Abstract NS20: Improving Stroke Evidenced-Based Best Practices Across a Multi-State Healthcare System

Background: Nearly 2 million neurons die each minute during an acute ischemic stroke (AIS). Research demonstrates patients receiving timely treatment for AIS can have more favorable outcomes. In 4 th quarter (Q) 2018, a Stroke Center’s average door-to-needle (DTN) time was 54 minutes, acceptable for American Stroke Association’s (AHA/ASA) Get with the Guidelines (GWTG) quality requirement of DTN in 60 minutes or less. Nevertheless, time is brain and decreased DTN times can potentially improve patient outcomes. With this in mind, the emergency department (ED) implemented a quality improvement project (QIP) focused on DTN time reduction. Purpose: Improve the ED workflow by developing standardized roles and task prioritization to reduce DTN times by 20% from 54 minutes to 42 minutes by 4 th Q 2019. Methods: Guidelines and goals were established using AHA/ASA GWTG-Stroke criteria. Included were AIS patients with symptoms occurring prior to ED arrival, met eligibility criteria, and received intravenous tissue plasminogen activator (IV t-PA). Patients with symptoms occurring after ED arrival or during the hospital stay were excluded. An interdisciplinary workgroup collaborated to formulate an evidence-based solution for workflow opportunities identified by simulations, observations, and subjective feedback. Standardized roles, similar to cardiac life support, were created. An innovative acronym, W.I.N.G.S. (weight, IV access, NIHSS, glucose, scan), was developed to strategize adoption and implementation. Education, chart reviews, and timely feedback were given to stakeholders for every stroke intervention to promote engagement. Results: In 4 th Q 2019, average DTN time decreased to 35 minutes (n=16, 35.2% reduction). The average DTN time for 1 st Q 2020 is 31 minutes (n=14, 42.6% reduction). Since QIP implementation, the current DTN record is 12 minutes. Conclusions: W.I.N.G.S. is now a commonly term used in the ED. The multidisciplinary approach was instrumental in implementing a feasible QIP based on evidence and did not compromise patient safety. Sustainability is dependent on continued commitment and engagement of the team to celebrate achievements and reflect, reevaluate, and revise any insufficiencies.

Background: Timely evaluation and treatment are essential to optimizing outcomes in ischemic and hemorrhagic stroke. National guidelines emphasize rapid provider response and multidisciplinary coordination. In complex settings such as inpatient units, delays in decision-making and care coordination can hinder time-sensitive interventions, including thrombolysis and thrombectomy. Purpose: As part of a broader institutional focus on continuous quality and process improvement (QI/PI) in stroke care, this project evaluated treatment time trends following integration of Advanced Practice Providers (APPs) into the acute stroke response workflow at a Comprehensive Stroke Center (CSC). The analysis focused on door-to-needle (DTN) and door-to-device (DTD) times for stroke alerts in inpatient units and the Emergency Department (ED). Methods: In Fiscal Year (FY) 2021, eight APPs were incorporated into the hospital-wide stroke response team. APPs were trained in acute stroke protocols and began responding in real time to stroke alerts across all hospital settings, assisting with rapid triage, examination, imaging review, and coordination with interventional teams. In FY24, three additional APPs joined the inpatient team, increasing coverage from 64% to 86%. Time metrics for ED and inpatient stroke activations were compared pre- and post-APP integration and monitored annually as the APP team expanded. Descriptive statistics were used to evaluate changes in treatment intervals. Results: Among inpatients, median DTN for thrombolysis decreased by 33 minutes and median DTD for thrombectomy by 37 minutes. For ED patients, median DTN decreased by 4 minutes and DTD by 34 minutes. Adherence to Get With The Guidelines (GWTG) target stroke measures also improved across all settings. The most significant improvements were seen in inpatient cases, where delays were historically greatest. Conclusions: As part of broader institutional efforts to enhance stroke care quality and efficiency, integration of APPs into the acute stroke response workflow was associated with improved key treatment time metrics. While not the sole intervention, APP integration did not extend and may contribute to reduced time to evaluation and treatment, particularly in complex inpatient settings. This experience provides valuable insights for health systems seeking to enhance multidisciplinary stroke care through scalable, team-based innovations.

Objectives: To examine whether thrombolysis care metrics have improved in all races and ethnicities with the launch and advance of Target: Stroke (TS) national quality initiatives. Methods: This cohort study included patients presenting to Get With The Guidelines (GWTG)-Stroke participating hospitals within 4.5 hours of ischemic stroke onset from 2003 to 2021. Thrombolysis rates and speed of treatment during TS phase I (2010-2013), II (2014-2018), and III (2019-2021) were compared with the pre-TS period (2003-2009). Results: Among all the patients with ischemic stroke, Asian, Black, and Hispanic individuals, compared with White, were significantly more likely to present after the 4.5-hour thrombolysis treatment window (Figure/Panel A and B). Among the 1,182,182 patients arriving within 4.5 hours, 33,375 were Asian, 180,315 Black, 86,831 Hispanic, and 881,661 White. Unadjusted rates of thrombolysis treatment increased in all race-ethnic groups from 2003 to 2021 (Figure/Panel C) with no significant disparities. Disparities were evident in adjusted analyses (Figure/Panel D) and persisted in TS:III when, compared with White patients, Asian, Black, and Hispanic patients had significantly lower odds of receiving thrombolysis (0.85, 0.76, and 0.86) (all p values<0.05). Door-to-needle (DTN) times significantly improved in all race-ethnic groups during TS (Figure/Panel E). However, compared with White patients, Asian, Black, and Hispanic patients had significantly lower odds of DTN≤60 minutes (Figure/Panel F) which persisted in TS:III (adjusted OR 0.91, 0.78, and 0.87) (all p values<0.05). Conclusion: Target: Stroke was associated with substantial improvement in thrombolysis frequency and timeliness for all races and ethnicities, but disparities persisted after risk adjustment. Further stroke system of care and health equity interventions should focus on early hospital arrival and quality reporting of risk-adjusted care metrics by race-ethnicity.

Readability & quality of large language model responses in CAR-T patient education

Assessing the Readability of Online Patient Education Resources Related to Neophallus Reconstruction

Proton pump inhibitor (PPI) deprescribing is recommended in case of inappropriate use. Patient education materials are key elements in the deprescribing process. The study objective was to develop patient education material for PPI deprescribing in primary care in France. This was a mixed-methods study involving (1) a literature review of the existing patient education materials on PPI deprescribing to identify key points to optimize the layout and content of the document; (2) development of a first version of the brochure by a pluri-professional steering group, following the national reference methodology of the French National Authority for Health (Haute Autorité de Santé) and iterative modifications of the patient brochure; (3) assessment of the content and understandability of the brochure by questionnaires followed by semistructured interviews with target patients; and (4) iterative brochure readability assessment with the Flesch reading ease tool. The final patient education material is a double-sided A3 brochure-that is, 4 A4 pages. The first round of user testing by questionnaire (n = 14 patients) led to modifications to improve the document understandability, validated in the second round of user testing by questionnaire (n = 10 patients). The semistructured interviews (n = 10 patients) highlighted an adequate comprehension, whereas actionability required some minor modifications. The readability test score of the final education brochure was 59.4. This patient education brochure for PPI deprescribing is targeted to patients in primary care. Its impact on PPI deprescribing will be assessed in a population-based pragmatic trial in primary care.

Clinical relevance Effective diabetic retinopathy (DR) patient education materials (PEMs) are vital for improving patient outcomes by fostering understanding and self-management. Background DR is a leading cause of vision impairment and blindness among Australians with diabetes, with Indigenous populations facing higher rates of severe complications. Despite the availability of online PEMs, their understandability and actionability, especially those designed for Indigenous Australians, remains underexplored, creating a gap in effective patient education. Methods This descriptive study assessed online PEMs using the Patient Education Materials Assessment Tool (PEMAT). Evaluations were conducted with online search platforms for printable and audiovisual PEMs on DR. Two independent reviewers scored the PEMs for understandability and actionability, with discrepancies resolved by a third adjudicator. A 70% threshold was used to indicate acceptable scores. Results From 540 identified PEMs, 54 met the inclusion criteria. Indigenous-targeted PEMs achieved higher in understandability (80%) than general population PEMs (75%). However, actionability scores were lower across all formats, with printable PEMs having a mean score of 42% for general population and 53% for Indigenous PEMs, and audiovisual PEMs at 29%. Conclusion While most DR-related PEMs are generally understandable, their low actionability, especially audiovisual formats, indicates a need for clearer, step-by-step guidance to support patient self-management. Improving the structure and content of both printable and audiovisual PEMs can improve engagement and adherence to preventive behaviours among people living with diabetes, potentially reducing the burden of DR.

Rationale During in-hospital cardiac arrests, timely and accurate documentation of key American Heart Association Get with the Guidelines (GWTG) components into the electronic medical record (EMR) is critical for patient care, education, and quality improvement. Real-time documentation, particularly when performed in close proximity to the code team, may enhance the completeness and accuracy of the data. It is unclear whether nurses typically document inside the room with the code team or from outside, and how well they can hear cardiac arrest events and thus how it can affect documentation. We hypothesized that nurses often stand outside the room, which may impair their ability to hear key events, thereby negatively impacting documentation quality. Methods We conducted a prospective observational pilot study from December 2023 to May 2024, using a convenience sample of in-hospital cardiac arrests. Independent observers recorded whether nurses documented events in real time and whether they were inside or outside the room. After each cardiac arrest, nurses rated their ability to hear the events using a three-point ordinal scale: “easy to hear,” “sometimes difficult to hear,” or “often difficult to hear.” EMR documentation was then reviewed for six essential GWTG cardiac arrest elements: compression start, initial rhythm, time of first epinephrine, defibrillation time, time of first airway management, and arrest end time. Results Thirteen cardiac arrests were observed. During 12 events (92%), nurses documented in real time. During 12 cardiac arrests (92%), the nurse responsible for documentation was stationed outside the patient's room. Among those outside the room, initial rhythm was documented in (75%) of events and time of first airway was not documented (0%). Nurses reported that the events were “easy to hear” during 6 (46%) cardiac arrests, “sometimes difficult” during 5 (38%) events, and “often difficult” during 2 (15%) codes. (78%) of the six essential GWTG elements were documented across all 13 cardiac arrest events. Conclusion Nurses frequently position themselves outside the room during cardiac arrest events and often report difficulty hearing. Airway management and initial rhythm documentation are commonly not documented. Further research is needed to assess whether stationing the nurse documenter inside the room could improve documentation quality.

The purpose of this study was to assess large language models (LLMs) for enhancing the readability of online patient education materials (PEMs) on pediatric cataracts through multilingual adaptation, content retrieval, and prompt engineering. This study included 103 PEMs presented in different languages and retrieved from diverse resources. Three LLMs (ChatGPT-4o, Gemini 2.0, and DeepSeek-R1) were used for content improvement. Readability was assessed for both the original and converted PEMs with multiple formulas. Different prompt engineering strategies for LLMs were also tested in this study. The PEMs directly generated by LLMs exceeded a 10th grade reading level. Compared to a traditional Google search, LLMs' web browsing feature provided online PEMs with better characteristics and a higher reading level. Original PEMs from Google showed significantly improved readability after LLM conversion, with DeepSeek-R1 achieving the greatest reduction in reading level from 10.59 ± 2.20 to 7.01 ± 0.91 (P < 0.001). Prompt engineering also showed statistically significant results in their effects on LLM conversion, and Zero-shot-Cot (APE) successfully achieving target readability below the sixth grade reading level. Besides, the LLMs' simplified Chinese conversion, as well as the LLMs conversion of other original Chinese PEMs, both showed that they meet the recommended standards for reading levels in multiple dimensions. LLMs can significantly enhance the readability of multilingual online PEMs on pediatric cataract. Combining it with web browsing and prompt engineering can further optimize outcomes and advance patient education. This study links LLMs with patient education and demonstrates their potential to significantly improve the readability of online PEMs.

Background:Temporary brigade trips to deliver international surgical care are increasingly common. For the purposes of this work, we use the term brigade to describe self-contained short-term medical or surgical mission trips where healthcare professionals are brought in from foreign regions to provide care to an underserved population. Many brigade programs have begun to collect and publish data on outcomes and complications, but few have examined their own patient education practices.Methods:We used evidence-based readability and suitability analyses along with patient interviews to develop improved patient education materials for a total joint replacement surgical brigade in the Dominican Republic.Results:Existing patient education materials required an eighth grade reading level and lacked suitability based on the principles of educational theory. The redesigned materials required fifth grade reading skills or less and had superior suitability. Pilot testing with patients from the target population suggested that the materials were appealing and appropriate.Conclusions:Patient education may play an important role in optimizing outcomes in the setting of medical or surgical brigades where resources and access to follow-up care are limited. More research is needed to bring attention to the importance of patient education during brigades, and programs should work with patients to develop educational materials that are suitable and effective.

Guidelines on postoperative pain management recommend inclusion of patient and caregiver education on opioid safety. Patient education materials (PEMs) should be written at or below a sixth grade reading level. We designed this study to compare the readability of online PEMs related to postoperative opioid management produced by institutions with and without a regional anesthesiology and acute pain medicine (RAAPM) fellowship. With institutional review board exemption, we constructed our cohort of PEMs by searching RAAPM fellowship websites from North American academic medical centers and identified additional websites using structured Internet searches. Readability metrics were calculated from PEMs using the TextStat 0.4.1 textual analysis package for Python 2.7. The primary outcome was the Flesch-Kincaid Grade Level (FKGL), a score based on words per sentence and syllables per word. We also compared fellowship-based and nonfellowship PEMs on the presence or absence of specific content-related items. PEMs from 15 fellowship and 23 nonfellowship institutions were included. The mean (SD) FKGL for PEMs was grade 7.84 (1.98) compared with the recommended sixth grade level (P < 0.001) and was not different between groups. Less than half of online PEMs contained explicit discussion of opioid tapering or cessation. Disposal and overdose risk were addressed more often by nonfellowship PEMs. Available online PEMs related to opioid management are beyond the recommended reading level, but readability metrics for online PEMs do not differ between fellowship and nonfellowship groups. More than two-thirds of RAAPM fellowship programs in North America are lacking readable online PEMs on safe postoperative opioid management.

To compare the readability of patient education materials (PEMs) on rhinologic conditions and procedures from the American Rhinologic Society (ARS) with those generated by large language models (LLMs). Forty-one PEMs from the ARS were retrieved. Readability was assessed through the Flesch Kincaid Reading Ease (FKRE) and Flesch Kincaid Grade Level (FKGL), in which higher FKRE and lower FKGL scores indicate better readability. Three LLMs-ChatGPT 4.o, Google Gemini, and Microsoft Copilot-were then used to translate each ARS PEM to the recommended sixth-grade reading level. Readability scores were calculated and compared for each translated PEM. A total of 164 PEMs were evaluated, including 123 generated by LLMs. The original ARS PEMs had a mean FKGL of 10.28, while AI-generated PEMs demonstrated significantly better readability, with a mean FKGL of 8.6 (P < .0001). Among the AI platforms, Gemini was the most easily readable, reaching a mean FKGL of 7.5 and FKRE of 65.5. LLMs improved the readability of PEMs, potentially enhancing accessibility to medical information for diverse populations. Despite these findings, healthcare providers and patients should cautiously appraise LLM-generated content, particularly for rhinology conditions and procedures. N/A.

Patients have unhelpful beliefs about low back pain (LBP), which are associated with worse outcomes. Education may modify these beliefs, but patients with LBP rarely receive education in practice. Patient education materials (PEMs) are a quick, inexpensive intervention to support information provision. assess PEMs for understandability, actionability, quality, readability, accuracy, comprehensiveness, and coverage of information about patients' needs to identify the best PEMs for practice. We searched published literature for PEMs tested in randomized trials or recommended in clinical guidelines. We used the Patient Education Materials Assessment Tool (PEMAT) to assess understandability and actionability, DISCERN to assess quality, the Patient Information and Education Needs Checklist for Low Back Pain (PINE-LBP) to assess information need coverage, and the Flesch Reading Ease (FRE) and Flesch-Kincaid Grade-Level (FKGL) algorithms to assess readability. We assessed accuracy (proportion of treatment recommendations aligning with guidelines) and comprehensiveness (proportion of correctly covered guideline recommendations), and qualitatively synthesized PEM content relating to 21 information and education needs about LBP. Nineteen PEMs were included. None were actionable or comprehensive, and many had inaccurate treatment recommendations. There was considerable variation and conflicting information in the content provided across PEMs. Only the My Back Pain website met acceptable standards for more than half (4/7) outcomes. Educational messaging for LBP varies substantially and PEMs require improvement in various areas. The My Back Pain website met acceptable standards across most outcomes and may be the best available option for practice.

Introduction: Increasing focus is being placed on quality metrics for stroke care in an effort to improve outcomes. This study aims to examine if quality of stroke care is the same for Veterans experiencing an in-hospital stroke compared to patients presenting through the emergency department (ED). Methods: We analyzed data from an 11-site VA quality improvement study, where 30 months of ICD-9 defined stroke admissions were chart reviewed by a central, trained group of abstractors to assess stroke diagnosis, clinical data, and eligibility and passing for 11 stroke quality indicators (QIs; 8 Joint Commission and 3 others). Stroke severity was determined by retrospective NIHSS scoring of the admission exam. Strokes were classified as presenting to the ED or in-hospital (already admitted for another diagnosis). Transfers (N = 362) were excluded. We compared clinical and QI data between the in-hospital and ER groups using Student’s t-tests and Chi-square tests. Results: There were 35 in-hospital and 1788 ED strokes. The two groups did not differ with respect to age, race or sex, however in-hospital strokes had higher stroke severity (mean 11.1 vs 5.1, p=0.002), increased length of stay (12.8 vs 7.3, p=0.003), and were less likely to be discharged home (34.3% vs 63.8%, p&lt;0.001). QI results are shown in the Table; those with in-hospital stroke were more likely to be eligible for tPA, but received less dysphagia screening. Conclusions: Veterans who develop an in-hospital stroke receive similar quality of care as patients presenting to the ED although fewer in-hospital patients had dysphagia screening. Interestingly, tPA eligibility and utilization were higher for in-hospital strokes although utilization did not reach significance. While it is reassuring that in-hospital strokes are receiving similar quality of care, there is still room for improvement in all patient care settings and in-hospital stroke patients should be included in future QI processes.

IntroductionDespite the first goal of the 2010 National Action Plan to Improve Health Literacy, the literacy demands of much health information exceeds the reading skills of most US adults. The objective of this study was to assess the health literacy level of publicly available patient education materials for people with sickle cell disease (SCD).MethodsWe used 5 validated tools to evaluate 9 print and 4 online patient education materials: the simple measure of gobbledygook (SMOG) to assess reading grade level, the Peter Mosenthal and Irwin Kirsch readability formula (PMOSE/IKIRSCH) to assess structure and density, the Patient Education Materials Assessment Tool (PEMAT) to assess actionability (how well readers will know what to do after reading the material) and understandability, the Centers for Disease Control and Prevention’s (CDC’s) Clear Communication Index (Index) to obtain a comprehensive literacy demand score, and the Printed Cancer Education Materials for African Americans Cultural Sensitivity Assessment Tool.ResultsMaterials’ scores reflected high reading levels ranging from 8th grade to 12th grade, appropriate (low) structural demand, and low actionability relative to understandability. CDC suggests that an appropriate Index score should fall in or above the 90th percentile. The scores yielded by materials evaluated in this assessment ranged from the 44th to the 76th percentiles. Eight of the 13 materials scored within the acceptable range for cultural sensitivity.ConclusionReading levels of available patient education materials exceed the documented average literacy level of the US adult population. Health literacy demands should be a key consideration in the revision and development of patient education materials for people with SCD.