bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP348: Early Palliative Care Consultation in Acute Stroke
Authors: Hartman Adam , Ashby Misty , Buechel Victoria , Williams Molly , Trantum Lindsay , Karlekar Mohana , Zimmerman Eli
Published: January 2019

Introduction:
Despite great strides in management, stroke remains a significant cause of disability and death. Families are often abruptly confronted with critical decisions about end-of-life care; providers must balance these concerns with urgent medical or surgical treatment and an uncertain prognosis. This trial examined early Palliative Care (PC) consultation as a means to assist acutely ill patients and their families.

Methods:
This interdisciplinary, prospective, randomized trial used alternating days to dichotomize patients into a control group who received routine care, including PC consultation if appropriate, and an intervention group, who had PC consultation on the day after admission. Inclusion criteria were a diagnosis of acute ischemic or hemorrhagic stroke, admission to the neurological intensive care unit, and any one of: NIHSS > 14, baseline severe cognitive dysfunction, premorbid modified Rankin score > 3, metastatic cancer, intubation at admission, prior stroke with disability, readmission within 30 days, or admission from a nursing facility. PC consultation identified surrogate decision makers, addressed advance care directives and code status, and co-facilitated multidisciplinary meetings. Outcome measures were identification of a surrogate, documentation of code status, discharge destination and length of stay.

Results:
We enrolled 50 patients in the PC intervention group. Of the 64 patients in the control group, 18 had PC consultations as routine care; 46 (72%) did not have PC consults. There were no differences between the groups in surrogate identification, documentation of code status or discharge destination. However, compared with the 46 control patients without PC consultation, the intervention group had a significantly higher rate of surrogate identification (98% vs. 87%), χ2 (1) = 4.32, p = 0.037, and code status documentation (94% vs. 78%), χ2 (1) = 5.07, p = 0.024. Length of stay data is pending; not all patients had been discharged at the time of submission.

Conclusion:
Palliative Care consultation, particularly when pursued early in a patient’s hospitalization for acute stroke allows for clear documentation of a surrogate and delineation of code status, both critical to a patient’s trajectory after acute stroke.
Abstract TP35: Rates of Endovascular Therapy in Acute Ischemic Stroke Patients With NIHSS < 6 and Outcomes
Authors: Ali Syed F , Schwamm Lee H , Nalleballe Krishna , Onteddu Sanjeeva , Hemmen Thomas
Published: January 2019

Introduction:
Prior reports showed poor outcomes in patients who did not receive IV tPA after acute ischemic stroke (AIS), due to mild or rapidly improving symptoms. (“too good to treat”, TGTT). Many factors have been associated with poor outcomes in this group of patients. We sought to evaluate individual NIHSS items associated with poor outcomes in these TGTT patients who didn’t receive thrombolysis.

Methods:
Using the GWTG stroke registry data from a large comprehensive stroke center in the Northeast, we analyzed 9,215 consecutive stroke admissions from 02/2002 - 04/2018 and identified patients who did not receive IV tPA due to TGTT. NIHSS items were grouped into Level of Consciousness (LOC), Language, Vision, Motor, Sensory and Coordination. Factors associated with poor outcome (defined as all discharge locations other than home) and in-hospital mortality were evaluated by univariate and multivariable regression with significance at p<0.05.

Results:
Of the 9, 215 analyzed patients, 444 (4.8%) didn’t received tPA due to being TGTT despite presenting within 4.5 hours of last know well. Patients with poor outcomes were more likely to be older, female, have a history of diabetes, atrial fibrillation, and present more often with deficits in level of consciousness, vision, motor, language and sensation. On multivariable analysis, age (OR 1.06, 95% CI (1.04, 1.08)), diabetes (OR 3.65, 95% CI (2.00, 6.71)), and deficits in LOC (OR 4.91, 95% CI (2.35, 10.24)) and strength (OR 4.65, 95% CI (2.79, 7.74)) were independently associated with poor outcome. Factors independently associated with in-hospital mortality were age, and deficits in LOC and strength.

Conclusion:
Half of all patients who did not receive thrombolysis due to TGTT in our sample had poor outcomes and 8.8% of those died in-hospital. Advanced age, and initial deficits in LOC and strength were strong predictors of a poor outcome. When present in milder strokes, these factors warrant careful consideration for tPA use.
Abstract TP350: Expansion of Advanced Practice Provider Stroke Service to 24/7 In-House Coverage Improves Stroke Measure Compliance and Ensures Successful Comprehensive Certification
Authors: Mathews Christina , Morrow Benjamin , Jadhav Ashutosh , Underwood Susan , Clements Annette
Published: January 2019

Background:
Successful development of a Comprehensive Stroke Center (CSC) requires resources to meet the certifying body requirements including 24/7 on site coverage of neurocritical care as well as provider resources to support the clinical care on off hours. Non-academic centers may be challenged to meet these needs. PURPOSE: We analyzed the impact of designing and implementing a hybrid stroke/neurocritical care Advanced Practice Provider (APP) service.

Methods:
A 24/7 APP service was recruited, hired and trained from January 2017 through full implementation in January 2018. APP training included a 12 week orientation with a well-developed neuro critical care center, stroke service training with two CSCs, and Emergency Neurological Life Support certification. Their role was to provide consultation for all stroke alerts as well as in-house clinical management of all stroke patients on service and/or requiring neuro critical care services in the ICU. Stroke attending and fellow physicians continued in a partnership and supportive role.

Results:
Through retrospective analysis outcomes were compared Pre (January 2017-June 2017) and post(January 2018 - June 2018) Implementation. Primary outcomes measured included length of stay (LOS), compliance with quality metrics, order set utilization, door to needle times, and door to puncture times Transferred patients accepted from other facilities on off hours was also tracked. The results are displayed in the table.

Conclusions:
These results demonstrate that an APP driven stroke and neurocritical care service is feasible and can lead to improved care such as better compliance with stroke CSC measures including the time specific measures indicating quicker face to face assessments, improved documentation of severity scores, increased standard order set usage, enhanced inpatient stroke alert response, and increased presence with families and nursing staff which improved communication on all shifts.
Abstract TP353: Accuracy of Self-reported 90-day Home Time in Stroke Survivors: Data from the Michigan Stroke Transitions Trial (MISTT)
Authors: Reeves Mathew J , Fritz Michele C , Bridges Michael P
Published: January 2019

Introduction:
Home time, defined as the number of days spent away from home following hospital discharge, is used as a proxy measure of functional recovery in stroke studies. Data on home time may be obtained from clinical or administrative data, or by direct patient interview. There is little information on the accuracy of self-reported home time.

Methods:
We measured the accuracy of self-reported home time using data from the Michigan Stroke Transitions Trial (MISTT) - a randomized trial of case management to improve outcomes in acute stroke patients who returned home after hospitalization. We calculated 90-day home time using information on readmissions to hospitals or rehab facilities obtained from the eMRs of the original admitting hospital and other external reports. Patients or their proxies who completed a 90-day telephone interview reported the number of nights they spent away from home due to medical reasons since first returning home. We compared the agreement between calculated and self-reported home time using kappa statistics.

Results:
Of 265 enrolled subjects, 214 (81%) completed a 90-day interview and of these, self-reported home time data was available on 195 (91%). Based on calculated home time, 21.5% (42/195) of patients spent at least one night away from home during the 90-day period. The mean and median calculated home time was 88 and 90 days, respectively. When compared to self-reported home time, the kappa statistic for the binary outcome of 90-day home time versus <90days was 0.64 (95%CI = 0.51-0.77). When home time was classified into 3 categories (Table), the observed agreement was 85% and the weighted kappa 0.59 (95%CI = 0.45-0.72) indicating good agreement beyond chance. Women and patients first discharged to a rehab facility were more likely to report discrepancies of >= 1 week in home time.

Conclusions:
Self-reported home time data has acceptable reliability for use as an outcome measure in stroke studies.
Abstract TP357: Large Five State Health System Standardizes Stroke Patient Education While Significantly Improving Health Literacy
Authors: Swearingen Natalie , Corless Leslie , Swann Jessica , Cox Kailey , Lada Diane , Baraban Elizabeth
Published: January 2019

Background:
Written stroke patient education materials are instrumental to improving the patient care experience. Since 2010, national certifying bodies recommend written materials at a maximum reading level of 5th grade to meet health literacy needs. In 2016 certified comprehensive and primary stroke centers from a multi-state health system discovered significant variation among stroke patient education booklets (SPEB) developed by separate facilities/states, and in 2018 implemented a standard SPEB by partnering with an external organization (EO). The health system worked with the EO to add information in the SPEB specific to carotid disease and stroke symptoms.

Purpose:
Compare the health literacy of pre-standardization SPEBs to the updated EO SPEB with and without carotid education.

Methods:
Readability assessments were used to determine reading grade levels for pre-standardization SPEBs consisting of 7 SPEB among 18 facilities in 5 states, the EO standardized SPEB with and without the additional carotid education, and the carotid education additions alone. Assessments included: 1) Flesch Reading Ease Formula, 2) Flesch-Kincaid Grade Level, 3) Gunning Fog Index Readability Formula, 4) Simple Measure of Gobbledygook (SMOG) Readability Formula, 5) Coleman-Liau Index, 6) Automated Readability Index, and 7) Linsear Write Formula. These assessments were then used to calculate a readability consensus score (RCS), reported as grade levels, using an online tool. Visual Imagery was not included in the assessments.

Results:
The range of RCS grade levels for pre-standardization materials was 7th to 12th grade. A grade level of 11 - 12 was found for 57.1% of sites. The EO SPEB without carotid education had an RCS grade level of 7 and with the additional information had a grade 8 level. The carotid education alone was at a college graduate level. Utilization of the EO SPEB decreased the health literacy level for 88.9% of sites.

Conclusion:
A standardized SPEB was implemented for a large five state health system. The health literacy level significantly improved at almost 90% of the participating facilities. The recommended 5
th
grade health literacy level was not achieved based on the RCS. More research is needed on the impact visual imagery has on health literacy.
Abstract TP36: Readmissions After Intravenous Thrombolysis for Acute Ischemic Stroke-A Review of 5-Year National Data
Authors: Kumar Varun , Savani Chirag , Singh Tejinder , yi Xiyan , Pathak Ambarish , Rose David Z
Published: January 2019

Background:
Despite widespread use of Intravenous thrombolysis (IVT) for acute ischemic stroke (AIS), little is known about the frequency and etiologies of early readmission rates to the hospital soon after initial discharge. Understanding the causes associated with 30-day readmissions following IVT is critical to reduce cost and improving the quality of life in AIS patients.

Methods:
Nationwide Readmissions Database (NRD) from 2010-14 was utilized to identify AIS and IVT using appropriate ICD-9CM codes in primary diagnosis and ICD9 procedure code 99.10 in any procedural field. Admissions within 30 days of discharge were considered as early readmission. Readmission causes were identified by ICD 9 CM code in primary diagnosis field of readmissions. P values for trends were generated by Cochrane-Armitage test for categorical variables and simple linear regression for continuous variables.

Results:
We identified 164,007 AIS patients undergoing IVT (Mean age=69.5 years,49.6% Female) of which 10.9% (N=17,844) were readmitted. Significant decline in readmission rate has been observed during our study period (from 11.8% in 2010 to 10.4% in 2014, Ptrend =<0.001) and half of all readmissions were within 12 days post discharge. Common etiologies of readmissions were Neurological (32.2%), cardiac (15.5%), infections (10.3%), Pulmonary (8.6%), Kidney or urinary (7.4%), Gastrointestinal (4.5%) and Bleeding (3.6%). Among neurological readmissions causes, Ischemic stroke accounted for 18.6%, Transient cerebral ischemia (2.9%), and Intracerebral hemorrhage (2.6%). Heart failure (3.8%) and Atrial fibrillation (2.7%) were the most common cardiac causes.

Conclusion:
About 1 in 10 patients who received IVT for AIS are prone to get readmitted within 30 days, most likely secondary to neurological or cardiac complications. Additional interventions, consultations or workup may be warranted to recognize and mitigate preventable post-thrombolysis readmissions.
Abstract TP360: Does Weekend Admission for Intravascular Thrombolysis Post-Acute Ischemic Stroke Associated With Worse Short-Term Outcomes? A 5-Years Us Experience
Authors: Kumar Varun , Savani Chirag , Singh Tejinder , yi Xiyan , Motwani Reena , Chib Anjula , Pathak Ambarish
Published: January 2019

Background:
No large-scale study available to establish ‘weekend effect’ of higher in-hospital mortality and 30-day readmissions after admission for post-Acute ischemic stroke (AIS) thrombolysis. Our objective was to determine short term outcomes and its trends associated with weekend vs weekday index hospitalization.

Methods:
Nationwide Readmissions Database (NRD) from 2010-14 was utilized to identify AIS using appropriate ICD-9CM codes in primary diagnosis fields. IVT was identified by ICD9 procedure code 99.10 in any procedural field. HCUP variable “aweekend” was used to identify weekend vs weekday admission and Cochrane-Armitage test was used to generate p value.

Results:
We identified 164,007 AIS patients undergoing IVT (Mean age=69.5 years,49.6% Female). Weekend admission (6,229 in 2010 to 11,156 in 2014) were associated with increasing trends of hospitalization for thrombolysis with a relative change of 78%. Weekend admissions were associated with overall higher 30-day readmissions (11.03% vs 10.8%), with decreasing trend from 11.5% (vs 12% weekdays) in 2010 to 10.5% (vs 10.3% weekdays) in 2014 with a relative decrease of 8.1% (vs 16.5%- weekdays) (p<0.001). Weekend admissions were associated with overall higher in hospital mortality 9.2% vs 9.03% as compared to weekdays, though exhibiting a decline from 10.9% to 7.5% (relative change -32.5%, p<0.001). Weekend admissions were associated with overall lower cost of hospitalization 25,929$ vs 26,523$ as compared to weekdays, though exhibiting a decline from 27,215$ to 24,613$ (relative change -10.5%, p<0.001). There is no significant difference in length of stay between weekend vs weekday admission (9days vs 9 days).

Conclusion:
Our study showed that weekend admissions for AIS patients undergoing IVT are associated with higher in-hospital mortality, 30-day readmission and lower cost of hospitalization. We speculate that better access of care on weekends will improve then outcome for patients getting IVT and reduce the healthcare burden associated with readmissions.
Abstract TP361: Implementation of a 24-Hour Stroke Code Window Does Not Impact Stroke Code Volume or Yield
Authors: Velickovic Ostojic Lili , Wheelwright Danielle , Roche Tara , Fara Michael G , Fifi Johanna T , Shoirah Hazem , Singh I. Paul , Morey Jacob R , Tuhrim Stanley , Stein Laura
Published: January 2019

Objective:
To assess for changes in stroke code volume and yield after implementation of an extended 24-hour acute stroke code window (ASCW).

Background:
The DAWN and DEFUSE-3 trials showed that extended time windows of 16 to 24 hours benefit select patients with confirmed large vessel occlusion (LVO) of the anterior circulation. The Mount Sinai Hospital emergency department (MSH ED) extended its ASCW from 12 to 24 hours in anticipation of those results.

Methods:
We retrospectively analyzed de-identified data collected for patients presenting to the MSH ED as stroke codes, estimated by the number of acute stroke non-contrast head CT scans performed. We compared last known well (LKW)-to-arrival time, door-to-CT time, ancillary imaging, and intervention status seven months prior to (baseline cohort), and following (intervention cohort), implementation of the 24-hour ASCW. This work was part of a departmental quality improvement project to optimize local policy in the context of new acute stroke treatment guidelines.

Results:
Baseline cohort: 197 stroke codes were called. Median NIHSS was 7. 27 (14%) presented after 12 hours. Median LKW-to-arrival was 212 minutes and median door-to-CT was 22 minutes. 136 (69%) received a CT angiogram (CTA) and 32 (16%) received CT perfusion (CTP). 25 (13%) were treated with intravenous alteplase (IV tPA). 44 (22%) underwent mechanical thrombectomy (MT) with a median LKW-to-arrival of 209 minutes.

Intervention cohort: 200 acute stroke codes were called. Median NIHSS was 6. 58 (29%) presented after 12 hours. Median LKW-to-arrival was 280 minutes, and median door-to-CT was 19 minutes. 135 (68%) received CTA and 27 (14%) received CTP. 36 (18%) were treated with IV tPA. 43 (22%) underwent MT with a median LKW-to-arrival of 283 minutes.

Conclusions:
The number of stroke codes called with an extended 24-hour ASCW remained stable. Although the number of patients presenting after 12 hours more than doubled, there was no increase in the number of patients who underwent MT. This likely reflects the practice that stroke codes are called whenever there is a high suspicion for LVO regardless of the determined ASCW, so that the change to 24-hour ASCW did not significantly impact demand and work flow.
Abstract TP365: Clinical Predictors of Ischemic Stroke in Patients Presenting With Altered Mental Status
Authors: Nacu Aliona , Moussaoui Asma , Alkuwaiti Mohammed , Ezzeddine Mustapha
Published: January 2019

Introduction:
Acute changes in mental status could be secondary to an acute ischemic stroke and is often a diagnostic dilemma in the emergency department. Identifying clinical parameters with the highest correlation with the diagnosis of stroke would help guide timely diagnostic studies and appropriate treatment.

Hypothesis:
We aimed to establish clinical predictors of acute stroke as compared to non-stroke diagnosis, in patients presenting with altered mental status in the emergency department.

Methods:
We studied clinical characteristics of a cohort of patients presenting with the chief complaint of altered mental status to four emergency departments in the state of Minnesota, over a five-year period (2011 to 2016) and have received an MRI of the brain within one week of admission. Two groups were defined based on diagnose at discharge: patients diagnosed with ischemic stroke (stroke group) and patients with a different diagnose than ischemic stroke (non-stroke group).

Results:
A total of 841 patients met the inclusion criteria. Neurology consult was requested in 56% of the patients, a focal neurological deficit was reported in 20% of the patients and stroke alert was called in 8% of the patients. Ischemic stroke was diagnosed in 16% of the patients. Multiple strokes affecting various brain structures, left frontal lobe and left parietal lobe were the most frequent ischemic stroke locations identified in patients with altered mental status. Focal neurological deficit (p < 0.0001), older age (p < 0.0001), speech disturbance (p = 0.0003), prior stroke/TIA (p < 0.005), prior hypertension (p < 0.0005) and prior hypercholesterolemia (p < 0.0002) are the clinical predictors that were significantly more frequent in patient diagnosed with ischemic stroke compared with non-stroke patients. In conclusion, a significant number of patients presenting in the emergency department with altered mental status have acute ischemic stroke. Identified clinical predictors in this study may contribute to differentiate stroke from non-stroke patients with altered mental status. Further work will include a predictive model and a screening tool to detect an ischemic stroke as the underlying diagnosis of patients presenting with acute mental status changes.
Abstract TP368: Development of the Close the Gap-stroke in the J-aspect Study: A Nationwide Quality Improvement Initiative of Japan
Authors: Nishimura Ataru , Nishimura Kunihiro , Matsuo Ryu , Kada Akiko , Kamitani Satoru , Higashi Takahiro , Ogasawara Kuniaki , Shimodozono Megumi , Harada Masafumi , Hashimoto Yoichiro , Hirano Teruyuki , Hoshino Haruhiko , Itabashi Ryo , Itoh Yoshiaki , Iwama Toru , Kohriyama Tatsuo , Matsumaru Yuji , Osato Toshiaki , Sasaki Makoto , Shiokawa Yoshiaki , Shimizu Hiroaki , Takekawa Hidehiro , Nishi Toru , Uno Masaaki , Yagita Yoshiki , Ido Keisuke , Kurogi Ai , Kurogi Ryota , Arimura Koichi , Kitazono Takanari , Minematsu Kazuo , Iihara Koji
Published: January 2019

Background:
Improving the quality of stroke care is an urgent issue worldwide. To facilitate the measurement of quality of stroke care in Japan, we aimed to develop the Close The Gap-Stroke initiative in the J-ASPECT Study.

Methods and Results:
Quality indicators (QIs) were developed by a multidisciplinary board between 2015 and 2017. The process involved a systematic review of domestic and international studies related to primary and comprehensive stroke care. Adherence rates for the defined QIs were calculated for 8,826 patients with acute ischemic stroke from 227 hospitals between 2013 to 2015. Seventeen and 12 measures were identified as QIs for primary and comprehensive stroke care (PSC and CSC), respectively. We analyzed adherence rates of all 17 QIs for PSC and 8 QIs for CSC related with acute ischemic stroke. We found NIHSS documentation (91.0 %), CT/MRI performed within 25min and 24hr (80.9 % and 99.1 %), evaluation of extracranial vascular imaging (90.4 %), treated in stroke unit (57.4 %), tPA administration (89.5 %), tPA performed within 1hr (37.4 %), early and discharge antithrombotics medication (75.1 % and 49.0 %), discharge anticoagulation for atrial fibrillation patients (76.2 %), discharge statin medication (32.7 %), discharge antihypertensive agents (54.3 %), deep vein thrombosis prophylaxis (34.5 %), early rehabilitation (57.0 %), dysphagia screening (76.6 %), smoking cessation (59.8 %) and stroke education (71.4 %) for primary stroke care; and median time to multimodal CT or MR brain and vascular imaging (33 min), proper endovascular recanalization (81.7 %), tPA before endovascular recanalization (65.7 %), TICI grade 2b/3 after endovascular recanalization (73.0 %), median time of door to puncture (105 min), symptomatic intracranial hemorrhage after thrombolytic or endovascular therapy (7.45 %), 90 days mRS documentation after thrombolytic or endovascular therapy (60.8 %), occurrence of complication within 24 hours of diagnostic neuroangiography (7.27 %) for comprehensive stroke care.

Conclusion:
This is a promising first step to measure the QIs related to primary and comprehensive stroke care at a national level in Japan.
Abstract TP369: Home Address is a Reasonable Proxy for Location of Stroke Symptom Onset in Medicare Aged Individuals
Authors: Zachrison Kori S , Clemmons James , Goldstein Joshua N , Schwamm Lee H
Published: January 2019

Background:
With increasing focus on optimization of the prehospital transport of acute stroke patients, location of emergency medical services (EMS) pickup is a critical variable. However administrative data do not routinely include this. It is not clear whether we can impute home address as the location of pickup. Our objective was to determine the proportion of EMS transports originating at patients’ homes, and to identify characteristics associated with home pickup.

Methods:
We used our institutional Get with the Guidelines-Stroke data to identify acute stroke patients presenting 12/01/16-02/20/18. Consecutive charts and EMS run sheets were reviewed for date, time and address of EMS pick-up and patient home address. We categorized pickup as workhours (Monday-Friday, 09:00-17:00), versus not. We used logistic regression to examine the relationship between age (stratified at 65 years), and workhours on home pickup, including an interaction term for age and workhours.

Results:
Of the 740 charts reviewed, 457 patients arrived by EMS (61.8%). Among EMS-transported patients, 313 (68.5%) were picked up at home, 298 (65.3%) were
>
65 years, and 142 were during workhours (31.1%). In bivariate analyses, home pickup was more common among patients
>
65 (74.5% vs 57.2%, p<0.001), and was not different during workhours (66.9% vs 69.2%, p=0.62). Relative to other EMS-transported patients, patients with home pickup had similar tPA treatment rates (17% vs 18%, p=0.08) and discharge to home (28% vs 31%, p=0.54). In logistic regression analysis, home pickup was more likely among patients
>
65 years (OR 2.23, 95% CI 1.48-3.37), and not impacted by workhours (OR 0.82, 95% CI 0.53-1.26). The relationship between age and home pickup was not mediated by workhours, so for simplicity we report the model results without the interaction term.

Conclusion:
Among stroke patients transported by EMS, home pickup is more common among patients 65 years and older. Imputing home address would be accurate for 74.5% of Medicare-aged patients. If these findings are validated in larger datasets, these findings suggest that home address may be a reasonable proxy for onset location among older stroke patients.
Abstract TP37: Border Hospital With Predominantly Hispanic Population Significantly Improves Outcomes in Subarachnoid Hemorrhage Patients After Implementation of Endovascular and Neurocritical Care Services
Authors: Hassan Ameer E , Pedraza Andrea , Kotta Hari , Garza LeeRoy , Preston Laurie , Tekle Wondwossen G , Qureshi Adnan I
Published: January 2019

Background:
Although comprehensive 24/7 endovascular capability and neurocritical care have been effective in the treatment of Subarachnoid Hemorrhage (SAH), studies have shown that there exists a historically significant disparity in providing access to such care within border Hispanic populations. As such, the efficacy of endovascular and neurocritical care within such populations groups has not been thoroughly investigated, particularly for SAH treatment.

Objective:
To evaluate the differences in outcomes before and after the implementation of comprehensive neurocritical care upon an SAH patient population comprised primarily of hispanics within border states.

Methods:
SAH patient data was collected before (2008 - August 2012) and after (September 2012 - 2018) the establishment of comprehensive 24/7 endovascular and neurocritical care services at the hospital. Data collected from both groups included demographic information, glascow coma scale scores, comorbidities, rates of functional independence (modified Rankin scale (mRS) 0-2), and dispositions. Univariate analyses were conducted.

Results:
Hispanics constituted 322 (89.4%) of 360 SAH patients and 265 (82.2%) of those who underwent comprehensive neurocritical care. The collected demographic variables and premorbidity rates were not found to be significantly different between the ‘before’ and ‘after’ groups. Patients treated with comprehensive neurocritical care were found to have higher rates of home dispositions (44.9% vs. 30.9%, p = 0.035) as well as lower rates of death dispositions (26.7% vs. 44.2%, p = 0.0048) compared to patients without neurocritical care.

Conclusion:
SAH patients with access to comprehensive neurocritical care had lower mortality rates and higher home dispositions compared to those who did not have such access. Larger prospective studies are needed in order to demonstrate the efficacy of endovascular and comprehensive neurocritical care in treating SAH.
Abstract TP370: Increased Blood Pressure Variability During the Subacute Phase is Associated With 3-month Functional Poor Outcome in Patients With Acute Ischemic Stroke
Authors: Naito Hiroyuki , Hosomi Naohisa , Kuzume Daisuke , Nezu Tomohisa , Aoki Shiro , Shiga Yuji , Kinoshita Naoto , Ueno Hiroki , Ochi Kazuhide , Yamasaki Masahiro , Maruyama Hirofumi
Published: January 2019

Background:
The increased blood pressure (BP) variability may influence on the stroke outcome. However, in the acute phase of large stroke, reactive hypertension would occur and sustain for a few days. Therefore, in this phase, it is difficult to understand a cause of BP variability whether it is from reactive hypertension or original blood pressure reactivity. Thus, we aimed to evaluate the association of BP variability using ambulatory blood pressure monitoring (ABPM) in the subacute phase of ischemic stroke, when restoration from reactive hypertension can be observed, with 3-month outcomes.

Method:
We retrospectively enrolled a consecutive series of 840 patients hospitalized for acute ischemic stroke (55.2% males, age: 76 ± 12 years) performing 24-hour ABPM during the subacute phase of stroke (median 9 days from onset). Variability in BP was evaluated with the standard deviation (SD) and with the coefficient of variation (CV) of systolic (SBP) and diastolic BP (DBP). The primary outcome was evaluated from the 3-month functional status: poor outcome as a modified Rankin Scale score of 3 or more and good outcome as 2 or less.

Results:
Patients with dipper, non-dipper and riser type were 11.4%, 50.5%, and 38.1%, respectively among the total enrolled cohort. Of these, 651 patients (77.5 %) were assessed for the functional outcomes at 3 months. The rates of patients with poor functional outcome were higher in patients with non-dipper or riser type than in the dipper type (47.7%, 57.1%, and 35.1%, respectively). The mean level of SBP and DBP were not associated with functional outcome. The variability of SBP and DBP was significantly associated with poor functional outcome in univariate analysis. After adjusting for age, sex and initial stroke severity, one increase of SD value (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.03 to 1.13, P<0.001), CV value (OR 1.06, 95% CI 1.01 to 1.12, P = 0.02) for SBP, and SD value (OR 1.07, 95% CI 1.04 to 1.10, P<0.001), CV value (OR 1.05, 95% CI 1.02 to 1.08, P<0.001) for DBP were independently associated with poor outcome.

Conclusion:
The variability of BP in the subacute phase of ischemic stroke is expected to be a useful prognostic factor of a 3-month functional outcome.
Abstract TP374: Implementation of Stroke Pathways to Reduce Length of Stay, Cost, Readmissions, and Mortality
Authors: Strauss Jayme , Hartnett Daniel R , Ductant Jenny , De Armas Peter , Fernandez Albert J , Waisbrot Andrew R , Starosciak Amy K , De Los Rios La Rosa Felipe
Published: January 2019

Introduction:
Acute stroke is a major contributor to healthcare costs. In 2012, estimated direct costs associated with stroke was $71B, which is projected to double to $184B by 2030. As healthcare evolves and reimbursements decrease, cost control in disease specific populations is critical. In January 2017, length of stay (LOS) peaked at 5.25 days, as did variable and total cost/case (Table). In fiscal year 2017 the 30-d readmission rate was 9% and the mortality rate was 12%. Compliance with stroke admission order sets was at 55%.

Methods:
A multidisciplinary committee was formed in February 2017 to develop standardized, evidence-based clinical pathways for three populations: Ischemic stroke (IS) treated with IV tPA, TIA/IS without IV tPA, and intracerebral hemorrhage. The team met biweekly to standardize clinical pathways, decrease time to follow-up imaging, focus on physician order set utilization, and control costs. A comprehensive education program for all clinical staff was completed; official implementation of the pathways was in November 2017. Pathways are discussed in stroke multidisciplinary rounds and rapid discharge rounds daily to ensure compliance and identify opportunities for improvement. We reviewed a retrospective financial report of all in-hospital cases coded as MS-DRG 61-69 from 12/2017 through 6/2018 and compared it the 1/2017 report.

Results:
A total of 83 cases where available for 1/2017 and of 456 for 12/2017 through 6/2018. There was a reduced LOS by 10% (4.74 days), reduced variable cost/case by 24% ($5,958), reduced total cost/case by 23% ($13,790), reduced the 30-d readmission rate to 6%, and reduced the mortality rate to 9%. Case mix index was 6% higher at 1.2753 (vs. 1.2055 previously). Order set compliance improved to 91% (Table).

Discussion:
Standardization of stroke clinical pathways led to improved order set compliance, almost ¼ reduction in variable and total costs per case, shortened LOS, and reduced mortality and readmission rates.
Abstract TP377: Routing for Rapid Results
Authors: Greif Sherri , Aguilar Michelle
Published: January 2019

Background:
In 2016, the American Heart Association (AHA) published recommendations for emergent large vessel occlusion (ELVO) routing at the International Stroke Conference based on symptomatology and distance from a thrombectomy capable stroke center. Research has shown that a rapid door to puncture and reperfusion time leads to improved patient outcomes in large vessel occlusion patients who meet criteria for thrombectomy. The door to puncture (D2P) benchmark for the AHA Get with the Guidelines data registry and the local Emergency Medical Services (EMS) is 90 minutes.

Purpose:
The purpose of the project was to find a way to shorten the D2P time in ELVO patients in a 265 bed community hospital.

Method:
The solution to shortening the D2P time was to identify ELVO patients using an evidenced based stroke severity scale. Collaboration ensued between the thrombectomy capable stroke centers and local EMS to discuss ELVO routing. Previously, stroke patients were identified by EMS only using the Cincinnati Prehospital Stroke Scale (CPSS). The local EMS and the participating hospitals selected the Ventura ELVO Scale (VES), an evidenced based stroke severity scale, to assess positive CPSS patients in the field. Policies were developed, education was rolled out, and ELVO routing went live in October 2017 with two ELVO receiving centers. Our hospital, one of the receiving centers, collected data to follow the trend of D2P times.

Results:
D2P median prior to going live with ELVO routing was 127 minutes. Only one patient out of fifteen patients between December 2016 and August 2017 had a D2P less than 90 minutes. Between October 2017 and July 2018, after ELVO routing began, ten out of fourteen patients had D2P less than 90 minutes. The median improved to 89 minutes on these patients. All D2P times were then tabulated together to calculate a total median time of all cases.

Conclusion:
ELVO routing combined with the implementation of the VES enabled us to be successful in shortening our D2P to below the benchmark of 90 minutes. This method may be beneficial in other community based hospitals and counties looking to shorten their D2P.
Abstract TP378: Elevated Creatinine at Presentation is Associated With Higher In-Hospital Mortality Among Acute Ischemic Stroke Patients
Authors: Ali Syed F , Schwamm Lee H , Leslie-Mazwi Thabele M , Nalleballe Krishna , Onteddu Sanjeeva , Hemmen Thomas
Published: January 2019

Introduction:
Impaired renal function is an established predictor of survival in the general population, and in patients with myocardial infarction or heart failure. Recent evidence suggests that reduced kidney function may predict mortality after acute ischemic stroke (AIS). We sought to evaluate if elevated creatinine (Cr >1.5mg/dL) at presentation is associated with higher in-hospital mortality in AIS patients.

Methods:
Using GWTG stroke registry data from three large comprehensive stroke centers in Northeast, South and West, we analyzed 9,472 consecutive stroke admissions from 02/2002 - 06/2018 with documented Cr. Patient were divided into Group 1: normal renal function (Cr ≤1.5) and Group 2: elevated Creatinine (>1.5). Chi-square was used for categorial data, T-Test for parametric continuous and Wilcoxon for non-parametric continuous variables. Multiple regression analysis was used to identify associations.

Results:
Of the 9,472 AIS patients, 977 (10.3%) had baseline Cr > 1.5. Patients with elevated Cr were older, more often male, less often White and had higher frequency of hypertension, diabetes, hyperlipidemia, CAD/MI, heart failure and atrial fibrillation, and had increased pneumonia during the incident admission. They had higher NIHSS at presentation and underwent IV tPA +- endovascular therapy more often than patients with Cr ≤ 1.5. The in-patient mortality was twice as high in Group 2 than Group 1 (OR 1.17 per 1.0 mg/dL increase in Cr (95% CI 1.10, 1.30; p<0.001)). Renal impairment (Cr > 1.5) remained a strong predictor for mortality in multivariable regression (OR 1.91 (95% CI 1.47, 2.48; p<0.001)).

Conclusion:
Patients with elevated Cr at presentation were found to have higher in-hospital mortality, suggesting an independent association between renal function and mortality after AIS. Further research is warranted, especially since many of these patients are exposed to nephrotoxic contrast agents.
Abstract TP38: Re-Occlusion During Endovascular Therapy for Acute Stroke Patients With Large Vessel Occlusion
Authors: Hao Qing , Morey Jacob , Zhang Xiangnan , Chapman Emily , DeLeacy Reade , Fifi Johanna
Published: January 2019

Introduction:
Endovascular Therapy (EVT) has demonstrated significant benefits for selected acute ischemic stroke (AIS) with emergent large vessels occlusion (ELVO). Early recanalization is one of the most significant predictors of favorable outcome. However, re-occlusion during the procedure remains a challenge and may prolong the time needed for recanalization in a subset of patients. We planned to explore the clinical, radiographic and laboratory features that are associated with intra-procedural re-occlusion.

Method:
We retrospectively reviewed consecutive patients who received EVT for ELVO in a single academic health system. Re-occlusion was defined if the occluded target vessel recanalized with TICI ≥2, but became TICI<2 on repeated diagnostic angiography. T test/Wilcoxon test and Chi-square were used to compare risks factors, atherosclerotic plaque burden, and coagulation profile (obtained prior to procedure) between patients with and without re-occlusion.

Results:
Among 265 patients (male 46.4%, mean age 69 ±14.4 year old), 25 patients had re-occlusion intra-operatively. The history of cardiovascular risks factors (HTN, HLD, DM, smoking, atrial fibrillation), prior use of antiplatelets or antithrombotics, the number of cerebral arteries with atherosclerotic lesions, and the level of platelets, PT, PTT, INR, LDL and HbA1c were similar between patients with and without re-occlusion. Compared to patients without re-occlusion, those with re-occlusion had a higher proportion of stroke with the etiology of large artery atherosclerosis (34.8% vs 3.2%, p<0.001), and tended to have a longer time from last know well to groin puncture (498 ± 411 vs 408±328 minutes, p=0.15).

Conclusion:
Large artery atherosclerotic disease was a more common stroke etiology in patients with re-occlusion during thrombectomy for ELVO. Underlying vasculopathy and plaque rupture may have precipitated the thrombotic process.
Abstract TP381: Discrepancies in Arrival Time for Acute Ischemic Stroke Patients: An Opportunity for Improvement
Authors: Mendelson Scott J , Richards Christopher T , Prabhakaran Shyam
Published: January 2019

Background:
Current guidelines and national quality improvement efforts emphasize door-to-needle (DTN) time in stroke thrombolysis. Stroke center certifying bodies depend on hospital-reported DTN to appraise compliance and award designations. However, the validation of hospital reported arrival times against ambulance arrival times has not been previously reported.

Objective:
To determine differences in Emergency Medical Services (EMS) reported arrival time of stroke patients versus hospital documented arrival times at 10 primary and comprehensive stroke centers in Chicago.

Methods:
We performed a retrospective analysis of stroke admissions using the regional Get With The Guidelines (GWTG) Stroke registry of 10 Chicago hospitals between July 1 and December 31, 2013. We matched ambulance run numbers from EMS records to those in the GWTG-Stroke EMS special initiative tab. GWTG-Stroke data included arrival time, age, sex, race, initial NIHSS score, and whether tPA was administered. EMS data included hospital arrival time in addition to age, sex, hospital name, and clinical impression. We compared GWTG-Stroke and EMS reported arrival times overall and whether any clinical factors were associated with time discrepancy.

Results:
Among 308 matched EMS to GWTG-Stroke records, 51 (16.6%) received tPA. Overall, EMS documented arrival time was a median 5 minutes earlier than hospital documented arrival time (range -35 to +14min). There was no significant difference in time discrepancy by tPA administration, stroke type, NIHSS score, age, sex, race, insurance status, or hospital. Median DTN based on EMS data was 88m versus 82m for hospital-reported data (p>0.05). The proportion with DTN times <60 minutes was 22% based on EMS versus 29% based on hospital arrival times.

Conclusions:
EMS reported arrival time is on average 5 minutes earlier than hospital documented arrival time at 10 stroke centers in Chicago. Further studies should investigate factors contributing to discrepancies in DTN times between EMS and hospitals. Such investigation may lead to facilitating efficient hand-offs between EMS and hospital providers and promote earlier notification of receiving hospital stroke team in order to initiate care at time of EMS arrival.
Abstract TP383: Development of Continuous Quality Improvement in a Telestroke Network
Authors: Lesko Alexandra , Corless Leslie , Gaede Claudia , Baraban Elizabeth , Lucas Lindsay , Yanase Lisa R
Published: January 2019

Introduction:
Continuous Quality Improvement (CQI) in Telestroke across diverse institutions requires reliable data abstraction, centralized analysis and interactive multidisciplinary review of metrics. Data abstraction depends on each site’s resources and accountability, and is facilitated through network support. Central analysts provide site-specific, interactive dashboards with network benchmarks. Evidenced-based data reviews with local multidisciplinary care teams provide ongoing monitoring of quality measures and support site- and network-driven CQI. Reviews are supplemented by clinical education and sponsorship to a statewide conference and summit to share best practices and honor high performers. We examine the impact of a telestroke CQI process on acute stroke care across our multistate network by comparing quality measures from initiation in 2011 to those in 2017.

Methods:
Ischemic stroke patients presenting to 13 emergency departments (ED) were included. Inpatient, age <18, non-ischemic stroke, and non-acute patients (last known well-to-door > 4.5 hours) were excluded. Quality measures included door-to-CT (DCT) and door-to-IV-alteplase (tPA) times (DTN), and percentage transferred, treated with tPA, and treated in <60 and <45 minutes. Chi-squared, Fisher’s exact, and Mann-Whitney U tests were used to compare quality measures between patients discharged in 2011 and 2017.

Results:
Overall, 143 patients discharged in 2011 and 260 in 2017 presented with acute ischemic stroke within the tPA treatment window. There were no differences in gender, age, or admission NIHSS between years. In 2017, median DCT times were shorter (16.0 vs 29.0 min, p<.001) as were median DTN times (56.0 vs 75.0 min, p<.001) compared to 2011. In 2017, more patients were transferred (40% vs. 26%, p=0.035) and treated by tPA overall (51% vs. 29%, p<.001), in under 60 minutes (57% vs. 23%, p<.001) and in under 45 minutes (27% vs. 8%, p=0.009).

Conclusions:
Collaborative, interactive data processes, including reliable data abstraction and utilization, support both site-specific and network-wide quality improvement.
Abstract TP384: Effective Communication and Engagement Cultivates Teamwork Among Virtual Telestroke Providers
Authors: Williams Linda S , Patel Himalaya , Martin Holly , Rattray Nicholas , Miech Edward , Savoy April , Graham Glenn , Martini Sharyl , Anderson Jane , Damush Teresa
Published: January 2019

Background:
In most hub-and-spoke telestroke systems, geographically co-located hub stroke specialists support regional spoke sites. In the VA’s National Telestroke Program (NTSP), a virtual hub of stroke specialists located around the country provides 24/7 consults nationwide. We examined how stroke specialists adapted to virtual teamwork, and identified factors important in developing and sustaining a high-functioning virtual team.

Methods:
Semi-structured, confidential interviews with hub stroke specialists were audiotaped and transcribed. Probes were used to explore the extent to which providers had developed a sense of a teamness or a community of practice, and what factors helped or hindered this development. Core elements of a high-functioning team were defined using Mitchell's taxonomy, developed as part of the IOM's Best Practices Innovation Collaborative. Each interview transcript was independently coded by two investigators using NVivo11. The constant comparative method and matrix displays were used to identify themes, with special attention to themes about team, communication, trust, and satisfaction.

Results:
Of 13 hub providers with > 8 months NTSP participation, 12 were interviewed; 7 had prior telestroke experience. Participants reported high levels of trust and sense of teamwork with their virtual colleagues, sometimes even more than with local colleagues. Factors facilitating perceived teamness included communicating via a weekly case conference call, a sense of transparency in discussing challenges, engagement in NTSP development tasks, and leadership support. Lack of in-person contact decreased perceived teamness, but having an in-person NTSP meeting helped mitigate this issue. Despite technical challenges, providers reported high levels of satisfaction with the NTSP.

Conclusions:
Practicing as a virtual Telestroke hub provider can provide an equal or greater sense of trust and sense of teamwork with colleagues compared with traditional practice. Engaging in transparent discussion of challenging cases and contributing to program improvements may be key to promoting high-functioning virtual teams. Ongoing surveys will assess providers’ satisfaction with program outcomes over time.