Stroke Certification Research Articles

TCT-903 Association of TVT Site Risk Adjusted Stroke Rates and Joint Commission Stroke Certification Designation Level

TCT-903 Association of TVT Site Risk Adjusted Stroke Rates and Joint Commission Stroke Certification Designation Level

Provision of Stroke Care Services by Community Disadvantage Status in the US, 2009-2022

Stroke center certification is granted to facilities that demonstrate distinct capabilities for treating patients with stroke. A thorough understanding of structural discrimination in the provision of stroke centers is critical for identifying and implementing effective interventions to improve health inequities for socioeconomically disadvantaged populations. To determine whether (1) hospitals in socioeconomically disadvantaged communities (defined using the Area Deprivation Index) are less likely to adopt any stroke certification and (2) adoption rates differ between entry-level (acute stroke-ready hospitals) and higher-level certifications (primary, thrombectomy capable, and comprehensive) by community disadvantage status. This cohort study used newly collected stroke center data merged with data from the American Hospital Association, Healthcare Cost Report Information datasets, and the US Census. All general acute hospitals in the continental US between January 1, 2009, and December 31, 2022, were included. Data analysis was conducted from July 2023 to May 2024. The primary outcome was the likelihood of hospitals adopting stroke care certification. Cox proportional hazard and competing risk models were used to estimate the likelihood of a hospital becoming stroke certified based on the socioeconomic disadvantage status of the community. Among the 5055 hospitals studied from 2009 to 2022, 2415 (47.8%) never achieved stroke certification, 602 (11.9%) were certified as acute stroke-ready hospitals, and 2038 (40.3%) were certified as primary stroke centers or higher. When compared with mixed-advantage communities, adoption of any stroke certification was most likely to occur near the most advantaged communities (hazard ratio [HR], 1.24; 95% CI, 1.07-1.44) and least likely near the most disadvantaged communities (HR, 0.43; 95% CI, 0.34-0.55). Adoption of acute stroke-ready certification was most likely in mixed-advantage communities, while adoption of higher-level certification was more likely in the most advantaged communities (HR,1.41; 95% CI, 1.22-1.62) and less likely for the most disadvantaged communities (HR, 0.31; 95% CI, 0.21-0.45). After adjusting for population size and hospital capacity, compared with mixed-advantage communities, stroke certification adoption hazard was still 20% lower for relatively disadvantaged communities (adjusted HR, 0.80; 95% CI, 0.73-0.87) and 42% lower for the most disadvantaged communities (adjusted HR, 0.58; 95% CI, 0.45-0.74). In this cohort study examining hospital adoption of stroke services, when compared with mixed-advantage communities, hospitals located in the most disadvantaged communities had a 42% lower hazard of adopting any stroke certification and relatively disadvantaged communities had a 20% lower hazard of adopting any stroke certification. These findings suggest that there is a need to support hospitals in disadvantaged communities to obtain stroke certification as a way to reduce stroke disparities.

Abstract WP56: Neuroscience Nurse Navigator a New Compass in Continuation of Care Among Stroke Populations

Background and Purpose: Due to continued growth in our neurosciences program, of more than 1,400 discharged stroke patients per year, we saw a need for the creation of a Neuroscience Nurse Navigator (NNN) position, with initial efforts specifically focused in the stroke program. This role was developed as a means to meet and fulfill Joint Commission recommendations, along with the Comprehensive Stroke Certification (CSC) standards. Prior to the NNN role, compliance for attempted patient callbacks (a CSC requirement for those discharged home) was only 70%. Resources to support patient needs post-discharge were limited. Method: The process in creating this role began in 2020 and came to fruition in 2022. As a means to address patient call back compliance, those patients who have been identified as having a stroke, are visited as a point of introduction, also allowing time for unanswered questions. All stroke patients are called within a seven-day window, including those on our Neurosurgery service line. Patients are asked a series of 12 pre-set questions with calls varying from 6-10 minutes. To address the issue of post-discharge resources, the NNN aids in facilitating and arranging follow up appointments and is available to assist with patient questions prior to follow up appointments. The development of the stroke support group was initiated as well. Working with marketing and IT, the NNN created the Brain Matters stroke support group, which includes an informational postcard with QR code provided to stroke patients at time of discharge, and a separate email account. Patients can use this email to ask for a registration form for Brain Matters and allows the facilitator to communicate to the group as a whole. Results: Since implementing the NNN, attempted call-back rate among the 7-day calls have reached 100%, and completed call-backs (patient or family reached) increased from 70% to 85%. In relation to post-discharge resources, the creation of the Brain Matters stroke support group has been implemented and data is currently ongoing. Conclusion: The future plan is to further develop the NNN role as a necessary resource for all patients within the entire Neuroscience service line, including General Neurology, Epilepsy and Neurosurgery, as they navigate toward recovery.

Relationships among hospital acute ischemic stroke volumes, hospital characteristics, and outcomes in the US

Background and ObjectivesPrior research on volume-based patient outcomes related to acute ischemic stroke (AIS) have demonstrated contradictory results and fail to reflect recent advances in stroke care. We sought to examine contemporary relationships between hospital AIS volumes and outcomes. MethodsWe used complete Medicare datasets in a retrospective cohort study using validated International Classification of Diseases Tenth Revision codes to identify patients admitted with AIS from January 1, 2016 through December 31, 2019. AIS volume was calculated as the total number of AIS admissions per hospital during the study period. We examined several hospital characteristics by AIS volume quartile. We performed adjusted logistic regressions testing associations of AIS volume quartiles with: inpatient mortality, receipt of tissue plasminogen activator (tPA) and endovascular therapy (ET), discharge home, and 30-day outpatient visit. We adjusted for sex, age, Charlson comorbidity score, teaching hospital status, MDI, hospital urban-rural designation, stroke certification status and ICU and neurologist availability at the hospital. ResultsThere were 952400 AIS admissions among 5084 US hospitals; AIS 4-year volume quartiles were: 1st: 1-8 AIS admissions; 2nd: 9-44; 3rd: 45-237; 4th: 238+. Highest quartile hospitals more often were stroke-certified (49.1% vs 8.7% in lowest quartile, p<0.0001), with ICU bed availability (19.8% vs 4.1%, p<0.0001) and with neurologist expertise (91.1% vs 3%, p<0.0001). In the highest AIS quartile (compared to the lowest quartile), there was lower inpatient mortality (odds ratio [OR] 0.71 [95%CI 0.57-0.87, p<0.0001]), lower 30-day mortality (0.55 [0.49-0.62], p<0.0001), greater receipt of tPA (6.60 [3.19-13.65], p<0.0001) and ET (16.43 [10.64-25.37], p<0.0001, and greater likelihood of discharge home (1.38 [1.22-1.56], p<0.0001). However, when the highest quartile hospitals were examined separately, higher volumes were associated with higher mortality despite higher rates of tPA and ET receipt. ConclusionsHigh AIS-volume hospitals have greater utilization of acute stroke interventions, stroke certification and availability of neurologist and ICU care. These features likely play a role in the better outcomes observed at such centers, including inpatient and 30-day mortality and discharge home. However, the highest volume centers had higher mortality despite greater receipt of interventions. Further research is needed to better understand volume-outcome relationships in AIS to improve care at lower volume centers.

Relationships among Hospital Acute Ischemic Stroke Volumes, Hospital Characteristics, and Outcomes in the US (P14-5.025)

<h3>Objective:</h3> We sought to examine contemporary relationships between hospital acute ischemic stroke (AIS) volumes and outcomes. <h3>Background:</h3> Prior research on AIS volume-based patient outcomes demonstrated contradictory results and failed to reflect recent advances in stroke care. <h3>Design/Methods:</h3> We used complete Medicare datasets in a retrospective cohort study employing validated International Classification of Diseases Tenth Revision codes to identify patients admitted with AIS from January 1, 2016 through December 31, 2019. AIS volume was calculated as the total number of AIS admissions per hospital during the study period. We examined hospital characteristics by AIS volume quartile. We performed adjusted logistic regression testing associations of AIS volume with: inpatient mortality, receipt of tissue plasminogen activator (tPA) and endovascular therapy (ET), discharge home and 30-day outpatient visit. We adjusted for sex, age, Charlson comorbidity score, teaching hospital status, socioeconomic status, hospital urban-rural designation, stroke certification status, and ICU and neurologist availability at the hospital. <h3>Results:</h3> There were 952400 AIS admissions among 5084 US hospitals; AIS 4-year volume quartiles were: 1st: 1–8 AIS admissions; 2nd: 9–44; 3rd: 45–237; 4th: 238+. Highest quartile hospitals more often were stroke-certified (49.1% vs 8.7% in lowest quartile, p&lt;0.0001), with ICU bed availability (19.8% vs 4.1%, p&lt;0.0001) and with neurologist expertise (91.1% vs 3%, p&lt;0.0001). For every ten-unit increase in volume, there were higher odds of receiving tPA (OR 1.009, 95% CI 1.008–1.01, p&lt;0.0001) and ET (1.041, 1.037–1.046, p&lt;0.0001), but also higher inpatient mortality (1.004, 1.003–1.005, p&lt;0.0001) and 30-day mortality (1.001, 1.001–1.002, p&lt;0.0001). <h3>Conclusions:</h3> High AIS-volume hospitals have greater utilization of acute stroke interventions, stroke certification and availability of neurologist and ICU care. Despite these advantages, higher AIS volumes were associated with increased inpatient and 30-day mortality. Further research is needed to better understand volume-outcome relationships in AIS to provide effective stroke care and accurately risk-adjust hospital outcomes. <b>Disclosure:</b> Dr. McCarthy has nothing to disclose. Dr. Daniel has nothing to disclose. Dr. Santos has nothing to disclose. Dr. Dhamoon has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Faegre Baker Daniels LLP. Dr. Dhamoon has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Wellstar Health System Inc. Dr. Dhamoon has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Fabiani Cohen &amp; Hall, LLP. Dr. Dhamoon has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Kramer, Dillof, Livingston &amp; Moore. Dr. Dhamoon has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Robins Kaplan. Dr. Dhamoon has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Parker Waichman LLP. Dr. Dhamoon has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Heidell, Pittoni, Murphy &amp; Bach, LLP.

Variation in US acute ischemic stroke treatment by hospital regions: limited endovascular access despite evidence

BackgroundAlthough national organizations recognize the importance of regionalized acute ischemic stroke (AIS) care, data informing expansion are sparse. We assessed real-world regional variation in emergent AIS treatment, including growth in...

Abstract TP28: Support For The Stroke Program Coordinator

Introduction: The role of stroke program coordinator (SPC) has historically been underestimated and not well supported. SPCs generally have overall responsibility and accountability for the program yet are rarely afforded the appropriate training and support. A network that is focused on improving stroke prevention and care in three midwestern states recognized the turn-over in this integral role and prioritized efforts to provide better support by offering a variety of services, resources, and education. Methods: Network staff provide new SPCs an initial personal orientation to the network and to their role. There is also a full-day training session that is offered twice a year to learn more in-depth information about stroke and program management. The network hosts a SPC teleconference quarterly to provide information about important programmatic and clinical updates, upcoming events, and to encourage sharing of best practices. One resource offered to affiliate hospitals of the network, the Stroke Program Management Guidebook was created with over 200 deliverables that are designed to help efficiently and effectively build/maintain a program, and to help with certification goals. New affiliate hospitals receive a comprehensive “Initial Program Curriculum”, including a review of these deliverables, strategic planning, advisory services, education about program development/management, community education, continuous quality improvement, and multi-disciplinary clinical care. Conclusion: An evaluation of how these support services affect the hospital and their stroke program coordinator has not been formally completed. However, in 2014 the network had 24 hospitals, 25% of those had achieved some level of stroke certification. Today there are 37 hospitals and 51% of these hospitals have achieved some level of stroke certification. Of those hospitals, 10 have reached acute stroke ready certification, seven primary stroke certification and two have obtained comprehensive stroke certification. From 2014 to today this network has trained 166 stroke program coordinators within affiliate hospitals. Further research is needed to determine the true impact of the additional SPC support provided by the network.

Abstract TP113: Stroke Escape Room: A Novel Stroke Education Technique

Introduction: Georgia is one of the leading states in the country with high mortality rates from stroke. Even in post-COVID times, beside nurses have been challenged with obtaining the required number of stroke education hours for the organization’s stroke certification. A Stroke Escape Room was developed as an innovative way to meet annual stroke education hours. Purpose: The Stroke Escape Room is designed to help front-line staff achieve their annual stroke education requirements while promoting their understanding and retention of clinical practice guidelines. Methods: Three independent stroke patient scenarios were developed. Each patient scenario was associated with a combination access lock box. Participants answer questions about the scenario. The answers to the questions are associated with the numbers to unlock the box and move on to the next scenario. A final lock box contains an evaluation to assess learning. The session took approximately 30 minutes to complete. With course completion, the nurse receives 30 minutes of stroke education credit, a certificate for completion, and a BE FAST badge buddy. Participants were encouraged to attend the activity in small groups with at least one member being a Registered Nurse. A poster displaying stroke related clinical practice guidelines was displayed in the Escape Room. Results: A total of 22 staff participated in the activity. The participants attended in groups varying from one participant to four participants. Most (63.6%) participants work in the Emergency Department, 13.6% work on the stroke unit, 13.6% are educators, and 9% work in the Intensive Care Unit. Feedback received was extremely positive. Majority of participants reported positive experience, stating the education technique was fun, engaging, and promoted critical thinking. In addition, more than half the participants requested to use similar technique in other settings. Conclusion and Next Steps: Implementing an escape room for learning encouraged participants to interact. This type of educational design promotes collaboration and critical thinking. In conclusion, additional scenarios are being developed along with questions designed to promote critical thinking related to the phases of care.

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.

Structural Inequities for Historically Underserved Communities in the Adoption of Stroke Certification in the United States

Stroke centers are associated with better outcomes. There is substantial literature surrounding disparities in stroke outcomes for underserved populations. However, the existing literature has focused primarily on discrimination at the individual or institutional level, and studies of structural discrimination in stroke care are scant. To examine differences in hospitals' likelihood of adopting stroke care certification between historically underserved and general communities. This study combined a data set of hospital stroke certification from all general acute nonfederal hospitals in the continental US from January 1, 2009, to December 31, 2019, with national, hospital, and census data to define historically underserved communities by racial and ethnic composition, income distribution, and rurality. For all categories except rurality, communities were categorized by the composition and degree of segregation of each characteristic. Cox proportional hazard models were then estimated to compare the hazard of adopting stroke care certification between historically underserved and general communities, adjusting for population size and hospital bed capacity. Data were analyzed from June 2021 to April 2022. Hospitals' likelihood of adopting stroke care certification. A total of 4984 hospitals were included. From 2009 to 2019, the total number of hospitals with stroke certification grew from 961 to 1763. Hospitals serving Black, racially segregated communities had the highest hazard of adopting stroke care certification (hazard ratio [HR], 1.67; 95% CI, 1.41-1.97) in models not accounting for population size, but their hazard was 26% lower than among those serving non-Black, racially segregated communities (HR, 0.74; 95% CI, 0.62-0.89) in models controlling for population and hospital size. Adoption hazard was lower in low-income communities compared with high-income communities, regardless of their level of economic segregation, and rural hospitals were much less likely to adopt any level of stroke care certification relative to urban hospitals (HR, 0.43; 95% CI, 0.35-0.51). In this analysis of stroke certification adoption across acute care hospitals in the US from 2009 to 2019, hospitals in low-income and rural communities had a lower likelihood of receiving stroke certification than hospitals in general communities. Hospitals operating in Black, racially segregated communities had the highest likelihood of adopting stroke care, but because these communities had the largest population, patients in these communities had the lowest likelihood of access to stroke-certified hospitals when the model controlled for population size. These findings provide empirical evidence that the provision of acute neurological services is structurally inequitable across historically underserved communities.

Racial Disparity in Mechanical Thrombectomy Utilization: Multicenter Registry Results From 2016 to 2020.

BackgroundPrevious studies on racial disparity in mechanical thrombectomy (MT) treatment of acute large vessel occlusion stroke lack individual patient data that influence treatment decision‐making. We assessed patient‐level data in a large US health care system from 2016 to 2020 for racial disparities in MT utilization and eligibility.Methods and ResultsA retrospective study was performed of 34 596 patients admitted to 43 hospitals from January 2016 to September 2020. Data included patient age, sex, race, residential zip code median income and population density, presenting hospital stroke certification, baseline ambulation, and National Institutes of Health stroke scale. The cohort included 26 640 White, non‐Hispanic (77.0%), and 7956 African American/Black (23.0%) patients. In multivariable logistic regression, Black patients were less likely to undergo MT (adjusted odds ratio [OR], 0.65; 95% CI, 0.54–0.76), arrive within 5 hours of “last known well” (adjusted OR, 0.73; 95% CI, 0.69–0.78), and have documented anterior circulation large vessel occlusion (adjusted OR, 0.78; 95% CI, 0.64–0.96). Race was not associated with MT rate among patients arriving within 5 hours of last known well with documented acute large vessel occlusion.ConclusionsBlack patients with stroke underwent MT less frequently than White patients, likely in part because of longer times from last known well to hospital arrival and a lower rate of documented acute large vessel occlusion. Further studies are needed to assess whether extending the MT time window and more aggressive large vessel occlusion screening protocols mitigate this disparity.

Inpatient Rehabilitation Facility Change in Self-Care and Change in Mobility Quality Measures: Development and Reliability and Validity Testing

ObjectiveTo describe the development, implementation and reliability and validity testing of the inpatient rehabilitation facility (IRF) Change in Self-Care and Change in Mobility quality measures. DesignWe describe the activities involved in developing and implementing the 2 facility-level quality measures, including public comment opportunities. We examined facility-level reliability using split-half testing and Pearson product-moment correlations, Spearman rank correlations, and intraclass correlation coefficients (ICC2,1). We examined validity by comparing facility-level quality measure scores and facility disease-specific certification status. SettingAll 1117 IRFs in the United States with at least 20 Medicare stays that ended in 2017. ParticipantsFacility-level quality measure scores (N=1117) were derived from data from 427,517 (self-care) and 427,956 (mobility) Medicare fee-for-service and Medicare Advantage IRF patient stays in 2017. InterventionsNot applicable. Main Outcome MeasuresFacility-level Change in Self-Care and Change in Mobility quality measure scores and facility Disease-Specific Certification for Stroke Rehabilitation from The Joint Commission were used in validity analysis. ResultsThe split-half quality measure scores showed strong, positive correlations for the facility-level self-care (Pearson=0.903, Spearman=0.884, ICC=0.903, P<.0001) and mobility (Pearson=0.903, Spearman=0.884, ICC= 0.903, P<.0001) quality measure scores, providing evidence of reliability. ICCs remained strong when stratifying by provider volume. IRFs with stroke certification had slightly higher mean and median quality measure scores than IRFs without certification, and IRFs with the higher quality measure scores tended to have a higher percentage of certified IRFs. ConclusionsOur analyses support the reliability and validity of the Change in Self-Care and Change in Mobility quality measure scores in IRFs.

Unfavorable Dietary Quality Contributes to Elevated Risk of Ischemic Stroke among Residents in Southwest China: Based on the Chinese Diet Balance Index 2016 (DBI-16).

Background: Little is known about the effects of dietary quality on the risk of ischemic stroke among Southwest Chinese, and evidence from prospective studies is needed. We aimed to evaluate the associations of ischemic stroke with dietary quality assessed by the Chinese Diet Balance Index 2016 (DBI-2016). Methods: The Guizhou Population Health Cohort Study (GPHCS) recruited 9280 residents aged 18 to 95 years from 12 areas in Guizhou Province, Southwest China. Baseline investigations, including information collections of diet and demographic characteristics, and anthropometric measurements were performed from 2010 to 2012. Dietary quality was assessed by using DBI-2016. The primary outcome was incident ischemic stroke diagnosed according to the International Classification of Diseases 10th revision (ICD-10) until December 2020. Data analyzed in the current study was from 7841 participants with complete information of diet assessments and ischemic stroke certification. Cox proportional hazards models were used to estimate the risk of ischemic stroke associated with dietary quality. Results: During a median follow-up of 6.63 years (range 1.11 to 9.53 years), 142 participants were diagnosed with ischemic stroke. Participants with ischemic stroke had a more excessive intake of cooking oils, alcoholic beverages, and salt, and had more inadequacy in meats than those without ischemic stroke. (p < 0.05). Compared with participants in the lowest quartile (Q1), those in the highest quartile (Q4) of the higher bound score (HBS) and of the dietary quality distance (DQD) had an elevated risk for ischemic stroke, with the corresponding hazard ratios (HRs) of 3.31 (95%CI: 1.57–6.97) and 2.26 (95%CI: 1.28–4.00), respectively, after adjustment for age, ethnic group, education level, marriage status, smoking and waist circumference, and the medical history of diabetes and hypertension at baseline. In addition, excessive intake levels (score 1–6) of cooking oils, excessive intake levels (score 1–6) of salt, and inadequate intake levels (score −12 to −7) of dietary variety were positively associated with an increased risk for ischemic stroke, with the multiple HRs of 3.00 (95%CI: 1.77–5.07), 2.03 (95%CI: 1.33–3.10) and 5.40 (95%CI: 1.70–17.20), respectively. Conclusions: Our results suggest that unfavorable dietary quality, including overall excessive consumption, excessive intake of cooking oils and salt, or under adequate dietary diversity, may increase the risk for ischemic stroke.

Abstract NS7: Steps To An Early And Successful Adoption Of Iv Tenecteplase By A Large Integrated Medical System

Background: In 2020, a large integrated healthcare system consisting of 21 stroke centers implemented IV tenecteplase as the first line pharmaceutical treatment for acute ischemic stroke (AIS) prior to universal adoption in national clinical practice guidelines and FDA approval for stroke. Purpose: To describe the steps taken for successful implementation of IV tenecteplase as a first therapy for AIS in 21 stroke centers, part of an integrated system. Methods: Pre-implementation steps included gaining systemwide acceptance, especially from key stakeholders such as emergency department staff, patient care services, tele-stroke and neurology physicians, as well as risk management. We addressed potential impacts to related to reimbursement, stroke certification, and national award status. Inclusive changes were made to related policy and procedures, order sets, and other documentation. Standardized training and beta-testing were conducted and a sequential roll-out implemented along the real-time central monitoring. Results: Stakeholder groups were engaged prior to implementation with town halls and in-person and desktop simulation exercises. Beta-testing took place in August 2020 with three pilot sites with full system wide implementation by Nov. 2020. Since full implementation, tenecteplase is the only thrombolytic that has been ordered (n=423). Door in door out times have decreased (median 131 minutes pre- to 88 minutes post; p&lt;0.05). In addition, symptomatic ICH rates have decreased by greater than 50% (p&lt;0.05) and there are no reports of systemic bleeding or angioedema. Conclusion: Tenecteplase has been shown to be safe and feasible as a first line thrombolytic within our organization. Strong nurse and physician leads, as well as thoughtful and inclusive implementation steps were key in the successful adoption of this system-wide change.

Abstract TMP35: Prehospital Bypass Policies Increase The Proportion Of Stroke Patients Transported To Primary Stroke Centers - A Quasi-experimental Study In A National Sample Of Medicare Beneficiaries.

Objective: Prehospital bypass policies were designed to encourage transport of eligible stroke patients to stroke centers in order to receive rapid assessment and treatment. In a national dataset we examined the relationship between implementation of bypass policies and the proportion of patients transported to stroke centers. Methods: We included EMS transported ischemic stroke patients aged 66+ from a 20% sample of Medicare claims (2007 - 2014). We excluded patients not admitted through the ED, and those not continuously enrolled in parts A/B in the prior year. The outcome measure was transport to PSC. Stroke certification status was validated by multiple stroke certification databases; policy implementation details were obtained from review of statutes and regulations. We employed difference-in-differences (DID) analyses with a state-level random intercept. Results: A total of 20,345 patients were included in the study with 7,239 from policy states and counties and 13,106 from non-policy states and counties. The proportion of patients arriving at PSCs increased from 28% to 43% in non-policy areas and 33% to 57% in policy areas. The DID analysis revealed a net effect of 11% (p&lt;.001): policy areashad 17% higher probability of transporting stroke patients to PSCs after policy implementation (p&lt;.001) while non-policy areas demonstrated a 6% increase (p&lt;.001). Patients from rural areas had 49% lower odds of transport to PSC (OR 0.51, p&lt;.001). Discussion: In pre-thrombectomy era, statewide prehospital bypass policies were related to significant increases in proportion of stroke patients transported to stroke centers. Future analyses will assess if these effects occur in the thrombectomy era, and if these policies influence delivery of stroke treatments.

Abstract WP87: Statewide Availability Of Acute Stroke Treatment And Services In North Carolina Hospitals

Introduction: With recent advancements in acute stroke treatments, evidence-based care capabilities among hospitals are believed to vary widely; however, current data are limited. Therefore, we conducted a statewide assessment of hospital-based stroke care capabilities in North Carolina (NC). Methods: An online survey was emailed to each licensed hospital in NC. Based on prior surveys and current stroke care guidelines, questions asked about diagnostic testing, acute stroke treatments and protocols, and post-acute management. All 112 hospitals responded (100% response rate) between October 2020 and April 2021. Descriptive statistics were computed from responses for 109 hospitals that reported providing acute stroke care. Results: Among 109 hospitals, 10 (9%) were Comprehensive Stroke Centers, 2 (2%) were Thrombectomy-Capable Stroke Centers, 35 (32%) were Primary Stroke Centers, 16 (15%) were Acute Stroke Ready Hospitals, and 46 (42%) had no stroke certification. Ninety-eight (90%) had an acute stroke clinical care pathway, and 92 (84%) had pre-written stroke care orders. All 109 (100%) reported non-contrast CT imaging capability. Further, hospitals reported the following: CT angiography (104, 95%), CT perfusion (55, 50%), and diffusion-weighted MRI (63, 58%) . Almost all (108, 99%) administered intravenous alteplase for stroke, whereas only 16 (15%) had capabilities to provide endovascular thrombectomy for stroke. Ninety-five (87%) hospitals reported transferring stroke patients treated with alteplase or transferring those in need of endovascular treatment. Eighty-nine (82%) used telestroke services for the treatment and management of acute stroke patients, of which 78 (72%) relied on telestroke exclusively 24/7; and 80 (73%) used telestroke to decide when and where to transfer stroke patients. Conclusions: Among NC hospitals, basic capabilities, such as CT imaging and acute stroke care protocols, were widely available. However, advanced imaging and endovascular capabilities were less common. Most hospitals used telestroke services for treatment as well as transfer decisions. This statewide assessment is an important first step in improving access to evidence-based stroke care and developing stroke systems of care.

Abstract P838: Stroke Center Certification of a Community Hospital Results in Six Fold Increase in Thrombolytic Treatment for Stroke

Introduction: Prior studies that have demonstrated improved quality metrics after stroke certification often have added new neurological services to become certified. We aimed to evaluate the changes in volume of acute stroke/TIA and thrombolytic treatments in a hospital that underwent Primary Stroke Certification after seven years of established inpatient neurology and telestroke support. Methods: A retrospective analysis of prospectively collected data was completed from a community hospital. Data included 20 months prior to stroke certification (including 12 months with a stroke coordinator) and 17 months after certification. Annualized thrombolytic treatment and total stroke/TIA admissions were reviewed. Mann Whitney tests were used to determine if thrombolytic treatment, patients identified for mechanical stroke thrombectomy (MST), or both [total acute ischemic stroke (AIS) treatment] and total stroke/TIA volume per month differed before and after stroke certification. A subgroup analysis used a Mann Whitney to determine if the addition of a stroke coordinator during preparation for certification affected outcome metrics. Results: The hospital admitted 677 stroke/TIA patients during the study period, 230 before (82 without a stroke coordinator, 148 with a stroke coordinator) and 447 after stroke certification. Thrombolytic treatment increased from 2.4 patients per year prior to certification and 14.8 patients per year after stroke certification. The following outcome variables were increased after certification: thrombolytic treatments (1 vs. 0, p&lt;0.001), patients identified for MST (1 vs. 0, p=0.001), total AIS treatments (1 vs. 0, p&lt;0.001) and total stroke/TIA volume (27 vs. 11, p&lt;0.001). Subgroup analysis suggested that preparation with a stroke coordinator was associated with increases in total AIS treatments (p=0.04) and telestroke requests (p=0.04); however, no differences in total stroke/TIA volume (p=0.18), thrombolytic treatments (p=0.08) or MST (p=0.41) were appreciated in absence of stroke coordinator. Conclusions: We found significantly increased rates of thrombolytic treatments, total stroke/TIA volume and patients identified for MST in a community hospital after primary stroke certification.

Abstract P862: Successes and Impact of a Statewide Stroke Education Campaign for Healthcare Providers

Introduction: The North Dakota Mission: Lifeline Stroke program is a 3-year initiative which aims to improve statewide stroke systems of care. Due to complexities in recognizing and treating stroke patients, effective education of prehospital and hospital health care providers on guideline-based assessments and treatment methods were identified as an essential intervention. In person lectures, conferences, workshops, stroke simulation trainings, online courses, webinars, and a stroke certification program were deployed throughout the project. Purpose: The purpose of the post-education survey was to determine the impact, value, and success of different types of education provided during the project. Methods: North Dakota healthcare professionals (n=221) completed a 20-question online survey about their experiences participating in the stroke trainings provided from 2017 to 2020. Results: Survey respondents consisted of 76 Emergency Medical Service (EMS) providers and 145 hospital-based healthcare professionals. The majority of hospital-based staff respondents were nurses (80.1%), while most EMS-based respondents were paramedics or EMTs (75.0%). Half of all respondents (49.8%) participated in 2 or more educational offerings. Respondents were asked to rank the educational offerings in which they participated in by order of the benefit to their everyday practice. The two highest ranking educational offerings were the Advanced Stroke Life Support Class (mean rank=1.6) and Simulation in Motion (SIM) ND (mean rank=2.3). More than 90% of respondents stated that these trainings were extremely or very applicable to their everyday practice. When asked about the overall impact of all the educational offerings they participated in, almost all (92.6%) respondents indicated they agree that because of the trainings they have a better understanding of the key issues related to caring for stroke patients. Conclusions: Overall, the comprehensive survey provides concrete evidence and feedback that multi-modal education campaigns are well-received and effective in furthering awareness of guideline-based stroke assessments and treatment methods. Activities with a kinesthetic learning approach were found to be especially well-received.

Abstract P142: The Impact of Regional Socioeconomic Status on Stroke Center Certification in the Northeastern United States

Introduction: The northeastern United States has been a national leader in stroke healthcare delivery. The current roster of designated comprehensive, primary, thrombectomy-capable and acute stroke ready centers is the result of respective state initiatives. Access to certified stroke centers (SCs) varies by county as states have widely varied certification processes and typically rely on certifying organizations (COs) to identify stroke centers. Previous research has found an association at the national level between likelihood of stroke certification and local socioeconomic status. Objective: This study describes the relationship between socioeconomic status of patient populations in the Northeast U.S. and their access to quality stroke care by comparing median household income and wealth in counties with and without certified SCs. Methods: Population and median household income for 218 counties in Connecticut, Delaware, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont were collected from the U.S. Census (2010), stroke epidemiological data were collected from the Center for Disease Control, and Area Deprivation Index (ADI) data (ranked within the U.S.) were collected from the Neighborhood Atlas, a project that quantifies disadvantage. Median household income has been used to quantify local population wealth and ADI to analyze community health risks. Certification data were mined from quality check databases for The Joint Commission and Det Norske Veritas, the most commonly used COs, and yielded 259 certified centers. Linear regression characterized the relationship between income and ADI with number of certified SCs, stroke incidence and stroke mortality. Results: Higher income (p&lt;0.001) and lower ADI (p&lt;0.001) were associated with having more certified SCs (p&lt;0.001). Counties with a higher stroke incidence had significantly more certified SCs (p=0.01). Conclusions: Throughout the counties of the Northeastern U.S., access to quality stroke care depends on local wealth and resources. At the same time, the current analysis indicates that SC certification distribution does appear to correlate to those counties where stroke incidence is highest.

Factors Associated With Emergency Department Length of Stay and In-hospital Mortality in Intracerebral Hemorrhage Patients.

BACKGROUND: Spontaneous intracerebral hemorrhage (ICH) is a medical emergency that requires rapid identification and focused assessment early to ensure the best possible outcomes. The purpose of this study is to evaluate the associations between system and patient factors and emergency department (ED) length of stay and in-hospital mortality in patients given a diagnosis of ICH. METHODS: A sample of 3108 ICH patients was selected from a statewide administrative database for cross-sectional retrospective analysis. System characteristic (hospital stroke certification), patient characteristics (age, sex, and race), and covariate conditions (stroke severity and comorbidities) were analyzed using descriptive statistics and hierarchical logistic regression models to address the study questions. RESULTS: The mean ED length of stay is 2.9 ± 3 hours (range, 0-42 hours) before admission to an inpatient unit. Inpatient mortality is 14.9%. Stroke center certification (P < .000) and stroke severity (P ≤ .000) are significant predictors of ED length of stay, whereas age (P < .000), stroke severity (P < .000), comorbidities (P = .047), and ED length of stay (P = .04) are significant predictors of in-hospital mortality. Most notably, an ED length of stay of 3 hours or longer has a 37% increase in the odds of in-hospital mortality. CONCLUSION: Our findings support age, stroke severity, and ED length of stay as predictors of in-hospital mortality for ICH patients. The importance of timely admission to an inpatient unit is emphasized. Optimal systems of care and expedited inpatient admission are vital to reduce morbidity and mortality for ICH stroke patients.