To determine interest in and format of the review, we conducted interviews with coordinators from 3 highly-engaged sites of varying sizes and capabilities. We had strong consensus that a bi-directional quality review would be helpful and that group-based discussion was preferred over single-site reviews. Coordinators chose review flags of long process metrics, missed treatments, thrombectomies, complications, and mortalities with sentinel events reviewed immediately, off-cycle. A case review sheet is uploaded to HIPAA-compliant Box drive and neuroimaging to PACS. Hub and spoke clinicians present cases over Zoom using standard SOAR format: Situation, Outcome, Assessment, Recommendation. The group grades each case as standard of care (SOC) met, exceeded, or not met, +/- opportunities for improvement (OFI). Discussion includes recommendations to individual hospitals or network.

From 4/2019-7/2020, we conducted 8 bi-directional case reviews of 21 TS cases with 9 spokes (mean 4.3 spokes/review, range 2-6). Of 47 spoke participants, 43% were stroke coordinators and 34% were ED managers, and occasional hospitalists. Hub participants were 8 vascular neurologists/fellows and 3 TS coordinators/managers. Case content was 33% stroke recognition, 49% acute treatment, 19% disposition. SOC was rated as met or exceeded in 86% of cases with OFI noted in 100%. Discussion topics included: when to use advanced imaging, young stroke etiologies, DIDO improvement techniques, tPA reversal protocols, and sharing of inpatient stroke protocols.