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Background: Patients with symptoms that simulate Acute Ischemic Stroke (AIS), but are ultimately determined to have another diagnosis are referred to as Stroke Mimics (SM). SM are reported to be 1.4% to 30% of Emergency Department (ED) cases, and reducing door-to-needle time (DTN) has been associated with increased treatment of SM (from 6.7% to 30%). The risk of tPA in SM patients is unclear. We are challenged with the conflicting goals of timely administration of therapy and mitigating unnecessary risk. We successfully reduced DTN and were interested to see if that effected SM. Objectives: To evaluate the impact of DTN on diagnostic accuracy in patients receiving tPA in the ED; and to determine the associated complication rate in patients with AIS compared to SM. Methods: We performed a retrospective cohort study of patients receiving tPA for suspected AIS between 2013-2015. Patients were identified through our Stroke registry and confirmed by pharmacy audit of tPA orders. We performed a structured chart review and provide a descriptive analysis of variables. Results: In our study period, 97 patients were treated with tPA for the presumptive diagnosis of AIS, 90 (92.8%) had a final diagnosis of AIS, while 7 (7.2%) were SM. The only complications of treatment with tPA reported were in the AIS group, 4 (15%) and 1 (4.2%) in 2013/2014 repectively. There were no complications reported in either group in 2015. This reduction in complications was achieved while reducing the DTN to less than 45 min in 50% of patients and less than 60 min in 75% of patients. Conclusion: While doubling the number of patients treated, we reduced the DTN and the complication rate in AIS patients. Contrary to prior studies, we found a decrease in the number of SM treated. None of the SM patients had a complication. The reduction in DTN and SM over time suggests that our screening of tPA candidates is appropriate.

Background and Purpose: At least 12% of stroke patients are readmitted to a hospital within 30 days of discharge. We know that patients hospitalized for other conditions are less likely to be readmitted within 30 days if they are seen by their PCP shortly after discharge. However, less than a third of patients in the New York metropolitan area admitted for heart failure, heart attacks, and pneumonia see their PCP within 14 days after discharge and nearly 40% of patients do not adhere to their prescribed regimen. In the case of cerebrovascular diseases, outpatient follow-up may prevent the majority of avoidable readmissions. The purpose of this project is to identify and reduce unnecessary, unplanned hospital readmissions after stroke. Our goal is to encourage patient adherence to prescribed medication and other therapies, as well as to ensure timely follow-up with their PCP. Methods: Stroke and transient ischemic attack (TIA) patients with a disposition of either home or short-term rehabilitation are visited and offered enrollment. Participants are given a kit which includes a personalized binder (to manage essential medical information) and a 28-slot pill box. Each patient then receives 3 phone call interviews at 7, 21 and 32 days after discharge. The aim of the phone calls is to identify obstacles to compliance with treatment regimen and follow-up care. Results: From January 2015 to June 2016, 247 patients were enrolled and followed up. Within 30 days of discharge, 10% were readmitted and 50% of all readmissions occurred within the first 7 days. Of those readmitted, 19% were due to an injury from physical therapy. Data from follow-up phone calls revealed that 83% were taking all prescribed medications, 89% had completed a follow-up with any physician, 69% were using the binder, and 61% had done all three. Conclusions: While we have not enrolled enough patients to see a statistically significant reduction in readmissions, our interviews showed that weather, depression, as well as a lack of insurance, family support, and a home health aide are all determinants on how patients will follow their prescribed regimen. The results of this study have allowed us to begin implementing stroke support groups and pre-discharge follow-up appointment scheduling.