Reduction of IV Thrombolytic Door-to-Needle Times for Acute Ischemic Stroke Patients

Because stroke is a leading cause of death, the American Heart Association and American Stroke Association have implemented the national quality improvement initiative, “Target Stroke,” to improve the care of stroke patients. Target Stroke focuses on reducing door-to-needle times in acute ischemic stroke patients and on increasing the portion of eligible patients who receive “clot busting” thrombolytic therapy within 60 minutes after hospital arrival.

To maximize the clinical benefit for the acute ischemic stroke population, Marshfield Medical Center began a focused initiative to shorten door-to-needle time for IV thrombolytic administration. The project was led by the Stroke Performance Improvement Team and required a collaborative effort by clinicians from neurology, emergency medicine, radiology, laboratory, pharmacy, EMS and administrative staff. 

To decrease the overall time from patient entry to IV thrombolytic administration within the 60-minute “Target Stroke” timeframe, the following Code Stroke time goals were set, and each phase of the process was examined to identify improvement opportunities to meet these goals: 

Code Stroke Time Goals:

Door to MD  - 5 minutes
Door to Code Stroke  -  10 minutes
Door to CT  -  15 minutes
Door to CT Report  -  25 minutes
Door to ISTAT PT/INR -  20 minutes

“Code Stroke” protocol modifications were made to help achieve these time goals.
 

• Pre-hospital notification by EMS.  
• Education provided to EMS providers and medical transporters regarding warning signs and recommended EMS response to suspected stroke.
• Activation of “Code Stroke” team via pager.
• Stroke patients triaged directly to the CT scanner for initial neurologic examination and brain imaging to determine thrombolytic eligibility. In some scenarios, patients transfer directly from the ambulance bay to CT.
• ISTAT to measure international normalized ratio for anticoagulated patients. Glucose testing by EMS in the field or prior to arrival as applicable.
• Thrombolytic mixing and administration in the CT scanner, as soon as hemorrhage ruled out by neurologist. Recently, the conversion was made in the thrombolytic medication from Alteplase to Tenectaplase to simplify the administration process.

For continuous improvement, the multidisciplinary Stroke Performance Improvement Team reviews all Code Stroke patient cases and target time data to identify further opportunity for additional provider/staff/EMS education or modification of stroke protocols. The data is also shared with all stakeholders and improvements are celebrated by the stroke care team.