Reducing Door-To-Needle Times for Treatment of Acute Ischemic Stroke: Quality Improvement Initiative at a High Volume Comprehensive Stroke Center (P4.309)

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.