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BackgroundMobile stroke units (MSUs) performance dependability and diagnostic yield of 16-slice, ultra-fast CT with auto-injection angiography (CTA) of the aortic arch/neck/circle of Willis has not been previously reported.MethodsWe performed a prospective observational study of the first-of-its kind MSU equipped with high resolution, 16-slice CT with multiphasic CTA. Field CT/CTA was performed on all suspected stroke patients regardless of symptom severity or resolution. Performance dependability, efficiency and diagnostic yield over 365 days was quantified.Results1031 MSU emergency activations occurred; of these, 629 (61%) were disregarded with unrelated diagnoses, and 402 patients transported: 245 (61%) ischemic or hemorrhagic stroke, 17 (4%) transient ischemic attack, 140 (35%) other neurologic emergencies. Total time from non-contrast CT/CTA start to images ready for viewing was 4.0 (IQR 3.5–4.5) min. Hemorrhagic stroke totaled 24 (10%): aneurysmal subarachnoid hemorrhage 3, hemorrhagic infarct 1, and 20 intraparenchymal hemorrhages (median intracerebral hemorrhage score was 2 (IQR 1–3), 4 (20%) spot sign positive). In 221 patients with ischemic stroke, 73 (33%) received alteplase with 31.5% treated within 60 min of onset. CTA revealed large vessel occlusion in 66 patients (30%) of which 9 (14%) were extracranial; 27 (41%) underwent thrombectomy with onset to puncture time averaging 141±90 min (median 112 (IQR 90–139) min) with full emergency department (ED) bypass. No imaging needed to be repeated for image quality; all patients were triaged correctly with no inter-hospital transfer required.ConclusionsMSU use of advanced imaging including multiphasic head/neck CTA is feasible, offers high LVO yield and enables full ED bypass.

Background and Purpose- The impact of a mobile stroke unit (MSU) on access to intraarterial thrombectomy (IAT) is a prespecified BEST-MSU substudy (Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit Compared to Standard Management by Emergency Medical Services). On the MSU, IAT decision-making steps, such as computed tomography, neurological exam, and tPA (tissue-type plasminogen activator) treatment are completed before emergency department arrival. We hypothesized that such pre-ED assessment of potential IAT patients on an MSU improves the time from ED arrival to skin puncture time (door-to-puncture-time, DTPT). Methods- BEST-MSU is a prospective comparative effectiveness study of MSU versus standard management by emergency medical services (EMS). We compared ED DTPT among the following groups of MSU and EMS patients: all IAT patients, IAT patients post-tPA, and IAT patients post-tPA meeting thrombolytic adjudication criteria over the first 4 years of the study. Results- From August 2014 to July 2018, a total of 161 patients underwent IAT. Ninety-four patients presented to the ED via the MSU and 67 by EMS. One hundred forty patients received tPA before IAT, 85 in the MSU arm, and 55 in the EMS arm. One hundred twenty-six patients received tPA within thrombolytic adjudication criteria: 76 MSU and 50 EMS. DTPT in minutes was shorter for MSU patients (all IAT MSU versus EMS 89 versus 99, P=0.01; IAT post-tPA MSU versus EMS 93 versus 100, P=0.03; and IAT post-tPA within adjudicated criteria MSU versus EMS 93 versus 99.5, P=0.03). From 2014 to 2018, DTPT decreased at a faster rate for EMS compared with MSU-managed patients, improving by about an hour. Conclusions- Pre-ED IAT evaluation on an MSU results in faster DTPT compared with arrival by EMS. Since 2014, dramatic improvement in ED IAT metrics has attenuated this difference. However, DTPT in all groups indicates substantial room for improvement.

Introduction: The impact of a Mobile stroke unit (MSU) on access to Endovascular Thrombectomy (ET) is a pre-specified BEST-MSU sub-study. On the MSU, ET decision-making steps such as CT, neurologic exam, and tPA treatment are completed prior to Emergency Room (ER) arrival. We hypothesized that such pre-ER assessment of potential ET patients on a MSU improves metrics. Methods: BEST-MSU is a prospective comparative effectiveness study of MSU vs Standard Management by Emergency Medical Services (SM). We compared ER door-to-puncture-time (mins, DTPT) among the following groups of MSU and SM patients: all ET patients (ETP), ET patients post-tPA (ETT), and ET patients post-tPA meeting thrombolytic adjudication criteria (ETTA) over the first four years of the study. Results: There were 161 ETP (67 SM, 94 MSU), 140 ETT (55 SM, 85 MSU), and 126 ETTA (50 SM, 76 MSU) patients. DTPT was shorter for MSU patients (ETP 89 vs 99, p=0.01; ETT 93 vs 100, p=0.03; ETTA 93 vs 99.5, p=0.03). From 2015 to 2018, DTPT decreased at a faster rate for SM compared with MSU-managed patients, improving by about an hour (Figure). Conclusion: Pre-ER ET evaluation on a MSU results in faster DTPT. Since 2015, dramatic improvement in ER ET metrics has attenuated this difference. However, DTPT of 90-100 mins in all groups indicates substantial room for improvement.

Introduction: There is preliminary data indicating potential racial disparities in use of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). We sought to compare “drip and ship” (DNS) tPA use between African-Americans (AA) and Caucasians (CS) in a high-volume tertiary care stroke center. Methods: AIS patients treated with IVT during a seven-year period were evaluated. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. All patients who received IVT at an outside facility with subsequent transfer to our center were included in the DNS group. Safety of IVT was evaluated SITS-MOST symptomatic intracranial hemorrhage (sICH) definition. Three-month functional status was assessed using modified Rankin Scale (mRS) scores. Results: Out of total 1339 IVT-treated AIS patients [51% men, 63% AA, mean age 63±15years, median baseline NIHSS-score: 7 pts (IQR: 3-13)], 521 (39%) were treated using the DNS approach. DNS tPA use was less common in AA compared to CS (33% vs. 51%; p < 0.001). AA race was independently associated with lower likelihood of DNS tPA use (OR: 0.46; 95%CI: 0.35-0.62; p Conclusions: Our study uncovers substantial racial disparities in the selection of AIS patients for DNS thrombolytic therapy that cannot be explained by racial geographic proximity to the primary stroke center.

Introduction: There is mounting evidence indicating that first pass (FP) complete reperfusion (CR) may reduce peri-procedural complications for emergent large vessel occlusion (ELVO) patients treated with mechanical thrombectomy (MT). We investigated the impact of device passes (DP) on the clinical outcomes of ELVO patients who achieved CR following treatment with MT in a high-volume tertiary care stroke center. Methods: Consecutive ELVO patients with CR (modified Thrombolysis in Cerebral Infarction grades IIb/III) at the end of MT were evaluated during a five-year period. Baseline stroke severity was assessed by NIHSS-score. The numbers of DP during the procedure were documented. Standard safety outcomes included symptomatic Intracranial Hemorrhage (sICH) by SITS-MOST criteria and three-month mortality. Standard efficacy outcomes included neurological improvement at 24 hours (determined by the relative reduction in NIHSS-score compared to baseline) and functional improvement at three months [determined as the shift in modified Rankin Scale (mRS) scores]. Results: Among 258 ELVO patients achieving CR during MT the rate of FPCR was 67% (n=173). Patients with FPCR had greater median relative NIHSS-reduction at 24 hours (46% vs. 33%; p=0.033), lower median mRS-scores at three months (2 vs. 3; p=0.034) and lower three-month mortality rates (12% vs. 26%; p=0.005) compared to the rest. The two groups did not differ in sICH rates (5% vs. 10%; p=0.200). FPCR was associated with lower odds of three-month mortality (OR:1.64; 95%:1.03-2.61; p=0.036) on multivariable logistic regression models adjusting for potential confounders (demographics, risk factors, occlusion site, collateral status, stroke severity, onset to groin puncture time, baseline blood pressure and serum glucose values). Conclusions: FPCR appears to impact favourably clinical outcomes in ELVO patients treated with MT. CR following FP results in greater neurological and functional improvement at 24 hours and 3 months respectively.

Background: Clinical and geospatial differences in acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) patients within stroke belt region mobile stroke units (MSU) have not been described. We sought to understand presentation differences in the Mid-South. Methods: Consecutive MSU patients were analyzed for demographic, call, and clinical characteristics. Cases were geocoded, spatially joined to zip code shapefile with raw counts normalized to population; incidence rates were calculated and symbolized by mathematical natural breaks. Results: 292 AIS and 29 ICHs were transported in 52 weeks; age was similar (ICH 63 + 15 vs. AIS 64 + 15), cases were mostly female (ICH 64%; AIS 60%), with African Americans (AA) significantly more likely to have AIS (74%) compared to ICH (64%; p=0.023). Median ICH NIHSS was significantly higher (median 9.5, IQR 5.5-17) then AIS NIHSS (median 5, IQR 2-9; p+ 37mmHg vs. AIS 159 + 35mmHg; p+ 21mmHg vs. AIS 91 + 21mmHg; p=0.003). ICH patients were significantly more likely to be treated within the first 60 minutes of symptom onset (p Conclusions: Mid-South ICH MSU patients have surprisingly different demographics than National data, and were most commonly female, but less likely to be of AA. A discreet geospatial ICH pattern was identified for high ICH risk.

Background: Both Glasgow Coma Scale (GCS) and NIH Stroke Scale (NIHSS) are commonly used as serial assessment tools in ICH, however, the NIHSS lacks formal validation in this population. Methods: We prospectively collected ICH assessments, imaging, and outcome data. Direct comparisons of discrimination were made using GCS and NIHSS on prediction of 24-hour poor functional outcome (mRS-3-6) and hematoma volume >30cm 3 using ROC analysis; c statistics were calculated and compared with DeLong test. Results: 672 ICH patients (mean age 62±14 years; 56% men; median ICH score = 1, IQR 0-2; median ICH volume 7cm 3 , IQR 2-19) were included in the analysis. Median NIHSS and GCS were 8 (IQR 3-18) and 15 (IQR 7-15) respectively. NIHSS correlated strongly to GCS (r -0.773; p Conclusions: The NIHSS has greater discriminative power than GCS to identify patients with poor functional outcomes and large hematoma volumes.

Background: Strict criteria for recombinant tissue plasminogen activator (rtPA) eligibility are stipulated on licences for use in ischaemic stroke; however, practitioners may also add non-standard rtPA criteria. We examined eligibility criteria variation in 3 English-speaking countries including use of non-standard criteria, in relation to rtPA treatment rates. Methods: Surveys were mailed to 566 eligible hospitals in Australia (AUS), the UK, and the USA. Criteria were pre-classified as standard (approved indication and contraindications) or non-standard (approved warning or researcher “decoy”). Percentage for criterion selection was calculated/compared; linear regression was used to assess the association between use of non-standard criteria and rtPA treatment rates, and to identify factors associated with addition of non-standard criteria. Results: Response rates were 74% AUS, 65% UK, and 68% USA; mean rtPA treatment rates were 8.7% AUS, 12.7% UK, and 8.7% USA. Median percentage of non-standard inclusions was 33% (all 3 countries) and included National Institutes of Health Stroke Scale (NIHSS) scores > 4, computed tomography (CT) angiography documented occlusion, and favourable CT perfusion. Median percentage of non-standard exclusions was 25% AUS, 28% UK, and 60% USA, and included depressed consciousness, NIHSS > 25, and use of antihypertensive infusions. No AUS or UK sites selected 100% of standard exclusions. Conclusions: Non-standard criteria for rtPA eligibility were evident in all three countries and could, in part, explain comparably low use of rtPA. Differences in the use of standard criteria may signify practitioner intolerance for those derived from original efficacy studies that are no longer relevant.

Background: MSU’s are capable of ultra-early treatment of acute stroke patients in the field. We tested field use of a high-resolution CT and CT-angiography on our MSU. Methods: We designed and implemented the first of its kind MSU equipped with a 16 slice CT scanner (24-row adaptive detector array, fixed 70 cm gantry, auto-injection system, Somatom Scope, Siemens), led by stroke fellowship trained MDs or ANVP-board certified nurse practitioners without telemedicine support. Head/neck CTA was performed on all suspected stroke patients immediately following noncontrast CT. The MSU is embedded within local Fire/EMS and is activated by 911, or by on-scene medics 14 days/month. Transport and drug re-stock agreements were developed with Comprehensive, Primary, and CSC-Capable (CSC-cap) competing stroke centers. Results: Of 420 activations in the first year, our MSU transported a total 206 patients: 127 (62%) strokes and 79 (38%) stroke mimics. In all 127 acute stroke patients (68±16 years, 58% women, 65% African American, 34% White, 1% Hispanic), median CT/CTA completion time, from start of scan, to images ready for diagnostic viewing, was 3.5 minutes (IQR 3-4). Diagnosis was 15 (12%) hemorrhages, 12 (9%) suspected TIA, 100 (79%) acute ischemic stroke (AIS). AIS median NIHSS was 9, IQR 7-17. IV-tPA treatment rate was 38% with median scene arrival to bolus time of 13 min, IQR 11-16. Large vessel occlusion (LVO) was found in 30% of ischemic strokes. No patients required repeat imaging on arrival due to image quality, and 100% were accurately triaged to CSC, PSC, or CSC-cap hospitals without the need for subsequent transfer. Conclusions: MSUs can effectively operate a high-resolution automated CT similar to in-hospital radiology settings. The addition of head/neck CTA in the field yields a high rate of LVO detection supporting definitive prehospital triage to Comprehensive Stroke Centers.

Background: Understanding geospatial regional stroke burden and emergency medical services (EMS) response locations may benefit attainment and distribution of prehospital resources, enabling rapid diagnosis and treatment. We sought to understand the spatial distribution of all Mobile Stroke Unit (MSU) dispatches and diagnosed strokes during the first year of operation. Methods: All MSU dispatched cases from July 2016 to July 2017 were assembled and aggregated into groups based on stroke diagnosis status. The raw count of incidents was aggregated by zip code, normalized to population, and geocoded. The resulting incidence rate was symbolized by standard deviation and mapped by zip code for inspection. Five- and ten-minute drive time service areas were defined around our MSU base. Results: A total of 420 dispatches for suspected stroke occurred, of which 394 were able to be geocoded. On the initial analysis of all 394 cases, a five-minute service area was sufficient to rapidly reach areas with high rates of suspected stroke burden (> 1.5 SD) (figure 1). However, repeating the analysis on 123 cases diagnosed as true strokes redefined the areas that were strongly positive for high stroke burden requiring a ten-minute service area from our MSU base (figure 2). Conclusions: Use of geospatial findings helps plan EMS and MSU dispatch to high burden regional pockets of stroke, and may assist in improving dispatch scripting for 911 calls.

Background: Lowering of blood pressure (BP) is discouraged in current ASA guidelines for emergency medical service (EMS) personnel. However, ultra-early treatment with IVtPA and BP lowering in ICH are possible on mobile stroke units (MSU). We examined the effectiveness and safety of two antihypertensive agents for MSU treatment. Methods: Consecutive MSU patients were treated with target ICH BP parameters less than 140/90, and IVtPA BP parameters by current guidelines. BP was measured by noninvasive oscillometric cuff, and cycled every 5 minutes per EMS MSU protocol. Available agents were labetalol IV 10-20mg and/or nicardipine double-strength premix infusion started at 5mg/hour and titrated. Preference in usage, and effect were recorded and analyzed for the first year of MSU operation. Results: During 168 service days, 127 acute stroke patients were transported (68±16, range 23-96 years; 58% women; 65% African American, 34% White; 1% Hispanic). Fifteen (12%) had hemorrhage on CT (1 aneurysmal SAH, 1 SDH, 1 subacute AIS with HT-2; 12 HTN ICH [median ICH score 2, IQR 1-3] of which 1 had a positive spot sign on CTA). AIS cases (n=100) had median NIHSS 9 (IQR 7-17); 38% were treated with IVtPA at a median 13 (IQR 11-16) minutes from scene arrival, one of these by IO route, with 1 angioedema and 0 sICH. Labetalol was used for 9 patients, with all but one (89%) requiring the addition of nicardipine infusion. In 24 patients nicardipine was the first agent selected, with 100% achieving target BP control prior to hospital arrival. Conclusions: MSU use of nicardipine double-strength premix infusions provides rapid, reliable, and safe BP control. When time is of the essence, elimination of labetalol, in favor of a dihydropyridine calcium channel blocker infusion may provide the most rapid achievement of prescribed BP parameters.

Background: Mobile Stroke Units (MSU) are growing in numbers throughout the U.S. and abroad, with numerous staffing configurations, telemedicine, and differing imaging capabilities. We aimed to test the diagnostic accuracy and treatment safety, alongside time to diagnosis and treatment delivery of a novel advanced practice provider (APP) led MSU team. Methods: We launched an MSU housing a hospital-grade Siemens Somatom CT with CTA capabilities, and hired APPs with advanced neurovascular practitioner board certification to lead field medical diagnosis and order/initiate treatment for encountered stroke patients. Consecutive MSU patients were evaluated for differences between APPs and Vascular Neurologists (VNs) diagnosis and management, and scene diagnosis and treatment times were collected. Results: Agreement between APP field medical diagnosis and MD hospital diagnosis was 100%; stroke mimic diagnosis agreement was 98%. Overall agreement for field interpretation of CT/CTA was 97%, with discrepancies not associated with stroke treatment decisions. MDs’ agreement with APPs’ identification/treatment of ICH was 100%, and IVtPA treatment decisions 98% (APPs more conservative). Scene arrival to medical diagnosis (including clinical exam and imaging completion/interpretation) ranged from 7-10 minutes, of which 4 minutes were CT/CTA start to finish times. Scene arrival to IVtPA bolus ranged from 16 minutes to 33 minutes and was driven primarily by need for control of excessive hypertension, with scene arrival to start of nicardipine premix infusion ranging from 10-14 minutes. Conclusions: Use of an APP-led MSU is safe and non-inferior to VN diagnosis/management, and may be faster than telemedicine guided MSU treatment.

Background: Leading cultural change and performance improvement within a Stroke Center is often associated with resistance to increased workload and resources. We sought to understand neurologists’ experiences with transition to high performing U.S. Comprehensive Stroke Centers (CSC). Methods: Qualitative interviews were used to develop a survey for physicians currently or formerly working in CSC leadership positions identified thru listserv, fellowship directors, and web. The survey was 29 items with 6 items tied to DSM-IV PTSD experiential criteria and 3 qualitative items. Quantitative data were entered and analyzed in SPSS; qualitative data were analyzed to determine themes. Results: 48 CSC directors responded: 60% fellowship trained vascular neurologists (VN); 65% certified VN; 8% neurocritical care certified; 6% interventionalists. Sites were 67% academic; this was the first leadership position for 54%, with 9.3+6.5 (median 8) years as program leader. Prior to assuming leadership, tPA rates averaged 2.8%+4.8%, median 1.2%, with 40% not giving tPA; leader tPA rates averaged 12.1%+8.7%, median 9.5% (mean diff 9.1; 95% CI 6.9-11.3; p Conclusions: Despite challenges, CSC leaders are highly motivated, although rates of experiences tied to PTSD approaches that of soldiers. Hospital/physician administrators must improve support of stroke warriors to ensure optimal performance.

Background: Perception of hospital quality is typically collected from mailed surveys distributed to a random sample of discharges. These surveys capture few strokes, and fail to capture data addressing preparedness for transition to home, ability to identify/respond to stroke symptoms, or perceptions tied to acute stroke team performance. We sought to determine the feasibility of using an iPAD™ for collection of stroke perception of care data using the reliable/valid STROKE Perception Report (SPR) instrument. Methods: A cloud-based SPR database was established and IRB approval was obtained at 5 U.S. study sites. Consecutive stroke patients were offered an iPAD™ for data entry immediately prior to discharge. Families completed the survey for patients with severe stroke. Data were downloaded for analysis in SPSS. Results: A total of 153 surveys were collected with 101 (67%) collected from stroke patients averaging 62+/-14 years (median 62, range 19-94 years). Subjects were 74% White, 14% African American, 6% Asian, 2% Native Hawaiian/Pacific Islander, and 4% Native American/Alaskan Native; 17% were Hispanic. Education was: 37% high school (HS) graduates, 26% some college, 20% college graduates, 12% >college degree, and 5% some HS. The median score for difficulty was 4 (easy to use); only 2% (patients) rated data entry difficult. No users rated their entries as “at risk for confidentiality/privacy loss,” and 77% perceived entries as “more confidential” than paper entries. Of note, 62% indicated that they do not respond to mailed surveys. There was no difference in “ease of use” or “confidentiality protection” by patients, families, or race, however, higher levels of education with associated with perceptions of improved confidentiality (Chi Square 16.3; p=0.039). Interestingly, as patient age increased, perceptions of difficulty of use decreased (r=.29; p=0.029). Conclusions: Use of an electronic tablet to collect important perception of care data in stroke patients or family at discharge is feasible, and may constitute an improved method for obtaining sample sizes sufficient to draw conclusions about stroke service quality. Our findings support use of a discharge data collection model that can be widely disseminated regardless of age and education.

Background: Nurses caring for acute stroke patients require significant knowledge and skills to deliver expert evidence-based care. However, stroke nurse knowledge has not been captured with standardized methods until recently. We sought to measure knowledge in nurses participating in the NET SMART Junior program. Methods: NET SMART Junior is a novel on-line acute stroke learning system with more than 2500 users worldwide. The program provides both didactic and optional clinical skills exercises, with topics covering all aspects of prehospital and acute hospital management. We analyzed an international sample of test scores from NET SMART Junior, among users that completed the clinical competency portion of the program. Data were auto-assembled in Moodle and analyzed in SPSS. Results: 216 scores were analyzed; the sample consisted of 8 MSN nurses and 208 (96%) basic nurses. Overall program entry knowledge scores were 37%+/-14%, median 39% correct; significantly lower scores of 36%+/-14%, median 38% correct were found among staff nurses, as compared to 50%+/-15%, median 49% correct (mean diff 13.8; 95% CI 3.8-23.8; p=0.007) among MSN nurses. The lowest knowledge scores were found for reperfusion therapy, neurocritical care and complication avoidance (Table). No differences were found in users indicating completion of unit-based stroke educational programs or other for-profit on-line educational programs. Post-test scores were similar between groups with MSN nurses scoring 94%+/-5% (median 90%) and staff nurses scoring 95%+/-5% (median 100%; p=ns) on completed modules. Among 29 (13%) users indicating completion of a stroke certification examination (SCRN or NVRN), 100% pass rates were reported. Conclusions: Staff nurses have a variety of learning needs tied to acute stroke management. Comprehensive acute stroke education programs should include more expert level content and be supported by clinical application methods to ensure content mastery.

Background: The stroke coordinator is largely responsible for Stroke Center quality. With more than 800 certified Stroke Centers now available, we sought to understand how coordinators manage their mission. Methods: U.S. Stroke Center coordinators were invited to participate in two surveys via mail, fax, or SurveyMonkey. TM Data were entered and analyzed in SPSS using descriptive methods. Results: Responses (n=301) were received from coordinators in 48 states and the District of Columbia. Highest degree earned was RN Diploma (4%), ADN (6%), BSN (36%), MSN (44%), PhD (3%), and post-APN neurovascular fellowship training (7%); approximately 15% of hospitals did not utilize the stroke coordinator role. Stroke coordinators were self-taught 59% of the time and all worked at certified Stroke Centers; 58% of centers were considered Comprehensive Stroke Centers, however 100% of Primary Stroke Centers identified goals for comprehensive status. The most common educational needs identified were neuroimaging interpretation (68%), research design (60%), how to conduct/interpret statistical analyses (58%), and developing a research program (56%). There was considerable diversity in the definition of sICH, with 11% of coordinators confusing the term sICH with primary ICH despite the term being defined on the survey. The most significant barrier to role conduct was competing job functions, followed closely by data collection/entry that removes coordinators from clinical; 49% of Master’s prepared nurses were expected to collect/enter data, spending on average 11.6 hours/week + 6.3 (median 10 hours/week) in this function; of these, 52% would prefer to this work give away. Most valued role functions included overseeing clinical practice and quality management (> Master’s), and data collection/entry and patient education (< BSN). Conclusions: The stroke coordinator role has largely evolved without educational support and standardization to oversee the quality needs of Stroke Centers. Formal education, credentialing and role standardization based on education level may empower stroke coordinators to improve role effectiveness.

Background: Measuring sICH is an important accountability of Stroke Centers. Since the NINDS rt-PA Study, the sICH definition has changed as knowledge of reperfusion-associated hemorrhagic transformation has grown. We aimed to determine what sICH definition was used by Stroke Centers and how this impacts sICH rates. Methods: Stroke Centers were invited to participate in a survey with the option to complete it via SurveyMonkey TM or by mail. Instructions to adhere to the sICH definition adopted in policies/procedures were provided, and to ask for clarification from Stroke Team members if needed. Data were assembled in SPSS, and analyzed using descriptive statistics and Student t-tests. Results: 229 responses were received representing 84% of U.S. states and the District of Columbia; 31% represented academic medical centers and 69% community hospitals. 64% of respondees were responsible for collecting the stroke quality data that supports certification. Overall tPA treatment rate for the sample was 8.7% + 6.4 (median 7%), with an overall reported sICH rate of 9.5% + 16.4 (median 5%). Official definitions supported sICH for 86% of responding hospitals, however the most common definition (48%) reported was, “any hemorrhage on non-contrast CT or MRI in combination with any clinical deterioration.” Only 17% identified the definition for sICH adopted by TJC for Comprehensive Stroke Center reporting. Among those that adhered to the TJC definition, sICH rates were significantly lower at 3%+2.3 (median 3%; t=4.7; mean difference = 7.7%; p Conclusions: Our study documents a significant need for education and inter-rater reliability monitoring of the use of sICH classification after intravenous tPA to ensure accuracy in local quality improvement processes, as well as the validity of data submitted to national stroke registries. Additionally, because sICH associated with reperfusion therapy is a new measure undergoing testing by TJC that could ultimately be tied to future pay-for-performance and public reporting, consensus on its definition as well as reliable sICH classification will be essential to future Stroke Center evaluation.

Background: U.S. IV tPA treatment rates are lower than many countries, despite more than 800 certified Stroke Centers. We sought to understand if Stroke Centers utilized expanded inclusion/exclusion criteria beyond the Activase® label, and how use of these impacts treatment rates. Methods: U.S. Stroke Centers were invited to participate in a survey consisting of a checklist of tPA inclusions/exclusions derived from the Activase® label and stroke center websites. Data were entered and analyzed in SPSS using descriptives, Student t-test, Pearson’s correlation, and binary logistic regression. Results: 229 responses were received from 43 states and the District of Columbia; 31% were academic medical centers, 69% were community hospitals, 92% were PSC certified. Annual ischemic strokes averaged 374+261 (median 300), with 31+41 (median 20) IV tPA cases, for an overall tPA treatment rate of 8.7% + 6.4 (median 7%). Academic hospital tPA treatment rate was significantly higher (10.8 + 7.7; median 8%; t=2.3; mean difference 2.75; p=.026, 95% CI .33-5.2) than community hospitals (8+5.9; median 6%); 24% limited treatment to 3 hours. Additional criteria beyond the Activase® label (Table 1) were reported by 81%, the most common additional inclusions were “total NIHSS > 4 points” and “occlusion on CTA;” the most common additional exclusion was “rapid improvement despite remaining disabling deficit.” As the number of non-standard inclusions/exclusions increased, the tPA treatment rate decreased (r = -.153; p=.038). Using binary logistic regression, utilization of non-standard inclusions/exclusions was predicted by hospital type, admission volume, and use of the 3 hour window (p Conclusions: Custom inclusion/exclusion criteria are common and likely contribute to national treatment rates. Certifying bodies should consider requiring adherence to Activase®-label defined criteria as a method to improve tPA treatment rates.

The evidence base supporting the management of patients with acute stroke is evolving at a rapid rate, as new methods that aim to reduce disability and death from stroke are explored. Intravenous tissue plasminogen activator remains the only treatment shown in numerous studies to reduce disability 3 months after stroke with no increase in the risk of death and a relatively minor rate of symptomatic intracerebral hemorrhage complications. Despite these findings, health care providers have been slow to adopt this evidence-based treatment, which results in many patients experiencing disability caused by stroke. Numerous controversies exist related to the management of patients with acute stroke, including the use of tissue plasminogen activator, positioning and early mobility, blood pressure lowering in acute intracerebral hemorrhage, and even the use of innovative advanced practice nurse–led stroke treatment teams, with varying amounts of evidence available to provide direction. This article explores controversies associated with both approved and evolving treatments for ischemic and hemorrhagic stroke and makes recommendations for practice on the basis of the body of existing evidence, with an aim to improve the delivery of acute stroke treatment.