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Greenberg K, Veznedaroglu E, Liebman K, Hakma Z, Kurtz T, Binning M. Stroke thrombolysis given by emergency physicians: The time is here. Am J Emerg Med 2023; 68:98-101. [PMID: 36963177 DOI: 10.1016/j.ajem.2023.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/10/2023] [Accepted: 03/16/2023] [Indexed: 03/19/2023] Open
Abstract
Emergency Medicine core clinical privileges include administration of thrombolytic therapy for myocardial infarction and stroke. However, emergency medicine providers have created their own paradigm to rely on neurology specialty consultation to treat acute stroke patients. A 2013 study supported by the American Academy of Neurology showed an 11% shortage of neurologists at that time and projected a 19% shortage by 2025. The lack of neurologists is a worldwide problem. To help ease the shortage, teleneurology and telestroke care has been implemented by neurologists, most notably for acute ischemic stroke (AIS) patients. We present a model in which an Emergency Medicine (EM) Stroke Champion (SC); an EM physician within our Neurologic Emergency Department, directs care for acute stroke patients at our comprehensive hub and primary stroke center spoke hospitals. The SCs independently treat patients with fibrinolytic therapy and provide teleneurology to fellow emergency physicians caring for acute stroke patients at spoke hospitals. Over nineteen months the SCs received 457 phone calls for patients meeting stroke alert criteria. Sixteen patients were deemed eligible for IV alteplase with one hemorrhagic conversion (6.25%). Sixty-four patients required transfer, and this was facilitated by the SCs. The concept of emergency physician SCs providing teleneurology consultation to other fellow emergency physicians was found to be feasible and safe. This model has the potential to be generalized not to just stroke champions, but to all emergency physicians to feel both confident and comfortable treating acute stroke patients.
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Affiliation(s)
- Karen Greenberg
- Drexel Neurosciences Institute, Drexel University College of Medicine, Department of Neurosurgery, Global Neurosciences Institute, 10 NJ-31 North, Pennington, NJ 08534, United States of America.
| | - Erol Veznedaroglu
- Drexel Neurosciences Institute, Drexel University College of Medicine, Department of Neurosurgery, Global Neurosciences Institute, 10 NJ-31 North, Pennington, NJ 08534, United States of America
| | - Kenneth Liebman
- Drexel Neurosciences Institute, Drexel University College of Medicine, Department of Neurosurgery, Global Neurosciences Institute, 10 NJ-31 North, Pennington, NJ 08534, United States of America
| | - Zakaria Hakma
- Drexel Neurosciences Institute, Drexel University College of Medicine, Department of Neurosurgery, Global Neurosciences Institute, 10 NJ-31 North, Pennington, NJ 08534, United States of America
| | - Thomas Kurtz
- Drexel Neurosciences Institute, Drexel University College of Medicine, Department of Neurosurgery, Global Neurosciences Institute, 10 NJ-31 North, Pennington, NJ 08534, United States of America
| | - Mandy Binning
- Drexel Neurosciences Institute, Drexel University College of Medicine, Department of Neurosurgery, Global Neurosciences Institute, 10 NJ-31 North, Pennington, NJ 08534, United States of America
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Yuan G, Xia H, Xu J, Long C, Liu L, Huang F, Zeng J, Yuan L. Reducing intravenous thrombolysis delay in acute ischemic stroke through a quality improvement program in the emergency department. Front Neurol 2022; 13:931193. [PMID: 36226088 PMCID: PMC9548581 DOI: 10.3389/fneur.2022.931193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/26/2022] [Indexed: 11/14/2022] Open
Abstract
Objective This study aims to investigate the effectiveness of a quality improvement program for reducing intravenous thrombolysis (IVT) delay in acute ischemic stroke (AIS). Materials and methods We implement a quality improvement program consisting of 10 interventions for reducing IVT delay, including the establishment of an acute stroke team, standardized management of stroke teams, popularization of stroke and its treatment, emergency bypass route (BER), the achievement of computed tomography (CT) priority, no-delay CT interpretation, intravenous thrombolysis on the CT table, payment after treatment, whole recording, and incentive policy. We retrospectively analyzed the clinical time and outcome data of AIS patients treated with IVT in pre-intervention (108 patients) and post-intervention groups (598 patients), and further compared the differences between the non-emergency bypass route (NBER) and BER in the post-intervention group. Results The thrombolysis rate increased from ~29% in the pre-intervention group to 48% in the post-intervention group. Compared with the pre-intervention group, the median of door-to-needle time (DNT) was greatly shortened from 95 to 26 min (P < 0.001), door-to-CT time (DCT) was noticeably decreased from 20 to 18 min (P < 0.001), and onset-to-needle time (OTT) significantly declined from 206 to 133 min (P = 0.001). Under the new mode after the intervention, we further analyzed the IVT delay difference between the NBER (518 patients) and BER groups (80 patients) from the post-intervention group. The median values of DNT (18 vs. 27 min, P < 0.001), DCT (10 vs. 19 min, P < 0.001), and OTT (99 vs. 143 min, P < 0.001) showed significant reductions in the BER group. The quality improvement program under the emergency platform successfully controlled the median of DNT to within 26 min. Conclusions Collectively, the BER mode is a feasible scheme that greatly decreased DNT in AIS patients, and the secret to success was to accomplish as much as possible before the patient arrives at the emergency room.
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Affiliation(s)
- Guangxiong Yuan
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Hong Xia
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Jun Xu
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Chen Long
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Lei Liu
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Feng Huang
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Jianping Zeng
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, China
- *Correspondence: Jianping Zeng
| | - Lingqing Yuan
- National Clinical Research Center for Metabolic Diseases, Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Lingqing Yuan
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Espiritu AI, San Jose MCZ. A Call for a Stroke Referral Network Between Primary Care and Stroke-Ready Hospitals in the Philippines: A Narrative Review. Neurologist 2021; 26:253-260. [PMID: 34734903 DOI: 10.1097/nrl.0000000000000357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The increasing stroke burden, inequity in the distribution of local neurologists, and the recent signing of the Universal Health Care Law in the Philippines provide compelling reasons for policy-makers to devise strategies to establish networks between primary care and stroke-ready hospitals. In this review, we explored the current literature and evidence that emphasized the roles of primary care providers (PCPs) and specialists, care transition, and telemedicine/teleneurology in various stages of stroke management. REVIEW SUMMARY Clear delegation of stroke care responsibilities among PCPs and specialists is needed. Due to the limited number of specialists/neurologists, PCPs may contribute to addressing the insufficiency of community knowledge of acute stroke symptoms/risk factors, coordination with specialists and stroke-ready hospitals during acute stroke, and continuity of care during the poststroke stage. At present, the Philippines has only 49 stroke-ready hospitals; thus, an efficient and functional referral system for the care transition between the PCPs and specialists must be organized in our country. To provide remote access to expert stroke care for underserved areas and to increase thrombolysis utilization, the establishment of an effective telestroke system is indispensable. The empowerment of PCPs in teleneurology may assist in strengthening communication and networking with specialists with the ultimate goal of improving patient outcomes. CONCLUSIONS In the era of Universal Health Care in the Philippines, the roles of PCP and specialists must be delineated. Increased access to stroke care through the establishment of networks among PCPs and stroke-ready hospitals (ie, via effective transition of care/teleneurology) must be prioritized especially in resource-constrained settings.
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Affiliation(s)
- Adrian I Espiritu
- Department of Neurosciences, Philippine General Hospital and College of Medicine
- the Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Maria Cristina Z San Jose
- Department of Neurosciences, Philippine General Hospital and College of Medicine
- the Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Manila, Philippines
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Greenberg K, Hedayat HS, Binning MJ, Veznedaroglu E. Innovations in Care Delivery of Stroke from Emergency Medical Services to the Neurointerventional Operating Room. Neurosurgery 2019; 85:S18-S22. [PMID: 31197327 DOI: 10.1093/neuros/nyz021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 01/28/2019] [Indexed: 01/01/2023] Open
Abstract
Acute ischemic stroke (AIS) and its care is currently one of the most dynamic and evolving illnesses across the globe. Among the most crucial factors in providing the best care to patients are the expedient delivery of thrombolytics and endovascular intervention when indicated. Here, we review our unique model of efficient care centered in our innovative Neurological Emergency Department (Neuro ED). The Neuro ED acts as our hub for EMS communication, imaging, administration of intravenous alteplase, and transition to the Neurointerventional OR. Our structure with its enabling of shortened IV alteplase delivery times and faster door-to-needle (DTN) times may serve as an international model for stroke centers.
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Affiliation(s)
- Karen Greenberg
- Department of Neurosurgery, Global Neurosciences Institute, Philadelphia, Pennsylvania
| | - Hirad S Hedayat
- Department of Neurosurgery, Global Neurosciences Institute, Philadelphia, Pennsylvania
| | - Mandy J Binning
- Department of Neurosurgery, Global Neurosciences Institute, Philadelphia, Pennsylvania
| | - Erol Veznedaroglu
- Department of Neurosurgery, Global Neurosciences Institute, Philadelphia, Pennsylvania
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Jauch EC, Holmstedt CA. Fast Protocol for Treating Acute Ischemic Stroke by Emergency Physicians: What Took So Long? Ann Emerg Med 2018; 73:113-115. [PMID: 30420233 DOI: 10.1016/j.annemergmed.2018.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Edward C Jauch
- Mission Research Institute/Mission Health System, Asheville, NC.
| | - Christine A Holmstedt
- Departments of Neurology and Emergency Medicine, MUSC Health Comprehensive Stroke Program, and MUSC Health Teleneuroscience Program, Medical University of South Carolina, Charleston, SC
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Heikkilä I, Kuusisto H, Holmberg M, Palomäki A. Fast Protocol for Treating Acute Ischemic Stroke by Emergency Physicians. Ann Emerg Med 2018; 73:105-112. [PMID: 30236416 DOI: 10.1016/j.annemergmed.2018.07.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 06/01/2018] [Accepted: 06/25/2018] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE Thrombolysis with tissue plasminogen activator should occur promptly after ischemic stroke onset. Various strategies have attempted to improve door-to-needle time. Our objective is to evaluate a strategy that uses an emergency physician-based protocol when no stroke neurologist is available. METHODS This was a retrospective before-after intervention analysis in an urban hospital. Reorganization of the acute ischemic stroke treatment process was carried out in 2013. We evaluated time delay, symptomatic intracerebral hemorrhage, and clinical recovery of patients before and after the reorganization. We used multivariable linear regression to estimate the change in door-to-needle time before and after the reorganization. RESULTS A total of 107 patients with comparable data were treated with tissue plasminogen activator in 2009 to 2012 (group 1) and 46 patients were treated during 12 months in 2013 to 2014 (group 2). Median door-to-needle time was 54 minutes before the reorganization and 20 minutes after it (statistical estimate of difference 32 minutes; 95% confidence interval 26 to 38 minutes). After adjusting for several potential cofounders in multivariable regression analysis, the only factor contributing to a significant reduction in delay was group (after reorganization versus before). Median onset-to-treatment times were 135 and 119 minutes, respectively (statistical estimate of difference 23 minutes; 95% confidence interval 6 to 39 minutes). The rates of symptomatic intracerebral hemorrhage were 4.7% (5/107) and 2.2% (1/46), respectively (difference 2.5%; 95% confidence interval -8.7% to 9.2%). Approximately 70% of treated patients were functionally independent (modified Rankin Scale score 0 to 2) when treated after the reorganization. CONCLUSION Implementation of a stroke protocol with emergency physician-directed acute care decreased both door-to-needle time and onset-to-treatment time without increasing the rate of symptomatic intracerebral hemorrhage.
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Affiliation(s)
- Iiro Heikkilä
- Department of Emergency Medicine, Kanta-Häme Central Hospital, Hämeenlinna, Finland.
| | - Hanna Kuusisto
- Department of Neurology, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - Markus Holmberg
- Department of Emergency Medicine, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - Ari Palomäki
- Department of Emergency Medicine, Kanta-Häme Central Hospital, Hämeenlinna, Finland; Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
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Tan BY, Ngiam NJ, Sunny S, Kong WY, Tam H, Sim TB, Leong BS, Bhartendu C, Paliwal PR, Seet RC, Chan BP, Teoh HL, Sharma VK, Yeo LL. Improvement in Door-to-Needle Time in Patients with Acute Ischemic Stroke via a Simple Stroke Activation Protocol. J Stroke Cerebrovasc Dis 2018; 27:1539-1545. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.01.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 11/30/2017] [Accepted: 01/01/2018] [Indexed: 12/26/2022] Open
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Huang Q, Zhang JZ, Xu WD, Wu J. Generalization of the right acute stroke promotive strategies in reducing delays of intravenous thrombolysis for acute ischemic stroke: A meta-analysis. Medicine (Baltimore) 2018; 97:e11205. [PMID: 29924046 PMCID: PMC6024468 DOI: 10.1097/md.0000000000011205] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The generalization of successful efforts for reducing time delays in intravenous thrombolysis (IVT) could help facilitate its utility and benefits in acute ischemic stroke (AIS) patients.We searched the PubMed and Embase databases for articles reporting interventions to reduce time delays in IVT, published between January 1995 and September 2017. The IVT rate was chosen as the primary outcome, while the compliance rates of onset-to-door time (prehospital delay) and door-to-needle time (in-hospital delay) within the targeted time frame were the secondary outcomes. Interventions designed to reduce prehospital, in-hospital, or total time delays were quantitatively described in meta-analyses. The efficacy of postintervention improvement was illustrated as odds ratios (ORs) and 95% confidence intervals (95% CIs).In total, 86 papers (17 on prehospital, 56 on in-hospital, and 13 on total delay) encompassing 17,665 IVT cases were enrolled, including 28 American, 23 Asian, 30 European, and 5 Australian studies. The meta-analysis revealed statistically significant improvement in promoting IVT delivery after prehospital improvement interventions with an OR of 1.45 (95% CI, 1.23-1.71) for the new transportation protocol, 1.38 (95% CI, 1.11-1.73) for educational and training programs, and 1.83 (95% CI, 1.44-2.32) for comprehensive prehospital stroke code. The benefits of reducing in-hospital delay were much greater in developed western countries than in Asian countries, with ORs of 2.90 (95% CI, 2.51-3.34), 2.17 (95% CI, 1.95-2.41), and 1.89 (95% CI, 1.74-2.04) in American, European, and Asian countries, respectively. And telemedicine (OR, 2.26; 95% CI, 2.08-2.46) seemed to work better than pre-notification alone (OR, 1.94; 95% CI, 1.74-2.17) and in-hospital organizational improvement programs (OR, 2.10; 95% CI, 1.97-2.23). Mobile stroke treatment unit and use of a comprehensive stroke pathway in the pre- and in-hospital settings significantly increased IVT rates by reducing total time delay, with ORs of 2.01 (95% CI, 1.60-2.51) and 1.77 (95% CI, 1.55-2.03), respectively.Optimization of the work flow with organizational improvement or novel technology could dramatically reduce pre- and in-hospital time delays of IVT in AIS. This study provided detailed information on the net and quantitative benefits of various programs for reducing time delays to facilitate the generalization of appropriate AIS management.
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Affiliation(s)
- Qiang Huang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
| | - Jing-ze Zhang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
| | - Wen-deng Xu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
| | - Jian Wu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
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Chang BP, Rostanski S, Willey J, Kummer B, Miller E, Elkind M. Can I Send This Patient with Stroke Home? Strategies Managing Transient Ischemic Attack and Minor Stroke in the Emergency Department. J Emerg Med 2018; 54:636-644. [PMID: 29321107 PMCID: PMC6446571 DOI: 10.1016/j.jemermed.2017.12.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 11/05/2017] [Accepted: 12/01/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND While transient ischemic attack and minor stroke (TIAMS) are common conditions evaluated in the emergency department (ED), there is controversy regarding the most effective and efficient strategies for managing them in the ED. Some patients are discharged after evaluation in the ED and cared for in the outpatient setting, while others remain in an observation unit without being admitted or discharged, and others experience prolonged and potentially costly inpatient admissions. OBJECTIVE OF THE REVIEW The goal of this clinical review was to summarize and present recommendations regarding the disposition of TIAMS patients in the ED (e.g., admission vs. discharge). DISCUSSION An estimated 250,000 to 300,000 TIA events occur each year in the United States, with an estimated near-term risk of subsequent stroke ranging from 3.5% to 10% at 2 days, rising to 17% by 90 days. While popular and easy to use, reliance solely on risk-stratification tools, such as the ABCD2, should not be used to determine whether TIAMS patients can be discharged safely. Additional vascular imaging and advanced brain imaging may improve prediction of short-term neurologic risk. We also review various disposition strategies (e.g., inpatient vs. outpatient/ED observation units) with regard to their association with neurologic outcomes, such as 30-day or 90-day stroke recurrence or new stroke, in addition to other outcomes, such as hospital length of stay and health care costs. CONCLUSIONS Discharge from the ED for rapid outpatient follow-up may be a safe and effective strategy for some forms of minor stroke without disabling deficit and TIA patients after careful evaluation and initial ED workup. Future research on such strategies has the potential to improve neurologic and overall patient outcomes and reduce hospital costs and ED length of stay.
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Affiliation(s)
- Bernard P Chang
- Department of Emergency Medicine, Columbia University Medical Center, New York, New York
| | - Sara Rostanski
- Department of Neurology, New York University, New York, New York
| | - Joshua Willey
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Benjamin Kummer
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Eliza Miller
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Mitchell Elkind
- Department of Neurology, Columbia University Medical Center, New York, New York
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Lesenskyj AM, Maxwell CR, Veznedaroglu E, Liebman K, Hakma Z, Binning MJ. An Analysis of Transient Ischemic Attack Practices: Does Hospital Admission Improve Patient Outcomes? J Stroke Cerebrovasc Dis 2016; 25:2122-5. [PMID: 27450386 DOI: 10.1016/j.jstrokecerebrovasdis.2016.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 06/03/2016] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Immediate treatment has been shown to decrease the recurrence of cerebrovascular accidents following transient ischemic attacks (TIA), prompting the use of a specialized neurologic emergency department (Neuro ED) to triage patients. Despite these findings, there is little evidence supporting the notion that hospital admission improves post-TIA outcomes. Through the lens of a Neuro ED, this retrospective chart review of TIA patients examines whether hospital admission improves 90-day outcomes. MATERIALS AND METHODS Two hundred sixty charts of patients discharged with TIA diagnosis were reviewed. These charts encompassed patients with TIA who presented to a main emergency department (ED) or Neuro ED from January 2014 to April 2015. Demographic information, admission ABCD(2) scores, admission National Institutes of Health Stroke Scale scores, and admission Modified Rankin Scale, and reason for any return visits within 90 days were collected. RESULTS This review shows that patients triaged by the Neuro ED were admitted at a lower rate than those seen by the standard ED. Further, patients triaged by the Neuro ED experienced lower readmission and recurrence of stroke or TIA within 90 days. CONCLUSIONS These results provide preliminary support for the notion that discharging appropriate TIA patients, with adequate follow-up, will not adversely affect the recurrence of TIA or stroke within 90 days.
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Affiliation(s)
- Alexandra M Lesenskyj
- Drexel University College of Medicine, Drexel Neurosciences Institute, Philadelphia, Pennsylvania
| | - Christina R Maxwell
- Drexel University College of Medicine, Drexel Neurosciences Institute, Philadelphia, Pennsylvania
| | - Erol Veznedaroglu
- Drexel University College of Medicine, Drexel Neurosciences Institute, Philadelphia, Pennsylvania
| | - Kenneth Liebman
- Drexel University College of Medicine, Drexel Neurosciences Institute, Philadelphia, Pennsylvania
| | - Zakaria Hakma
- Drexel University College of Medicine, Drexel Neurosciences Institute, Philadelphia, Pennsylvania
| | - Mandy J Binning
- Drexel University College of Medicine, Drexel Neurosciences Institute, Philadelphia, Pennsylvania.
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Busby L, Owada K, Dhungana S, Zimmermann S, Coppola V, Ruban R, Horn C, Rochestie D, Khaldi A, Hormes JT, Gupta R. CODE FAST: a quality improvement initiative to reduce door-to-needle times. J Neurointerv Surg 2015; 8:661-4. [DOI: 10.1136/neurintsurg-2015-011806] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 06/02/2015] [Indexed: 11/04/2022]
Abstract
BackgroundRapid delivery of IV tissue plasminogen activator (tPA) in qualifying patients leads to better clinical outcomes. The American Heart Association has reduced target door-to-needle (DTN) times from 60 to 45 min in the hopes of continued process improvements across institutions.ObjectiveTo start a quality improvement project called CODE FAST in order to reduce DTN times at our institution.Materials and methodsWe retrospectively reviewed data from our internally maintained database of patients treated with intravenous tPA before and after implementation of the CODE FAST protocol. We assessed demographic information, time of day and times of arrival to first image and delivery of tPA in patients from February 2014 to February 2015. Outcomes were assessed based on discharge to home. Univariate analysis was performed to assess for improvement in DTN times before and after implementation of the protocol.ResultsA total of 93 patients (41 pre-CODE FAST and 52 post-CODE FAST) received IV tPA during the study period. Patients were equally matched between the two groups except that in the pre-CODE FAST era patients receiving tPA were younger and more likely to be men. There was a substantial reduction in door-to-imaging time from a median of 16 to 8 min (p<0.0001) and DTN time with a reduction in the median from 62 to 25 min (p<0.0001). In logistic regression modeling, there was a trend towards more discharges to home in patients treated during the CODE FAST era.ConclusionsWe present a quality improvement project that has been overwhelmingly successful in reducing DTN time to <30 min. The template we present may be helpful to other institutions looking to reduce their DTN times and may also reduce costs as we note a trend towards more discharges to home.
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