Abstract W P188: Achieving Sub-20min tPA Door-to-needle Times - the Importance of Patient Details on Prenotification and Point-of-care INR

Background and purpose: Institutions around the world have re-engineered acute stroke care to achieve dramatic reductions in tPA door-to-needle times (DNT). We investigated the effects of specific process elements on DNT. Methods: The “code stroke” system at Royal Melbourne Hospital was systematically evaluated and redesigned in 2012 to take patients directly from triage to CT on ambulance stretchers and deliver tPA on the CT table. We studied the 12 months post implementation data within business hours (when stroke team members were located in the hospital) for effects of variably utilized key components of the new system - ambulance pre-notification including patient name and date of birth (allowing transfer direct to CT), and point-of-care (POC)-INR. Results: In the 12 months post-implementation, 40/80 (50%) of patients who received tPA were treated in-hours. In-hours DNT reduced from pre-implementation median 43 min to 23 min (p<0.001). However, only 33% of the patients had full pre-notification including name and date of birth. In these patients median DNT was 16 min vs. pre-notification without personal details 22 min, p=0.02. Patients with no prenotification which prevented transfer direct to CT had significant delays (median DNT 51 min; p<0.001 vs prenotification). After-hours where the system remained unchanged there was no change in DNT (median 67 min vs. 65 min; p=0.87). Patients possibly taking warfarin previously required laboratory INR pre-tPA (median DNT 77 min; range 38-92 min). Subsequently 6/80 (7.5%) patients were treated after confirming sub-therapeutic POC-INR (25 min; range 14-34 min). Conclusions: Pre-notification and going direct to CT have the greatest impact in reducing treatment delays. Combined, these simple, resource-neutral procedures halved our median DNT. The optimal pre-notification includes patient details, allowing pre-registration, pre-ordering of CT, and access to prior medical history during transport. POC-INR is helpful in select patients.