62 Utilizing BEFAST to Implement “Direct to CT” Stroke Algorithm at Triage Decreases Door to CT Perform Time in Emergency Department

Abstract

In early 2019, the American Heart Association released “Target Stroke: Phase III” which set a primary goal to achieve door-to-needle times within 60 minutes in 85 percent or more of acute ischemic stroke patients treated with IV thrombolytics. Obtaining a Head Computed Tomography (CT) Scan is the rate limiting step in the process of administering IV thrombolytics in the emergency department (ED). Emergency Medical Services (EMS) pre-notification “Direct to CT” (DCT) is one of several interventions recommended as a best practice to streamline this process. However, DCT protocols existed only for 9% of our ED stroke population whom arrived via EMS pre-notification. A new Triage DCT algorithm was implemented May 15, 2019 to address this treatment gap. Triage DCT leverages nursing use of the Balance-Eyes-Face-Arms-Speech-Time (BEFAST) scale to identify stroke patients at triage. This study retrospectively evaluates reductions from Triage DCT in (i) door to CT performed and (ii) door to Tissue Plasminogen Activator (tPA) administered. This study occurred from May 15, 2019 to December 31, 2019 in a tertiary, urban ED with 50,000 visits/year. Prior to implementation, all ED nurses were educated during daily in-person briefs on the use of the BEFAST scale to identify potential stroke patients and initiate DCT at triage. Mock drills were simulated to prepare staff. All ED patients who activated a stroke code and had stroke symptoms onset prior to their arrival were sampled for retrospective chart review. Patients less than 18 years old or who declined interventions were excluded. All data was recorded in a secure database and included time stamps of a patient’s arrival, Head CT performed, and tPA administered, in addition to their mode of arrival and final disposition. A two - tail T-test was used to determine significance in reductions between (i) Triage DCT (ii) EMS DCT and (iii) No DCT (baseline). A 2-sided alpha level of less than 0.05 was considered statistically significant. Of 609 patients, 54 (8.9%) were EMS DCT and 151 (24.7%) were Triage DCT. Baseline mean door to CT performed was 26 minutes compared to 6 (p = 0.000) for EMS DCT and 10 (p = 0.000) for Triage DCT. Of 609 patients, 30 (4.9%) received tPA. 11 (36.6%) were EMS DCT and three (10%) were Triage DCT. Baseline mean door to tPA administered was 59 minutes compared to 34 (p = 0.035) for EMS DCT and 71 (p = 0.727) for Triage DCT. Triage DCT reduced mean door to CT performed (p=0.000) as significantly as EMS DCT. A comparable mean door to tPA administered reduction was not seen. It is possible a larger sample size would support such a difference.