To develop an unbiased mechanism to make the COAST (Coordinating Options for Acute Stroke Therapy) stroke advance directive sustainable in a comprehensive stroke center.

The discussion of acute stroke treatment options often happens in a hectic emergency environment. Stroke deficits can prevent patients from expressing their own preferences about acute stroke therapies. COAST is an advance directive developed at UCSD in December 2014 to discuss acute stroke treatment options before potential future strokes. 

We designed a Standard Operating Procedure (SOP) for the UCSD stroke team, which includes implementation of the following: (1) COAST eligibility for every patient is discussed daily on rounds, (2) COAST completion is included in the daily progress notes, (3) a COAST checkbox is addressed on the daily inpatient handout, (4) COAST is incorporated into the admission code status discussion and for stroke consultations, (5) a stroke team member is assigned to check whether a prior COAST exists during a stroke code activation, (6) COAST training is provided to stroke providers quarterly throughout the academic year, and (7) the electronic medical record is adjusted that reminds providers of COAST and that keeps track of COASTs completed. This SOP applies to all patients under the UCSD Stroke service. 

During the one-month pre-implementation period (9/1/2018 to 10/1/2018), we had a total of 21 COASTs accounting for approximately 10.2% (21/205) of all COASTs completed since its first utilization on 12/10/2014. Our sustainability plan was officially started at UCSD on 10/15/2018. We will assess the rate of COAST completion over time and the results will be presented.

A sustainability plan can significantly increase the number of COASTs, potentially improving patient education and autonomy. It also provides a mechanism for long-term efficiency of acute stroke care.