Abstract 351: Size Matters: Saving the Penumbra

Abstract

Background: New Hanover Regional Medical Center (NHRMC) is a DNV-GL certified Comprehensive Stroke Center with its primary service area encompassing the seven-county region of Southeastern North Carolina. As the stroke hub of our region, the organization recognized the need to create a highly functional stroke center to provide optimal care to our community.In 2017, we began our comprehensive journey to include endovascular treatment of patients with large vessel occlusions. Based on the success of the Code Stroke response, which decreased door to needle times, Code ELVO (Emergent Large Vessel Occlusion) was layered in resulting in a seamless process. Objectives: The team completed a value-stream analysis by examining each step in the process. The stroke team care goals were to:•Increase the percentage of eligible stroke patients who received treatment with alteplase•Decrease the median time to treatment below the AHA/ASA “Get With the Guidelines” standards•Achieve Door to recanalization below the AHA/ASA “Get With the Guidelines” standards•Improve stroke systems of care in the region. Methods: 1. Use of Lean problem solving and PDSA methodology to identify opportunities for improvement and implement countermeasures 2. Creation of interdisciplinary team for oversight and continuous process improvements 3. Code Stroke/Code ELVO processes were developed and are continuously evaluated for improvement 4. Weekly Stroke Huddle: Representatives from the interdisciplinary stroke team gather to review cases, identify opportunities for improvement, and celebrate successes. 5. Stroke Steering Committee: Interdisciplinary committee that meets monthly to review Code Stroke, Code ELVO, and acute cerebrovascular data including quality metrics, treatments and mortality. Results: The number of patients who were treated with alteplase significantly increased 5-fold (547%), from 30 patients per year (2014) to 194 patients (2019). During this period, median alteplase treatment times were reduced by 51%, from 63 minutes (2014) to 31 minutes (2019). The percentage of patients who received alteplase in 45 minutes or less at NHRMC was 76% from 2016 - October 2019, compared to 44% nationally participating in the AHA/ASA Get with the Guideline Stroke registry. Risk adjusted mortality rate during the same period was 4.9% for NHRMC, 5.6% for all hospitals. Bleeding complications from alteplase were 3.2% for NHRMC, 4.1% nationally. The number of patients who were treated with mechanical thrombectomy significantly increased by 61% from 53 patients in 2017 to 137 patients in 2019. During this period, median door to recanalization times were reduced by 5%, from 80 minutes (2017) to 76 minutes (2019). During this period, we expanded to 24/7 coverage, extended the treatment window, and added a cerebrovascular neurosurgeon to the team.