bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP291: Outcomes and Predictors of Percutaneous Endoscopic Gastrostomy tube placement in Acute Ischemic Stroke versus Intracerebral Hemorrhage
Authors: Dubin Perry H , Boehme Amelia K , Siegler James E , Albright Karen C , Martin-Schild Sheryl
Published: March 2022

Background:
The circumstances for morbidity differ between acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH). The need for Percutaneous Endoscopic Gastrostomy (PEG) tube placement may be associated with further morbidity. This study aims to identify differences in outcomes between AIS and ICH patients who undergo PEG placement.

Methods:
We conducted a retrospective analysis of patients admitted consecutively within 24 hours of acute stroke to Tulane University Hospital from 07/2008-12/2010. Demographic and clinical data were recorded throughout admission and compared across patients with AIS and ICH using Chi square and t-test with nonparametric tests when appropriate. A prediction score was developed separately for AIS and ICH patients by using 55% of the dataset and tested on the remaining 45%. Associations were further evaluated as potential score variables using logistic regression. ROC curves were used to evaluate the final score.

Results:
Seventy-six patients who had a PEG placed were identified and included in the analyses (42 AIS and 34 ICH). Of patients with PEG, a greater proportion of ICH patients had dysarthria (p=0.0137) or impaired consciousness (p=0.0018) on admission than AIS patients. Patients with ICH and PEG had more tracheostomy placement (p=0.0216), increased length of stay (8 vs. 6 days; p=0.0005), increased discharge NIHSS Score (21 vs. 3; p<0.0001), and increased discharge modified Rankin Scale (4 vs 3; p<0.0001) compared to patients with AIS and PEG. The odds of an AIS patient with PEG score ≥3 of getting a PEG are greater than those with PEG score <3 (OR 25.806, 95% CI 11.370-58.572). The odds of an ICH patient with PEG score ≥3 of getting a PEG are greater than those with PEG score <3 (OR 4.627, 95% CI 1.839-11.642).

Conclusions:
The PEG score may be a powerful predictor of PEG placement in patients with acute stroke. Impaired consciousness and dysarthria are significant driving forces in PEG placement in ICH vs. AIS patients.
Abstract WP294: CT Angiography Spot Sign Predicts Perioperative Bleeding in Primary Intracerebral Hemorrhage
Authors: Brouwers H. B , Raffeld Miriam R , Falcone Guido J , Ayres Alison M , Schwab Kristin , Romero Javier M , Viswanathan Anand , Greenberg Steven M , Ogilvy Christopher S , Goldstein Joshua N , Rosand Jonathan
Published: March 2022

Purpose:
While hematoma evacuation for intracerebral hemorrhage (ICH) showed no clinical benefit in one large randomized trial, meta-analyses have suggested an effect for certain subgroups. Knowledge of which patients will be found to show active bleeding may help guide surgical treatment. The spot sign, i.e. contrast extravasation following CT angiography (CTA), is thought to represent active bleeding. We therefore investigated whether spot sign presence predicts active bleeding during surgery for ICH.

Methods:
Consecutive primary ICH patients who underwent a CTA followed by surgical hematoma evacuation were included over a 10-year period. CTAs were reviewed for spot sign presence by an experienced reader, blinded to clinical and surgical data. Active bleeding and re-bleeding following surgery were assessed using 5-point rating scales. The association between the spot sign and active perioperative bleeding, postoperative re-bleeding, and postoperative change in hematoma volume was evaluated using univariate and multivariate logistic regression.

Results:
During the study period, 1082 ICH patients presented to our institution, of whom 75 met inclusion criteria. 34 (45%) were lobar, 13 (17%) deep, 26 (35%) cerebellar, 1 (1%) brainstem, and 1 (1%) primary intraventricular hemorrhage. At least one spot sign was identified in 29 patients (39%). In multivariate analysis, spot sign was the sole predictor of active bleeding during surgery (OR 2.86 [95%CI 1.05-8.17],
p
= 0.044). Presence of spot sign (OR 4.46 [95%CI 1.24-18.17],
p
= 0.027) and female sex (OR 6.71 [95%CI 1.79-33.28],
p
= 0.009) were predictive of re-bleeding and larger postoperative ICH volumes. A trend toward significance was found for the association of re-bleeding with both discharge mortality (
p
= 0.055) and 90-day mortality (
p
= 0.073).

Conclusion:
This is the first study to show that CTA spot sign marks ongoing bleeding in patients undergoing hematoma evacuation following acute ICH. Patients with this finding suffer more perioperative bleeding, more postoperative re-bleeding, and larger residual ICH volumes. Our results may contribute to the selection of which ICH patients may benefit from surgery.
Abstract WP296: Direct Cost Savings Associated with Intensive Systolic Blood Pressure Reduction in Patients with Intracerebral Hemorrhage
Authors: Qureshi Adnan I
Published: March 2022

INTRODUCTION:
The Antihypertensive treatment of Acute Cerebral Hemorrhage (ATACH) II is determining whether intensive systolic blood pressure (SBP) reduction (SBP ≤140mm Hg) using IV nicardipine initiated within 4.5 hours of onset of intracerebral hemorrhage (ICH) reduces the likelihood of death or disability (modified Rankin scale [mRS] score of 4-6) at 3 months by ≥10% compared with standard SBP reduction (SBP ≤180mm Hg).

Objective:
To determine the direct cost savings by intensive systolic blood pressure reduction if the 10% reduction in death and disability goals are met in patients with ICH.

Methods:
The dose and duration of IV nicardipine to achieve different SBP goals were derived from ATACH I and the probability of death or disability were obtained from placebo treated ICH patients recruited in recombinant factor VII trials. Total cost associated with acute hospitalization was derived from Nationwide Inpatient Sample files 2010 for none-mild disability (home discharge considered equivalent to mRS 0-1), moderate disability (in-patient rehabilitation=mRS 2-3), severe disability (nursing home=mRS=4-5), and death. The cost of nursing home stay, in-patient and out-patient rehabilitation services, and physician visits were derived from MetLife Market Survey of Nursing Home and Home Care and Medicare re-imbursement policy.

Results:
The estimated incremental costs for IV nicardipine for intensive SBP reduction was $85,600 for 100 patients treated. The direct cost of death and disability (cost of acute hospitalization, post-hospital care, and physician visits visit for 90 days) was estimated to be $4,377,142 in 100 patients treated with standard SBP reduction. The cost saving was estimated to be $147,570 if 10% of patients with mRS 4-5 changed to mRS 2-3. The cost saving was estimated to be $357,685 if 10% of patients with mRS 4-5 changed to mRS 2-3 (5%) and mRS 0-1 (5%). The net savings in the first and second scenario were $61,970 and $272,085 per 100 patients treated in the first 90 days, respectively.

Conclusions:
Intensive SBP reduction in patients with ICH appears to result in prominent cost savings if the ATACH II goals of reduction in death and disability are met.
Abstract WP297: A Mouse Model of Cerebral Microbleeds
Authors: Liu Shuo , Vasilevko Vitaly , Cribbs David H , Fisher Mark
Published: March 2022

Cerebral microbleeds are microscopic hemorrhages with deposits of blood products in the brain that can be visualized with MRI. Microbleeds are increased with age and in diseases such as cerebral amyloid angiopathy, hypertension, and stroke. There are few studies of either a) pathological correlates of cerebral microbleeds or b) imaging microscopic hemorrhage in brain tissue. The existing animal models of cerebral microbleeds involve transgenic mice (e.g. Tg2576) that spontaneously over-express β-amyloid, mimicking cerebral amyloid angiopathy. However, these models have limited use due to the fact that a) microbleeds may develop independent of amyloid deposition and b) the transgenic animals may require two years to fully develop microbleeds. In the current study, we used lipopolysaccharide (LPS) to induce cerebral microscopic hemorrhages over the course of several days. In this model, adult C57B6 mice (3 months of age) were injected with LPS (5mg/kg ip) or vehicle (phosphate buffered saline) at baseline and at 24 hr, and animals were sacrificed two days after initial injection. Mouse brains were analyzed for fresh hemorrhage using hematoxylin and eosin (H&E) staining, iron deposition using Prussian blue staining, and blood-brain barrier (BBB) permeability by measuring sodium flouorescein (NaF) content. H&E staining revealed small fresh hemorrhages visible grossly and microscopically in all animals treated with LPS, but not in control animals. Prussian blue staining revealed markedly increased iron deposition with LPS treatment, with positive stains in cerebral cortex, midbrain, and hippocampus regions. Quantification of Prussian blue staining revealed that LPS induced more than four-fold increase in number of positive stained foci (p<.05 vs control). BBB permeability to NaF was increased from 2.9 ± 0.3 in control to 8.2 ± 1.8 ug NaF/g brain tissue in LPS-treated animals (p<.05 vs control). In conclusion, this mouse model shows rapid production of cerebral microscopic hemorrhage, is associated with BBB dysfunction, and may be useful to study mechanistic and intervention strategies of cerebral microbleeds.
Abstract WP310: Outcomes after Intracranial Hemorrhage in Patients with Atherosclerotic Vascular Disease: Observations from the TRA 2°P-TIMI 50 Trial
Authors: Bonaca Marc P , Alberts Mark J , Mohr Jay P , Ameriso Sebastian F , Hankey Graeme J , Murphy Sabina A , Scirica Benjamin M , Braunwald Euegene , Morrow David A
Published: March 2022

Intracranial hemorrhage (ICH) is a serious complication of antithrombotic therapy and is associated with high mortality (>50% at 30 days). The frequency of ICH subtypes and their outcomes in the era of contemporary oral antiplatelet therapy have not been well described.

Methods:
TRA 2°P-TIMI 50 was a randomized trial of 26449 pts with history of atherothrombosis randomized to vorapaxar or placebo plus standard antiplatelet therapy. Patients qualified with myocardial infarction (MI), peripheral artery disease (PAD) (N=21,492 combined), or recent ischemic stroke (CVD, 2 wks to 12 mo. N=4860). ICH was adjudicated by an independent CEC and analyzed in the safety cohort (N=26,352)

Results:
A total of 155 ICH events occurred. Traumatic/Provoked ICH was most frequent (Figure A). ICH occurred more frequently in patients qualified with CVD compared to those qualified with MI/PAD (1.4% vs 0.4%, p<0.001). In CVD patients spontaneous intracerebral/subarachnoid (44%) occurred most frequently followed by traumatic/provoked (30%), ischemic stroke with conversion (24%), and non-traumatic subdural/epidural hematoma (1.6%) (Figure A). In MI/PAD patients, traumatic/provoked ICH occurred most frequently (Figure A). Overall ICH was associated with a 32.9% mortality. Mortality varied by subtype with the highest after spontaneous intracerebral/subarachnoid (Figure B). ICH was more frequent with vorapaxar compared to placebo (HR 1.94, p<0.001). There was no difference in mortality (p=NS) after any ICH or in Rankin Score >= 4 (p=NS) after stroke associated ICH in patients receiving vorapaxar compared with placebo.

Conclusions:
The frequency and subtypes of ICH vary based on patient history. Case-fatality rates vary based on subtype. These findings suggest that events traditionally categorized broadly as ICH are heterogeneous in specific types and outcomes. These subtypes should be considered discretely both clinically and in research.
Abstract WP313: Prism Adaptation Simulation Program for the Treatment of Hemispatial Neglect
Authors: Lee Ju Kang , Lee Kwang Lae , Lee Yeong-Bae
Published: March 2022

Objectives:
To develop a prism adaptation simulation program and to evaluate the effectiveness of the program for hemispatial neglect

Methods:
Thirty subjects with hemispatial neglect due to right hemisphere lesion were involved. The prism adaptation simulation program consists of three sessions of personal computer mouse pointing tasks. In the first session, the subjects perform target pointing task with the PC mouse. The mouse curser starts from starting point located lower end of the vertical midline of the screen. Then the subjects move the mouse curser to the target point located upper end of the vertical midline. During the task, the path of the curser is blinded, so the subjects develop proprioceptive motor learning of the targeting after twenty repetitions of the task. In the second session, the mouse curser is programed to move 20 degree rightward deviation from the midline which simulate the prism adaptation condition. After completion of the adaptation to the deviation condition, the third session started. The third session was same to the first session. Due to the adaptation to the deviation condition, the subjects’ targeting are deviated to the left side of the target which is similar to the post-adaptation condition of prism treatment. Each subject was randomly assigned into 2 groups.

Each subject was randomly assigned into 2 groups. The one group performed a prism adaptation simulation program treatment first and then a prism adaptation treatment after one week. The other group performed the interventions, reversely. Neglect tests(star cancellation test, line cancellation test, line bisection test) were used before and after each program to evaluate the effectiveness of the treatment programs.

Results:
All neglect test scores became significantly higher after the prism adaptation simulation program as well as the prism adaptation (
p
< 0.0001). The improved scores were significant higher after the prism adaptation than after prism simulation program (
p
< 0.05).

Conclusions:
Hemispatial neglect was significantly improved by the prism adaptation simulation program as well as the prism adaptation, although the prism adaptation was more effective than the prism simulation program.
Abstract WP33: Reduced Cerebral Blood Flow on Acute Whole Brain CT Perfusion Best Predicts Hemorrhagic Transformation
Authors: Yassi Nawaf , Campbell Bruce C , Christensen Soren , Sharma Gagan , Bivard Andrew , Lin Longting , Levi Christopher R , Desmond Patricia M , Donnan Geoffrey A , Davis Stephen M , Parsons Mark W
Published: March 2022

Objective:
Hemorrhagic transformation in ischemic stroke is a potentially life threatening complication of thrombolysis. Using perfusion MRI, very low cerebral blood volume (VLCBV) strongly predicts hemorrhagic transformation after reperfusion. CT perfusion (CTP) is currently more widely accessible than MRI and recent data have shown that CT relative cerebral blood flow (relCBF) provides a better estimate of infarct core than CBV. We aimed to determine the optimal parameter to predict hemorrhagic transformation using whole brain CTP.

Methods:
Patients with ischemic stroke were imaged with whole brain CTP within 6hrs of symptom onset. Hemorrhagic transformation was assessed on CT/MRI within 7 days of stroke using ECASS grade. CBF and CBV were analyzed within a relative time to peak >4sec region of interest. Results were expressed as volumes below a given percentile relative to the contralateral hemisphere (relCBF and relCBV). Receiver operating characteristic (ROC) and logistic regression analysis were performed to determine the optimal parameter and percentile threshold correlating with parenchymal hemorrhage (PH).

Results:
128 patients with acute CTP were analyzed, median age 76yr (IQR 66-83), median NIHSS 13 (IQR 9-16), 59% received IV thrombolysis. 11 patients had PH on follow-up. On ROC analysis, the optimal threshold for very low CBF (VLCBF) was at the <0
th
centile. VLCBF was significantly associated with PH in ROC analysis (AUC=0.760, p<0.01) whereas VLCBV (AUC 0.638 at <5
th
centile, 0.618 at <2.5
th
centile, 0.440 at <0
th
centile) was not significant. Using VLCBF, the optimal lesion volume to predict PH was >3mL with OR 12.0 (95%CI 2.4-58), sensitivity 0.82 (95%CI 0.48-0.98), specificity 0.73 (95%CI 0.64-0.80), negative predictive value 0.98 (95%CI 0.92-1.0) and positive predictive value 0.22 (95%CI 0.11-0.38). In logistic regression, PH was associated with increased VLCBF (p<0.01) but not with VLCBV (p=0.08). The Bayesian information criterion for VLCBF compared to VLCBV was +5 indicating improved model fit.

Conclusions:
VLCBF appears to be more reliably associated with hemorrhagic transformation than VLCBV when CT perfusion is used. This may be due to reduced ability of VLCBV to distinguish regions of ischemia from normal white matter.
Abstract WP334: The Positive Impact of Role Definition and Communication on Door to Needle Times in Acute Stroke Patients Receiving Intravenous Alteplase
Authors: Ashcraft Susan , Clark Katherine , Mintmier Rita , Britt Debra , Rhew Denise
Published: March 2022

Background and Issues:
Intravenous IV t-PA (IV t-PA) is indicated for the management of acute stroke in adults for improving neurological recovery and reducing the incidence of disability. The decision making process prior to administration of IV t-PA is complex and requires analysis of critical patient data to ensure safe administration. Communication of patient data is shared among many different departments and individual team members. The goal of administering IV t-PA within 60 minutes of patient arrival is heavily dependent upon the shared knowledge of this goal and the required patient data necessary for the treatment decision. From January 2011 through March 2012, 60 percent (76 of 127 patients) of our IV t-PA patients received treatment within 60 minutes. Our median door to treatment time remained at 58 minutes for the same 15 months.

Purpose:
The purpose of our team was to identify role responsibilities and points of essential communication of information to meet a goal of 75 percent of eligible patients to safely receive IV t-PA within 60 minutes of presentation to the hospital.

Methods:
Analysis of patients receiving IV t-PA during 2011 revealed 64.8 percent of TPA was administration during late afternoon and evening hours when stroke team resources were most lean. The importance of communication between the emergency department staff and responding stroke team was identified. After flow-charting the process, responsibilities for key processes and intentional points of communication required between team members were defined without regard to time of day stroke patients present to the hospital. Each department received education of their responsibilities.

Results:
In the first quarter after staff education and acknowledgement of their roles and required points of communication, 68.4 percent (13 of 19) of our IV t-PA patients received treatment within the goal of 60 minutes. The median time from patient presentation to IV t-PA administration dropped to 49 minutes suggesting decrease in variability of the process.

Conclusion:
Defining role responsibilities to ensure effective communication among stroke team members improves time to treatment decisions in eligible stroke patients.
Abstract WP337: Role of the Outreach Manager in a Multi-Hospital Acute Stroke Network
Authors: Connelly Kerrin M , Seagraves Karen B
Published: March 2022

Purpose:
To describe the role of the Outreach Manager in helping to develop and grow a multi-hospital acute stroke network

Background:
With the availability of formal Comprehensive Stroke Certification, stroke networks are becoming more defined, with higher levels of care being provided at regional comprehensive stroke centers (CSC). It is crucial for CSCs to build and maintain relationships with Primary Stroke Centers (PSC) and Emergency Medical Service (EMS) providers. The Outreach Manager serves a key role in relationship building, provides vital education and feedback to referring sites, and identifies new opportunities for collaboration.

Methods:
The Outreach Manager serves a variety of key functions aimed at maintaining internal and external relationships:

Initiates and maintains consultative and collaborative relationships with key personnel at referring hospitals

Monitors all inter-facility patient transfers and referrals to ensure effective and efficient processes

Maintains transfer agreements as appropriate

Tracks all direct stroke admissions including those of emergency medical transport teams

Provides education, feedback and consultation with referring providers

Evaluates and manages various telemedicine platforms

Reviews and refines processes related to hospital network

Identifies new opportunities for collaboration

Networks with professional organizations and community stroke leaders

Results/Conclusion:
The position of Outreach Manager has the potential to greatly impact an evolving multi-hospital acute stroke network. Successful implementation of the role increases knowledge of available stroke resources. Ongoing outreach helps to strengthen the affiliation between the CSC and referring providers. Relationship building and oversight is essential for growth and development of the CSC and the overall network.
Abstract WP343: Role of the Clinical Pharmacist in Reducing Decision-to-Needle tPa Times During Code Stroke in the Emergency Department
Authors: Brandon Kevin , Kramer Amanda , Mulawka Catherine
Published: March 2022

Background:
Clinical observation revealed inconsistent ED decision-to-needle tPa times due to differing processes including pharmacist mixing in the central pharmacy, ED RN mixing at the bedside, and holding the tPa vial for stroke neurologist to mix upon arrival at the bedside

Purpose:
Implement a consistent process for tPa calculation and mixing Reduce decision-to-needle times, increasing the opportunity for successful patient outcome

Method:
Conduct retrospective chart review to establish baseline tPa decision-to-needle times in the ED Review current process of calculating, mixing, and administering tPa Identify areas for process streamlining and reducing potential for error by calculating and mixing tPa at the bedside Established goal of zero minute decision-to-needle time Clinical Pharmacist added to Code Stroke pager team in May 2010 Initial Clinical Pharmacist role consisted of dose calculation and verification with ED nurse at bedside Expanded Clinical Pharmacist role to include mixing tPa at beside in conjunction with nurse, while maintaining compliance with
USP 797 Guidelines
* Implement process of bedside conference between Clinical Pharmacist and ED RN to identify eligible candidates, allowing the Clinical Pharmacist to prepare tPa in preparation of anticipated administration Clinical Pharmacist’s role progressed to include immediate bedside medication education to patient and/or family, including verbal and written education materials

Results:

Addition of Clinical Pharmacist to Code Stroke team, with responsibility of calculating and mixing tPa at the bedside, has resulted in improved zero minute decision-to-needle times.

2010: zero minute decision-to-needle time not achieved

2011: zero minute decision-to-needle achieved in 60% of administrations

2012: (through July): zero minute decision-to-needle achieved in 78% of administrations

Conclusion:
Addition of a Clinical Pharmacist to the Code Stroke team resulted in a reduction of decision-to-needle tPa times in the Emergency Department

Implications for Practice:
Utilization of Clinical Pharmacist during Code Stroke to calculate and mix tPa reduces decision-to-needle time *
http://www.emlab.com/s/services/USP_797.html
Abstract WP344: Effective Nursing Strategy to Accurately Document Patient/Family Education
Authors: Warrington Heidi R
Published: March 2022

Background:
Evidence based guidelines recommend education be provided to stroke patients and their family/caregivers on stroke pathology, stroke prevention, stroke signs and symptoms, actions to take, and the importance of follow-up appointments. It was identified that there was inconsistent documentation of this education. A process to accurately document the provided education was needed.

Purpose:
To design a process that ensures that 100% patients admitted for stroke or TIA are provided with consistent and concise education, to provide consistent documentation of education completion for the patient’s record, to document level of understanding, and to determine satisfaction with care.

Method:
Utilizing GetWell Network an interactive education system, the patient views and completes a 5-question views education post test and a program satisfaction questionnaire. Education documentation includes all 5 points: Activation of EMS -Call 911, Post Discharge Follow-up, Medications Prescribed/Education, Personal Risk Factors, and Warning Signs of Stroke. This methodology provides immediate feedback to staff, allowing them to provide patient/family/caregivers more education if needed.

Results:
Prior to implementation, patient/ family/caregiver completion rates for all 5 points of stroke education was 85%, post implementation completion rates increased to 99%, a 14% increase.

Conclusion:
This method of education and data collection provides effective consistent education, assessment of understanding of content, provides increased documentation compliance and prompt feedback regarding program satisfaction. A future plan to measure quality improvements by utilizing a similar process in the area of stroke perception of care and stroke program satisfaction is warranted.
Abstract WP348: Nurse-Led Stroke Teams Can Effectively and Efficiently Manage In-Hospital Stroke Events
Authors: Handler Diane , Kane Catherine , Wehr Michelle , Steffens Christa , Alexandrov Anne W
Published: March 2022

Background:
Up to 15% of all acute strokes occur while patients are in the hospital, and given their association with other acute conditions, recognition and treatment can be complex. We sought to determine the effectiveness of our nurse-led Stroke Team management of in-hospital stroke within a community hospital setting.

Methods:
In 2011, our nurse-led Stroke Team was designated as the primary responders for all in-hospital Stroke Alerts. Along with an “In Hospital Stroke Alert Protocol” designed to eliminate barriers and penalties associated with any staff member’s notification of a Stroke Alert, the nurse-led Stroke Team assumed responsibility for hospital-wide education on stroke identification and response, including provision of feedback sessions following the occurrence of a stroke on any inpatient unit.

Results:
In the 24 months prior to the launch of the new system, two in-hospital stroke patients were treated with intravenous tPA. In 2010, there was 1 intravenous tPA given at 120 minutes, and in 2011 there was 1 intravenous tPA given at 84 minutes. For the first 6 months of 2012 there have been 3 patients treated with intravenous tPA as in-hospital stroke alerts, given at 58, 62 and 38 minutes from time of call respectively. There were no sICH or systemic hemorrhages for any patients. Staff have voiced considerable satisfaction with the process, and no barriers to use of the team have been identified.

Conclusion:
Nurse-led Stroke Team responders are capable of managing the appropriate and safe use of intravenous tPA treatment for in-hospital stroke patients, while engaging diverse groups of providers in the rapid identification of acute stroke events. Community hospitals should consider development of nurse-led Stroke Teams to complement existing rapid response team efforts.
Abstract WP350: Evolution of a Stroke Center Utilizing Systems Thinking and Collaborative Strategies
Authors: Burnett Nicole M , Huang David Y
Published: March 2022

Background:
As a large health system, positioned in the stroke belt, expansion was essential to meeting the growing demand for stroke care. The mission and vision was to meet the needs of stroke patients and become a recognized leader in stroke care in the South East. Stroke Center leadership established a strategic plan to gain organizational commitment to achieve this goal.

Methods:
In 2003, patients were cared for in a 6-bed stroke unit and a 30-bed acute care unit directed by Neurology. These beds became increasingly insufficient and care delivery fragmented. While still being able to meet patient needs and achieving Primary Stroke Center designation, the center lacked a comprehensive delivery model. Initial goals began with increasing capacity, volumes and streamlining care. Strong multidisciplinary partnership was crucial for change. To streamline care, Neurology and Neurosurgery partnered to create a NeuroCare Team (NCT) and aligned themselves under Surgery Services. The 8-bed Neurosurgery Intensive Care Unit expanded to a 16-bed Neuroscience Intensive Care Unit, the step-down converted to 18 stroke-capable beds, the 6-bed stroke unit dissolved and a 36-bed acute care unit designated stroke capable. All levels of care were now able to provide consistency by stroke trained nursing staff and physicians. With this increased capacity, the team implemented a new patient flow framework called ‘Open Access’. This concept required each member of the team to say ‘yes’ to stroke patient referrals, every patient, every time. The multidisciplinary team created a plan for bed availability to accommodate this vision.

Results:
Between 2009 and 2010, the center expanded capacity from 36 to 72 stroke-capable beds, with volumes increasing for outside hospital transfers by 100% in FY11. The Stroke Center was recognized by the American Heart Association’s Get With The Guidelines Bronze Achievement Award and by US News and World Report as a High Performing Hospital in 2012.

Conclusions:
Clinical collaboration, strategic leadership and organizational commitment can build a high quality, comprehensive and financially strong Stroke Center. Alignment of physician and nursing staff delivering stroke care is key to streamlining, consistency and quality of care.
Abstract WP356: Building a Regional System of Care for Stroke and ST-elevation Myocardial Infarction (STEMI) using the Trauma System
Authors: Worden Eileen , Scott Phillip , Klausner Howard , Lewandowski Christopher , Hussain Syed , Sunne Robert , Barkholz Amy , Shivley Robin , Busman Denise , Detro-Fisher Deborah , Mitchell Marylou , Poole Sarah ,   Michigan DCH, Heart Disease and Stroke Prevention/EMS and Trauma System Section-SOC Workgroup
Published: March 2022

Background and Issues
Michigan Michigan does not have a systematic approach to address acute stroke care, treatment time is impacted, and this influences positive patient outcomes. Michigan is building a system of care for time dependent, cardiovascular emergencies (stroke and STEMI), using the existing regional trauma system as its framework. Michigan Department of Community Health, EMS and Trauma System Section, and other stakeholders are collaboratively writing Administrative Rules to develop a regional system of care for stroke and STEMI throughout the state.

Purpose
A regional approach will remove barriers related to geography, timeliness, communication and enhance efficiency. Patient outcomes will be improved by increasing access to the most appropriate setting for time dependent treatments.

Methods
Use existing Trauma Rules and structure, and expertise from stakeholders and area experts, Administrative Rules are in development which will provide structure and functionality for a regional system of care for stroke and STEMI. Language under development: Designation/Verification, Destination /Transfer/Field Triage, and Data collection.

Results
Over 140 experts from across the state convening in workgroups developed drafts of language for Designation, Destination, Transfer and Field Triage. Verification and Data discussions are ongoing. Completed language will be folded into existing trauma rules.

Conclusions
A Michigan Systems of Care for cardiovascular emergencies is leading a newly developing regional approach to increase emergent stroke treatment, add non-traditional stakeholders (cardiology, neurology), improve communication, collect data, and make the most efficacious use of dwindling resources.
Abstract WP358: The Toronto Stroke Networks Virtual Community of Practice: Collaborative Change Leadership to create enhanced purpose for best practice implementation
Authors: Linkewich Elizabeth , Fortin Joanne
Published: March 2022

Background/Issues
Systems changes within the Toronto Stroke Networks (TSNs) prompted the development of a virtual community of practice to connect administrators, academics, and clinicians, enhance professional and organizational expertise, foster implementation of best practices, and improve patient outcomes in stroke care.

Purpose
To use a collaborative approach to develop and implement an innovative method of supporting knowledge translation of stroke best practices, the TSNs Virtual Community of Practice (TSNs VCoP).

Methods
Four 90 minute focus groups were held using an appreciative inquiry methodology to identify desired outcomes of the TSNs VCoP its features, structure, and components. An iterative process, using beta testers, generated stakeholder stories, and integrating the TSNs VCoP into systems change and knowledge translation initiatives were used to inform the ongoing development of the initiative to enhance utility and knowledge exchange.

Results
Focus Group Results

Four desired outcomes for use of the TSNs VCoP:

Better knowledge exchange via peer-to-peer support

Improved dissemination and adoption of stroke best practices.

More efficient ways to find relevant people or material resources

Collaboration between stakeholders across the TSNs

Three key features of the TSNs VCoP were identified to support these desired outcomes:

A searchable membership directory

A resource repository

Discussion forums

Generative Results

A fourth key feature (4. Groups Section) was identified by beta testers and key stakeholders as a need to support additional program implementation. This was built into the site to allow for public, private, or hidden communications among groups of healthcare providers working with the same interests on a particular topic.

Conclusions
Using a generative and collaborative approach has enhanced the utility and integration of the TSNs VCoP as a knowledge exchange tool. It has ensured a responsive and adaptive approach that supports the changing needs of its stakeholders. The themes from the focus groups reinforce the identified need and benefits of the TSNs VCoP.
Abstract WP362: Stroke Survivors in a 12-Week Yang-Style Tai Chi Intervention Have Fewer Falls
Authors: Taylor-Piliae Ruth E , Hoke Tiffany M , Najafi Bijan , Coull Bruce M
Published: March 2022

Background:
Compared to same age healthy adults, stroke survivors experience 7 times as many falls annually. Such falls often cause hip or other fractures, loss of mobility, and increased fear of falling resulting in social isolation and/or dependence. Effective interventions for preventing falls among stroke survivors are critically needed. Tai Chi exercise has been shown to significantly reduce the number of falls in healthy older adults.

Purpose:
To examine the effect of a 12-week Yang-style Tai Chi (TC) intervention on fall rates among stroke survivors compared to SilverSneakers® (SS) and Usual Care (UC) groups.

Methods:
A randomized prospective clinical trial was conducted among stroke survivors (n=89), aged ≥ 50 years, and at ≥ 3 months post-stroke (TC, n=30; SS, n=31; or UC, n=28). TC and SS groups attended a 1-hour class 3 times/week for 12 weeks. The UC group received a weekly phone call along with written materials for participating in community-based physical activity. All subjects were interviewed weekly to ascertain fall data over the 12 weeks. Falls were defined as: “events in which subjects end up on the floor or ground when they did not expect to.” Data were analyzed using χ2 statistics with Yate’s continuity correction.

Results:
Subjects (46% women) were on average 70±10 years old. The majority reported an ischemic stroke (80%), were White/European-American (79%), married/partnered (60%), college-educated (79%), and retired/unemployed (93%). Over the 12-week trial, a total of 34 falls occurred; all happened at home, yet only 4 subjects sought medical attention for the fall. Most falls happened because subjects slipped or tripped (21%). The TC group had fewer falls (n=5 falls) than SS (n=14 falls) or UC (n=15 falls) groups (χ2=5.60, p=0.06). Post-hoc tests indicated that TC had significantly fewer falls than UC (χ2=4.29, p=0.04); while there was no significant difference between TC and SS (χ2=2.61, p=0.11), or SS and UC (χ2=0.29, p=0.59) groups.

Conclusion:
Our data suggest that a 12-week Yang-style TC intervention decreases fall rates among stroke survivors. Future studies examining the effectiveness of TC as a fall prevention strategy are recommended.
Abstract WP364: Key Stakeholders Recognize the Need for a Structured Approach to Psychological Support with Input from a Clinical Psychologist
Authors: Harrison Madeleine A , Gardiner Clare , Ryan Tony , Jones Amanda
Published: March 2022

Background:
International guidelines recommend the routine assessment and management of mood and cognition post-stroke. However there is no consensus regarding the optimal method of assessment and a recent audit demonstrated limited access to clinical psychologists in England. Recent UK guidelines promote a structured approach to psychological care with the level of input and expertise corresponding to need. The purpose of this study was to explore patients’, carers’ and health professionals’ experiences of the psychological support delivered and received post-stroke.

Methods:
Thirty-two semi-structured interviews were conducted with dyads of patients (n=31) and carers (n=28). Eight focus groups and 9 interviews were conducted with stroke care health professionals (n=66), including a variety of disciplines and grades from 7 UK centres. The interviews were recorded and transcribed verbatim, and analysed using thematic analysis.

Results:
Three themes emerged: lack of availability of psychological support and clinical psychologists; factors mediating the need for psychological support; benefits of a structured approach. Lack of psychological services post-stroke resulted in reliance on medication and other disciplines assuming the role of a psychologist without the required expertise. Some patients perceived psychological support to be synonymous with information provision, which they wanted to provide reassurance. Factors perceived to mediate the need for psychological support included: the attitude and personality of the patient, availability of social support, downward social comparison with other stroke survivors and the patient’s age. Staff highlighted the benefits of a structured approach to psychological care, but some degree of clinical psychology input was essential.

Conclusions:
Despite awareness of the limited access to psychological support for stroke patients in England, results suggest little is being done to address the deficit. If a structured approach is to be used effectively nurses and therapists need further training and some degree of clinical psychology input must be made available.
Abstract WP366: Secondary Stroke Prevention Program: Effect on Stroke Specific Quality of Life
Authors: Damush Teresa , Anderson Jane , Yu Zhangsheng , Ofner Susan , Myers Laura , Schmid Arlene , Williams Linda
Published: March 2022

We conducted an evaluation of the implementation of a Veteran Secondary Stroke Prevention Program at two VA medical center sites. We prospectively recruited patients hospitalized for stroke/TIA and randomized to either an intervention or a control group. Each site locally tailored the intervention. The program targeted stroke self-management and risk factors or a placebo telephone call program that mimicked the intervention schedule. The self-management program followed a standardized manual (control call simply asked how the patient was doing), and interviews were conducted at baseline during hospital visit, 3 and 6 months. To address veteran preferences, both sites implemented the ASA Sharegiver peer support program to subjects in the intervention.We assessed stroke health-related quality of life with the SS-QOL and depression with the PHQ9.

Results:
The final sample included 174 veteran patients with an acute stroke/TIA and were randomized to receive either a VSPP (n=87) or a control program (n=87) stratified by stroke/TIA and by receipt of inpatient rehabilitation to control for stroke severity. A random subject effect was used to correlate observations from the same subject. Subgroup analyses were run with subgroups defined as diagnosed TIA or Stroke at acute event. On the SSQoL overall score and the Language subscale, those with a TIA in the intervention group reported an improved score while those in the control group reported a declined score at 3 mos. For those with Stroke in the intervention group, improvements in the Energy subscale were reported compared to declines in the control group at 3 months. For those with TIA in the intervention reported less depression than those in the control group and this effect was maintained at 6 months. Self-efficacy increased among those with stroke in the intervention group while decreased among the control group; although not significant.

Our results indicate the feasibility of delivering a local, secondary stroke prevention program. We report better stroke specific quality of life at 3 months among stroke/TIA survivors and less depression among those with TIA 6 months after the intervention suggesting that a post stroke program may enhance recovery.

Funded by Veterans Health Administration HSRD IAB 05-297-2
Abstract WP377: Outcome After Stroke - “Good” Or “Poor”?
Authors: Creutzfeldt Claire J , Becker Kyra J , Schubert Glenn B , Longstreth WT , Tirschwell David L
Published: March 2022

Background:
The modified Rankin Scale (mRS) is a commonly used instrument to measure outcome in stroke research and is often dichotomized into good and poor outcome. Quality of life (QoL) is likely affected by factors besides level of disability. The goal of this study was to assess the correlation between the mRS and a more patient-centered QOL measure, the European QoL visual analog scale (EQVAS).

Methods:
The Medic One Stroke Study reviewed pre-hospital and hospital records from 11 acute care hospitals in the Seattle area from June 2000-January 2003. Subjects with a final hospital diagnosis of stroke were telephoned 3-4 months after stroke onset and both mRS (0-6, with 0 the best) and EQ VAS (0-100 with 100 best) were assessed.

Results:
We identified 574 patients with stroke: 420 ischemic stroke (IS), 121 intraparenchymal hemorrhage (IPH) and 33 subarachnoid hemorrhage (SAH). At three months after discharge, the proportion with mRS of ≤ 3 varied significantly with stroke type: 50% IS, 20% IPH, and 27% SAH (p<0.001). Similarly, good quality of life, defined as EuroQoL ≥ 75, occurred in 48% IS, 25% IPH, and 27% SAH (p<0.001). Spearman’s rho showed a strong correlation of 0.89 (p<0.001) between mRS and EuroQoL. Likelihood of good QoL progressively decreased with increasing mRS (82%, 58%, 33%, 31%, 21%, 11% for mRS 0-5, respectively, p<0.001), yet a number of patients with high mRS (4,5) still reported good QoL (16/102 = 16%). Among patients with low mRS (0,1), 32% did not achieve good QoL.

Conclusion:
Following stroke, QoL decreases with increasing mRS, but exceptions exist with good QoL despite high mRS scores. In the endeavor to advance patient-centeredness as a core component of quality health care, factors other than disability need further exploration, both by researchers doing clinical trials as well as by physicians making treatment recommendations.
Abstract WP392: Reducing Readmissions through Secondary Stroke Prevention Clinics
Authors: Khan Ferhana , Hall Ruth , Hodwitz Kathryn , Fang Jiming , Kapral Moira , Silver Frank
Published: March 2022

Introduction:
Secondary Stroke Prevention Clinics (SPCs) were established in Ontario to provide the opportunity for appropriate patients to access best practice stroke care approaches to reduce the risk of recurrent stroke/TIA. Previous evaluations have shown that SPCs provide high quality care based on evidence-based performance measures; however the impact of SPCs on readmission rates has not been examined. Information on the proportion of patients who are readmitted to hospital for stroke/TIA after being seen at an SPC is important to understanding the role of SPCs in preventing stroke/TIA in Ontario.

Methods:
The Ontario Stroke Registry’s SPIRIT-SPC database was used to identify patients with presumed stroke/TIA referred to 13 SPCs between January 2007 and April 2011. Patients with a first clinic visit and an index stroke/TIA event between January 2007 and September 2010 were linked to Canadian Institute of Health Information (CIHI) inpatient database to calculate stroke-related readmission rates. Patients with elective admissions were excluded. The rates were based on the four years of data and were age- and sex- adjusted.

Results:
The study included 15,163 patients from SPIRIT-SPC seen at 13 SPCs in Ontario. The mean age was 66 years (±14) and 49.3% of patients were female. Seventy-eight percent (n= 11,777) of patients had an index stroke/TIA event reported on the SPC referral and of these only 60% (n = 9,040) had an ED visit or inpatient admission record in the CIHI databases capturing the index stroke/TIA event. The median time from referral to initial visit was 11 days. The stroke/TIA 30-, 90- and 180-day readmission rates following the SPC first visit were 0.7%, 1.3% and 1.8%, respectively. Variation in readmission rates across 13 SPCs ranged from 0 - 6%.

Conclusion:
Stroke/TIA-related readmission rates among patients seen at the 13 SPCs in Ontario patients are lower than what is reported in the literature and lower than observed among patients discharged from acute hospitals following a stroke/TIA ED visit or in-hospital stay. The lower rates observed at the 13 clinics may reflect less severe patients being seen at SPCs. Risk-adjusted models will be taken into consideration for future studies.
Abstract WP393: Exploration Of Time-course Combinations Of Outcome Scales For Use In A Global Test Of Stroke Recovery
Authors: Goldie Fraser C , Fulton Rachael L , Dawson Jesse , Lees Kennedy R ,   VISTA Collaboration
Published: March 2022

Background:
Clinical trials for acute ischaemic stroke treatment require large numbers of patients and are expensive to conduct; any method to enhance statistical power or sensitivity is desirable. We explored whether treatment effects may be detected more strongly if outcome is assessed by using combined early and late measures (e.g. 7 day NIH Stroke Scale (NIHSS) combined with 90-day modified Rankin scale (mRS)) than either measure alone.

Methods:
Data on 4077 patients were available from the Virtual International Stroke Trials Archive (VISTA). We analysed sensitivity to treatment effect, contrasting alteplase as standard care versus non-thrombolysed care. We used proportional odds logistic regression for ordinal scales and Generalised Estimating Equations for global outcomes, with all analyses adjusted for baseline severity and age. We ran simulations to assess relation between sample size and power for each ordinal scale and corresponding global outcomes. We used R 2.12.1 for simulations and SAS 9.2 for all other analyses.

Results:
All scales were sensitive to treatment effect in isolation. The Table shows ordinal scales and global outcomes of combined early and late outcomes ranked in order of sensitivity to treatment effect, displayed as odds ratio (OR).

Discussion:
When early and late outcomes were combined in a global test and compared to solitary ordinal scales, any enhancement of the OR appeared marginal. However, this conferred a 20% reduction in required sample size at 80% power. The greatest increment in power arose when component measures were less correlated.