Abstract TP363: A Successful Nurse-Driven Acute Stroke Code Algorithm to Reduce Door-to-Needle Time at a Telestroke Site

Abstract

Background and Issues: In Hawaii, where stroke remains the 3 rd leading cause of death, a large comprehensive stroke center serves as the telestroke hub site for multiple telestroke spoke sites. Among these spoke sites, an 80-bed suburban community hospital within the same healthcare system has the highest number of IV alteplase administrations in Hawaii. Although both hospitals share similar resources and clinical expertise, the median “door-to-needle” (DTN) time at the spoke site was significantly longer compared to the hub site (by ~13-15 minutes). The main difference between the two sites was the traditional acute stroke (in person) vs. telestroke (telemedicine) workflow. Purpose: To transform the process and experience of a telemedicine stroke code into those similar to that of an in-person stroke code, with the aim to reduce the median IV alteplase DTN time to 20 minutes at the telestroke spoke site. Methods: Upon case review, the telestroke neurologist was seen as ineffective in running the stroke code remotely, an on-site stroke code leader was necessary to efficiently guide the team through the stroke code. The stroke code leader did not need to be an expert in stroke neurology, thus it was decided to have the primary nurse or charge nurse be the code leader. The code leader followed a simple Acute Stroke Code Checklist similar to that of the ACLS algorithm. The checklist included time targets to focus on the 20 minute DTN goal. In addition, the neurological exam was standardized into a primary and secondary assessment; imaging studies were also separated into primary and secondary neuro-imaging. The DTN times between pre- and post- period were compared by non-parametric Wilcoxon test. Results: The ED Acute Stroke Code Checklist was implemented on October 16, 2017. Following implementation DTN times decreased; the first 5 cases after the intervention were under the pre-intervention median time. DTN time decreased from a median DTN: Pre vs. Post 42.5 to 33.0 min (p = 0.0012) with data through March 2019 analyzed. Conclusions: The nurse-driven acute stroke code algorithm significantly improved the DTN times and reduced variation in outcomes in a community hospital telestroke site.