bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP445: Utility of VAN Assessment for Early Identification of Patients With Intracerebral Hemorrhage
Authors: Samai Alyana A , Vahidy Farhaan , Navalkele Digvijaya , Martin-Schild Sheryl
Published: January 2019

Background:
The Vision, Aphasia, Neglect (VAN) assessment has been demonstrated as highly sensitive for detection of large vessel occlusion in acute ischemic stroke patients. As a rapidly performed, highly accurate assessment, many emergency medical services have begun utilizing the VAN as a screening tool to help triage patients to endovascular-capable facilities. We previously demonstrated that VAN can distinguish neurosurgical ICH patients from non-surgical ICH patients.

Methods:
This retrospective study utilized data on consecutively admitted patients from a single high-volume stroke center. Patients over 18 years old diagnosed with ICH between 2008-2015 were included. A positive or negative VAN score was determined for all patients via abstraction from the NIHSS score. Demographics, clinical characteristics, and short-term outcomes were compared between VAN+ and VAN- patients.

Results:
Of the 201 patients included, 176 (87.56%) were VAN+. Patients in the VAN+ group were more frequently black (73.9% vs. 51.9%, p=0.003) and had lower median GCS (11 vs. 15, <0.001) scores upon arrival. Patient in the VAN+ group had a higher frequency of baseline intraventricular hemorrhage (50.0% vs. 30.8%, p=0.01) and a higher median ICH volume (19 vs. 1, p<0.001) compared to VAN- patients. Additionally, VAN+ patients had higher median modified Rankin Scale scores on discharge (5 vs. 3, p<0.001) and longer median lengths of stay (8 vs. 5, p=0.01).

Discussion:
VAN can identify neurosurgical ICH patients who have more severe presentations with larger hemorrhages with higher frequency of intraventricular hemorrhage. VAN positive ICH patients have longer lengths of stay and worse early functional outcomes. Ascertainment of VAN in the pre-hospital setting can facilitate initial destination of ICH patients to advanced stroke centers with access to neurosurgical expertise.
Abstract TP447: Coagulation Differences Between Deep and Lobar Intracerebral Hemorrhage Detected by Thromboelastography
Authors: Roh David , Torres Glenda L , Cai Chunyan , Zammit Christopher , Connolly E. Sander , Claassen Jan , Grotta James C , Choi Huimahn A , Chang Tiffany R
Published: January 2019

Introduction:
Despite smaller baseline hematoma volumes, deep primary intracerebral hemorrhage (ICH) is known to have worse clinical outcomes and preliminary evidence of more hematoma expansion compared to lobar ICH. This is not thought to be related to differences in functional coagulation as prior studies have not identified differences in traditional, plasma-based coagulation tests between these locations. We investigated for clotting differences between deep and lobar ICH using Thromboelastography (TEG: whole-blood coagulation assessment).

Methods:
Clinical, radiographic and laboratory data was prospectively collected between 2009-2018 for primary ICH patients admitted to University of Texas Health Sciences Center at Houston. Deep and lobar ICH patients, without preceding history of anticoagulation use or coagulopathy on admission testing, who received admission TEG and traditional plasma coagulation tests were included for analysis. Patients receiving hemorrhage reversal transfusions prior to TEG were excluded. Multivariable linear regression assessed the association of ICH location with functional coagulation tests after adjusting for age, sex, NIHSS, and baseline hematoma volume.

Results:
Of 207 ICH patients included for analysis, there were 154 (74%) deep and 53 (26%) lobar ICH. Deep ICH patients were significantly younger (mean: 56 vs 68 years), had higher admission systolic blood pressures (mean: 200 vs 182mmHg) and smaller admission hematoma volumes (median: 16.2 vs 28.7mL) than lobar ICH patients. Deep ICH had longer TEG R times (mean: 5.1 vs 4.4 minutes) indicating a slower and less optimal time to clot formation compared to lobar ICH. After controlling for potential confounders, the adjusted mean R times continued to be longer in deep compared to lobar ICH by 0.57 minutes (95% CI 0.02-1.11, p=0.04).

Conclusions:
Our findings suggest that there may be functional coagulation differences detected with whole blood coagulation testing between deep and lobar ICH. Further work is needed to determine whether whole blood coagulation testing to assess coagulopathy after ICH should play a role in hemorrhage reversal treatment paradigms.
Abstract TP45: Mechanical Thrombectomy for Acute Ischemic Stroke in Patients Over 80 Years in a Real Clinical Practice: Give All a Chance?
Authors: Černik David , Šanák Daniel , Cihlář Filip , Janoušová Petra , Divisova Petra , Kocher Martin , Zapletalová Jana , Veverka Tomáš , Prcuchova Andrea , Ospalik Dusan , Král Michal , Franc David , Dorňák Tomáš , Černá Marie , Prášil Vojtech , Kanovsky Petr
Published: January 2019

Introduction:
Randomized trials showed a certain benefit of mechanical thrombectomy (MT) also in selected patients over 80 years, however data about non-selected population from a real clinical practice are missing. Thus, we aimed to report outcomes of patients over 80 years and compared them to younger ones.

Methods:
Retrospective analysis involved all patients treated with MT (stent-retrievers) in both centers in 2010-2017. Neurological deficit was assessed with the National Institutes of Health Stroke Scale (NIHSS) and final outcome after 3 months using the modified Rankin scale (mRS); good clinical outcome was scored 0-2. The achieved recanalization was rated with Thrombolysis in Cerebral Infarction (TICI) scale. Presence of symptomatic intracerebral hemorrhage (SICH) was assessed according to the SITS- MOST criteria.

Results:
Of 703 enrolled patients, 138 (19.6%) were over 80 years (52 males, mean age 84 ± 3.4 years) with a median admission NIHSS of 18 points. Recanalization (TICI 2b-3) was achieved in 107 (77.5%) patients, SICH in 8 (5.8%) and good clinical outcome in 47 (34.1%) patients. 59 (42.8 %) patients died within 3 months. No difference was found in rate of achieved recanalization (p-0.38) and SICH (p-0.67) between patients over 80 years and patients aged 65-80 years, but the rate of mRS 0-2 was lower (p-0.004) and mortality higher (p-0.001) in older patients.

Conclusion:
MT seems to be beneficial also in patients over 80 years however, it is associated with higher mortality related to age.

Acknowledgment:
Supported by the grant of MH CR n. 17-30101A, IGA LF UP_018_2018 and KZ- IGA-KZ-2017-1-2.
Abstract TP450: Implementation of Informal Caregiver and Veteran Dyadic Intervention: Acquiring New Skills While Enhancing Remaining Strengths
Authors: Wilder Virginia D , Plue Laurie D , Murray Laura , Kimmel Barbara , Dube Archana , Schwartzkopf Ashley , Walker Kiara C , Shah Ami , Loughnane Megan , Beech Sandra , Saha Chandan , Anderson Jane , Judge Katherine S
Published: January 2019

Objectives:
ANSWERS-VA dyadic intervention, a strength-based protocol, was adapted for Veterans and their informal Caregivers (CGs). Immediate aims were to tailor the implementation for Veterans and CGs and test the short-term efficacy for improving outcomes of caregiving self-efficacy and caregiver appraisal of threat.

Methods:
Intervention protocol and materials were modified for telephone delivery to Veterans (n = 130) with definitive diagnosis of stroke and/or traumatic brain injury enrolled at two Level 1 Complexity VA Medical Centers and CGs. Dyads were recruited and randomly assigned to ANSWERS-VA or the attention control group and received 8 telephone sessions with one booster session. Acceptability and feasibility were assessed by participants in the intervention arm. Caregiver threat appraisal and self-efficacy of caregiving were measured in 52 informal CGs randomized to ANSWERS-VA (n = 20) or the attention control group (n = 32) at week 8. Comparisons of two groups in threat appraisal and caregiving self-efficacy were conducted using the Wilcoxon Two-Sample Test.

Results:
Veterans and CGs found ANSWERS-VA an acceptable and feasible approach and reported that sessions were: a) educational, thought- provoking and supportive while simultaneously facilitating communication about difficult issues; and b) provided practical and tailored skills. Preliminary data analyses indicate that CGs assigned to both groups were similar demographically. No significant changes were demonstrated in Caregiver threat appraisal (
p
= 0.74) or caregiving self-efficacy (
p
= 0.71) between both groups at 8 weeks.

Conclusions:
Implementing virtual, dyadic interventions to Veterans with ABI and their informal CGs presented unique challenges: 1) time-intensive processes in pre-implementation phase; 2) field's ambiguity regarding TBI diagnoses and screening protocols within VA Computerized Patient Record System; 3) transition to ICD-10 codes; 4) clear CG eligibility criteria; 5) telephone recruitment; 6) recruitment expertise; and 7) natural disaster, Hurricane Harvey. Though a small sample, analyzing for change in caregiving self-efficacy and caregiver appraisal at 8 weeks may have been premature to determine the short-term efficacy of ANSWERS-VA.
Abstract TP452: Evaluation of Post Tissue Plasminogen Activator (tPA) Mobility Guideline Revisions: Focus on Education Process
Authors: Campbell Margie , Reckner Katie , Polly Megan , Lee Jessica
Published: January 2019

Background and Purpose:
There is limited data regarding the safety of and nursing attitudes towards early mobilization of acute ischemic stroke (AIS) patients after thrombolysis. It is common to maintain patients on bedrest for 24 hours post-IV tPA infusion, delaying time to rehabilitation assessment, which may increase length of stay. There is considerable variability in protocols regarding mobilization of stroke patients among US hospitals. The purpose of this project was to assess the current attitudes of nursing staff regarding mobilization of post-thrombolysis patients and to assess the safety of early mobilization of AIS patients post-thrombolysis.

Methods:
A literature search and review of other benchmark institutions’ protocols was conducted. A change to post-thrombolysis order sets was made, stratifying timeframes for early mobilization based on NIHSS and treatment provided. A survey of the nursing staff (n=30) was conducted prior to the implementation of mobility order set changes, to assess comfort level with post tPA mobility guideline revisions and understanding of the actions of tPA. Education was provided to staff. A follow up survey (n=22) was conducted 3 months after order set implementation.

Results:
In a survey of other stroke programs (n=17), 59% indicated they had a bedrest protocol while 41% did not. Of the respondents, 52.9% required PT/OT evaluation prior to mobilization. On the internal pre- education survey, 14% of the nursing staff correctly identified the duration of action of tPA, with an increase to 45% on the post- education survey. On the pre- education survey, 75% of respondents indicated they would be comfortable mobilizing patients prior to 24 hours post-thrombolysis, with an increase to 95% on the post -education survey. Initially, 23% responded they would not be comfortable mobilizing patients prior to assessment by PT/OT, which decreased to 9% on the post- education survey.

Conclusions:
The early mobilization guidelines for the post tPA patient can be safely instituted using a stratification based on NIHSS severity. This may result in earlier rehabilitation assessment times and decrease lengths of stay.
Abstract TP456: Code Brain or Code Cluster: The Significance of Stroke Education for In-House Patients
Authors: Levesque Denise , Steiner Nili , Robertson Betty , Wolber Nicole , Guerra Sonia , Nunez Nancy , Paletz Laurie
Published: January 2019

Background:
The AHA/ASA guidelines for acute stroke management recommends stroke education. Rapid recognition and response to acute stroke warning signs is linked to improved functional outcome. Delays in recognition and inefficiencies during the code process lead to delays in care, which correlate with poorer outcomes.

Purpose:
Does increasing staff education via Code Brain In-services impact patient care for in-house stroke patients?

Method:
The target population was in-house stroke patients and 42 units were identified. Education highlighted Stroke Team Nurses as staff resources, stroke warning signs, Code Brain Pathway, and strategies to improve efficiency during a code. A retrospective analysis of the Acute Stroke Quality Improvement database was done. We compared the number of in-house Code Brain Activations and the number of Patients Treated for acute stroke.

Results:
3/17-7/17 average of 25.2 calls per month and patients treated for acute stroke was 4%. 8/17 -12/17 average number of calls increased to 39 and patients treated increased to 7%. During 9/17 when most in-services had been completed, a surge was noted. There were 56 calls and 6 patients were treated for acute stroke, compared to an average of only 1 per month prior to in-services. The trend for increased number of patients who were treated, continue to be evident through 12/17.

Implications:
Preliminary data suggests that Code Brain In-services provided to the nurses, appears to have directly led to an increased number of stroke patients identified and treated. Data review is ongoing. We continue to experience higher call volumes and treatments than before the education was implemented. This preliminary study demonstrates the merit of increased education over the standard practice of annual competencies. The hurdles of staff turnover and infrequent exposure to code brain, are best surmounted with frequent education. We seek to improve efficiency and effectiveness by focusing our attention to units that require more education and recognize units that are high performing. Our hope is that with these efforts, we will continue inspiring excellence in stroke care and demonstrate the value of a stroke-educated staff nurse.
Abstract TP457: Implementation of Stroke Champions as an Educational Tool for Improving Nursing Performance During In-hospital Stroke Codes at an Academic Institution: A Pilot Project
Authors: Hroma Elizabeth A , Reindl Deborah , McKoy Cedric , Ortiz Garcia Jorge G
Published: January 2019

Background and Purpose:
Identifying in-hospital strokes poses a challenge during stroke codes (SC) because stroke symptoms among hospitalized patients are often confounded with other symptoms and the medical history or symptomatology onset may be unknown by the covering provider. Nursing staff (NS) are frequently the first responders and must be adept at recognizing neurologic changes, as the SC requires accurate identification of stroke symptoms, prompt and reliable collection of sensitive information and compliance to an effective sequence of steps during the SC.

Methodology:
A retrospective analysis of in-hospital SC activations from January 1
st
to December 31
st
, 2017 was performed. Two intensive care units (ICU) and six general floors (GF) were included in this project. We surveyed NS to identify the level of training, clinical experience, and stroke knowledge. Stroke champions (SCH) were recognized in each unit as the most knowledgeable nurses regarding stroke. The SCH initiated the educational process with a lecture series then distributed handouts and a printed algorithm to aid NS during SC in the intervened units.

Results:
A total of 416 in-hospital SC were activated in 2017. The NS were the first responders in 360 cases (87%). We found that of the in-hospital SC, 29% were activated in the ICU and 71% in the GF. A significant high rate of non-stroke diagnosis was identified in Medical ICU (n=27, 93%), Cardiothoracic ICU (n=48, 67%), Medicine GF (n= 50, 80%) and Oncology GF (n= 54, 80%). A total of 139 nurses were surveyed. In this sample, 89 (64%) nurses have more than five years of clinical experience, 78 (56%) have RN or RN, BSN credentials, and 116 (83%) received some type of stroke training prior to this project. Only 75 (54%) responded correctly to questions about stroke symptoms and mimics. However, 135 (97%) nurses accurately recognized the acronym FAST in acute stroke.

Conclusions:
Prompt diagnosis is essential in patients experiencing acute stroke as treatment efficacy is highly time-dependent. The educational intervention by our SCH and implementation of a SC algorithm is beneficial to improve recognition of stroke symptoms and the performance during SC activations, increase the accuracy of diagnosis, and ultimately improve patient care and outcomes.
Abstract TP458: Stroke Disparities: Longer Lengths of Stay in Acute Stroke Patients With Medicaid
Authors: Grenier Rachel E , Palka Sydney , Monacci Kelsey , Leutbecker Jacqueline , Zimmerman William D , Yin Anqi , Geng Xue , Denny M C
Published: January 2019

Introduction:
Prolonged hospital stays expose stroke patients to hospital-acquired infections, increase overall cost of care, and delay the initiation of rehabilitation therapies. We sought to examine the factors associated with length of stay (LOS) in acute ischemic stroke (AIS) patients at a comprehensive stroke center (CSC) in an urban center. We hypothesized that patients being discharged to subacute rehabilitation (SAR) or nursing home facilities would have longer LOS.

Methods:
Consecutive patients admitted to our stroke service from April to July 2018 with a principal diagnosis of AIS were included. Patients with transient ischemic attack, intracerebral hemorrhage or subarachnoid hemorrhage were excluded. Demographics, admission NIHSS, baseline modified Rankin Scale (mRS), discharge mRS, and discharge disposition were collected. LOS was calculated from date/time of patient registration to discharge.

Results:
Baseline characteristics are shown in table 1. LOS and NIHSS were significantly correlated (

r
s

0.745, p <0.001). Medicaid as primary insurance on admission was associated with longer LOS (21.9 days) as compared to Medicare (6.5 days) or commercial insurance (2.6 days) [p=0.017]. Higher discharge mRS was associated with longer LOS [p=0.002]. Discharge to SAR was associated with longer LOS (22.9 days) as compared to acute rehab (8.8 days), home with home health (3.2 days), or home (2.6 days) [p = 0.001]. There was no difference in LOS according to baseline mRS, age, gender, or race.

Conclusions:
Higher admission NIHSS, Medicaid insurance on admission, discharge to SAR, and discharge mRs >4 were significantly associated with longer LOS in AIS patients. Systems of care interventions are needed to address disparity in LOS for Medicaid patients.
Abstract TP459: Reducing Door-to Needle Time in Half-Lessons Learned
Authors: Fuhrman Susan , Lazarro Marc
Published: January 2019

Background and Issues:
For each minute reperfusion is delayed, 1.9 million neurons die. In early 2017, the door-to-needle (TPN) times for initiating Alteplase (TPA) for our institution were starting to creep up over fifty-six minutes. Though the Joint Commission’s minimum standard is to start TPA on eligible patients in less than sixty minutes on average, we wanted to do better. A team had utilized Six Sigma approaches in prior years and saw some improvement; however, in this effort the interprofessional team chose to utilize those methods as well creation of a culture shift toward patient-centered reduction of DTN time.

Purpose:
Reduce DTN time to an average of less than or equal to thirty minutes on eligible patients.

Methods:
The interprofessional team was established to represent key stakeholders who then reached consensus on the current process. Goal timeframes for the subcomponents of the process were determined. A fishbone diagram was used to identify key barriers to meeting time goals. The four barrier areas identified included: Scan interpretation; documentation and communication; location where TPA was administered; and completion of other tasks before TPA. Subgroups worked on each barrier category. A tracking feedback tool was revised and utilized for consistent feedback on each TPA case. The Get With the Guidelines criteria for sixty-minute TPA timeliness was used to determine eligible patients for the thirty-minute window. Information was shared with the team at least monthly. Recognition was provided to staff, providers, and emergency medical system units involved in fastest TPA administration times.

Results:
Quarterly DTN needle times dropped from 56.1 to 26.4 minutes for all patients and from 54.6 to 26.1 minutes for eligible patients (pre-task force/2nd quarter 2017 to final post-task force/2nd quarter 2018, respectively). The volume of patients receiving TPA also increased from 11.5 to 13.75 patients/quarter. Increased collegiality and joint problem solving between services and departments were also noted as a result of this effort.

Conclusions:
By emphasizing teamwork and collaboration, not only were DTN times dropped by more than half, the culture of care was enhanced to truly reflect the patient at the center.
Abstract TP46: Evaluation of Aspiration Thrombectomy versus Anticoagulation in a Large Cohort of Patients With Cerebral Venous Sinus Thrombosis
Authors: Cheng Pamela , Lin Jane , Valdovinos Cristina , Feng Lei , Chao Kuo , Le Duy , Ajani Zahra , Sangha Navdeep
Published: January 2019

Introduction:
Cerebral venous sinus thrombosis (CVST) is an uncommon cause of stroke. Studies have assessed the efficacy of aspiration thrombectomy (AT), but have been limited to smaller populations, and AT was often reserved for patients with worsening neurological deterioration, which itself portends a poor prognosis.

Purpose:
To compare outcomes of AT vs. medical management (MM) in a large referral population without neurological deterioration at a single Comprehensive Stroke Center.

Methods:
We retrospectively identified patients using ICD-10 codes within our network between 2007-2017. Baseline demographics and clinical data were abstracted. Mann-Whitney U test and chi-square test were used for continuous and categorical variables, respectively.

Results:
383 patients were identified, and 99 were excluded due to age <5, cortical vein or cavernous sinus thrombosis, and venous stenosis. 284 were analyzed; 237 in MM and 47 in AT. There was no difference in baseline demographics or imaging modality. AngioJet™ was used in 90% of AT patients. Focal neurological deficit on presentation (57% vs 35%, p = 0.0033) and venous/hemorrhagic infarct on imaging (68% vs 37%, p = 0.001) was more common in AT. More patients received AT if superior sagittal plus any other venous sinus or straight sinus alone was involved (66% vs 32%, p = 0.003). All in AT received anticoagulation; 25 in MM did not due to perceived risks (100% vs 89%, p = 0.0194). MM had a better modified Rankin Score (mRS) at discharge (mRS 0-1: 72% vs 50%, p = 0.0037). There was no difference in mRS at 3, 6 and 12 months, and the development of chronic daily headache, migraine, or epilepsy. Subgroup analysis using those with only superior sagittal plus any other venous sinus or straight sinus alone showed MM had a better mRS at discharge (mRS 0-1: 68% vs 42%, p = 0.014).

Conclusion:
This study shows that MM was more likely to have a favorable outcome at discharge than AT. No difference in outcome measured at 3, 6 and 12 months was seen.
Abstract TP460: Recognizing Large Vessel Occlusions Earlier in the Stroke Alert Process
Authors: Hartmann Brenda L
Published: January 2019

Background:
As an Agency for Healthcare Administration (AHCA) Comprehensive Stroke Center we were looking for ways to decrease our door to groin puncture time for patients that had Large Vessel Occlusions (LVO) requiring mechanical thrombectomy. We found patients were often making two trips to the CT scanner. First for their plain brain CT to rule out blood and then for a CT Angiogram and CT Perfusion scan if it appeared the patient was having a Large Vessel Occlusion (LVO). Our mean groin puncture time for mechanical thrombectomy was 116 minutes in 2015.

Purpose:
To recognize the signs and symptoms of a LVO and save time by completing the plain brain CT scan, the CT Angiogram, and the CT Perfusion scan on the same trip to the CT department.

Method:
Our vascular neurologist reviewed the signs and symptoms of Large Vessel Occlusions utilizing V.A.N. (vision, aphasia, neglect) criteria with the Emergency Room Physicians, the Emergency Room Nurses, the Clinical Resource Nurses as well as all Emergency Medical Services (EMS) personnel. Lectures were given as well as hands on demonstrations. Telemedicine was asked to see the patient upon arrival in the ambulance bay to observe for LVO as well. Mock codes were run on both campuses with success.

Results:
Initially all stroke alerts were getting CT Angiograms and CT Perfusions completed regardless of whether they were VAN positive. However, after we reviewed all the false positives the number of patients actually getting these scans decreased to those that truly needed them. EMS now feels comfortable and competent calling LVO’s in the field. As do the Emergency Room physicians. As a result of these patients getting their required scans in one trip to the CT department, our door to groin puncture time has decreased from 116 minutes to a mean of 56 minutes.

Conclusion:
In conclusion, we found that adopting the utilization of VAN criteria to recognize LVO’s has decreased the mean door to groin puncture time for mechanical thrombectomy allowing for sooner return of circulation to the brain and improving patient outcomes.
Abstract TP462: Recruitment of African Americans in Blood Pressure Reduction Trials for Secondary Stroke Prevention
Authors: Cooksey Gail , Okpala Munachi N , Hinojosa Evelyn , Baldridge Lyric , Wynne Keona , Denny M C , Savitz Sean I , Sharrief Anjail Z
Published: January 2019

Background and Purpose:
Reductions in blood pressure (BP) after stroke are associated with dramatic reductions in stroke risk. African Americans (AA) have higher risk of recurrent stroke than Whites and higher rates of uncontrolled BP after stroke. Prior studies have shown under-representation of minorities in secondary prevention trials. We identified studies of BP control for secondary stroke prevention and explored minority representation in the trials.

Methods:
Relevant MeSH headings were used to conduct a PubMed search of randomized trials for secondary prevention of ischemic and hemorrhagic stroke and TIA, focused on BP reduction. We included studies published 1998 to 2018 that included participants from the US. We categorized articles according to timing post stroke, stroke type, intervention type, race/ethnic distribution, and mentioned efforts to increase minority proportions.

Results:
Of 703 abstracts identified from PubMed, 42 studies were retained, and 8 met criteria after manuscript review. Six were US based and 2 international. All included ischemic stroke and/ or TIA patients. None focused on hemorrhagic stroke. Six trials included behavioral modification as a component of the intervention. Enrollment period ranged from 0 to 180 days post-stroke. For US based studies, 5 reported AA race (race reporting complete for 3 studies). The proportion of AA participants ranged from 8.4% to 41.5% Three studies recruited from diverse populations. There was no specific mention of oversampling of AAs in any trial.

Conclusion:
Despite strong data to support BP reduction after stroke, there is a lack of US-based studies for secondary stroke prevention. More studies of BP control interventions to test medications and behavioral strategies for secondary stroke prevention in diverse patient populations are urgently needed.
Abstract TP464: System Changes Decrease Emergency Department Length of Stay for Hemorrhagic Stroke Patients
Authors: Cobos Carrie A , DeSouza Cleidi C , Duke Leslie , Kotlar Donna , Desara Shipley
Published: January 2019

Background/Purpose:
American Stroke Association guidelines recommend that a length of stay (LOS) in the Emergency Department (ED) of less than 6 hours improve outcomes in patients with hemorrhagic stroke. In the second quarter of 2017, patients at our academic medical facility averaged an ED LOS of 6.3 hours. Issues identified that extended LOS were: 1) a lack of process to alert required providers and stroke RN, 2) unfamiliarity of ED nurses with complex hemorrhagic stroke protocols, and 3) need for hemorrhagic stroke clinical care pathways with standardized order sets.

Methods:
Collaboration was formed between the emergency department, neurosurgery, neuro ICU, stroke program manager, and neuro ICU trained stroke nurses. The following improvements were implemented: 1) a subarachnoid hemorrhage and intra-cerebral hemorrhage (SAH/ICH) activation was developed to formalize a process to alert and mobilize specialty services upon patient arrival in the ED, 2) formation of a collaboration between an ED RN and expertly trained stroke nurses to provide care for the complex hemorrhagic stroke patient, and 3) implementation of standardized order sets for the electronic medical record.

Results:
Eleven months after the implementation of process improvements, there was a statistically significant reduction in ED LOS for hemorrhagic stroke patients. LOS decreased from an average of 6.3 hours to 3.1 hours.

Conclusion:
An activation system expediting specialty services and expert nursing care with the use of hemorrhagic stroke clinical care pathways and order sets reduces LOS in the ED and may improve patient outcomes.

Future Recommendations:
Monitor LOS statistics on a quarterly basis. Periodically re-evaluate the timeliness of SAH/ICH activation and compliance with clinical care pathways and standardized order sets to ensure sustainability.
Abstract TP465: Improved 30 Day Readmission Rates in the Acute Stroke Population Through Patient Teach Back
Authors: Buerck Angelina , Rupp Allison , Kozub Elizabeth
Published: January 2019

Background:
Our comprehensive stroke center focused on decreasing hospital readmissions and improving patient experience. In 2015, our stroke program had a CMS readmission rate of 9.0%, which was the highest amongst the metro stroke programs in a 12-hospital system.

Method:
In evaluating the opportunities to reduce hospital readmissions, patient education and patients’ ability to understand discharge instructions were identified as a gap. To improve patient education the stroke coordinator collaborated with the neurology unit nurse manager and CNS to develop teach back education. The team determined that the teach back method would be the primary technique used for stroke education for patients and caregivers. Floor nurses with the responsibility of completing stroke education were trained in the teach back method of instruction. The training was presented at staff meetings and new nurse orientation and reinforced in newsletters and nursing communications. Teach back was reinforced by the stroke nurse clinician who checked in daily with floor nurses to review patient education and plan of care. Further interventions to reinforce patient comprehension included the creation and use of tools and references such as stroke care maps, magnets, posters, and booklets sent home with patients. The stroke nurse clinician who performed seven day post-discharge follow up phone calls used consistent technique during telephone encounters. Additionally, a stroke nurse clinician conducted follow-up calls at 30 and 90 days with teach back strategies imbedded in the phone call script.

Results:
The consistency of the education and workflow led to improved outcomes in 30 day readmissions. From the 9.0% in 2015, the readmission rate decreased to 5.8% in 2017. The other metric used to measure progress was HCAHPS overall patient satisfaction scores in neurology patients, which improved from 62.1% top box in 2015 to 71.7% in 2017. These results were shared with the stroke providers monthly.

Conclusion:
Implementation of patient education using teach back was associated with a decrease in hospital readmissions and improved patient satisfaction in the stroke population. Future plans are to expand the use of the teach back method to the stroke provider team.
Abstract TP467: Prioritize- Ensure the Health of Your Community
Authors: Anderson Nicole L , Fleming Claire K , Tsai Albert W
Published: January 2019

Background:
As a rural stroke program in an aging community, we learned that more of our community members were choosing to drive to the hospital rather than utilizing EMS services when experiencing stroke symptoms. In collaboration with the Minnesota Department of Health we aimed to increase stroke awareness in our community, thus increasing EMS arrivals of patients with stroke symptoms.

Methods:
From June 2016 to June 2017, we participated in multiple community events. These included personal interaction with stroke-specific materials at three separate wellness events. We designed listener-specific radio PSA’s reaching over 30,000 listeners/hour on 6 local stations. We sent direct mailings via a postcard with a detachable magnet to 16,796 households. This highlighted stroke signs/symptoms, treatment options, and the importance of calling 9-1-1. We provided a stroke specific table service dinner with a presentation that was booked at max occupancy. Lastly, we utilized a “Mega-Brain” inflatable at an event with over 400 attendees and distributed stroke awareness materials.

Results:
Prior to the campaign from October 2015- June 2016 there were 140 stroke alerts (50%EMS vs 50% private vehicle, 25% stroke treated). The median last known well to arrival time was 121 [0,5760] minutes. During active participation from July 2016-June 2017, there were 151 stroke alerts (53% EMS vs 47% private vehicle arrivals, 21% strokes treated). The median last known well to arrival time was 115 [0,4320] minutes. At the conclusion from July 2017 – March 2018 there were 152 stroke alerts (53% EMS vs 47% private vehicle arrivals, 24% strokes treated). The median last known well to arrival time was 108 [1,10080] minutes.

Conclusion:
By identifying an educational gap and providing educational opportunities to the community, we experienced an increase in EMS activations for stroke symptoms as well as an unexpected increase in treated stroke cases. Educating the community on recognition of potential stroke symptoms, seeking early treatment, and utilization of EMS was an effective intervention in our service area. Continued community education is likely an important component of reducing death and disability from stroke by increasing early recognition and treatment of symptoms.
Abstract TP468: Inter-rater Reliability Process Optimizes Quality of a Registries Data
Authors: Bluma Dot , Polum Kathy , Link Jessica
Published: January 2019

Background and Purpose:
Ensuring the quality of a registry’s data is essential to its credibility and reliability of the information gathered. The Wisconsin Coverdell Stroke Program (WI Coverdell) monitors inter-rater reliability (IRR) through quarterly re-abstraction of five patient records from each of its participating hospitals. The goal for individual sites is 90% or greater concordance rate for each of the 28 data elements measured. This quarterly process ensures two abstractors at participating sites are familiar with the oftentimes difficult stroke data entry process. It also provides added benefit to hospitals by supporting continued quality improvement initiatives, as well as assists in meeting their certification bodies’ requirements.

Methods:
Participating hospitals gain access to two stroke data entry sites. One site is for entry of stroke abstracts; the second is utilized solely for re-abstraction entry. Quarterly, WI Coverdell performs an analysis of data agreement of the abstractions and re-abstractions. A subsequent quality report is sent to the hospital contact where the data elements that had mismatches are highlighted.

Findings:
Over nine quarters we have found individual sites agreement rates between two abstractors have varied from 70% to 100%. Whereas, WI Coverdell hospitals aggregated agreement rate has been stable at 92%-94%. Perceived rationales for agreement rates that are <90% include (1) the need for an identified source of truth for certain data elements, and (2) as new abstractors or re-abstractors begin stroke data entry, due to turnover in their roles, educational opportunities exist for understanding or clarification of the stroke coding instructions.

Conclusions:
A quarterly IRR process ensures two abstractors are proficient at data entry at participating hospitals, demonstrates the need for creating a source of truth document, and identifies learning opportunities for individual data abstractors.
Abstract TP469: The Goal Attainment Measure (GAM-S) for Secondary Stroke Risk Factors Management: Pilot Test and Psychometric Analysis
Authors: Kimmel Barbara , Anderson Jane , Swank Paul R , Swartz Michael D , Burns Joyce , Shegog Ross
Published: January 2019

Background and Purpose:
Stroke is strongest predictor of a subsequent stroke. Risk factor self-management (SM) prevents many strokes. In SM context, goal setting has been used as outcome measure to assess improvements of physical function. However, there is a dearth of psychometrically valid instruments to measure goal attainment through SM of risk factors. We pilot GAM-S with patients and providers and test scale for usability, content validity and internal consistency.

Methods:
Ten registered nurse dyads and 44 patients were recruited from Veterans Administration Medical Center. In a pre-experimental pre/post design, nurses delivered one-on-one education and set goals with patients. Nurses in primary care phoned patients 2-weeks post-discharge and evaluated goal attainment with GAM-S. Content validity was evaluated based on experts’ rating. Patients and providers rated GAM-S on ease of use, understandability, credibility and motivational appeal.

Results:
Participants: patients, N=44, 95% male, 36-81 yrs, mean age 67: providers, N=20, and experts, N=7. Forty-two patients (95%) completed GAM-S. Most experts (71%) specified that each scale item is essential, indicating content validity. GAM-S usability was analyzed descriptively. Detailed results will be presented. GAM-S providers’ usability was scored high: mean score 3.7 (SD 0.24), on 4 points scale. Coefficient of variation (SD/mean) was 6%. Cronbach's alpha for 42 respondents based on 4 items was 0.962 indicating strong internal consistency.

Conclusion:
We established acceptable ratings for GAM-S for use in clinic setting and demonstrated content validity and internal consistency. These findings suggest future efficacy of GAM-S to determine its impact on patient goal setting behavior.
Abstract TP471: Sustained Success of a Time-Out Process Prior to Administration of Tissue Plasminogen Activator for Acute Ischemic Stroke for the Prevention of Administration Errors
Authors: Spahr Catherine A , Walter Leslie , Failing Judith
Published: January 2019

Background and Purpose:
The goal to administer tissue plasminogen activator within 60 minutes of patient arrival, with 45 minutes on the horizon as the standard, is attainable through rigorous attention to a standardized process and interdisciplinary collaboration. Given the increasing complexity of the environment of care and the growing evidence that prompt and efficient delivery of acute stroke care saves lives and mitigates disability, organizations must continually strive to implement and enhance the safety infrastructure surrounding the patient with stroke. The concept of a safety time-out immediately prior to administration of tissue plasminogen activator was operationalized as an electronic tool within the EHR in 2015 as a pilot project that sought to mitigate an increase administration error rate. The purpose of this project was to evaluate sustained implementation of the time-out process.

Methods:
Primary goal: prospectively monitor the tool’s reliability over the next 3 years. Objective 1: show sustained improvement in preventing tissue plasminogen administration errors (Sustained failure rate of <10
-3
). Objective 2: ensure alignment with current work flow associated with bar code administration as the organization migrated to a new EHR. The elements to the safety time out remained unchanged: time of last known well, blood glucose, anticoagulation status, blood pressure, other contraindications, consensus to proceed, and assurance of a functional IV. There was no negative impact to achieving the standard of care at the end of the pilot in August 2015 with 0 administration errors.

Results:
There were 182 administrations of tissue plasminogen activator from 9/1/2015-6/30/2018. Compliance in tool utilization was 100% largely due to the hard stop function. There were 0 administration errors identified. Successful design and deployment of the tool in the new EHR. Anecdotal reports indicate positive collaborative experience between nursing and ED providers. The tool and process was rolled out system wide to 3 other Primary Stroke Centers.
Abstract TP473: Stroke Care and Mental Health: Improving Patient Care With National Institutes of Health Stroke Scale Certification of Registered Nurses
Authors: Baker Joshua
Published: January 2019

Stroke Care and Mental Health:
Improving Patient Care with National Institutes of Health Stroke Scale Certification of Registered Nurses

Background:
Numerous risk factors increase likelihood of stroke for the chronic mentally ill; best practice for care of acute stroke includes early recognition and early assessment using a scoring tool. The identified gaps in facility practice included: (a) a lack of acute stroke recognition and assessment skills by medical emergency response RNs; (b) outdated and lack of practice guidelines for medical care of acute stroke patients; and (c) non-standardized RN handoff communication to receiving stroke care center. The focus was a change in practice providing guidelines for assessment and documentation of National Institutes of Health Stroke Scale (NIHSS) score thus standardizing handoff communication.

Purpose:
The purpose of this quality improvement (QI) project was to improve the recognition and assessment skills of RNs responding to acute stroke emergencies at a Department of Veterans Affairs psychiatric care facility.

Method:
Data were collected before and after completion of NIHSS certification. The convenience sample (N=10) was drawn from medical emergency response RNs. Participants chose random identifiers and were given a pre-implementation questionnaire measuring level of comfort with identifying and assessing acute stroke symptoms and comfort using the NIHSS tool. Participants completed certification and using their selected identifier completed a post certification questionnaire. A retrospective chart review was conducted to review acute stroke emergencies and use of the NIHSS tool. Lippitt’s Change Theory was the framework utilized to implement the change in practice.

Results:
Improvement in skills of acute stroke recognition and assessment, comfort when caring for acute stroke patients, and a marked increase (59%) in the use of a stroke assessment tool was noted after the intervention.

Conclusion:
Despite a small sample size the outcomes of the QI project were positive. RNs providing medical emergency response treatment at a psychiatric facility noted an increase in comfort levels in recognition, assessment, and care of acute stroke emergencies. Expansion of the QI project can be beneficial.
Abstract TP474: Implementation of a Nursing Stroke Change Scale: A Multicenter Challenge
Authors: Broadway Katie , Jeansonne Stephanie , Lee Jason
Published: January 2019

Background and Issues:
The Houston Methodist Stroke Change Scale (HMSCS) was developed to identify neurological changes for ischemic stroke patients who received tissue plasminogen activator (tPA). This scale was developed and validated through an IRB approved study in 2017. The process of implementing a change in practice can be challenging, especially in a large, multicenter hospital system.

Purpose:
The purpose of this project was to educate and train nurses in direct bedside care of post-tPA patients in a large, seven facility hospital system on a new stroke change scale.

Methods:
The HMSCS was approved through various hospital system leadership councils, including the System Emergency Department Council, System Chief Nursing Officer Council, System Stroke Council, and System Critical Care Council. The research team worked with the EPIC development team to create a documentation area within the stroke narrator and tPA flowsheet. An interactive, e-learning module was developed and assigned to the 1126 nurses in the system who have potential to care for post-tPA stroke patients.

Results:
992 nurses completed the assigned module (88% completion rate). Once the training was completed at all seven facilities, the scale was implemented in the electronic medical record on April 16, 2018. Several issues were identified within the electronic medical record once the scale was active. These issues could have been identified prior to implementation had a pilot been explored. Future recommendation is to do a pilot study at one location prior to implementation at multiple sites.

Conclusion:
Creating and implementing new innovative ideas is the driving force behind being leaders in nursing. Implementing the HMSCS was challenging due to the multiple center design of the system but through teamwork and collaboration with various experts, it was implemented effectively.
Abstract TP477: Breaking Down the Barriers: Creating a Successful Regional Stroke System of Care
Authors: Cave-Brown Jennifer , Fairbanks Maria , Meighan Melissa , Petrucci Gunn Elaina
Published: January 2019

American health care is accused of being disorganized and competitive with a greater interest in financial gain over the health of our population. The stroke world is in jeopardy of such criticism as discussions of bypassing PSC’s toward CSC’s or TSC’s could be influenced by the needs for volume to maintain such certifications over what is best for the populations they serve. This abstract outlines the development of a county wide stroke system of care. This county has an ethnically and financially diverse population with challenges of a large geographic size, complex traffic flow patterns, competing health systems, and the lack of an academic level medical center.

Methods:
Through collaboration between emergency medical services, health care systems, and the AHA, barriers were broken down to improve stroke care and outcomes at a county wide level. Goals identified during this partnership included reductions in on-scene time, door to needle time, and door to groin time. Recognizing that 50% of all patients who present with suspected stroke symptoms do not call 911 but will walk in, the decision was made to focus on strengthening the transfer process and to share expertise with county hospitals which serve the medically indigent. Collaboration on community and EMS education on stroke symptoms was also done with an agreed upon commitment by the entities. This system of care is a fluid model which has adapted based on the services available within the system. In 2017, one of its entities became CSC certified. Most recently, plans were devised for patients in need of CSC services for rapid transport between all entities. The patients are identified as possible LVO candidates in the field using a (LAMS) but taken to the primary stroke center initially where they are evaluated with CT perfusion imaging.

Results:
Over a period of 6 years the mean door to needle time was decreased by 34.3% (63.6 min to 41.78 min respectively) and median door to groin time decreased by 16% (25 min to 21 min respectively). Through this model, the utilization of stroke services is targeted to benefit all residents of the county regardless of what health system they belong to.