Abstract W P178: Multiple Concurrent Strategies are Required to Achieve Door-to-Needle Time Under One Hour for Thrombolysis of Acute Ischemic Stroke in the Majority of Patients

Abstract

Introduction: Reducing door-to-needle time (DTNT) for acute ischemic stroke (AIS) thrombolysis is a major public health priority. Various strategies to reduce DTNT have been evaluated in academic but less so in community hospital settings. At our hospital, weekly debriefings of all AIS cases were conducted to develop process improvement strategies using a rapid cycle test of change model; which allows for quickly implementing changes in organizational structure. Methods: Paired t-test was used to compare mean DTNT before and after implementation of changes. First, stroke patients arriving by ambulance were transferred directly to CT scan, eliminating the time delay of gurney transfers. In response to a delay due to IV tubing issues, pharmacy included tubing with the t-PA. Next, the algorithm was changed to allow ED staff to order t-PA while neurologist was en route. Later, a neurologist was assigned to be on-site at the hospital for immediate response. Pharmacy began hand delivering t-pa after a delay in communication of when it was ready. After triage delays for posterior territory strokes, ED began pre-shift nursing messages and displayed posters that emphasized atypical stroke symptoms. A single pharmacy phone number was used and “t-pa alert” was called overhead for all thrombolysis candidates. Finally, graphs highlighting DTNT among involved hospital staff were placed in a visible area to encourage competetion for timeliness. Results: At the start of the quality improvement initiative, average DTNT was 84 minutes, and 13% of patients were treated within an hour. Over 3 years of process changes, DTNT was reduced to 57 minutes, and 68% of AIS patients were treated within an hour. Conclusion: Multiple concurrent strategies are needed to achieve and maintain a DTNT under 60 minutes in the majority of AIS patients in a community hospital.