Abstract
Background: Despite substantial to minimize ischemic stroke treatment delays, hospital door-to-needle (DTN) time variations persist. We sought to identify sources of variation in practice as well as understand stroke team member perceptions of factors that influence DTN performance in a sample of hospitals that participate in a statewide stroke registry. Methods: We conducted a series of semi-structured interviews with stroke coordinators and emergency department (ED) staff. Participants were invited from hospitals with the fastest or slowest DTN times in 2022. Transcripts of the interviews were coded to identify differences in hospital acute stroke code processes as well as interviewee perceptions of facilitators and barriers to optimal performance. Results: Ten individuals from 6 hospitals participated in interviews (6 stroke coordinators, 3 ED physicians, 1 ED nurse). Variations in stroke code processes included location of initial patient evaluation, stroke team composition (inclusion of pharmacy or in-person neurology provider), imaging strategy for large-vessel occlusion stroke screening, thrombolytic medication utilized, and team members primarily responsible for thrombolytic decision-making, mixing, and delivery. Common facilitators of rapid DTN times included integration of EMS, multidisciplinary engagement with quality improvement teams (especially physician engagement), embedding critical care nurses in stroke teams, and providing rapid, individualized feedback to clinical personnel. Common barriers included identifying stroke in triage, staff turnover, and inadequate stroke coordinator resources. Participants from higher performing hospitals reported having larger stroke teams with in-person neurology support. Participants from lower performing hospitals highlighted staffing shortages and difficulties with video-based teleneurology. Conclusion: Stroke code process variation is common and largely driven by hospital resources. Highly engaged, physician-led multidisciplinary teams and timely, actionable feedback were seen as key elements of achieving DTN goals. Staffing shortages and lack of access to timely neurological consultation are system-level barriers to optimal stroke care.
Published Version
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