bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP484: Care Coordination Barriers at Key Transition Points in Post-Ischemic Stroke Care - the Case for Nurse Navigators
Authors: Bottomley Sharon , Keefner Lisa , Fenton Brenda , Burrone Laura , Sico Jason
Published: January 2019

Background:
Post-stroke, patients and caregivers require a wide array of services to promote recovery, facilitate risk factor reduction, and reduce adverse events. Providers face the challenge of coordinating timely, accessible, and comprehensive services across the continuum of post-stroke care. We sought to understand stakeholders’ perceptions of care collaboration of and barriers to post stroke follow-up care within Veterans Health Administration (VHA) facilities, including patients referred from non-VHA hospitals.

Methods:
Thematic analysis of 27 semi-structured qualitative interviews conducted from February to April 2018 among health care providers and administrators at two diverse VHA facilities was performed. A multidisciplinary team conducted consensus-based coding of transcripts. Coded descriptions of “coordination of care” and “barriers to stroke care” were compared across sites and among providers.

Findings:
A total of 122 quotes from qualitative interviews were coded, with a majority of respondents being in-patient medical hospitalists, neurologists, and outpatient primary care providers. Lack of owning processes of care delivery was the most commonly noted barrier (41/122) and applied to: (a) arranging post-discharge follow-up; (b) making referrals for post-discharge testing and rehabilitative services, and; (c) managing vascular risk factors during the post-discharge phase. VHA-based providers also reported not: (a) being informed of admissions to outside hospitals; (b) having access to outside records and; (c) being made aware of the need for a post-hospitalization visit (7/122). When used, nursing services were noted to overcome these barriers (14/122).

Conclusions:
We identified barriers to stroke care at transition points both within the VHA, from inpatient to outpatient care and across internal medicine and neurology, and from non-VHA acute care to VHA-based chronic care management. Nurses are in a position to address lack of communication and attribution of care responsibility by offering continuity of care to specialty providers, primary care clinicians, and stroke patients and their families. The study provides rationale and guidance regarding the role of stroke nurse navigators.
Abstract WP485: Early Mobilization After 12 Hours Post Thrombolysis is Feasible and Safe in Minor Stroke Patients
Authors: Tubergen Tricia , LaCroix Hattie , Packard Laurel , Huffman Cuyler , Garcia Alana , Ames Nicholas , Newell Dawn , Packard Donald , Raad Bassel , Zachariah Joseph , James Elysia , Goosen Andrea , Frye Angela , Abdelhak Tamer , Silver Brian , Khan Muhib
Published: January 2019

Background:
Current guidelines recommend 24 hours of hospital bed rest after thrombolysis for acute ischemic stroke. We sought to compare outcomes and in-hospital complications of 12- and 24-hour bed rest protocols following thrombolysis in minor stroke patients.

Methods:
Consecutive patients age >18 years with a diagnosis of ischemic stroke with initial National Institute of Health Stroke Scale (NIHSS) 0-6 who received intravenous thrombolysis only from 1/1/2017 until 4/30/2018 were included. Standard practice bed rest order for 24 hour protocol prior to 07/15/2017 was compared with 12 hour bed rest order protocol after that date. Primary outcome was length of stay. Secondary outcome measures included symptomatic intracerebral hemorrhage (sICH), deep venous thrombosis (DVT), pulmonary embolism (PE), pneumonia, favorable discharge to home or acute rehabilitation, readmission within 30 days and modified rankin scale (mRS) at 90 days.

Results:
77 patients were identified, 36 patients in the 24-hour protocol and 41 in 12-hour bed rest protocol groups. There was no significant difference for length of stay in the 24-hour bed rest protocol (2.8 days) compared with the 12-hour bed rest protocol (2.3 days) (p=0.37) (Table). Compared with the 24-hour bed rest group, the rates of sICH (p=1.00), DVT (p=NS), PE (p=NS), pneumonia (p=1.00), favorable discharge disposition (p=0.69), 30 day readmission (p=0.80) and 90 day mRS 0-2 (p=0.36) were also not different between the groups (Table). Time to mobilization was significantly different between the two groups (p<0.001) (Table).

Conclusion:
Compared with 24-hour bed rest, 12-hour bed rest after thrombolysis for minor acute ischemic stroke was associated with significantly earlier patient mobilization without any adverse outcomes. A randomized trial is needed to verify these findings.
Abstract WP488: Transition of Care Needs of Stroke Patients Discharged From the Hospital
Authors: Guhwe Mary , Patel Nilam , Forrest Heather , Chancy Stephanie , Napier Sandra , Provenzano Alicia , Chioffi Susan , Hauck Erik , Gonzalez Fernando , Graffagnino Carmelo
Published: January 2019

Background:
Poststroke patients with residual deficits that do not require inpatient rehabilitation are at an increased risk of adverse events during transition of care especially readmission within 30 days of discharge. However, using readmission as a marker for successful discharge is misleading as lack of readmission does not always translate into a measure of patient wellbeing. Identifying specific needs instead allows for targeted interventions in improving the discharge process and patient satisfaction.

Methods:
This QI project analyzed transition of care issues identified in poststroke patients discharged home from a large academic center via a post discharge phone call by an advanced practice provider (APP) between July 2017 and April 2018. All patients admitted to the neurology stroke or neurosurgery service with a diagnosis of stroke and discharged home received a phone call within 7days of discharge by an APP. The telephone encounter was documented in the medical record.

Results:
Of 324 patients, 67% answered, 32% did not answer and 1% had contact deferred. Fifty-eight percent had no issues identified. Common issues identified were related to medications, rehabilitation therapy, follow-up appointments and new health issues. More SAH patients had issues with medication insurance coverage (17%) and more ICH patients had knowledge deficits related to their medications (6%). More SAH patients lacked scheduled appointments at discharge (33%) and lacked insurance coverage for appointments (6%). More ICH patients reported no contact from therapy (6%) but ischemic stroke patients reported more falls (2%). SAH patients had more unexpected new health issues (6%). Patient satisfaction with discharge ranged from 92 to 96%.

Conclusion:
ICH and SAH patients discharged home have more transition of care needs. A post discharge follow-up phone call by an APP within 7 days of discharge allows for early intervention of identified post discharge complications. These early interventions result in timely connection with rehabilitation services, medication regimen adherence and appointments with follow-up providers in the community. Additionally, the APP can intervene on unexpected health problems that develop prior to contact with a community provider.
Abstract WP49: Emboli in New Territory After Mechanical Thrombectomy: Systematic Review and Meta-Analysis
Authors: Shimbo Daisuke , Hernandez Adrian V , Deshpande Abhishek , Uchino Ken
Published: January 2019

Introduction:
As mechanical thrombectomy (MT) for acute ischemic stroke has become standard therapy, interest has grown in treatment of milder strokes. Minor complications might therefore be important in mild strokes. The primary objective of the systematic review was to report the rate of emboli in new territory (ENT) following MT. Secondary objectives included describing rates other non-CNS hemorrhage procedural complications of arterial perforation, dissection, vasospasm and access site complications.

Methods:
We searched randomized controlled trials (RCTs) published in MEDLINE/PubMed from 2010 to 2018 supplemented by a hand-search of reference lists and review articles. Random-effects models using the inverse variance method were used to estimate the pooled complication rates. We also performed subgroup analyses by technique (stent retriever first group or other devices) and year of publication (2010-2015 or 2016-2018).

Results:
A total 19 RCTs with 2454 procedures for MT were included in our analysis. ENT, perforation, dissection, vasospasm, and access site complications were reported in 9 (47%), 11 (58%), 7 (37%), 7 (37%), 8 (42%) studies, respectively. The pooled ENT rate was 3.5% (95% CI 2.0-5.4), and there was no significant difference in the rate of ENT between stent retriever first group (2.8%, 95% CI 0.4-6.7) and other devices group (4.4%, 95% CI 2.6-6.7, p=0.43). There was no differences in ENT rates by year of publication. Other complication rates were perforation 2.2% (95% CI 0.9-4.0), dissection 2.0% (95% CI 1.1-3.3), vasospasm 10.7% (95% CI 3.8-20.2), and access site complication 2.9% (95% CI 0.9-5.9). There were no differences in the subgroups of perforation, dissection, and vasospasm by procedural methods or year of publication, but the rates of access site complications from 2016-2018 was significant lower compared to 2010-2015 (0.6% vs 5.2%, p<0.001).

Conclusions:
The risks of 3.5% rate of ENT and low rates of other complications might become relevant in treatment of mild stroke.
Abstract WP491: A Multi-Disciplinary Approach to Improve Transitions of Care
Authors: Bluma Dot , Vilar Paul , Link Jessica
Published: January 2019

Background and Purpose:
In 2013, the Wisconsin Coverdell Stroke Program (WI Coverdell) initiated an analysis of EMS and hospital data. These examinations revealed opportunities for improvement in transitions of care (toc) for timelier stroke treatment. Due to the importance of pre-hospital triage and teamwork on stroke outcomes, WI Coverdell knew it was essential to conduct joint performance improvement among EMS and hospital staff.

Methods:
WI Coverdell’s 61 participating hospitals represent 77% of annual stroke admissions to Wisconsin hospitals. Coverdell hospitals participate in the quarterly Coverdell Learning Collaborative (CLC) where they review several aggregated data points. Of these, arrival to computed tomography (CT) initiation and door to needle (DTN) times are analyzed and discussed. Stroke Coordinators at hospitals’ performing at a high level share with the CLC their performance improvement (PI) activities and best-practices. Establishing a cooperative, trusting relationship with hospitals EMS services is essential. Since November 2013 many Outreach events to Coverdell participating hospitals acute stroke teams (AST) and their EMS service providers have occurred. These events aim to foster a trusting relationship between EMS providers and Coverdell hospitals AST. The Outreach event focuses on the toc from EMS to the hospitals, and emphasizes the important role of EMS in the stroke patient’s chain of survival. The areas of education for EMS providers include content on triage, treatment, and pre-notification to the hospital of the suspected stroke patient. The AST caregivers gain an increased awareness of EMS’s existing knowledge and triage processes that occur in the field.

Findings:
In analyzing annual data from 2013 to 2017 our multi-disciplinary approach demonstrates impressive results. For arrival to CT initiation, the median time decreased from 22 minutes in 2013 to 13 minutes in 2017. The percentage of acute ischemic stroke patients who received alteplase in 60 minutes or less increased 33.7% from 2013 to 2017. Finally, the N increased from 111 in 2013 to 359 in 2017.

Conclusion:
A multi-disciplinary approach focused on improving toc between EMS and hospitals have led to remarkable improvements in WI Coverdell’s outcome data.
Abstract WP492: Dysphagia Severity and Decision Making Algorithm Impact on Length of Hospital Stay, Restraint Use and Cost in Stroke Patients
Authors: Collins Lindsay B , Ward Cindy W , Boggs Barbara
Published: January 2019

Introduction:
Enteral feeding tubes, nasally inserted (NGT) or percutaneous endoscopic gastrostomy tubes (PEG) are used to provide nutrition and hydration to stroke patients with dysphagia. For patients with severe dysphagia, a PEG tube should be considered early in treatment. A delay in a PEG consult and placement may lead to an increased number of NGTs due to dislodgement, abdominal x-rays, physical restraint use, hospital length of stay, and cost. The purpose of this IRB-approved research was to determine the effect of a dysphagia severity and decision making algorithm on patient hospital length of stay, restraint use and cost.

Methods:
A retrospective chart review of 40 stroke patients hospitalized between August 14, 2016 and February 14, 2017 who required NGT feeding due to dysphagia was conducted. The algorithm was implemented for 36 stroke patients with dysphagia who required tube feeding from August 14, 2017 through February 14, 2018. Data collected included dates of nasally inserted tubes, number of tube re-insertions, number of abdominal x-rays performed for placement verification, dates of PEG consult and placement, restraint use and hospital length of stay. Non-equivalent T-Tests were used to determine differences between groups.

Results:
The pre-algorithm group experienced more days prior to insertion of a nasal feeding tube (6 days) compared to the post-algorithm group (3.3 days;
p
=0.146). Nasal tube replacements (
p
=0.009) and repeat x-rays (
p
=0.0073) both decreased in the post-algorithm group. There were no differences between the two groups in restraint use (
p
=.2621) or length of stay (
p
=0.0746), although the post-algorithm group experienced a mean seven day shorter length of stay and restraint use was decreased by an average of six days.

Conclusion:
Although not statistically significant, the shorter length of stay and restraint reduction, combined with fewer tube replacements and x-rays translates clinically to decreased cost. This algorithm is a promising tool to encourage early consult and placement of PEG tubes to impact reduced length of hospital stay, restraint usage, and cost.
Abstract WP493: Benefit of an Advanced Practice Nurse-Led Stroke Telemonitoring Program
Authors: Murphy Deborah A , Shah Qaisar , Bussinger Patricia , Peiritsch Heather , Kozak Osman , MacKenzie Larami , Choe Hana , Griffin Lisa , Hargarves Joelle D
Published: January 2019

Introduction:
Hypertension (HTN) remains the leading modifiable risk factor for stroke. Recently updated guidelines from the American Heart Association support a blood pressure (BP) goal of ≤ 130/80 mmHg and home blood pressure monitoring (Benjamin et al., 2017). The purpose of this evidence-based practice change project was to implement a new home blood pressure telemonitoring (HBPT) program for stroke patients with HTN, promote self-care management and reduce secondary stroke risk.

Methods:
An advanced practice nurse (APN) led 16-week HBPT pilot project was implemented to monitor blood pressure (hospital admission, discharge, 7-days HBPT and 30-days post discharge) and perception of the HBPT experience. Eligibility for HBPT was determined by the stroke team in collaboration with case management. Home care nurses assured home delivery of the HBPT device and educated the patient/family on device management. Daily readings were transmitted to the home care dashboard and monitored for alerts. Patients returned to the stroke office 30-days post discharge for evaluation of BP and HBPT experience.

Results:
Sixteen out of 112 patients were eligible for HBPT. The mean age was 71 years-old; 54% males; 55% females. Stroke types included 67% ischemic and 33% hemorrhagic. A significant change (improvement) in BP was noted from: admission to discharge (P = 0.007) and admission to 30-days post-discharge (P < 0.001). All patients achieved target BP at discharge and 30-day post-discharge. All patients reported a positive HBPT experience.

Conclusion:
An HBPT program can be beneficial in promoting secondary stroke risk reduction and enhancing patient self-care management skills.
Abstract WP494: Stroke Risk and Symptom Recognition Post Cardiac Catheterization
Authors: Schaefer Karen , Rivet Cindy , Strom Carmelia
Published: January 2019

Over 1.4 million cardiac catheterization procedures(CCPs) take place yearly. CCP related stroke incidence in 1973 was reported as 0.23%. CCPs are invasive in nature; complications occurring due to unintentional trauma to atherosclerotic aortic plaques or thrombus formation on catheters/guidewires. With improved practice, current incidence is 0.06%. Performing >4000 procedures in FY2017, our facility sought to compare our statistics vs. current literature. Cardiovascular disease was the leading cause of global death in 2013 (17.3 million); stroke at 11.8 million. Ninety-two million Americans live with cardiovascular disease/stroke after effects accruing $316 billion in indirect costs. Seventeen percent of strokes occur in hospital; with stroke suffered post CCPs having morbidity/mortality rates 19-37%. Time to recognition/treatment of stroke symptoms is vital for best outcomes. Increase in visual symptoms post CCPs was noted with questionable correlation to radial access. Staff education on atypical stroke symptom recognition/empowerment and comfort to initiate Code Strokes was conducted. There was variability in practitioner approach to calling Code Strokes vs. observing patients post symptom recognition. Meetings held with Cardiology, Neurology, Hospital Administration, Departmental Leadership, Stroke Manager came to consensus on patient management. There should be low threshold for performing screening neurological exams and calling Code Strokes. With more sensitive diagnostic tools, diagnosis should be streamlined. Code Stroke data was collected December 2015-November 2017. Data analysis showed 48 Code Strokes called; 30 confirmed (67% male, 63% radial, 57% interventional procedures). Presenting symptoms, in order of frequency, were: vision, arm drift/weakness, facial droop, speech. The typical FAST stroke assessment would not be helpful in majority of these patients, however, education to atypical symptoms was beneficial. Literature shows women have higher stroke risk after CCPs. Our analysis showed higher prevalence in men with radial access. The most common symptom of visual changes, results in NIHSS of 0, which may impact practitioners ordering stroke work-ups; when focus should be patient disability.
Abstract WP495: Building Relationships With Emergency Medical Services Utilizing a Stroke Feedback Tool
Authors: Reck Cynthia L
Published: January 2019

Background and Purpose:
Acute stroke care is rapidly evolving and EMS play a critical role in clinical outcomes. Historically, EMS providers have received little to no feedback regarding patient outcomes. An EMS Stroke Feedback Tool was created at our hospital to share key information. The purpose of this tool is to increase communication with our local EMS, improve knowledge of stroke care interventions and increase EMS awareness of their impact on patient outcomes. This study aims to determine the efficacy of the feedback tool in improving EMS provider satisfaction and communication.

Methods:
Data is collected concurrently by the Stroke Data Coordinator and sent to the EMS liaison for distribution to their team. Variables on the feedback tool include: RACE Score, blood glucose, IV initiated, prehospital notification, admission & discharge NIHSS, timeline during hospitalization and discharge disposition.
See figure 1 attached
. A sample survey (n=40) was sent to our largest local EMS agency to determine EMS provider satisfaction with this new tool.

Results:
97.5% (n=39) of the EMS providers surveyed, agreed providing feedback to EMS assists in driving better practices and improving patient outcomes. 90% (n=36) of EMS providers strongly agreed feedback is appreciated on stroke patient outcomes. 92.5% (n=37) EMS providers agreed this feedback tool provides data in a clear & concise format. Of the 10% (n=4) of providers who did not agree, all offered feedback how to make the tool more impactful.

Conclusion:
In conclusion, most EMS providers surveyed collectively agree the EMS Stroke Feedback Tool is an excellent starting point towards improving communication between hospitals and EMS regarding key prehospital care and impact on patient outcomes. Additionally, this tool will be used to drive recognition of EMS providers that successfully perform key initiatives.
Abstract WP5: The Age Effect on tPA Response Was Regulated by ADAMTS13/vWF
Authors: Deng Wenjun , Liu Kai , Fisher Lindsay , Chou Richard , Bunda Bridget , Wang Andrew , D'Souza Erica , Wang Xiaoying , McMullin David , Buonanno Ferdinando , Lo Eng H , Ning MingMing
Published: January 2019

Background:
Although growing evidence has suggested that elderly stroke patients can benefit from intravenous tissue plasminogen activator (tPA), impaired functional outcome and increased risk of hemorrhagic transformation have also been frequently observed in those patients after tPA treatment. By cleaving von Willebrand factor (vWF), ADAMTS13 (A Disintegrin and Metalloproteinase with Thrombospondin motifs 13) is involved in arterial thrombosis and tPA regulation. Recent studies have identified decreased ADAMTS13 activity and increased vWF levels with aging and vascular cognitive impairment, which may put elderly individuals in a prothrombotic status at baseline. We therefore hypothesized that the ADAMTS13/vWF axis may also play a role in regulating the age effect on tPA response.

Method:
Consecutive tPA-treated ischemic stroke patients were prospectively recruited in accordance with IRB protocol. Peripheral venous blood was sampled at 12, 24 and 72hr post tPA administration.

Result:
A total of 173 patients were recruited, of whom 128 were younger than 70 years and 45 were older than 70 years. Impaired tPA response (mRankins > 2 at 3 months) was observed in patients ≥70 years compared to patients <70 years. Increased age was associated with decreased ADAMTS13 level and enhanced vWF (Figure 1A and 1B). Post tPA treatment, patients <70 years old had rapid and persistently elevated ADAMTS13 levels, which may enhance thrombolysis by cleaving vWF multimers (Figure 1C). However, in patients ≥70 years old , ADAMTS13 levels was lower and also rose slowly, which may have resulted in delayed vWF degradation and impaired thrombolytic efficacy (Figure 1C).

Conclusion:
Our results suggest that the ADAMTS13/vWF axis may contribute to impaired tPA response in older stroke patients and that ADAMTS13 may be a potential adjunct therapy to enhance the tPA efficacy. This proof of concept data may pave the way for future clinical trials.
Abstract WP500: Stroke Transitions of Care Coordination Program is Feasible and May Reduce 30-day Readmissions
Authors: Monacci Kelsey , Palka Sydney , Leutbecker Jaqueline , Grenier Rachel , Yin Anqi , Geng Xue , Denny M. Carter
Published: January 2019

Introduction:
Transitions of care from the acute hospital to other medical facilities and home is a national health care priority. We designed a randomized pilot study to assess the feasibility of a Transitions of Care Coordinator (TOCC) program led by a nurse navigator. We hypothesized that the navigator would complete all portions of TOCC program in at least 75% of acute ischemic stroke (AIS) pts.

Methods:
Consecutive AIS patients admitted from April to July 2018 were randomized to TOCC group or usual care group. Pts discharged to subacute rehab, nursing home and hospice or died during hospitalization were excluded. In TOCC, the navigator met patient/caregiver on admission, followed up discharge pending diagnostics, attended multi-disciplinary rounds, facilitated rehab referrals, provided stroke education, and arranged clinic follow-up. Demographics, NIHSS, mRS and discharge disposition were collected. Hospital length of stay (LOS) was calculated from date/time of patient registration to discharge. Patient satisfaction questionnaire and readmission rate was assessed at 30 days by phone. Continuous variables were analyzed using Wilcoxon rank-sum and categorical variables using Fisher’s exact test.

Results:
TOCC pts were older, but other demographics were well matched (table 1). The navigator completed all portions of the TOCC program in 80% of pts. The mean time spent by the navigator per TOCC pt was 111 minutes (SD 23). There was no difference in distribution of LOS between the TOCC and usual care groups (5.7 vs. 5.1 days, p=0.51). There was no difference in the mean patient satisfaction scores between TOCC and usual care groups (30.3 vs. 29.6, p=0.66). There were no 30-day readmissions or ER visits in TOCC group vs. 3 and 2 in the usual care (p=0.25, p=0.50).

Conclusion:
A nurse navigator-led TOCC program is feasible and may be associated with decreased 30-day readmissions. The ongoing TOCC study will assess any association with LOS and patient satisfaction.
Abstract WP506: Looking for Themes to Improve Outcomes Through Team Debriefing
Authors: Friedrich Sherri H , Klein Karen S , Welch Debbie , Cassling Susan K
Published: January 2019

Background:
Acute ischemic stroke (AIS) patients risk grave disability when treatment is delayed. The benchmark for door to needle (DTN) time for thrombolysis in AIS is less than 60 minutes; The American Stroke Association's (ASA) Target Stroke, Phase II (TSP II) sets a higher standard of less than 45 minutes. Emergency department caregivers at a 377 bed community hospital with primary stroke center designation were educated about the TSP II toolbox; however DTN times in 2016 were less than 60 minutes only 29% of the time with a mean time of 78 minutes, a medium time of 77 minutes and a range of 178 minutes.

Purpose:
Using a lean methodology approach we organized team debriefings to evaluate cases of time delay with the aim to develop strategies to improve outcome.

Methods:
As a process improvement project, an interprofessinal team was assembled to debrief and evaluate all patients receiving thrombolytic therapy. A comprehensive checklist was developed to include all of the critical components of care along with target benchmark timelines. Each data point was scrutinized to evaluate for possible time delays. The caregiver team was encouraged to objectively identify time delays and look for themes. Through root cause analysis, the most common theme identified was the performance of unnecessary tasks that could wait until after initiation of therapy. The other theme identified was delay in critical interventions such as timely lowering of blood pressure to prevent hemorrhage in patients undergoing thrombolysis. We engaged in coaching conversations among members of the team in an effort to promote better critical thinking and better patient outcomes.

Results:
From January, 2017 to August, 2018 there were 69 thrombolytic therapy cases The DTN rate of less than 60 minutes was 78%. Mean, median and mode times were 53,51 and 57 minutes respectively. The range was from 28-93 minutes. DTN in 45 minutes or less occurred at a rate of 30%.

Conclusion:
Improved outcome for exemplary professional practices can be afforded through a systematic approach to debrief about time sensitive treatments. Bringing team members together for a guided discussion designed to look for themes that lead to performance deficits will develop better patient outcomes.
Abstract WP508: Improved Access to Stroke Care in Saskatchewan Canada
Authors: Whelan K. Ruth , Hunter Gary , Hamilton Jessica , Schwartz Laura , Latta Lori , Davy Kim , Onaemo Vivian , Kelly Michael
Published: January 2019

Background:
The province of Saskatchewan, Canada represents a large geographic territory with 1.2 million residents. Approximately 2000 Saskatchewan residents per year are hospitalized due to stroke, with care being provided at a variety of facilities.

Method:
The Saskatchewan Acute Stroke Pathway (ASP) was established to implement Canadian Stroke Best Practice Recommendations (CSBPR) province wide. Recommendations included: creation of primary and comprehensive stroke centers, expansion of emergency medical service (EMS) stroke alert bypass window, increased use of telehealth technologies, twenty-four-hour access to computer tomography and angiography, standardized assessment, and diagnostic and treatment tools that integrate best practice guidelines into workflow. All stroke centres are accountable to report key metrics.

Results:
A significant improvement in access to acute stroke care was achieved. Eight primary stroke centres (PSC) and 1 comprehensive stroke centre (CSC) were established, and a 12 hour EMS bypass window was implemented. EMS adopted the FAST tool to correctly identify stroke patients 78% of the time. Sixty-eight percent of patients arrived at the stroke centre within 4.5 hours of symptom onset, in 2016. The median provincial door to needle time decreased from 82 minutes to 66 minutes. Pathway implementation saw an increase in mechanical thrombectomy from 42, in 2016 to 70 per year in 2017.

Conclusion:
Standard processes were adopted by all stroke centers. Lower volume centres continue to experience challenges in meeting CSBPRs resulting in ongoing improvement work. The primary limitation has been resistance to CTA and limited use of existing telestroke resources. Transfer of patients requiring endovascular therapy has improved provincial mechanical thrombectomy numbers to 58 patients per 1 million population. Further process improvements are focusing on increasing access to this service from more remote centers. Our results show that the implementation of a comprehensive provincial acute stroke pathway leads to significant improvements in access to optimal care.
Abstract WP509: Stroke Survivors’ Perceptions of Well-Being and Recovery After a Tai Chi Exercise Intervention
Authors: Taylor-Piliae Ruth E , Zeimantz Melinda A , Rosenfeld Anne G
Published: January 2019

Background:
Tai Chi exercise is known to improve health and well-being among older adults. Most Tai Chi studies conducted among stroke survivors have focused on physical functioning, whereas inclusion of stroke survivors’ feelings and perceptions of Tai Chi is lacking. Understanding the benefits and difficulties of participating in Tai Chi exercise from stroke survivors’ perspectives is important for healthcare providers to investigate.

Objective:
Using storytelling, we sought to identify stroke survivors’ feelings and perceptions of participating in a Tai Chi intervention during their post-stroke recovery.

Methods:
This descriptive qualitative study examined stories from community-dwelling stroke survivors, collected as part of a larger randomized clinical trial. Participants (n=17) were on average 71 years old (range=54-87 years) mainly men (65%); and had the option of writing their own story or having someone write it for them. To examine these stories, an inductive content analysis approach was used with
a priori
theoretical codes (and sub-codes): 1.) Feelings (confidence, enjoy, hopeful, helpful, other), and 2.) Perceptions of Impact (physical abilities, mental/cognitive abilities, challenges, other). Lincoln and Guba’s criteria were followed to ensure trustworthiness of the data.

Results:
When examining these stories, the majority of stroke survivors felt that participating in a Tai Chi intervention was helpful and enjoyable, and some felt improved confidence. Further, they perceived the impact of Tai Chi on their post-stroke recovery led to improved physical abilities, such as better balance and walking, along with fewer falls. Likewise, stroke survivors perceived that their mental and cognitive abilities improved due to learning a sequence of Tai Chi movements. There were no perceived challenges. Overall, they perceived the impact of Tai Chi helped them to be more independent, move forward, develop friendships and make connections in their communities again.

Conclusions:
Using storytelling, healthcare providers can discuss the benefits of Tai Chi and then relate the feelings and perceptions of other stroke survivors’ experiences to encourage engagement in regular physical activity to aid in the post-stroke recovery process.
Abstract WP51: Mechanical Thrombectomy for Anterior Circulation Large Vessel Occlusion With Low DWI-ASPECTS
Authors: Nakajima Hideki , Miura Yoichi , Suzuki Hidenori , Toma Naoki , Yasuda Ryuta , Shiba Masato , Kishimoto Tomoyuki , Ichikawa Tomonori
Published: January 2019

Background:
Even in acute anterior circulation large-vessel occlusion(LVO) patients with low Alberta Stroke Program Early Computed Tomography Score(ASPECTS), the DWI-FLAIR mismatch is considered to be a prognostic finding to obtain good outcomes. We performed mechanical thrombectomy for acute anterior circulation LVO with DWI-ASPECTS≤5 and DWI-FLAIR mismatch, and investigated prognostic factors.

Methods:
We retrospectively analyzed 25 consecutive patients with acute anterior circulation LVO with DWI-ASPECTS≤5 and DWI-FLAIR mismatch treated by mechanical thrombectomy from August 2014 to July 2018.We compared various clinical factors between patients with good outcome defined as modified Rankin Scale(mRS) 0-3 at discharge and poor outcome.

Results:
Nine(36%) of 25 patients had good outcomes: good outcomes were attained in 5 of 13 patients with ICA occlusion and 4 of 12 patients with M1 occlusion.Intravenous thrombolysis(IVT) was performed in 5 patients in good outcome group and 3 patients in poor outcome group.Successful recanalization(TICI2B-3) was obtained in 9(100%) patients of good outcome group and 14(87.5%) of poor outcome group.There was no symptomatic complication associated with mechanical thrombectomy and IVT in both groups.Baseline clinical characteristics including age, initial NIHSS and initial DWI-ASPECTS were similar between 2 groups.Onset-to-picture time was also similar between 2 groups (median [IQR], 109 min [63-127] vs. 110 [81-168]; p=0.58).Picture-to-puncture time and puncture-to-recanalization time were significantly shorter in patients with good outcomes compared with poor outcomes (77 min [60-82] vs. 94 [86-113], p=0.008; and 34 min [20-37] vs. 45 [32-60], p=0.047, respectively).

Conclusions:
To achieve a good outcome in mechanical thrombectomy for acute anterior circulation LVO with low DWI-ASPECTS and DWI-FLAIR mismatch, quick and complete recanalization may be mandatory.
Abstract WP510: Standardizing Stroke Education on the Neuroscience Units for Nursing Orientation
Authors: Cisco Jessica , Ellison Jessica
Published: January 2019

Background:
Education regarding the unit’s patient population is an important part of nursing orientation. However, the content and delivery can vary between teachers. In 2016, members of the UAB Comprehensive Neurovascular and Stroke Center recognized that there was a lack of standardization for stroke specific education on the neuroscience units during orientation. A survey was created to assess the neuroscience nurses’ perception of content of stroke education and their confidence in caring for the complex stroke patient population. Following the results of the survey, a structured stroke specific orientation course was developed.

Purpose:
The purpose of this quality improvement project was to assess if a structured approach to providing stroke specific education to new nurses during orientation was effective.

Methods:
The stroke orientation course was designed to provide a full day of onboarding education through live lectures, demonstrations, and case studies. Content covered in the course included neuroanatomy, treatment and management of acute ischemic stroke, treatment and management of hemorrhagic stroke, the National Institutes of Health Stroke Scale (NIHSS), and alteplase mixing and dosing. The course was provided quarterly beginning in October 2016 and was mandatory for all new nurses working on the neuroscience nursing units. At the completion of the course, attendees completed an anonymous evaluation of the course including their perception of their stroke knowledge prior to the course compared with their knowledge after the course.

Results:
Over the past 2 years, 203 nurses have attended the stroke orientation course and completed the post-course evaluation. The results of the course evaluations were compiled and analyzed to see if the course made a difference in the nurse’s perception of their stroke knowledge. Prior to the course, 41% of the attendees felt they did not have sufficient stroke knowledge. After completion of the course, 95% of attendees ranked their knowledge as having improved “for the most part” or “very much so.”

Conclusions:
Implementing a standardized approach to orienting new neuroscience nurses is an effective way to increase the nurse’s knowledge regarding the care and management of the complex stroke patient.
Abstract WP512: Leisure-time Physical Activity Reduces the Risk for Stroke in Adults: A Meta-Analysis of Prospective Cohort Studies
Authors: Kelley George A , Kelley Kristi S
Published: January 2019

Introduction:
The magnitude of the association between physical activity and stroke in adults has not been firmly established.

Hypothesis:
Physical activity is associated with a reduction in the risk of stroke among adults.

Methods:
Data from a previous meta-analysis of nine prospective cohort studies representing 269,594 men and women 25-84 years of age that examined the association between leisure-time physical activity (LTPA) and incident stroke was examined using recently developed and more robust methods than those previously employed. Follow-up periods ranged from 7.7-32.0 years. Relative risks (RR) from each study were pooled using the more robust inverse-heterogeneity model. Heterogeneity was examined using the Q statistic, inconsistency using

I
2

, and small-study effects using funnel and Doi plots. Influence and cumulative meta-analysis were also conducted. A two-tailed alpha level <0.05 was considered statistically significant.

Results:
Using low LTPA as the reference, moderate LTPA was associated with a statistically significant reduction in the risk for stroke in men (RR = 0.79, 95% CI = 0.65 to 0.95, p = 0.01) and a trend for the same in women (RR = 0.88, 95% CI = 0.78 to 1.0, p = 0.05). High LTPA was associated with a statistically significant reduction in the risk for stroke in both men (RR = 0.72, 95% CI = 0.60 to 0.86, p <0.001) and women (RR = 0.78, 95% CI = 0.66 to 0.92, p = 0.004). No statistically significant heterogeneity was observed and inconsistency was low. However, potential small-study effects were observed. With each study deleted once, results remained statistically significant. Cumulative meta-analysis demonstrated stability in results since at least 2005.

Conclusions:
Leisure-time physical activity is associated with a reduced risk of stroke in both men and women. However, the small-study effects observed suggest the possibility that results may be exaggerated.
Abstract WP514: Association Between Statin Utilization and Short- and Long-term Mortality Among Patients With TIA and Ischemic Stroke
Authors: Sico Jason , Hu Xin , Ofner Susan , Baye Fitsum , Dearborn Jennifer , Concato John , Myers Laura , Bravata Dawn
Published: January 2019

Introduction:
Current hyperlipidemia guidelines recommend prescribing a moderate/high potency statin after a cerebrovascular event. We sought to compare 30-day and 1-year mortality rates among patients who were discharged on moderate/high potency statin versus those discharged on low dose or no statin.

Methods:
Administrative data from 10,871 Veterans presenting to one of 134 Veterans Health Administration facilities with a stroke/TIA in fiscal year 2011 were analyzed. Statin medication was assessed two times: at the time of admission and within 7 days of discharge. Each time point was categorized as low, moderate, or high potency, thus creating six mutually categories. Patients were considered at goal if they were prescribed moderate/high-potency statin at baseline and within 7-days of discharge. Deintensification occurred when patients were at goal at baseline but not at the second-time point. We used multivariate logistic regressions to compare the 30-day and 1-year mortality among statin treatment groups, controlling for patients’ demographic characteristics and medical comorbidities.

Results:
Among 9,380 eligible patients (86.3%), 79.5 % (n=7,456) were prescribed statins by the 7-days post-discharge, with a majority (59.2%) of patients receiving moderate/high potency statins. The multivariate regression analysis did not identify a significant difference in 30-day or 1-year post-event mortality among patients receiving moderate/high potency statins at both time points or at the second-time point (purple and orange shading in the table). Statin deintensification or never receiving a statin was associated with 1.26 to 1.93 higher odds of mortality as compared to participants who were on medium or high potency statins.

Conclusions:
Prescribing moderate/high potency statins soon after a cerebrovascular event is associated with reduced short- and long-term mortality, whereas statin deintensification is associated with worse outcomes. This data supports current secondary stroke prevention guidelines. Providers should be aware that deintensifying statin therapy is associated with worse post-stroke/TIA outcomes.
Abstract WP516: Association of Pre-Stroke Statin Use With Initial Severity and In-Hospital Outcomes After First-Ever Acute Ischemic Stroke Among Patients With Atrial Fibrillation
Authors: Zong Lixia , Li Zixiao , Gu Hongqiu , Wang Chunjuan , Wang Yongjun
Published: January 2019

Background and Objective:
Pretreatment with statins has been shown in several studies to be associated with reduced infarct volume and improved functional outcomes after ischemic stroke, but limited data were available specific to atrial fibrillation (AF) related ischemic stroke. The present study investigated the impact of statin use before onset on both initial severity and in-hospital outcomes in ischemic stroke patients with AF.

Method:
All cases of first-ever ischemic stroke patients with AF were prospectively identified from China Stroke Center Alliances from June 2015 to November 2017. Moderate and severe stroke was defined as National Institutes of Health Stroke Scale score ≥16. In-hospital adverse outcomes included intracerebral hemorrhage, deep vein thrombosis or pulmonary embolism, and pneumonia. We used logistic regression model to estimate propensity score and then we performed inverse probability weighting to assess the association of pre-stroke statin use with moderate and severe stroke and in-hospital adverse outcomes.

Results:
Among the 18,076 patients included, 1589 (3.9 %) had previously been treated with statins. The risk of moderate and severe stroke was significantly lower in pre-stroke statin users than nonusers (15.3% vs. 18.7%; adjusted odd ratio: 0.85; 95% confidence interval: 0.81-0.90; p<0.0001). Pre-stroke statin use was independently associated with reduced risk of in-hospital adverse outcomes (28.6% vs. 29.7%; adjusted odd ratio: 0.82; 95% confidence interval: 0.78-0.86; p<0.0001).

Conclusion:
Use of statins before first-ever ischemic stroke in patients with AF was associated with reduced stroke severity at admission and decreased risk of adverse outcomes during hospitalization.
Abstract WP518: Use of American Heart Association/American Stroke Association Secondary Stroke Prevention Recommendations in Hispanic/Latino Adults With Stroke/TIA: The Hispanic Community Health Study/Study of Latinos
Authors: Bai Fang , Sharma Vinny , Chen Jinsong , Pandey Dilip , Durazo-Arvizu Ramon , Talavera Gregory A , Allison Matthew A , Perreira Krista M , Schneiderman Neil , Sutherland Melanie W , Cai Jianwen , Daviglus Martha L , Testai Fernando D
Published: January 2019

Background:
Population studies showed that Hispanic/Latino adults have elevated rates of uncontrolled cardiovascular risk factors (CVRFs) with noticeable sex-specific variations
.
We investigated prevalence of CVRFs and the use of American Heart Association (AHA) secondary stroke prevention strategies in Hispanics/Latinos in the United States.

Methods:
Data from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) were used to examine sociodemographic characteristics, use of antithrombotic agents and statins, and treatment of CVRFs in persons with a history of stroke or transient ischemic attack (TIA). CVRFs were categorized as “controlled” if the CVRF met the goals defined by the AHA irrespective of whether the subject was on treatment for it or not; and “unaware” if the participant denied having a CVRF but met the diagnostic criteria for it. Differences between men and women were tested using ANOVA test and Pearson’s χ
2
. Factors associated with adherence to AHA recommendations were investigated using logistic regression.

Results:
These analyses included 404 individuals with history of stroke/TIA (men=159; women=245). Women were slightly older than men (55.1±1.5 vs. 54.1±1.6 years; p<0.0001). The prevalence of hypertension (HTN), hypercholesterolemia (HC), and diabetes (DM) were 59%, 65% and 39%. The rates of awareness/controlled CVRFs were 90%/49%, 75%/32%, and 83%/54% for HTN, HC, and DM, respectively. Approximately 49% of the individuals were on antithrombotic agents, 39% on statins, and 26% on dual treatment with antithrombotics and statins. Rates were comparable between men and women except for HC control which was lower in women (41±6% vs. 23±5%; p=0.02). In logistic regression analysis, older age was associated with poorer adherence to AHA recommendations. Female sex and residence >10 years in the US were associated with uncontrolled HC and DM, respectively.

Conclusion:
Hispanics/Latinos with stroke have elevated rates of awareness but suboptimal use of AHA secondary stroke prevention strategies. Older persons and women are vulnerable groups that may benefit from targeted interventions.