Utility of the novel guide catheter in mechanical thrombectomy for emergent large vessel occlusion stroke.

BACKGROUND: A number of large bore guide catheters are currently available for use in neuroendovascular surgery. This study represents a multi-institutional retrospective series of patients undergoing mechanical thrombectomy with the use of a TracStar Large Distal Platform (LDP) guide catheter and assessed its performance in vivo in 107 patients. OBJECTIVE: To review a multi-institutional initial experience with the TracStar LDP guide catheter during mechanical thrombectomy for emergent large vessel occlusion (ELVO). METHODS: A retrospective review was performed at two level one stroke centres to include all patients who underwent mechanical thrombectomy and had the TracStar LDP guide catheter used during the intervention. RESULTS: The TracStar LDP guide catheter was successfully used in 107 mechanical thrombectomies. In anterior circulation ELVO, the guide catheter advanced into the cavernous segment of the internal carotid artery in 62.6% (62/99) of cases. In posterior circulation cases, the guide catheter advanced to the basilar artery in 87.5% (7/8) of cases. A thrombolysis in cerebral infarction 2b or greater reperfusion was obtained in 90.7% (97/107). No complications occurred related to the TracStar LDP guide catheter. Three complications occurred with aspiration catheters including a small dissection that did not require further intervention and fracturing of the AXS Catalyst 6 catheter tip in two cases. No thromboembolic events occurred. CONCLUSIONS: The TracStar LDP large bore guide catheter is safe and effective at navigating the tortuous vascular anatomy often encountered during mechanical thrombectomy for stroke. The flexible distal and stiffer proximal components provide a good combination of navigability and support for use in neuroendovascular interventions.

Hospital value-based purchasing: How acute care advanced practice nurses demonstrate value.

ABSTRACT: Hospital value-based purchasing (HVBP) is a budget neutral initiative from the Centers for Medicare & Medicaid Services designed to adjust the hospital payment system based on health care quality data. Hospital value-based purchasing is designed to promote improved clinical outcomes and better patient experience in the acute care setting. Advanced practice registered nurses (APRNs) in the acute care setting are instrumental to the success of health care institutions under the current payer model in the United States health care system. When APRNs use their advanced knowledge and leadership skills to champion quality improvement and patient experience projects, they may increase financial reimbursement within the HVBP system, thus demonstrating value to the health care institution. Four basic steps could help APRNs demonstrate value to the organization, understand the standard, evaluate your performance compared with the standard, identify opportunities, and implement projects or participate in projects. This article provides a broad overview of the HVBP structure and describes how APRNs can positively influence performance measures, thereby potentially increasing hospital reimbursement.

Perception Versus Actual Performance in Timely Tissue Plasminogen Activation Administration in the Management of Acute Ischemic Stroke.

BACKGROUND: Timely thrombolytic therapy can improve stroke outcomes. Nevertheless, the ability of US hospitals to meet guidelines for intravenous tissue plasminogen activator (tPA) remains suboptimal. What is unclear is whether hospitals accurately perceive their rate of tPA "door-to-needle" (DTN) time within 60 minutes and how DTN rates compare across different hospitals. METHODS AND RESULTS: DTN performance was defined by the percentage of treated patients who received tPA within 60 minutes of arrival. Telephone surveys were obtained from staff at 141 Get With The Guidelines hospitals, representing top, middle, and low DTN performance. Less than one-third (29.1%) of staff accurately identified their DTN performance. Among middle- and low-performing hospitals (n=92), 56 sites (60.9%) overestimated their performance; 42% of middle performers and 85% of low performers overestimated their performance. Sites that overestimated tended to have lower annual volumes of tPA administration (median 8.4 patients [25th to 75th percentile 5.9 to 11.8] versus 10.2 patients [25th to 75th percentile 8.2 to 17.3], P=0.047), smaller percentages of eligible patients receiving tPA (84.7% versus 89.8%, P=0.008), and smaller percentages of DTN ≤60 minutes among treated patients (10.6% versus 16.6%, P=0.002). CONCLUSIONS: Hospitals often overestimate their ability to deliver timely tPA to treated patients. Our findings indicate the need to routinely provide comparative provider performance rates as a key step to improving the quality of acute stroke care.

Development and initial testing of the stroke rapid-treatment readiness tool.

No instruments are currently available to help health systems identify target areas for reducing door-to-needle times for the administration of intravenous tissue plasminogen activator to eligible patients with ischemic stroke. A 67-item Likert-scale survey was administered by telephone to stroke personnel at 252 U.S. hospitals participating in the "Get With The Guidelines-Stroke" quality improvement program. Factor analysis was used to refine the instrument to a four-factor 29-item instrument that can be used by hospitals to assess their readiness to administer intravenous tissue plasminogen activator within 60 minutes of patient hospital arrival.

A qualitative assessment of practices associated with shorter door-to-needle time for thrombolytic therapy in acute ischemic stroke.

Early treatment with intravenous (IV) recombinant tissue plasminogen activator/alteplase (tPA) is associated with improved outcomes for patients with an acute ischemic stroke. Thus, rapid triage and treatment of stroke patients are essential, with a goal of door-to-needle time of no more than 60 minutes. We sought to identify best practices associated with faster treatment among hospitals participating in Get With the Guidelines--Stroke. Qualitative telephone interviews were conducted to elicit strategies being used by these centers to assess, treat, and monitor stroke patients treated with IV tPA. We sequentially carried out these interviews until we no longer identified novel factors. Interviews were conducted with 13 personnel at 7 top-performing U.S. hospitals. With the use of a hermeneutic-phenomenological framework, 5 distinct domains associated with rapid IV tPA delivery were identified. These included (a) communication and teamwork, (b) process, (c) organizational culture, (d) performance monitoring and feedback, and (e) overcoming barriers.