Abstract
Background: Faster treatment with tPA in acute ischemic stroke is associated with better outcomes. Starting in 2015, Kaiser Permanente Northern California (KPNC) redesigned its acute stroke workflow across all 21 KPNC stroke centers to have all stroke alerts actively managed by a core group of vascular neurologists via telemedicine. We examined the effect of KPNC’s Stroke EXPRESS (EXpediting the PRrocess of Evaluating and Stopping Stroke) program on door-to-needle (DTN) time and symptomatic intracranial hemorrhage (sICH) rates. Methods: The Stroke EXPRESS program was rolled out across KPNC in a staggered fashion from 9/2015 to 1/2016 with the goals of expediting the evaluation and determination for tPA and speeding up the assessment for large vessel occlusion to allow for timely transfer for thrombectomy. We compared DTN times for 6 months before implementation to the same 6-month calendar period after implementation. Results: After implementation, tPA administrations increased from 38/month at baseline to 80/month (P<.001). Mean DTN times decreased significantly after implementation (40.8 ± 31.5 min vs. 61.3 ± 30.9 min at baseline, P<.001; median 33 min vs. 52 min, P<.001.) [Figure], and all centers achieved DTN time of <60 minutes routinely (88% vs 64%, Risk Ratio =1.4, p<.001). DTN times of < 30 min were much more common in the Stroke EXPRESS period (46% vs. 5% at baseline, P<0.001). There was no difference in sICH rates by ECASS criteria in the two periods: 4.3% vs. 4.3%, P=1.00. Conclusions: Implementation of the Stroke EXPRESS regional telemedicine program in KPNC was associated with an increase in tPA administrations, markedly shorter DTN times, and no change in the rate of sICH.
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