Stroke Team Members Research Articles

National assessment of clinicians participating in stroke treatment decisions at strokenet regional coordinating centers: Clinicians Making Stroke Treatment Decisions

ObjectivesSince the introduction of thrombolytics, stroke teams evolved to improve thrombolytic care delivery. The impact of the advent of endovascular therapy on the composition of acute stroke teams is unknown. Materials and MethodsA two-part pilot-tested survey was deployed to site-Principal Investigators (PIs) of the 27 StrokeNet Regional Coordinating Centers (RCCs) regarding institutional acute stroke teams. Part A inquired about the participation of personnel in each type of stroke response. Part B identified stroke team physicians and the types of responses in which they participate to assess training background of stroke team members. ResultsResponse rates for Part A and B were 66% and 48%, respectively. In Part A, 67% (12/18) of sites reported trainees always responded to ED stroke activations with significant autonomy. 44% (7/16) and 27% (4/15) of sites reported NP and PA response to ED stroke alerts, respectively, but with limited autonomy. In Part B, 124 physicians involved in ED stroke alerts were identified, the large majority of whom (79%, 95% CI: 71-85) were vascular neurology trained. The 39 (23%) stroke team members involved in endovascular therapy had the following training: 49% (34-64) neurosurgery, 28% (17-44) radiology, 18% (9-33) vascular neurology 5% (1-16) neurology. ConclusionsWe identified modest heterogeneity in the composition of acute stroke team members across StrokeNet RCCs. Individuals performing endovascular therapy had a variety of clinical specializations, reflecting the evolving multidisciplinary nature of interventional acute stroke care. At StrokeNet RCCs, teams have significant trainee involvement in both ED and inpatient acute stroke responses.

Attitudes of cardiac rehabilitation and stroke teams towards integration of stroke survivors into adapted cardiac rehabilitation: A focus group study

Objective To explore the attitudes and beliefs of cardiac rehabilitation and stroke teams towards adapted cardiac rehabilitation, and the broader topics of exercise, healthy lifestyles and health behaviour change, for people with mild-to-moderate severity stroke in the sub-acute phase of recovery. Design Qualitative focus group-based study. Setting Acute and community national health service trusts. Participants Stroke and cardiac rehabilitation team members. Intervention Adapted cardiac rehabilitation. Main measures Focus groups. Thematic analysis was applied to the transcribed data. Results Overall, 57 health professionals participated in 12 focus groups. Positive impacts for teams and stroke survivors were identified particularly confidence. However, there were negatives, barriers and adaptations identified. In addition, there was a lack of knowledge for cardiac rehabilitation teams in relation to stroke survivors and stroke teams in relation to cardiac rehabilitation, exercise and healthy lifestyles. Conclusions Cardiac rehabilitation and stroke staff attitudes to cardiac rehabilitation for stroke survivors showed a range of benefits, negatives, barriers and adaptations needed. Confidence and knowledge of the cardiac rehabilitation and stroke teams needs to be addressed. Registration ISRCTN65957980.

Abstract P122: A Semi-Automated Tool Can Increase Stroke Clinical Trial Recruitment

Introduction: Stroke is a major public health problem, and stroke-related research is crucial. However, enrollment in randomized controlled stroke trials of acute therapies is challenging, leading to missed patients during the screening phase. The current screening process is person-dependent and can be highly variable across stroke team members, time of the day, and hospitals. High-volume stroke centers participate in more than 15 simultaneous NIH and industry-sponsored stroke trials. We hypothesize that a HIPAA-compliant screening tool can optimize screening and increase trial enrollment. Methods: This tool is a HIPAA-compliant application, developed by the Power Team at the University of Pittsburgh Medical Center, using Microsoft Power Apps. It has three purposes: screening, maintaining the database, and reporting. The screening process begins with patient demographics, and basic stroke-related data, followed by acute ischemic, subacute ischemic, and hemorrhagic stroke trial groups. Users can select their preferred subgroup of studies and continue filling in the rest of the form by answering pertinent questions. Upon form submission, the tool calculates the patient’s eligibility status for each trial in that group. The database is immediately available on the opening page or on the cloud. After submission, this can be edited, e.g., refusal for enrollment, or change in the patient’s condition. Reporting can be automated by using Power tools or it can be done manually. For manual reporting, the database gives filtering options based on time frames, patients, trials, and more. Results: The tool is in the testing phase, and we expect to have enrollment data by the time of the meeting. Conclusions: This tool has several advantages over manual screening. First, it reduces the orientation time for new research team members. Second, it mitigates the risk of overlooking potentially eligible patients in time-sensitive scenarios. Third, it is highly customizable by editing the codebook and can be adjusted per research site. This can be particularly helpful for smaller hospitals surrounded by underserved areas and can decrease health disparities by extending the chance of clinical trial participation. Fourth, it automatically maintains an up-to-date data log, which can be extracted at various intervals, such as monthly or per study. This not only streamlines the data recording but also simplifies reporting to study sponsors. Lastly, it expedites trial completion by accelerating the enrollment process. In conclusion, this tool can have significant benefits for research teams and for the broader public.

Abstract TP110: Strengthening Neurology and Cardiology Care Collaboration: Getting to the Heart of Stroke Initiative

Introduction: The American Heart Association (AHA) estimates 1 in 3 acute ischemic strokes (AIS) are cryptogenic and approximately 1 in 4 survivors will have another event. Identifying the AIS etiology will help define appropriate therapy and lower the likelihood of having another stroke. Over 67% of Black Americans have at least 1 risk factor for AIS and a higher morbidity & mortality compared to any other racial group. To address these gaps, the AHA launched Getting To The Heart Of Stroke in 2022, in conjunction with HCA Healthcare and HCA Healthcare Foundation, to improve the identification of stroke etiology by strengthening neurology & cardiology care collaboration. An overarching goal of this initiative is to improve healthcare disparities by assuring correct data collection of socioeconomic data, assessing barriers to care and addressing social determinants of health. Methods: Using a learning collaborative model, 10 HCA Comprehensive Stroke Centers, along with their clinical and administrative leadership were engaged. Monthly virtual performance improvement consultations are held to discuss actions taken, identify trends between sites, and develop PDSAs (Plan-Do-Study-Act). Their clinical multidisciplinary teams defined custom and existing metrics using Get With The Guidelines®-Stroke to measure the impact of best practice implementation. Results: Gaps include inconsistent identification of stroke etiology, lack of race documentation and lack of standardized social needs assessments. Barriers include a lack of standard triggers for cardiology and neurology consults on cryptogenic stroke and widely variable documentation by hospital. Sites are creating communication points between departments utilizing a multidisciplinary committee of stroke and cardiology team members. Conclusion: Early data suggest the need to establish standardized processes for the identification of cryptogenic stroke. A framework is necessary to build the foundational relationship between neurology & cardiology to positively impact cryptogenic stroke patient care. Over the next 2 years, the initiative will continue to explore an enhanced framework to identify cryptogenic stroke, optimize secondary prevention strategies, and ensure equitable care.

Exploring the perspectives of people with stroke, caregivers and healthcare professionals on the design and delivery of a mHealth adaptive physical activity intervention: a qualitative study protocol

Background: Despite recent advances in acute stroke intervention, secondary prevention strategies are lacking. Physical activity (PA) is the second-largest predictor of stroke and a cornerstone of secondary prevention therapies. Interventions to promote PA post-stroke include components aimed at reducing sedentary behaviour and increasing participation in lifestyle PA and structured exercise. Despite guidelines to adapt PA to individuals’ needs, there is no evidence on the empirical development of adaptive PA interventions post-stroke. This study will explore patient, caregiver and multidisciplinary healthcare professional perspectives on the design and delivery of adaptive, personalised PA interventions, delivered using a smartphone application, following mild-to-moderate stroke. Findings will directly inform the protocol of an experimental trial, using a novel adaptive trial design. Methods: A descriptive qualitative study will be undertaken to inform the design, delivery and subsequent acceptability of a smartphone application to reduce sedentary behaviour and promote PA post-stroke. Data will be collected via one-to-one interviews and focus groups and analysed according to a six-step thematic analysis. Findings will be reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) checklist. One-to-one interviews and focus group interviews will be conducted with three stakeholder groups: 1) People post-stroke, who are independently mobile, without communication and cognitive deficits, living in the community, and without other diagnosed neurological conditions. 2) Caregivers (formal and informal) involved in post-stroke care. 3) Healthcare professionals who are members of multidisciplinary stroke teams. Ethics and dissemination: Ethical approval has been granted by the Faculty of Education and Health Sciences Research Ethics Committee at the University of Limerick [Ref: 2019_10_03_ EHS]. Findings will be shared locally with all stakeholder groups, submitted for publication, and will inform the protocol and conduct for a novel and flexible experimental trial, examining the effectiveness of an adaptive PA intervention post-stroke.

Abstract WP93: An Internet Of Things Based Real Time Location System With Machine Learning For Coordination Of Acute Stroke Endovascular Intervention: A Proof-of-concept Study

Introduction: The delivery of mechanical thrombectomy in acute stroke can be challenging because it requires coordination between patient travel and multiple stroke team members across different locations in the hospital. A Real Time Location System (RTLS) can facilitate a streamlined workflow by determining a patient’s location, but the required infrastructure can be costly to set up. We investigated the feasibility of a machine learning based RTLS using an Internet Of Things (IOT) device prototype to coordinate acute stroke endovascular intervention. Methods: In this proof-of-concept study, study investigators programmed an IOT device to collect WiFi signals from different hospital zones relevant to the mechanical thrombectomy workflow. Different machine learning (ML) algorithms were trained on location labelled training WiFi signals to predict location. The accuracies of the different ML algorithms to predict unlabeled testing WiFi signals collected on a separate day were measured, in percentages. Results: The training and testing datasets contained 1,179 and 293 samples respectively, with 2,516 and 2,618 unique WiFi signals detected in each dataset. The trained neural network, random forest, support vector machine, K-nearest neighbors, decision tree and ensemble classifiers achieved accuracies of 96.6%, 96.2%, 97.3%, 97.3%, 83.6% and 97.3% on the testing dataset respectively. Additionally, the neural network model produced estimates of uncertainty, which were significantly associated with the correctness of predictions based on logistic regression analysis (p < 0.001). Conclusions: An IOT based real time location system with machine learning can accurately predict locations within the hospital, demonstrating immense potential for the future applications of streamlining delivery of acute stroke endovascular intervention.

The use of a smartphone application to improve stroke code workflow metrics: A pilot study in a comprehensive stroke centre.

Timely coordination between stroke team members is of relevance for stroke code management. We explore the feasibility and potential utility of a smartphone application for clinical and neuroimaging data sharing for improving workflow metrics of stroke code pathways, and professionals' opinions about its use. We performed an observational pilot study including stroke code activations at La Paz University Hospital in Madrid, from June 2019 to March 2020. Patients were classified according to the activation or not of the JOIN app by the attending physician. Clinical data and time-to-procedures were retrieved from the app or from the hospital records and the Madrid regional stroke registry as appropriate and compared between both groups. An anonymous survey collected professionals' opinions about the app and its use. A total of 282 stroke code activations were registered. The JOIN app was activated in 111 (39%) cases. They had a significant reduction in imaging-to-thrombolysis (31 vs 20 min, p = .026) and in door-to-thrombolysis times (51 vs 36 min, p = .004), with more patients achieving a door-to-needle time below 45 min (68.8% vs 37.8%, p = .016). About 50% of the users found the app useful for facilitating the diagnosis and decision-making; interoperability with clinical files was considered an opportunity for improvement. This pilot study suggests that JOIN helps improve and document workflow metrics in acute stroke management in a comprehensive stroke centre. These results support testing JOIN in a prospective randomised study to confirm its usefulness and the general applicability of the results.

Abstract P173: Stroke Mimics in Patients With Discordance Between VAN Determination by EMS and Experienced Stroke Teams

Background: Discordance between pre-hospital (EMS) and experienced stroke team (ED) determination of Vision-Aphasia-Neglect (VAN) assessment threatens VAN’s utility in routing patients with large vessel occlusion (LVO) to thrombectomy centers. Discordance may be due to a fluctuating exam in the setting of stroke or stroke mimics. We sought to evaluate the rate and etiology of stroke mimics in patients with discordant versus concordant VAN assessments. Methods: The EMS run reports were linked with stroke registries from three CSCs in New Orleans, Louisiana from 2/2019-7/2019. EMS-VAN was compared to that of CSCs in all patients who presented within 6 hours of last seen normal. Stroke mimics were compared in patients with concordance vs discordance between VAN determination by EMS and experienced stroke teams. Results: EMS documented VAN in 63.2% of stroke codes brought to CSCs. Concordance was 66.9%; the k, CI was 0.35, 0.20 - 0.50. The proportion of stroke mimics was largest in concordant VAN negative patients (64.4%) with seizures and altered mental status (23.7% each) the most frequent causes. The proportion of stroke mimics was smallest in concordant VAN positive patients (17.3%) with seizures as the most frequent cause (44.4%). Similar high frequency of seizure mimic was determined in VAN discordant patients; seizure accounted for 47.8% of discordant mimics and 20% of all discordant patients. Discussion: VAN assessment as performed by trained EMS providers had only fair correlation with experienced stroke team members. The rapidly evolving exam of patients with seizures may explain a significant portion of stroke mimics among patients whose exams change between EMS and ED stroke team assessments.

Abstract P503: Inter-Rater Reliability and Validity of Pre-Hospital Vision-Aphasia-Neglect Assessment for Triage of Patients With Suspected Large Vessel Occlusion: Analysis of Data From Three Comprehensive Stroke Centers in New Orleans (VAN NOLA Study)

Background: The Louisiana pre-hospital routing protocol for acute stroke patients is modeled after Mission Lifeline Stroke. The Vision-Aphasia-Neglect (VAN) assessment was adopted for large vessel occlusion (LVO) screening after education was provided to pre-hospital providers (EMS). We sought to establish the inter-rater reliability (IRR) of VAN between EMS and experienced stroke team members at comprehensive stroke centers (CSC) and assessed validity of EMS and CSC VAN. Methods: The EMS run reports were linked with stroke registries from three CSCs in New Orleans, Louisiana from 2/2019-7/2019. EMS-VAN was compared to that of CSCs in all patients who presented within 6 hours of last seen normal. Validity analyses were performed comparing EMS-VAN and CSC-VAN with radiologically confirmed (CTA) LVO as the gold standard. Kappa (k) and 95% confidence interval (CI) are reported as a measure of IRR. Likelihood of VAN non documentation by EMS and VAN discordance between EMS and CSC was determined as Odds Ratios (OR) and CI. Results: EMS documented VAN in 63.2% of stroke codes brought to CSCs. Advanced age (OR, CI: 1.02, 1.01 - 1.04) and pre-existing disability (OR, CI: 1.53, 1.32 - 1.76) increased the likelihood that VAN was not documented by EMS. Both EMS and CSC VAN assessments were documented for 166 patients Concordance was 66.9%; the k, CI was 0.35, 0.20 - 0.50. Discordance was more likely when EMS assessed a patient as positive than when assessed as negative, but no clinical predictor of discordance was identified. The accuracy of EMS-VAN was 60.2% for distinguishing LVO positive and negative patients; CSC-VAN was 65.5% accurate. Discussion: VAN assessment as performed by trained EMS providers had only fair correlation with experienced stroke team members. Further education is needed to increase the inter-rater reliability and accuracy of the VAN assessment in order to improve its utility in meeting the goal of routing patients with LVO to the thrombectomy centers.

Exploring self-management within hospital-based stroke care: current and future opportunities

Purpose This study explored stroke self-management within a tertiary hospital setting from the perspectives of health professionals working across the continuum of stroke care. Materials and methods A qualitative descriptive design guided five focus groups in the acute stroke service (n = 2), inpatient rehabilitation (n = 2), and outpatient day hospital service (n = 1). Focus groups were transcribed verbatim and analysed using thematic analysis. Results Twenty-eight health professionals participated representing medical, nursing, and allied health services. Two themes emerged from the data: Pieces of the puzzle illustrates the inconsistent understanding about self-management with elements of the puzzle described but rarely within the full concept of self-management; Readiness for self-management highlighted that although self-management should commence in the acute setting, there were many factors influencing why this was not always happening. Conclusions A consistent conceptualisation and approach to stroke self-management in the hospital setting is required. Interprofessional education and shared intentional language can enhance understanding and practice. IMPLICATIONS FOR REHABILITATION Understanding and application of stroke self-management varies among members of hospital-based stroke teams. Health professionals working in hospital-based stroke care should use the term self-management with their patients. Education of healthcare teams is necessary to develop knowledge about self-management and develop consistent practices across the continuum of care.

Integrating New Staff into Endovascular Stroke-Treatment Workflows in the COVID-19 Pandemic

A health care crisis such as the coronavirus disease 2019 (COVID-19) pandemic requires allocation of hospital staff and resources on short notice. Thus, new and sometimes less experienced team members might join the team to fill in the gaps. This scenario can be particularly challenging in endovascular stroke treatment, which is a highly specialized task that requires seamless cooperation of numerous health care workers across various specialties and professions. This document is intended for stroke teams who face the challenge of integrating new team members into endovascular stroke-treatment workflows during the COVID-19 pandemic or any other global health care emergency. It discusses the key strategies for smooth integration of new stroke-team members in a crisis situation: 1) transfer of key knowledge (simple take-home messages), 2) open communication and a nonjudgmental atmosphere, 3) strategic task assignment, and 4) graded learning and responsibility. While these 4 key principles should generally be followed in endovascular stroke treatment, they become even more important during health care emergencies such as the COVID-19 pandemic, when health care professionals have to take on new and additional roles and responsibilities in challenging working environments for which they were not specifically trained.

Temporary Emergency Guidance to US Stroke Centers During the Coronavirus Disease 2019 (COVID-19) Pandemic: On Behalf of the American Heart Association/American Stroke Association Stroke Council Leadership.

During this unprecedented time of extraordinary stress on the US healthcare system, the AHA/ASA Stroke Council-as individuals in our localities and together as an entity at the national level-acknowledge the mounting concern regarding optimal stroke care during the COVID-19 pandemic among vascular neurologists and those clinicians who care for patients with stroke. We therefore seek to provide guidance for the care of stroke patients in the midst of the crisis. Ordinarily, national recommendations go through a rigorous process of development, refinement, peer review, and thoughtful promulgation. None of that is possible at this time, yet we believe there is a substantial need for a broad policy statement that reflects both the commonality of the pandemic across the US and the individual variability necessary at local sites. We issue this temporary statement as an interim stopgap opinion, pending a more thorough and considered process.

Studi Fenomenologi: Pengalaman Keluarga Merawat Penderita Pasca Stroke di Kota Jambi Tahun 2019

Stroke has a negative impact on families who provide care for post-stroke patients, the effect of which is due to functional deficits experienced by post-stroke sufferers which result in dependence on families for daily activities. The research objective was to explore in depth the experiences of families caring for post-stroke sufferers in Jambi city in 2019. This study used a qualitative method with a descriptive phenomenology approach. Participants in this study amounted to nine people who were selected using purposive sampling. Data is collected by semi-structured interview in duration of 60-90 minutes. Data analysis using the colaizzi method. The results found four themes, namely: dependence on daily activities on the family, family efforts to fulfill self-care activities, constraints faced by caregivers and family expectations. Conclusion: Families experience limited knowledge and skills, difficulties in meeting patients' ADLs, changes in physical conditions, changes in rest and sleep, changes in psychological conditions, changes in social activities, and economic changes. Therefore families need to get education from doctors, nurses and stroke team members starting from the time the patient is admitted to the hospital and re-evaluated when the patient is going home, about the knowledge and skills to treat post-stroke patients at home.

Communication, the Key in Creating Dignified Encounters in Unexpected Sudden Death - With Stroke as Example.

Aim:The aim of this study was to illuminate the communication and its meaning in unexpected sudden death with stroke as example, as experienced by stroke team members and next of kin.Subject and Methods:The study has a qualitative design. Secondary analysis of data from four previous interview studies with stroke team members; physicians, registered nurses, and enrolled nurses from the stroke units (SU) and next of kin of patients who had died due to acute stroke during hospital stay were utilized.Results:Communication is revealed as the foundation for care and caring with the overarching theme foundation for dignified encounters in care built-up by six themes illuminating the meaning of communication in unexpected sudden death by stroke.Conclusion:Communication shown as the foundation for dignified encounters in care as experienced by stroke team members and next of kin enables the patient to come forth as a unique person and uphold absolute dignity in care. Acknowledging the next of kin's familiarity with the severely ill patient will contribute to personalizing the patient and in this way be the ground for a person centeredness in care despite the patients’ inability to defend their own interests. Through knowledge about the patient as a person, the foundation for dignified care is given, expressed through respect for the patient's will and desires and derived through conversations between carers and next of kin.

Motivational interviewing for low mood and adjustment early after stroke: a feasibility randomised trial

BackgroundManagement of psychological adjustment and low mood after stroke can result in positive health outcomes. We have adapted a talk-based therapy, motivational interviewing (MI), and shown it to be potentially effective for managing low mood and supporting psychological adjustment post-stroke in a single-centre trial. In the current study, we aimed to explore the feasibility of delivering MI using clinical stroke team members, and using an attention control (AC), to inform the protocol for a future definitive trial.MethodsThis parallel two-arm feasibility trial took place in north-west England. Recruitment occurred between December 2012 and November 2013. Participants were stroke patients aged 18 years or over, who were medically stable, had no severe communication problems, and were residents of the hospital catchment. Randomisation was to MI or AC, and was conducted by a researcher not involved in recruitment using opaque sealed envelopes. The main outcome measures were descriptions of study feasibility (recruitment/retention rates, MI delivery by clinical staff, use of AC) and acceptability (through qualitative interviews and completion of study measures), and fidelity to MI and AC (through review of session audio-recordings). Information was also collected on participants’ mood, quality of life, adjustment, and resource-use.ResultsOver 12 months, 461 patients were screened, 124 were screened eligible, and 49 were randomised: 23 to MI, 26 to AC. At 3 months, 13 MI and 18 AC participants completed the follow-up assessment (63% retention). This was less than expected based on our original trial. An AC was successfully implemented. Alternative approaches would be required to ensure the feasibility of clinical staff delivering MI. The study measures, MI, and AC interventions were considered acceptable, and there was good fidelity to the interventions. There were no adverse events related to study participation.ConclusionsIt was possible to recruit and retain participants, train clinical staff to deliver MI, and implement an appropriate AC. Changes would be necessary to conduct a future multi-centre trial, including: assuming a recruitment rate lower than that in the current study; implementing more strategies to increase participant retention; and considering alternative clinical staff groups to undertake the delivery of MI and AC.Trial registrationISRCTN study ID: ISRCTN55624892Trial fundingNorthern Stroke Research Fund

Selected abstracts from the 24th Annual Meeting of the Society in Europe for the Simulation Applied to Medicine

Ethics statement: The authors declare that they have followed the guidelines for scientific integrity and professional ethics. The article does not contain any studies with human or animal subjects. Introduction & Aim: Stroke is one of the leading causes of morbidity and mortality worldwide. In eligible patients with acute ischemic stroke, early treatment with intravenous thrombolysis is crucial for a good patient outcome. We introduced simulation training sessions in conjunction with an improved treatment protocol as part of a quality improvement project to reduce door-to-needle times in stroke thrombolysis. Methods: A questionnaire assessing our preexisting treatment protocol was sent to all members of the stroke team. A panel of experts reviewed the responses and suggested potential changes to streamline the treatment protocol. In February 2017, we introduced the new protocol along with weekly videotaped in-situ scenario based simulation sessions with all stroke team members as participants. Previous stroke patients acted as markers. Kirkpatrick’s four-level training evaluation model was used for assessment. Here we present 1) Participant reactions (level 1) on a Likert item from 0-10, and 2) Median door-to-needle times in stroke thrombolysis, a measure of clinical behavioral change (level 3), using a statistical process control method. Simulated performance and long term patient outcomes will be assessed in future analysis. Results & Discussion: Participant reactions were predominantly positive. Self-perceived learning scored a median of 8 (IQR 7-9). We compared door-to-needle times for 478 prospectively included patients with acute ischemic stroke treated with intravenous thrombolysis at our hospital from January 2014 – July 2017. There was a significant reduction in median door-to-needle time from 27 (IQR 19-41) to 13 minutes (IQR 9-21, p<0.001) for the 78 patients in the post-intervention group. The results remained significant regardless of time of admission. There were no significant changes in the rate of stroke mimics, prehospital time or fatal intracranial hemorrhage. Simulation training in conjunction with protocol improvement led to an immediate and significant reduction of median door-to-needle time in stroke thrombolysis (Fig. 1). To our knowledge, no other published data have shown lower median treatment times. Combining simulation training with protocol change holds promise as a method both for effective implementation and significant results in attempts to reduce in-hospital delays in stroke thrombolysis. Effects on non-technical skills, provider variability and long term patient outcomes are yet to be evaluated.

Stroke code simulation benefits advanced practice providers similar to neurology residents.

Advanced practice providers (APPs) are important members of stroke teams. Stroke code simulations offer valuable experience in the evaluation and treatment of stroke patients without compromising patient care. We hypothesized that simulation training would increase APP confidence, comfort level, and preparedness in leading a stroke code similar to neurology residents. This is a prospective quasi-experimental, pretest/posttest study. Nine APPs and 9 neurology residents participated in 3 standardized simulated cases to determine need for IV thrombolysis, thrombectomy, and blood pressure management for intracerebral hemorrhage. Emergency medicine physicians and neurologists were preceptors. APPs and residents completed a survey before and after the simulation. Generalized mixed modeling assuming a binomial distribution was used to evaluate change. On a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree), confidence in leading a stroke code increased from 2.4 to 4.2 (p < 0.05) among APPs. APPs reported improved comfort level in rapidly assessing a stroke patient for thrombolytics (3.1-4.2; p < 0.05), making the decision to give thrombolytics (2.8 vs 4.2; p < 0.05), and assessing a patient for embolectomy (2.4-4.0; p < 0.05). There was no difference in the improvement observed in all the survey questions as compared to neurology residents. Simulation training is a beneficial part of medical education for APPs and should be considered in addition to traditional didactics and clinical training. Further research is needed to determine whether simulation education of APPs results in improved treatment times and outcomes of acute stroke patients.

Feasibility and utility of an integrated medical imaging and informatics smartphone system for management of acute stroke.

Background Rapid dissemination and coordination of clinical and imaging data among multidisciplinary team members are essential for optimal acute stroke care. Aim To characterize the feasibility and utility of the Synapse Emergency Room mobile (Synapse ERm) informatics system. Methods We implemented the Synapse ERm system for integration of clinical data, computerized tomography, magnetic resonance, and catheter angiographic imaging, and real-time stroke team communications, in consecutive acute neurovascular patients at a Comprehensive Stroke Center. Results From May 2014 to October 2014, the Synapse ERm application was used by 33 stroke team members in 84 Code Stroke alerts. Patient age was 69.6 (±17.1), with 41.5% female. Final diagnosis was: ischemic stroke 64.6%, transient ischemic attack 7.3%, intracerebral hemorrhage 6.1%, and cerebrovascular-mimic 22.0%. Each patient Synapse ERm record was viewed by a median of 10 (interquartile range 6-18) times by a median of 3 (interquartile range 2-4) team members. The most used feature was computerized tomography, magnetic resonance, and catheter angiography image display. In-app tweet team, communications were sent by median 1 (interquartile range 0-1, range 0-13) users per case and viewed by median 1 (interquartile range 0-3, range 0-44) team members. Use of the system was associated with rapid treatment times, faster than national guidelines, including median door-to-needle 51.0 min (interquartile range 40.5-69.5) and median door-to-groin 94.5 min (interquartile range 85.5-121.3). In user surveys, the mobile information platform was judged easy to employ in 91% (95% confidence interval 65%-99%) of uses and of added help in stroke management in 50% (95% confidence interval 22%-78%). Conclusion The Synapse ERm mobile platform for stroke team distribution and integration of clinical and imaging data was feasible to implement, showed high ease of use, and moderate perceived added utility in therapeutic management.

Defining the Role of the Stroke Physician During Endovascular Therapy of Acute Ischemic Stroke.

Six recent trials and a patient-level meta-analysis have demonstrated the superiority of endovascular therapy (EVT) compared with standard care (including intravenous alteplase) among patients with large-artery anterior circulation strokes.1–7 The absolute benefit of EVT was substantial in these trials, and EVT now requires careful implementation and optimization in real-world settings to provide all eligible patients with this new standard of care. Parallel rather than serial workflow, with team members having well-defined roles, is a crucial element in providing rapid and effective delivery of acute stroke care.8 There is little or no literature on the division of labor or the expected role for each individual in this setting, and existing stroke guidelines do not elaborate on this issue. Although each system may require customization, it is clear is that there must be physician leadership outside of the angiography suite, a physician in addition to the neurointerventionalist (who is most commonly a radiologist, but who may be a neurosurgeon or neurologist) in the angiography suite, and a physician to coordinate care between the other stroke team members throughout the periprocedural period. We suggest that it is necessary to designate a physician to fulfill these roles during the EVT process, and we have termed herein the individual fulfilling this role the stroke physician. The stroke physician must work in close collaboration with the neurointerventionalist to optimize the speed, efficiency, and safety of EVT, elements which are critical to enhancing patient outcomes. A proposed division of physician roles is shown in Table, with emphasis on parallel rather than serial workflow. The administration of intravenous alteplase is ideally performed under the guidance of a stroke physician with specialized training in stroke care. This is most often a neurologist but may also be an emergency physician, geriatrician, internist, or family physician, …

Setting Up a Stroke Team Algorithm and Conducting Simulation-based Training in the Emergency Department - A Practical Guide.

Time is of the essence when caring for an acute stroke patient. The ultimate goal is to restore blood flow to the ischemic brain. This can beachieved by eitherthrombolysis with recombinant tissue-plasminogen activator (rt-PA), the standard therapy for stroke patients who present within the first hours of symptom onset without contraindications, or by an endovascular approach, if a proximal brain vessel occlusion is detected. As the efficacy of both therapies declines over time, every minute saved along the way will improve the patient's outcome. This critical situation requires thorough work and precise communication with the patient, the family and colleagues from different professions to acquire all relevant information and reach the right decision while carefully monitoring the patient. This is a high fidelity situation. In nonmedical high-fidelity environments such as aviation, Crew Resource Management (CRM) is used to enhance safety and team efficiency. This guide shows how a Stroke Team algorithm, which is transferable to other hospital settings, was established and how regular simulation-based trainings were performed. It requires determination and endurance to maintain these time-consuming simulation trainings on a regular basis over the course of time. However, the resulting improvement of team spirit and excellent door-to-needle times will benefit both the patients and the work environment in any hospital. A dedicated Stroke Team of 7 persons who are notified 24/7 by a collective call via speed dial and run a binding algorithm that takes approximately 20 min, was established. To train everybody involved in this algorithm, a simulation-based team training for all new Stroke Team members was conceived and conducted at monthly intervals. This led to a relevant and sustained reduction of the mean door-to-needle time to 25 min, and enhanced the feeling of stroke readiness especially in junior doctors and nurses.