Abstract NS3: Multidisciplinary Innovations in Acute Stroke Response: Integrating Advanced Practice Providers

Regionalization, systems of care design, and quality improvement (QI) registry participation all promote the widespread dissemination of guideline-based evidence into actual practice. As a result, policy statements from the American Heart Association/American Stroke Association (AHA/ASA) advocate for the creation of regional systems of care for various time-critical diagnoses, including ST-elevation myocardial infarction (STEMI), out-of-hospital cardiac arrest resuscitation, and acute stroke.1–3 Creation of these regional networks requires multidisciplinary collaboration to implement 5 mutually reinforcing core elements4 that build each system: (1) Designation of certain hospitals with special treatment capabilities as Receiving Centers for STEMI, resuscitation, or stroke; (2) emergency medical services (EMS) destination protocols that allow for direct transport of certain patients identified by explicit triage criteria to a designated Receiving Center, thus allowing for bypass of closer hospitals if they lack the needed specialty service; (3) organized interhospital transfer and transport protocols to a Receiving Center for appropriate patients who initially self-present or are mistriaged to a Referral Hospital; (4) communication or telemedicine options to provide real-time expert consultation as needed from a Receiving Center to its associated Referral Hospitals or EMS providers; and (5) participation in a regional and/or national QI registry to track relevant process-of-care metrics and meaningful risk-adjusted clinical outcomes. Within each of the 50 states, unique challenges exist for stakeholders attempting to implement the 5 aforementioned core elements of regional or statewide systems of care. In particular, substantial variation exists with regard to the starting point for these initiatives. For example, some states already have sufficient regulatory authority within their EMS agency or state department of health (DOH) to regionalize care of time-critical diagnoses, whereas other states require new legislation to create coordinated systems. In October 2011, the Advocacy Coordinating Committee of the AHA convened a multispecialty task force to assess the …

Introduction: Stroke alerts enable rapid detection of acute ischemic stroke and timely access to IV thrombolysis (IVT) and/or endovascular therapy (EVT). Differentiating true stroke from mimics is resource-intensive and constrained by personnel and imaging capacity; overactivation can strain teams and expose patients to unnecessary risk. Appropriate utilization is essential. Emergency departments (EDs) are accustomed to time-critical workflows, whereas inpatient units are heterogeneous and are more likely to face stroke mimics (e.g., isolated encephalopathy). Hypothesis: Compared with ED alerts, inpatient alerts would have lower true stroke rates, fewer acute interventions, and longer treatment times. We also evaluated outcomes among alerts with isolated encephalopathy. Methods: Single-center, retrospective analysis of all stroke alerts in 2024. Alerts were categorized as ED or inpatient. Outcomes: final stroke confirmation; IVT; EVT; composite any acute intervention (IVT or EVT). Door-to-needle (DTN) among IVT recipients was summarized as median (IQR). Proportions were compared by χ2/Fisher with odds ratios (OR, 95% CI); DTN time by Mann–Whitney U. Analyses were performed in Python. Results: We analyzed 1,306 alerts (ED 1,012; inpatient 294). Stroke was confirmed in 46.1% of ED vs 24.5% of inpatient alerts (OR 2.64, 95% CI 1.97–3.54; p < 0.0001). IVT occurred in 7.8% vs 3.1% (OR 2.68, 1.33–5.41; p = 0.0064). EVT occurred in 11.9% vs 3.7% (OR 3.46, 1.84–6.51; p < 0.0001). Any acute intervention occurred in 18.2% vs 6.1% (OR 3.41, 2.06–5.63; p < 0.0001). DTN was 41 min (IQR 34–64, n=79) in the ED vs 81 min (IQR 75–96, n=7) inpatient (p = 0.0016). Isolated encephalopathy alerts comprised 10.3% overall (ED 6.9%, inpatient 21.8%). Among isolated encephalopathy alerts, 14.9% were stroke and 5.2% received any intervention. In inpatient isolated encephalopathy activations, IVT rate was 1/64 (1.6%) and 0% underwent EVT. Conclusions: Under real-world resource constraints, inpatient stroke alerts were lower yield, far less likely to lead to acute intervention, and had substantially longer DTN than ED alerts. Isolated encephalopathy accounted for about 1 in 5 inpatient activations but rarely resulted in treatment. These findings support the need for improved education about and context-aware activation criteria for isolated encephalopathy to optimize the use of limited stroke resources while preserving rapid treatment for high-probability stroke.

Introduction: Intravenous tissue plasminogen activator (IV tPA), for acute ischemic stroke, has a more robust effect if given early. Improving Door-to-Needle (DTN) times in order to allow quicker administration of IV tPA continues to be the primary aim of TARGET:STROKE. The Stroke Champion (SC) Program, an American Heart Association’s Get with the Guidelines recommendation, was implemented in our emergency department (ED) in 2018. Purpose: The purpose of this study was assess if an ED Nurse SC would help to improve DTN, with a specific goal to increase the percentage of patient’s receiving IV tPA ≤30 minutes. Methods: The SC program was initiated in our ED in January 2018. The ED Nurse SC carries the following responsibilities: respond to all stroke alerts, weekly audit of all stroke alert charts, peer to peer follow up for any fallouts to determine if there was a system error or if there was an educational opportunity, weekly update of ED staff virtual communication board, weekly meeting with ED director for any challenges or expected changes, development of a relevant stroke education topic to be delivered at the biweekly ED nursing huddle, participate at the weekly code stroke huddle to collaborate with the stroke team, and attend relevant stroke conferences or stroke-related educational opportunities. A weekly “Stroke Shout Out” was also initiated by the ED Nurse SC to recognize a high performing member of the ED team. Data was compared 6 months pre and post-intervention, and analyzed using a Wilcoxon Rank Sum Test. Results: More patients received IV tPA after the initiation of the ED Nursing SC program than before (38 vs. 23 p=0.03). The median DTN was 36 (IQR 23-49) mins after implementation vs. 47 (IQR 40-56) mins before implementation (p=0.004). A higher percentage of patients received IV tPA less than 30 minutes post intervention vs. pre-intervention (42.1% vs. 17.4% , p <0.001) Conclusion: Implementation of an ED Nurse SC can increase the number of patients who receive IV tPA, improve DTN, and increase the percentage of patients who receive IV tPA less than 30 minutes from door time.

Background and Purpose: As a National effort to provide a framework to improve stroke best practices, a multi- center healthcare system with 48 hospitals across ten states established a stroke collaborative working group. The purpose was to develop a forum to standardize and improve stroke evidenced-based best practices with sister facilities. Methods: A questionnaire was developed and distributed to the stroke collaborative group. A telephone conference was held to review survey results and organizational trends from the 2010 Get With The Guidelines (GWTG) stroke quality metrics. Three quality metrics, dysphagia screening, patient education and door to needle (DTN) were initially identified along with establishing three subcommittees to focus upon improving best practices for each of these measures. Educational webinars, best practice successes and barriers were shared on monthly conference calls as well as a development of an email stroke distribution list serve to improve communication. Results: The three chosen GWTG stroke quality metric score aggregates from 2010 to 2013 second quarter were: dysphagia screen 78.8% to 85.7%, patient education 86% to 94.6%, DTN 60 minutes or less 31% to 72.8% with a mean DTN time of 91 minutes to 68.8 minutes. Conclusion: Formation of a stroke collaborative group for this organization had a positive effect on improving stroke best practices. Areas of focus identified were standardized best practice processes which included creation of system-wide electronic stroke order sets, development of staff and patient educational materials, implementation of templates and development of a DTN challenge. As the Stroke Collaborative expanded three additional working subcommittees were established, Patient Satisfaction, Emergency Medical Service collaboration and Stroke Support Group Development. In conclusion facilitation of communication and collaboration utilizing individual talents and resources is an effective way to improve stroke evidenced-based best practice across a multi-state healthcare system.

Background and Issues: Decreasing thrombolytic door-to-needle (DTN) time has been shown to improve neurological outcomes of ischemic stroke patients as well as decrease incidence of bleeding. At Aultman, a dedicated pharmacist responds to all stroke alerts between 0700 and 1700 Monday through Friday. In September of 2014, a clinical pharmacist was added to the stroke team to attend stroke alerts and focus solely on facilitating the TPA ordering, dispensing, and delivery, with the goal of decreasing DTN times. The mixing of the tPA was done in the central pharmacy during all alerts. At the same time of hiring a clinical pharmacist, Aultman changed the stroke alert procedure to immediately send patients straight to CT after an alert was called. Purpose: To compare DTN times with and without the presence of a pharmacist on emergency department stroke alerts. Methods: For all stroke cases where tPA was administered from January 1 2014 to July 31 2016, the DTN was grouped based on pharmacist presence - before a pharmacist was present on any stroke alerts (January 1 2014 to September 30 2014), when a pharmacist was present, and when a pharmacist was not present after September 30 2014. A Shapiro-Wilk analysis was run to assess normality, and the Mann-Whitney U test was used to compare the means. Results: From January 2014 to the placement of a pharmacist on the stroke team, the mean DTN time was 80.68 minutes (95% CI: 62.23-99.14 min, n=19). After hiring a pharmacist (September 2014 to July 2016), the mean DTN time was significantly different (p=0.001) when a pharmacist responded to stroke alerts (48.26 minutes, 95% CI: 38.11-58.40 min, n=27) compared to when a pharmacist was not present (68.63 minutes, 95% CI: 59.57-80.69 min, n=31). Conclusion: Having a pharmacist who can focus solely on the tPA portion of a stroke alert can significantly decrease DTN times. The pharmacist knows the computer ordering system more fluently than the provider increasing ordering speed and can allow other members of the stroke team to focus on their responsibilities during the alert. The decrease in DTN time from early 2014 to post-September 2014 when a pharmacist was not present could be attributed to implementation of new policies routing stroke alerts directly to CT.

Background: Patient outcomes improve when the initial management of acute ischemic stroke (AIS) focuses on decreasing process times in recognition, imaging, and treatment. American Stroke Association guidelines recommend Door to Needle (DTN) times of <60 minutes for at least 85% of AIS patients, with further goals of DTN times of <45 minutes for 75% of patients, and <30 minutes for 50% of patients. Our community hospital system consists of a hub-n-spoke model of five community Primary Stroke Centers (PSC), one Acute Stroke Ready Center, and a hub regional Comprehensive Stroke Center (CSC). In the spoke centers, we moved all initial care processes to the Radiology suite, site by site over a period from 2020 to 2024. We present data showing improved DTN times across the system as these changes were implemented. Methods: Multidisciplinary Stroke Teams at each site examined delays in DTN times, identifying treatment barriers to develop the Transition of Care to Computed Tomography (CT) process. This retrospective study analyzes prospectively collected data from our system's six spoke hospitals during and after implementation of the new process. The care process consists of initial Physician evaluation at Emergency Department (ED) triage for patients with stroke-like symptoms. Stroke Alert is initiated for patients concerning for acute stroke, who are within the therapeutic window. The patient is then taken directly to the CT scanner in the Radiology suite, with a Tele-Stroke robot and Pharmacy cabinet stocked with thrombolytics and anti-hypertensives. After initial non-contrast CT head imaging, the Stroke Neurologist evaluates the patient via Tele-Stroke and makes recommendations for thrombolytics. Thrombolytics are administered in the Radiology suite before transferring the patient back to the ED for continued care. Results: Moving the initial stroke care process to CT resulted in improvement in average DTN times across the system, from 41 minutes in 2023 (one site with process) to 36.8 minutes in 2024 (four sites with process, two sites initiating), to 35.5 minutes for the first half of 2025 (all sites fully transitioned). Tele-Neuro volumes remained consistent with 753 patients in 2023, 754 in 2024, and 462 for the first half of 2025, with thrombolytic administration rates of 5.4% to 9.95% during this time. Conclusions: Transition of initial stroke care completely to CT resulted in system-wide improvements in DTN metrics in our community hospital system.

Essential Workflow and Performance Measures for Optimizing Acute Ischemic Stroke Treatment in India.

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 and Issues: Eliminating treatment delays for acute ischemic stroke patients to meet the national door to needle (DTN) Target Stroke Phase II goals continues to present a challenge for many facilities. Although the Stroke Alert process is usually guided by strict protocols it can still suffer delays from a lack of communication and facilitation to ensure rapid patient assessment and treatment. Purpose: The purpose of this project was to eliminate Stroke Alert delays related to communication and lack of facilitation by implementing a Stroke Nurse Facilitator (SNF) and allow intravenous tissue plasminogen activator (tPA) to be successfully started in the CT room. Methods: An interdisciplinary team conducted a Pareto analysis on DTN delays and found communication to be the most common. Communication was also felt to be the biggest barrier to starting tPA in the CT room. The role of a SNF was created and mapped into the Stroke Alert process to overcome these barriers. The role launched in November 2016. Six months later, after the role became an integral part in the Stroke Alert process, the team moved forward with administering tPA in the CT room as part of the process. Results: DTN was measured in 61 emergency department stroke patients, 34 in the pre-intervention, 12 in the SNF only, and 15 in the SNF and tPA in CT groups. Data were analyzed using the non-parametric Mann Whitney U test. Although not statistically significant due to the small sample size, there was a large improvement in DTN from pre (n=34) to the first intervention group [Z= 11.19, p=.06, d =.84]. The improvement from DTN from pre to the second intervention group was very large and statistically significant [Z= 24.00, p<.001, d = 1.34]. There was no statistically significant difference in the outcome between the two post groups. The total difference between pre and post samples was large and statistically significant (t=4.46, p<.001, d = 1.10). Conclusions: Successful communication and facilitation is crucial to achieve positive outcomes or process improvements. Implementing a SNF to overcome these barriers could prove to be a successful strategy to improving DTN times for acute stroke patients.

Introduction: With recent advancements in acute stroke treatments, evidence-based care capabilities among hospitals are believed to vary widely; however, current data are limited. Therefore, we conducted a statewide assessment of hospital-based stroke care capabilities in North Carolina (NC). Methods: An online survey was emailed to each licensed hospital in NC. Based on prior surveys and current stroke care guidelines, questions asked about diagnostic testing, acute stroke treatments and protocols, and post-acute management. All 112 hospitals responded (100% response rate) between October 2020 and April 2021. Descriptive statistics were computed from responses for 109 hospitals that reported providing acute stroke care. Results: Among 109 hospitals, 10 (9%) were Comprehensive Stroke Centers, 2 (2%) were Thrombectomy-Capable Stroke Centers, 35 (32%) were Primary Stroke Centers, 16 (15%) were Acute Stroke Ready Hospitals, and 46 (42%) had no stroke certification. Ninety-eight (90%) had an acute stroke clinical care pathway, and 92 (84%) had pre-written stroke care orders. All 109 (100%) reported non-contrast CT imaging capability. Further, hospitals reported the following: CT angiography (104, 95%), CT perfusion (55, 50%), and diffusion-weighted MRI (63, 58%) . Almost all (108, 99%) administered intravenous alteplase for stroke, whereas only 16 (15%) had capabilities to provide endovascular thrombectomy for stroke. Ninety-five (87%) hospitals reported transferring stroke patients treated with alteplase or transferring those in need of endovascular treatment. Eighty-nine (82%) used telestroke services for the treatment and management of acute stroke patients, of which 78 (72%) relied on telestroke exclusively 24/7; and 80 (73%) used telestroke to decide when and where to transfer stroke patients. Conclusions: Among NC hospitals, basic capabilities, such as CT imaging and acute stroke care protocols, were widely available. However, advanced imaging and endovascular capabilities were less common. Most hospitals used telestroke services for treatment as well as transfer decisions. This statewide assessment is an important first step in improving access to evidence-based stroke care and developing stroke systems of care.

BACKGROUND: The objective was to optimize conditions that increase dysphagia compliance after stroke-a measure recognized by The Joint Commission in designating institutions as primary or comprehensive stroke centers and by the American Heart Association that promotes stroke treatment adherence and bestows achievement and quality awards. Failure to meet stroke measures, including medication documentation, may produce poor patient outcomes that directly affect consumer confidence and choice of treatment facility. Stroke patient care requires multidisciplinary team collaboration to manage multiple factors; variations in practice create fallouts that need correction, the absence of which jeopardizes standards for maintaining stroke center designation. PURPOSE: Aims were to determine the nature of dysphagia fallouts in our quaternary academic teaching hospital, assess multidisciplinary workflows and barriers to success, and develop strategies to enhance dysphagia compliance. DESCRIPTION: We used a multidisciplinary approach using James Reason's Swiss cheese model to examine compliance. The clinical nurse specialist interviewed physicians, advanced practice providers, pharmacists, speech-language pathologists (SLPs), nurses, and informaticists to ascertain discipline-specific success barriers, targeting top issues for each discipline to develop solutions. Unit educators unified their dysphagia reduction strategies; physicians, pharmacists, and informaticists collaborated to clarify standardized medication route orders and to increase electronic health record swallow screen visibility to multidisciplinary users; and SLPs adjusted workflow and documentation. EVALUATION: Outcomes included reinforcing correct nursing charting, pharmacy oral-to-feeding tube conversion order revision, optimization of delivery and awareness of medication routes, electronic health record system enhancements, and SLPs aligning documentation with nursing medication administration. The multidisciplinary approach proved successful and increased dysphagia compliance by 9.6% ( P = .001). These outcomes contributed to a successful The Joint Commission survey, redesignation as a comprehensive stroke center, and American Heart Association Gold Plus achievement award.

Background: Landmark trials selecting acute ischemic stroke patients with large vessel occlusion with salvageable brain tissue, as determined by CT perfusion, have extended the therapeutic time window for mechanical thrombectomy (MT) from 6 to 24 hours after onset. This prompted extensive change to stroke care paradigms. While the benefit in functional outcomes has been proven, the effect of implementing this evidence-based medicine on care in a large urban university affiliated Level 1 and Comprehensive Stroke Center is not known. Purpose: To evaluate the impact on process of care metrics after extending the acute stroke alert from 6 to 24 hours from symptom onset or last known normal. Methods: A retrospective QI project evaluating all stroke patients who presented after implementing the extended window at our Comprehensive Stroke Center was developed. All ED stroke alerts presenting from March-August 2017 prior to implementation of the extended time protocol were compared to alerts from October 2017-March 2018 after the extended protocol was implemented. Metrics evaluated and compared between groups included number of stroke alerts, mean times for door to CT, door to decision, decision to drug administration, door to needle for IV-thrombolytic, and door to groin puncture for MTs. Results: Although the number of ED stroke alerts increased by 44.1%, this translated into only a 7.3% increase in total acute ischemic stroke treatments (IV tPA, tPA transfers, MTs or a combination) despite a 53.6% increase in MT alone. Increases in mean time (mins) for door to CT (7.4), door to decision (15), door to drug (11.4), and door to puncture (23.3) were observed however decision to administration times remained unchanged. Conclusion: Although extended time windows have increased the number of MTs by 53.6%, delays in almost all care metrics were observed. The increase in stroke alerts and patients triaged with acute urgency are a likely cause for delays with more requiring CT upon presentation. Other factors include increased case processing and the additional perfusion imaging required. Review of our process through a Lean Management Kaizen in June 2018 has produced additional resources and novel approaches to handle increases in volume as needed to prevent delays in the ED.

Are there disparities in acute stroke treatment between the Jewish and Arab populations in Israel? Results from the National Acute Stroke Israeli registry

To improve stroke care, the Brain Attack Coalition recommended establishing primary stroke center (PSC) and comprehensive stroke center (CSC) certification. This study aimed to compare ischemic stroke care and in-hospital outcomes between CSCs and PSCs. We analyzed patients with acute ischemic stroke who were hospitalized at stroke centers participating in Get With The Guidelines-Stroke from 2013 to 2015. Multivariable logistic regression models were generated to examine the association between stroke center certification (CSC versus PSC) and performances and outcomes. This study included 722 941 patients who were admitted to 134 CSCs and 1047 PSCs. Both CSCs and PSCs had good conformity to 7 performance measures and the summary defect-free care measure. Among emergency department admissions, CSCs had higher intravenous tPA (tissue-type plasminogen activator) and endovascular thrombectomy rates than PSCs (14.3% versus 10.3%, 4.1% versus 1.0%, respectively). Door to intravenous tPA time was shorter at CSCs (median, 52 versus 61 minutes; adjusted risk ratio, 0.92; 95% confidence interval, 0.89-0.95). More patients at CSCs had door to intravenous tPA time ≤60 minutes (79.7% versus 65.1%; adjusted odds ratio, 1.48; 95% confidence interval, 1.25-1.75). For transferred patients, CSCs and PSCs had comparable overall performance in defect-free care, except higher endovascular thrombectomy therapy rates. The overall in-hospital mortality was higher at CSCs in both emergency department admissions (4.6% versus 3.8%; adjusted odds ratio, 1.14; 95% confidence interval, 1.01-1.29) and transferred patients (7.7% versus 6.8%; adjusted odds ratio, 1.17; 95% confidence interval, 1.05-1.32). In-hospital outcomes were comparable between CSCs and PSCs in patients who received intravenous tPA or endovascular thrombectomy. CSCs and PSCs achieved similar overall care quality for patients with acute ischemic stroke. CSCs exceeded PSCs in timely acute reperfusion therapy for emergency department admissions, whereas PSCs had lower risk-adjusted in-hospital mortality. This information may be important for acute stroke triage and targeted quality improvement.

Introduction: Our comprehensive stroke center provides community outreach and stroke education to patients, caregivers, and community members on the importance of calling 911 in the event of a stroke. However, approximately 1/3 of our center’s stroke alerts are walk-ins. With a walk-in stroke, rapid assessment is essential because the stroke response team has no information compared to information that otherwise would be provided by EMS. As such, our center developed a rapid assessment by the emergency triage nurse or technician, who can then activate a stroke alert. Methods: The change to rapid stroke assessment and stroke alert activation by triage nurses and technicians (rather than waiting for an emergency physician to assess and activate a stroke alert) was made in March 2018. Cases from one year prior to the intervention were compared to cases from the year after implementation. Differences in turnaround times (door to stroke alert activation, door to needle [DTN]) were calculated. Results: In the period before implementation, there were 1200 stroke alerts, of which 420 arrived via triage (35%). Median door to stroke alert was 0 min. Of those who arrived through triage, 8 received IV alteplase (8/420=2%). For those patients, median DTN was 39 min. In contrast, after implementation, there were 1401 stroke alerts, of which 342 arrived via triage (24%). Median door to stroke alert was 2 min. Of those, 15 received IV alteplase (15/342=4%), with a median DTN of 32 min. Discussion: A nursing driven initiative at Emergency Department triage was effective at improving stroke treatment rate and decreasing DTN for IV alteplase for walk-in stroke patients.