Abstract TMP38: Enhancing Door-In-Door-Out Time in a Rural Primary Stroke Center: Early Activation of a Large Vessel Occlusion Alert/Bundle of Care Utilizing EMS Pre-Alert, Parallel System Processing and Auto-Launch of Transfer Resources

Abstract

Background: Thrombectomy has become the primary treatment in the management of acute stroke Large Vessel Occlusions (LVO). For a rural primary stroke center that does not have in house thrombectomy services, expedited transfer to a Comprehensive Stroke Center is imperative. The purpose of this quality improvement initiative is aimed at optimizing the Door-In-Door-Out (DIDO) time for stroke patients at a Rural Primary Stroke Center, with a specific goal of DIDO time of <90 minutes, 50% of the time and <120 minutes, 75% of the time. Methods: System inefficiencies in serial event processing, radiology interpretation, teleneurology application and activation of transferring Emergency Medical Services (EMS) were identified. We implemented several systematic changes utilizing multiple Plan Do Study Act cycles. The final implementation was an “LVO-Alert” process, which utilized parallel event processing of emergency medicine, teleneurology, radiology, and transfer center auto-lance of EMS transfer resources. This process is activated based on a positive prehospital modified Rapid Arterial Occlusion Evaluation score prior to the patient’s hospital arrival rather than a positive Computed Tomography Angiogram and can be cancelled in the case of negative imaging or declination of transfer. Pre and post metrics were compared. Results: Pre LVO-Alert implementation, DIDO time averaged 184 minutes (n=21) over 2 years, and anterior circulation LVO’s achieved a <90-minute DIDO time 5% of the time. Post implementation, DIDO averaged 109 minutes (n=21) and anterior circulation LVOs achieved a <90-minute DIDO 48% of the time. Post implementation, anterior circulation LVOs went from 19% to 90% transferred in <120 minutes. Pre implementation, posterior circulation LVO’s achieved a <120-minute DIDO time 0% (n= 2) of the time while post implementation, posterior circulation LVOs achieved a <120-minute DIDO 50% (n=4) of the time. Among LVO alert activations over the post-implementation period, 27.4% resulted in transfer for thrombectomy. Conclusion: The application of a parallel process bundle of care model with early activation from a prehospital positive LVO scale may help to improve DIDO times in this patient population.