bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T MP54: Hospital Characteristics Associated with Advanced Primary Stroke Center Designation
Authors: McDonald Catherine , Cen Steven , Ramirez Lucas , Mack William J , Sanossian Nerses
Published: July 2021

Background:
Organized stroke systems of care, including accreditation of hospitals as primary stroke centers (PSC), are meant to improve patient care and compliance with national guidelines. Nationwide, less than a third of eligible hospitals have achieved advanced certification in stroke. We aimed to characterize hospital factors associated with achievement of stroke center certification.

Methods:
We utilized the 2011 American Hospital Association survey to obtain data on hospital characteristics. Only hospitals with ≥ 25 beds and 24-hour emergency departments were evaluated. The Joint Commission (TJC), Healthcare Facilities Accreditation Program and DNV Healthcare websites were used to determine certification status of each hospital as a primary stroke center. All comprehensive SC were considered as PSC. Factors found to be associated with achievement of certification (P<0.010) were evaluated by logistic regression to determine a final model of independent association.

Results:
Of the 3696 hospitals to complete the survey, 3069 fulfilled study criteria, including 908 PSC (31%) and 2161 non-PSC. PSC were larger (mean 354 vs. 136 beds), had busier EDs (56,000 vs. 24,000 visits/year), were more often affiliated with ACGME residency programs (43% vs. 14%), AMA medical schools (51% vs. 21%), TJC-accreditation (95% vs. 65%), inpatient neurological services (94% vs. 46%) and trauma centers (55% VS 38%); and were less likely to be governmental (Federal/State/County 10% vs. 26%) and designated sole community provider (1% vs 9%). Independent hospital characteristics associated with PSC certification were TJC accreditation (OR 3.5, 95%CI 2.4-5.0), sole community provider (OR 0.22, 0.10-0.47), hospital type (governmental vs. non 0.61, 0.44-0.84), increasing size (per quartile in number of beds OR 2.5, 2.1-3.1) and neurological services (OR 3.2, 2.4-4.6).

Conclusions:
PSC hospitals are larger non-governmental hospitals with availability of neurological services. Increasing the low numbers of governmental (i.e. County or State) hospital achievement of PSC may be a potential area of focus.
Abstract T MP75: Effect of Subacute BP Variability on Subsequent Vascular Events in Patients with Acute Ischemic Stroke
Authors: Kang Jihoon , Jang Min Uk , Park Hong-Kyun , Hong Jeong-Ho , Yeo Min Ju , Kim Beom Joon , Jang Myung Suk , Yang Mi Hwa , Lee Ji Sung , Lee Juneyoung , Kim Wook-Joo , Han Moon-Ku , Bae Hee-Joon
Published: July 2021

Objectives:
We recently reported that blood pressure variability (BPV) during a subacute stage of ischemic stroke may affect functional outcome. This study aimed to test a hypothesis whether subacute BPV increases a risk of subsequent vascular events following acute ischemic stroke.

Methods:
From a prospective stroke registry database, consecutive ischemic stroke patients hospitalized within 48 h of onset were identified. Subacute BPV parameters were defined as maximum
2
-minimum, standard deviation (SD) and coefficient of variation (CV) of systolic BP (SBP) from 72 hours after onset to discharge. Primary outcome was a time to a subsequent vascular event (SVE), which was a composite of stroke, myocardial infarction and other vascular death. The BPV parameters were categorized into tertiles and dose-response relationships between BPV parameters and SVE were examined. The hazard ratios (HRs) of BPV parameters were estimated using Cox proportional hazard models with adjustments for predetermined confounders.

Result:
Of 3047 patients (mean age, 66.4 years and median NIHSS score, 3); BP was measured by median 46 times per person during the subacute stage (median 7 days). Median follow-up duration was 352 days (interquartile range, 112 to 389 days) and cumulative SVE rates were 7.0%. SVE rates differed by the tertiles of BPV parameters; SVE rates of lower, middle and upper thirds of maximum-minimum were 5.2%, 6.4% and 9.6%, those of SD were 5.4%, 8.5% and 7.9% and those of CV were 4.9%, 8.4% and 7.6%, respectively (P’s < 0.05 on log rank test).

There were significant dose-response relationships of SVE with maximum-minimum and SD (P < 0.01 and 0.01), not with CV (P = 0.14) independent of mean SBP, age, sex, history of stroke, hypertension, diabetes mellitus, hyperlipidemia, atrial fibrillation and stroke subtypes. Adjusted HRs of one-SD of maximum-minimum, SD and CV of SBP were 1.24 (95% confidence interval, 1.09-1.40), 1.16 (1.01-1.32) and 1.15 (1.01-1.30), respectively.

Conclusion:
This study suggests that the increase of blood pressure variability at subacute stage of ischemic stroke may increase the risk of subsequent vascular events.
Abstract T MP82: Time to Recanalization after Cerebral Venous Thrombosis
Authors: Arguelles-Morales Nayelli , Vargas-Gonzalez Juan Camilo , Ruiz-Franco Angelica , Quiroz-Compean Alejandro , Arauz-Gongora Antonio
Published: July 2021

Background and Purpose:
Cerebral venous thrombosis (CVT) comprises around 0.5% of strokes. Early initiation of anticoagulants, is safe and ensues a better functional prognosis. Different studies have addressed the issue, the rate and moment of recanalization has not been sufficiently defined, and it may have relevancy regarding treatment decisions. Our purpose was to estimate the time to recanalization of adults with acute CVT at one year follow-up.

Methods:
We prospectively studied a group of patients with confirmed diagnoses of CVT. Neuroimaging and clinical follow-up were performed at 3, 6, 9 and 12 months. All patients were treated with oral anticoagulant for 12 months or until complete recanalization. Statistical analysis used Kaplan-Meier method for survival tables.

Results:
We included 101 patients; median age was 33.6+11, women 79 (78.2%); 99 (98.0%) were evaluated and follow-up with MR venography. Complete recanalization at one year was accomplished in 65 (64.4%), partial in 29 (28.7%) and no recanalization in 7 (6.9%). We found that the proportion of any recanalization at 3 months was 65.3±4.7%, 6 months 89.1±3.1%, 9 months 91.5%±2.8% and 12 months 93.9%±6.1%. Complete recanalization at 3 months was 27.7±4.5%, 6 months 55.6±5.0%, 9 months 63.2%±5.0% and 12 months 68.5%±4.9%.

Conclusions:
Our result displays that at least partial recanalization in CVT occurs mainly within the first 6 months. However, there is a significant proportion of patients that achieve complete recanalization until 9 months of treatment regardless of the site of occlusion.
Abstract T P101: Low Serum Eicosapentaenoic Acid- Arachidonic Acid Ratio is Associated With Intracranial Stenosis in Patients With Acute Ischemic Stroke
Authors: Abe Yuko , Otsubo Ryoichi , Murase Sho , Nakazawa Kenichiro , Kitagawa Kazuo
Published: July 2021

Purpose:
A low ratio of serum eicosapentaenoic acid to arachidonic acid (EPA/AA) has been associated with atherosclerotic disease. Few studies investigate the association of serum fatty acid (FA) composition with the acute ischemic stroke so far. Our aim of this study is to evaluate the relationships between FA composition and stroke subtypes, extra-/intracranial atherosclerotic stenoses, and other cerebrovascular indicators

Methods:
This study included 154 consecutive patients who were admitted to our hospital because of acute ischemic stroke between April 2011 and March 2012. We examined the FA composition and classical vascular risk factors. We conducted brain MRI/MRA, carotid ultrasonogram, transthoracic echocardiogram, 24hr Holter electrocardiogram, ankle brachial index (ABI) and pulse wave velocity (PWV) in order to evaluate the severity of atherosclerotic change, stroke subtype, and cardiovascular status.

Results:
The mean value of EPA/AA was 0.33±0.22 in all patients with acute cerebral infarction. The 154 patients in this study (mean age 71 years) were categorized as follows; large artery atherosclerosis (LA; n=57), small artery occlusion (SA; n=48), cardiogenic embolism (CE; n=18), and others (n=31). We found intracranial artery stenosis greater than 50% in 70 patients (45%). The intracranial artery stenosis was associated with low EPA/AA ratio (P=0.013) and low EPA concentration (P=0.013). This association remained significant (P<0.05) after controlling for classical atherosclerotic risk factors. We could not find a significant correlation between FA composition and stroke subtype. However, there was a tendency for the EPA/AA ratio of LA patients to be the lowest among all subtype groups. The EPA/AA ratio was not associated with ABI, PWV, prevalence of arrhythmia, or cardiac function.

Conclusions:
A low EPA/AA ratio was significantly associated with intracranial stenosis in patients with acute ischemic stroke. This study shows the EPA/AA ratio might be an important marker to reflect the cerebral artery stenosis.
Abstract T P125: The Effects of Robot-assisted Training With Electrical Stimulation on Health-related Conditions in Patients With Chronic Stroke: A Pilot Randomized Controlled Trial
Authors: Wu Ching-yi , Huang Pai-chuan , Hsieh Fu-han , Hsiao Man-chiao , Chen Hsiao-wen
Published: July 2021

Background:
Robot-assisted therapy (RT) is an effective approach to promote upper extremity motor recovery in patients with stroke. Previous research showed that severely affected patients were less responsive to RT than those with mild to moderate motor severity. It’s necessary to develop a combined therapy which can expand the optimal treatment effect of RT to all kinds of stroke patients. Neuromuscular electrical stimulation (ES) could be used to supplement RT to improve movement awareness and output.

Purpose:
To compare the effects of RT with ES, dose-matched RT with placebo ES, and conventional rehabilitation (CR) on motor and daily function, and quality of life in patients with chronic stroke.

Methods:
This is a single-blind randomized controlled trial. There were 30 patients with chronic stroke who were randomly assigned to one of the three groups: (1) RT with neuromuscular ES (RT+ES); (2) RT with placebo ES (no stimulations into the electrodes); (3) CR. All participants engaged in 90 to 105 minutes of training in each session, 5 times a week for 4 weeks. Outcome measures were Action Research Arm Test (ARAT) for motor function, accelerometer data of 3-day active level in affected hand for daily function, and Stroke Impact Scale (SIS) for quality of life. Analysis of covariance was used to compare the treatment effects among groups.

Results:
Significant between-group differences favoring the RT+ES group were shown on the grip subtest of ARAT (η2=.614, p <.05,) and the activity of accelerometer (η2=.260, p <.05) while a non-significant trend but large effect favoring RT+ES was observed on total score of ARAT (η2=.192, p=.411). A group effect favoring CR group on activity of daily living subscale of SIS was revealed (η2=.286, p <.05). There were no statistically significant differences on other outcome measures.

Conclusions:
Providing four weeks of RT+ES during chronic stroke appears to produce further improvements on hand grip and active level of affected hand in daily living than providing CR alone. Adding ES to RT could provide additional effect, given that active level of affected hand did not improved in the placebo group. Future study may incorporate more task-oriented practice into RT+ES treatment program to enhance treatment effects on life quality.
Abstract T P132: Rapid loss of the Mexican American Survival Advantage After Stroke--The BASIC Study
Authors: Morgenstern Lewis B , Sánchez Brisa N , Smith Melinda , Brown Devin , Garcia Nelda , Lisabeth Lynda
Published: July 2021

Background/Objective:
As a primary, pre-specified objective of the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project we studied trends in mortality following ischemic stroke among Mexican Americans (MAs) and non Hispanic whites (NHWs). MAs were previously found to have lower mortality following stroke than NHWs.

Methods:
We performed active and passive surveillance, and using source documentation, validated all ischemic stroke cases from January, 2000-December, 2010. Deaths were ascertained from the Texas Department of Health through December 31, 2011. Cumulative 30 day and 1 year mortality adjusted for covariates was estimated using log-binomial models with a linear term for year of stroke onset used to model time trends. Pre-specified adjustment factors were: age, sex, prior stroke or TIA, atrial fibrillation, diabetes, heart disease, hypertension, smoking, high cholesterol and stroke severity. Models used data from the entire study period to estimate adjusted mortality among stroke cases in 2000 and 2010, and to calculate projected ethnic differences.

Results:
There were 1,822 ischemic strokes among NHWs and 2,211 among MAs. Between 2000 and 2010, 30 day and 1 year mortality declined among NHWs, from 8.6% to 5.9% (p=0.14), and 21.7% to 17.0% (p=0.06), respectively. Among MAs, 30 day mortality remained stagnant at 5.6% (p=0.98), and a slight decline from 18.3% to 16.4% was observed for 1 year mortality (p=0.41). While, the ethnic differences in 30 day (p=0.01) and 1 year (p=0.07) mortality were robust in 2000, they were not so in 2010 (30 day, p=0.76; 1 year p=0.78). See figure. MAs are projected to have higher post-stroke mortality by 2022.

Conclusions:
Overall, mortality following ischemic stroke has declined in the last decade. However, the survival advantage previously documented among MAs vanished by 2010. Further, faster declines in mortality among NHWs than MAs imply a reversal of the survival advantage by approximately 2022.
Abstract T P137: Temporal Trends in Hospitalization for Ischemic Stroke in the United States, 2000-2010
Authors: Sanossian Nerses , Kim-Tenser May A , Ramirez Lucas , Valle Natalie , Cen Steven , Mack William J , Towfighi Amytis
Published: July 2021

Background:
Recent population-based studies have revealed declining ischemic stroke hospitalization rates in the US, particularly among whites, but no study has assessed recent nationwide trends in race/ethnic-, age- and sex-specific stroke hospitalization rates in the US.

Aims:
To assess temporal trends in race/ethnic-, age-, and sex-specific rates of hospitalization for ischemic stroke in the US.

Methods:
Temporal trends in hospitalization for ischemic stroke (ICD-9 codes 433.x1, 434, 436) from 2000 to 2010 were assessed among adults ≥25 years using the Nationwide Inpatient Sample. Age-, sex-, and race/ethnic-specific stroke hospitalization rates were calculated using the weighted number of hospitalizations as the numerator and the US civilian population as the denominator. Age-adjusted rates were standardized to the 2000 US Census population.

Results:
From 2000 to 2010, age-adjusted stroke hospitalization rates decreased from 169 to 138 per 100,000 (overall rate reduction 18.3%). The decline in stroke hospitalizations was driven by the ≥65 age group, with the sharpest decline among 65-84 year olds (Figure). Sex-specific rates showed higher age-adjusted rates in women, with a steeper reduction in women than in men (from 228 to 180 vs. 183 to 157 per 100,000). Race/ethnic-specific trends revealed that hospitalizations decreased for whites and Hispanics but increased for blacks (from 144 to 193 per 100,000 in black men and from 191 to 211 per 100,000 in black women).

Discussion:
Although overall stroke hospitalizations have decreased in the US, the reduction has been more pronounced among older individuals, whites and Hispanics. Renewed efforts at targeting risk factor control among blacks and middle-aged individuals may be warranted.

Figure 1.
Abstract T P21: Improved Ischemic Stroke Outcomes After Intra-Arterial Interventions Associated With Higher HDL Cholesterol
Authors: Sultan-Qurraie Ali , de Havenon Adam , Tirschwell David L , Sharma Deepak , Ghodke Basavaraj , Hallam Danial , Kim Louis , Becker Kyra J
Published: July 2021

Background/Objective:
The effect of pre-morbid lipid levels on neurologic outcome after Acute Ischemic Stroke (AIS) is variable in the published literature. In this study, we retrospectively use a cohort to evaluate the relationship of cholesterol subfractions to outcome.

Methods:
The cohort consists of AIS patients treated with IA therapy between September 2008 and December 2010. Favorable outcome for these analyses was defined as a modified Rankin Scale of ≤ 3 at time of discharge. Univariate associations with favorable outcome were sought for demographic, co-morbidity, stroke risk factor, and procedure related variables. Independent associations were identified by relative risk regression using generalized linear models with a logit link, a Poisson distribution for variance and robust standard errors. All analyses were performed in STATA.

Results:
The cohort included 42 patients; mean age was 62 years, 62% were women, median pre-procedure NIHSS was 16, 70% of patients achieved a mRS ≤ 3. Univariate analysis suggested significance of a number of variables with favorable outcome. In multivariate analysis only three variables-previous tobacco use, highest procedural SBP, and history of atrial fibrillation-remained significant. Adding LDL to the multivariate model did not show association, though adding HDL as a continuous variable did show an association. Results are shown in the table.

Conclusions:
In our cohort there was no association between favorable outcome at time of discharge and LDL, but higher HDL was associated with an increased chance of good outcome. While this association between HDL and outcome is reported for patients treated with intravenous tPA, it is novel for patients treated with IA therapy and warrants further study. Our data collection is ongoing and we aim to double the size of our dataset; the updated analyses will be presented at the meeting.
Abstract T P222: Docosahexaenoic Acid as a Promising Neuroprotectant in Brain Ischemia: New Experimental Evidence
Authors: Belayev Ludmila , Hong Sung-Ha , Khoutorova Larissa , Anzola Daniela , Obenaus Andre , Bazan Nicolas G
Published: July 2021

Introduction:
Docosahexaenoic acid (DHA; 22:6n-3) is an omega-3 essential fatty acid family member and the precursor of neuroprotectin D1, a lipid mediator which downregulates apoptosis and promotes cell survival. Recently, we have shown that DHA improved behavior in animals allowed to survive for 7 d after stroke. This study was conducted to establish whether the behavioral improvement induced by DHA persists with chronic survival. In addition, we examined the effect of DHA on blood-brain barrier (BBB) integrity using Evans Blue (EB) and FITC-dextran markers.

METHODS:
Physiologically-controlled SD rats received 2 h middle cerebral artery occlusion (MCAo). DHA (5 mg/kg; n=10) or vehicle (saline; n=9) was administered i.v. at 3 h after onset of MCAo.
In behavioral studies,
the composite 12-point neuroscore, rota-rod, Y-maze and beam walking test were conducted 1, 2 and 3 weeks after MCAo.
Ex vivo
imaging of the brains and histopathology were carried out on day 21.
In BBB studies,
fluorometric quantitation of Evans Blue (EB) was performed in six brain regions at 6, 24 or 72 h after stroke. FITC dextran leakage was analyzed on day 3 after MCAo.

RESULTS:
Physiological variables were stable and showed no significant differences between groups. DHA treatment significantly improved the 12-point neuroscore compared to vehicle on day 1 (by 16%), day 2 (by 19%), day 3 (by 22%), week 1 (by 20%), week 2 (by 22%) and week 3 (by 33%) respectively. Treatment with DHA prolonged latency time in the rota-rod test on weeks 1-3 (by 44-68%), enhanced the score in the balance beam (by 29%) and improved Y-maze performance by 19% compared to the saline group. DHA decreased EB extravasation in the posterior ischemic hemisphere at 6 h (by 34%), 24 h (by 42%) and 72 h (by 38%). EB extravasation was decreased by DHA in the cortex and total hemisphere as well. FITC dextran leakage was reduced by DHA treatment on day 3 by 68% compared to the saline group.

CONCLUSION:
DHA therapy accelerates long-lasting behavioral recovery and diminishes BBB damage in a model of experimental stroke. Thus, it is reasonable to hypothesize that DHA may have potential use in treating focal ischemic stroke in the clinical setting.
Abstract T P232: Brain CD47 Expression in a Piglet Model of Intracerebral Hemorrhage
Authors: Zhou Xiang , Xie Qing , Xi Guohua , Keep Richard F , Hua Ya
Published: July 2021

Differentiation 47 (CD47) has a role in ischemic brain injury and phagocytosis. The role of CD47 in intracerebral hemorrhage (ICH) has not been investigated and the current study examined brain CD47 expression in a piglet ICH model.

Methods:
Piglets received a blood injection or needle insertion into the right frontal lobe and were euthanized at different times to examine CD47 expression. Piglets were also treated with an iron chelator, deferoxamine, (50 mg/kg, i.m.) or vehicle and euthanized at day-3 to examine the effects on CD47.

Results:
ICH resulted in upregulation of brain CD47 in both white and grey matter by both immunohistochemistry and Western blot. A time-course showed ICH-induced CD47 upregulation from 4 hours to day-14. ICH-induced CD47 upregulation peaked at day-3. CD47 positive cells were neurons, microglia/macrophage and oliogodendrocytes. Systemic treatment with deferoxamine (started at 2 hours after ICH and every 12 hours for 3 days), an iron chelator, reduced CD47 levels in the ipsilateral white matter (CD47/beta-actin: 0.35 ± 0.08 vs. 0.73 ± 0.09 in vehicle-treated pigs, p<0.01) and grey matter (0.64 ± 0.16 vs.1.19 ± 0.20 in vehicle-treated pigs, p<0.01) at day-3 after ICH.

CD47 expression on erythrocytes was reduced at 24 hours compared with that at 4 hours after ICH (p<0.05), and significant erythrophagocytosis was present in the clot.

Conclusion:
CD47 expression was increased in the perihematomal white and grey matter and was decreased in the clot after ICH. Alterations in CD47 expression may play a role in parenchymal injury and hematoma resolution. Deferoxamine and iron may modulate CD47 expression.

Key words:
cerebral hemorrhage, CD47, deferoxamine, erythrophagocytosis, piglets
Abstract T P241: Deletion of PGE2 EP1 Receptor Results in Reduced Phagocytosis and Exacerbates Hemorrhagic Injury
Authors: SIngh Nilendra , Ma Bo , Leonardo Christopher C , Ahmad Abdullah S , Narumiya Shuh , Dore Sylvain
Published: July 2021

Background:
Spontaneous intracerebral hemorrhage (ICH) is the deadliest and most debilitating form of stroke with a first year mortality rate as high as 50% to 60%. Role of prostaglandin E2 (PGE2) receptor EP1 has been extensively studies in ischemic stroke; however, the precise role of this receptor in intracerebral hemorrhage-induced brain injury is unknown. Therefore, in this study we determined the role of the EP1 receptor in collagenase-induced hemorrhagic stroke.

Methods:
ICH was induced randomly in 2.0-2.5 month old male C57BL/6 wildtype (WT) and EP1 knockout (EP1-/-) mice by intrastriatal injection of collagenase. Functional outcomes including neurologic deficits, rotarod performance, open field activity, and adhesive removal performance were evaluated at 72h post ICH. Hematoma volume, and cell survival and death, were assessed using cresyl violet and Fluoro-Jade staining respectively. Microglial activation was estimated using Iba1 immunoreactivity. Phagocytosis was assessed with fluorescently-labeled microspheres injected into the site of the hematoma and at the end of the survival time Iba1 immunoreactivity was used to label cells with microspheres. Values are expressed in (mean±SEM) and the number of cells/field was provided by averaging four different regions surrounding the hematoma.

Results:
Following 72h post injury, EP1-/- mice showed worsened outcomes compared to the WT mice. The results revealed elevated neurological and sensorimotor deficits and exacerbated hematoma volume. Fluoro-Jade staining showed significantly increased numbers of degenerating neurons and reduced neuronal survival in EP1-/- as compared with the WT mice. The in vivo phagocytic behavior of microglial cells in WT and EP1-/- suggested that the number of microspheres incorporated into Iba1-positive cells was 145.4±15.4% greater in WT than in EP1-/- mice.

Conclusion:
These results suggest that, the deletion of PGE2 EP1 receptor results in augmented hemorrhagic brain injury partially through reduced phagocytosis.[Supported by NIH R01 funds (SD)]
Abstract T P248: All Wrapped Up in a Bundle: Aultman Hospital’s Journey with the Bundled Payment for Care Improvements in Stroke
Authors: McGee Angela M , Brackman Jennifer M
Published: July 2021

Background:
In January of 2013, Aultman Hospital was selected among 500 hospitals nationwide to participate in the CMS Bundled Payments for Care Improvement (BPCI) Initiative. The hospital chose to participate with this initiative using the stroke patient population during the acute hospital stay and services up to 90 days after hospital discharge. During the discovery phase, data was analyzed that helped to identify opportunities within the transitions of care across the continuum for stroke patients.

Purpose:
To identify areas of opportunity to improve transitions of care across the continuum for stroke patients under the bundled payment initiative.

Methods:
A multi-disciplinary steering committee, driven by engaged physician champions, came together to review the analyzed data and identify care coordination opportunities. Reviewed data included stroke patients from 2008 to current, with a strong focus on readmissions and complications of care. Data analysis was performed internally by the steering committee and externally by Brandeis University.

Results:
The committee was able to identify trends in readmissions, potential quality and financial opportunities, create a stroke opportunity matrix and stroke bundled payment dashboard, and enhance the partnership between Aultman Hospital and Aultman Post-Acute Care by creating a Continuum of Care Collaboration Plan for stroke patients. A potential nurse navigator was also identified as a possible need. The position would provide a consistent person(s) that would ensure that individual needs are met across the continuum and possibly prevent readmissions. The team was also able to provide feedback to CMS regarding the BPCI, which ultimately were consistent with the changes CMS made to proposed data collection and reporting requirements.

Conclusions:
Throughout Aultman’s journey with the BPCI, common themes remained: the need for collaboration of services for stroke patients to ensure continuity of care and to streamline the encounter for the patient. Aultman’s BPCI for Stroke team was able to identify ways to reduce readmissions, prevent complications of care, explore the potential for a stroke nurse navigator, and reduce the overall financial impact to an overburdened public health system.
Abstract T P258: Improving Nursing Practice Through Telestroke Partnerships
Authors: Morrison Kathy , Humbert Jennifer
Published: July 2021

Background:
Emergency department (ED) nurses play a vital role in initiating the appropriate care of stroke patients. Nurses must demonstrate a proficient skill level in order to partner with the health care team to ensure the delivery of quality stroke care. Education is a key component to attaining and maintaining proficiency and comfort in these skills. Telestroke partnerships provide a unique opportunity to improve the knowledge and skill level of nurses in community hospital emergency departments.

Purpose:
The purpose of this study is to measure the impact on nursing knowledge and practice through the establishment of a telestroke partnership between a Comprehensive Stroke Center and community partner hospitals.

Methods:
After a literature review, a questionnaire was developed and evaluated by the nursing research council. The proposed research was approved by our Institutional Review Board (IRB). Prior to any education related to stroke care and telestroke technology, the ED nurses in our partner hospitals completed the questionnaire measuring their knowledge and comfort level in caring for acute stroke patients. Education related to stroke identification, assessment, tPA administration, and advanced interventions was provided via small group lecture by the telestroke coordinator. A follow up questionnaire was completed at 3 month post education and implementation.

Results:
As a result of the education and support provided through the telestroke partnership, the community hospital ED nurses’ scores demonstrated an increased level of comfort and knowledge related to the care of an acute stroke patient.

Conclusions:
Stroke care and patient outcomes are directly impacted by the level of nursing knowledge and practice at the bedside. Telestroke partnerships between comprehensive centers and community hospitals strengthen the nursing practice levels in the community hospital setting.
Abstract T P260: Utilizing Concurrent Chart Review With Electronic Medical Record to Improve Stroke Core and Quality Measures
Authors: Fung Jenny
Published: July 2021

Background and Purpose:
The purpose of this project was to utilize concurrent chart review with electronic medical record as one method to improve stroke performance measures. In order to standardize and improve stroke care in the acute care setting, stroke performance measures have been set forth by the American Heart Association/American Stroke Association through Get With The Guidelines Registry, and from the Joint Commission. Maintaining stroke measures above goal can present a challenge in the world of paper documentation and chart review after discharge. Electronic medical record (EMR) allows multiple providers, including physicians, nurses, therapists, and stroke coordinator to access the health record concurrently during the patient’s hospital stay.

Methods:
Guided by a successful program implemented by St Mary’s Health Center in Jefferson City, Missouri, a 2 step concurrent chart review process was initiated for all stroke and transient ischemic attack (TIA) patients admitted to our facility. A stroke coordinator conducted chart review via EMR focusing on 8 of the quality measures (Early Antithrombotics, venous thromboembolism prophylaxis, antithrombotics at discharge, anticoagulation at discharge for atrial fibrillation/atrial flutter, smoking cessation, statin at discharge, dysphagia screen, and stroke education). Chart review was conducted the day after admission and the day of discharge with the goal of correcting potential outliers on the same day of chart review. Monthly performance data was collected over 1 year.

Results:
Concurrent chart review was conducted on 409 stroke/TIA patients. There was gradual improvement in quality and core stroke measures following implementation with achieving and sustaining 100% in 7 measures by month 6 and acheivement of >90% for dysphagia screen.

Conclusions:
In conclusion, concurrent chart review with the use of electronic medical record allows the stroke coordinator to focus on core and quality measures, while allowing multiple members of the stroke team (physician, nurse, and therapist) to access the same patient record. This also provides opportunities for collaboration and process improvement within the same stroke team.
Abstract T P261: Non-Contrast Head CT Prior to Comprehensive Neurological Evaluation Reduces Door to Needle Times for Administration of Intravenous rtPA
Authors: Mooney Lesia , Shaw Suzanne , Barrett Kevin , Raper Carol
Published: July 2021

Background:
American Heart Association/American Stroke Association recommends treatment of eligible acute ischemic stroke patients with intravenous rtPA <60 minutes from emergency department arrival.

Purpose:
A quality improvement project was designed to reduce the door to needle times for intravenous rtPA administration at Mayo Clinic Florida. We hypothesized that workflow changes in emergency department evaluation of suspected stroke patients would decrease door to needle times. The goal was to treat >75% of patients eligible for IV t-PA within 60 minutes of ED arrival.

Methods:
We utilized LEAN methods to develop a project charter, identify stakeholders, and visually map the emergency department clinical workflow. Prior to project initiation, suspected stroke patients were taken upon arrival to an exam room for clinical evaluation followed by transport to the CT scanner and return to the exam room for decision-making and rtPA administration. The clinical workflow was changed to obtain patient weight immediately upon arrival, abbreviated patient assessment and lab draws outside of the CT scanner in a holding bay and performing CT scanning prior to transport to an examination room for decision making and rtPA administration.

Results:
In a 12 month period preceding project initiation, 29 patients were treated with rtPA, 55 % were treated <60 minutes of emergency department arrival. In the 11 month period following implementation of CT scanning prior to neurological evaluation, 57 patients were treated with rtPA, 80 % were treated in <60 minutes of emergency department arrival. The mean door to needle time was reduced from 66 minutes to 46 minutes following the clinical workflow change. No patients experienced clinical deterioration at the time of CT scanning.

Conclusions:
Non-contrast head CT scan be safely performed prior to comprehensive neurological evaluation and reduces door-to-needle times for intravenous rtPA administration in eligible stroke patients. Validated process improvement paradigms such as LEAN have the potential to reduce door to needle times and improve patient outcomes.
Abstract T P267: Development of an EMS Interfacility Ground Transport Protocol for Patients During/After IV tPA Administration for Acute Ischemic Stroke
Authors: Connelly Kerrin , Gupta Rishi , Nogueira Raul , Yancey Arthur , Isakov Alexander , Colman Michael , Lairet Julio , Jernigan Michael , Billings Marty , O'Neal J. Patrick , Wages Keith , Clarkson Lydia , Lugtu James , Camp Deb , Gaunt Susan , Newsome Teri , Hula Holly , Krompf Kerrie , Frankel Michael R
Published: July 2021

Purpose:
To standardize the care of acute stroke patients who receive IV tPA being transported by ground EMS from a treating hospital to a stroke center.

Background:
National consensus guidelines exist for the hospital management of patients receiving IV tPA for acute ischemic stroke. Such patients require close monitoring and management to minimize risk of clinical deterioration. Although patients are often emergently transported from local hospitals to a stroke center, there are no treatment specific national guidelines for managing such patients enroute. As a result, there is a need to develop and implement a standardized approach to guide EMS personnel, particularly in states like Georgia where the public health burden of stroke is high.

Methods:
In 2012, the “Georgia EMS Interfacility Ground Transport Protocol for Patients during/after IV tPA Administration for Acute Ischemic Stroke” was developed in conjunction with the Georgia Coverdell Acute Stroke Registry, the Georgia State Office of EMS, a representative group of Georgia hospitals and EMS providers. Stakeholders were brought together with the goal of creating a unified statewide protocol. The intent was to create a streamlined protocol which could be readily implemented by pre-hospital care providers.

Results:
Stakeholders discussed challenges and opportunities to change the process of pre-hospital care. Challenges included recognition of the broad diversity of EMS providers representing over 250 agencies in the state. Opportunities included establishing the framework for greater collaboration across organizations and providers. The final protocol was endorsed by both the Georgia Coverdell Acute Stroke Registry and the State Office of EMS, and distributed to all EMS regions in Georgia. EMS agencies are currently implementing the protocol.

Conclusion:
Engaging a diverse group of statewide stakeholders to develop a new treatment protocol enhances success in implementation and serves to further the public health mission of improving care of acute stroke patients.
Abstract T P277: Time Out: Safe Patient Transition Pre-Hospital to Hospital
Authors: Nunn Tony , Barth Bradley , Bram David , Sandt Janice , Murphy Seamus , Ediger David M , Lechtenberg Colleen , Smith Brian R , Blevins Rick
Published: July 2021

Background and Purpose:
Historically, Emergency Medical Services (EMS) and Emergency Department (ED) nursing staff have had no standardized method of hand-off reporting, and documentation of the communication has been difficult to locate in the medical record. Comprehensive Stroke Centers (CSC) are called to collaborate and communicate with all care delivery partners, including providers from transferring facilities. A standardized method of communication and documentation sets the stage for safe patient care transitions.

Methods:
Regional community discussion began in 2011. Proposals were made and no early adopters came forward. Internal discussion was readdressed. A team was assembled consisting of researchers and frontline staff from ED, EMS and the CSC. A hand-off communication tool was developed using Situation, Background, Assessment, and Treatments format. The tool includes stroke specific data points important to care and pilot data will be collected during fourth quarter of 2013. Metrics include compliance of tool use and an accurate medical history with home medications. Three EMS providers representing urban, suburban and rural services have been recruited. Each Paramedic-RN team involved in a hand-off will receive an electronic survey measuring engagement and satisfaction.

Results:
A standardized method for communicating important hand-off information was developed and will be demonstrated. Final analysis of the data at the end of the quarter will provide direction to further improve the tool with the goal of permanent implementation within the region. Ongoing data analysis will be communicated to all providers monthly via electronic communication. Sharing the story with the region on a regular basis presents a road-map for successful safe patient transitions.

Conclusions:
The development of consistent standardized hand-off communication between pre-hospital and hospital staff is essential to patient safety. Collaboration empowers best practice solutions. Accurate medical history assists in rapid emergent evaluation. Engaged pre-hospital and hospital personnel using standardized tools are likely to provide consistent safe patient transitions. Safe hand-off communication is paramount for all CSC partners.
Abstract T P293: Determinants of Early Withdrawal of Care in Patients Who Die During Index Hospitalization for Acute Ischemic Stroke
Authors: Wingkun Neil , Ali Syed F , Thankachan Tijy K , Schwamm Lee H , Singhal Aneesh B
Published: July 2021

Introduction:
CMS recently announced plans to report risk-standardized stroke mortality. Decisions to withdraw medical care after acute ischemic stroke are based on numerous factors, not just the severity of the incident stroke. Withdrawal of care decisions have the potential to confound these adjusted mortality rates. We investigated factors associated with early withdrawal of care in patients hospitalized with AIS.

Methods:
We used our institutional GWTG database (1474 consecutive stroke inpatients from 12/2009 - 12/2012) to identify 176 consecutive in-hospital mortalities; of these, 100 patients were transitioned to comfort care during hospitalization. Chart review was performed on these 100 patients to identify factors associated with early (< 5 days) withdrawal of care.

Results:
Seventy-eight patients (78%) had early withdrawal of care. Table 1 shows the comparison of patients with early (<5 days) versus late (≥ 5 days) withdrawal of care decisions. As shown, Early-CMO patients were younger, and less often were Hispanic, had a college level or higher education, and annual income >$100,000. They had more often expressed a DNR request, had placed limits on life sustaining measures prior to admission or had a known health care proxy (84% vs. 68%). They had pre-existing comorbidities of prior MI, atrial fibrillation, cancer and dementia. They had slightly higher NIHSS scores, and lower rates of thrombolysis. Early-CMO patients had lower rates of post-stroke pneumonia.

Conclusion:
Several non-clinical variables appear to be associated with early withdrawal of care decisions and contribute substantially to in-hospital stroke mortality. Many of these factors are non-modifiable, and the association with pneumonia may be confounded by the reduced opportunity to develop pneumonia in cases of very early death. Given the vigorous debate about preventable stroke mortality and public reporting, these data suggest the need for more complex mortality risk models.
Abstract T P298: A Comparison of Stroke Time Targets for In-Hospital Versus Emergency Department Ischemic Stroke Patients at a Primary Stroke Center
Authors: Lee-Ekblad Deborah R , Meyers Nan , Becker Kelly , Chinoy Milind , Lawrence Brandon , Wilt Jeffrey
Published: July 2021

Introduction:
Based on the 2013 Guidelines for Early Management of Patients With Acute Ischemic Attack, hospitals and emergency departments (ED) should develop efficient processes and protocols to manage stroke patients. The guidelines have several time targets for early stroke evaluation and treatment such as door to physician, door to CT initiation, door to CT interpretation, and door to drug. The goal of these time targets is to reduce morbidity and mortality associated with stroke.

Hypothesis:
We hypothesize that inpatient stroke evaluation and treatment is equivalent to patients presenting to the emergency department (ED) with stroke symptoms since the same stroke team responds to both inpatient stroke call downs and ED stroke call downs. This is to obtain initial data for a quality improvement project at Borgess Medical Center, Kalamazoo, MI.

Methods:
Between September 2010 and June 2013, all in-hospital stroke call down charts were retrospectively reviewed. For each month that there was an inpatient stroke call down, ED stroke call downs were retrospectively chart reviewed as well. There were 24 inpatient stroke call downs and 93 ER stroke call downs during this time period. Each chart was reviewed for time targets: door to physician, door to CT initiation, door to CT interpretation, and door to drug.

Results:
The hospitalized stroke patients experienced more delays in care than ED stroke patients. The inpatient target times are below recommended time targets. The average time to physician for inpatient stroke patients was 5 minutes as compared to the ED was 4.2 minutes. Time to CT initiation was 31.45 minutes for hospitalized patients as compared to 25.48 minutes for ED patients. CT interpretation was 52.83 minutes for inpatient strokes as compared to 47.21 minutes for ED stroke patients. Time to tPA was 122 minutes for hospitalized patients as compared to 94 minutes for ED stroke patients.

Conclusion:
Hospitalized patients developing stroke symptoms have delays in care as compared to patients that present to the emergency department with stroke symptoms. This may be due to emergency department patients getting preferential treatment for tests. Identifying these delays in care is important to improve stroke treatment for hospitalized patients.
Abstract T P313: Sensitivity of ICD-9 Discharge Codes to Identify TIA Cases in 4 Community-Based Emergency Departments
Authors: Reeves Mathew J , Nasiri Mojdeh , Glynn Ted , Hughes Mary , Kothari Rashmi , Oostema John A , Brown Michael
Published: July 2021

Introduction:
The diagnosis of TIA is often challenging in the emergency department (ED) setting. ICD-9 discharge code 435 is often used to identify TIA cases; however, its accuracy is unclear. Our objective was to determine the sensitivity of ICD-9 code 435 to identify confirmed TIA cases treated in 4 community-based EDs.

Methods:
Over a 12 month period suspect TIA cases were prospectively identified using hot-pursuit mechanisms in 4 EDs. A time-based definition of TIA was used (i.e., acute onset focal unilateral symptoms with duration <24 hours and no alternative diagnosis). All cases had a final clinical diagnosis of TIA confirmed following an independent physician panel review. Data were abstracted from medical charts and the primary ICD-9 discharge code was obtained from the hospital or ED billing records. ICD-9 discharge codes were neither used to identify cases or confirm the final diagnosis.

Results:
Of 366 subjects with suspected TIA, 336 (92%) had a confirmed final diagnosis of TIA. Mean age was 66 years, 54% female, 31% non-white and 83% were hospitalized. The relative frequency of primary ICD-9 discharge codes at each of the 4 EDs are shown in the Table. The overall sensitivity of the 435 code was 64.3% (95% CI 58.9-69.4). Alternative codes used included stroke-related (8.0%), other CVD-related (2.7%), miscellaneous (8.3%) and non-specific symptoms codes (16.7%). The frequency of 435 coding varied non-significantly between sites (56% to 72%; p= 0.13); however, sites varied substantially in their use of non-specific symptoms codes (4.8% to 26.7%; p=0.002).

Conclusions:
In this series of confirmed TIA cases, more than 1/3
rd
would not have been identified if the 435 code was used. These findings suggest that the 435 code should not be relied upon to identify TIA cases. Future studies should determine the causes of the variation in coding between sites, and also measure both sensitivity and specificity of the 435 code.
Abstract T P318: Comparative Effectiveness of tPA on 6 Month, Patient-Centered Outcomes: A Pilot Analysis
Authors: Lang Catherine E , Bland Marghuretta D , Corbetta Maurizio , Lee Jin-Moo
Published: July 2021

We examined the real-world benefit of tPA, delivered as part of usual care, on patient-centered outcomes. All persons with a diagnosis of stroke or TIA from our hospital are contacted for telephone follow-up at 6 mos. after the event. The survey includes the Stroke Impact Scale (SIS), Patient Health Questionnare-9 (PHQ9), and other questions about aspects of daily life.

This study retrospectively compared outcomes in patients who received tPA as part of usual care with patients who would have received tPA had they arrived at the hospital within the time window, i.e. criteria other than time were met. From hospital records, we acquired demographic and medical data. Patients in each group with completed surveys were matched on initial NIHSS score, age, race, gender, and date of stroke. Staff conducting surveys were independent from staff determining matches and were blinded to the others data. Matching was done with 1:2 ratio of tPA to controls. Results were compared between groups with 1-tailed tests due to directionally-specific hypothesis in favor of the tPA group.

Persons receiving tPA and controls completed the surveys at the same rate. Sample size was 67 for the tPA group and 137 for the control group, with the groups matched across the above variables as intended. On the SIS, the tPA group reported better physical function (p=.001), communication (p=.048), cognition (p=.029), and quality of life (p=.04) compared to the control group. Depressive symptomatology, as indicated by PHQ9 scores, was not different between groups (p=.48). Fewer people in the tPA group (27%) reported 1 or more emergency room visits in the 6 months after their stroke compared to controls (44%, p=.03). Of those driving prior to their stroke, 72% had returned to driving, vs. 58% of controls (p=.045). Return to work rates were not different (52% tPA vs. 39% controls, p=.19) within the smaller subset of people working prior to their stroke.

While it is known that tPA reduces long-term disability, this is the first study to demonstrate the effectiveness of tPA in improving meaningful, patient-centered outcomes, such as physical function and communication. These data indicate that use of tPA provides a large benefit to the daily lives of people with ischemic stroke.