Abstract WP62: Skilled Nursing Facilities As A Bridge For Acute Rehabilitation In Acute Stroke Patients Who Are Not Immediate Candidates For Intensive Therapy

Background: Rehabilitation after hospital discharge is an essential component of stroke recovery. However, many stroke patients are not immediately ready for an Inpatient Rehabilitation Facility (IRF) after hospital discharge because of poor endurance, weakness, cognitive status, or medical condition. The purpose of this study is to demonstrate the efficacy of skilled nursing facilities (SNF) as a bridge to improve the number of post-stroke IRF admissions, and better understand the factors that allow transfer from a SNF to IRF by assessing differences between patients who are discharged from a SNF with vs. without an IRF referral.

Methods: We included subjects with a primary diagnosis of ischemic stroke, subarachnoid hemorrhage, or intracerebral hemorrhage who were admitted to an urban CSC and discharged to a SNF from 1/2015 to 12/2021. Baseline demographics including gender, race, age, and risk factors were abstracted. Data were retrieved from both our EMR and Get With the Guidelines Stroke Database. Wilcoxon rank sum tests and chi square tests were used to analyze the data.

Results: 1120 patients with a stroke diagnosis were discharged to a SNF, of which 173 (15%) received an IRF referral after SNF discharge. Nine to 19% (mean=15, SD=3) of SNF patients received an IRF referral between 2015 and 2021. Patients with an IRF referral were younger (mean age: 61.90, SD=14.05 vs 73.09, SD=12.12; p < 0.0001). There were no statistically significant differences in length of stay, discharge mRS, and prevalence of hypertension, diabetes mellitus, coronary artery disease, dyslipidemia, heart failure, and smoking. Men more frequently received an IRF referral (20% vs 11%, p < 0.0001). Racial differences in referral patterns were not significant (p = 0.19).

Conclusions: SNFs are an effective bridge between the hospital and IRF settings, given that 15% of all stroke patients discharged to a SNF were ultimately referred to an IRF. SNFs should be considered as an alternate route for post-stroke patients who are not immediately ready for IRFs after hospital discharge but may still benefit from IRF therapy.

Abstract NS1: Depression Vs Psychiatry Appointments Post Stroke Discharge Phone Call

Background: Post-stroke depression (PSD) affects up to one-third of stroke survivors and remains under-recognized. The optimal time for PSD screening seems to be about 30-45 days post-stroke. However, screening and follow up remains insufficient.

Methods: Our stroke certified registered nurse contacted stroke patients admitted to Kaiser Permanente Los Angeles in 2021 to assess depression within 30-45 days post discharge using the Patient Health Questionnaire Screening Tool (PHQ9). Two call attempts were made. Based on the PHQ9 scores, patients were referred to different clinical care pathways. Patients who scored10-19 were referred to depression care management (DCM), while 20 and above were referred to psychiatry directly. We collected the demographics, stroke types and discharge disposition inpatients who were lost to follow up and patients who completed the follow up. Data were analyzed using R-Statistics.

Results: Among 92 patients, 41 (45%) had follow-up depression screening completed; 13 (32%)received psychiatry referral given severity of depression, and 28 (68%) received a depression care management referral. Of 51 patients who did not complete follow-up screening, 27 (53%)declined to participate in screening, while 22 (43%) could not be reached. Patients who did not receive follow-up screening were older (P=0.02). Race, gender, discharge mRS or length of acute hospital stay did not have a significant effect on patient’s depression screening follow-up status. Patients discharged home with home health showed a trend for better completed follow-ups despite not reaching statistical significance (P=0.07).

Conclusion: Raising awareness about the necessity of depression screening and its treatment is of utmost importance for reaching optimal recovery and rehabilitation potential in stroke patients. Post-discharge follow-up and education can be implemented to narrow the PSD recognition gap.

Abstract WP167: Pregnancy And Neonatal Outcomes After A Stroke In An Integrated Healthcare System

Background: Stroke in women of childbearing age is not only disabling but also has lifelong consequences for family planning. There are no large studies on maternal and fetal outcomes in patients with a history of stroke.

Methods: We retrospectively collected data from January 2004 to December 2021 on women aged 18-50 years, who had a pregnancy following their cerebrovascular event (CVE) using ICD-10 codes to identify the eligible subjects. Demographic data including maternal age, race, gestational age, mode of delivery, associated medical conditions were collected.

Results: 219 patients were included in this cohort with a mean age of 29.1±6.2 at the time of CVE, and a median time between CVE and delivery of 34 months (IQR:13-65). 17 (7.8%) had history of factor V Leiden, Protein C deficiency or lupus associated hypercoagulable state. The initial CVE was identified as acute ischemic stroke in 77 (35.2%), transient ischemic attack (TIA) in 64 (29.2%), subarachnoid hemorrhage in 46 (21%), intracerebral hemorrhage in 23 (10.5%), and cerebral venous thrombosis in 9 (4.2%). The maternal adverse events were seen in 38 (17.3%) patients: 29 (13.2%) with HELLP Syndrome/eclampsia/pre-eclampsia, and 9 (4.1%) with recurrent TIA/stroke within 1 year after pregnancy. The rate of maternal adverse events decreased 5 years after the index stroke (Figure 1A). Patients with a history of stroke were at higher risk of having preterm delivery 38 (17.4%) than the general population. 27 (12.3%) of newborn infants had 1min Apgar<7 while 6 (2.7%) had 5 min Apgar<7. The rate of neonatal poor outcomes (preterm birth or Apgar<7) decreased over time (Figure 1B).

Conclusion: The rate of maternal and neonatal adverse events are high in the first 5 years after the CVE and begin to decline thereafter.

Abstract 74: Transition To Tenecteplase From Alteplase Improves Ambulance And Interfacility Transfer Time Metrics In A Large Regional Healthcare System

Introduction: The effect of tenecteplase (TNK) use on reducing interfacility transfer times and ambulance-based metrics for patients with a large vessel occlusion (LVO) eligible for endovascular thrombectomy (EVT) is not well studied. We analyzed how the administration of IV-TNK vs IV-tPA affected the Door In Door Out time (DIDO) as well as two novel ambulance-based metrics in patients arriving to the emergency department (ED) with an LVO who were transferred from 13 primary stroke centers to undergo EVT.

Methods: Data were retrospectively abstracted for patients with an LVO from 09/2020 to 04/2022. Median DIDO times were calculated for patients who received no thrombolysis, tPA, and TNK. Subgroup analyses were performed for two novel time metrics, Door to Ambulance Arrival (DAA) and Ambulance Arrival to Ambulance Departure (AAAD), for patients that received IV thrombolysis. Statistical analysis was performed using the Wilcoxan rank sum and chi square tests.

Results: There were 191 patients with AIS and an LVO. 130 received no IV thrombolysis and 62 received IV thrombolysis (32 tPA vs 29 TNK). There were no significant differences in baseline demographics between the thrombolysis and non-thrombolysis groups. Our sample was diverse in ethnicity with 60.7% being non-white. DIDO (TNK: 73 min {IQR 59-107} vs tPA: 106 min {IQR 88-137}, p = 0.01), DAA (TNK: 52.5 min {IQR 38-84} vs tPA: 77 min {IQR 61-105}, p = 0.03), and AAAD (TNK: 16.5 mins {IQR 10-22} vs tPA: 22 mins {IQR 18-40}, p = 0.01) were all faster for TNK cases compared to tPA cases. 58.5% of the TNK cases had a DIDO of ≤ 90 minutes vs 34.4% of tPA cases.

Conclusions: Switching from IV-tPA to IV-TNK improved the DIDO by 33 minutes. This improvement was driven by two novel DIDO metrics: Door to Ambulance Arrival Time (DAA) and Ambulance Arrival to Ambulance Departure Time (AAAD) likely because the absence of a tPA infusion (drip & ship) allowed the use of non-critical care ambulances, which are more widely available, to transport patients.

Abstract NS2: The Optimal Timing Of Nurse-driven Depression Identification: 7 Vs. 30-45 Days Post Discharge

Introduction: Post-stroke depression (PSD) is under-recognized and affects the recovery and rehabilitation of stroke patients. PSD affects one-third of stroke survivors, but there is little known when to screen for depressive symptoms. The purpose of this study is to determine the optimal timing of depression screening at 7 days vs. 30-45 days post discharge.

Methods: All stroke patients received a phone call from a stroke certified RN (SCRN) to assess depression within 7 days and within 30-45 days post discharge using the Patient Health Questionnaire Screening Tool (PHQ9). Three call attempts were made. Data were analyzed from 2018 to 2020. Based on the PHQ9 scores, patients were referred to different clinical care pathways. Patients who scored 1-9 received lifestyle modification information, 10-19 were referred to depression care management, 20 and above were referred to psychiatry. The number of patients evaluated and the percentage of those who were referred to specific pathways were assessed. Data were analyzed using a t-test.

Results: Stroke subtype were as follows: 17% ICH, 80% ischemic, 2% SAH. 1001 patients were called: 564 at 7 days, 437 at 30-45 days. 421 (75%) at 7 days and 277 (63%) at 30-45 days were reached. 11 (3%) at 7 days, 30 (11%) (p=0.045) at 30-45 days scored ≥10 on the PHQ9. Of those who scored ≥10 on PHQ9, 28 (68%) were female and more than half were over the age of 65. 91% of patients had NIHSS ≤5.

Conclusion: A higher percentage of patients with PHQ9 ≥10 was detected within 30-45 days post discharge. The 30-45 day time period is more optimal to detect PSD than the 7-day time period post discharge.

Abstract NS6: ED Pause: A Nursing Driven Approach To Improving Thrombectomy Times

Introduction: The current Joint Commission recommendation for door to skin puncture is less than 60 minutes for transfer cases. It is imperative that no time is lost in moving these patients safely through the Emergency Department (ED) to the Interventional Radiology (IR) Suite. The goal of this study was to assess if a rapid, 11-step nursing driven checklist could decrease time spent in the ED and subsequently improve our thrombectomy times in transfer patients.

Methods: We developed the following 11 steps: (1) ED staff is notified of incoming ED Pause transfer. (2) ED receives report from sending facility RN. (3) Register the patient upon arrival.(4) Activate EMS Stroke alert. (5) Verify patient’s identity using two patient identifiers, apply wristband. (6) Vital signs (to ensure no decompensation en route), connect patient to the transport monitor. (7) Chart weight in the system. (8) Confirm two working IVs. (9) Confirm negative Covid test or send a rapid if a negative Covid test cannot be confirmed. (10) Ensure the patient is undressed and ready to go to IR. (11) Confirm the “admit to inpatient” order is placed. ED staff were educated and checklists were posted in the ambulance bay and nurses’ station. Data were reviewed pre- (April 2019 to March 2020) and post- (April 2020 to March2021) implementation to assess the percentage of patients captured by the tool and its impaction thrombectomy times. Data were analyzed using a t-test.

Results: There were 25 patients transferred in the post vs 16 in the pre-implementation group. The median door to skin puncture (DTS) (post: 37 mins {IQR 31-43} vs. pre: 50 mins {IQR 47-71}p=0.045), door to device deployed (post: 52 mins {IQR 45-65} vs. pre: 70 mins {IQR 65-94}p=0.037), and door to recanalization (post: 71 mins {IQR 54-102} vs. pre: 99 mins {IQR 70-118}p=0.043) times decreased in the post implementation group.

Conclusion: A nursing driven ED checklist is a successful tool in decreasing thrombectomy times in transfer patients.

Abstract WP207: Switching Antiplatelets In Breakthrough Ischemic Stroke: Long Term Outcomes And Safety

Introduction: Previous studies have shown that switching antiplatelets after having an ischemic stroke on aspirin may have better outcomes. However, these studies included patients who were switched to dual antiplatelets, which have an established benefit in the immediate post-stroke period. The purpose of this study is to assess outcomes in patients who continue aspirin versus switch to clopidogrel after having a cerebrovascular event on aspirin.

Methods: We retrospectively identified patients within 14 Southern California hospitals using ICD-9 and ICD-10 codes who had a diagnosis of ischemic stroke on aspirin from January 2017-December 2019. Outcomes included recurrent hospital admission or emergency room visit for ischemic stroke, TIA, or intracranial hemorrhage up to two years post index event. Patients were grouped by which antiplatelet was prescribed at discharge. Those prescribed dual antiplatelets or an anticoagulant were excluded. Cox regression analysis was used to estimate risk of readmission.

Results: Of the 580 patients who met the inclusion criteria, 372 (64%) continued aspirin and 208 (36%) switched to clopidogrel. Those with coronary artery disease (55.0% versus 45.0%, p = 0.015), dyslipidemia (61.4% versus 38.6%, p = 0.001), diabetes (59.5% versus 40.5%, p = 0.007), and a higher NIHSS score (mean 6.06 +/- 6.96 SD versus 4.08 +/- 4.32 SD, p = 0.001) were more likely to be discharged on aspirin. There were no differences in recurrent ischemic stroke {18.8% versus 15.4%, HR 1.12 (95% CI, 0.74-1.72), p = 0.587}, ischemic stroke plus TIA {19.9% versus 18.3%, HR (95% CI, 0.84-1.86), p = 0.253}, systemic embolism {25.5% versus 21.6%, HR 1.16 (95% CI, 0.82-1.66), p = 0.413} or intracranial hemorrhage {3.2% versus 2.4%, HR 0.94 (95% CI, 0.34-2.70), p = 0.919} between those discharged on aspirin versus clopidogrel, respectively.

Conclusion: This study suggests that switching antiplatelets after having an ischemic stroke on aspirin may not be warranted.

Abstract P858: The Impact of a Dedicated Stroke Program Quality Coordinator Registered Nurse on the Volume of Performance Improvement Projects

Background: Performance Improvement (PI) enhances processes, services, and outcomes. The Joint Commission (TJC) standards require a comprehensive approach to PI. This can be challenging due to variability of staffing within a stroke program. The stroke coordinator is often left to manage PI projects, which can be arduous due to the multiple demands of their role. A dedicated Stroke Quality Coordinator RN (SQCRN) manages quality improvement activities solely for the stroke program. It is a unique position that requires clinical knowledge of stroke, neuro-interventional and neurosurgical procedures, as well as, comprehension of regulatory requirements, PI and data analysis.

Purpose: To determine if having an SQCRN dedicated to a stroke program results in an increased number of PI Projects implemented.

Methods: The SQCRN initiative was implemented in 2020 with the objective of determining the impact of having a dedicated SQCRN on the number of projects completed. A survey was created consisting of 5 questions and sent to 328 individuals via email utilizing an anonymous Microsoft Forms Link. The survey was emailed to the Los Angeles Stroke Coordinator Network and National Stroke Coordinator group. Fifty-eight (17.6%) responded. Survey results were compared for stroke programs with a Dedicated SQCRN to those without. Data were analyzed using T-Test.

Results: In stroke programs with a dedicated SQCRN, there were more respondents who reported 6 or greater PI projects than stroke programs who did not have a dedicated SQCRN. This was statistically significant when compared to both 2 or less (p=0.001) or 4 or less projects p=0.035.

Conclusion: A dedicated SQCRN improves the number of PI projects that a stroke program can implement. PI initiatives help to improve the safety, treatments, services and quality of care in order to improve patient outcomes.

Abstract 46: An Innovative Approach to the Bedside Nursing Swallow Screening Tool: Can Be Used as a Trigger for an Inpatient Cognitive Evaluation to Improve Timeliness of Post-Discharge Cognitive Therapy Referrals

Background: According to the American Heart Association, a formal assessment of cognitive dysfunction caused by stroke is a level I recommendation. However, cognitive evaluation is often missed or overlooked in the inpatient setting. When and who performs the assessment is not well-defined. Stroke nurses can corroborate with clinicians in completing the Montreal Cognitive Assessment (MoCA) 8.1, a validated tool for assessing cognitive function in stroke patients.

Purpose: The purpose of this study was to evaluate the process of using the bedside nursing swallow screen (NSS) as a trigger for an inpatient cognitive evaluation by the Speech Therapist (ST). This study was also used to determine if post-discharge cognitive therapy referrals were placed based on the MoCA scores.

Methods: All STs completed the required MoCA certification. The new process was implemented in October 2019. Data were analyzed from October 2019 through March 2020. NSS was performed on newly admitted stroke patients. If failed, an ST consult was ordered for a dysphagia evaluation. However, if passed, a cognitive evaluation consult was triggered by the RN. MoCA was completed within 24 hours. The total possible score is 30; a score of 26 or above is considered normal. A MoCA score of 25 or less, prompted a post-discharge cognitive therapy referral.

Results: 229 patients were assessed, all of whom had an NSS completed. 120 (52.4%) passed the NSS, of which 85 (71%) completed a MoCA evaluation. 42 (49.4%) scored 25 or less, of which 35 (83.3%) were referred for a post-discharge cognitive therapy. 7 (17%) had no referral, of which 4 (57%) were discharged home to self-care; 2 (29%) discharged to other healthcare facility; and 1 (14%) left against medical advice.

Conclusions: Repurposing the NSS as a standardized tool to trigger an inpatient MoCA evaluation was innovative, practical and efficient. Timely post-discharge cognitive therapy referrals were also evident on MoCA scores of 25 or less.

Abstract P822: In-Hospital Stroke Treated With IV tPA at a Comprehensive Stroke Center Compared to Primary Stroke Centers Pre and Post Telestroke Implementation

Introduction: In-hospital strokes (IHS) often have delayed recognition time and a delay in physician assessment, playing a role in unfavorable outcomes. Telestroke (TS) participation is linked to lower odds of hospital mortality and is safe and effective in treating acute ischemic stroke. We implemented a TS program for IHS patients at primary stroke centers (PSC) and assessed tPA time metrics, complications and 90-day functional outcomes as compared to a robust in hospital stroke system of care at a comprehensive stroke center (CSC).

Methods: Using a network database, data for all in-hospital code strokes were retrospectively abstracted between 2010-2020 at a CSC and 11 PSC’s. The CSC was compared to PSC’s pre and post implementation of a TS program. Data were analyzed using Wilcoxon rank-sum test, chi-square and exact tests.

Results: We identified 193 patients, 77 at the CSC, 71 at pre-tele PSC’s, and 45 at post-tele PSC’s. Symptom-recognition-time (SRT) to neurology evaluation (median 15min {IQR 10-27} vs 75min {IQR 45-126, p=<0.0001) and SRT to IV t-PA (median 65min {IQR 46-91} vs 94min {IQR 73-112}, p=<0.001) were all faster at the CSC vs pre-tele PSC’s. There was no difference in rate of complications (p=0.05). When stroke mimics were excluded, CSC patients had a favorable 90-day mRS of 0-1 (24 patients, 35% vs 11 patients, 19%, p=0.04). After implementation of TS at PSC’s, there was no difference in tPA time metrics, except SRT to neurology evaluation remained faster at CSC (median 15min {IQR 10-27} vs 31min {IQR 18.5-52.5}, p=0.0002). There was no difference in rate of complications (p=0.21) and mRS at 90 days (p=0.82).

Conclusions: Implementation of a TS program for IHS at PSC’s may improve tPA time metrics and 90 functional outcomes to the standards of CSC’s without increasing complication rates. Our study was limited by retrospective design and small sample size.

Abstract P313: Feasibility of Nurse-Driven Identification of Depression in the Setting of Stroke at 30 Days Post Discharge

Background: Poststroke depression (PSD) is under-recognized and affects the recovery and rehabilitation of stroke patients. PSD affects one-third of stroke survivors and there is little known when depressive symptoms manifest. Early identification of PSD may reduce its related functional impairment and mortality.

Purpose: The purpose of this study is to demonstrate the feasibility of nursing driven depression identification at 30-45 days post discharge.

Methods: All primary stroke patients received a phone call from SCRN to assess depression between 30 to 45 days post discharge using the Patient Health Questionnaire (PHQ9). Three attempts were made per patient. Data were analyzed from August 2019 thru March 2020. Based on the PHQ9 scores, patients were referred to different clinical care pathways. Patients who scored 1-9 received lifestyle modification information, 10-19 were referred to depression care management (DCM), 20 and above were referred to psychiatry. The number of patients evaluated and the percentage of those who were referred to specific pathways were assessed.

Results: 427 patients were discharged with a stroke diagnosis. 197 (46.1%) completed the PHQ9 assessment. 14 (7%) were ages 18 to 44 years, 65 (33%) were 45 to 64 years, and 118 (60%) were 65 years and above. 92 (47%) were female. 64% were Caucasian, 19% Asian, 13% Black, and 5% Other. 30% were Hispanic. 72% were ischemic, 19% ICH, and 9% SAH. 230 patients (53.9%) were not able to complete PHQ9. 88 (38%) were unavailable, and 120 patients (52%) were not able to participate due to stroke severity. 20 (10%) were referred to DCM and/or psychiatry.

Conclusions: Nurse-driven 30-day PHQ9 assessment is feasible and identifies patients with depressive symptoms. The 30-45-day post-stroke timeframe may be reasonable to diagnose depression after an acute stroke.

Abstract P816: Nurse-Driven Rapid Covid-19 Testing in Emergency Department Stroke Patients

Introduction: The COVID-19 pandemic presents obstacles to time sensitive emergencies, such as stroke care. In acute strokes, knowing the COVID-19 status may help to preserve personal protective equipment (PPE) in patients in whom a thrombectomy may be indicated and helps to decrease unnecessary exposure. This study aims to demonstrate that rapid evaluation of a patient’s COVID-19 status is feasible without delaying treatment times.

Methods: An intradisciplinary team was convened to create a workflow for rapid COVID-19 testing. The Abbott Rapid® COVID-19 swab kit and assay were stocked in the ED Pyxis, utilizing the narcotic count feature to ensure all swabs were accounted. Upon activation of Code Stroke, the ED RN donned PPE and swabbed the patient’s naso-oral pharynx. The collected swab was labeled, placed in a bio-hazard bag, sanitized and handed to a second RN outside of the room. The specimen was taken to a pre-alerted lab technician who prepped the assay after hearing the code stroke. After specimen collection, the patient followed the normal code stroke pathway and was taken to the CT scanner. Metrics were analyzed for the pre COVID-19 (January through April) and during active COVID-19 (May through July) periods.

Results: There were 136 code strokes from January thru July 2020. 81 were during pre-COVID vs. 55 during active-COVID. 47 of 55 (96%) were swabbed, 2 (4%) of whom were positive. There was no difference between pre-COVID and active-COVID door to CT initiated time (16 mins [IQR 13-24] vs. 22 mins [IQR 13-25] p=0.75), door to CT resulted time (21 mins [IQR 15-26]) vs. 23 mins [IQR 16-29] p=0.63). 18 patients received tPA pre-COVID and 5 during active-COVID with no difference in DTN (pre: 37.5 mins [IQR 30-43] vs. active: 28 mins {IQR 26-41] p=0.37). Door to CT initiated was faster for those who had their COVID swab performed pre-CT (14 mins [IQR 11.5-16.5] p=0.034) vs. post-CT (20 mins [IQR 17-28]). Likewise, door to CT resulted was also faster pre-CT: 24 mins [IQR 19-32] vs. post-CT: 17 mins [IQR 15-23] (p=0.04).

Conclusion: The COVID-19 rapid swab code stroke process was feasible and did not delay treatment times.

Abstract MP1: Safety and Efficacy of IV-tPA for Acute Ischemic Stroke After Transcatheter Aortic Valve Replacement

Introduction: Peri-procedural acute ischemic stroke (AIS) risk after Transcatheter Aortic Valve Replacement (TAVR) is between 3% to 6.7%, and administration of IV-tPA for its management is not well studied. We analyzed patients who had peri-procedural AIS after TAVR and compared those treated with IV-tPA to those who were not.

Methods: Data were retrospectively abstracted for patients with an AIS after TAVR within a large regional healthcare system. Baseline demographics were analyzed using the Pearson Chi-Square test. Post AIS outcomes (bleeding events, cardiac events, and functional outcomes) were analyzed using the Pearson Chi Square test and Kruskal-Wallis test.

Results: From 2011 - 2019, 779 patients underwent TAVR, of which 22 (2.6%) had peri- procedural AIS. 8 received tPA and 14 did not. There was no difference in baseline characteristics. See Table 1. During index hospitalization, there were more groin bleeding events in the tPA group (6 {75%} in tPA vs. 0 {0%} in non-tPA p=0.005). More patients in the tPA group had a trend towards a drop in hemoglobin by 2 g/dL and total aggregate bleeding events. There were no differences in symptomatic ICH, other intracranial bleeding, post-procedural Afib/flutter, post-procedural new CHF, and discharge functional outcomes. At 90 days, there were no differences in safety outcomes and median 90-day mRS.

Conclusions: This is the largest case series to describe patients who had AIS after TAVR and received tPA. There was no difference between adverse neurological or cardiac outcomes at discharge and 90 days in the tPA group vs. non-tPA group. More tPA patients had groin bleeding, which did not cause any long-term functional impairment. There was a trend toward tPA patients having a lower discharge NIHSS. Overall, tPA appears to be a safe intervention for AIS after TAVR. More evidence is needed to determine its efficacy in TAVR patients.

Abstract P16: Alteplase Within 4.5 Hours via Telemedicine and In-Person for Central or Branch Retinal Artery Occlusion vs Medical Management

Introduction: Central or branch retinal artery occlusion (CRAO/BRAO) results in acute monocular vision loss. Only one prospective study of IV tPA use within 4.5 hours with a recent updated patient-level meta-analysis showed favorable visual outcomes but long-term visual outcomes were not reported. We evaluated the use of IV tPA within 4.5 hours for CRAO/BRAO vs medical management and assessed 90-day visual outcomes. Given the increasing use of telemedicine (TM), we also assessed the diagnostic accuracy of CRAO/BRAO evaluated via TM vs in-person.

Methods: Data were retrospectively abstracted for CRAO/BRAO treated with IV tPA vs medical management within a large managed healthcare system. 90-day visual outcomes were reported as Low Vision (no light perception, light perception, hand motion, finger counting) and mean LogMAR, which was converted from Snellen, and classified as normal-mild impairment (LogMAR 0.4-0.5), moderate-severe impairment (LogMAR 0.6-1.3) and blind-low vision (LogMAR >1.3). Visual outcomes were analyzed using the Wilcoxon rank-sum and signed-rank tests.

Results: Between 2012-2019, 21 patients received IV tPA within 4.5 hours for presumed CRAO/BRAO vs 34 medically managed. One patient evaluated via TM and one patient evaluated in-person were misdiagnosed and excluded from analysis. Of those accurately diagnosed and treated with IV tPA, 15 were evaluated via TM and 4 in-person. At 90 days, intragroup analysis revealed at least a one-point improvement on the Low Vision scale (68% tPA, p= 0.007 vs 30% non-tPA, p=0.63) and the LogMAR scale (32% tPA, p=0.03 vs 12% non-tPA, p=0.38) with 26% of tPA patients having normal-mild impairment in vision vs 9% in non-tPA patients. Initial to 90-day vison on the Low Vision scale showed visual improvement in the tPA group (p=0.001) and a trend towards improvement on the LogMAR scale (p=0.07).

Conclusions: Similar to a recent prospective study with patient level meta-analysis, we found that IV tPA within 4.5 hours for CRAO/BRAO may lead to improved visual outcomes at 90 days compared to medical management. Diagnostic accuracy of CRAO/BRAO was similar irrespective of method of being evaluated via TM or in-person. Our study was limited by small sample size and retrospective design.

Increased Access to and Use of Endovascular Therapy Following Implementation of a 2-Tiered Regional Stroke System

Background and Purpose—

We quantified population access to endovascular-capable centers, timing, and rates of thrombectomy in Los Angeles County before and after implementing 2-tiered routing in a regional stroke system of care.

Methods—

In 2018, the Los Angeles County Emergency Medical Services Agency implemented transport of patients with suspected large vessel occlusions identified by Los Angeles Motor Scale ≥4 directly to designated endovascular-capable centers. We calculated population access to a designated endovascular-capable center within 30 minutes comparing 2016, before 2-tiered system planning began, to 2018 after implementation. We analyzed data from stroke centers in the region from 1 year before and after implementation to delineate changes in rates and speed of administration of tPA (tissue-type plasminogen activator) and thrombectomy and frequency of interfacility transfer.

Results—

With implementation of the 2-tier system, certified endovascular-capable hospitals increased from 4 to 19 centers, and within 30-minute access to endovascular care for the public in Los Angeles County, from 40% in 2016 to 93% in 2018. Comparing Emergency Medical Services–transported stroke patients in the first post-implementation year (N=3303) with those transported in the last pre-implementation year (N=3008), age, sex, and presenting deficit severity were similar. The frequency of thrombolytic therapy increased from 23.8% to 26.9% (odds ratio, 1.2 [95% CI, 1.05–1.3]; P =0.006), and median first medical contact by paramedic-to-needle time decreased by 3 minutes ([95% CI, 0–5] P =0.03). The frequency of thrombectomy increased from 6.8% to 15.1% (odds ratio, 2.4 [95% CI, 2.0–2.9]; P <0.0001), although first medical contact-to-puncture time did not change significantly, median decrease of 8 minutes ([95% CI, −4 to 20] P =0.2). The frequency of interfacility transfers declined from 3.2% to 1.0% (odds ratio, 0.3 [95% CI, 0.2–0.5]; P <0.0001).

Conclusions—

After implementation of 2-tiered stroke routing in the most populous US county, thrombectomy access increased to 93% of the population, and the frequency of thrombectomy more than doubled, whereas interfacility transfers declined.

Abstract WP105: A Practical Wake up Tpa Protocol at a United States Based Comprehensive Stroke Center Hub and Its Telestroke Spokes

Background: IV tPA is established as an effective treatment for acute ischemic stroke. Currently it is endorsed up to 4.5 hours of last known well time by major guidelines. A randomized trial, WAKE-UP, displayed its safety and efficacy in patients who presented within 4.5 hours of waking up with their symptoms.

Objective: To establish a practical tPA protocol for patients who wake up or are found with stroke symptoms at a large Comprehensive Stroke Center (CSC) and its 13 telestroke spokes (TS) based on the WAKE-UP trial.

Methods: A wake up tPA protocol was created and given to all teleneurologists. Door to needle times (DTN) and reasons for no tPA were collected for 12 months post implementation and evaluated for differences between wake up (WU) and non-wake up (NW) patients.

Results: 93 WU patients were identified; 23 at CSC and 70 at TS. 11 (47.8%) vs. 4 (5.7%) patients received tPA at CSC and TS, respectively. Median DTN was not significantly different for WU patients at CSC vs. TS (64 vs. 89 mins, p=0.54). Median DTN at CSC was shorter for NW vs. WU (37 vs. 64 mins; p=0.003). Similarly, median DTN at TS trended toward being shorter for NW vs. WU (44 vs. 89 mins; p=0.062). The reasons for no tPA at CSC were no mismatch found in 6 (50%), and MRI unavailability in 6 (50%); at TS were no mismatch found in 11 (16.6%), MRI unavailability in 54 (81,1%) and MRI was contraindicated in 1 (1.5%).

Conclusion: Treating WU patients using a CSC Hub and TS model is feasible. DTN are longer for WU vs. NW. In the United States, MRI availability is the main barrier to WU tPA at both CSC and community hospitals. The difference between median DTN for WU between CSC and TS did not reach statistical significance, likely due to the small sample size.

Abstract WP435: Post Procedural Monitoring Tool Improves the Joint Commission Comprehensive Stroke Center Standard Compliance

Background: The Joint Commission (TJC) Comprehensive Stroke Center standard requires monitoring of patients after IV tPA administration, diagnostic angiography, aneurysm coiling, carotid angioplasty and stenting, mechanical endovascular reperfusion (MER) and carotid endarterectomy. Meeting 100% compliance of the standard is challenging. In 2018, monitoring and documentation were among the TJC’s top ten cited survey findings.

Purpose: To determine if an electronic tool can improve documentation compliance and reduce delays in monitoring of vital signs, and neurologic, pedal pulse and skin site assessments.

Methods: The initiative was implemented in 2018 with the objective for all patients to have 100% of their post procedural monitoring completed. A documentation tool was created and introduced to nursing units via annual stroke education updates. The tool was added to an online nursing resource SharePoint website and application, which was accessible to all nurses within the hospital. The procedure end time was entered in the tool, which automatically calculated the documentation times. Data was compared 12 months pre and post intervention. Analysis and reporting of data were conducted monthly via the program’s quality oversight committee. Data was analyzed using T-Test.

Results: In post-IV tPA patients, more patients had 100% complete documentation (79% post vs. 29% pre-implementation; p=0.006). For all post neuro-interventional radiology procedures, more patients had 100% complete documentation (68% post vs. 17% pre-implementation; p<0.001). For post carotid endarterectomy revascularization, there was a trend toward more patients with 100% complete documentation (83% vs 38%; p=0.07).

Conclusion: Utilization of an electronic monitoring tool for post procedural documentation adherence can improve the percentage of patients who have 100% completed assessments and help meet the TJC standard.

Abstract WP430: Implementation of Inpatient Stroke Champions Leads to Improved Inpatient Code Stroke Metrics

Introduction: Stroke Champions (SC) are AHA recommended designated inpatient nurses that serve as expert resources for their units to ensure that evidence-based practices for stroke care are implemented. Inpatient Code Strokes (ICS) are difficult to recognize which results in delayed treatment. The purpose of this study is to determine if there was an improvement in inpatient acute stroke metrics with the addition of SC in the hospital.

Methods: Over a 12-month period at a Comprehensive Stroke Center (CSC), 12 nurses in the inpatient stroke units were trained as SC. This training consisted of advanced education in CSC metrics, guidelines and required documentation. SC provided peer-to-peer education, served as expert resources, conducted comprehensive chart reviews, shift huddles, and “on the spot” feedback to nurses and physicians. The metrics were examined pre and post intervention and included: Symptom Recognition Time (SRT) to CT interpretation, SRT to tPA bolus time, and SRT to groin puncture. SRT is equivalent to Emergency Department door time for inpatient strokes. Statistical analysis was performed using T-test and the Mann-Whitney test.

Results: There were 114 pre-SC and 101 post-SC ICS. There was a trend toward more patients being accurately diagnosed with a TIA or stroke (75.3% post vs. 65.8% pre-SC; p=0.06). The SRT to CT interpretation time for patients who received tPA improved from 43 to 35 mins. The number of patients treated with tPA increased from 10 to 17. SRT to tPA bolus time trended toward improvement from 57 to 42 mins (p=0.07). SRT to groin puncture time in patients who received both tPA and thrombectomy trended toward improvement from 81 vs. 65 mins (p=0.07). There were twice as many inpatient thrombectomy cases in post-SC (n=23) vs. pre-SC (n=12).

Conclusion: The knowledge and expertise provided by SC resulted in a higher percentage of ICS having a final diagnosis of stroke. This demonstrates an increased accuracy of stroke specific symptom recognition by the inpatient nursing teams. There was improved SRT to tPA bolus and groin puncture time. This is the only study that shows implementation of the AHA recommended SC program improves inpatient code stroke recognition and treatment metrics.

Abstract TP377: Nurse Entered Stroke Order Sets Improve Emergency Department Metrics at a Comprehensive Stroke Center

Introduction: The Joint Commission has established time sensitive metrics for stroke care in the Emergency Department (ED) including door to initial physician evaluation, door to lab and CT order placement, door to lab resulted and door to CT interpretation.

Purpose: The purpose of this quality improvement project was to assess if nurse entered protocolized order sets for stroke patients would help to improve these metrics.

Methods: A code stroke order set was initiated independently by nursing staff upon symptom recognition in the ED. The order set included CBC, electrolyte panel, BUN, creatinine, glucose, troponin, PT/INR, aPTT, non-contrast CT head, EKG, swallow screen and continuous cardiac monitoring. Data was collected for 3 months pre and post intervention. All ED nurses were trained on order set entry and their skills were validated. Data was analyzed using a T-Test.

Results: 60 patient pre and 52 post-implementation were evaluated. Door to initial physician evaluation was faster (7 mins pre vs. 5 mins post; p=0.029). Door to lab order placement was faster (8 mins pre vs. 3 mins post; p=0.038). Door to CT ordered was faster (8 mins pre vs. 6 mins post; p<0.01). Door to labs resulted was faster (32 mins pre vs. 27 mins post; p=0.01). Door to CT interpretation was faster (19 mins pre vs. 18 mins post; p=0.04).

Conclusion: Implementation of nurse entered order sets can improve ED metrics for door to initial physician evaluation, door to lab and CT order placement. This subsequently led to faster interpretation of the CT scan and lab results.

Abstract TP46: Evaluation of Aspiration Thrombectomy versus Anticoagulation in a Large Cohort of Patients With Cerebral Venous Sinus Thrombosis

Introduction: Cerebral venous sinus thrombosis (CVST) is an uncommon cause of stroke. Studies have assessed the efficacy of aspiration thrombectomy (AT), but have been limited to smaller populations, and AT was often reserved for patients with worsening neurological deterioration, which itself portends a poor prognosis.

Purpose: To compare outcomes of AT vs. medical management (MM) in a large referral population without neurological deterioration at a single Comprehensive Stroke Center.

Methods: We retrospectively identified patients using ICD-10 codes within our network between 2007-2017. Baseline demographics and clinical data were abstracted. Mann-Whitney U test and chi-square test were used for continuous and categorical variables, respectively.

Results: 383 patients were identified, and 99 were excluded due to age <5, cortical vein or cavernous sinus thrombosis, and venous stenosis. 284 were analyzed; 237 in MM and 47 in AT. There was no difference in baseline demographics or imaging modality. AngioJet™ was used in 90% of AT patients. Focal neurological deficit on presentation (57% vs 35%, p = 0.0033) and venous/hemorrhagic infarct on imaging (68% vs 37%, p = 0.001) was more common in AT. More patients received AT if superior sagittal plus any other venous sinus or straight sinus alone was involved (66% vs 32%, p = 0.003). All in AT received anticoagulation; 25 in MM did not due to perceived risks (100% vs 89%, p = 0.0194). MM had a better modified Rankin Score (mRS) at discharge (mRS 0-1: 72% vs 50%, p = 0.0037). There was no difference in mRS at 3, 6 and 12 months, and the development of chronic daily headache, migraine, or epilepsy. Subgroup analysis using those with only superior sagittal plus any other venous sinus or straight sinus alone showed MM had a better mRS at discharge (mRS 0-1: 68% vs 42%, p = 0.014).

Conclusion: This study shows that MM was more likely to have a favorable outcome at discharge than AT. No difference in outcome measured at 3, 6 and 12 months was seen.

Abstract 139: Inpatient Nursing Stroke Champions Improve Stroke Education Retention at 7 Days and 90 Days Post Discharge

Background: Patients with deficient stroke knowledge characteristically present to the hospital outside the treatment window. Providing effective inpatient stroke education motivates patients to change their modifiable risk factors, hence reducing the threat of a secondary stroke.

Purpose: The purpose of this study is to validate the effectiveness of the American Heart Association’s Get with the Guidelines Stroke Champion (SC) Program. Inpatient Nursing SC (INSC) endeavored to optimize patients’ retention of stroke education. This study is one of the first to provide data supporting the use of INSC to improve stroke education retention post discharge.

Methods: The INSC initiative was implemented in 2017. Data was compared 6 months pre and post intervention. INSC conducted chart reviews, provided peer to peer feedback, implemented “1 Learner 1 Topic” education theme per shift, and ensured education throughout the care continuum. The aggregate data was collected from 7day survey calls (n=340) and stroke-specific HCAHPS topbox survey scores completed by the patient at 90 days post discharge (n=155). Statistical analysis was performed using a chi-squared test.

Results: At 7 days, more patients were able to recall stroke risk factors and prevention (54% pre vs. 85% post intervention; p<0.003), and stroke symptoms (54% pre vs. 95% post; p<0.003). At their 90day HCAHPS survey, more patients were able to recall the stroke risk factors and prevention (52% pre vs. 67% post intervention; p<0.05) and stroke symptoms (61% pre vs. 71% post; p=0.003). A trend towards more patients recalling the knowledge and diagnosis of their stroke based on their HCAHPS was seen (59% pre vs. 66% post intervention; p=0.07).

Conclusions: Implementation of an INSC can improve patients’ retention of stroke symptoms, risk factors, prevention, and cause at 7 days and 90 days post discharge.

Abstract TP372: BRAIN ALERT: An Emergency Department Initiative to Improve Time Metrics for Patients that Walk in with Stroke Symptoms

Introduction: Patients with minor stroke symptoms tend not to call 911. They often come to the Emergency Department (ED) via personal transport, and walk in through the triage area. These patients historically have longer door to needle times. We established the Brain Alert (BA) nurse driven initiative with ED education on an algorithm applicable to patients who walk in with stroke symptoms. This study assesses the difference between time metrics before and after implementation.

Methods: BA metrics were based on the TARGET:STROKE guidelines. The intervention was an ED wide education of all ED staff on F.A.S.T symptoms and the BA process. The ED triage nurse was empowered to page a BA and rapidly initiate the bedding of the patient. The BA page triggered the stroke team to rapidly come to the ED and examine the patient simultaneously with the ED physician. Data were recorded for 6 months pre and post implementation. Outcomes included door to initial MD evaluation, stroke team notification, CT scan initiation and interpretation and thrombolytic administration (DTN). Fisher’s Exact and Wilcoxon Rank Sum Tests were used for data analysis.

Results: There were 38 walk in patients pre intervention vs. 36 post intervention. Thirteen (35.1%) BA activations occurred post intervention. The most common reason for not calling a BA was the patient did not have F.A.S.T symptoms. No differences in baseline demographics were found. CT scans were ordered and completed quicker post intervention (median ordered: 13.5 [IQR 7-18.5] mins post vs. 17.5 [IQR 12.5-22.5] mins pre, p=0.021), (median completed: 22.5 [IQR 18-27] mins post vs. 25 [IQR 20-30] mins pre, p= 0.024). A higher percentage of patients received thrombolytics ≤60 mins post intervention (84.6% vs. 78.7%), but was not statistically significant, p=0.41).

Conclusion: The BA process improved door to CT order and completion times. There was higher percentage of patients who received IVtPA ≤ 60 minutes, which did not reach statistical significance likely due to the small number of patients involved in the study. Institution of a specific algorithm to address patients who walk in with stroke symptoms into a hospital triage area, can result in improved code stroke time metrics.

Abstract WP321: Strokes in Your Own Backyard: A Hospital Wide Quality Improvement Initiative to Create and Improve Inpatient Code Stroke Metrics Which Lead to Quicker Interventions

Introduction: TARGET:STROKE (TS) has established metrics for hospitals to measure the timely administration of thrombolytics. However, these time metrics may not apply to patients who suffer a stroke while admitted to the hospital, since the initial time is the emergency department (ED) door time. The aim of this project was to create metrics and an algorithm applicable to an Inpatient Code Stroke (ICS), and assess a hospital wide education series to improve times to intervention.

Methods: ICS metrics defined by TS were established with the Symptom Recognition Time (SRT) to equate to the ED door time, and assessed pre and post intervention. The intervention was a hospital wide education of stroke symptoms, as well the ICS process. A badge reference card with this information was given to nurses. Data were recorded for 6 months pre and post implementation. Outcomes included SRT to stroke team notification, CT scan initiation and interpretation, thrombolytic administration and groin puncture. Fisher’s Exact and Wilcoxon Rank Sum Tests were used for data analysis.

Results: There were 86 ICS activations (34 pre and 51 post intervention). There was no difference in baseline demographics, and ICS activation based on unit type. Surgical patients were the most common to have an ICS activation (25.8%). There was a strong trend of SRT to stroke team notification being faster post intervention (median: 22 [0-435] mins pre vs. 12 [0-187] mins post, p=0.059). SRT to groin puncture was faster post intervention (median: 131 [0-286] mins pre vs. 67 [38-91] post, p=0.006). There were more patients who had SRT to thrombolytic ≤ 60 mins or SRT to groin puncture ≤ 90 mins post-intervention (4 [33.3%] pre vs. 10 [71.4%] post, p=0.036).

Conclusion: This is the first study to demonstrate that implementation of an ICS algorithm and its accompanying education can increase the percentage of patients who receive thrombolytics and groin puncture for thrombectomy ≤ 60 mins and ≤ 90 mins from SRT, respectively.

Multiparametric Magnetic Resonance Imaging for Prediction of Parenchymal Hemorrhage in Acute Ischemic Stroke After Reperfusion Therapy

Background and Purpose—

Patients with acute ischemic stroke are at increased risk of developing parenchymal hemorrhage (PH), particularly in the setting of reperfusion therapies. We have developed a predictive model to examine the risk of PH using combined magnetic resonance perfusion and diffusion parameters, including cerebral blood volume (CBV), apparent diffusion coefficient, and microvascular permeability (K2).

Methods—

Voxel-based values of CBV, K2, and apparent diffusion coefficient from the ischemic core were obtained using pretreatment magnetic resonance imaging data from patients enrolled in the MR RESCUE clinical trial (Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy). The associations between PH and extreme values of imaging parameters were assessed in univariate and multivariate analyses. Receiver-operating characteristic curve analysis was performed to determine the optimal parameter(s) and threshold for predicting PH.

Results—

In 83 patients included in this analysis, 20 developed PH. Univariate analysis showed significantly lower 10th percentile CBV and 10th percentile apparent diffusion coefficient values and significantly higher 90th percentile K2 values within the infarction core of patients with PH. Using classification tree analysis, the 10th percentile CBV at threshold of 0.47 and 90th percentile K2 at threshold of 0.28 resulted in overall predictive accuracy of 88.7%, sensitivity of 90.0%, and specificity of 87.3%, which was superior to any individual or combination of other classifiers.

Conclusions—

Our results suggest that combined 10th percentile CBV and 90th percentile K2 is an independent predictor of PH in patients with acute ischemic stroke with diagnostic accuracy superior to individual classifiers alone. This approach may allow risk stratification for patients undergoing reperfusion therapies.

Clinical Trial Registration—

URL: https://www.clinicaltrials.gov. Unique identifier: NCT00389467.

Safe and Effective Implementation of Telestroke in a US Community Hospital Setting

CONTEXT

There is substantial hospital-level variation in use of tissue plasminogen activator (tPA) for treatment of acute ischemic stroke. Telestroke services can bring neurologic expertise to hospitals with fewer resources.

OBJECTIVE

To determine whether implementation of a telestroke intervention in a large integrated health system would lead to increased tPA utilization and would change rates of hemorrhagic complications.

DESIGN

A stepped-wedge cluster randomized trial of 11 community hospitals connected to 2 tertiary care centers via telestroke, implemented at each hospital incrementally during a 1-year period. We examined pre- and postimplementation data from July 2013 through January 2015. A 2-level mixed-effects logistic regression model accounted for the staggered rollout.

MAIN OUTCOME MEASURES

Receipt of tPA. Secondary outcome was the rate of significant hemorrhagic complications.

RESULTS

Of the 2657 patients, demographic and clinical characteristics were similar in pre- and postintervention cohorts. Utilization of tPA increased from 6.3% before the intervention to 10.9% after the intervention, without a significant change in complication rates. Postintervention patients were more likely to receive tPA than were preintervention patients (odds ratio = 2.0; 95% confidence interval = 1.2-3.4). Before implementation, 8 of the 10 community hospitals were significantly less likely to administer tPA than the highest-volume tertiary care center; however, after implementation, 9 of the 10 were at least as likely to administer tPA as the highest-volume center.

CONCLUSION

Telestroke implementation in a regional integrated health system was safe and effective. Community hospitals' rates of tPA utilization quickly increased and were similar to the largest-volume tertiary care center.

Emergency Care of Patients with Acute Ischemic Stroke in the Kaiser Permanente Southern California Integrated Health System

CONTEXT

Tissue plasminogen activator (tPA) is underutilized for treatment of acute ischemic stroke.

OBJECTIVE

To determine whether the probability of tPA administration for patients with ischemic stroke in an integrated health care system improved from 2009 to 2013, and to identify predictors of tPA administration.

DESIGN

Retrospective analysis of all ischemic stroke presentations to 14 Emergency Departments between 2009 and 2013. A generalized linear mixed-effects model identified patient and hospital predictors of tPA.

MAIN OUTCOME MEASURES

Primary outcome was tPA administration; secondary outcomes were door-to-imaging and door-to-needle times and tPA-related bleeding complications.

RESULTS

Of the 11,630 patients, 3.9% received tPA. The likelihood of tPA administration increased with presentation in 2012 and 2013 (odds ratio [OR] = 1.75; 95% confidence interval [CI] = 1.26-2.43; and OR = 2.58; 95% CI = 1.90-3.51), female sex (OR = 1.27; 95% CI = 1.04-1.54), and ambulance arrival (OR = 2.17; 95% CI = 1.76-2.67), and decreased with prior stroke (OR = 0.47; 95% CI = 0.25-0.89) and increased age (OR = 0.98; 95% CI = 0.97-0.99). Likelihood varied by Medical Center (pseudo-intraclass correlation coefficient 13.5%). Among tPA-treated patients, median door-to-imaging time was 15 minutes (interquartile range, 9-23 minutes), and door-to-needle time was 73 minutes (interquartile range, 55-103 minutes). The rate of intracranial hemorrhage was 4.2% and 0.9% among tPA- and non-tPA treated patients (p < 0.001).

CONCLUSION

Acute ischemic stroke care improved over time in this integrated health system. Better understanding of differences in hospital performance will have important quality-improvement and policy implications.

Abstract WP331: The Effect of ABCD2 Score as a Triage Tool for TIA Patients on 90 Day Hospital Re-Admission

Introduction and Objectives: After a transient ischemic attack, there is a 90 day increased risk of stroke that can be predicted by ABCD2 score. A TIA clinic for low risk (ABCD2 score <4) was established at Kaiser Permanente. We hypothesized that patients seen in this clinic would have the same 90 day re-admission rate as those evaluated inpatient.

Methods: At Kaiser Permanente LAMC, a TIA clinic was established in November 2, 2010. TIAs were triaged by a Neurologist who calculated the ABCD2 score. Patients were referred to the TIA clinic with a score <4 and evaluated inpatient if score ≥4. Patient data was abstracted for all patients with a TIA clinic referral placed between November 2, 2010 and February 28, 2013 (182 charts) and 148 were included in the analysis. Patients were excluded if the ABCD2 score could not be calculated or referral was inappropriate. The ICD-9 code was used to abstract patients with TIA for the same time period (145 charts) and 58 patients were included. Non-Kaiser members and patients for which a Neurologist was unable to calculate ABCD2 score were excluded. All charts were reviewed for 90 day re-admission. Data was analyzed using chi-squared testing of independence and Fischer’s exact test to assess for a difference in all cause and stroke only 90 day re-admission rates for patients with ABCD2 scores <4 and ≥4 who were evaluated in TIA clinic vs. inpatient.

Results: No significant difference in the rate of re-admission for all cause with ABCD2 score ≥4 in TIA clinic (20%) vs inpatient (28.2%) was found (p= 0.379), but a significant rate of re-admission for stroke was found with TIA clinic (0%) vs inpatient (10.3%) (p= 0.042). A significant rate of re-admission for all cause with ABCD2 score <4 in TIA clinic (14.4%) vs inpatient (5.6%) was not found (p = 0.462) and re-admission for stroke in TIA clinic (2.9%) vs inpatient (0%) was not found (p=1.00).

Limitations: Non-members were excluded due to inability for follow up, and there may have been variability in documentation of pertinent information for calculating ABCD2 scores.

Conclusion: TIA clinic evaluation of low risk patients (ABCD2 score <4) does not increase the risk for 90 day re-admission for all causes or stroke only.

Abstract 161: Prediction of Thrombolysis-induced Parenchymal Hemorrhage in Patients With Acute Ischemic Stroke: Use of MR Perfusion and Diffusion Biomarkers

Purpose: Ischemic stroke patients with low cerebral blood volume (CBV), low apparent diffusion coefficient (ADC) and increased microvascular permeability (K2) have increased risk of parenchymal hemorrhage (PH) after recanalization therapies. We have developed a predictive model to examine the risk of PH following revascularization therapies using combined MR perfusion and diffusion biomarkers.

Methods: Voxel-based values of rCBV, K2, and ADC from the infarction core were obtained using pre-treatment MRI data from patients enrolled in the Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE) clinical trial. Using histogram analyses the 10 th and 90 th percentile values were calculated for the rCBV, ADC, and K2 variables for each patient. The associations between PH and extreme values of CBV (10%rCBV), ADC (10%ADC), and K2 (90%K2) in each patient were assessed in univariate and multivariate analyses. Receiver operating characteristic (ROC) analysis was performed to determine the optimal parameter/s and threshold for predicting PH.

Results: In 83 patients included in this analysis, 20 (24%, 13 PH1, 7 PH2) developed PH. Univariate analysis showed significantly lower 10%rCBV and 10%ADC values and significantly higher 90%K2 values in patients with PH. After controlling for age, baseline NIHSS, infarct volume, and status of recanalization, multivariate logistic regression analysis identified 10%rCBV (p=0.002) and 90%K2 (p=0.03), but not 10%ADC (p=0.07), as independent predictors of PH. For 10%RCBV, ROC analysis showed the greatest AUC (0.87) at a threshold < 0.45 with sensitivity/specificity of 95%70%. For 90%K2, the greatest AUC (0.75) was obtained at a threshold of > 0.27 with sensitivity/specificity of 90%/60%. In a separate model, a combined K2-rCBV classifier remained the single independent predictor of PH (OR=33).

Conclusion: Our results suggest that combined increased permeability and decreased rCBV derived from MR perfusion can be used for risk stratification in patients with AIS before undergoing revascularization therapies.

Abstract T P204: t-PA Utilization is Improving within Kaiser Permanente Southern California

Background and Objectives: Despite the efficacy of t-PA for acute ischemic stroke (IS), most patients do not receive the treatment. Due to aligned incentives, integrated health systems have shown to deliver higher-value care than their counterparts, therefore we sought to describe patterns of t-PA use within a large integrated health system (Kaiser Permanente Southern California). Our objectives were to describe the proportion of IS patients treated with t-PA, and to identify predictors associated with t-PA receipt.

Methods: This was a retrospective cohort analysis using existing structured data from an electronic health record encompassing 14 emergency departments between 2009-2013. We included patients 18 years or older with a primary or secondary ICD-9 diagnosis of acute IS. To focus on patients with acute presentations, we limited our sample to those who were imaged within 180 minutes of arrival. We built a multivariable regression model using random intercept for medical center to identify predictors of t-PA receipt.

Results: Of the 11,630 patients in our analysis, half were female (49.5%) and median age was 72 years (IQR 61-81). Four percent received t-PA during the study period (n=453), and treatment rate increased from 2.6% in 2009 to 6.4% in 2013 (p-value for trend <0.0001). Of the treated patients, median door-to-needle time was 73 minutes (IQR 55-103). Predictors of t-PA receipt are outlined in the table.

Conclusion: Between 2009-2013, 4% of all acute IS patients presenting to an integrated health system were treated with t-PA. Utilization of t-PA is improving over time, with age, gender, prior stroke, and ambulance arrival associated with t-PA treatment.

Abstract T P212: One Year Experience Of An Urban Primary Stroke Center With An Integrated Internal Telestroke System

Background: Telestroke systems have offered expert stroke care to underserved communities across the United States. Usually, the telestroke service is provided by external consultants, from other institutions with limited access to patients’ medical charts and prior imaging. Here, we report on our one-year experience of an internal telestroke system at a community Primary Stroke Center. Methodology: Prior to August 2013, assessment of thrombolytics was provided by in-house neurologists through bedside consultation during the day and telephone consultation after hours. However, starting August 2013 acute stroke care is provided by neurologists using a telemedicine device via an integrated internal telestroke program. Given the integrated nature of our hospital system, these physicians have immediate access to medical charts, history, laboratory, and prior as well as current imaging. In order to prove the viability of this program, we compared outcomes between the two acute stroke care processes. We determined thrombolytic utilization rate, door-to-needle time (DNT), rate of stroke mimics, and discharge destination of those patients who received thrombolytics 12 month before and after telestroke implementation. Results: We noted improvement in the percentage of eligible stroke patients receiving thrombolytics (8% vs 18.2%). Our DNT decreased by 23 minutes (mean 93.4 vs 69.7 minutes, P<0.005). Thrombolytics administered to stroke mimics was reduced from 16.7% to 8.6%. Patients discharged to a non-home facility (acute rehabilitation or skilled nursing facilities) decreased from 16.6% to 8.6%. Conclusion: Compared to our previous local acute stroke management, stroke care was not inferior. In fact, as a result of an internal telestroke system implementation, our thrombolytic utilization rate increased, our DNT improved, our stroke mimic rate decreased, and non-home discharge disposition decreased. Although not specifically assessed in our study, we suspect that internal telestroke systems also offer obvious advantages for patient care compared to external systems. Further studies evaluating stroke outcomes in these distinct systems are needed.

Abstract T P26: Combining Clinical and Imaging Data to Develop a Highly Predictive Model of Outcomes in the MR RESCUE Trial

Background: Identifying patient characteristics that predict outcomes in acute ischemic stroke may assist in triaging those who are candidates for endovascular therapies. We sought to identify predictors of outcome in the overall Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE) cohort and compare results to the previously validated Totaled Health Risks in Vascular Events (THRIVE) score.

Methods: MR RESCUE randomized 118 acute ischemic stroke patients with multimodal imaging to embolectomy or standard care within 8 hours of onset. For this analysis, we investigated 17 baseline variables (e.g. age, predicted core volume, time to enrollment) and 8 intermediate variables (e.g. hemorrhagic transformation, day 7 recanalization, final infarct volume) with the potential to impact outcomes (day 90 mRS). The baseline variables were analyzed employing bivariate and multivariate methods (random forest and logistic regression). Two models were developed, one including only significant baseline variables, and the second also incorporating significant intermediate variables.

Results: A multivariate model (Table) employing only baseline covariates achieved an overall accuracy (C statistic) of 85% in predicting poor outcome (day 90 mRS 3-6) compared to 80.5% for the THRIVE score. A second model (Table) adding significant intermediate variables achieved 89% accuracy in predicting day 90 mRS.

Conclusions: In the MR RESCUE trial, advanced imaging variables, including predicted core volume and site of vessel occlusion, contributed to a highly accurate multivariable model of outcome. In the development phase, this model achieved higher accuracy than the THRIVE score. Future studies are needed to validate this model in an independent cohort.

Abstract T MP9: Analysis of MR RESCUE Dataset Employing DEFUSE 2 Target Mismatch Criteria for Defining Penumbra

Background: The MR RESCUE trial failed to show a benefit of endovascular therapy over standard medical care for first generation thrombectomy devices within 8 hours of onset of acute ischemic stroke. We now report a subset analysis of patients enrolled with MRI, employing DEFUSE 2 criteria to define favorable penumbral pattern (target mismatch) which differed from MR RESCUE penumbral prediction criteria.

Methods: Patients with large vessel, anterior circulation strokes were randomized to mechanical embolectomy (Merci Retriever or Penumbra System) or standard care. Patients were categorized as having a favorable penumbral or non-penumbral pattern employing the DEFUSE 2 criteria for target mismatch ([Tmax > 6s / thresholded ADC < 600 х 10 −6 mm 2 /s] > 1.8, thresholded ADC < 70 cc, and Tmax > 10 s < 100 cc).

Results: Among 118 total patients, 94 qualified for this analysis. Mean age was 65.8, mean time to enrollment 5.6 hours, median NIHSS 17, and 47% had target mismatch. Predicted core volume using DEFUSE 2 criteria (thresholded ADC volume < 600 х 10 −6 mm 2 /s) was 18.8 cc (target mismatch) and 64.3 cc (non-target mismatch; p<0.001). Revascularization in the embolectomy group was achieved in 62% (TICI 2a-3), and 21% (TICI 2b-3). Among all patients, mean 90-day mRS scores did not differ between embolectomy and standard care (3.8 vs 3.8; p=0.92). In patients with target mismatch, embolectomy was not superior to standard care (mean mRS 3.5 vs 3.3, p=0.78). Similarly, in patients without target mismatch, embolectomy was not superior (4.1 vs 4.3, p=0.67). Furthermore, there was no interaction between pretreatment penumbral imaging pattern employing DEFUSE 2 target mismatch criteria and treatment assignment in these 90-day mRS scores (p=0.11).

Conclusions: In this analysis MR RESCUE patients enrolled with pretreatment MRI, use of the DEFUSE 2 criteria for target mismatch as a definition of penumbral pattern failed to identify a subset of patients with improved outcomes when treated with embolectomy. Further randomized, controlled studies employing new generation thrombectomy devices are needed to validate target mismatch as a selection criterion for acute stroke treatments.

A trial of imaging selection and endovascular treatment for ischemic stroke

BACKGROUND

Whether brain imaging can identify patients who are most likely to benefit from therapies for acute ischemic stroke and whether endovascular thrombectomy improves clinical outcomes in such patients remains unclear.

METHODS

In this study, we randomly assigned patients within 8 hours after the onset of large-vessel, anterior-circulation strokes to undergo mechanical embolectomy (Merci Retriever or Penumbra System) or receive standard care. All patients underwent pretreatment computed tomography or magnetic resonance imaging of the brain. Randomization was stratified according to whether the patient had a favorable penumbral pattern (substantial salvageable tissue and small infarct core) or a nonpenumbral pattern (large core or small or absent penumbra). We assessed outcomes using the 90-day modified Rankin scale, ranging from 0 (no symptoms) to 6 (dead).

RESULTS

Among 118 eligible patients, the mean age was 65.5 years, the mean time to enrollment was 5.5 hours, and 58% had a favorable penumbral pattern. Revascularization in the embolectomy group was achieved in 67% of the patients. Ninety-day mortality was 21%, and the rate of symptomatic intracranial hemorrhage was 4%; neither rate differed across groups. Among all patients, mean scores on the modified Rankin scale did not differ between embolectomy and standard care (3.9 vs. 3.9, P=0.99). Embolectomy was not superior to standard care in patients with either a favorable penumbral pattern (mean score, 3.9 vs. 3.4; P=0.23) or a nonpenumbral pattern (mean score, 4.0 vs. 4.4; P=0.32). In the primary analysis of scores on the 90-day modified Rankin scale, there was no interaction between the pretreatment imaging pattern and treatment assignment (P=0.14).

CONCLUSIONS

A favorable penumbral pattern on neuroimaging did not identify patients who would differentially benefit from endovascular therapy for acute ischemic stroke, nor was embolectomy shown to be superior to standard care. (Funded by the National Institute of Neurological Disorders and Stroke; MR RESCUE ClinicalTrials.gov number, NCT00389467.).