Abstract WP119: Alteplase Given Within 4.5 Hours via Telemedicine and in Person to Patients Presenting With a Central Retinal Artery Occlusion

Introduction: Central or branch retinal artery occlusion (CRAO/BRAO) results in acute monocular vision loss. Studies on the efficacy of IV t-PA, treated patients up to 30 hours from symptom onset. There has only been one prospective study of early IV t-PA use. With the increasing use of telemedicine (TM), we evaluated the use of IV t-PA within 4.5 hours for CRAO/BRAO and assessed visual outcomes up to 90 days amongst patients evaluated via TM versus in-person.

Methods: Data were retrospectively abstracted for CRAO/BRAO treated with IV t-PA within a large managed healthcare system. Visual outcomes abstracted at 24 hours were classified as Low Vision (light perception, hand motion, finger counting) and converted to mean LogMAR. Visual outcomes abstracted within 2 weeks and 3 months were 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). Descriptive statistics were performed on all variables. Visual outcomes were analyzed using the sign test.

Results: Between 2013-2019, 16 patients received IV t-PA within 4.5 hours of symptom onset. 11 were evaluated via TM and 5 in-person. All patients were accurately diagnosed with CRAO/BRAO. 24 hours post t-PA, 37.5% of TM vs 25% of in-person patients had at least a one-point improvement on the low vision scale. Within 2 weeks, 12.5% of TM vs 18.75% of in-person, and within 90 days, 13.33% of TM vs 20% of in-person patients improved from low vision to normal-mild impairment in vision. In all patients, at 24 hours post t-PA 56.25% (p= 0.04) had at least a one-point improvement on the low vision scale. Within 2 weeks, 31.25% (p= 0.03) and 90 days, 33.3% (p= 0.03) of patients continued to improve from low vision to normal-mild impairment in vision.

Conclusions: All patients were correctly diagnosed with CRAO/BRAO irrespective of method of evaluation. More patients improved on the low vision scale at 24 hours via TM than in-person. More in-person diagnosed patients improved from low vision to normal-mild impairment in vision within 2 weeks and 90 days of IV t-PA. IV t-PA use within 4.5 hours for CRAO/BRAO may lead to improved visual outcomes at 90 days regardless of TM or in-person diagnosis. Our study was limited by small sample size and no control group.

Abstract WP184: The Road to Recovery Stroke Support Group: A Feasibility Assessment of an Inpatient Multi-Disciplinary Stroke Support Group

Background: Stroke is life changing for both patients and caregivers. Recovery from stroke affects the physical, social and emotional aspects of life. Transitioning to a new normal should begin immediately after stroke, ideally during hospital admission. Most support groups exist outside of the hospital setting and begin weeks to months after the ictus. The Road to Recovery Stroke Support Group (RRSSG) was created to bridge the gap between the inpatient and outpatient setting.

Purpose: RRSSG aims to provide a weekly platform for stroke survivors and caregivers in an in-hospital setting. During sessions, attendees learn about types of challenges after stroke, rehabilitation services available to them and what to expect after leaving the hospital. Patients can return to the same support group once discharged from the hospital.

Methods: RRSSG was launched in November 2018. Candidates for the weekly RRSSG meeting were identified by nurses and the stroke case manager. Meetings were facilitated by a stroke survivor volunteer, case management and physical and social medicine. Invitations were extended to patients and their caregivers prior to discharge. Data were collected for 7 months and analyzed for the following: patient demographics, types of stroke and discharge disposition.

Results: During the 7-month period, 514 patients were discharged with a stroke diagnosis, 24.3% of which attended the RRSSG. The demographics were 53.7% women with a median age of 66 years; 33.1% White/European, 36% Hispanic/Latino, 18.0% African American, 10.8% Asian, and 2.1% other. 61.6% had an ischemic stroke, 30.4% had an intracerebral hemorrhage, 11.2% had a subarachnoid hemorrhage. More patients who attended RRSSG were discharged to an acute rehabilitation hospital (6.5% RRSG vs. 1.8% non-RRSG, p=0.04). There was no difference in those discharged to: home (54.0% RRSSG vs. 55.5% non-RRSSG) and skilled nursing facility (27.3% RRSSG vs. 20.1% non-RRSSG).

Conclusion: Creating and sustaining an inpatient multi-disciplinary stroke support group on a weekly basis is feasible. The future goals are to assess the impact of the in-hospital support group on stroke knowledge retention, medication compliance, post-stroke depression, recurrent stroke and re-admission rates.

Abstract TP288: Emergency Department Nursing Stroke Champions Improve Door to Needle Times at a Comprehensive Stroke Center

Introduction: Intravenous tissue plasminogen activator (IV tPA), for acute ischemic stroke, has a more robust effect if given early. Improving Door-to-Needle (DTN) times in order to allow quicker administration of IV tPA continues to be the primary aim of TARGET:STROKE. The Stroke Champion (SC) Program, an American Heart Association’s Get with the Guidelines recommendation, was implemented in our emergency department (ED) in 2018.

Purpose: The purpose of this study was assess if an ED Nurse SC would help to improve DTN, with a specific goal to increase the percentage of patient’s receiving IV tPA ≤30 minutes.

Methods: The SC program was initiated in our ED in January 2018. The ED Nurse SC carries the following responsibilities: respond to all stroke alerts, weekly audit of all stroke alert charts, peer to peer follow up for any fallouts to determine if there was a system error or if there was an educational opportunity, weekly update of ED staff virtual communication board, weekly meeting with ED director for any challenges or expected changes, development of a relevant stroke education topic to be delivered at the biweekly ED nursing huddle, participate at the weekly code stroke huddle to collaborate with the stroke team, and attend relevant stroke conferences or stroke-related educational opportunities. A weekly “Stroke Shout Out” was also initiated by the ED Nurse SC to recognize a high performing member of the ED team. Data was compared 6 months pre and post-intervention, and analyzed using a Wilcoxon Rank Sum Test.

Results: More patients received IV tPA after the initiation of the ED Nursing SC program than before (38 vs. 23 p=0.03). The median DTN was 36 (IQR 23-49) mins after implementation vs. 47 (IQR 40-56) mins before implementation (p=0.004). A higher percentage of patients received IV tPA less than 30 minutes post intervention vs. pre-intervention (42.1% vs. 17.4% , p <0.001)

Conclusion: Implementation of an ED Nurse SC can increase the number of patients who receive IV tPA, improve DTN, and increase the percentage of patients who receive IV tPA less than 30 minutes from door time.

Abstract WP249: Comparison of Telestroke Metrics Between an Internal Telestroke Model to an External Telestroke Vendor Within the Same System of Care

Background: Telestroke (TS) has been used to provide acute stroke care through a variety of different models. Two of these include an external vendor model (EVM), where care is provided by specialists that are not intrinsically related to the hospitals to which the care is being delivered, and another is an internally designed model (IDM) run by neurologists employed by the same hospital system. Our hospital system at Kaiser Permanente employed coverage via an outside vendor at certain sites as well as concurrently used an internally designed telestroke program at other sites.

Objective: We aimed to determine if an IDM would provide quicker telestroke services and improve the door to needle time (DTN) to that provided by EVM in the management of acute ischemic stroke.

Methods: Charts in which tPA was administered using TS, from 1/1/2015 to 12/31/2015, were retrospectively reviewed from two different medical centers of similar size and patient volume. One center utilized an EVM while the other employed an IDM. Several metrics were compared including DTN, door to telestroke consultation time and call back time from telestroke neurologist. A 2 tailed T-test was used to compare the differences between both groups.

Results: Thirty three patients received tPA via IDM, and 37 patients via EVM. The median door to telestroke consultation placement time was 11 minutes (mins) in both hospitals (p=0.10). The median telestroke physician call back was 16 (IQR 13-18) mins in EVM vs. 7 (IQR 10-24) mins in IDM (p=0.024). The overall door to telestroke consultation was 44 (IQR 29-40) mins in the EVM vs. 21 (IQR 14-40) mins in IDM (P=0.006). The median DTN was 86 (IQR 69-107) mins in EVM vs. 51 (IQR 42-70) mins in IDM (p= 0.005).

Conclusion: The IDM cohort had quicker call back and consultation times compared to the EVM group. However, there was no difference between door to consult placement time helping to remove local emergency department variability. This suggests that a model that is internally developed with physicians intrinsically related to the hospital system compared to an external vendor may provide quicker telestroke services and improve DTN.

Aspiration Thrombectomy After Intravenous Alteplase Versus Intravenous Alteplase Alone

Background and Purpose—

Thrombectomy, primarily with stent retrievers with or without adjunctive aspiration, provided clinical benefit across multiple prospective randomized trials. Whether this benefit is exclusive to stent retrievers is unclear.

Methods—

THERAPY (The Randomized, Concurrent Controlled Trial to Assess the Penumbra System’s Safety and Effectiveness in the Treatment of Acute Stroke; NCT01429350) was an international, multicenter, prospective, randomized (1:1), open label, blinded end point evaluation, concurrent controlled clinical trial of aspiration thrombectomy after intravenous alteplase (IAT) administration compared with intravenous-alteplase alone in patients with large vessel ischemic stroke because of a thrombus length of ≥8 mm. The primary efficacy end point was the percent of patients achieving independence at 90 days (modified Rankin Scale score, 0–2; intention-to-treat analysis). The primary safety end point was the rate of severe adverse events (SAEs) by 90 days (as treated analysis). Patients were randomized 1:1 across 36 centers in 2 countries (United States and Germany).

Results—

Enrollment was halted after 108 (55 IAT and 53 intravenous) patients (of 692 planned) because of external evidence of the added benefit of endovascular therapy to intravenous-alteplase alone. Functional independence was achieved in 38% IAT and 30% intravenous intention-to-treat groups ( P =0.52). Intention-to-treat ordinal modified Rankin Scale odds ratio was 1.76 (95% confidence interval, 0.86–3.59; P =0.12) in favor of IAT. Secondary efficacy analyses all demonstrated a consistent direction of effect toward benefit of IAT. No differences in symptomatic intracranial hemorrhage rates (9.3% IAT versus 9.7% intravenous, P =1.0) or 90-day mortality (IAT: 12% versus intravenous: 23.9%, P =0.18) were observed.

Conclusions—

THERAPY did not achieve its primary end point in this underpowered sample. Directions of effect for all prespecified outcomes were both internally and externally consistent toward benefit. It is possible that an alternate method of thrombectomy, primary aspiration, will benefit selected patients harboring large vessel occlusions. Further study on this topic is indicated.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01429350.

Abstract WP367: Comparison of Standard Emergency Room Care with Tele-Stroke Evaluation in Acute Intracerebral Hemorrhage Management

Introduction: Intracerebral hemorrhage (ICH) management includes rapid blood pressure (BP) control and correction of any coagulopathy. It is unknown if the addition of tele-medicine (TM) assessment by vascular neurologists would improve time to intervention of these factors. We hypothesized that TM assessment would improve the time to BP control and anticoagulation reversal compared to standard emergency physician management with telephone neurosurgical consultation (ED).

Methods: Charts were retrospectively reviewed for all patients with a primary ICD-9 diagnosis of ICH who presented directly to the ED between 8/15/2013 and 5/30/2015, in three urban primary stroke centers in a Southern California integrated healthcare system that utilizes a internalized tele-stroke system. Patients who were transferred from outside hospitals were excluded. Data collected were patient demographics and specific time points to assess door to BP reduction and anticoagulant reversal initiation. These were compared for patients evaluated by ED vs TM using Fisher’s exact test, Chi-squared test, and Wilcoxon test.

Results: Data for 105 ED and 19 TM patients were compared. There was no difference in gender (54.8% male), median age (67 yrs {IQR 58.5-80 yrs}), and median presenting BP (180/93 {IQR 157-207/79.5-108}). Patients seen by TM had a significantly shorter median time from onset to presentation (102.5 min {IQR 37-191 min}) compared to patients evaluated by ED (171 min {IQR 60-492 min}). Patients seen by TM were more likely to have NIHSS documented, faster times to CT head completion and interpretation, higher rates of BP agent administration with faster times to BP agent order and administration, faster time to BP control (both less than systolic 160 and 140), and faster times for anticoagulation reversal order and administration.

Conclusion: TM assessment of patients with ICH improves time to BP control and anticoagulation reversal agent initiation.

Abstract W P217: Improvement of Door to Needle Times and IV rt-PA Utilization with the Application of TARGET:STROKE Recommendations to an Urban Integrated Tele-Medicine System

Background and Objectives: Tele-medicine (TM) has been proven to provide quality acute stroke care. The type of consultation and services provided by TM vendors vary. None seem to provide a comprehensive service to the receiving center that includes methods on how to improve door to needle times (DTN). We hypothesized that creating a comprehensive TM solution in an integrated medical system using TARGET: STROKE (TS) principles would improve DTN times and IV rt-PA utilization.

Methods: Five urban Joint Commission certified primary stroke center community hospitals in a Southern California integrated healthcare system participated. Prior to initiation of TM services, each hospital had two separate meetings with the TM provider (two vascular neurologists). The first meeting was with emergency room physicians, explaining the need to have a low threshold to call a tele-code stroke within 4.5 hours of last seen normal regardless of inclusion/exclusion criteria and prior to obtaining the head CT. The second meeting included a multi-disciplinary group to outline the TS principles and organize a stroke team with a focused goal to improve DTN. The 10 TARGET: STROKE best practice strategies were implemented. Data regarding the key time interval goals were gathered and reviewed with each hospital on a bi-weekly basis. The TM providers worked with each hospital to improve specific time intervals where necessary by providing proven strategies, and assisting in their implementation. Data were analyzed using a parallel time period at each hospital comparing pre-TM to post-TM, the longest period being 11 months.

Results: Twenty-eight patients were given rt-PA pre-TM compared to 50 patients post-TM. The percent of patients who received rt-PA ≤ 60 minutes (min) pre-TM was14% vs. 42% post-TM (p=0.02). The median pre-TM DTN was 78 min (IQR 68-116) compared to a post-TM DTN of 67 min (IQR 56-78), an absolute difference of 11 min (p=0.007).

Conclusion: Application of TARGET: STROKE guidelines can be implemented successfully via an integrated TM system of stroke care to improve DTN and rt-PA utilization.