Abstract WP236: The Acute Ischemic Stroke Process in the Emergency Department: Improving Door to Needle Times and Advancing Best Practice
Background The Acute Ischemic Stroke (AIS) process of care in the emergency department (ED) continues to evolve with interventions that help expedite administration of tPA and decrease “Door-to-Needle” (DTN) time and the burden associated with AIS. We hypothesized that redesigning the ED stroke process using selected best practice strategies would increase the percentage of patients receiving tPA in under 60 minutes, increase the percentage of patients treated with tPA within 4.5 hours, decrease the mean DTN time, and increase the percentage of stroke code activations (Code S) that occur in under 15 minutes. The variables implemented in the AIS process were analyzed for correlation of impact on decreasing DTN time.
Methods The team mapped current AIS processes and developed an initiative to redesign the process including developing an AIS treatment room, a “stroke clot box” for storing and mixing tPA at bedside, and NIHSS certification of leadership staff. Multiple regression analysis of the correlation of these strategies as well as the presence of an in-house neurologist and EMS pre-notification on DTN time was performed.
Results The initiatives increased the percentage of AIS patients treated with tPA within 4.5 hours from 67% to 100%. AIS patients treated under 60 minutes increased from 50% to 65%. The mean DTN time has decreased from 88.4 to 54.1 minutes. Of patients treated with tPA under 60 minutes (n=11) the mean DTN time was 40.6 minutes (lowest DTN time of 24 minutes). Code S activations within 15 minutes increased by 14 % to 47.8%. Multiple Regression analysis revealed that the presence of an in-house neurologist had the highest correlation (β=0.810, p=0.001) with lower DTN times, followed by using a "stroke clot box" (β=0.631, p=0.008) and a dedicated AIS treatment room (β=0.244, p=0.03). EMS pre-notification was done for nearly every tPA treated patient and its impact was therefore negligible (β=0.05, p=0.2).
Conclusions These initiatives increased the number of patients treated, decreased mean DTN time, and increased the percentage of tPA eligible AIS patients within 60 minutes. An in-house neurologist, tPA at bedside, and a dedicated treatment room correlate with lower DTN times and therefore advance best practice for acute stroke care.
- © 2012 by American Heart Association, Inc.