Background: Delay in hospital arrival for stroke patients continues to be a persistent problem in Wisconsin (WI). Research shows outcomes are better with earlier arrival and treatment with IV tPA. The proportion of patients activating 911 and arriving quickly after a stroke has not improved over time. Arrival via EMS versus private transport has seen a slight decrease. Purpose: Evaluate the trends of patient arrival mode and trends of last known well to arrival time in order to work collaboratively with state partners on public awareness of stroke signs,symptoms and importance of calling 911. Methods: Two benchmarking groups were established in WI through the Get With The Guidelines Patient Management tool: the All WI hospital benchmark and the WI PSC benchmark. The benchmarks include 65 WI hospitals and 27,197 stroke records between 2009 and 2012. We evaluated trends in onset-to-arrival times and use of EMS among stroke patients in both benchmark groups. Results: During the study period, approximately 22% of stroke patients arrive to hospital within 120 minutes of time last known well with no change over time despite stroke systems work throughout the state. Onset-to-arrival times were similar at Wisconsin PSCs versus any Wisconsin hospital. Arrival by EMS has decreased over time at both PSCs (44% in 2009 to 30.1% in 2012) and all hospitals (35.6% in 2009 to 32% in 2012). Conclusions: Many stroke patients do not activate 911 or arrive to a hospital in a timely manner. Collaborative attempts by state partners to provide education to the public has not made much difference in arrival mode and arrival from time last known well. Structured outreach activities utilizing initiatives such as the American Heart Association’s signs and symptoms materials can continue to be utilized, but a more comprehensive plan among state stakeholders, EMS, hospitals and the AHA will need to be developed to improve patient awareness and subsequently patient arrival times, resulting in better outcomes.

Background and Issues— Stroke continues to be a significant cause of morbidity and mortality. Research has shown improved outcomes when IV tPA is started as close as possible to the time the patient was last known well. Although the use of IV tPA has increased over time, there still an opportunity to increase the use of IV tPA so more patients may benefit from this acute intervention. Purpose— To explore the top reasons documented for not giving IV tPA in WI Rural and WI PSC Hospitals. Methods— Two groups (Rural and WI PSC) were established in Wisconsin through the Get With The Guidelines-Stroke database. The Rural hospital group includes an average of 13 hospitals with 282 total documented reasons for no IV tPA being given. The WI PSC Hospital group includes 26 hospitals with 2552 documented reasons for not giving IV tPA. The time period in which these reasons were tracked was January 1, 2008 through December 31, 2011. Reasons were ranked as a percentage of the whole for each group, and the top five are listed in the Results section. Results— Conclusions— Advanced age and rapid improvement of symptoms are commonly documented reasons for not giving IV tPA in both Rural and PSC Hospitals in WI. Rural hospitals also note some facility reasons; whereas the PSC hospitals noted delay in presentation to their facility or that tPA was started elsewhere as common reasons for not administering this acute intervention. Of all the reasons listed above, the patient that already received tPA at another institution is the only absolute contraindication for more tPA. An opportunity exists to increase education to providers on weighing the relative risk for tPA criteria versus the potential benefit of the patient, as well as community education of early treatment necessity. Further research is also needed to determine other factors (i.e. salvageable penumbra) in deciding on treatment options.

Background and Issues- Stroke continues to be a significant cause of morbidity and mortality in Wisconsin. Research has shown improved outcomes when IV tPA is started as close as possible to the time the patient was last known well. Wisconsin has continued to work on the improvement of stroke systems of care through rural and urban initiatives and the awareness of time critical factors. Purpose- To evaluate the current state of compliance with factors known to increase the percentage of eligible patients receiving IV tPA within 60 minutes of arrival in both rural and urban settings. Methods- Two benchmarking groups were established in Wisconsin through the Get With The Guidelines online Patient Management tool. The Rural hospital benchmark includes an average of 21 hospitals and the Primary Stroke Center (PSC) group includes 24 hospitals. A total of 15,783 patient records between Q1 2008 and Q4 2010 were reviewed. Results- Both groups show similar barriers in getting IV tPA to the patient within 60 minutes of arrival. The measures that showed the greatest opportunity for improvement included pre-notification of an acute stroke from EMS to the receiving hospital allowing the hospital team to prepare and CT turnaround time. The rural group received pre-notification 64.8% between 2008 and 2010 and the PSC group at 66.1% during that same time frame. Another time critical factor is CT <= 25 minutes. The PSC group achieved that timeframe 21.9% of the time, doing slightly better than the rural group at 18.5%. Conclusions- Structured outreach activities utilizing national initiatives such as the American Heart Association’s Target: Stroke has highlighted the distance between the current situation and desired goal. This indicates the need to implement targeted QI programs, with follow up data collection to increase DTN <60. Specifically targeting small rural hospitals has increased awareness of the current barriers in administering IV tPA. Wisconsin hospitals in both benchmarks have committed to work on the identified measures, analyze progress and resolve specific barriers to timely IV tPA administration.

Background and Purpose —Diagnosis and treatment of transient ischemic attacks (TIAs) is often delayed by lack of access to immediate comprehensive evaluation of the underlying etiology. Early initiation of treatment can reduce the risk of early recurrent stroke by up to 80%. Up to 40% of people who have experienced a TIA will go on to have a stroke. The purpose of this review was to determine the efficacy of an Emergency Department (ED)-based TIA observation unit using a standardized TIA protocol designed to provide rapid evaluation and treatment of patients presenting with TIA in reducing the rates of readmission with stroke to a community-based hospital. Methods —We did a retrospective chart review of all patients discharged from Bellin Hospital with a diagnosis of stroke before implementing a standardized TIA protocol in our ED-based TIA observation unit (July to December 2010) and after implementation of the TIA observation unit (November 2011 to April 2012). We identified the patients in these cohorts who had previously been evaluated in the ED with signs or symptoms of stroke in the 6 months prior to admission and compared their stroke readmission rates. Patients who received evaluation through the TIA observation unit from November 2011 to April 2012 were monitored for readmission for stroke in the 6 months after evaluation. Results —Prior to use of the TIA observation unit, 7 of 51 (13.7%) patients discharged with a diagnosis of stroke had been seen in the ED in the previous 6 months with stroke-like symptoms. After implementation of the TIA observation unit, 7 of 119 (5.9%) patients discharged with a diagnosis of stroke had been seen in the ED, a 57.1% reduction in stroke readmission at 6 months. Of these, 4 (57.1%) had not completed the work-up during their previous ED visit. 122 patients underwent evaluation using the TIA observation unit. Of these, only 3 (2.5%) patients were readmitted for stroke in the next 6 months. 16 of these 122 (13.1%) patients were diagnosed with stroke during their TIA work-up. Conclusions —Rapid evaluation and treatment of TIA through an ED-based TIA observation unit substantially reduces the risk of readmission for stroke.

Background and Purpose: Ensuring the quality of a registry’s data is essential to its credibility and reliability of the information gathered. The Wisconsin Coverdell Stroke Program (WI Coverdell) monitors inter-rater reliability (IRR) through quarterly re-abstraction of five patient records from each of its participating hospitals. The goal for individual sites is 90% or greater concordance rate for each of the 28 data elements measured. This quarterly process ensures two abstractors at participating sites are familiar with the oftentimes difficult stroke data entry process. It also provides added benefit to hospitals by supporting continued quality improvement initiatives, as well as assists in meeting their certification bodies’ requirements. Methods: Participating hospitals gain access to two stroke data entry sites. One site is for entry of stroke abstracts; the second is utilized solely for re-abstraction entry. Quarterly, WI Coverdell performs an analysis of data agreement of the abstractions and re-abstractions. A subsequent quality report is sent to the hospital contact where the data elements that had mismatches are highlighted. Findings: Over nine quarters we have found individual sites agreement rates between two abstractors have varied from 70% to 100%. Whereas, WI Coverdell hospitals aggregated agreement rate has been stable at 92%-94%. Perceived rationales for agreement rates that are <90% include (1) the need for an identified source of truth for certain data elements, and (2) as new abstractors or re-abstractors begin stroke data entry, due to turnover in their roles, educational opportunities exist for understanding or clarification of the stroke coding instructions. Conclusions: A quarterly IRR process ensures two abstractors are proficient at data entry at participating hospitals, demonstrates the need for creating a source of truth document, and identifies learning opportunities for individual data abstractors.