Abstract 101: A Learning Collaborative Model to Improve Door to Needle Time for Stroke Thrombolysis in Chicago

Abstract

Background: Door-to-needle (DTN) times have remained suboptimal despite overall increases in tissue plasminogen activator use (tPA) for stroke in Chicago. The American Heart Association’s (AHA) Quality Enhancement for Speedy Thrombolysis in Stroke (QUESTS) initiative aimed to identify barriers to reduce DTN times at Chicago’s 15 primary stroke centers (PSCs) and increase the proportion of patients treated with tPA within 60 minutes of hospital arrival. Methods: Starting in January 2013, we used face-to-face and on-site meetings with each PSC’s stroke team members to share AHA Target Stroke best practices and strategies to reduce DTN time. A survey of current practice was completed at each site to determine opportunities for improvement and repeated at 1 year to assess implementation of new strategies. We used the Get With The Guidelines (GWTG) Stroke registry to aggregate baseline data DTN times and track performance in each quarter of 2013. Results: At baseline, 5 strategies were notably under-utilized at Chicago’s 15 PSCs: 1) Direct to CT scanner (baseline: 0 sites; 1 year: 5 sites); 2) pre-mixing tPA (baseline: 1 site; 1 year: 14 sites); 3) tPA prior to laboratory results (baseline: 3 sites; 1 year: 7 sites); 4) stroke code activation at triage (baseline: 4 sites; 1 year: 13 sites); and 5) streamlined consent process (baseline: 0 sites; 1 year: 12 sites. The proportion of patients treated within 60 minutes increased in each quarter of 2013 from 25% in quarter 1 to 60% in quarter 4 (p<0.01). The median DTN time decreased from 89.5 minutes in quarter 1 to 55 minutes in quarter 4 (p<0.01). Conclusions: Using a learning collaborative model to implement strategies to reduce DTN times among 15 PSCs in Chicago, we observed major improvements within a few months. Regional collaboration and best practices sharing should be a model for rapid and sustainable system-wide quality improvement.