Abstract TP398: Improving Tpa Utilization and Door to Tpa Times in a Community Hospital: Lessons Learned

Abstract

Objective: To improve door to thrombolysis time to less than 60 minutes for acute stroke patients in a community hospital with telestroke access. Background: Earlier initiation of thrombolysis (tPA) therapy in acute stroke patients is associated with improved patient outcomes. Delays in the identification and workup of stroke patients can impact thrombolysis treatment time. Methods: A multidisciplinary workgroup was created in 2015. The care of stroke alert patients was observed over several weeks, identifying barriers and delays in treatment. Multiple interventions were implemented utilizing plan-do-study-act (PDSA) cycles. Door-to-tPA (DTT) times were retrospectively collected for patients with final diagnosis of ischemic stroke and monitored monthly using statistical process control charts. Results: Baseline average DTT was 77 minutes. Initiation of a stroke launch pad and revision of the process to obtain CT scans resulted in a significant decrease in average time to CT to 9 minutes, which was sustained, but without subsequent improvement in DTT times. Further interventions to the stroke alert process improved DTT times transiently but performance was not sustainable. Multiple PDSA cycles were carried out targeting various inefficiencies in the process, knowledge gaps amongst staff, and cultural barriers within the ER physicians. DTT times have gradually improved over time, with average DTT of 48 minutes achieved for Jan-June 2018 (Figure 1). The average number of tPA cases per month increased from 1.3 in 2015 to 2.5 in 2017-2018, likely attributable to revisions in the stroke alert process and stroke alert criteria, and staff education. Conclusion: Continuous quality improvement methodology can be utilized to improve door to tPA times in acute stroke patients. This may require multiple PDSA cycles, addressing cultural and educational barriers, as well as continually revisiting the process to ensure sustained performance.