Background and Purpose:
The AHA/ASA Stroke Guidelines recommend intravenous Recombinant Tissue Plasminogen Activator (rtPA) within 60 min from hospital arrival in eligible patients. Patient outcomes are time dependent and require a multidisciplinary approach between the hospital and Emergency Medical Services (EMS). In 2012, we implemented a process improvement initiative that included pre-hospital EMS lab draws, emergency department (ED) patient flow changes, immediate physician evaluation and EMS direct transport to CT. The purpose of this project was to improve stroke care by minimizing door to needle time (DTN) in patients with acute ischemic stroke.
Methods:
We used the Plan-Do-Check-Act method of performance improvement in our implementation process. A multidisciplinary performance Improvement team was established which included EMS, ED Laboratory, and Imaging participants. The four highest volume EMS stations were chosen to participate in the pilot process improvement strategy. Education was provided to EMS, ED physicians and staff, radiology, laboratory and patient registration personnel. Concurrent review of 100% of the stroke alert cases was conducted. We analyzed the door to CT result, the door to laboratory result and the DTN time for the four pilot stations. Based on the results, the decision was made to extend this process countywide.
Results:
Twenty-nine patients were enrolled in the pilot, and 15 labs were successfully drawn in the field for an average door to result time of 30.4 min. Fourteen labs were drawn on arrival for an average of 46.6 min. The door to CT result for the patients sent directly to CT by EMS was an average of 16 min. Seven out of the 29 patients were diverted to a room, and their average door to result was 30.6 min. Four patients received IV rtPA with an average DTN time of 47 min, and 100% of the 4 patients received IV rtPA within 60 min. During the same time period, IV rtPA was given to 9 patients that were not in the pilot for an average DTN of 61 min, and only 5/9 (55%) received IV rtPA within 60 min.
Conclusion:
The performance improvement initiative decreased our door to lab result, door to CT result and DTN time in this small sample and was implemented county wide.
