Background and Purpose: At least 12% of stroke patients are readmitted to a hospital within 30 days of discharge. We know that patients hospitalized for other conditions are less likely to be readmitted within 30 days if they are seen by their PCP shortly after discharge. However, less than a third of patients in the New York metropolitan area admitted for heart failure, heart attacks, and pneumonia see their PCP within 14 days after discharge and nearly 40% of patients do not adhere to their prescribed regimen. In the case of cerebrovascular diseases, outpatient follow-up may prevent the majority of avoidable readmissions. The purpose of this project is to identify and reduce unnecessary, unplanned hospital readmissions after stroke. Our goal is to encourage patient adherence to prescribed medication and other therapies, as well as to ensure timely follow-up with their PCP. Methods: Stroke and transient ischemic attack (TIA) patients with a disposition of either home or short-term rehabilitation are visited and offered enrollment. Participants are given a kit which includes a personalized binder (to manage essential medical information) and a 28-slot pill box. Each patient then receives 3 phone call interviews at 7, 21 and 32 days after discharge. The aim of the phone calls is to identify obstacles to compliance with treatment regimen and follow-up care. Results: From January 2015 to June 2016, 247 patients were enrolled and followed up. Within 30 days of discharge, 10% were readmitted and 50% of all readmissions occurred within the first 7 days. Of those readmitted, 19% were due to an injury from physical therapy. Data from follow-up phone calls revealed that 83% were taking all prescribed medications, 89% had completed a follow-up with any physician, 69% were using the binder, and 61% had done all three. Conclusions: While we have not enrolled enough patients to see a statistically significant reduction in readmissions, our interviews showed that weather, depression, as well as a lack of insurance, family support, and a home health aide are all determinants on how patients will follow their prescribed regimen. The results of this study have allowed us to begin implementing stroke support groups and pre-discharge follow-up appointment scheduling.

Background: Patients with symptoms that simulate Acute Ischemic Stroke (AIS), but are ultimately determined to have another diagnosis are referred to as Stroke Mimics (SM). SM are reported to be 1.4% to 30% of Emergency Department (ED) cases, and reducing door-to-needle time (DTN) has been associated with increased treatment of SM (from 6.7% to 30%). The risk of tPA in SM patients is unclear. We are challenged with the conflicting goals of timely administration of therapy and mitigating unnecessary risk. We successfully reduced DTN and were interested to see if that effected SM. Objectives: To evaluate the impact of DTN on diagnostic accuracy in patients receiving tPA in the ED; and to determine the associated complication rate in patients with AIS compared to SM. Methods: We performed a retrospective cohort study of patients receiving tPA for suspected AIS between 2013-2015. Patients were identified through our Stroke registry and confirmed by pharmacy audit of tPA orders. We performed a structured chart review and provide a descriptive analysis of variables. Results: In our study period, 97 patients were treated with tPA for the presumptive diagnosis of AIS, 90 (92.8%) had a final diagnosis of AIS, while 7 (7.2%) were SM. The only complications of treatment with tPA reported were in the AIS group, 4 (15%) and 1 (4.2%) in 2013/2014 repectively. There were no complications reported in either group in 2015. This reduction in complications was achieved while reducing the DTN to less than 45 min in 50% of patients and less than 60 min in 75% of patients. Conclusion: While doubling the number of patients treated, we reduced the DTN and the complication rate in AIS patients. Contrary to prior studies, we found a decrease in the number of SM treated. None of the SM patients had a complication. The reduction in DTN and SM over time suggests that our screening of tPA candidates is appropriate.

Background: Rapid administration of intravenous alteplase (IV tPA) for acute ischemic stroke leads to improved clinical and functional outcomes. However, several barriers delay or preclude patients from undergoing timely treatment, including delayed triage and evaluation in the emergency department (ED). Patients with acute ischemic stroke who arrive by emergency medical services (EMS) receive a higher level of care, but mode of arrival has not been specifically evaluated as a predictor of IV tPA door-to-needle (DTN) times. Hypothesis: Patients with acute ischemic stroke who arrive by EMS to the ED will be treated more quickly than patients who arrive by other means. Methods: This was a retrospective cohort study evaluating all adult patients presenting with suspected acute ischemic stroke to the ED of an academic hospital and New York State Department of Health-designated stroke center in Brooklyn, NY, who received IV tPA from June 2011 to June 2017. Using Get With the Guidelines - Stroke Program data, a stroke coordinator abstracted data on patient age, sex, NIHSS, arrival mode, emergency severity index (ESI), DTN time, and discharge disposition. Results: A total of 156 patients received IV tPA for suspected acute ischemic stroke in the ED during the study period. Baseline characteristics of the sample were mean age of 66 (SD 14.4) years, 48.5% were female, and mean DTN time 46 minutes. The majority of these patients (79.5%) arrived by EMS. The median DTN time in the EMS arrival group was 42.5 (IQR 34-54) minutes compared to 51.5 (IQR 44-58) minutes in the non-EMS arrival group ( P < 0.05). There was a trend toward more severe strokes in the EMS arrival group but this was not statistically significant (median NIHSS 10 [IQR 6-19] for EMS vs. 4 [IQR 3-5.25] for non-EMS, P = 0.05). While arrival mode was not a significant predictor of DTN time (χ 2 [2, N = 156] = 59.2, P = 0.32), NIHSS was significantly negatively correlated with DTN time (r = -0.20, P = 0.01). This may be due to less diagnostic uncertainty and faster clinical decision-making with more severe strokes. Conclusions: Arrival by ambulance to the ED is not associated with a significantly shorter DTN times in patients with acute ischemic stroke. However, there is a significant inverse correlation between NIHSS and DTN time.