Abstract WP306: Admission Stroke Severity is a Major Driver of Variation in Acute Stroke Care

Introduction: High reliability and bundling initiatives focus on reducing unnecessary practice variation to improve the value of care. It is uncertain whether models that address provider variability for elective procedures can be translated to analyze team-based care of patients with acute stroke.

Methods: All stroke discharges from 2015 at University Hospitals- Case Medical Center were analyzed for clinical and quality data from the GWTG PMT, including admission stroke severity scores, and reconciled with EPSi ™ financial data. Tableau was used for statistical analysis.

Results: Variation by provider for the 6 Stroke faculty for DRGs 61-69 ranged from average LOS 2.3-5.6 days and total margin $257,301 to ($51,846). However, the provider-defined as Attending at Discharge- represented the key decision-maker in < 50% of cases (mean 103, range 16-176) due to service rotations of 2-18 wks/year. Variation in total cost/case was driven by Room & Board and LOS- especially ICU LOS- more than pharmacy, radiology or lab costs. Variation by admission stroke severity score tracked with patient outcome at discharge. The lowest variation in LOS and total cost was observed for patient groups: NIHSS 0-3, 4-6, ICH Score 4, 5, and Hunt & Hess Score 5 and was significantly related to either rapid recovery or early mortality. The greatest variation in direct cost per case, LOS and ICU LOS was seen for NIHSS 21+, 16-20, ICH Score 2, 3, and Hunt & Hess Score 1, 2. Patients with severe ischemic stroke NIHSS 21+ had the highest utilization of pharmacy and radiology resources.

Conclusions: Admission stroke severity is a major driver of clinical variation in the cost of care, resource utilization and length of stay for patients with acute stroke. Using stroke severity scores to guide data analysis showcases opportunities for new clinical practice guidelines and care paths. Provider variability data is only reliable when is the attributed provider was the key decision maker in the patient’s care.

Abstract TP416: Does Hands-on tPA Education Really Improve Nurses' Knowledge Retention?

University Hospitals Comprehensive Stroke and Cerebrovascular Center (UHCSCC) Registered Nurses (RNs) in the Neurological Intermediate Unit (NIU) often care for patients after Intravenous (IV) tissue plasminogen activator (tPA) has been initiated. IV tPA is a high-alert medication that has potential bleeding risks. Due to the limited opportunity for initiating IV tPA, we identified the need for enhanced education among this group of RNs. Currently, NIU RNs complete an annual competency via an online learning management system (LMS). Our goal is to identify the best teaching method to heighten the ability for the RNs to retain and apply information. This project is to evaluate if an individualized hands-on educational approach improves the RN’s knowledge of IV tPA administration. In 2015, 36 NIU RNs were given a 20 question pretest that assessed their baseline knowledge on dosing, administration, monitoring, and complications of IV tPA. Each RN then completed the annual LMS competency. Eighteen RNs from this group were randomly selected to participate in an additional 30 minute one-on-one instructional session that included both verbal information and hands-on practice. Approximately 2 weeks later, all 36 RNs completed a 20 question post test to assess knowledge retention. All of the 36 NIU RNs had some education on IV tPA prior to this study. The years of experience working as an RN varied from 6 months to 20 years. Group 1 consisting of 18 RNs that solely received LMS education averaged 50.8% on the pretest and averaged 83.3% on the post test. Group 2 consisting of 18 RNs that had the additional hands-on educational session averaged a 42.2% on the pretest and averaged 95.8% on the post test. The data was analyzed using paired t -tests, and the difference in scores were significant for both groups (P=0.000). Additionally, a 2-sample t -test found significant difference (P=0.004) in the score changes from pre to post when comparing hands-on instruction to the LMS training. Both methods of education were associated with significant increased scores on the post test. Our data suggests that the hands-on approach along with our current practice improves knowledge retention. Further research would be useful to assess retention several months post education.

Interstitial Cystitis - Elucidation of Psychophysiologic and Autonomic Characteristics (the ICEPAC Study): design and methods

BACKGROUND AND PURPOSE

Interstitial cystitis/bladder pain syndrome (IC/BPS) is relatively common and associated with severe pain, yet effective treatment remains elusive. Research typically emphasized the bladder's role, but given the high presence of systemic comorbidities, the authors hypothesized a pathophysiologic nervous system role. This paper reports the methodology and approach to study the nervous system in women with IC/BPS. The study compares neurologic, urologic, gynecologic, autonomic, gastrointestinal, and psychological features of women with IC/BPS, their female relatives, women with myofascial pelvic pain (MPP), and healthy controls to elucidate the role of central and peripheral processing.

METHODS AND RESULTS

In total, 228 women (76 IC/BPS, 76 MPP, 38 family members, and 38 healthy controls) will be recruited. Subjects undergo detailed screening, structured neurologic examination of limbs and pelvis, tender point examination, autonomic testing, electrogastrography, and assessment of comorbid functional dysautonomias. Interpreters are blinded to subject classification. Psychological and stress response characteristics are examined with assessments of stress, trauma history, general psychological function, and stress response quantification. As of December 2012, data collection is completed for 25 healthy controls, 33 IC/BPS ± MPP, eight MPP, and three family members. Recruitment rate is accelerating and strategies emphasize maintaining and encouraging investigator participation in study science, internet advertising, and presentations to pelvic pain support groups.

CONCLUSION

The study represents a comprehensive, interdisciplinary approach to sampling autonomic and psychophysiologic characteristics of women with IC/BPS. Despite divergent opinions on study methodologies based on specialty experiences, the study has proven feasible to date and different perspectives have proved to be one of the greatest study strengths.