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INTRODUCTION: During the COVID-19 pandemic, hospitals still have to meet external regulations while delivering compassionate patient care. This reflections article provides a solution for certified stroke programs to continue to meet stroke certification requirements. One area of focus, in this article, is stroke education. Because of “shelter-in-place orders,” there were no visitors permitted at the bedside, yet we know that high-quality poststroke education is important to improve outcomes. The purpose of this reflections article is to share what has worked at my institution. INNOVATIONS: We found that calling family members to engage them in stroke education was a great option. They seemed engaged, took notes, and asked questions. Nurses document details from these phone encounters in the patient's medical record. Many people placed the call on speaker so other family members could listen to the education session. While family members were at home, telehealth nursing has its own set of challenges. Although telehealth is not a perfect solution, it was one we found most reasonable and found it to work well through this unprecedented time. SUMMARY: These strategies are being shared to promote dissemination of innovative nursing interventions that will help to continue providing loved ones with the information and education they deserve to receive even during the COVID-19 pandemic.

ImportanceSymptomatic intracranial hemorrhage (sICH) is a serious complication of stroke thrombolytic therapy. Many stroke centers have adopted 0.25-mg/kg tenecteplase instead of alteplase for stroke thrombolysis based on evidence from randomized comparisons to alteplase as well as for its practical advantages. There have been no significant differences in symptomatic intracranial hemorrhage (sICH) reported from randomized clinical trials or published case series for the 0.25-mg/Kg dose.ObjectiveTo assess the risk of sICH following ischemic stroke in patients treated with tenecteplase compared to those treated with alteplase.Design, Setting, and ParticipantsThis was a retrospective observational study using data from the large multicenter international Comparative Effectiveness of Routine Tenecteplase vs Alteplase in Acute Ischemic Stroke (CERTAIN) collaboration comprising deidentified data on patients with ischemic stroke treated with intravenous thrombolysis. Data from more than 100 hospitals in New Zealand, Australia, and the US that used alteplase or tenecteplase for patients treated between July 1, 2018, and June 30, 2021, were included for analysis. Participating centers included a mix of nonthrombectomy- and thrombectomy-capacity comprehensive stroke centers. Standardized data were abstracted and harmonized from local or regional clinical registries. Consecutive patients with acute ischemic stroke who were considered eligible and received thrombolysis at the participating stroke registries during the study period were included. All 9238 patients who received thrombolysis were included in this retrospective analysis.Main Outcomes and MeasuressICH was defined as clinical worsening of at least 4 points on the National Institutes of Health Stroke Scale (NIHSS), attributed to parenchymal hematoma, subarachnoid, or intraventricular hemorrhage. Differences between tenecteplase and alteplase in the risk of sICH were assessed using logistic regression, adjusted for age, sex, NIHSS score, and thrombectomy.ResultsOf the 9238 patients included in the analysis, the median (IQR) age was 71 (59-80) years, and 4449 patients (48%) were female. Tenecteplase was administered to 1925 patients. The tenecteplase group was older (median [IQR], 73 [61-81] years vs 70 [58-80] years; P < .001), more likely to be male (1034 of 7313 [54%] vs 3755 of 1925 [51%]; P < .01), had higher NIHSS scores (median [IQR], 9 [5-17] vs 7 [4-14]; P < .001), and more frequently underwent endovascular thrombectomy (38% vs 20%; P < .001). The proportion of patients with sICH was 1.8% for tenecteplase and 3.6% for alteplase (P < .001), with an adjusted odds ratio (aOR) of 0.42 (95% CI, 0.30-0.58; P < .01). Similar results were observed in both thrombectomy and nonthrombectomy subgroups.Conclusions and RelevanceIn this large study, ischemic stroke treatment with 0.25-mg/kg tenecteplase was associated with lower odds of sICH than treatment with alteplase. The results provide evidence supporting the safety of tenecteplase for stroke thrombolysis in real-world clinical practice.

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Background: Race and ethnicity can have a major impact on the quality of care patients with acute ischemic stroke (AIS) receive. We sought to assess the impact of race and ethnicity on quality benchmarks of AIS therapy and clinical outcomes at a comprehensive stroke center (CSC). Methods: A retrospective analysis of AIS patients presenting to a CSC between 2015 to 2020 was performed. Data included demographics, NIH Stroke Scale scores, time to thrombolysis, discharge diabetic and hypertensive medications, length of stay (LOS), discharge functional status, 30-day readmission, and 30-day mortality. Quality benchmarks and outcomes were analyzed by the five most prevalent racial-ethnic groups including Non-Hispanic White (NHW), Hispanic, Black, Asian, Other and Unknown. Results: 3,735 AIS patients were identified. NHW represented 53.3% (n=1992),Black 21.3% (n=797), Hispanic 10.4% (n=390), Asian 7.2% (n=267), Other 4.6% (n=170) and Unknown 3.2% (n=119). There were no significant differences in door to needle (P=0.93), door to puncture time (P=0.98), intravenous thrombolysis (P=0.32) and mechanical thrombectomy utilization (P=0.19) by race-ethnicity. In univariable analysis, there was a higher rate of 30-day mortality in Unknown 23.5% vs NHW 7.3% (P< 0.0001). A significantly (P>0.05) higher rate of 30-day readmission was noted in NHW 20.3% vs Black 15.7%, Hispanics 15.6%, Others 11.8% and Unknown 8.4%. Black 67.6%, Hispanic 64.9% and Unknown 80.5% had a significantly (P<0.05) higher rate of post stroke disability (mrs>2) vs NHW 60.3%. A significant difference (P<0.05) in LOS with Black patients staying 8.4, Hispanic 10.8, Asians 11.9 and Unknown 11.2 days vs NHW 7.7.Adjusting for age, sex, NIHSS and comorbidities, multivariable logistic regression continued to show differences in post stroke disability for Black (OR=1.40, P=0.003), Hispanic (OR=1.49, P=0.008) and Unknown (OR=2.03, P=0.016) vs NHW. Median LOS was 0.85 and 0.77 days longer for Asian and Hispanic (P=0.006, P=0.014) respectively vs NHW. Conclusions: Our analysis reveals persistent disparities in stroke outcomes, with Black and Hispanic patients suffering greater disability post stroke. Further investigation is needed to uncover how race-ethnicity mediates stroke care and outcomes.