Abstract 3373: Fibrinolytic Therapy in a Community Hospital: the Same Old Protocol with a New Perspective

Abstract

Background: In 2007 Union Memorial Hospital, a 300 bed urban community hospital began the journey to Primary Stroke Center certification including the challenge of administering rtPA to qualified candidates within the golden hour of arrival. Our 50 bed Emergency Department worked with the hospital Stroke Committee to improve our processes. It proved difficult to get the head CT and lab work completed within the hour much less administer the rtPA. While these processes improved, our door to needle times did not decrease. We worked to standardize, bundle and electronically post our forms and order sets. With each rtPA patient we identified a new area for improvement and continued staff education, promoted early recognition and obtained interdisciplinary feedback. Purpose: To decrease our door to needle time. Methods: Based on literature review and stakeholder feedback, the Nurse Manager, Quality Coordinator and Medical Directors decided to model the Acute Stroke response off of our Hazmat response as both of these are low volume, critical incidents requiring every staff member to be knowledgeable and prepared to respond. We developed job action sheets, clearly identifying the required duties, for each member of the ED team. Acute Stroke response was divided into four phases: 1) Notification/Arrival of Potential BAT, 2) CT completion to Decision to administer rtPA, 3) Decision to Administer rtPA, and 4) rtPA administration to CCU. Overhead page of Code Stroke notified all staff of the time intensive emergent process allowing work loads to be temporarily re-assigned minimizing interruptions, the rtPA protocol was now available in red folders with instructions for proper action or completion, and a timekeeper/facilitator was assigned. The new protocol was disseminated to staff in early March 2011. Lab and CT staffs were also re-educated with emphasis on the critical nature of their roles. Results: Two weeks later the new protocol was put to the test with rtPA door to needle time of 50 minutes! In July 2011, the mean door to needle time was 49 minutes. Conclusion: Looking at the same process or problem from a different perspective can change the approach of a whole team. Changing the protocol format, informing all staff, reassigning work load, designating a time keeper and creating job action sheets made a Code Stroke successful!