 Paul Coverdell National Acute Stroke Program. Chi-square tests were performed to examine the differences on demographic and pre-hospital measures by gender and race. The median age was greater for females than males (75 vs 68 years) and for whites than blacks (74 vs 63 years). A higher percentage of females had Medicare coverage than males (67.8% vs. 57.4%, p&lt;0.001), while blacks had higher Medicaid coverage than whites (12.8% vs. 4.2%, p&lt;0.0001). Females (49.9%) and blacks (48.8%) had the highest percentage of arrival by EMS. Among patients who arrived by emergency services, the percentage of blacks with advance notification of stroke was lower than whites (49.8% vs. 58.2%, p&lt;0.0001). Females (53.0%) were slightly less likely to have last known well time recorded than males (53.8%). Blacks were significantly less likely to have last known well time and stroke severity recorded compared whites (p&lt;0.0001). The median time interval between last known well and emergency department arrival for blacks were 4.8 hours, significantly longer than median time of 4.0 hours for whites (p&lt;0.001). Differences in documentation of pre-hospital measures, particularly between racial groups, suggest room for improvement in communication of information from the pre-hospital environment to emergency department staff, which may support access to critical links in the chain of stroke survival, including activation of stroke care teams who can provide swift access to life-saving treatment.

The integrated care pathway for post stroke patients (iCaPPS): a shared care approach between stakeholders in areas with limited access to specialist stroke care services

BackgroundLack of intersectoral collaboration within public health sectors compound efforts to promote effective multidisciplinary post stroke care after discharge following acute phase. A coordinated, primary care-led care pathway to manage post stroke patients residing at home in the community was designed by an expert panel of specialist stroke care providers to help overcome fragmented post stroke care in areas where access is limited or lacking.MethodsExpert panel discussions comprising Family Medicine Specialists, Neurologists, Rehabilitation Physicians and Therapists, and Nurse Managers from Ministry of Health and acadaemia were conducted. In Phase One, experts chartered current care processes in public healthcare facilities, from acute stroke till discharge and also patients who presented late with stroke symptoms to public primary care health centres. In Phase Two, modified Delphi technique was employed to obtain consensus on recommendations, based on current evidence and best care practices. Care algorithms were designed around existing work schedules at public health centres.ResultsIndication for patients eligible for monitoring by primary care at public health centres were identified. Gaps in transfer of care occurred either at post discharge from acute care or primary care patients diagnosed at or beyond subacute phase at health centres. Essential information required during transfer of care from tertiary care to primary care providers was identified. Care algorithms including appropriate tools were summarised to guide primary care teams to identify patients requiring further multidisciplinary interventions. Shared care approaches with Specialist Stroke care team were outlined. Components of the iCaPPS were developed simultaneously: (i) iCaPPS-Rehab© for rehabilitation of stroke patients at community level (ii) iCaPPS-Swallow© guided the primary care team to screen and manage stroke related swallowing problems.ConclusionCoordinated post stroke care monitoring service for patients at community level is achievable using the iCaPPS and its components as a guide. The iCaPPS may be used for post stroke care monitoring of patients in similar fragmented healthcare delivery systems or areas with limited access to specialist stroke care services.Trial registrationNo.: ACTRN12616001322426 (Registration Date: 21st September 2016).

Abstract TP406: Mapping Stroke Team Network Structure and Function to Enhance Acute Stroke Care Quality Improvement Efforts

Background: Acute ischemic stroke (AIS) clinical outcomes are time-dependent and are influenced by the organization and capability of the care delivery system. The focus of stroke care quality improvement has emphasized process and procedure. Integrating a systematic assessment of the structure and inter-dependencies of the stroke care team members has the potential to enhance the understanding of the overall function of the team and strengthen existing quality improvement efforts. Objective: Describe a multi-modal quality improvement approach consisting of process/clinical outcome measures, workflow analysis and personnel structure mapping of acute stroke care teams. Method: Key site-specific hospital characteristics, including the variability of stroke treatment processes of individual teams, were identified. A critical path analysis was created based on a standard acute stroke care process model. Stroke care team structures and inter-dependencies were mapped based on the responses to a short survey and the responses were analyzed using open source network analytic software (Gephi). Analysis results were interpreted in context of the characteristics of the hospital units. Results: The care team personnel structures were overlayed on the stroke care process pathways to create a final synthesis of the process and team structure ( (Example in figure below). Critical path analyses combined with previously unidentified opportunities to strengthen the individual team member interactions were linked to process/clinical outcomes. Opportunities for site-specific improvement in both process and personnel organization and communication were identified. Case studies will be presented. Conclusion: A clinical microsystems analytic approach that includes formal site-specific representations of the care team structure is feasible and provides a valuable addition to process analysis for quality improvement programs.

Abstract WP254: Emergency Medicine Pharmacist Impact on Door-to-Needle Time in Patients with Acute Ischemic Stroke

Introduction: Current AHA/ASA guidelines recommend a door-to-needle time (DTN) of 60 minutes or less when administering tPA for acute ischemic stroke (AIS). Several studies have correlated early administration of tPA for AIS to improved outcomes. At the study setting, emergency medicine pharmacists (EMPs) are part of the acute stroke care team and are heavily involved in initial stroke care including patient evaluation, acute hypertension management, and preparation and administration of tPA. The purpose of this study was to determine the impact of EMPs on the outcomes of patients with AIS treated with tPA in the emergency department. Methods: This was a retrospective, single-center, cohort study of patients who received tPA between August 1, 2012 and August 30, 2014. Patients were included if they had a preliminary diagnosis of AIS. Patients were excluded if they received tPA at an outside medical facility or received tPA for an indication other than AIS. The primary objective of this study was to compare DTN times with or without EMP involvement in AIS care. Secondary objectives included evaluating changes in neurological status via measurement of the National Institutes of Health stroke scale (NIHSS), rate of symptomatic intracranial hemorrhage, rate of in-hospital mortality, and discharge disposition. Results: A total of 100 patients were included. EMPs were involved in the care of 49 patients. EMP care was associated with a significant improvement in DTN time (median 46 [IQR 34.5 - 67] minutes vs. 58 [IQR 45 - 79] minutes), p=0.019. There was also a significant improvement in NIHSS scores at 24 hours post-tPA in favor of the EMP group (median NIHSS 1 [IQR 0 - 4] vs. 2 [IQR 1 - 9.25]), p=0.047. There were no other significant differences between groups with regard to secondary outcomes. Conclusions: The involvement of an EMP in the initial care of AIS patients was associated with a significant improvement in DTN times and NIHSS scores at 24 hours post-tPA.