Abstract 268: Is There a Weekend Effect on Telestroke Code Time Metrics?

Background: It has been suggested that there is a “weekend effect” resulting in higher mortality rates for stroke patients admitted on weekends. We examine this phenomenon for acute ischemic stroke (AIS) patients presenting to telestroke (TS) sites to determine its effect on stroke code process times and outcomes. Methods: From October 2015-June 2017, we reviewed consecutive AIS patients receiving IV alteplase within our TS network who then were transferred to our CSC. We compared patients presenting to TS sites on weekdays (Monday 0700 to Friday 1859) to patients presenting on weekends (Friday 1900 to Monday 0659). We analyzed door to code activation, code activation to TS evaluation, door to imaging, and door to needle times. Rates of favorable outcome (modified Rankin Scale score ≤2) and death at 90 days were compared. Results: We identified 89 (54 weekday, 35 weekend) patients (mean age 71.8±13.3 years, 47.2% women) during the study period. Median door to code activation (15 [5, 27] vs 8 [1, 17] mins, p=0.01) and door to needle (61 [49, 73] vs 47 [35, 59] mins, p=0.003) times were significantly longer for patients presenting on weekends compared to weekdays. There were no significant differences in median door to imaging (weekend 17 [7, 30] vs weekday 11 [6, 21], p=0.1) and code activation to TS evaluation (weekend 7 [6, 10] vs weekday 5 [4, 9], p=0.14) times. The rates of favorable outcome (weekend 50% vs weekday 66.7%, p=0.18) and death (weekend 8.3% vs weekday 4.8%, p=0.56) at 90 days were not significantly different. Conclusion: While there were no significant differences in outcomes, the “weekend effect” results in slower door to code activation and door to needle times. Efforts to improve methods in increasing efficiency of care on weekends should be considered.

Realignment of ASME Operations Maintenance Committee: Improving Responsiveness and Efficiency

The O&M Code was developed when it was decided to move Pump and Valve Inservice Testing (IST) Requirements from the American Society of Mechanical Engineers (ASME) Boiler and Pressure Vessel (B&PV) Code, Section XI to a standalone Code. The Code review process structure at the time was quite small and generally consisted of changing Section XI Subsections IWP and IWV into OM language. At the same time, new testing techniques were being developed that included check valve condition monitoring and current trace testing of motor actuated valves. This necessitated adding groups that were specific to these new initiatives. Although that was several decades ago, these groups remained and, over the years, it was identified that actions, such as Inquiries, were taking much too long to process. This became abundantly clear with the development of the newly published Mandatory Appendix IV for Air Operated Valve Testing. This paper discusses how the Code Committee became the organization that it is and how a new realignment will streamline the Code process and make it more efficient and responsive to the industry/regulatory needs. Paper published with permission.

Abstract TP289: Code Neuro-Intervention a New Necessity: Reality of Shifting Stroke Care Paradigm

Background: Various strategies have been implemented to reduce acute stroke treatment times. A unique code process pathway was designed at our hospital specifically to be activated by the stroke team for the purpose of rapidly assembling the Neurointerventional team. Methods: Code Neurointervention (NI), was designed and tested from January 2014 to April 2014 for all the patients who presented with ischemic strokes to our community based, university affiliated comprehensive stroke center. We retrospectively analyzed all patients who had Code NI called from May 1, 2014 to April 30, 2015 and compared them to patients who underwent acute endovascular treatment the prior year (Non Code NI). The following parameters were compared: decision to recanalization and door to recanalization times. Further analysis was done to compare patients presenting during business hours (Monday-Friday 8am-5pm) and off hours using GraphPad QuickCalcs Web site. Results: There were 28 Code NI; 14 were called during work hours and 14 during off hours. The previous year 25 patients underwent acute endovascular intervention; 12 during work hours and 13 during off hours. Mean decision to recanalization time was 106 (Code NI) vs 115 minutes (Non Code NI) (p<0.0.6) during work hours and 154 (Code NI) vs 139 minutes (Non Code NI) (p<0.37) during off hours. Mean door to recanalization time was 169 (Code NI) vs 173 minutes (Non Code NI) (p<0.85) during work hours and 252 (Code NI) vs 243minutes (Non Code NI) (p< 0.75) during off hours. Subset analysis of time parameters for patients in Code NI group showed mean decision to recanalization times of 106 minutes during work hours vs 154 minutes off work hours (p<0.004). Mean door to recanalization times were 169 minutes vs 251 minutes (p<0.0003), respectively. Conclusion: Institution of Code NI significantly improved intervention time parameters during work hours as compared to off hours. Rapid assembly of the neurointervention team, rapid availability of imaging and angiography suite likely contribute to these differences. Further initiatives, such as improving neurointervention staff availability during off hours or cross training other staff can further improve acute intervention time parameters.

The Struggle to Fashion the NRA Code: The Triumph of Studio Power in 1933 Hollywood

This article traces the long and antagonistic fashioning of the National Recovery Adminstration's code of practice for the film industry during 1933. The NRA code process publicly exposed resentful fissions within Hollywood, and the oligarchic, if not monopolistic, way in which the major film studios had set up their vertically integrated consolidation of the motion-picture industry in terms of production, distribution and exhibition on a national scale. A media spotlight flooded onto their soundstages and executive suites, and many, including President Franklin Roosevelt, were not pleased with what they saw. The NRA, signed into law in 1933 by Roosevelt, implemented an unprecedented reorganization of the American economy to restore employment to combat the Great Depression. Perhaps most controversially, especially for the union-averse film industry, the NRA established collective bargaining. Though they supported it initially, the major studios would not long abide by the NRA. Throughout 1933, they violated the spirit and letter of the code, ensuring as much as possible that the economic pain and sacrifice of the Great Depression in Hollywood was visited upon artists and technicians, not studio heads and executives. They used the making of the code to attempt to cement and further the advantages they enjoyed while offering little to other interests in the film industry.

Abstract TP353: Use of Telestroke in a Metropolitan Stroke Code Process

BACKGROUND: Reperfusion therapy is the most important recent advance in early treatment for acute ischemic stroke, but remains underused and the timing of administration of treatment continues to be unacceptably delayed. The complexity of the decision tree and risk of treatment may be limiting use in the emergency department (ED) when those directing the therapy have limited knowledge and less comfort with administration of the drug. This review supports the hypothesis that utilizing telestroke to increase the Stroke Neurology expertise early in the stroke code in an organized stroke code process in a metropolitan hospital ED will improve the rate of use of reperfusion therapy and decrease the door-to-drug (DTD) times. METHODS and RESULTS: Telestroke was used to allow for Stroke Neurology presence and leadership in a redesigned stroke code process at 2 busy metropolitan hospitals beginning in 2009 at St. Joseph’s Hospital and 2010 at St. John’s Hospital. CONCLUSION: Telemedicine run stroke codes in a busy metropolitan ED resulted in increased use of reperfusion therapy and dramatic decreases in DTD times.