Abstract TP366: Implementation of an Interdisciplinary Code Stroke Protocol to Facilitate Consistent Evidence Based Assessment and Treatment of Stroke Patients

Abstract

Introduction: A shorter door-to-TPA time reduces stroke mortality and risk of hemorrhagic conversion. Although the Brain Attack Coalition recommends a goal of door-to-TPA in 60 minutes for 80% of ischemic stroke patients, the Joint Commission reported less than 29% of TPA eligible patients met this goal in CY2010. To meet these targets without 24 hour neurology coverage, we examined and changed processes, developed a team-oriented Code Stroke protocol, and compared FY2010 baseline to 9 consecutive months of door-to-TPA times for eligible patients and “ideal” TPA candidates. Methods: Our Stroke Taskforce, of more than six departments, used the Six Sigma DMAIC methodology to map acute stroke processes and look at delays in assessment, testing, medication dispensing and through-put. Stroke symptom education was provided to EMS, hospital security, triage technicians, nursing and nursing assistants. Each department had a list of responsibilities to facilitate the protocol. De-briefings occurred after each code stroke to examine process deficiencies. Data was reviewed monthly. Results: Process evaluation identified inefficiencies (e.g., lab notified of “Code Stroke” blood samples; replaced an old centrifuge in the laboratory which decreased spin times of coagulation studies and processing time). Protocol implementation included EMS advanced notification and an ED physician-initiated “Code Stroke” algorithm involving the House Supervisor, IV room pharmacy, CCU charge nurse, CT charge technician, On-call Neurologist, and the care nurse. Implementation phase (11/2010-07/2011) mean door-to-TPA time was 74.6 ± 24.6 minutes (range 35-119) for 13 patients compared to baseline (07/2009-06/2010) mean of 105.4 ± 28.6 minutes (range 59-151) for 10 patients. Mean door-to-TPA time for the nine ideal” patients (obvious stroke symptoms on admission; no intubation, sutures, or IV drip for blood pressure control) was 61.3 minutes. Improved stroke symptom recognition and expedited test results were also found for non-TPA candidates. Discussion: Our systematic team approach with delineation of responsibilities decreased door-to-needle times for our stroke population and improved timeliness of results for all acute stroke patients.