Stroke Team Members Research Articles

Feasibility and Efficacy of Nurse-Driven Acute Stroke Care

Acute stroke care requires rapid assessment and intervention. Replacing traditional sequential algorithms in stroke care with parallel processing using telestroke consultation could be useful in the management of acute stroke patients. The purpose of this study was to assess the feasibility of a nurse-driven acute stroke protocol using a parallel processing model. This is a prospective, nonrandomized, feasibility study of a quality improvement initiative. Stroke team members had a 1-month training phase, and then the protocol was implemented for 6 months and data were collected on a "run-sheet." The primary outcome of this study was to determine if a nurse-driven acute stroke protocol is feasible and assists in decreasing door to needle (intravenous tissue plasminogen activator [IV-tPA]) times. Of the 153 stroke patients seen during the protocol implementation phase, 57 were designated as "level 1" (symptom onset <4.5 hours) strokes requiring acute stroke management. Among these strokes, 78% were nurse-driven, and 75% of the telestroke encounters were also nurse-driven. The average door to computerized tomography time was significantly reduced in nurse-driven codes (38.9 minutes versus 24.4 minutes; P < .04). The use of a nurse-driven protocol is feasible and effective. When used in conjunction with a telestroke specialist, it may be of value in improving patient outcomes by decreasing the time for door to decision for IV-tPA.

Reasoning about truth-telling in end-of-life care of patients with acute stroke.

Ethical problems are a universal phenomenon but rarely researched concerning patients dying from acute stroke. These patients often have a reduced consciousness from stroke onset and thereby lack ability to convey their needs and could be described as 'incompetent' decision makers regarding their own care. The aim of the study was to deepen the understanding of stroke team members' reasoning about truth-telling in end-of-life care due to acute stroke. Qualitative study based on individual interviews utilizing combined deductive and inductive content analysis. Participants and research context: A total of 15 stroke team members working in stroke units of two associated county hospitals in western Sweden participated. Ethical considerations: The study was approved by the Regional Ethics Review Board, Gothenburg, Sweden. The main findings were the team members' dynamic movement between the categories 'Truth above all' and 'Hide truth to protect'. Honesty was highly valued and considered as a reason for always telling the truth, with the argument of truth as common morality. However, the carers also argued for hiding the truth for different reasons such as not adding extra burden in the sorrow, awaiting a timely moment and not being a messenger of bad news. Withholding truth could both be seen as a way of protecting themselves from difficult conversations and to protect others. The results indicate that there are various barriers for truthfulness. Interpreted from a virtue of ethics perspective, withholding of truth might also be seen as an expression of sound judgement to put the patient's best interest first. The carers may need support in the form of supervision to be given space to reflect on their experience and thereby promote ethically justified care. Here, the multi-professional team can be of great value and contribute through inter-professional sharing of knowledge.

Abstract 101: A Learning Collaborative Model to Improve Door to Needle Time for Stroke Thrombolysis in Chicago

Background: Door-to-needle (DTN) times have remained suboptimal despite overall increases in tissue plasminogen activator use (tPA) for stroke in Chicago. The American Heart Association’s (AHA) Quality Enhancement for Speedy Thrombolysis in Stroke (QUESTS) initiative aimed to identify barriers to reduce DTN times at Chicago’s 15 primary stroke centers (PSCs) and increase the proportion of patients treated with tPA within 60 minutes of hospital arrival. Methods: Starting in January 2013, we used face-to-face and on-site meetings with each PSC’s stroke team members to share AHA Target Stroke best practices and strategies to reduce DTN time. A survey of current practice was completed at each site to determine opportunities for improvement and repeated at 1 year to assess implementation of new strategies. We used the Get With The Guidelines (GWTG) Stroke registry to aggregate baseline data DTN times and track performance in each quarter of 2013. Results: At baseline, 5 strategies were notably under-utilized at Chicago’s 15 PSCs: 1) Direct to CT scanner (baseline: 0 sites; 1 year: 5 sites); 2) pre-mixing tPA (baseline: 1 site; 1 year: 14 sites); 3) tPA prior to laboratory results (baseline: 3 sites; 1 year: 7 sites); 4) stroke code activation at triage (baseline: 4 sites; 1 year: 13 sites); and 5) streamlined consent process (baseline: 0 sites; 1 year: 12 sites. The proportion of patients treated within 60 minutes increased in each quarter of 2013 from 25% in quarter 1 to 60% in quarter 4 (p&lt;0.01). The median DTN time decreased from 89.5 minutes in quarter 1 to 55 minutes in quarter 4 (p&lt;0.01). Conclusions: Using a learning collaborative model to implement strategies to reduce DTN times among 15 PSCs in Chicago, we observed major improvements within a few months. Regional collaboration and best practices sharing should be a model for rapid and sustainable system-wide quality improvement.

Abstract TP312: Simulation Based Education for Neurology Nurses to Improve In-hospital Stroke Emergency Performance

Introduction: An in-hospital stroke emergency demands timely decision making and prioritization of tasks by the stroke team nurse. Simulation-based medical education (SBME) focuses on obtaining clinical skills in psychomotor, cognitive and affective domains and is superior to the traditional style of education with improved outcomes of knowledge, skills and behaviors and demonstrable effects for patient-related outcomes. A stroke simulation study at our center showed significant improvements in the cognitive and affective domain of new residents and this next phase aims at incorporating members of the multidisciplinary stroke team. Hypothesis: SBME improves stroke emergency performance, particularly for inexperienced stroke team members. Methods: Eight neuro ICU nurses participated in a high fidelity patient simulation of an in-hospital ischemic stroke eligible for IV tPA. The nurse independently managed every nursing task including a focused patient assessment, verifying and evaluating vitals and treating appropriately, expediting labs, managing common obstacles and coordinating care with the stroke team. Nurses completed an affective survey, pre- and post-test cognitive assessment and debriefing with feedback. An evaluator completed a real-time checklist of pre-defined tasks and the subject participated in a review of their performance with the stroke team. Results: Subjects showed a 19.4% improvement in the cognitive assessment post-simulation (p=0.02). The affective survey showed nurses were confident in their ability to perform the NIHSS. While there was no significant change in the affective domain post simulation due to the subject groups being too small for statistical comparison, recognition of normal parameters (labs and vitals) for treatment of stroke showed an improvement of 6.25%. Conclusion: SBME can facilitate the acquisition of technical skills and non-technical skills such as team work, communication, decision-making and cognizance of personal limitations. This pilot demonstrated that nurses can benefit in the cognitive domain through simulation and feedback indicated that a stroke simulation with increased interaction among stroke team members, with defined roles would add to the fidelity of the simulation.

Abstract WMP68: Smartphone Support System for Mobile Imaging Display and Management of Acute Stroke

Introduction: Rapid dissemination and coordination of clinical and imaging data among multidisciplinary team members is essential for optimal acute stroke care. Standard desktop EMRs are ill-suited for this purpose, but mobile smartphone and tablet applications are highly promising platforms for accelerated, data-driven patient diagnosis and treatment. This study tested an advanced mobile integrated system for distribution of patient clinical and imaging information. Methods: We tested the iStroke/Synapse ERm system (Figure) for smartphone and tablet display and integration of clinical data, CT, MR, and catheter angiographic imaging, and real-time stroke team communications, in consecutive acute neurovascular patients at a Comprehensive Stroke Center. Results: From 5/2014 to 10/2014, the Synapse ERm application was installed and used by 33 stroke team members, in 84 Code Stroke ED patients. Patient age was 69.1 (±17.5), with 40.5% female. Final diagnosis was: ischemic stroke 66%, TIA 7%, ICH 6%, and CV mimic 21%. Each patient record was viewed on average 13 times by at least 3 team members. The most used feature was CT, MR and cath angio image display, viewed on average 4 times per patient by at least 2 users. In-app tweet team communications were sent by average 2 users per case and viewed by average 6 team members. Use of the system was associated with treatment times that exceeded national guideline targets for thrombolysis and endovascular thrombectomy, including door-to-needle 50 min (IQR 24-60) and door-to-groin 92 min (IQR 65-128). In user surveys, the mobile information platform was judged easy to employ in 91% of uses and of added help in stroke management in a substantial majority of cases. Conclusion: The Synapse ERm system, a smartphone/tablet platform for stroke team communication and distribution and integration of clinical and imaging data, showed high ease of use, substantial added management value, and association with rapid processes of care.

Feasibility of a Pre-Hospital Notification System Using Direct Calls from Paramedics of 119 EMS Ambulances for Acute Stroke Patients: Accuracy of Diagnosis and Efficacy of Shortening of Door-to-Imaging Time

Background: A pre-hospital notification (PN) system is required to optimize government-initiated comprehensive stroke center (CSC) programs in South Korea. We accordingly conducted a feasibility study in the Busan region. Methods: We determined the stroke detection accuracy and the door-to-imaging (DTI) time as a result of using PN in the Busan region among acute stroke (AS) patients who were diagnosed by paramedics of the Busan 119 Emergency medical service (EMS). All paramedics of 119 EMS were trained using the Cincinnati Pre-hospital Stroke Screen. Beginning in 2011, stroke team members received direct calls from paramedics notifying them of suspected AS patients. Stroke identification results from paramedics were compared with emergency department and final hospital discharge diagnoses. Finally, we compared the DTI time between patients with and without PN by para medics of the Busan 119 EMS. Results: During the observation period, 91 suspected AS patients were referred to our CSC from paramedics of the Busan 119 EMS. Among them, 57 patients (62.6%) were diagnosed with AS. Their mean DTI time was 13.4 ± 8.1 min. The accuracy rate was similar and imaging time was significantly shorter (32.7 ± 252.8 min, p<0.01), as compared to patients diagnosed by ER doctors during the same period. Conclusion: In this study, we confirmed the feasibility of successful implementation of a PN system for AS patients in the Busan region. J Neurocrit Care 2015;8(2):98-102

Care Provision for Poststroke Visual Impairment

We sought to explore the care provision for poststroke visual impairment and variations in this in the United Kingdom. Survey questions were developed and piloted with clinicians, academics, and users. Questions addressed types of visual problems; how these were identified, treated, and followed up; care pathways in use; links with other professions; and referral options. The survey was accessed via a Weblink, which was circulated through UK professional organizations to multiprofessional members of ophthalmic and stroke teams. A total of 548 completed electronic surveys were obtained. In all, 49.5% of respondents represented stroke teams, 42.5% eye teams, and 8% from other teams, for example, emergency care. Many respondents (41%) saw patients within 1 week of stroke. Nineteen percent did not personally test vision: 11% had a visiting clinician to test vision, and 22% used screening tools. Validated tests were used for the assessment of visual acuity (39.5%), visual field (57.5%), eye movement (48.5%), and visual function (58.5%). Visual problems suspected by family or professionals were high (88.5%). Typical overall follow-up period of vision care was less than 3months. In all, 46% of respondents used designated care pathways for stroke survivors with visual problems; 33.5% of respondents did not provide visual information leaflets. Significant inequality exists in care for stroke survivors who experience visual problems. There is great variability in how vision screening is undertaken, which vision tests are used, methods of referral to eye care services, how visual problems are managed, and what vision information is provided tostroke survivors/carers. Further work is required to ensure equality and effectivecare.

Abstract 66: Is Hospital Discharge Day of the Week Associated with Measures of Care Continuity for Stroke Patients?

Background: Facilitating care continuity from hospital to home has been shown for other disease states to reduce adverse health events. In this study we examined whether weekend discharges were less likely to have a follow-up appointment scheduled with either primary or specialty care for acute stroke patients discharged home. Methods: We examined data from 44 hospitals participating in the Ohio Coverdell Stroke program to determine the proportion of adult stroke patients discharged home who had a follow-up appointment scheduled with primary care or with specialty care (neurology, neurosurgery, or neurology provider) and whether this varied by patients’ hospital discharge day of the week (weekday vs. weekend). Facilitators and barriers to scheduling appointments prior to discharge were reported by stroke team members at a meeting of participating hospitals. Results: Among 44 hospitals, there were 4,635 patients discharged home from April-December 2013. Prior to discharge, hospital staff scheduled follow-up appointments for post-discharge care with a primary care provider for 15.2% of patients and with a specialty care provider for 27.2% of patients. A higher proportion of patients with a weekday discharge compared with weekend discharge had a follow-up appointment with primary care (16.4% vs. 8.5%, p&lt;0.001) and specialty care (29.6% vs. 17.5%, p&lt;0.001). Reported barriers to facilitating care continuity for weekend patient discharges included lack of availability of dedicated weekend hospital personnel to plan appointments with the patient and family, and limited or no access to online or electronic appointment scheduling or primary or specialty care office staff to schedule appointments. Conclusions: Although a significant number of patients were discharged home without a primary or specialty care appointment, patients discharged on the weekend were at a disadvantage for having a follow-up appointment scheduled prior to hospital discharge. Discharge planning earlier in the hospital stay and creative approaches to improving appointment scheduling with community-based providers could be explored as options for promoting improved care continuity for weekend discharges.

Abstract T MP83: Simulation Based Medical Education For Incoming Neurology Trainees to Improve Hospital Stroke Emergency Performance

INTRODUCTION: An ED-based “stroke code” demands timely decision making and prioritization of tasks by the stroke team neurologist while coordinating care with ED staff, radiology and pharmacists. Simulation-based medical education (SBME) focuses on obtaining clinical skills belonging to the psychomotor, cognitive and affective domains. SBME is superior to the traditional style of medical education and has shown improved outcomes of knowledge, skills and behaviors and moderate effects for patient-related outcomes in other emergency based scenarios including ACLS and procedure-based learning. HYPOTHESIS: To describe the rationale and design for a novel hospital based stroke simulation. SBME can improve stroke code efficiency particularly for inexperienced stroke team members. METHODS: Six incoming PG2 neurology residents participated in a pilot study using a high fidelity patient simulation of an acute ED-based stroke code at week 1 and 3 of orientation. The trainee independently managed every step from activation of the stroke pager including a focused patient assessment, ordering and interpreting labs and imaging, managing common obstacles, staffing with the on-call attending, working with ancillary staff and appropriate treatment as indicated. Residents completed an affective survey, pre- and post-test cognitive assessment and debriefing with feedback, as well as real time checklist and review of videotaped assessment of their performance. RESULTS: Subjects showed a 16.1% improvement in the cognitive assessment from week 1 to week 3 (p=0.02). The affective survey showed residents were moderate to highly confident in their ability to perform a history and physical prior to participation, yet they had low confidence utilizing the NIHSS and managing medications for acute stroke in the ED prior to participation. CONCLUSION: SBME can facilitate the acquisition of technical and non-technical skills such as leadership, team work, communication, situational awareness, decision-making, cognizance of personal limitations important for patient safety and a learning cycle of debriefing and feedback. Post-test and affective survey results demonstrate improvements in the cognitive domain and resident confidence respectively.

Abstract 18789: A Learning Collaborative Model to Improve Door to Needle Time for Stroke Thrombolysis in Chicago

Background: Door-to-needle (DTN) times have remained suboptimal despite overall increases in tissue plasminogen activator use (tPA) for stroke in Chicago. The American Heart Association’s (AHA) Quality Enhancement for Speedy Thrombolysis in Stroke (QUESTS) initiative aimed to identify barriers to reduce DTN times at Chicago’s 15 primary stroke centers (PSCs) and increase the proportion of patients treated with tPA within 60 minutes of hospital arrival. Methods: Starting in January 2013, we used face-to-face and on-site meetings with each PSC’s stroke team members to share AHA Target Stroke best practices and strategies to reduce DTN time. A survey of current practice was completed at each site to determine opportunities for improvement and repeated at 1 year to assess implementation of new strategies. We used the Get With The Guidelines (GWTG) Stroke registry to aggregate baseline data DTN times and track performance in each quarter of 2013. Results: At baseline, 5 strategies were notably under-utilized at Chicago’s 15 PSCs: 1) Direct to CT scanner (baseline: 0 sites; 1 year: 5 sites); 2) pre-mixing tPA (baseline: 1 site; 1 year: 14 sites); 3) tPA prior to laboratory results (baseline: 3 sites; 1 year: 7 sites); 4) stroke code activation at triage (baseline: 4 sites; 1 year: 13 sites); and 5) streamlined consent process (baseline: 0 sites; 1 year: 12 sites. The proportion of patients treated within 60 minutes increased in each quarter of 2013 from 25% in quarter 1 to 60% in quarter 4 (p&lt;0.01). The median DTN time decreased from 89.5 minutes in quarter 1 to 55 minutes in quarter 4 (p&lt;0.01). Conclusions: Using a learning collaborative model to implement strategies to reduce DTN times among 15 PSCs in Chicago, we observed major improvements within a few months. Regional collaboration and best practices sharing should be a model for rapid and sustainable system-wide quality improvement.

Understanding nursing practice in stroke units: a Q-methodological study

Purpose: Nurses represent the largest professional group working with stroke-survivors, but there is limited evidence regarding nurses’ involvement in post-stroke rehabilitation. The purpose of this study was to identify and explore the perspectives of nurses and other multidisciplinary stroke team members on nurses’ practice in stroke rehabilitation. Method: Q-methodological study with 63 multidisciplinary stroke unit team members and semi-structured interviews with 27 stroke unit team members. Results: Irrespective of their professional backgrounds, participants shared the view that nurses can make an active contribution to stroke rehabilitation and integrate rehabilitation principles in routine practice. Training in stroke rehabilitation skills was viewed as fundamental to effective stroke care, but nurses do not routinely receive such training. The view that integrating rehabilitation techniques can only occur when nursing staffing levels were high was rejected. There was also little support for the view that nurses are uniquely placed to co-ordinate care, or that nurses have an independent rehabilitation role. Conclusions: The contribution that nurses with stroke rehabilitation skills can make to effective stroke care was understood. However, realising the potential of nurses as full partners in stroke rehabilitation is unlikely to occur without introduction of structured competency-based multidisciplinary training in rehabilitation skills.Implications for RehabilitationMultidisciplinary rehabilitation in stroke units is a cornerstone of effective stroke care.Views of stroke unit team members on nurses’ involvement in rehabilitation have not been reported previously.Nurses can routinely incorporate rehabilitation principles in their care.Specialist competency-based stroke rehabilitation training needs to be provided for nurses as well as for allied health professionals.

Strategies for handling ethical problems in end of life care: obstacles and possibilities.

In end of life care, ethical problems often come to the fore. Little research is performed on ways or strategies for handling those problems and even less on obstacles to and possibilities of using such strategies. A previous study illuminated stroke team members' experiences of ethical problems and how the teams managed the situation when caring for patients faced with sudden and unexpected death from stroke. These findings have been further explored in this study. The aim of the study was to illuminate obstacles and possibilities perceived by stroke team members in using strategies for handling ethical problems when caring for patients afflicted by sudden and unexpected death caused by stroke. A qualitative method with combined deductive and inductive content analysis was utilized. Data were collected through individual interviews with 15 stroke team members working in stroke units of two associated county hospitals in western Sweden. The study was approved by the Regional Ethics Review Board, Gothenburg, Sweden. Permission was also obtained from the director of each stroke unit. All the studied strategies for handling of ethical problems were found to have both obstacles and possibilities. Uncertainty is shown as a major obstacle and unanimity as a possibility in the use of the strategies. The findings also illuminate the value of the concept "the patient's best interests" as a starting point for the carers' ethical reasoning. The concept "the patient's best interests" used as a starting point for ethical reasoning among the carers is not explicitly defined yet, which might make this value difficult to use both as a universal concept and as an argument for decisions. Carers therefore need to strengthen their argumentation and reflect on and use ethically grounded arguments and defined ethical values like dignity in their clinical work and decisions.

Trends in yield of a code stroke program for enhancing thrombolysis

As the benefit of thrombolytic therapy in acute ischemic stroke is time-dependent, a code stroke program needs to be implemented, maintained, and improved with continuous efforts to expedite thrombolytic therapy. We analyzed the long-term yield and efficiency of our code stroke program. Using a prospective single-center registry, we assessed the rates of stroke diagnosis and thrombolysis, door-to-CT scan and door-to-needle times, and annual trends in patients with code stroke activation between May 2007 and December 2011. Of the 791 patients with code stroke activation during the 4.7year study period, 626 (79.1%) had a stroke, with 461 (58.3%) ischemic strokes and 165 (20.9%) hemorrhagic strokes. Along with an increase of code stroke activation (from 105/year to 236/year) and thrombolytic therapy volumes (from 24/year to 77/year), the rate of thrombolytic therapy among ischemic stroke patients increased from 33.3% to 59.2% (p for trend=0.0001). However, code activations for a non-stroke case also significantly increased (p for trend=0.0001). Door-to-CT scan time (p for trend=0.0011) and proportion of CT scan initiation ⩽25minutes after arrival improved (p for trend=0.0022), and were 18.4minutes and 76.7%, respectively, in 2011. However, the door-to-needle time and proportion of door-to-needle time ⩽60minutes did not significantly improve, they were (43.3minutes and 83.1%, respectively, in 2011). Our code stroke program yielded a high rate of detecting thrombolysis candidates and a continuous increase in rates of administration of thrombolytic therapy. These findings support the stroke team members’ collaborative effort to treat more patients and to treat patients faster.

Abstract 270: Primary and Specialty Care Follow-up Appointments after Stroke: Rates, Variability, and Opportunities for Improvement

Background: Follow-up care after an acute stroke can facilitate patient recovery and limit recurrence. In other disease states, scheduling a follow-up appointment with primary and specialty care prior to hospital discharge can facilitate smooth care transitions. However there are limited data on the variability in care continuity after acute stroke. Methods: We examined overall and hospital specific rates of follow-up appointments with primary care and specialty care scheduled prior to hospital discharge among the 44 Ohio Coverdell Stroke Program hospitals. Patients of any stroke type, without documented comfort measures, and discharged home, alive and not to hospice care were eligible for a follow-up appointment with primary care. To be eligible for the specialty care appointment, patients of any stroke type needed an order for a follow-up appointment with a neurologist or neurosurgeon, be without documented comfort measures, and discharged home, to rehabilitation or a skilled nursing facility. Multivariable logistic regression was used to examine patient and hospital factors associated with each follow-up appointment measure. Facilitators and barriers to scheduling appointments prior to discharge were reported by stroke team members at a meeting of participating hospitals. Results: Of the 4,162 patients eligible for the specialty care measure over 6 months, 24.8% had a neurologist or neurosurgeon appointment scheduled before hospital discharge. Hospital-level specialty appointment arrangement ranged from 0-83%. Among 3,141 patients eligible for a primary care appointment, 14% had one scheduled prior to discharge; hospital specific variability ranged from 0-50%. In the multivariable model, age, gender, stroke type, insurance type, and hospital stroke volume were not associated with either primary or specialty care appointments. Facilitators of follow-up care reported by some participating hospitals were paradoxicallly reported as barriers by others. These included availability of dedicated personnel to plan with the patient and family and schedule with post-hospital providers, functionality of electronic medical records, provider perspectives on the importance of follow-up, schedule availability of post-hospital providers, geographic accessibility for patients, integration with other discharge planning processes, and inclusion of the scheduled appointments on discharge summaries for patients. Conclusions: A high proportion of patients with acute stroke failed to have a primary care or specialty care follow-up appointment scheduled prior to discharge and this varied widely across participating hospitals. A collaborative approach for data-driven change and exchange of local best practices and facilitators could lead to significant improvement.

Abstract W P188: Achieving Sub-20min tPA Door-to-needle Times - the Importance of Patient Details on Prenotification and Point-of-care INR

Background and purpose: Institutions around the world have re-engineered acute stroke care to achieve dramatic reductions in tPA door-to-needle times (DNT). We investigated the effects of specific process elements on DNT. Methods: The “code stroke” system at Royal Melbourne Hospital was systematically evaluated and redesigned in 2012 to take patients directly from triage to CT on ambulance stretchers and deliver tPA on the CT table. We studied the 12 months post implementation data within business hours (when stroke team members were located in the hospital) for effects of variably utilized key components of the new system - ambulance pre-notification including patient name and date of birth (allowing transfer direct to CT), and point-of-care (POC)-INR. Results: In the 12 months post-implementation, 40/80 (50%) of patients who received tPA were treated in-hours. In-hours DNT reduced from pre-implementation median 43 min to 23 min (p&lt;0.001). However, only 33% of the patients had full pre-notification including name and date of birth. In these patients median DNT was 16 min vs. pre-notification without personal details 22 min, p=0.02. Patients with no prenotification which prevented transfer direct to CT had significant delays (median DNT 51 min; p&lt;0.001 vs prenotification). After-hours where the system remained unchanged there was no change in DNT (median 67 min vs. 65 min; p=0.87). Patients possibly taking warfarin previously required laboratory INR pre-tPA (median DNT 77 min; range 38-92 min). Subsequently 6/80 (7.5%) patients were treated after confirming sub-therapeutic POC-INR (25 min; range 14-34 min). Conclusions: Pre-notification and going direct to CT have the greatest impact in reducing treatment delays. Combined, these simple, resource-neutral procedures halved our median DNT. The optimal pre-notification includes patient details, allowing pre-registration, pre-ordering of CT, and access to prior medical history during transport. POC-INR is helpful in select patients.

Abstract 87: Evolution of the 24-Hour In-House Stroke Team

Background and Issues: In 1998, Providence St. Peter Hospital (PSPH) created its first stroke team. An on-call Stroke RN/neurologist duo responded to pages from the emergency center and inpatient attending physicians and nurses 24 hours a day, 365 days a year. By late 2010, the responsibilities of the stroke team members had significantly increased, but only two Stroke RNs and one neurologist participated on the team. It became clear that the 100% on-call model had become resource limited and processes were now inconsistent. The development of a sustainable new stroke model was critical. Purpose: The purpose of the project was to create a sustainable in-house stroke patient care process that would meet the community’s need for excellent stroke care while maintaining Joint Commission Primary Stroke Center certification. Methods: In early 2011, an interdisciplinary team convened to develop the new process. Members included RNs and physicians from neuroscience, emergency center, and primary care, radiologists, CT technicians, pharmacists, and phlebotomists. Stroke clinical guidelines, best practices and outcome data were reviewed. Operational, financial and clinical opportunities for improvement were identified. Results: As a result, two separate initiatives were implemented, (a) in-house acute stroke response and (b) emergency center acute stroke response, both which are active 24 hours per day, 365 days per year. Seven neurologists now rotate call as the stroke neurologist. One of sixteen neuroscience RNs is onsite 24 hours a day as the Stroke RN. Acquisition of a telestroke robot enables the stroke neurologist to assess the patient immediately and make treatment decisions that are initiated before the neurologist arrives at the hospital. Procedures are outlined for all involved departments, ensuring timely diagnostics completion, appropriate medication administration or intervention, and consistently high standards of care. Conclusions: In conclusion, the revised stroke patient care management processes have proven to be sustainable and effective in ensuring timely intervention and positive outcomes for stroke patients. The program is reviewed and updated monthly.

Abstract T P247: An Interdisciplinary Approach Using a Root Cause Analysis to Decrease Door to IV tPA Times

Background and Issues: The benchmark goal for stroke treatment is door to IV tPA in 60 minutes. In 2010, average door to IV tPA treatment time for acute stroke patients at our acute care, tertiary teaching hospital was 87 minutes. Purpose: As a TJC certified primary stroke center, our purpose was to improve door to IV tPA times. Methods: Causes for lengthy tPA treatment times were identified by the stroke interdisciplinary team using a root cause analysis approach. Identified delays included: lab turn-around times, order entry, clinical decision making time, and tPA preparation, delivery, and administration. Process improvement initiatives for order entry included revisions to electronic order sets to auto-populate and enhance efficiency and safety of order entry. Lab audits revealed that the BMP took the most time to process, resulting in initiation of point of care testing. For clinical decision making delays by neurology, immediate feedback was provided to the neurologist after each tPA administration. A year end summary was compiled showing door to tPA times for each attending neurologist. In addition, 3 APNs completed a neurovascular advanced practice fellowship program. Pharmacy instituted a tracking log to audit prep-to-delivery time which encouraged earlier notification and faster delivery times. Mixing of tPA was changed from (2) 50mg vials to reconstitution of (1) 100mg vial. Nurses who administer tPA were re-competencied using a simulation lab. Patients were triaged to a room in ED closer to the CT scanner. And, a count-down clock was initiated upon patient arrival to ED to enhance time awareness for all stroke team members. Results: Average door to tPA time has decreased from 87 minutes in 2010 to 50 minutes YTD 2013, a 37 minute improvement. In addition, volume increased by 25 more tPA administrations in 2012. Chi square comparisons of discharge dispositions showed no statistical differences for 2010 vs 2013 (p=.56) or 2012 vs 2013 (p= .18). Our hospital has received the American Stroke Association’s Target Stroke award for the past 2 years. Conclusions: An interdisciplinary approach using a root cause analysis is effective in identifying and implementing process improvements, ultimately leading to decreased door to IV tPA times.

Abstract W MP2: Daily Goals Poster Supports Effective Patient Education

Background: Patient education is a central component of any stroke program. Patients are educated on their stroke etiology, warning signs of stroke, activation of EMS, individualized stroke risk factors, medications prescribed at discharge and follow-up care. Patients are frightened and overwhelmed with the sudden change in their life leading to information overload. Education is further challenged due to the average LOS of 4 days during which patients are busy with tests, therapy and frequent nursing assessments. Purpose: The purpose of this process improvement is to develop a tool to support and facilitate effective stroke education. Methods: Stroke team members met to develop an interactive daily goals poster to address patient education and to serve as a communication tool between staff members, patients and families. This tool focused on the first four days, included all of the core measures and reflects documentation in the electronic medical record. The tool allows the staff to customize educational components to address patient-specific risk factors, is used as a teaching chart between the nurse and patient to track individual progress and remains with the patient from admission thru discharge. After discharge, the tool continues to serve as a reference for personal risk factors and prevention education. Results: This poster served as a communication tool to educate the patient and families on daily expectations and prompted questions of their individual treatment plan. After the tool was implemented, the stroke education core measure compliance improved from 75% in June 2011 to 86% in June 2013. Additionally, there was a marked improvement in patient satisfaction rating of 74% (n=322) in June 2011 to 88% (n=976) in June 2013. Indirectly, the tool served as a guide for new staff and fostered continuity of care between units. Conclusion: This tool proved to be an effective means to support and facilitate stroke patient and family education. Based on the new self- management standards implemented by The Joint Commission, this tool can easily be revised to successfully include an area to establish mutually agreed upon goals between patient and practitioners.

Strategies for handling ethical problems in sudden and unexpected death

How ethical praxis is shaped by different contexts and situations has not been widely studied. We performed a follow-up study on stroke team members' experiences of ethical problems and how the teams managed the situation when caring for patients faced with sudden and unexpected death from stroke. A number of ways for handling ethical problems emerged, which we have now explored further. Data were collected through a three-part form used as base for individual interviews with 15 stroke team members and analyzed using both quantitative and qualitative content analysis. In the analysis, the approaches in the form were condensed into strategies, and the two different ways those strategies were preferred and used by the team members were shown. Hindrances perceived by the team members to impede them from working the preferred way were also revealed and grouped into eight categories.

Abstract TP373: Classification of sICH in Stroke Center Hospitals: Reliability in Question

Background: Measuring sICH is an important accountability of Stroke Centers. Since the NINDS rt-PA Study, the sICH definition has changed as knowledge of reperfusion-associated hemorrhagic transformation has grown. We aimed to determine what sICH definition was used by Stroke Centers and how this impacts sICH rates. Methods: Stroke Centers were invited to participate in a survey with the option to complete it via SurveyMonkey TM or by mail. Instructions to adhere to the sICH definition adopted in policies/procedures were provided, and to ask for clarification from Stroke Team members if needed. Data were assembled in SPSS, and analyzed using descriptive statistics and Student t-tests. Results: 229 responses were received representing 84% of U.S. states and the District of Columbia; 31% represented academic medical centers and 69% community hospitals. 64% of respondees were responsible for collecting the stroke quality data that supports certification. Overall tPA treatment rate for the sample was 8.7% + 6.4 (median 7%), with an overall reported sICH rate of 9.5% + 16.4 (median 5%). Official definitions supported sICH for 86% of responding hospitals, however the most common definition (48%) reported was, “any hemorrhage on non-contrast CT or MRI in combination with any clinical deterioration.” Only 17% identified the definition for sICH adopted by TJC for Comprehensive Stroke Center reporting. Among those that adhered to the TJC definition, sICH rates were significantly lower at 3%+2.3 (median 3%; t=4.7; mean difference = 7.7%; p&lt;.0001, 95% CI 4.4-10.95), compared to 10.6%+17.5 (median 6%). Conclusions: Our study documents a significant need for education and inter-rater reliability monitoring of the use of sICH classification after intravenous tPA to ensure accuracy in local quality improvement processes, as well as the validity of data submitted to national stroke registries. Additionally, because sICH associated with reperfusion therapy is a new measure undergoing testing by TJC that could ultimately be tied to future pay-for-performance and public reporting, consensus on its definition as well as reliable sICH classification will be essential to future Stroke Center evaluation.