Prehospital and Emergency Department-Focused Mission Protocol Improves Thrombolysis Metrics for Suspected Acute Stroke Patients

Background/Objective: There is growing importance on discovering factors that delay time to intervention for acute ischemic stroke (AIS) patients, as rapid intervention remains essential for better patient outcomes. The management of these patients involves a multidisciplinary effort and quality improvement initiatives to safely increase treatment with intravenous thrombolytic (IV tPa). The objective of this pilot is to evaluate factors of acute stroke care in the emergency department (ED) and the impact they have on IV tPa administration. Methods: A sample of 89 acute ischemic stroke patients that received IV tPa from a single academic medical institution was selected for retrospective analysis. System characteristics (presence of a stroke nurse and time of day) and patient characteristics (mode of arrival and National Institutes of Health Stroke Scale score (NIHSS) on arrival) were analyzed using descriptive statistics and multiple regression to address the study question. Results: The mean door to needle time is 53.74 minutes ( + 38.06) with 74.2% of patients arriving to the ED via emergency medical services (EMS) and 25.8% having a stroke nurse present during IV tPa administration. Mode of arrival ( p = .001) and having a stroke nurse present ( p = .022) are significant predictors of door to needle time in the emergency department (ED). Conclusion: While many factors can influence door to needle times in the ED, we did not find NIHSS on arrival or time of day to be significant factors. Patients arriving to the ED by personal vehicle will have a significant delay in IV tPa administration, therefore emphasizing the importance of using EMS. Perhaps more importantly, collaborative efforts including the addition of a specialized stroke nurse significantly decreased time to IV tPa administration for AIS patients. With this dedicated role, accelerated triage and more effective management of AIS patients is accomplished, leading to decreased intervention times and potentially improving patient outcomes.

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Basic Clinical Syndromes and Definitions

Acute Stroke Management in the First 24 Hours ◽

10.1093/med/9780190856519.003.0001 ◽

2018 ◽

pp. 1-21

Author(s):

Aparna Pendurthi ◽

Maxim Mokin

Keyword(s):

Emergency Department ◽

Acute Stroke ◽

Clinical Characteristics ◽

Clinical Presentation ◽

Clinical Manifestations ◽

Transient Ischemic Attacks ◽

Stroke Patients ◽

Duration Of Symptoms ◽

Surgical Interventions ◽

Clinical Syndromes

The goal for neurological evaluation in the Emergency Department is to appropriately route potential acute stroke patients toward medical or surgical interventions in the most expedient manner possible. This chapter focuses on familiarizing the reader with main stroke subtypes and clinical manifestations associated with specific syndromes. Acute neurologic episodes being evaluated in the emergent setting for stroke workup can be divided into broad categories based on duration of symptoms, clinical presentation, and findings from basic imaging. This chapter explores the most common of these stroke syndromes and discusses the classification and clinical characteristics of transient ischemic attacks and ischemic and hemorrhagic strokes.

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Factors associated with late arrival of acute stroke patients to emergency department in Saudi Arabia

SAGE Open Medicine ◽

10.1177/2050312118776719 ◽

2018 ◽

Vol 6 ◽

pp. 205031211877671 ◽

Cited By ~ 4

Author(s):

Ali M Al Khathaami ◽

Yasmeen O Mohammad ◽

Fatimah S Alibrahim ◽

Hoda A Jradi

Keyword(s):

Emergency Department ◽

Saudi Arabia ◽

Acute Stroke ◽

Delayed Presentation ◽

Stroke Patients ◽

Cross Sectional Survey ◽

Community Based Interventions ◽

Cross Sectional ◽

Factors Associated ◽

Late Arrival

Background: Tissue plasminogen activator within 4.5 h of onset is effective for acute ischemic stroke. However, only small proportion of patients is treated due to delayed presentation. We aimed to examine the factors associated with delays of stroke patients in Riyadh, Saudi Arabia. Methods: A cross-sectional survey was conducted at King Abdulaziz Medical City, Riyadh, Saudi Arabia, during a 6-month period. An interviewer administered structured questionnaire addressed to the acute stroke patients or their relatives was used to explore the factors associated with delayed arrival. Results: A total of 227 patients attending the emergency department were interviewed. The mean age was 60.4 ± 15.6 years. Approximately 56.4% presented after 4.5 h of stroke onset. Factors associated with late arrival were being alone during the onset of stroke, not being transported in an ambulance, not knowing that they were experiencing a stroke, and residing outside the city of Riyadh. Conclusion: More than half of patients missed the golden hours for thrombolysis due to delayed presentation. Reasons include lack of knowledge, underuse of ambulance and difficult access to care. Urgent community-based interventions are needed to address these factors.

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ACT-FAST: a quality improvement project to increase the percentage of acute stroke patients receiving intravenous thrombolysis within 60 minutes of arrival at the emergency department

Singapore Medical Journal ◽

10.11622/smedj.2020040 ◽

2020 ◽

Author(s):

LQ Chiu ◽

DYJ Quek ◽

RB Salihan ◽

WM Ng ◽

RB Othman ◽

...

Keyword(s):

Emergency Department ◽

Quality Improvement ◽

Acute Stroke ◽

Intravenous Thrombolysis ◽

Quality Improvement Project ◽

Stroke Patients ◽

Improvement Project

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The Effect of Emergency Department Treatment Time on Outcomes in Acute Stroke Patients

The Korean Journal of Critical Care Medicine ◽

10.4266/kjccm.2010.25.2.76 ◽

2010 ◽

Vol 25 (2) ◽

pp. 76

Author(s):

Dong Wook Lee ◽

Eui Chung Kim ◽

Ok Jun Kim ◽

Sung Wook Choi ◽

Young Tae Park ◽

...

Keyword(s):

Emergency Department ◽

Acute Stroke ◽

Treatment Time ◽

Stroke Patients

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Abstract NS8: The Effects of Introducing a Nurse Practitioner Stroke Champion into the Emergency Department

Stroke ◽

10.1161/str.45.suppl_1.ns8 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Lindsay Olson-Mack ◽

Jacqueline Reardon ◽

Elton Hedden ◽

Rowena Carino ◽

Cynthia VanWyk ◽

...

Keyword(s):

Emergency Department ◽

Acute Stroke ◽

Nurse Practitioner ◽

Treatment Effectiveness ◽

Stroke Care ◽

Stroke Patients ◽

Acute Stroke Care ◽

Assessment And Treatment ◽

Iv Tpa

Background and Purpose: Emergency Department (ED) physicians often manage acute stroke patients without Neurology support at the bedside. Without guidance, they are left to rapidly assess, diagnose and treat acute stroke patients with minimal follow up on treatment effectiveness and patient outcomes. We hypothesized that introducing a Nurse Practitioner (NP) as Stroke Champion into an ED that did not have access to in-house Neurology would drive awareness of acute stroke care, and positively change practice to decrease door to needle times. Methods: The NP started in the 24-bed ED in June 2012. The average daily census of the ED for 2012 was 135 patients per day, and from January to June 2012, ED physicians initiated 46 stroke codes. Although Neurologists were available via telephone, ED physicians were left to accurately assess and initiate stroke codes, determine eligibility, and order IV tPA. In collaboration with the Stroke Medical Director, the Stroke NP conducted multiple education sessions regarding timing metrics in acute stroke care and door to tPA goals with ED clinicians, radiology, lab and pharmacy departments. Data was shared with stakeholders monthly to drive performance improvement initiatives. Results: Rapid improvements were made in all metrics. Mean time to CT first image improved by 19.3 minutes (37.3 to 18.0 minutes) in 6 months, and to 14.7 minutes in 1 year. CT result mean turn-around-time decreased by 19 minutes (from 54.0 to 29.1 minutes) in the first 6 months, and by 22.6 minutes (from 54.0 to 26.0 minutes) at 12 months. Likewise, laboratory result turn-around-times dramatically decreased by a mean of 15.9 minutes (54.4 to 38.5 minutes) over 6 months, and by a mean of 23 minutes (54.4 to 31.0 minutes) within 12 months. IV tPA treatment rates increased from 5% to 14.4% of all ischemic strokes. Door to IV tPA treatment times decreased by a mean of 33.9 minutes (104.5 to 70.6 minutes) in 6 months, and by 46.8 minutes (from 104.5 to 57.7 minutes) within the year. Conclusions: Introducing an NP into the ED to serve as Stroke Champion can provide added support to improve care of acute stroke patients by expediting assessment and treatment.

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