Reducing Door-To-Needle Times for Treatment of Acute Ischemic Stroke: Quality Improvement Initiative at a High Volume Comprehensive Stroke Center (P4.309)
2015
OBJECTIVE: To describe QI initiative in reducing DTN time.
BACKGROUND:
Earlier intra-venous tissue-type plasminogen activator (tPA) treatment for acute ischemic stroke increases efficacy and safety. We describe interventions to reduce door-to-needle times (DTN) for tPA at Erlanger Medical Center.
MATERIAL AND METHODS:
All consecutive ischemic stroke patients who received tPA were retrospectively and prospectively registered in stroke registry. A series of interventions to reduce treatment delays were implemented as follows:
• Pre hospital:
- Extensive EMS education and feedback
- MENDS replaced by FAST
- Focus on pertinent info- time of onset/last seen normal /OAC status
• Emergency Department (ED):
- ED RN education-Stroke recognition by FAST protocol
- Bypass ED: when appropriate
- ‘Code Stroke’: pre existing -reinforced
- Focused /Pertinent information gathering for tPA :
- Trauma Model: evaluation/labs/EKG/CT in parallel
- ‘Stroke bag’
• CT/Lab:
- Priority CT for ‘code stroke’ pre-existing
- ‘Stroke alert ‘ label for all labs (PT/INR)
• Stroke Team:
- 24hrs; 7days In-house attending stroke neurologist starting April 2013
- CT interpretation and tPA order by stroke neurologist at the CT table before advanced imaging
In-hospital delays were analyzed as annual mean/median DTN time with inter quartile range (IQR)
RESULTS:
A total of 356 patients received IV-tPA between 2011 to 2014.The DTN was reduced annually, from mean 97minutes (median57;IQR 115-73) in 2011, to 41 minutes (median35;IQR 58-20) in 2014.
Similarly, the onset-to-treatment time (OTT) was reduced annually, from mean 174 minutes in 2011 to 142 minutes in 2014.
In 2013, 16.5[percnt] of ischemic stroke patients admitted to our hospital were treated (from 4.2[percnt] in 2011). The in-hospital mortality, LOS (length of stay) and sICH (symptomatic ICH) were not adversely affected.
CONCLUSION:
With multiple institution specific interventions it is possible to improve the DTN time even at a high volume non-academic center. One of the key component appears to be the in-house presence of a stroke neurologist 24hours /7days a week. Disclosure: Dr. Sapkota has nothing to disclose. Dr. Sirelkhatim has nothing to disclose. Dr. Devlin has received personal compensation for activities with Concentric Medical, Inc. as a consultant. Dr. Pitiyanuvath has nothing to disclose. Dr. Dellinger has nothing to disclose. Dr. Fesmire has nothing to disclose.
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