Stroke Thrombectomy Optimization

Mentored Implementation Program

Resource Supplement
By: Nirav H. Shah, MD
with Contributions from:
Sunil A. Sheth, MD • Sheila Smith, MD
David Likosky, MD, SFHM, FAAN, FAHA, FACP

March 2018
Acknowledgment
This project was supported by a grant from Medtronic Inc. The authors had full responsibility in
designing and compiling the content of this Resource Supplement. Medtronic had no involvement,
or influence over, the development of the content of this Resource Supplement.

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For more information contact SHM at:

Phone: 800-843-3360
Email: TheCenter@hospitalmedicine.org
 Table of Contents

Introduction …………….……………………………………………………………………………………………………...…. 3
Program Overview
Technical Approach and Mentored Implementation Program
Pre-Implementation Actions
Review of Best Practices in Stroke Intervention in the Hospital ………………..……………………..….. 6
Some Relevant Steps of Stroke Care
Extended Thrombectomy Window
Telestroke .............................................................................................................................12
Measuring the Effectiveness of Your Stroke Intervention: Processes and Outcomes ……………14
Improvement Metrics
Metrics for Thrombectomy Process
Data Dictionary
Implementing Interventions to Improve Stroke Care ……………….…………………………………..……. 17
Process Interventions
Outcome Measures and Further Intervention
Addressing Resistance and Challenges to Change and Improvement Efforts …………………..……30
Sustaining Improvements and Building Them into Usual Care …………………..…………………………31
Common Challenges
Quality Review Process
Documentation Templates
Appendix I: Data Dictionary ……………………………………………………………………………………………..…48
Appendix II: Key Resources ..……………………………………………………………………………………………….57
Appendix III: Glossary of Terms ……………………………….………………………………………………………….59
Appendix IV: References ……………………………………………………………………………………………………..61

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Introduction
Stroke care has undergone a dramatic change in the past decade. Data supporting endovascular
intervention for stroke shows it has burgeoned to be effective up to 24 hours after the onset of
an ischemic stroke. This has resulted in changes both outside and inside hospitals.
The external environment has changed dramatically. Stroke systems of care have developed,
resulting in diversion of patients to centers that offer intervention. Larger hospital systems
employ many approaches to intervention including facilitating patient transfers at times over
significant distance. The nature of this care has fundamentally changed, and the anticipation is
that this process will continue as indications expand and devices evolve.
What is the case for change? “Time is brain.” In clinical studies, a typical stroke patient loses 1.9
million neurons a minute.1 Studies have demonstrated that each minute saved in time to
treatment results in approximately four days of healthy life.2 Saving 20 minutes has been shown
to increase the likelihood of recanalization as well as three months of disability-free life on
average.2 Last known well (LKW) to recanalization within four hours is associated with a good
outcome of 80% at 90 days.3 With the new efficacy data of tissue-based reperfusion in DAWN
and DEFUSE 3, centers will offer selective treatment to patients after six hours. Therefore, the
standard of care will allow aggressive treatment of more patients requiring more diligence and
improved systems to ensure accurate patient selection.4 Expediting care across a
heterogeneous disease presentation while maintaining safety is the goal of this implementation
guide.

Program Overview
This program aims to provide the resources and training to equip neurologists and hospitals
with the skills to help develop, participate in and assure continuous quality in the care of stroke
patients with large vessel occlusion (LVO). The program will help neurohospitalists and other
clinicians identify opportunities to engage multidisciplinary team members to implement
evidence-based management practices in their hospital. Amongst these are team-based
approaches to rapid identification of candidates for intervention, systems to measure speed to
intervention, standardization of post-procedure care, and optimizing handoffs and care
transitions.
Many hospitals will have some or all of the components needed but will have not coordinated
the care or developed the rigor or structure necessary to track appropriate metrics. Other
hospitals may not have the appropriate staffing or staff mix, or not developed and
implemented the training necessary for success.
The tools necessary to develop and implement these programs are, to some degree, available
in a piecemeal fashion from a number of different resources. However, they are typically
segregated into clinical, financial, leadership and quality areas. Neurohospitalist leaders and
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mentors have been able to assimilate data and processes from these disparate sources to
develop coherent and successful programs. Doing so involves not only subject matter expertise
but also real-world experience in how to work with stakeholders and resource constraints, as
well as sustain progress in healthcare systems.
Key components of this program include how to assemble a team, develop program goals,
define data metrics, implement and refine interventions, and evaluate outcomes. The physician
mentors supporting the program will also integrate other key resources including personal
experience, national practice patterns and examples, and an extensive neurohospitalist
network to guide hospitals in improving best practices in patient care.

Technical Approach and Mentored Implementation Program

By partnering with the Society of Hospital Medicine (SHM), the Neurohospitalist Society (NHS)
leverages its groundbreaking and well-respected infrastructure and expertise. The two societies
have a long history of partnership. Applying the neurology, stroke and neurohospitalist
expertise of NHS to the hospital and mentored implementation expertise of SHM results in a
uniquely positioned and qualified program offered to hospitals and healthcare systems.
Strong institutional support for participation and allocation of resources are critical to the
success of the program. Each hospital is expected to collect data on four key process metrics
and two key outcome metrics pertaining to LVO and intervention. All enrolled hospitals are
expected to identify and implement interventions related to patient selection processes, flow,
post-procedure transitions and neurological assessment.
Physician faculty mentors will support hospital teams in the implementation of the program.
The physician mentors will provide monthly mentored support to each hospital and assist the
four hospital teams in facilitating 1) the identification of appropriate quality metrics and 2) data
collection and reporting through a benchmarking platform. Sites will be asked to conduct
baseline data and submit regular reports on their selected metrics.
The enrolled hospital sites will begin their participation in the program by forming their project
team led by a neurohospitalist/neurologist physician champion. Hospitals will identify key
members to form their interdisciplinary team including a program coordinator,
neurointerventionalist and a nurse leader. Hospital sites will complete a needs assessment to
identify where there are current gaps in practice related to implementing optimal stroke
intervention. Sites will develop a data collection plan with the specific performance metrics and
collect three months of baseline data, 12 months of implementation data and three months of
sustainability data. Hospital sites will participate in monthly calls with their physician mentors
over an 18-month period to discuss progress to date including identifying gaps in practice,
developing interventions, implementing interventions, measuring outcomes and identifying
plans to sustain successful improvements. Physician mentors will conduct a site visit to each

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hospital to meet key stakeholders, review implementation strategies and assess progress. The
site visit observations will inform recommendations for implementation at the hospital site.
Upon formal conclusion of the program, NHS and SHM will also consult with a monitoring and
evaluation expert to review the data findings and conduct a formal evaluation of the program,
identifying which components were most successful and opportunities for refinement and
developing key recommendations for the next iteration of the program.
Pre-Implementation Actions
The following steps are recommended prior to initiation of a neurovascular intervention
program:
• Identify key stakeholders, reporting hierarchy and approval process.
• Obtain support and approval from the institution.
• Assemble an effective multidisciplinary quality improvement (QI) team.
• Set general goals and a timeline for each intervention to be launched.
• Turn general aims into specific aims.
• Follow a framework for quality improvement (see Data Model as an example).

Other initial steps include the following:

• Learn about best practices.
• Review the literature for large vessel stroke care. Then, along with your assigned
mentor, select (or tailor) the interventions that align with the scope and goals identified
by your project team.
• Analyze the patient’s potential care pathway in your system.
• Identify interrelated steps and “failure modes” (i.e., steps in the process prone to error
and that lead to suboptimal outcomes).
• Identify steps that should become targets for improvement efforts.

Each medical center may have different stakeholders who should be involved in the program.
Some examples include:
• Neurologists/Neurohospitalists • Marketing and Public Relations
• Neurointerventionalist Divisions
• Radiology — Neuroradiology,
technologists
• Emergency Medical Services (EMS)
• Emergency Department (ED)
• Anesthesiology
• Interventional Radiology Staff
• Pharmacists
• Hospitalists and Intensivists
• Nursing Leadership
• Hospital Administration
• Patient Safety Personnel
• Information Technology Department
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Review of Best Practices in Stroke Intervention in the Hospital
The adage “time is brain” is a critical sentiment in acute stroke care for LVO. In all areas of
acute care, we perform processes and evaluations simultaneously as opposed to sequentially.
These parallel as opposed to serial processes are critical to timely care. One example is the
work we do while the patient is in the CT scanner: in cases warranting tissue plasminogen
activator (tPA) administration, we will ideally have made that decision prior to the CT and can
make preparations to administer the drug once the scan shows no hemorrhage.

Some Relevant Steps of Stroke Care

• Prehospital Notifications
Best practices include prehospital notification of potential stroke patient arrival so that
the stroke team can be ready.

• ED Arrival
As soon as the patient arrives an initial set of vitals, a finger stick glucose (if not
performed in the field) and EKG are performed (timed so as not to delay other care),
and routine labs are sent off.

• ED Assessment and Activation of Acute Stroke Process

The ED clinician performs an abbreviated examination. An initial assessment of LKW is
corroborated.

The neurologist or neurohospitalist is notified of an acute stroke. The neurohospitalist

proceeds to meet the patient in the ED or via telehealth. A neurological examination is
performed to obtain the NIH Stroke Scale/Score (NIHSS) and to determine safety for IV
tPA.

• Door to Imaging
After activation the patient proceeds to neuroimaging, typically with a nurse transport
and vital sign monitor.

• CT/CTA
The patient presents to CT for a rapid non-contrast CT and a CT angiogram (CTA) of the
head and neck. The purpose of CT is to rule out hemorrhage and the CTA is to diagnose
an LVO (ICA, A1, M1, M2, intracranial vertebral, basilar).
o Patients with LKW within six hours and a head CT without large infarct (ASPECTS
≥6) may be candidates for intervention.
o Patients with LKW >6 hours but <24 hours may require advanced imaging with
CT perfusion or MRI to better determine whether there is salvageable tissue.5

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• Door to Thrombolytic Administration
If the patient is within 4.5 hours of LKW he or she is a candidate for IV thrombolysis. If
the patient has a LVO then endovascular care should be considered too. Notify the
pharmacy to mix drug and deliver IV thrombolytics. Standard of care is to achieve door
to needle (DTN) within 60 minutes, but many systems currently are targeting DTN of 45
minutes or less.

• Activation of Neurointerventional Team

There are many different approaches to activating the Neurointerventional Team
depending on local dynamics. Some systems activate from the field and may use a
stroke severity score to do so. Others wait until a LVO is seen on imaging with or
without results of a CT perfusion study. Key is to have a uniform, effective process that
results in a timely and effective response.

• Transfer to Angiography Suite

If the patient has a LVO that is a target for recanalization, transfer the patient to the
interventional suite for catheter-based recanalization by the neurointerventionalist. A
process for notification and assembly of the team is paramount.

Care metrics commonly include:

o Door to groin puncture (DTG)
▪ Standard DTG is <90 minutes. As centers expedite care or accept
transfers (drip-and-ships), DTG goals are <60 minutes.
o Time to recanalization and modified treatment in cerebral infarction (mTICI)
score
o Center documentation of time from LKW and from arrival to recanalization and
mTICI score

• Transition to Neuro-ICU
After targeted therapy for LVO with or without alteplase, transitioning to the Neuro-ICU
or equivalent for close monitoring and follow-up neuroimaging is warranted.
Standardized protocols, assessments, staff training and post-intervention medical
management are necessary for optimal care.

• Hospital Course and Discharge

After acute care is delivered, the hallmark of the stroke patient pathway is to determine
safety and therapy needs with physical, occupational and speech therapy teams.
Oftentimes acute stroke is a debilitating change requiring disposition adjustments.

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Guidelines of Stroke Care
As guidelines around stroke care change and systems of care evolve, it is important to be
mindful of the rapidly changing landscape. In just three years, the guidelines have changed
from not recommending endovascular therapy, to recommending it for patients within six
hours of LKW, to now recommending it in patients up to 24 hours from LKW.
Advanced Imaging
The eligibility of patients for thrombectomy often depends on the presence or absence of
salvageable tissue. Particularly for patients presenting in the late time window (between six to
24 hours from LKW), this assessment will depend on advanced imaging with CT perfusion
and/or MRI.
Screening for Thrombolysis
All patients should be screened for thrombolysis and endovascular therapy within an advanced
stroke system. A system of care with protocols for screening ensures all patients receive a
uniform standard of care. Even if thrombolytics cannot be offered, documenting the screening
is an important metric for quality.
Reasons for Delay
There are many reasons for delaying therapy. Most reasons are due to changes in the status of
a patient. Instability of the CABs (circulation, airway and breathing) are all indications to abort
the pathway and stabilize the patient with ventilation or hemodynamic support. It is best to
document these reasons for delay for survey purposes to achieve care metrics and facilitate
subsequent review.

Extended Thrombectomy Window

In 2017 and 2018, two trials evaluating extending thrombectomy for LVO from six to 16 hours
from LKW (DEFUSE 3) and six to 24 hours from LKW (DAWN) demonstrated effectiveness. The
number needed to treat for good stroke outcome for each trial was 2.8 (DAWN) and 2.0
(DEFUSE 3). The authors of DAWN articulated that the efficacy of thrombectomy in the
extended window could increase the number of patients who could be eligible for
thrombectomy by 270%.4
The following is excerpted from the 2018 American Heart Association Guidelines5:
1. Patients should receive mechanical thrombectomy with a stent retriever if they meet all
the following criteria: (1) prestroke mRS score of 0 to 1; (2) causative occlusion of the
internal carotid artery or MCA segment 1 (M1); (3) age ≥18 years; (4) NIHSS score of ≥6;

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 (5) ASPECTS of ≥6; and (6) treatment can be initiated (groin puncture) within 6 hours of
symptom onset.
2. Although the benefits are uncertain, the use of mechanical thrombectomy with stent
retrievers may be reasonable for carefully selected patients with AIS in whom treatment
can be initiated (groin puncture) within 6 hours of symptom onset and who have
causative occlusion of the MCA segment 2 (M2) or MCA segment 3 (M3) portion of the
MCAs.
3. Although the benefits are uncertain, the use of mechanical thrombectomy with stent
retrievers may be reasonable for carefully selected patients with AIS in whom treatment
can be initiated (groin puncture) within 6 hours of symptom onset and who have
causative occlusion of the anterior cerebral arteries, vertebral arteries, basilar artery, or
posterior cerebral arteries.
4. Although its benefits are uncertain, the use of mechanical thrombectomy with stent
retrievers may be reasonable for patients with AIS in whom treatment can be initiated
(groin puncture) within 6 hours of symptom onset and who have prestroke mRS score
>1, ASPECTS <6, or NIHSS score <6, and causative occlusion of the internal carotid artery
(ICA) or proximal MCA (M1). Additional randomized trial data are needed.
5. In selected patients with AIS within 6 to 16 hours of last known normal who have LVO in
the anterior circulation and meet other DAWN or DEFUSE 3 eligibility criteria,
mechanical thrombectomy is recommended.
6. In selected patients with AIS within 6 to 24 hours of last known normal who have LVO in
the anterior circulation and meet other DAWN eligibility criteria, mechanical
thrombectomy is reasonable.
a. The DAWN trial used clinical imaging mismatch (a combination of NIHSS score
and imaging findings on CTP or DW-MRI) as eligibility criteria to select patients
with large anterior circulation vessel occlusion for treatment with mechanical
thrombectomy between 6 and 24 hours from last known normal. This trial
demonstrated an overall benefit in function outcome at 90 days in the
treatment group (mRS score 0–2, 49% versus 13%; adjusted difference, 33%;
95% CI, 21–44; posterior probability of superiority >0.999). In DAWN, there were
few strokes with witnessed onset (12%). The DEFUSE 3 trial used perfusion-core
mismatch and maximum core size as imaging criteria to select patients with large
anterior circulation occlusion 6 to 16 hours from
last seen well for mechanical
thrombectomy. This trial showed a benefit in functional outcome at 90 days in
the treated group (mRS score 0–2, 44.6% versus 16.7%; RR, 2.67; 95% CI, 1.60–
4.48; P<0.0001). Benefit was independently demonstrated for the subgroup of
patients who met DAWN eligibility criteria and for the subgroup who did not.
DAWN and DEFUSE 3 are the only RCTs showing benefit of mechanical
thrombectomy >6 hours from onset. Therefore, only the eligibility criteria from
these trials should be used for patient selection. Although future RCTs may
demonstrate that additional eligibility criteria can be used to select patients who
benefit from mechanical thrombectomy, at this time, the DAWN and DEFUSE-3
eligibility should be strictly adhered to in clinical practice.

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 7. The technical goal of the thrombectomy procedure should be reperfusion to a modified
Thrombolysis in Cerebral Infarction (mTICI) 2b/3 angiographic result to maximize the
probability of a good functional clinical outcome.
a. Mechanical thrombectomy aims to achieve reperfusion, not simply
recanalization. A variety of reperfusion scores exist, but the mTICI score is the
current assessment tool of choice, with proven value in predicting clinical
outcomes. All recent endovascular trials used the mTICI 2b/3 threshold for
adequate reperfusion, with high rates achieved. In HERMES, 402 of 570 patients
(71%) were successfully reperfused to mTICI 2b/3. Earlier trials with less efficient
devices showed lower recanalization rates, 1 factor in their inability to
demonstrate benefit from the procedure (IMS III, 41%; MR RESCUE, 25%). The
additional benefit of pursuing mTICI of 3 rather than 2b deserves further
investigation.

Relative Clinical Exclusion Criteria (Note: These are not absolute contraindications)7

1. Serious, advanced or terminal illness (investigator judgment) or life expectancy is less

than six months
2. Pre-existing medical, neurological or psychiatric disease that would confound the
neurological or functional evaluations
3. Pregnant
4. Unable to undergo advanced imaging with either MRI or CT perfusion
5. Known allergy to iodine that precludes an endovascular procedure
6. Known hereditary or acquired hemorrhagic diathesis, coagulation factor deficiency;
recent oral anticoagulant therapy with INR >3 (recent use of one of the new oral
anticoagulants is not an exclusion if estimated GFR >30 mL/min)
7. Seizures at stroke onset if it precludes obtaining an accurate baseline NIHSS
8. Baseline blood glucose of <50mg/dL (2.78 mmol) or >400mg/dL (22.20 mmol)
9. Baseline platelet count <50,000/uL
10. Severe, sustained hypertension (systolic BP >185 mmHg or diastolic BP >110 mmHg)
11. Current participation in another investigational drug or device study
12. Presumed septic embolus; suspicion of bacterial endocarditis
13. Clot retrieval attempted using a neurothrombectomy device prior to six hours from
symptom onset

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14. Any other condition that, in the opinion of the physician, precludes an endovascular
procedure or poses a significant hazard to the subject if an endovascular procedure was
performed

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Telestroke
Telestroke was developed out of a need to improve access to acute stroke care expertise, and
its implementation has been demonstrated to enhance safety and appropriate usage of
alteplase. Widespread adoption of thrombolysis for acute stroke has been slow and remains
incomplete. Centers using telestroke have been shown to double their rates of thrombolysis in
acute stroke without increasing complication rates. As acute stroke care becomes progressively
more complicated, telestroke networks have become increasingly valuable given the limited
resource of neurological expertise.
With the advent of endovascular therapy for LVO, telestroke offers the ability for triage,
thrombolysis administration and transfer—often referred to as drip-and-ship—to
comprehensive stroke centers. Centers have three options for utilizing telestroke: 1) they can
collaborate with telehealth vendors who provide 24/7/365 telestroke care; 2) they can use
technology vendors and create the service in house; and 3) they can use a hybrid option that
provides nighttime teleneurology to support a daytime neurohospitalist or other inpatient
neurology service.
Given that in many settings telehealth provides a significant quality advantage, it is important
to consider a quality implementation strategy that can adapt to specific circumstances. The
American Heart Association Telemedicine Quality and Outcomes in Stroke offers guidelines on
technical specifications as well as clinical considerations.6

In addition to measuring standard stroke outcomes, the AHA telestroke guidelines are
consistent with other guideline data metrics (see Table 1).

An important outcomes and implementation consideration is evaluation of the timelines for

measuring the telestroke process:
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 • Time of consult notification
• Phone response
• Time on phone
• Video-consult initiation
• Consult completion

Maintaining these metrics will help ensure quality control and allow for comparison between
telestroke evaluations and in-person evaluations. Initially, some may find discrepancies in
utilizing a telestroke workflow. While seemingly basic, emergency department layout and
location of the telecart are important in planning. The following practices should be observed
as well:

• Keep the cart plugged in.

• Keep the cart turned on and if possible ID-badge login.
• Keep the cart near stroke evaluation area.
• Ensure nursing and ancillary staff are trained to use the cart and perform examinations.
• Perform regular IT updates, telestroke software updates and drills as needed.

During the acute process of telestroke initiation, the local emergency team collects data that
may lead to de-escalation of the acute stroke process. We would encourage centers to
collaborate with their telestroke providers to briefly document these encounters as well so that
the decision-making process and rationale is clear to subsequent providers.

The last telestroke consideration is when to initiate the video encounter. A typical workflow is
for the local emergency physician to evaluate the patient and activate the code stroke process
whereby a neurohospitalist or neurologist responds by phone. As initial history and LKW are
given, the patient should be emergently transferred for a stat noncontrast head CT. As such,
initiating telestroke in CT or after CT is dependent on staffing and local logistics. In general, it is
recommended to activate the telestroke team immediately after the identification of an acute
stroke patient who may be a candidate for IV thrombolytics or endovascular treatment. The ED
should not wait until the patient returns from head CT. Important information includes
symptoms, last seen normal (LSN) and any potential barriers to thrombolytics such as oral
anticoagulation, blood pressure or blood glucose.

Telestroke offers wonderful potential and real-world access to stroke care and collaborative
decision making for ischemic stroke. When utilized well it can meet and even exceed standard
processes.

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Measuring the Effectiveness of Your Stroke Intervention: Processes
and Outcomes
Improvement Metrics
Current Joint Commission or DNV Primary and Comprehensive Stroke Center Metrics
Primary, comprehensive and thrombectomy-capable are the center metric standards for
hospital stroke certifications. Their importance is twofold: 1) they set a base standard for a
hospital to demonstrate ability to take care of complex stroke patients and specifically LVOs
with ongoing quality assurance and 2) they help local, regional and state health agencies
determine emergency transport pathways for stroke patients. While all certified stroke centers
are capable of providing rapid identification, triage and treatment of acute ischemic stroke,
centers that have comprehensive or thrombectomy-capable certification are able to provide
24/7 endovascular care for LVO in addition to IV thrombolytic treatment. As systems develop,
some regions are bypassing primary centers if a higher-level center is easily accessible and does
not lead to any substantial delay in care. Bypass of primary stroke centers in favor of
thrombectomy-capable or comprehensive centers offers the advantage of avoiding later
hospital-to-hospital transfers for patients with possible LVO. The certification process has been
shown to increase the quality and outcomes of patients treated at those centers.8
If your center is not certified, the first steps are to determine which accrediting body your
hospital will utilize and then begin evaluating the specific criteria required for certification:
The Joint Commission: https://www.jointcommission.org/
DNV GL: http://www.dnvglhealthcare.com/
The American Heart Association’s Get With The Guidelines (GWTG) also offers a standardized
process for care and stroke reporting:
http://www.heart.org/HEARTORG/Professional/GetWithTheGuidelines/Get-With-The-
Guidelines-Stroke_UCM_306098_SubHomePage.jsp
Door to mechanical intervention time
The time from hospital arrival (door) to recanalization has been noted as a very important
metric for outcome with regard to LVO. To achieve fast and high-quality care requires an end-
to-end process with monitoring as described above in the section on best practices.
Response times by physicians/staff (neurology, neurointerventional team)
A significant component of LVO stroke care is efficient and reliable communication. Ensuring
that all members of the acute stroke team communicate and respond appropriately is an
important metric to avoid delays in care. Handoffs between EMS, the ED, the neurologists, the
neurointerventionalists and the neurocritical care unit should be seamless. Having a prehospital

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notification system and a modern communication system are essential. Additionally, a backup
notification system to ensure communication if the first on-call response team does not
respond is critical.
Radiology turnaround times for reads of CT or MR studies
While thrombolytic eligibility is based on a clinical diagnosis of acute ischemic stroke with a
LKW within the last 4.5 hours AND head imaging which rules out intracranial hemorrhage, the
diagnosis of LVO is largely contingent on positive neuroimaging that demonstrates a large
vessel occlusion. Radiologist reporting of neurovascular imaging (CTA, MRA, etc.) is important
to identify possible candidates. Expedient diagnosis and radiology reporting of LVO based on
neuroimaging can help ensure that the radiological evaluation will enhance diagnosis and
facilitate treatment.
Number of patients bypassing your hospital for intervention (if applicable)
Centers without endovascular readiness for LVO or without formal thrombectomy capable or
comprehensive stroke center status are bypassed in some regions. If this applies to your center,
tracking the number of potential stroke patients bypassed is important. These patients could
possibly be treated faster at your center and staffing requirements can be predicted. This data
can also help advocate for the need for full endovascular support and the investments
necessary.
Percent of patients for whom advance notification of arrival is made
Prehospital notification has been shown to expedite LVO treatment. This is mainly because the
team can be prepared to evaluate, diagnose and treat faster. As an example, the radiology
team can end other examinations and clear the table for the stroke patient. Tracking the
number of advanced in-field notifications is important as these patients will receive faster care.

Metrics for Thrombectomy Process

Tracking the interventional process is valuable to help maintain efficiency of procedure
initiation:

• Time from hospital arrival to groin puncture

• Time from groin puncture to first thrombectomy attempt
• Number of thrombectomy attempts
• Time from LKW to recanalization
• Degree of reperfusion

Tracking these metrics will help ensure a consistent thrombectomy process and can identify
benefits of different devices.
All-cause death within 72 hours of mechanical thrombectomy

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Tracking all deaths within 72 hours that could conceivably be related to thrombectomy is
important to ensure the safety of the acute LVO process. In trials supporting endovascular
thrombectomy, mortality at 90 days after thrombectomy is 15.3%.9
Symptomatic intracerebral hemorrhage following mechanical thrombectomy
Tracking all intracerebral hemorrhage following mechanical thrombectomy is also important to
ensure the safety of the acute LVO process. Recent studies of thrombectomy-related
symptomatic intracerebral hemorrhage (sICH) within 36 hours show occurrences of
approximately 6% (DAWN) to 7% (DEFUSE 3).10

Data Dictionary
For each metric, the data dictionary includes a detailed definition, information and guidance,
how to locate or obtain the metric (via EHR or some other means) and any additional
comments or opportunities related to the metrics. Please see the Appendix I for the full data
dictionary.

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Implementing Interventions to Improve Stroke Care
Each hospital is expected to collect data on their patients who receive thrombolytics or
thrombectomy. All enrolled hospitals are expected to identify and implement interventions
related to patient selection processes, flow, post-procedure transitions and neurological
assessment. In this section, you will find an outline of the key process and outcome
interventions, outcome measures, how to implement them, and any potential barriers for your
consideration as you begin this work.

Process Interventions

Identify Patients Prior to Arrival

• Identifying patients with stroke, and more specifically LVO, is the hallmark of acute
stroke diagnosis and subsequent ability to improve outcomes.
• While definite prehospital identification of LVO is not feasible, prehospital scales
such as the Los Angeles Motor Scale (LAMS) or the Cincinnati Prehospital Stroke
Scale (CPSS) are being used to identify and triage patients for LVO. Categorizing
these patients with true and false negatives and positive cases is important to help
expedite care. This can be done with a post-hoc analysis of neuroimaging and
diagnosis. A barrier to implementing this intervention is that it is contingent on
whether EMS provide prehospital notification for stroke. Partnering with local EMS
is an important role of stroke centers.
• Accuracy of LVO diagnosis after arrival can be performed by evaluating radiology
(CTA and MRA) reads identifying large vessel occlusion, correlating those to
neurologist and interventionalist clinical reads of the imaging, and the angiographic
evaluation.
• Interventions
o Prehospital scales by EMS: LAMS, CPSS
o Prehospital notification by EMS
o Correlation of prehospital scale with final diagnosis

Notification process of appropriate providers

Ensuring that all members of the stroke team are notified and respond appropriately is an
important metric in avoiding delays in care. The following are some of those who need to be
identified for the acute stroke intervention process (Code IR):
1. Neurologist/Neurohospitalist
2. Interventionalist
3. Anesthesia
4. Emergency Department Physician
5. Cath-Lab Team and Critical Care Nursing

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 6. Neuroradiologist

• Interventions
o Determine timing of notification (prehospital based on scale or after ED
evaluation).
o Determine whether there is a multistep activation; i.e., ED separate from stroke
team separate from intervention team or combined notifications.
o Track the timing of notifications received and responses via paging/messaging
systems to help evaluate if there are groups who could respond faster.
o Tracking this data can also ensure whether there is a group less equipped to
react efficiently.

Optimization of ED processes including expedited evaluation

Expedient ED evaluation is important for screening and initiating the acute stroke pathway.
Best practice requires early ED evaluation to determine whether acute stabilization is needed.

• Interventions
o Direct to CT – brief evaluation at arrival and prior to rooming patient
o Implementation of detailed tracking tool – identifying serial vs. parallel processes
and each element of the process

Optimization of imaging process (types of studies ordered, staging of evaluation and

prioritization of studies)

Efficient imaging to rule out hemorrhage and to diagnose LVO and ischemia is of paramount
importance to initiate recanalization therapy.

• After designing a protocol that works with your facility’s logistics and imaging
capabilities, track the studies ordered and the prioritization of studies. In general,
one must standardize the studies ordered and the process of staging the imaging
ordering. Many centers currently perform CT and CTA as one process. If your center
has imaging in stroke staged as a two-part process, evaluate the time delays and the
potential burden on transport, nursing and radiology throughput.
• Interventions
o Staging and determination of imaging protocol
▪ CT/CTA separate from CTP or as one process
▪ Clear protocol to determine who is eligible for all three studies to
avoid delays

18 | P a g e
 • Work with neuroradiology
o CT imaging should have reasonable quality for ASPECTS determination. CT
angiography and perfusion studies require monitoring for high-quality maps,
and multiphase imaging requires accurate timing of repeat images after
bolus to determine collaterals.
o MR imaging requires optimization of the DWI/ADC, FLAIR and perfusion
maps as well.
• Interventions
▪ Establish clear turnaround times for imaging reads.
▪ Establish clear processes for notification of providers.

Acute Blood Pressure Control

Blood pressure acutely after stroke is dependent on the treatment pathway. All patients
with acute stroke should have SBP <220/110 mmHg. If a patient receives thrombolytics, the
patient’s blood pressure should be <185/90 mmHg. However, after recanalization with
thrombectomy, there is some controversy. If a flow of mTICI2b or greater is achieved, some
practices will attempt to achieve normalization of blood pressure to <140 mmHg. However,
this may be provider dependent, and research is currently underway. Nonetheless, tracking
vital signs and whether they meet the ordered recommendation is feasible with nursing logs
and through an EMR. Ideally this type of care is standardized as much as possible.
• Interventions
o Track blood pressure during the following aspects of stroke pathway:
▪ Arrival
▪ Post-thrombolysis vitals
▪ Post-thrombectomy
▪ During ICU stay
o Establish clear protocols and parameters to facilitate nursing process/notification
of poor control.
o Strict blood pressure control and frequent neurological checks post IV
thrombolytic therapy are national standards. These two key nursing elements are
not only reviewed by stroke surveyors but also are the most difficult processes of
which to achieve 100% compliance. It is crucial that centers establish clear
protocols that outline the importance of monitoring blood pressure, rapidly
treating elevated blood pressure and performing frequent neurological checks
post thrombolytic therapy.
▪ Centers should have a tool that enables nursing to track the necessary
vitals and neurological checks real time so that nursing is aware of when
the next check is due. Some centers have a second nurse, such as the
19 | P a g e
 charge nurse, verify that the checks have been completed and
documented in order to avoid any misses.
▪ Centers need to work hard to avoid gaps in blood pressure and
neurological monitoring during nursing handoffs such as during transition
of a patient from the ER to the neurocritical care unit.
▪ Ideally there should be a well-established protocol with PRN anti-
hypertensive orders for patient status post thrombolytic therapy so that
the nursing staff does not have to call a provider for a PRN order once an
elevated blood pressure is recognized. Centers can accomplish this step via
standardized EHR stroke order sets.
▪ Audits of compliance should be done. The stroke center should have a
mechanism in place to give the nursing staff timely feedback on their
performance of these metrics.
• Because this metric is so heavily scrutinized and an important safety element in the care
of post-thrombolytic patients, ideally a center’s performance on this metric should be
followed closely at stroke quality meetings.

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This is an example of an acute blood pressure audit generated for patients with acute stroke:

21 | P a g e
Assess Acute Glucose Control

Part of the initial evaluation of stroke by EMS is to obtain a finger stick to rule out
hypoglycemia. Hypoglycemia is known to mimic stroke-like symptoms.11,12 The NINDS trials that
led to approval of alteplase excluded patients with blood sugar >400 mg/dL. When the ECASS
trial was completed in 2007 there was a clear correlation with increasing blood glucose and
alteplase-related hemorrhage. As such, the FDA approval has a relative contraindication for
hyperglycemia in alteplase administration. There has been significant work demonstrating that
hyperglycemia is neurotoxic and worse for stroke patients. Most centers will treat
hyperglycemia rapidly in acute stroke patients and still consider possible eligibility for
thrombolytics if the blood sugar reaches an acceptable range and the neurological deficits
persist.

• For patients with low blood glucose on arrival, track and ensure a protocol is in place to
monitor and manage hypoglycemia after arrival.
• Interventions
o For patients with hyperglycemia on arrival, track and ensure a protocol is in
place to monitor and measure hyperglycemic patients based on initial presenting
glucose. Ensuring repeat evaluations based on your hospital’s hyperglycemia
protocol is also recommended.

Improve Activation Process for Interventional Radiology (IR) Lab Staff

The code alert process for acute endovascular intervention for stroke patients requires a
number of team members to come together quickly. During off hours this can represent a
potential for delay if team members are unable to arrive efficiently. Some centers have policies
requiring staff to be on site within 30-45 minutes of pager activation. Other centers with high
volume have in-house teams. As all members of the IR team are critical, any individual could
represent a bottleneck in care if a backup plan or member is not available.

IR team members include:

• IR technologist
• IR nurse
• Interventionalist
• Anesthesia

A bottleneck could occur when there are multiple emergencies in the hospital requiring
anesthesia and IR staff, preventing triage of staff to manage an LVO. As such, monitoring this

22 | P a g e
team can help determine what other resources a hospital may need to dedicate to achieve
success.
• Interventions
o Monitor the availability of each component of the IR team.
o Additionally, track the ability of response, activation and arrival by the IR team.

Decrease Door to Needle (DTN) Times for Both tPA and Thrombectomy

As described above, achieving fast recanalization is predicated on DTN and thrombectomy

times. The bar for a standardized national goal DTN time was set by the American Heart
Association with the Target Stroke Phase II guidelines. Centers should strive to achieve DTN
times of 45 minutes or less in 50% of thrombolytic-eligible patients and 60 minutes or less in
75% of patients. Door to groin times are not as clearly established, but most centers use
either a goal of 60 or 90 minutes. Thrombectomy centers need to take into account the
variabilities between thrombectomy + thrombolytic-eligible patients who arrive at their ER
versus patients who are transferred from an external facility to the thrombectomy center
for endovascular treatment only. Decreasing these times without worsening outcomes is
paramount.

• Interventions
o Centers should review their own processes and determine what steps could be
removed or shortened safely in order to make the process more lean. Examples
of ways to achieve shorter DTN times include direct to CT without ED rooming,
rapid code alert notification to stroke team and pharmacy, and pre-mixing of
alteplase.
o Determine site of tPA administration – in CT scanner versus ED patient room. If a
telehealth consultation is used to aid in the process of thrombolytic
determination, feasibility of the telehealth cart in either location will have to be
taken into consideration.
o Set clear goals and expectations for timeliness in each element of the process
including decision-making.
o Track DTN from arrival including until thrombolytic administration or
thrombectomy. The following report is an example:

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Improving Transitions of Care In and Out of the Cath Lab

Given that patients arrive emergently from the field and potentially other facilities,
transitioning their care safely from the ED to the Cath Lab and to the Neuro-ICU is important.

• Interventions
o Monitor history, physical, labs with a standardized ED nursing handoff form.
o Monitor cath lab and ICU nursing sign-off process.
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This worksheet is an example of a handoff form that can easily be used during the acute
code stroke process:

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Establish neurocritical care protocols

One of the major differences between a comprehensive stroke center versus a primary stroke
center is the establishment of a 24/7 intensive care unit with dedicated neurological ICU beds.
An ICU with staff trained in the care of patients with complex neurological problems such as
acute stroke status post thrombolytic or endovascular treatment, cerebral edema,
subarachnoid hemorrhage (SAH), aneurysms and other vascular malformations, and intracranial
hemorrhage (ICH) is critical.

• Centers should develop clinical care pathways for the care of patients with acute
ischemic stroke status post thrombolytic and/or endovascular treatment, SAH, ICH and
normothermia. Use of standardized order sets can help achieve compliance with these
pathways.
• Staff in this unit should have annual education dedicated toward stroke. If centers staff
this ICU with non-neurocritcal care intensivists or advanced practice clinicians, they
should have a policy in place to provide and track neurocritical care and/or stroke
education on an annual basis for these caregivers.
• Nursing compliance with post-thrombolytic vitals and neurological checks should be
monitored closely (see above metric).
• Provider compliance with documentation of SAH and ICH severity scores should be
measured.
• Provider compliance with the use of nimodipine for aneurysmal SAH within 24 hours of
admission should be monitored.

Implement a “continuum of care” approach for each patient

It is easy to focus on the care of patients from the time of arrival to your hospital to the time of
discharge. However, comprehensive centers need to take a broader approach and focus on
stroke care from the time a patient calls 911 to the time a patient is released into the
community. This approach to stroke care takes a village and really requires an investment of
time and energy from stroke team members.

• Identify your state’s policies on the triage of stroke in the field. Ideally a representative
from your hospital should attend your department or health stroke meetings if possible.
• Meet your local EMS leaders and learn their local protocols for identification of stroke,
triage tools used in the field and hospital-to-hospital transfer protocols. Offer EMS
education annually.
o Establish a mechanism to have EMS records either scanned or electronically sent
to your EMR.

26 | P a g e
 o For hospital-to-hospital transfer of thrombolytic patients, work with EMS to
make sure that appropriate neurological checks and vitals are completed in
route.
o Consider establishing a system where you can provide EMS with feedback on
patients such as those who received thrombolytics or endovascular treatment.
Feedback not only strengthens the relationship between an organization and
EMS but also provides a venue for education and quality review on EMS’s end.
• Organize a seamless transition of stroke patients from acute care to clinic.
o Have a system in place to assure neurology follow-up post hospitalization.
o If a patient cannot be seen in clinic within a week, consider implementing a
nurse follow-up phone call within three days. Ideally the nurse should have
training in stroke so that he or she may identify worrisome new symptoms, be
familiar with expediting loose ends at discharge such as blood pressure
monitoring or resumption of anti-coagulation, and reiterate the importance of
compliance with the stroke medications and follow-up in clinic.
• Establish a support group for stroke patients. Some centers will pool resources and have
a combined support group for all patients with neurological disability.
• Commit to a few community outreach events per year to increase awareness of stroke.

Outcome Measures and Further Interventions

As a center develops its stroke program, it will need to have metrics for monitoring patient
outcomes. Standard metrics are utilized by DNV GL, JC and the AHA GWTG.

• Discharge and post-discharge

o Developing systems for tracking patient outcomes allow for comparisons on both
an individual as well as population basis.
o 90-day mRS patient outcomes for thrombolytic and thrombectomy patients
o 90-day patient outcomes
▪ Tracking 90-day outcomes is the standard to determine efficacy in acute
stroke trials. Given that stoke mortality is 8-9% in the first year and up to
15% for large vessel disease, monitoring 90-day outcomes is a standard
to help ensure quality.13,14 Centers can either standardize 90-day follow-
up clinic visits and have the provider document a mRS or have a trained
nurse obtain a mRS over the phone.
o Stroke readmissions
▪ Readmissions occur in 13-15% of all ischemic stroke patients within 30
days.15 Measuring this data is valuable due to CMS reimbursement as
well as quality of care. Stroke readmissions may occur due to UTI,
aspiration pneumonia, acute coronary syndromes, falls/syncope and
recurrent neurological events.
27 | P a g e
 o Interventions
▪ Discharge status checklist
• Vital sign stability
• Appropriate disposition
• PT/OT evaluation prior to discharge
• Follow-up appointments made
• Patient education received
▪ Expedited follow-up within seven days or a nurse follow-up phone call
within a few days of discharge to review medications and any new
potential symptoms, need for any follow-up imaging such as those who
may need imaging prior to anticoagulation for atrial fibrillation and any
other concerns the patients or their caregivers may have. It is important
for patients to feel connected with a clinic post discharge.

• Groin/procedure complications
After thrombectomy, it is important to monitor patients for retroperitoneal hematoma
and distal pulses. While rare, retroperitoneal hematoma is a life-threatening and
manageable complication. If a hematoma is identified, it is important to have a standard
process to manage it immediately with pressure maneuvers as well as a consistent
nursing handoff that can be documented.
o Interventions
▪ Implement standardized orders for post-thrombectomy care including
groin checks, neuro status and labs.

• Symptomatic hemorrhage
Symptomatic hemorrhage after thrombolytic therapy or thrombectomy is defined as a
drop in NIHSS 4 points or more and with a new intracerebral hemorrhage documented
on neuroimaging that is believed to be the cause of the deterioration. Many cases of
symptomatic hemorrhage are easy to identify but difficult. An example is a patient with
a large ischemic stroke and/or cerebral edema who will have neurological worsening
and may only have petechial hemorrhage on imaging. Similarly, sometimes delineating
between contrast extravasation versus frank hemorrhage can be challenging. Thus it is
important to have a system in place to review suspected symptomatic hemorrhage
cases, and usually provider input on these cases is needed. Review of symptomatic
hemorrhage is a requirement for DNV GL and JC certification. If centers identify that
their rate of hemorrhage is higher than national standards, then they should promptly
review both their patient selection criteria for thrombolytics and thrombectomy and
their compliance with blood pressure monitoring and treatment post intervention.

o Interventions

28 | P a g e
 ▪ Implement standardized order sets, which should include emergent CT
imaging and reversal of thrombolytics in patients with suspected
thrombolytic-related hemorrhage.
▪ Have a system in place for a stroke-trained provider to review
thrombolytic/thrombectomy cases flagged as potential symptomatic
hemorrhages.
▪ Review this data at your stroke quality meetings.

• 72-hour mortality for thrombolytic and thrombectomy patients

Mortality is a standard post-stroke metric to ensure patients are carefully monitored
after an acute stroke.
o Interventions
▪ Track mortality. Unfortunately, despite our best rescue efforts with
thrombolytic and thrombectomy interventions, a considerable number of
patients may still die within 72 hours of treatment if the treatment was
ineffective. Centers should have a system to flag cases for review by a
provider where there may be quality concerns versus cases where the
patient died from natural progression of the disease. An example of the
latter would be a patient with a basilar thrombosis who underwent
endovascular treatment but unfortunately still had a catastrophic stroke.
▪ Review mortality at your stroke quality meetings.

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Addressing Resistance and Challenges to Change and Improvement
Efforts
Resistance to change is a common theme in quality improvement efforts. This is particularly the
case in stroke where there has been a history of therapeutic nihilism. Our current era of rapid
change and evolving data and approach complicate the situation significantly.
However, stroke care has also traditionally not been a financially impactful service line. This has
changed both due to the investment needed to offer thrombectomy and the implication of
patient diversions and center certification status.
The following elements are among those critical to success in complicated projects such as
these:

• Identify key stakeholders.

o These may include administrators with significant influence (financial or
political), providers with roles in stroke or related areas (ICU director, ED
director), EMS chief, Director of Quality, etc.
• Identify key decision makers.
o Budgetary
o Determiners of institutional prioritization
o Medical – From whom will you need to get buy-in to change procedures?
Examples may include the head of neuroradiology to implement routine CT-
perfusion studies; the head of the ED to call the neurointervention team after
discussion with EMS, etc.
• Identify barriers to change and build a case.
o While some barriers cannot be easily predicted, others can.
o Discuss barriers directly and, ideally, prospectively.
o Ask or otherwise ascertain what it might take to overcome specific barriers,
enroll others and build a case/plan.
• Establish early wins and share them widely.
o Identify metrics you can measure and use to demonstrate success.
o Sharing of patient outcomes can have a similar effect.
• Identify a mechanism to communicate data and successes.
o Share widely through the continuum of patient care and administration.
▪ From EMS to ED to ICU
▪ Enroll outpatient physicians who share patients who have been treated
by the program
o Share data regularly and celebrate successes.

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Sustaining Improvements and Building Them into Usual Care
Creating a stroke program with high quality is an ongoing effort. A goal to strive for is to be
“survey-ready” at all times should there in fact be a spontaneous surveyor come to your
hospital. There are many ongoing strategies commonly utilized in hospitals for stroke care that
can help ensure ongoing discussion and collaboration.

Common Challenges
Frequent challenges in sustaining a stroke program are maintaining the quality after
improvement projects and changes are implemented. Oftentimes there is an early initial
success as the staff and teams are all motivated, but the effects of an intervention can decay as
teams focus on other priorities. As a result, a goal should be to have an ongoing sustainability
effort so that the increased efforts for accreditation surveys does not cause burnout.

Quality Review Process

It is paramount that each program identifies key leaders from each department that touches
stroke patients and engage them in the review of stroke care quality. As mentioned previously,
it takes a village to be a successful endovascular-capable or comprehensive stroke center, and a
neurologist and stroke coordinator cannot do it alone. Key stakeholders from each department
must assist a stroke program in troubleshooting any concerns relating to stroke within their
department. Programs should review the required stroke metrics in a regular venue, such as a
monthly or quarterly stroke meeting, with all the key stakeholders present. Once areas of
opportunity for improvement are identified in a department, the lead for that department must
work with the stroke program to make the necessary changes for success. In most cases it is not
feasible and/or sustainable for the stroke program to do this alone. Reviewing all of the stroke
metrics and measured outcomes at a stroke quality meeting with the department leads and key
hospital administrative staff allows the hospital to be aware of their successes and challenges
and where to focus resources.

• A pearl is to present the required stroke metrics and outcome data in the same format
as you would to a hospital surveyor so that you are, in essence, always survey ready.
• Some hospitals may choose to have a separate Morbidity and Mortality conference to
review specific cases with quality concerns and/or unexpected outcomes or to combine
review of data metrics with case reviews.
• These conferences should be multidisciplinary.

Mortality and Morbidity Conferences

Mortality and Morbidity (M&M) conferences are an excellent manner in which to have a
multidisciplinary evaluation and root-cause analysis (RCA) of what caused or could have caused
an adverse patient event. Cases discussed should not only have the relevant team members
involved, but also others who may have suggestions to offer. For example, if there is a neuro-IR

31 | P a g e
issue, body IR may be helpful at troubleshooting a problem. Neurosurgeons can perhaps learn
from cardiac surgery processes. Neurohospitalists can learn from general medicine hospitalists.
Continuing Education
As the field of LVO care evolves at a rapid pace it is important to have an education
maintenance plan for the staff at all levels. This can come in the form of Continuing Medical
Education at conferences, through in-service teaching sessions for nursing, as well as computer-
based education modules. There are different requirements for certification based on a staff
member’s role in stroke care as well.
Plan, Do, Study, Act
Quality improvement work is about incremental improvements and small tests of change.
Improvement science and quality improvement work is about increasing your knowledge,
knowing which changes work and which ones do not work. Plan, Do, Study, Act (PDSA) cycles
are a common tool to systematically evaluate a problem and to come up with a heuristic to
solve it. When using PDSA cycles it is recommended that you keep a log so that you can
determine what is and is not working and track what you and your team have tried in the past.
Here is an example of a PDSA for achieving DTN and DTG goals:

32 | P a g e
Create a PDSA Cycle Log to easily track what you have tried. Excel is a good program to use for
this effort. Columns to include are as follows:

• AIM (overall goal you wish to achieve)

• Description of the test of change
• Start date
• Action Item(s) required to implement the test of change
• Person who is responsible
• Due date/deadline
• Measures that will determine success
• Actual completion date
• Description of the outcome of the PDSA

Socialization of the Process Changes Made

• Post metrics, results and progress

• Present project at grand rounds
• Communication campaign in the hospital

Quality Improvement Reviews

QI reviews can be performed quarterly to evaluate all aspects of stroke care. For LVO
everything from carotid revascularization to IR times and imaging quality can be reviewed in an
interdisciplinary fashion. After these reviews, areas for improvement can be addressed with a
PDSA.

Documentation Templates
Templates for stroke care are useful to help maintain a standard checklist of structured data.
Structured metadata in the templates can be very useful to generate reports about stroke
metrics as well as to help clinicians recall standard steps that they may forget. Using templates
as a checklist can also help standardize care and offer opportunities to explain why one may
have deviated from standard care. The following sections contain suggestions of data to
incorporate into stroke templates.
Stroke note and documentation templates are invaluable to create a standardized process for
stroke care. With a modern electronic medical record they can help create a structured dataset
for data abstraction. They also can help the clinician expedite his or her workflow and ensure
consistency. Furthermore, they can create a reminder so that providers obtain all the necessary
information with regard to contraindications.
After LVO care, an important early consideration that some neurologists can easily miss is a
groin check and pulse checks as it is not part of their regular examination. The template note in
this case offers a reminder to evaluate this component of the exam.
33 | P a g e
Discharge summaries, for example, can have education within the note and be provided to the
patient at discharge so they are part of the patient’s care plan.
Below are the major elements for the following types of stroke encounters:
o Acute code stroke – “Neurology - Code Stroke Note”
o Acute code IR – “Neurology - Code IR Note”
o Initial stroke, “Neurology Inpatient Stroke Note”
o Stroke discharge – “Neurology – Stroke Discharge Summary”

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 Neurology - Code Stroke Note
Facility *** Patient ID:

Last Known Normal or time of symptom onset

***

Baseline mRS

***

Brief HPI

***

Past Medical History

***

Past Surgical History

***

Medications

***

Allergies

***

Family History

***

Social History

***

Review of Systems

***

Examination

Vital Signs: ***

NIHSS: ***

Total NIHSS: ***

Time NIHSS was completed (must be done prior to tPA and/or neuro IR): ***

CT Head read: ***

CT ASPECTS score: ***

Blood glucose: ***

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tPA Inclusion/Exclusion Criteria
Inclusion Criteria for Alteplase for Acute Ischemic Stroke

A significant neurological deficit expected to result in long-term disability

Non-contrast head CT showing no hemorrhage and no well-established new infarct

Acute ischemic stroke symptoms with last known well, clearly defined, within 4.5 hours of
alteplase infusion

Alteplase Contraindications/Warnings Checklist

Use of Direct Thrombin Inhibitor within Advanced dementia

Strong Recommendation 48 hours and elevated Thrombin Time
-----
Against Using Alteplase (it takes 2-3 hrs for TT to peak after last
dose)

Symptom onset >4.5 Life expectancy <6 months or very poor

---- Not Well Established
hours quality of life

Symptoms resolved ---- May be Considered Sickle Cell disease

Clinical Suspicion of SAH Seizure at the onset Current malignancy

Intracranial hemorrhage 3-4.5 hour window including age >80, Arterial puncture at non-
on CT (SAH, ICH, IVH, DM & prior clinical CVA, and INR <1.7 compressible site within 7 days
SDH, EDH)

INR >1.7 (if there is no
history of OAC use and
no suspicion of abnormal
INR based on PMHx, INR
evaluation should not
delay alteplase)
Cardiac Conditions: Concurrent MI (risk Intracranial arterial dissection
of tamponade), Pericarditis, LV
Thrombus, Intracardiac Mass, MI w/in 3 Ischemic stroke within 3 months
months)

Platelet Count <100K (if
there is no clinical
suspicion of low platelets
based on PMHx, then
CBC should not delay
alteplase)
Left Ventricular Assist Device (LVAD) Pediatric Patients (CALL
patients. MUST consult LVAD team CHILDREN’S HOSPITAL STAT)
STAT and evaluate INR and platelets
prior to decision

36 | P a g e
 Significant head/spine
surgery or trauma within
the past 3 months
History of ICH
Active internal bleeding
GI/GU Bleeding within 21
days
GI Malignancy
Endocarditis
Intra-axial brain tumor
Aortic dissection
Current uncontrolled
HTN >180/105 not
stabilized by IV drugs
Large, unsecured
aneurysms >10 mm
Use of LMWH within 24
hours
CT demonstrates “frank
hypodensity”
Use of Factor Xa Inhibitor
within 48 hours
There are NO contraindications or warnings
Time Stamps
Time code was called: ***
Time neurologist initiated consultation either by phone, in person or video consultation: ***
Time neurologist started video telestroke consultation: ***
Time CT was reviewed: ***
Hyperglycemia if symptoms persist Unruptured AVM
despite lowering glucose to <400 mg/dL
Hypoglycemia if symptoms persist No longer considered
---
despite raising blood glucose above 50 exclusions (*A level evidence
mg/dL - supports giving alteplase)
Lumbar puncture within 7 days N/A CT Early ischemic changes (NOT
frank hypodensity)*
Major trauma not involving spine or N/A Age >80*
brain within 14 days
Hemorrhagic retinopathy N/A High NIHSS*
Pregnancy (Need emergent OB consult) N/A Low NIHSS but disabling
symptoms*
Major surgery within 14 days N/A Rapidly improving but disabling
symptoms still present*
Post-angiogram stroke N/A Unable to give consent but clear
established last known normal
Cerebral microbleeds (2 physician consent)
Extra-axial neoplasm
Cerebral unruptured, unsecured
---
aneurysm <10 mm
Renal and/or Liver failure
----
Pre-existing disability, mRS >2
Conversion/Malingering/Migraine
----
variant if diagnosis unclear
37 | P a g e
Time EKG was reviewed: ***

Time labs were reviewed: ***

Time the decision was made to give tPA: ***

Time code was canceled and why: ***

Reasons door to needle time delay (if greater than 45 minutes): ***

Full risks and benefits of tPA and alternatives (not receiving tPA) were discussed with the patient including the
risk of symptomatic ICH (6.4% per NINDS trial): ***

Verbal consent was obtained from:

Reason for no endovascular intervention:

If code IR is initiated, time the code operator was called: ***

Impression/Plan:
# ***. Clinically the patient has {stroke deficits:24315}.

--Stroke pathway

--Goal Blood Pressure: ***

--Additional tests: ***

--Secondary stroke prophylaxis: ***

The following education has been initiated: ***

Critical Care Time:

Signature and Time Stamp

38 | P a g e
 Neurology - Code IR Note
External Facility: ***

IR Attending: ***

Patient ID:

Last Known Normal or time of symptom onset

***

Baseline mRS

Brief HPI

Past Medical History

Past Surgical History

Medications

Antithrombotic therapy: ***

Allergies

Examination

Vitals:

NIHSS: ***

Total NIHSS: ***

Time NIHSS was completed (must be done prior to neuro IR): ***

Imaging

Non-Contrast Head CT:

Stroke ASPECTS: ***

Time Stamps

Time the decision was made to go/no go to IR: ***

Reason Code IR was canceled if applicable: ***

Reasons door to groin time delay (if greater than 60 minutes): ***

39 | P a g e
Assessment/Plan

# ***. Clinically the patient has *** stroke deficits.

--Stroke pathway

--Goal Blood Pressure: ***

--Groin and Pulse Check: ***

--Additional tests:

--Secondary stroke prophylaxis:

Critical Care Time:

Signature and Timestamp

40 | P a g e
 Neurology - Inpatient Visit Note
ID/CC:

Impression/Plan

Active medical problems

#Acute ischemic stroke ***: Clinically the patient has stroke deficits. The presumed mechanism of stroke is *** .

--*** pathway: nursing NIHSS monitoring, vital signs and telemetry, PT, OT

--Goal Blood Pressure: ***

--Additional tests:

--Secondary stroke prophylaxis:

--neurology follow-up clinic: ***

Disposition: *** Anticipated discharge: ***

DVT prophylaxis: Code status: ***

Foley *** CLABSI: Central line ***

Time and Date Stamp

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Chief Complaint & Reason for Visit

***

History of Present Illness

I was asked to consult on this patient for the above complaint by ***.

History obtained from: ***

Limitations: ***

PAST MEDICAL HISTORY and Past Surgical History

Medications

Outpatient medications:

Antithrombotic therapy: ***

Statin therapy: ***

Inpatient medications:

Scheduled

41 | P a g e
Allergies

***

FAMILY HISTORY

SOCIAL HISTORY

***

Review of Systems

Positive for ***

Negative for ***

Physical Examination:

Vitals: ***

General Examination | Neurological Examination: ***

Imaging & Cardiac Studies

***

Telemetry

***

Laboratory Studies

***

============================================================

Stroke Quality Metrics for Acute Ischemic Stroke:

Last Known Normal or time of symptom onset: ***

Reason for not giving IV tPA: ***

Reason for no endovascular intervention: ***

mRS needed for:

If the patient received IV tPA or neuro IR intervention for acute stroke, document baseline mRS prior to
their acute stroke: ***

If the patient received carotid stent (outside of code stroke IR), document mRS immediately prior to the
procedure: ***

NIHSS on admission:

Total NIHSS: ***

Time NIHSS was completed: ***

42 | P a g e
VTE prophylaxis: ***

Rehabilitation: ***

Stroke Discharge Medications:

Statin therapy: ***

Antithrombotic therapy by end of hospital day #2: ***

Antithrombotic therapy prescribed at discharge: ***

If the patient has atrial fibrillation, oral anticoagulation must be prescribed at discharge or
contraindication must be documented: ***

The following education has been initiated: ***

The following smoking cessation counseling was reviewed with the patient: ***

============================================================

43 | P a g e
 Neurology – Stroke Discharge Summary
Admission Date: ***

Discharge Date: ***

PCP: ***

Principal Diagnosis: ***

Secondary Diagnoses:

Medications at Discharge:

Allergies: ***

Procedures/Significant Test Results: ***

Telemetry: ***

Consults: ***

Hospital Course: ***

Stroke Etiology: ***

Physical Exam at Discharge: ***

Condition on Discharge: ***

Code Status this Admission: ***

Discharge instructions given to the patient:

These instructions are from your provider, ***

Diagnosis:

You have been diagnosed with a ***. A stroke occurs when a blood vessel carrying oxygen and other nutrients to
the brain is blocked or bursts. When blood fails to get through to the brain, the brain cells die, causing a stroke.
Strokes caused by blocked vessels are called ischemic strokes, while strokes caused by a burst artery are
hemorrhagic strokes. A TIA (transient ischemic attack) is similar to a stroke, but lasts a few minutes to an hour. A
TIA occurs when the brain blood supply is blocked briefly and then reopens. It is a warning that a full stroke may
soon occur.

Your risk factors for stroke or TIA are: ***

If you experience new stroke symptoms, THINK F-A-S-T! Below some common symptoms of a stroke are listed:
F - Facial weakness or numbness on one side - NEW
A - Arm or leg weakness or numbness on one side - NEW
S - Slurred speech or difficulty with word finding - NEW
T - Time is BRAIN! Call 911 as soon as you recognize these symptoms
Follow-up appointments:

Primary Care: ***

44 | P a g e
Please follow up with your primary care doctor within 1-2 weeks of discharge. Please call for an
appointment.
Neurology: ***
Questions or concerns:
If you have not seen your clinic neurologist yet and you have questions or concerns, please do
not hesitate to call our Stroke Clinic at ***. Please ask to speak to our stroke nurse or our
patient care coordinator.
You may also reach out to your primary care doctor.
Your discharge medications:
All medication refills should be obtained through your primary care doctor or your clinic
neurologist. Please discuss prescription refills at your follow-up appointment. Please do not call
the hospital for medication refills. Normally at discharge patients receive a prescription for a
one-month supply of medication.
Statin: You are being discharged on ***, which is in a class of medications called a statin. These
medications not only lower your cholesterol, but they also have protective effects on the blood
vessels. Research has shown that statin therapy reduces the risk of a future stroke. Rare side
effects of statins include but are not limited to sore achy muscles and/or an elevation of the
liver enzymes. If you develop sore achy muscles, stop the medication and call your doctor right
away. Please discuss with your doctor whether or not you should have your liver function
tested (blood work) within one month after starting this medication.

Antiplatelet: You are being discharged on ***, which is a medication that essentially thins your
blood by making your platelets less sticky. *** has been shown to decrease your risk of having
another stroke or TIA (transient ischemic attack) in the future. Please take this medication on a
daily basis and do not miss doses. If another provider suggests that you stop this medication for
a procedure, please call your neurologist and discuss whether or not an interruption in this
medication is safe. If you develop a rash or bleeding side effects while taking this medication,
call your doctor right away. If you develop life-threatening bleeding or dark/black tarry stools
that are associated with sweating, lightheadedness or the feeling of wanting to pass out, then
call 911 immediately.

Restrictions: ***

Diet and Activity:

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For our patients who have had stroke and/or TIA, we recommend following "Life's Simple 7"
guidelines, which are promoted by the American Heart Association. Please visit
http://mylifecheck.heart.org and click on the "Life's Simple 7" option for more information.
"Life's Simple 7" Guidelines as per American Heart Association
(1) Get Active. Physical activity can help people lose weight, control high blood pressure and
cholesterol, feel emotionally better and sleep better.
(2) Control Cholesterol. Avoid a diet high in saturated fat, trans fat and cholesterol. Limit whole
milk and cream, ice cream, butter, egg yolks, processed meats (like sausage and hot dogs), and
fatty meats.
Choose healthy foods that are low in saturated fat, trans fat and cholesterol, which include
fruits and vegetables, fiber-rich grain products (like whole grain pasta and brown rice), lean
meat such as chicken, fish, nuts, seeds and legumes.
(3) Eat Better. Eat small portions. Shop at the grocery with a list and do not stray from it. Tips
for a healthy diet include: limit sodium intake to less than 1,500 mg daily; avoid prepackaged,
processed and fast foods; choose a diet rich in fruits, vegetables and whole grain, high-fiber
foods; and limit saturated fats and cholesterol in your diet.

(4) Manage Blood Pressure. If you have high blood pressure, you should have a cuff at home so
that you can check your blood pressure regularly. Be sure you have a good cuff. An arm one is
generally better than a wrist one. Bring the cuff to a doctor's appointment to validate that the
measurements that your cuff are taking are accurate. Take your blood pressure twice daily
when you are sitting down and relaxing. Record the numbers in a log, and bring this log with
you to your doctors' appointments.

(5) Lose Weight if Your BMI Is above 25. A healthy BMI is between 19-25. To calculate your
BMI, you may use the Standard BMI Calculator on the NIH BMI website:
www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm. Weigh yourself daily. If you are
overweight, set a goal to lose weight. A pound a week loss, if needed, is a good target.
(6) Reduce Blood Sugar. Limit foods and liquids with "added sugars." (Added sugars include
sucrose, fructose, glucose, maltose, dextrose, high fructose corn syrup, corn syrup,
concentrated fruit juice and honey.)
(7) Stop Smoking. If you smoke, quitting smoking is one of the best things that you can do for
your health. Smoking increases your risk of heart attack, stroke and peripheral vascular disease,
which is a build-up of plaque in your arteries. Please discard all the cigarettes and lighters in
your house. Have a plan for what you will do when you have the urge to smoke. Direct and
second-hand smoke shortens your life as well as the lives of your family, friends and others
around you. For your health and the health of those around you, please consider quitting!
46 | P a g e
Smoking Cessation:
Use the START Plan to Quit Smoking (please visit the Helpguide.org website listed below for
more information):
S = Set a quit date.
Choose a date within the next two weeks, so you have enough time to prepare without losing
your motivation to quit. If you mainly smoke at work, quit on the weekend, so you have a few
days to adjust to the change.
T = Tell family, friends and co-workers that you plan to quit.
Let your friends and family in on your plan to quit smoking and tell them you need their support
and encouragement to stop. Look for a quit buddy who wants to stop smoking as well. You can
help each other get through the rough times.
A = Anticipate and plan for the challenges you'll face while quitting.
Most people who begin smoking again do so within the first three months. You can help
yourself make it through by preparing ahead for common challenges, such as nicotine
withdrawal and cigarette cravings.
R = Remove cigarettes and other tobacco products from your home, car and work.
Throw away all of your cigarettes (no emergency pack!), lighters, ashtrays and matches. Wash
your clothes and freshen up anything that smells like smoke. Shampoo your car, clean your
drapes and carpet, and steam your furniture.
T = Talk to your doctor about getting help to quit.
Your doctor can prescribe medication to help with withdrawal and suggest other alternatives. If
you can't see a doctor, you can get many products over the counter at your local pharmacy or
grocery store, including the nicotine patch, nicotine lozenges and nicotine gum.
Resources for Quitting Smoking:
If you are a resident in the state of Washington, you may call Washington State Quit Line at 1-
877-270-7867 (STOP) and/or review their website http://www.quitline.com.
Visit the Helpguide.org website at
http://www.helpguide.org/mental/quit_smoking_cessation.htm.
Time Spent on Discharge Coordination:
***
Signature and Timestamp

47 | P a g e
 Appendix I: Data Dictionary

STOMP Metric Definition Get With The Guidelines GWTG Data Options Comments/Opportunities
(GWTG) Verbiage

Primary Stroke Center GWTG Data Fields

Patient Encounter Number PatCom or Financial ID

Final clinical diagnosis Final clinical diagnosis Ischemic Stroke, TIA (< 24
related to stroke related to stroke: hours), Subarachnoid
Hemorrhage Intracerebral
Hemorrhage, Stroke not
otherwise specified No
Stroke related diagnosis,
Elective Cartoid
Intervention only

Select documented stroke Select documented stroke 1. Large-artery

etiology etiology: athersclerosis (e.g. Carotid
or basilar stenosis 2.
Cardioembolism (atrial
fibrilation/flutter, posthetic
heart valve, recent MI) 3.
Small vessel occlusion (e.g.
subcortical or brain stem
lacunar infarction <1.5cm)
4. Stroke of other
determined etiology (e.g.
dissection, vasculopathy,
48 | P a g e

Arrival Date/Time
If patient transferred,
specify hospital name
Referring hospital discharge
date/time
If Patient transfer from
another hospital, select
transfer reason(s)
Arrival Date/Time
If patient transferred,
specify hospital name
Referring hospital discharge
date/time:
If Patient transfer from
another hospital, select
transfer reason(s):
hypercaogulable or
hematologic disorders) 5.
Cryptogenic stroke 6.
Unspecified
mm/dd/yyyy hh:mi
Select hospital name form
picker list, Hospital not on
the list, Hospital not
documented
mm/dd/yyyy hh:mi
Evaluation for IV tPA up to
4.5 hours, post
management of IV tPA (e.g.
Drip and Ship), Evaluation
for Endovascular
thrombectomy, Advanced
stroke care (e.g.
Neurocritical care, surgical
or other time critical
therapy), Patient/family
request, Other advanced
care (not stroke related),
Not documented
49 | P a g e
Discharge Date:
What was the patient's
discharge disposition on the
day of discharge?
ICD-10-CM Principal
Diagnosis Code
Patient location when
stroke symptoms
discovered
How patient arrived at your
hospital
Where patient first received
care at your hospital
Discharge Date:
What was the patient's
discharge disposition on the
day of discharge?
ICD-10-CM Principal
Diagnosis Code
Patient location when
stroke symptoms
discovered:
How patient arrived at your
hospital
Where patient first received
care at your hospital:
mm/dd/yyyy hh:mi
Home, Hospice-Home,
Hospice-Health Care Facility,
Acute Care Facility, Other
Health Care Facility, Expired,
Left Against Medical
Advice/AMA, Not
Documented or Unable to
Determine
Many
Not in a healthcare setting, Note: Answering Stroke
Another acute care setting, occurred after hospital
Chronic health care facility, arrival will identify Pt's as in-
Outpatient healthcare house thrombectomy group
facility, Stroke occurred
after hospital arrival, ND or
Cannot be Determined
EMS from home/scene,
Mobile Stroke Unit, Private
transport/taxi/other from
home/scene, Transfer from
other hospital, ND or
Unknown
Emergency
Department/Urgent Care,
Direct Admit, not through
50 | P a g e
 ED, Imaging suite, ND or
cannot be determined

Advanced notification by Advanced notification by yes, No/ND, N/A

EMS (Traditional responder EMS (Traditional responder
or mobile stroke unit)? or mobile stroke unit)?

Initial NIH Stroke Scale Initial NIH Stroke Scale yes, No/ND, N/A CSTK-01

Total Score Total Score: 0-42

Ambulatory status prior to Ambulatory status prior to able to ambulate

the current event the current event: independently w/ or w/o
device, with assistance
(from person), unable to
ambulate, ND

Date/Time patient last Date/Time patient last mm/dd/yyyy hh:mi

known to be well? known to be well?

Date/Time Brain Imaging Date/Time Brain Imaging mm/dd/yyyy hh:mi

Initiated Initiated:

Date/Time Stroke Team Date/Time Stroke Team mm/dd/yyyy hh:mi

Activated Activated:

Date/Time of ED Physician Date/Time of ED Physician mm/dd/yyyy hh:mi

Assessment Assessment:

Date/Time Neurosurgical Date/Time Neurosurgical mm/dd/yyyy hh:mi

Services Consulted Services Consulted:

51 | P a g e
Date/Time Brain Imaging
Ordered:
Date/Time Brain Imaging
Interpreted:
IV tPA intitated at this
hospital?
Date/Time IV tPA initiated
Was a target lesion (large
vessel occlusion) visualized?
If yes, select site of large
vessel occlusion
Complications of
Thrombolytic Therapy
(select all that apply)
Date/Time Brain Imaging
Ordered:
Date/Time Brain Imaging
Interpreted:
IV tPA intitated at this
hospital?
Date/Time IV tPA initiated:
Was a target lesion (large
vessel occlusion) visualized?
If yes, select site of large
vessel occlusion
Complications of
Thrombolytic Therapy
(select all that apply)
mm/dd/yyyy hh:mi
mm/dd/yyyy hh:mi
yes, No
mm/dd/yyyy hh:mi
Yes, No/ND
ICA (intracranial ICA,
Cervical ICA, Other/UTD),
MCA (M1, M2, Other/UTD),
Basilar Artery, Other
cerebral artery branch,
Vertebral Artery
Symptomatic intracranial CSTK 5a
hemorrhage <36 hours, Life
threatening, serious
systemic hemorrhage <36
hours, Other serious
complication, No serious
complications, UTD
52 | P a g e
Advanced Stroke Care Tab PSC GWTG
What is the date and time
of skin puncture at this
hospital to access the
arterial site selected for
endovascular treatment of a
cerebral artery occlusion?
Was a mechanical
endovascular reperfusion
procedure attempted
during this episode of care
(at this hospital)?
Are reasons for not
performing mechanical
endovascular reperfusion
therapy documented?
Reasons for not performing
mechanical endovascular
reperfusion therapy (select
all that apply):
What is the date and time mm/dd/yyyy hh:mi
of skin puncture at this
hospital to access the
arterial site selected for
endovascular treatment of a
cerebral artery occlusion?
Was a mechanical Yes, No
endovascular reperfusion
procedure attempted
during this episode of care
(at this hospital)?
Are reasons for not Yes, No
performing mechanical
endovascular reperfusion
therapy documented?
Reasons for not performing Significant pre-stroke
mechanical endovascular disability (pre-stroke mRS
reperfusion therapy (select >1), No evidence of
all that apply): proximal occlusion, NIHSS
<6, Brain imaging not
favorable/hemorrhage
transformation (ASPECTS
score <6), Groin puncture
could not be initiated within
6 hours of symptom onset,
Anatomical reason-
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If MER treatment at this
hospital, type of treatment
What is the date and time
of the first pass of a clot
retrieval device at this
hospital?
If MER treatment at this
hospital, type of treatment:
What is the date and time
of the first pass of a clot
retrieval device at this
hospital?
unfavorable vascular
anatomy that limits access
to the occluded artery,
Patient/family refusal, MER
performed at outside
hospital, Equipment related
delay, No endovascular
specialist available, Delay in
stroke diagnosis, Vascular
imaging not performed,
Advanced Age, Other
Retrievable stent, Other
Mechanical slot retrieval
device beside stent
retrieval, Clot suction
device, Intracranial
angioplasty, with or without
permanenet stent, Cervical
carotid angioplasty, with or
without permanent stent
mm/dd/yyyy hh:mi
54 | P a g e
Reasons for delay (select all Reasons for delay (select all Social/religious, Initial
that apply) that apply): refusal, Care-team unable
to determine eligibility,
Management of
concomitant
emergent/acute conditions
such as cardiopulmonary
arrest, respiratory failure
(requiring intubation),
Investigational or
experimental protocol for
thrombolysis, Delay in
stroke diagnosis, In-hospital
time delay, Equipment-
related delay, Other

Thrombolysis in Cerebral Thrombolysis in Cerebral Grade 0, Grade 1, Grade 2a,

Infarction (TICI) Post- Infarction (TICI) Post- Grade 2b, Grade 3, ND
Treatment Reperfusion Treatment Reperfusion
Grade Grade

Total Score: Total Score: 0-6

MANUAL ENTRY Comprehensive Stroke Center GWTG Data Fields

Performance Measure Description

CSTK 02 90 Day mRS Total Score 0-6

CSTK 5b Hemorrhagic 1. clinical deterioration ≥ 4-

Transformation with IV tPA point increase on NIHSS and
or MER: symptomatic brain image finding of
55 | P a g e
 intracranial hemorrhage
within (≤) 36 hours after the
onset of treatment with IA
thrombolytic (t-PA) therapy
or mechanical endovascular
reperfusion therapy.
parenchymal hematoma 2.
subarachnoid hemorrhage,
or 3. intraventricular
hemorrhage)

Not in GWTG but Auto-calculated by REDCap Using Data Entered

Length of Stay Number of days in hospital this would be a

computation based on
Discharge Date/time -Arrival
Date/Time

Thrombolytic Door to Time from arrival- this would be a

Needle Time (DTN) door/arrival time. Goal <60 computation based on
minutes Arrival Date/Time -
Date/Time IV tPA initiated

Door to Groin Puncture this would be a

computation based on
Arrival Date/Time -
Date/Time of skin puncture

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Appendix II: Key Resources

Guidelines/Metrics
Organization URL

The Joint
Commission https://www.jointcommission.org/stroke/

DNV GL https://www.dnvglhealthcare.com/certifications/stroke-certifications

AHA Get with the http://www.heart.org/HEARTORG/Professional/GetWithTheGuidelines/Get-With-

Guidelines The-Guidelines---HFStroke_UCM_001099_SubHomePage.jsp

AHA Telehealth http://stroke.ahajournals.org/content/early/2016/11/03/STR.0000000000000114

Clinical Scales

Scale Name URL

ASPECTS http://stroke.ahajournals.org/content/47/10/2553

MRS http://stroke.ahajournals.org/content/38/3/1091

NIHSS http://www.nihstrokescale.org/

LAMS https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2743906/

RACE https://www.ncbi.nlm.nih.gov/pubmed/24281224

FAST http://www.stroke.org/understand-stroke/recognizing-stroke/act-fast

57 | P a g e
Landmark Articles for Acute Stroke and Large Vessel Occlusion

Topic URL to the Journal Article

TPA http://www.nejm.org/doi/full/10.1056/NEJM199512143332401

ECASS III http://www.nejm.org/doi/full/10.1056/NEJMoa0804656

MR CLEAN http://www.nejm.org/do/10.1056/NEJMdo005013/full/

ESCAPE http://www.nejm.org/doi/full/10.1056/NEJMoa1414905

REVASCAT http://www.nejm.org/doi/full/10.1056/NEJMoa1503780

SWIFT PRIME https://www.nejm.org/doi/full/10.1056/NEJMoa1415061

DAWN http://www.nejm.org/doi/full/10.1056/NEJMoa1706442

DEFUSE 3 http://www.nejm.org/doi/full/10.1056/NEJMoa1713973

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Appendix III: Glossary of Terms

Term Description
A1 First segment of the ACA arising from the ICA
ACA Anterior cerebral artery, a branch of the internal carotid
Alteplase An intravenous drug for acute ischemic stroke recanalization
American Heart Association (AHA) The main guideline and standard-generating society for acute
ischemic stroke
ASPECTS Non-contrast radiological examination to determine the stage
of stroke
AVM Arteriovenous malformation, a neurovascular structure where
veins anomalously meet arteries
Basilar Intracerebral artery responsible for blood supply to the
brainstem
Code IR Process to identify large vessel occlusion requiring catheter-
based approach for thrombectomy
Code Stroke Process to identify emergency related to ischemic stroke care
Core Infarct Volume The area of tissue infarcted at time of perfusion imaging
CT Computed tomography, best for ruling out hemorrhage in
acute stroke
CTA Computed tomography angiography, a contrast-based study to
identify large vessel occlusion
CTP Computed tomography perfusion, a contrast-based study used
to demonstrate core infarct and salvageable tissue
DNV GL A hospital accrediting body for stroke care
Door to Groin Represents time from arrival to initiation of endovascular
thrombectomy
Door to Needle Represents the time from arrival to alteplase administration
Drip and Ship A practice of ruling out hemorrhage, treating a patient with
alteplase and transferring the patient to a higher level of care
for thrombectomy or neuro-ICU care
Emergency Medical Services First responders and ambulance crew responsible for in-field
evaluation and triage of stroke
FAST Face, Arm, Speech, Time – a screening test for stroke
Get With The Guidelines AHA's standardized metrics for data reporting and monitoring
of acute ischemic stroke
INR International normalized ratio, a lab to evaluate
hypercoagulability from anticoagulation
Internal Carotid Artery The main supply of anterior circulation
The Joint Commission A hospital accrediting body for stroke care
Los Angeles Motor Scale (LAMS) Used to help grade stroke severity in the field
Large Vessel Occlusion Arterial occlusion in a major intracerebral artery resulting in
ischemic stroke
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Last Known Well (LKW) Last time patient was documented in baseline status; this
critical information is obtained by history

MCA Middle cerebral artery

Modified Rankin Scale for measuring functional independence after stroke
MRA Magnetic resonance angiogram, a contrast- or non-contrast-
based study to identify large vessel occlusion
MRI Magnetic resonance imaging, best for tissue detail in acute
stroke
MRP Magnetic resonance perfusion, contrast-based study to
demonstrate core infarct and salvageable tissue
Neuro-checks Specific nursing examination for monitoring and evaluating
stroke patients; include pupillary assessment and motor
function assessment to ensure consistent examinations
Neuro-ICU High level of care with trained and dedicated nurses who
evaluate the patient with neuro-checks
NIH Stroke Scale/Score (NIHSS) Clinical scale for measuring severity of stroke symptoms
Penumbra The area of tissue at risk but not infarcted in an acute ischemic
stroke
Prehospital Notification Notification of hospital of a possible stroke by Emergency
Medical Services
Used to help grade stroke severity in the field
RACE - Rapid Arterial oCclusion

Evaluation score

Symptomatic Hemorrhage Defined as a drop in NIHSS >4 points with new intracerebral
hemorrhage documented on neuroimaging
Telestroke Evaluation of patients with video teleconferencing technology
Cincinatti Prehospital Stroke Scale Used to help grade stroke severity in the field
(CPSS)
Thrombectomy Catheter-based approach to remove an arterial occlusion
performed by neurointerventionalist in the intervention suite
tPA Tissue plasminogen activator, also known as alteplase, an
intravenous drug for acute ischemic stroke recanalization
Vertebral Arteries responsible for posterior circulation, meeting to form
the basilar
mTICI Modified thrombolysis in cerebral infarction

60 | P a g e
Appendix IV: References
1. Saver JL. Time is brain--quantified. Stroke. 2006;37:263–266.
2. Meretoja A, Keshtkaran M, Tatlisumak T, Donnan GA, Churilov L. Endovascular therapy
for ischemic stroke: Save a minute-save a week. Neurology. 2017;88:2123–2127.

3. Mazighi M, Chaudhry SA, Ribo M, Khatri P, Skoloudik D, Mokin M, et al. Impact of onset-
to-reperfusion time on stroke mortality: a collaborative pooled analysis. Circulation.
2013;127:1980–1985.

4. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. Thrombectomy
6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med.
2018;378:11–21.

5. Furie, Karen L., and Mahesh V. Jayaraman. "2018 Guidelines for the Early Management of
Patients With Acute Ischemic Stroke." (2018): 509-510.

6. Wechsler LR, Demaerschalk BM, Schwamm LH, Adeoye OM, Audebert HJ, Fanale C V, et
al. Telemedicine quality and outcomes in stroke: a scientific statement for healthcare
professionals from the American Heart Association/American Stroke Association. Stroke.
2017;48:e3–e25.

7. Powers, William J., et al. "2018 Guidelines for the Early Management of Patients With
Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American
Heart Association/American Stroke Association." Stroke 49.3 (2018): e46-e110.

8. Fonarow GC, Liang L, Smith EE, Reeves MJ, Saver JL, Xian Y, et al. Comparison of
performance achievement award recognition with primary stroke center certification for
acute ischemic stroke care. J Am Heart Assoc. 2013;2:e000451.

9. Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et al.
Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of
individual patient data from five randomised trials. Lancet. 2016;387:1723–1731.

10. Fransen PS, Berkhemer OA, Lingsma HF, Beumer D, van den Berg LA, Yoo AJ, et al. Time
to Reperfusion and Treatment Effect for Acute Ischemic Stroke: A Randomized Clinical
Trial. JAMA Neurol. 2016;73:190–196.

11. Hemmen TM, Meyer BC, McClean TL, Lyden PD. Identification of nonischemic stroke
mimics among 411 code strokes at the University of California, San Diego, Stroke Center.
J Stroke Cerebrovasc Dis. 2008;17:23–25.

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12. Libman RB, Wirkowski E, Alvir J, Rao TH. Conditions that mimic stroke in the emergency
department. Implications for acute stroke trials. Arch Neurol. 1995;52:1119–1122.

13. Lackland DT, Roccella EJ, Deutsch AF, Fornage M, George MG, Howard G, et al. Factors
influencing the decline in stroke mortality: a statement from the American Heart
Association/American Stroke Association. Stroke. 2014;45:315–353.

14. Lovett JK, Coull AJ, Rothwell PM. Early risk of recurrence by subtype of ischemic stroke in
population-based incidence studies. Neurology. 2004;62:569–573.

15. Rao A, Barrow E, Vuik S, Darzi A, Aylin P. Systematic Review of Hospital Readmissions in
Stroke Patients. Stroke Res Treat. 2016;2016:9325368.

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