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Supplemental Digital Content is available in the text., Background and Purpose: Shelter-in-place (SIP) orders implemented to mitigate severe acute respiratory syndrome coronavirus 2 spread may inadvertently discourage patient care-seeking behavior for critical conditions like acute ischemic stroke. We aimed to compare temporal trends in volume of acute stroke alerts, patient characteristics, telestroke care, and short-term outcomes pre- and post-SIP orders. Methods: We conducted a cohort study in 21 stroke centers of an integrated healthcare system serving 4.4+ million members across Northern California. We included adult patients who presented with suspected acute stroke and were evaluated by telestroke between January 1, 2019, and May 9, 2020. SIP orders announced the week of March 15, 2020, created pre (January 1, 2019, to March 14, 2020) and post (March 15, 2020, to May 9, 2020) cohort for comparison. Main outcomes were stroke alert volumes and inpatient mortality for stroke. Results: Stroke alert weekly volume post-SIP (mean, 98 [95% CI, 92–104]) decreased significantly compared with pre-SIP (mean, 132 [95% CI, 130–136]; P

Background: In 2020, a large integrated healthcare system consisting of 21 stroke centers implemented IV tenecteplase as the first line pharmaceutical treatment for acute ischemic stroke (AIS) prior to universal adoption in national clinical practice guidelines and FDA approval for stroke. Purpose: To describe the steps taken for successful implementation of IV tenecteplase as a first therapy for AIS in 21 stroke centers, part of an integrated system. Methods: Pre-implementation steps included gaining systemwide acceptance, especially from key stakeholders such as emergency department staff, patient care services, tele-stroke and neurology physicians, as well as risk management. We addressed potential impacts to related to reimbursement, stroke certification, and national award status. Inclusive changes were made to related policy and procedures, order sets, and other documentation. Standardized training and beta-testing were conducted and a sequential roll-out implemented along the real-time central monitoring. Results: Stakeholder groups were engaged prior to implementation with town halls and in-person and desktop simulation exercises. Beta-testing took place in August 2020 with three pilot sites with full system wide implementation by Nov. 2020. Since full implementation, tenecteplase is the only thrombolytic that has been ordered (n=423). Door in door out times have decreased (median 131 minutes pre- to 88 minutes post; p Conclusion: Tenecteplase has been shown to be safe and feasible as a first line thrombolytic within our organization. Strong nurse and physician leads, as well as thoughtful and inclusive implementation steps were key in the successful adoption of this system-wide change.

Background: Published data suggests tenecteplase (TNKase) is non-inferior to alteplase for acute ischemic stroke treatment. TNKase has certain advantages over alteplase including single-bolus administration. We evaluated TNKase performance in all acute stroke patients in a large integrated healthcare system. Methods: In 2016, we launched a standardized telestroke program for 21 certified stroke centers to include immediate video evaluation by a teleneurologist. In November 2020, we transitioned all centers to use TNKase for qualifying stroke patients presenting within 4.5 hours of last time known well. Selection criteria were the same as those for alteplase. Our study cohort included all potential acute stroke patients evaluated by telestroke. We compared the TNKase cohort treated during 12/1/20 - 3/31/21 to the alteplase cohort during 5/1/20 - 8/31/20. Assessment included demographics, mode of arrival, initial NIHSS, neuroimaging results, large vessel occlusion, rate of intracranial hemorrhage (ICH), discharge outcomes, percent with mRS (0-2) and mortality at 90 days with 95% CI. Results: Study cohort had 301 patients treated with TNKase and 248 patients with alteplase. Average age was about 70 years. Compared to alteplase, TNKase was associated significantly with faster door-to-needle (DTN) and door-in-door-out (DIDO) times [Table]. TNKase cohort had a larger percentage of stroke mimics. There was a trend of less symptomatic hemorrhage seen with TNKase. Multivariate model revealed that TNKase treatment was less likely to have 90-day mortality (OR=0.56, 95% CI 0.33-0.96, p=0.04). Percent 90-day favorable mRS score (0-2) was no different between the cohorts. Conclusions: We have successfully and safely transitioned to using TNKase for acute stroke treatment in our community setting. Compared to alteplase, TNKase cohort achieved faster DTN and DIDO times and less 90-day mortality. Further evaluation is needed to examine 90-day mRS in larger cohorts.

Background: Published data suggest that treating qualified acute strokes within the extended window (EW) or 6-24 hours of last seen normal with endovascular therapy (EST) is associated with better 90-day outcome. In a real-world multi-ethnic practice setting, we assessed our experience in triaging and treating patients in the EW. Methods: In 2016, our system of care launched a telestroke program for 19 primary and 2 comprehensive stroke centers to include immediate video evaluation by a stroke neurologist. In 2018, screening in the EW began. If the patient met clinical criteria (baseline independence and initial NIHSS ≥ 6), neuroimaging was performed to assess for a large vessel occlusion (LVO). Referral for EST was made for patients with an LVO and appropriate CT perfusion criteria. Our study included all health plan members presenting within the EW in 2019. Assessment included demographics, NIHSS, neuroimaging data, LVO, discharge outcomes, 90-day mRS and mortality with 95% confidence interval. Results: In 2019, there were 5349 suspected strokes (1255 EW) evaluated by teleneurologists; 2130 (39.8%) patients were appropriate for acute stroke imaging workup. Of 2130, final study cohort included 388 (18.2%) EW patients who met clinical criteria and underwent neuroimaging workup, and 117 of these patients (30.2%) had an LVO. There were 57 (14.7%) meeting CT perfusion criteria and referred for EST. Compared to 331 who were not referred for EST, the 57 patients were older and more likely to have atrial fibrillation, higher NIHSS, and to be discharged to a short-term facility than home. The 51 patients who went for EST within our system had 90-day good (mRS 0-2), bad (mRS 5-6), and mortality rates comparable to those from DAWN and DEFUSE-3 trials [Table]. Conclusions: In our system, only a small proportion of suspected strokes met criteria for EST during the EW. It was possible in a community setting to achieve 90-day outcomes that were comparable to those from clinical trials.

Background: Stroke patients have high rates of all-cause rehospitalization at 30 days (7-24%) and within one year (30-62%). Limited information is available on how to predict these outcomes. We assessed two existing predictive models and whether adding NIHSS or modified Rankin scale (mRS) score improved their predictive ability for 30-day non-elective rehospitalization and/or mortality post-stroke. Methods: Using a cohort of ischemic stroke patients in a large multi-ethnic integrated healthcare system from June 2010 to December 2017, we tested 2 existing predictive models for a composite outcome (30-day non-elective hospitalization or death). The models were based on administrative data (LACE) as well as a comprehensive model (Transition Support Level, TSL) that included multiple clinical data elements from the electronic health record, including admission acute physiology and discharge care directives. LACE score included information on length of stay, acuity, comorbidities, and emergency department visits. The models, NIHSS and mRS scores were tested independently, and in combination and combined with age and sex. We assessed model performance using the area under the receiver operator characteristic (c statistic), Nagelkerke pseudo-R 2 , and Brier score. Results: The study cohort included 4843 patients with 5,014 stroke hospitalizations. Average age was 71.9 ± 14 years with 50.6% female and 52.1% White. Median initial NIHSS was 4. Median length of stay was 4 days, and 55.6% were discharged home. There were 527 non-elective readmissions within 30 days. The logistic models revealed that the best performing models were TSL (c-statistic = 0.685) and TSL plus mRS score at discharge (c-statistic = 0.694) [Table]. Conclusions: We found that neither the initial NIHSS nor the mRS score at discharge enhanced the predictive ability of the LACE or TSL models. Future efforts at prediction of short-term stroke outcomes will need to incorporate new data elements.

Introduction Dysphagia occurs in up to 50% of patients with acute stroke symptoms, resulting in increased aspiration pneumonia rates and mortality. The purpose of this study was to validate a health system's dysphagia (swallow) screening tool used since 2007 on all patients with suspected stroke symptoms. Annual rates of aspiration pneumonia for ischemic stroke patients have ranged from 2% to 3% since 2007. Methods From August 17, 2015 through September 30, 2015, a bedside dysphagia screening was prospectively performed by 2 nurses who were blinded to all patients age 18 years or older admitted through the emergency department with suspected stroke symptoms at 21 Joint Commission accredited primary stroke centers in an integrated health system. The tool consists of 3 parts: pertinent history, focused physical examination, and progressive testing from ice chips to 90 mL of water. A speech language pathologist blinded to the nurse's screening results performed a formal swallow evaluation on the same patient. Results The end study population was 379 patients. Interrater reliability between 2 nurses of the dysphagia screening was excellent at 93.7% agreement (Ƙ = 0.83). When the dysphagia screenings were compared with the gold standard speech language pathologist professional swallow evaluation, the tool demonstrated both high sensitivity (86.4%; 95% confidence interval = 73.3-93.6) and high negative predictive value (93.8%; 95% confidence interval = 87.2-97.1). Conclusion This tool is highly reliable and valid. The dysphagia screening tool requires minimal training and is easily administered in a timely manner.

Background: Published data suggest that the faster acute stroke patients are treated with IV alteplase the better they do post discharge. It is not clear that reducing door-to-needle (DTN) time by 15 minutes (from 60 to 45 to 30) is associated with better functional outcome and/or less mortality. In a real-world practice setting, we assessed the effect of different DTN times on clinical outcomes. Methods: In 2016, a new standardized telestroke program for 21 stroke centers in an integrated healthcare system was launched. It included immediate evaluation by a stroke neurologist via video, expedited IV alteplase treatment, rapid CT angiographic study, and expedited transfer and treatment for patients with large vessel occlusion. From 2/15/18 to 2/25/19, we collected 90-day modified Rankin Score (mRS) for adult members who received IV alteplase. We also collected data on demographics, NIHSS, DTN times, thrombectomy, length of stay, discharge outcomes, 90-day mRS and mortality in those treated with IV alteplase stratified by the DTN time (60 vs. 45 vs. 30 minutes). Multivariate logistic regression was used to examine whether DTN category was predictive of good functional outcome (mRS=0-2) adjusted for age, gender, race, and NIHSS. Results: During the study period, the full cohort had 784 patients treated with IV alteplase. Average age was 71.5 ± 14.9 years with 51.8% female. Median NIHSS was 6. Median DTN time was 34 minutes. Those with faster DTN arrived more by EMS, had higher NIHSS, higher rate of thrombectomy, and shorter length of stay. A smaller cohort of 340 patients had a 90-day mRS. Multivariate models revealed a trend for faster DTN time being associated with less 90-day mortality (OR=0.81, p=0.24) and good functional outcome (OR=1.73, p=0.07) among EMS arrival (Table). Conclusions: In our study cohort, every 15-minute reduction in DTN had stronger association with better outcomes. Further efforts are underway to capture more complete mRS data for the full cohort.

Background: Risks and benefits of thrombectomy in elderly stroke patients remained unclear. We evaluated outcomes in the elderly who underwent endovascular therapy (EST) in a large integrated healthcare system. Methods: In 2016, our integrated healthcare system launched a new standardized acute telestroke care workflow for all 21 stroke centers. It included immediate evaluation by a stroke neurologist via video, expedited IV alteplase treatment, rapid CT angiographic investigation, and expedited transfer and EST for patients with large vessel occlusion (LVO). From January 2016 through December 2018, our study cohort included adult members who had EST within our care system. We compared patient characteristics, door-to-needle (DTN) times, door-to-groin (DTG) times, inpatient and 90-day mortality between those treated with EST aged Results: There were 291 acute stroke patients who underwent EST [Table]. The older subgroup had a higher percentage of female and higher rates of atrial fibrillation. They were more likely to arrive by EMS, to have a higher initial NIHSS and to have a faster DTN time. Average DTG times and inpatient mortality rates were not different between groups. The elderly had a higher rate of 90-day mortality. In multivariate model, being elderly was associated with higher 90-day mortality (OR=2.56, 95% CI 1.29-5.09, p=0.007). Conclusions: For those who underwent EST in a large community setting with a standardized approach to acute stroke treatment, being elderly was associated with a higher risk of 90-day mortality. Further data analyses are being carried out with additional co-morbidities, inpatient complications, and 90-day functional outcome to better understand outcomes in older patients undergoing EST.

Background and Purpose: Increasing knowledge of pertinent aspects of stroke disease may improve outcomes for stroke survivors and family members. Patients and families are educated in a large integrated health system on Joint Commission required elements of stroke education which include: importance of calling 911, stroke signs and symptoms, disease processes, risk factor management, and follow up. In 2018, despite 95% documented rates of education, 40 to 50% of stroke survivors in the health system replied “No” to three Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPs) "staff explained stroke..." questions. The purpose of this project was to improve stroke education as measured by an increase in HCAHPs scores. Methods: Current literature was reviewed. Stroke survivors spoke to a regional stroke coordinator group about their experiences. Staff nurses were surveyed on barriers to stroke education. Based on information from the literature, stroke survivors, staff nurses and neuroscience nursing, neurology and education experts, two interventions were undertaken. A flyer was designed using a well-spaced layout with required stroke education elements written at fourth grade reading level and translated into four common languages in the patient population. Community feedback was integrated after the initial design. A training module for teaching stroke education was completed by 886 nurses in eight facilities. The pre and post intervention HCAHPs scores were aggregated from the eight hospitals. The results were analyzed using a Chi2 statistical tool. Results: Unfortunately, a statistically significant increase in HCAHPs scores was not achieved. For question #1; “staff explained stroke diagnosis”, the percentage yes went from %53 (n=49) to %59 (n=59). Question #2; “staff explained risk factors” went from %52 (n=50) to %43 (n=58). Question #3 “staff explained stroke signs/symptoms” went from %47 (n=48) to %53 (n=69). Conclusion: This work supports literature and local stroke survivor feedback indicating stroke survivors and their families are too overwhelmed in the hospital to absorb education. Resources should be put into follow-up phone calls or other modalities after trauma from the stroke event has subsided.

Background and purpose The approved treatment by the Food and Drug Administration for acute ischemic stroke is intravenous tissue-type plasminogen activator (IV tPA). After IV tPA administration, patients are monitored for adverse events using an American Heart Association/American Stroke Association guideline instituted in 1996. There is limited evidence describing the safest and most efficient method to monitor patients during the first 24 hours after tPA administration. Although the overall rates of adverse events have been reported, the time when patients may be at most risk for an event has not been studied. The purpose of this study was to identify the time of adverse event occurrences in the first 24 hours after IV tPA administration. Method This was a descriptive, retrospective chart review study of patients admitted to an integrated health system and treated with IV tPA for acute stroke between July 2010 and July 2012. Charts were reviewed for adverse events using the Institute for Healthcare Improvement's Global Trigger Tool for Measuring Adverse Events. Possible chart indicators of adverse events or "triggers" included neurological decline, vital signs elevated above specified parameters, and emergent imaging. Adverse events included episodes of neurological decline, angioedema, allergic reactions, bleeding, and intracerebral hemorrhage (ICH). The timing of each detected event was determined, and descriptive statistics were used for data analysis. Results Fourteen adverse events (2.8%) were detected in a population of 498 patients. Reactions consisted of allergic reaction (n = 1), angioedema (n = 1), neurological decline without ICH (n = 1), gastrointestinal bleeding (n = 1), bleeding gums (n = 1), and high-risk ICH (n = 9). Thirteen of the 14 adverse events (92.9%) occurred within the first 12 hours after IV tPA administration. Conclusion Close monitoring during the first 12 hours after IV tPA treatment may be essential. However, close monitoring after 12 hours may not contribute significantly to improved patient outcomes. Larger studies may provide evidence for the safest and most efficient monitoring protocol for patients treated with IV tPA for ischemic stroke.

American health care is accused of being disorganized and competitive with a greater interest in financial gain over the health of our population. The stroke world is in jeopardy of such criticism as discussions of bypassing PSC’s toward CSC’s or TSC’s could be influenced by the needs for volume to maintain such certifications over what is best for the populations they serve. This abstract outlines the development of a county wide stroke system of care. This county has an ethnically and financially diverse population with challenges of a large geographic size, complex traffic flow patterns, competing health systems, and the lack of an academic level medical center. Methods: Through collaboration between emergency medical services, health care systems, and the AHA, barriers were broken down to improve stroke care and outcomes at a county wide level. Goals identified during this partnership included reductions in on-scene time, door to needle time, and door to groin time. Recognizing that 50% of all patients who present with suspected stroke symptoms do not call 911 but will walk in, the decision was made to focus on strengthening the transfer process and to share expertise with county hospitals which serve the medically indigent. Collaboration on community and EMS education on stroke symptoms was also done with an agreed upon commitment by the entities. This system of care is a fluid model which has adapted based on the services available within the system. In 2017, one of its entities became CSC certified. Most recently, plans were devised for patients in need of CSC services for rapid transport between all entities. The patients are identified as possible LVO candidates in the field using a (LAMS) but taken to the primary stroke center initially where they are evaluated with CT perfusion imaging. Results: Over a period of 6 years the mean door to needle time was decreased by 34.3% (63.6 min to 41.78 min respectively) and median door to groin time decreased by 16% (25 min to 21 min respectively). Through this model, the utilization of stroke services is targeted to benefit all residents of the county regardless of what health system they belong to.

With limited time and resources in the acute care hospital, the most effective methods of stroke education are crucial. A combination of methods of one-on-one counseling or teaching, print, and video has been shown to have the greatest effect. Video education is a component of a combination educational approach. This evaluation from a large integrated system comprising 21 medical facilities compared patient satisfaction data with stroke education from 5 facilities that have video educational services and print materials and 17 facilities that provide print materials only. All 21 facilities provided additional teaching by the nurse. From this evaluation, it seems that there may be no relationship between video or kiosk equipment on patient satisfaction scores for this integrated system.

Background: Dysphagia or difficulty swallowing occurs in up to 50% of patients with acute stroke symptoms. Dysphagia screening is considered standard stroke care. Few dysphagia screening tools have been well validated with high sensitivity and specificity. Purpose: The purpose was to validate our system’s dysphagia screening tool. Methods: From August 17, 2015 through September 30, 2015, bedside dysphagia screening was prospectively performed by 2 blinded nurses on all patients age ≥18 years admitted through the emergency department with stroke symptoms at 22 stroke centers in an integrated healthcare system. The tool consisted of three parts: history, physical exam and progressive testing from ice chips to water. A speech language pathologist blinded to the results performed an evaluation on the same patient. Patients with a feeding tube or intubation on arrival, treated with alteplase, or were discharged with a diagnosis other than stroke were excluded from final study analyses. The study quantified the reproducibility of the dysphagia screening tool by computing the percent agreement and kappa score for inter-rater reliability. Validity of dysphagia screening tool was determined using the speech pathologist evaluation as the reference standard. We assessed the sensitivity, specificity, and negative (NPV) and positive predictive values (PPV) for the dysphagia screening tool. The point estimate and 95% confidence interval (CI) were calculated. Results: Dysphagia screening was performed in 726 patients with stroke symptoms. There were 370 patients included in the analysis. Average age was 70 ± 14 years, and 48.2% female. Inter-rater reliability of the dysphagia screen was excellent between both raters at 93.5% agreement (k’= 0.83). The screen performed well when compared to speech language pathologist evaluation, demonstrating both high sensitivity (86.4%, CI: 73.3% to 93.6%) and high NPV (93.6%, CI: 86.8% to 97.0%). Conclusion: Our bedside dysphagia screening tool is highly reliable and valid. The tool had been used in over thirty-five facilities since 2007. The hospital acquired pneumonia rate for ischemic stroke patients has averaged 2-3% a year. This dysphagia screening tool requires minimal training and is easily administered in a timely manner.