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Introduction: Acute stroke (AS) is a highly time sensitive treatment condition affecting approximately 800,000 people/year in the US. Most AS patients receive care at a primary stroke center (PSC), but some require more advanced treatments, and rely on a timely transfer to a comprehensive stroke center (CSC) where such treatments can be given. Stroke teams at 2 Chicago area PSCs and 4 CSCs, collectively, developed solutions (Graph) targeting both reported and perceived failures/delays/weakness in the current PSC door-in-door-out (DIDO) process for transferring patients to a CSC. The study simulates the potential impact of the solutions on DIDO. Methods: Current state (baseline) times were calculated from time stamps in the electronic health record (EHR) (e.g., door to CT), estimated by the stroke teams (e.g., hand-off time) or retrieved (e.g., DIDO, door to stroke activation) from a prospectively maintained REDCap data registry (2/2018-1/2020). Proportions (e.g., % with ischemic stroke, % transferred) were estimated from hospital data. Changes in times after implementation of a solution were obtained from peer reviewed literature, when available, or by consensus expert opinion. Simio (version 11.197.19514) was used to simulate the current and future states with implementation of the solutions, with 500 replications, to estimate changes in DIDO. Results: Implementation of all solutions would achieve a decrease in DIDO of 33 minutes (19%) from current state. The largest driver of this change was direct to CT/CTA protocol implementation (21 minutes) followed by using a handoff tool for paramedics prior to transfer (13 minutes). Conclusion: The proposed solutions can achieve nearly a 20% reduction in DIDO times. The “Direct to CT/CTA Protocol” solution is the major driver of the improvement. Data simulation is helpful by assessing the potential impact of many solutions and the relative impact of each solution to inform implementation decisions.

Background: Dysphagia is a common complication after stroke. To ensure adequate nutritional intake, nasogastric (NG) or other feeding tubes may be inserted. Post-stroke agitation and aggression can occur in 15 to 35% of stroke survivors as early as 4 days after stroke. At Rush University Medical Center (RUMC), it is common for the Stroke Unit patients to have feeding tubes and any other tubes necessary for treatment. It is a growing concern that agitated stroke patients self-remove feeding and other tubes requiring reinsertion and/or limb restraints. Although historically sensory modulation has not been heavily utilized in stroke patients, sensory based treatment objects in psychiatric inpatient units have been reported to reduce the use of restraints. Purpose: The purpose of this quality improvement project was to decrease agitation in stroke patients using sensory distraction objects (SDO). The goal of this project was to decrease the use of limb restraints and prevent patient self-removal and staff reinsertions of feeding and other tubes during this study period. Method: This project targeted stroke patients in the RUMC 12 West Tower Unit who were agitated, restless, impulsive, or anxious. Each patient was given a SDO, such as a plastic ring toy, glitter ball, activity belt, or a silk handkerchief attached to their gown. A decision tree was used to assign a SDO based on the patient’s cognitive and motor function. The Agitation Behavior Scale (ABS) was used to measure agitation in stroke patients; the scale was used pre- and post-implementation. Post-implementation assessment was done within one hour after the SDO is given. The use of limb restraints and patient self-removal of feeding and other tubes was observed. Conclusion: The project included 15 participants. Eleven out of 15 patients showed a decrease in agitation with a distraction object using the ABS. Only 20% of participants pulled out their feeding or other tube and two patients required restraints during the study period. In conclusion, this project did showcase a decrease in agitation for stroke patients using a SDO and decreased the use of limb restraints. The SDO prevented patient self-removal and staff reinsertion of feeding and other tubes.

Objectives: Non traumatic intracerebral hemorrhage (ICH) is responsible for 10-20% of acute stroke events and carries significant mortality concern. The protocol at our comprehensive stroke centers (CSC) is to admit all ICH patients to Neurosciences Intensive Care Unit (NSICU). We also have a stroke Intermediate Care Unit (IMCU) at our hospital which is a dedicated stroke unit where patients can be closely monitored and maintained on IV nicardipine. Optimal bed utilization is essential at our busy referral center. We aimed to develop criteria to identify ICH patients at low risk for clinical deterioration who could be admitted directly to our IMCU rather than the NSICU thereby improving overall utilization of monitored beds. Methods: Retrospective chart review for patients admitted between July 2018-Dec 2018 was performed. Age, sex, race, presenting Glasgow coma scale (GCS), ICH score, ICH volume, presence of IVH and location of the hemorrhage was documented. Patients who did not need any neurosurgical procedures (external ventricular drain, craniectomy or hematoma evacuation) and were not documented to have acute respiratory failure during their admission were considered appropriate for IMCU admission and were further assessed for hematoma expansion to determine stability throughout their hospital course. Results: 118 patients with ICH were included in the analysis, out of which 61 patients were suitable for IMCU admission. On univariable analysis, patients that had lower ICH scores (0.6±0.7 vs 2.5±0.9) and higher GCS score (14.1±1.4 vs 7.8±3.7) did not need any acute intervention. In this group of patients, only 9 (14.7%) patients had hematoma expansion documented out of which 6 (67%) patients had coagulation abnormalities on admission either due to medications or low platelet count. Conclusions: We conclude that the patients who had admission ICH score < 2, GCS ≥ 12 and no coagulation abnormalities on admission could have safely been admitted to our IMCU instead of the NSICU for further care and management. This would have led to a decrease in ICU admission rate. Application of such separate protocols for stroke IMCU admission vs ICU admission would lead to better utilization of resources at comprehensive stroke centers throughout the country.