studies should examine the risk of mortality in less regionalized acute care geographies. Given the perceived quality and safety risks reported by clinicians, future work should also explore outcomes beyond in-hospital mortality including more rare safety outcomes.

Introduction: Timely emergency department (ED) recognition of acute strokes reduces morbidity and mortality and improves outcomes. Prehospital telehealth evaluation rapidly assesses patients with stroke symptoms and mobilizes resources before ED arrival, decreasing ED arrival to computed tomography (CT) result times. Expediting CT results reduces the decision time to determining thrombolytic therapy eligibility. Methods: Seventeen ambulances in our region were supplied with equipment to perform a nonrecordable video examination with an ED physician. Emergency Medical Service requested a physician video examination on patients with a positive prehospital Cincinnati Stroke Scale. The physician and paramedic conducted an NIH-8 scale, and, based on the assessment, the patients were placed directly on the CT scanner table. Results: Four time intervals that impact CT acquisition and thrombolytic decision-making were measured. There was improvement in all time intervals. Time from ED arrival to CT order decreased 1.7 minutes. Time from arrival to study start decreased 5.7 minutes. Time from CT order to result decreased 3.89 minutes and time from ED arrival to CT result decreased 5.6 minutes. Discussion: Prehospital telehealth consults with paramedics, and the receiving hospital for acute strokes significantly decreased times for all metrics studied including the time from ED arrival to CT result.

Background: Current guidelines for care of the acute stroke patient demonstrate that the benefits of tissue plasminogen activator (tPA) are time dependent and recommend it be given within 60 minutes from arrival to the Emergency Department (ED). Hypothesis: Door to tPA times would be reduced by using a multidisciplinary approach to acute stroke patients and by transporting them directly to the CT scanner. Methods: The community hospital restructured its Brain Attack process after creating a Door to Needle team to evaluate and expedite the care of the acute stroke patient. This multidisciplinary team was assembled in order to plan, implement, and study the new Brain Attack alert process. The team is activated via a touchscreen in the ED, many times prior to patient arrival. Stable patients who do not require airway intervention are taken directly to a newly renovated CT scan anteroom for initial assessment, point of care anticoagulation testing, and initial NIH stroke scale. In addition, education concerning the new process, as well as acute stroke care in general was presented to 35 local EMS services by emergency physicians and an EMS outreach coordinator. Results: In July of 2012, 54 Brain Attacks were evaluated with a median door to CT time of 41 minutes and door to CT interpretation time of 51 minutes. The new Brain Attack process was implemented on December 3, 2012. During the first month of the new process, 51 Brain Attacks were evaluated with median door to CT time of 28 minutes and door to CT interpretation time of 38 minutes. This represents a decrease in time to CT acquisition and interpretation of 13 minutes. tPA was given to 4 patients in July 2012 with only one patient (25%) receiving the medication in <60 minutes. In December, 4 patients received tPA, 3 (75%) within the 60 minute window. Conclusions: Patients who received tPA were treated more expeditiously after implementation of the restructured activation process. 75% of tPA patients were treated within the 60 minute timeframe as recommended by current guidelines. EMS also provided extremely positive feedback concerning the education and restructured Brain Attack activation.