An Emergent Large Vessel Occlusion Screening Protocol for Acute Stroke: A Quality Improvement Initiative.

BACKGROUND: Nurses play an integral role in triaging stroke patients. The purpose of this quality improvement initiative was to determine the efficacy of using an emergent large vessel occlusion (ELVO) screening protocol in the emergency department by nursing staff to improve identification of eligible patients as compared with current practice, improving time to endovascular treatment. METHODS: Retrospective chart review was used to identify 76 patients admitted to a large urban stroke center. Of these, 36 presented during a 4-month period before the implementation of the Stroke Vision, Aphasia, Neglect (Stroke VAN) tool for assessing ELVO risk; 40 patients were admitted during the 4 months after implementation of Stroke VAN. RESULTS: The mean door-to-computed tomography angiography scan times were reduced from 119 to 49 minutes (P < .0001) for all patients and reduced from 77 to 27 minutes in a subset of VAN-positive patients. CONCLUSION: Implementation of the VAN screening tool to assess for ELVO was associated with decreased door-to-computed tomography angiography times and more rapid identification of endovascular eligible patients with ischemic stroke.

Stroke vision, aphasia, neglect (VAN) assessment-a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices.

BACKGROUND: Identification of emergent large vessel occlusion (ELVO) stroke has become increasingly important with the recent publications of favorable acute stroke thrombectomy trials. Multiple screening tools exist but the length of the examination and the false positive rate range from good to adequate. A screening tool was designed and tested in the emergency department using nurse responders without a scoring system. METHODS: The vision, aphasia, and neglect (VAN) screening tool was designed to quickly assess functional neurovascular anatomy. While objective, there is no need to calculate or score with VAN. After training participating nurses to use it, VAN was used as an ELVO screen for all stroke patients on arrival to our emergency room before physician evaluation and CT scan. RESULTS: There were 62 consecutive code stroke activations during the pilot study. 19 (31%) of the patients were VAN positive and 24 (39%) had a National Institutes of Health Stroke Scale (NIHSS) score of ≥6. All 14 patients with ELVO were either VAN positive or assigned a NIHSS score ≥6. While both clinical severity thresholds had 100% sensitivity, VAN was more specific (90% vs 74% for NIHSS ≥6). Similarly, while VAN and NIHSS ≥6 had 100% negative predictive value, VAN had a 74% positive predictive value while NIHSS ≥6 had only a 58% positive predictive value. CONCLUSIONS: The VAN screening tool accurately identified ELVO patients and outperformed a NIHSS ≥6 severity threshold and may best allow clinical teams to expedite care and mobilize resources for ELVO patients. A larger study to both validate this screening tool and compare with others is warranted.