Abstract 179: Development and Initial Results of an Inclusive State-Wide Approach to Stroke Care

Introduction Though tPA was FDA approved for treatment of ischemic stroke in 1996, only ∼2% of patients receive thrombolysis and 64% of US hospitals do not administer the drug. Within a hospital, stroke-specific protocols increase the number of treated patients, shorten door-to-needle times, and improve outcomes. Regional systems of care can provide patient transport to hospitals ready and willing to treat with tPA. Stroke transport policies in urban areas typically suggest EMS bypass hospitals not certified as primary stroke centers (PSCs). In Utah, transport times to PSCs often exceed the 3-4.5 hour tPA window; thus UT stroke leaders felt that a system consisting primarily of bypassing non-PSC hospitals would not benefit the public. Methods In 2008-9, UT stroke leaders developed a statewide transport system to improve stroke care statewide. Leaders included all stakeholders: the UT Stroke Task Force, PSC Stroke Directors, the UT Hospital Association, the AHA, and the Bureau of EMS. We developed an inclusive spoke-and-hub system to enable rapid transport of stroke patients to facilities that provide appropriate acute care. PSCs act as hubs. Spokes, or Stroke Receiving Facilities (SRFs), are hospitals in surrounding communities that voluntarily agree to establish standard stroke care in their Emergency Departments (EDs). All 5 PSCs agreed to provide 24/7 expert neurologic consultation by phone to surrounding SRFs. SRF criteria include: 1) a 24/7 stroke team (nurse and ED physician or neurologist with physician certification in the NIHSS) and local stroke protocols including consultation plan (phone or telestroke) for those without onsite expertise. 2) 24/7 CT and lab services, resulted within 45 minutes. 3) Designation of a physician stroke director and nurse stroke coordinator. 5) Collection of outcome measures and quality improvement activities, including a minimal data set submitted quarterly to the Bureau of EMS. 6) Ongoing, stroke-specific continuing education. To aid hospitals, a Stroke Tool Kit was developed and distributed. It included: EMS and ED assessment and management guidelines; sample stroke protocol algorithms and transfer protocols; tPA criteria, dosing chart, and mixing instructions; the NIHSS; and educational resources. A hospital of any size and location may apply for SRF designation. Designation occurs after a site visit by a team of stroke experts and the Bureau of EMS, who verify that required systems are in place. After designation, local EMS agencies are notified that the SRF is “stroke ready” to receive acute stroke patients. Results SRF designation began in 1/2010. There are now 20 SRFs, ranging in size from an 11 bed rural hospital to a 300 bed urban hospital. We estimate that 90% of the UT population is now within 30 minute access to either a PSC or an SRF. Quarterly 2011 data shows that mean door-to-CT read time in SRFs is 24-31 minutes. Of patients presenting to an SRF within the 3 hour window, 55.1% (49/89) are eligible for tPA; 1/2 of these have received IV tPA, a marked improvement over the national average. Ongoing quality improvement efforts are to identify additional treatment barriers, engage remaining hospitals, and determine outcomes statewide.