Door-to-needle Research Articles

Driving stroke quality improvement at scale in EDs across a nationwide network of hospitals: strategies and interventions

ObjectivesReducing the treatment time while increasing the proportion of eligible stroke patients who receive intravenous tissue plasminogen activator (tPA) has been a priority for many quality improvement efforts. Recent studies...

Diurnal variations in the quality of stroke care in Sweden

A recent study of acute stroke patients in England and Wales revealed several patterns of temporal variation in quality of care. We hypothesized that similar patterns would be present in Sweden and aimed to describe these patterns. Additionally, we aimed to investigate whether hospital type conferred resilience against temporal variation. We conducted this nationwide registry-based study using data from the Swedish Stroke Register (Riksstroke) including all adult patients registered with acute stroke between 2011 and 2015. Outcomes included process measures and survival. We modeled time of presentation as on/off-hours, shifts, day of week, 4-hour, and 12-hour time blocks. We studied hospital resilience by comparing outcomes across hospital types. A total of 113862 stroke events in 72 hospitals were included. The process indicators and survival all showed significant temporal variation. Door-to-needle (DTN) time within 30minutes was less likely during nighttime than daytime (OR 0.50; 95% CI 0.41-0.60). Patients admitted during off-hours had lower odds of direct stroke unit (SU) admission (OR 0.72; 95% CI 0.70-0.75). 30-day survival was lower in nighttime vs daytime presentations (OR 0.90, 95% CI 0.84-0.96). The effects of temporal variation differed significantly between hospital types for DTN time within 30minutes and direct SU admission where university hospitals were more resilient than specialized non-university hospitals. Our study shows that variation in quality of care and survival is present throughout the whole week. We also found that university hospitals were more resilient to temporal variation than specialized non-university hospitals.

Factors affecting in-hospital delay of intravenous thrombolysis for acute ischemic stroke: A retrospective cohort study.

This study was designed to investigate the factors affecting the in-hospital delay of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS).Two hundred and forty-eight consecutive AIS patients treated with intravenous administration of alteplase in Gansu Provincial Hospital from December 2014 to August 2018 were enrolled retrospectively in this study. According to door-to-needle (DTN) time, the patients were divided into either a delay group (DTN time > 60 minutes; n = 184) or a non-delay group (DTN time ≤60 minutes; n = 64). The baseline data, laboratory tests, onset-to-door (OTD) time, door-to-accepting time (DTA), door-to-imaging time (DTI), and decision-making time in both groups were recorded. Multivariate logistic analysis was performed to analyze the data.There were significant differences in previous history of cerebral ischemic attack, emergency system admission, education degree of decision makers, annual income, admission National Institutes of Health Stroke Scale (NIHSS), OTD time, DTA time, decision-making time between the 2 groups (all P < .05). Other baseline data and clinical features showed no significant difference between 2 groups (P > .05). Multivariate logistic regression analysis revealed that the risk of in-hospital delay was lower for the higher NIHSS score (OR = 0.775, 95% CI: 0.644-0.933, P = .007), the longer OTD time (OR = 0.963, 95% CI: 0.937-0.991, P = .010), the shorter decision-making time (OR = 1.224, 95% CI: 1.004-1.492, P = .045).This study suggested that NIHSS score, OTD time and decision-making time are the independent factors affecting the in-hospital delay of IVT for AIS.

Effect on door‐to‐needle recombinant tissue plasminogen activator administration times for acute ischemic stroke with and without an emergency department pharmacist

Study ObjectiveA paucity of data exists on the impact emergency department (ED) pharmacists have on a stroke team's door‐to‐needle (DTN) administration time of recombinant tissue plasminogen activator (rTPA). The purpose of this study was to assess the odds of achieving a DTN administration time for rTPA of 60 minutes or less with an ED pharmacist present.MethodsThis was a retrospective, cohort study of patients who received rTPA for acute ischemic stroke (AIS) from May 2017 to May 2018. Patients were included if they were at least 18 years old and received tPA for AIS in the ED. The primary outcome for this study was the likelihood of patients receiving a DTN administration time of 60 minutes or less with or without an ED pharmacist present during a stroke alert at a primary stroke center.ResultsThe electronic medical record of 184 stroke alert patients was reviewed, and 65 patients were included in the final analysis. Baseline characteristics were similar in all aspects. The odds ratio was 3.3 (95% confidence interval [CI]: 1.1‐9.6; P = 0.04) to achieve a DTN administration time of 60 minutes or less when an ED pharmacist was present. The ED pharmacist present group had faster median (47 minutes vs 60 minutes; P = 0.001) and average (49 minutes vs 63 minutes; P = 0.003) DTN administration times compared with the ED pharmacist not present group.ConclusionAn ED pharmacists present during a stroke alert at our faculty resulted in reduced overall DTN rTPA administration times and increased the odds of a patient receiving rTPA less than 60 minutes from arrival for AIS. Further study is required to determine if this finding can be replicated in other EDs.

Abstract TP112: Achieving 30 Minute Median Door to Needle Time at an Urban Center Using Telemedicine

Introduction: We constantly strive to improve outcomes for stroke patients. Current ASA Guidelines recommend a door to needle (DTN) time of 60 minutes or less, with a secondary goal DTN time of 45 minutes or less. Our goal was to decrease IV Alteplase (tPA) DTN times to 30 minutes or less using primarily Telemedicine. Methods: In February of 2017, significant changes were made to our stroke alert process:Solidified process for direct neurology beam into the Telemedicine camera (rather than phoning first)Pharmacy responds to stroke alerts in person, and pre-mixes (if the neurologist deems appropriate) tPA at the bedsideThe Teleneurologist remains on the camera, which accompanies the patient to CAT Scan (CT). Through the camera, the neurologist reads the head CT in real timeIf no hemorrhage is confirmed on the CT scan, a verbal order to administer tPA is given while in the CT suite Challenges: Staff concern for patient safety, staff matrices, time constraints to implement these changes, our stroke committee collaborated with all affected departments. Resources were created including checklists and a Stroke Kit that contains tPA mixing guidelines, dosing charts, and blood pressure medications. The staff and physicians were educated on the new process via multiple venues including mock stroke alerts Summary: From 2016 to 2017, there was a significant increase in the percentage of stroke patients who received tPA within 45 minutes or less, and within 30 minutes or less. There were no symptomatic hemorrhages post tPA administration in either 2016 or 2017.Our median DTN time decreased by 11 minutes 8 months after the implementations discussed (from 41 minutes in 2016 to 30 minutes in 2017). Many individual DTN times were under 30 minutes.Because of our success, these process changes were adapted by sister facilities within our division.Our stroke alert process is an excellent example of staff interdisciplinary collaboration, open mindedness, flexibility, enthusiasm and knowledge.

Abstract WP331: Choice of Antihypertensive Agent Prior to Thrombolysis Has No Affect on Door-to-Needle Time: A Single Center Experience

Introduction: Treatment of acute ischemic stroke with intravenous thrombolysis (IVT) should be as rapid as possible. A subset of patients with acute ischemic stroke present with blood pressures above that considered safe for thrombolytic administration, and antihypertensive therapy is necessary. Guideline statements are ambivalent regarding which antihypertensive agent should be used to obtain a satisfactory blood pressure (BP &lt; 185/110 mmHg) prior to IVT. Hypothesis: DTN time will not differ amongst the antihypertensive agent groups. Methods: We reviewed data from consecutive patients at our institution treated with IVT from 01/2014 to 07/2018 and collected door-to-needle (DTN) time, antihypertensive agent (if used), and antihypertensive-to-needle (ATN) time. Patients were grouped by initial agent administered. An independent samples t-test was used to compare the labetalol and nicardipine group DTN and ATN times, as well as DTN times for patients receiving any antihypertensive agent with DTN times for those who did not. We performed a one-way ANOVA to compare DTN times across all groups (no agent, labetalol, nicardipine, hydralazine). Significance was defined as p &lt; 0.05 for all tests. Results: Analysis included 205 patients: 149 receiving no antihypertensive, 42 receiving labetalol, 12 receiving nicardipine, and 2 receiving hydralazine. Those not administered an antihypertensive prior to IVT had shorter DTN times (53.05 min versus 61.96 min, p = 0.039). Although not statistically significant, there was a trend towards longer DTN (64.76 min versus 51.33 min, p = 0.205) and ATN times (18.02 min versus 10.58 min, p = 0.171) in the labetalol group. There was not a difference in DTN time across all groups (F(3,205) = 2.213, p = 0.088), although labetalol trended towards higher times than those not administered any agent on post-hoc Tukey HSD test (p = 0.071). Conclusions: At our institution, patients requiring antihypertensive treatment did experience slower DTN times. Choice of antihypertensive agent did not affect DTN times, however there was a trend towards slower times with labetalol. This study is limited by relatively small sample size. Pooling data from multiple institutions could provide a more robust assessment and inform clinical practice.

Abstract WP506: Looking for Themes to Improve Outcomes Through Team Debriefing

Background: Acute ischemic stroke (AIS) patients risk grave disability when treatment is delayed. The benchmark for door to needle (DTN) time for thrombolysis in AIS is less than 60 minutes; The American Stroke Association's (ASA) Target Stroke, Phase II (TSP II) sets a higher standard of less than 45 minutes. Emergency department caregivers at a 377 bed community hospital with primary stroke center designation were educated about the TSP II toolbox; however DTN times in 2016 were less than 60 minutes only 29% of the time with a mean time of 78 minutes, a medium time of 77 minutes and a range of 178 minutes. Purpose: Using a lean methodology approach we organized team debriefings to evaluate cases of time delay with the aim to develop strategies to improve outcome. Methods: As a process improvement project, an interprofessinal team was assembled to debrief and evaluate all patients receiving thrombolytic therapy. A comprehensive checklist was developed to include all of the critical components of care along with target benchmark timelines. Each data point was scrutinized to evaluate for possible time delays. The caregiver team was encouraged to objectively identify time delays and look for themes. Through root cause analysis, the most common theme identified was the performance of unnecessary tasks that could wait until after initiation of therapy. The other theme identified was delay in critical interventions such as timely lowering of blood pressure to prevent hemorrhage in patients undergoing thrombolysis. We engaged in coaching conversations among members of the team in an effort to promote better critical thinking and better patient outcomes. Results: From January, 2017 to August, 2018 there were 69 thrombolytic therapy cases The DTN rate of less than 60 minutes was 78%. Mean, median and mode times were 53,51 and 57 minutes respectively. The range was from 28-93 minutes. DTN in 45 minutes or less occurred at a rate of 30%. Conclusion: Improved outcome for exemplary professional practices can be afforded through a systematic approach to debrief about time sensitive treatments. Bringing team members together for a guided discussion designed to look for themes that lead to performance deficits will develop better patient outcomes.

Abstract TP275: Impact of a Direct to Computed Tomography Protocol on Tissue Plasminogen Activator Door-to-Needle Time in Acute Ischemic Stroke

Background: Current American Heart Association/American Stroke Association (AHA/ASA) guidelines recommend brain imaging with computed tomography (CT) within 20 minutes of emergency department (ED) arrival and treatment with tissue plasminogen activator (tPA) in eligible patients with acute ischemic stroke within 60 minutes of arrival. In January 2017, we implemented a direct-to-CT protocol which consisted of direct patient transportation by emergency medical services (EMS) personnel from ambulance to CT scanner. Patients were then transported to the ED for evaluation and treatment as appropriate via telemedicine and ED staff. Objective: To determine if a direct-to-CT protocol would improve the percentage of patients with door-to-needle (DTN) time ≤ 60 minutes. Methods: This was a single center retrospective cohort study of patients who received tPA for acute ischemic stroke in the ED between October 2016 and May 2018. Patients were grouped based on the use of a direct-to-CT protocol. Results: Of 64 included patients, 23 patients (36%) were transported via the direct-to-CT protocol and 41 patients (64%) arrived via private vehicle or EMS without use of the protocol. Goal DTN time ≤ 60 minutes was achieved in 78% of patients when the protocol was used compared to 44% when it was not (p=0.0078). The mean DTN time was significantly shorter when the protocol was used (52.83±13.8 vs 70.98±32.6, p=0.003). Following adjustments for time of day and the need for blood pressure management with intravenous anti-hypertensives, a greater percentage of patients in the direct-to-CT protocol group achieved DTN ≤ 60 minutes (OR=8.09;95%CI=1.99-32.91, p=0.003). Conclusions: An EMS activated direct-to-CT protocol improved the percentage of patients achieving DTN ≤ 60 minutes and significantly reduced mean DTN time.

Abstract WP414: Stroke Door-to-Needle Target of 30 Minutes or Less: A Single Center Experience

Background: Early thrombolysis in acute ischemic stroke is associated with improved outcomes. Current guidelines emphasize early delivery of intravenous (IV) Alteplase (tPA). Additionally, door-to-needle (DTN) time is often a step in the pathway to mechanical thrombectomy. We sought to achieve average DTN time of ≤ 30 minutes in eligible patients. Methods: A multidisciplinary team was established. Goal timeframes for the subcomponents of the process were determined. A fishbone diagram was used to identify barriers. Subgroups focused on each category. A tracking feedback tool was used for consistent monthly feedback to all team members. Eligible patients included those meeting GWTG criteria for tPA. Results: Four main areas were identified for subgroup intervention: scan interpretation; documentation and communication; location of tPA administration; completion of ancillary tasks prior to tPA. Across 18 months, before and after intervention, quarterly average DTN times were reduced from 56.1 to 26.4 minutes for all patients and 54.6 to 26.1 minutes for eligible patients. Volume of IV tPA delivery increased from 11.5 to 13.75 patients/quarter. Average DTN time ≤ 30 minutes was sustained across 6 months. Symptomatic intracranial hemorrhage rate was unchanged. Conclusions: Consistent average DTN times ≤ 30 minutes for acute stroke is possible. A multidisciplinary approach with emphasis on a culture of teamwork and collaboration is essential.

Abstract TP381: Discrepancies in Arrival Time for Acute Ischemic Stroke Patients: An Opportunity for Improvement

Background: Current guidelines and national quality improvement efforts emphasize door-to-needle (DTN) time in stroke thrombolysis. Stroke center certifying bodies depend on hospital-reported DTN to appraise compliance and award designations. However, the validation of hospital reported arrival times against ambulance arrival times has not been previously reported. Objective: To determine differences in Emergency Medical Services (EMS) reported arrival time of stroke patients versus hospital documented arrival times at 10 primary and comprehensive stroke centers in Chicago. Methods: We performed a retrospective analysis of stroke admissions using the regional Get With The Guidelines (GWTG) Stroke registry of 10 Chicago hospitals between July 1 and December 31, 2013. We matched ambulance run numbers from EMS records to those in the GWTG-Stroke EMS special initiative tab. GWTG-Stroke data included arrival time, age, sex, race, initial NIHSS score, and whether tPA was administered. EMS data included hospital arrival time in addition to age, sex, hospital name, and clinical impression. We compared GWTG-Stroke and EMS reported arrival times overall and whether any clinical factors were associated with time discrepancy. Results: Among 308 matched EMS to GWTG-Stroke records, 51 (16.6%) received tPA. Overall, EMS documented arrival time was a median 5 minutes earlier than hospital documented arrival time (range -35 to +14min). There was no significant difference in time discrepancy by tPA administration, stroke type, NIHSS score, age, sex, race, insurance status, or hospital. Median DTN based on EMS data was 88m versus 82m for hospital-reported data (p&gt;0.05). The proportion with DTN times &lt;60 minutes was 22% based on EMS versus 29% based on hospital arrival times. Conclusions: EMS reported arrival time is on average 5 minutes earlier than hospital documented arrival time at 10 stroke centers in Chicago. Further studies should investigate factors contributing to discrepancies in DTN times between EMS and hospitals. Such investigation may lead to facilitating efficient hand-offs between EMS and hospital providers and promote earlier notification of receiving hospital stroke team in order to initiate care at time of EMS arrival.

Abstract WP398: Impact of a Direct Ambulance-to-CT Stroke Protocol on Race, Sex, and Language Disparities in Stroke Treatment Times

Introduction: Prior studies have documented disparities in key acute stroke care metrics, with women and minorities more likely to have treatment delays and less likely to receive IV tPA. Objective: To evaluate whether implementation of a direct ambulance-to-CT stroke protocol reduces race, sex, and primary language disparities in stroke treatment times. Methods: We identified patients with confirmed strokes that had been transported by ambulance to our emergency department before and after implementation of a direct ambulance-to-CT protocol for suspected stroke at our urban safety-net hospital. We used the Mann-Whitney U test to compare median door-to-CT (DTC) and door-to-needle (DTN) times by sex, race, and primary language during the pre- and post-intervention periods. Results: A total of 106 stroke patients in the pre-intervention group and 119 in the post-intervention group were included in this analysis. The pre-intervention group included 57 (53.8%) women, 20 (18.9%) whites, and 68 (64.2%) English-speaking patients. The post-intervention group included 58 (48.7%) women, 26 (21.9%) whites, and 77 (64.7%) English-speaking patients. A total of 48 pre-intervention patients and 47 post-intervention patients received tPA. Overall, median DTC and DTN times were significantly lower in the post-intervention group compared to the pre-intervention group (21 minutes vs. 10, p&lt;0.0001; 39 vs. 30, p=0.006). There were no significant differences in DTC or DTN times by sex, race, or primary language in the pre-intervention group, but women had longer median DTN times than men (34 vs. 24, p=0.02) in the post-intervention group. Conclusions: While no significant disparities in stroke treatment times by sex, race, or primary language were identified in the pre-intervention period, implementation of a direct ambulance-to-CT protocol was associated with greater improvements in DTN times for men than for women.

Abstract TP494: A Continuous Monitoring Led by a Nurse Working Group Plays a Key Role in the Improvement of Acute Ischemic Stroke Workflow-Metrics

Background and Purpose: In the workflow process for the management of acute ischemic stroke (AIS) patients, time is critical to improve functional outcome. Based on the recent 2018 AHA ASA guidelines, median door-to-imaging (DTI) time should be less than 20 minutes and median door-to-needle (DTN) time for tPA administration less than 60 minutes. Our comprehensive stroke center mostly recruits suspected AIS patients following a “mother ship” approach with systematic emergency medical services pre-notification and emergency room by-pass. Based on this specific patient’s care approach, the purpose of our study was to evaluate our capacity to get with the guidelines (GWTG) and to shorten our DTN/DTI times. Methods: In our stroke center, the stroke alert follows a workflow including 15 time-points from call notification to cath lab access. The stroke team work during the stroke alert was evaluated, during two periods of time (oct-to-march and april-to-august) based on its capacity to comply with DTI and DTN recommended median times. Continuous improvement of the workflow was based on prospective data collection analysis and interpretation by a working group led by nurses focusing on knowledge, organization and leadership difficulties identification. Results: From october 2017 to august 2018, 501 stroke alerts were identified in our comprehensive stroke center. Of these, 425 (85%) cases were analyzed. A total of 81 (19%) of the suspected AIS patients received tPA, 44 (10.3%) were treated with combined tPA infusion and thrombectomy and 44 (10.3%) with thrombectomy alone. Median DTI time was 15 min (3-62), median DTN time for tPA administration was 44 min (21-87), median door-to-cath lab time was 64 min (23-140). DTI median time improved significantly between the two time-periods (15,5 (3-62), vs 15(3-50), p= 0,01). Neither DTN time nor door-to-cath lab room time changed significantly during the studied time periods. Conclusion: Our comprehensive stroke center fulfilled the 2018 AHA ASA guidelines for DTI and DTN times. Under the supervision of a nurse working group, shortening of DTI times could be achieved. These findings support the key role of nurses working groups focusing on knowledge and management to improve stroke alert workflow, and finally patient care.

Abstract WP285: Comparison of Telestroke versus In-person Treatment of Acute Stroke by the Same Vascular Neurologists at a Comprehensive Stroke Center

Introduction: Telemedicine (TM) has enabled rapid treatment of acute ischemic stroke with intravenous (IV) t-PA in remote centers where vascular neurologists are scarce. We are a Comprehensive Stroke Center (CSC) serving a large rural community in Central Texas. 24/7 stroke coverage is provided by three vascular neurologists, who evaluate patients at the CSC in-person from 8am to 4pm on weekdays and over telemedicine during all other times. This provides a unique opportunity to isolate and compare the effects of telemedicine to in-person treatment. Objective: Compare door-to-needle (DTN) times of the same vascular neurology group, over TM versus in-person evaluation Methods: We retrospectively reviewed time metrics of patients treated with IV t-PA between October 2017 and June 2017. Patients treated outside of the emergency department were excluded. Results: In the study timeframe, 107 patients received IV t-PA, 34 (31.8%) of whom were treated over TM. There was no statistically significant difference in median DTN time between patients treated with IV t-PA in-person versus over TM (50 min, IQR 19.25 versus 47 min, IQR 24, p=0.193; Table 1). There was also no significant difference in door-to-CT and door-to-lab results between the two groups (Table 1). Conclusion: Our study demonstrates that our vascular neurology group achieves similar DTN times for patients our CSC regardless of whether they are evaluated on-site versus through TM. This suggests that the application of TM itself does not affect DTN times. Limitations include the usual hospital variability seen during nights and weekends.

Abstract WP288: Impact of Prehospital LVO Tools on the Delay of Care and Redistribution of Patients between Primary and Comprehensive Stroke Centers

Introduction: Several tools have been developed aimed at predicting large vessel occlusion (LVO) in the prehospital setting. If these tools are used to bypass Alteplase-but-not-thrombectomy-capable hospitals, this would speed the care for some patients, delay it for others, and unnecessarily redistribute some patients between hospitals. Methods: We examined a hypothetical scenario of 1,000 patients evaluated by EMS for possible stroke. We used data published by RACE (Rapid Arterial oCclusion Evaluation) that included 357 patients to calculate the rates of the different stroke subtypes. Ischemic stroke represented 67.2% of patients, hemorrhagic stroke 14.6%, transient ischemic attack 5.6%, and stroke mimic 12.6%. We applied the following assumptions: rate of LVO as 20% of total ischemic stroke, all patients evaluated by EMS within 3 hours from their last known well time with a rate of tPA utilization is 50%, endovascular-capable hospital is further away, similar door-to-needle (DTN) time in all hospitals, delay in DTN in false positive patients, and delay in door-to-groin time (DTG) in false negative patients. Seven tools were studied using published values for sensitivity and specificity. Results: Using no tools would lead to evaluation of all patients at the nearer hospital first, leading to delay in DTG of all 134 LVO patients, however no delay in DTN. Comparing the various tools, DTN delay would be highest with Cincinnati Prehospital Stroke Severity Scale (CPSSS; n=175) and least with 3-item stroke scale (3I-SS; n=23). DTG delay would be highest with Prehospital Acute Stroke Severity (PASS) and Field Assessment Stroke Triage for Emergency Destination (FAST-ED) (n=52 for both) and least with RACE (n=20). Redistribution of patients would be highest with CPSSS and lowest with 3I-SS (reduction in patient volume to non-thrombectomy capable hospital 63% and 16% respectively and increase in volume for the thrombectomy-capable hospital by 371% and 19% respectively). Conclusion: Current tools have a very wide variation in performance. Although some tools would likely reduce the delay in DTG time for most (but not all) LVO patients, they risk delaying care for other patients and may cause an unnecessary redistribution of patients between hospitals.

Abstract 173: Effect of a Regional Telestroke Program on Door-to-Needle Time and Clinical Outcomes

Background: Published data suggest that the faster acute stroke patients are treated with IV alteplase the better they do post discharge. Telestroke allows community hospitals to access stroke expertise in the management of acute stroke patients. In a real-world practice setting, we assessed the influence of a regional standardized telestroke program among community hospitals on door-to-needle (DTN) time and clinical outcomes. Methods: In January 2016, a new standardized acute telestroke program for 21 stroke centers in an integrated healthcare system was launched. It included immediate evaluation by a stroke neurologist via video, an expedited IV alteplase treatment program, rapid CT angiographic investigation, and expedited transfer and treatment for patients with large vessel occlusion. We compared patient characteristics, DTN times, length of stay (LOS), discharge outcomes, and 90-day mortality between those treated with IV alteplase pre- (July 2013 to June 2015) to post-telestroke program (January 2016 to December 2017). Results: Post-implementation of the telestroke program, more patients were treated with alteplase (Table). Median DTN time and LOS were shorter. A greater percentage of patients were discharged home (57.3% in post-telestroke vs. 12.1% in pre, p&lt;0.001). In-hospital mortality was higher in post-telestroke compared to pre. However, symptomatic hemorrhage rates were not significantly different, at 4.5% in 2014 pre-EXPRESS, 4.3% in 2016 and 3.2% in 2017 post-EXPRESS. In addition, 90-day mortality was not different between pre- and post-telestroke (Table). Conclusions: Implementation of a regional standardized telestroke program in a community setting increased utilization of alteplase, improved DTN time, decreased length of stay and significantly increased the chances of patients going home. Further analyses are needed to understand the significant contributing factors to the success of this program.

Abstract TP288: Emergency Department Nursing Stroke Champions Improve Door to Needle Times at a Comprehensive Stroke Center

Introduction: Intravenous tissue plasminogen activator (IV tPA), for acute ischemic stroke, has a more robust effect if given early. Improving Door-to-Needle (DTN) times in order to allow quicker administration of IV tPA continues to be the primary aim of TARGET:STROKE. The Stroke Champion (SC) Program, an American Heart Association’s Get with the Guidelines recommendation, was implemented in our emergency department (ED) in 2018. Purpose: The purpose of this study was assess if an ED Nurse SC would help to improve DTN, with a specific goal to increase the percentage of patient’s receiving IV tPA ≤30 minutes. Methods: The SC program was initiated in our ED in January 2018. The ED Nurse SC carries the following responsibilities: respond to all stroke alerts, weekly audit of all stroke alert charts, peer to peer follow up for any fallouts to determine if there was a system error or if there was an educational opportunity, weekly update of ED staff virtual communication board, weekly meeting with ED director for any challenges or expected changes, development of a relevant stroke education topic to be delivered at the biweekly ED nursing huddle, participate at the weekly code stroke huddle to collaborate with the stroke team, and attend relevant stroke conferences or stroke-related educational opportunities. A weekly “Stroke Shout Out” was also initiated by the ED Nurse SC to recognize a high performing member of the ED team. Data was compared 6 months pre and post-intervention, and analyzed using a Wilcoxon Rank Sum Test. Results: More patients received IV tPA after the initiation of the ED Nursing SC program than before (38 vs. 23 p=0.03). The median DTN was 36 (IQR 23-49) mins after implementation vs. 47 (IQR 40-56) mins before implementation (p=0.004). A higher percentage of patients received IV tPA less than 30 minutes post intervention vs. pre-intervention (42.1% vs. 17.4% , p &lt;0.001) Conclusion: Implementation of an ED Nurse SC can increase the number of patients who receive IV tPA, improve DTN, and increase the percentage of patients who receive IV tPA less than 30 minutes from door time.

Abstract WP290: Direct Ambulance to Imaging Based Mission Protocol Improves Thrombolysis Metrics for Prehospital Suspected Acute Stroke Patients

Background: The Mission Protocol was implemented in 2017 to expedite stroke evaluation and reduce door-to-needle (DTN) times at Zuckerberg San Francisco General Hospital. The key system change was emergency medical service (EMS) provider transport of patients directly to CT on arrival. Methods: Patients were eligible for a Mission Protocol prehospital stroke activation if an EMS provider found a positive Cincinnati Prehospital Stroke Scale and a last known normal time within 6 hours. We performed a chart review to compare treatment metrics between the first year of Mission Protocol patients and patients from the year prior who were also brought in via ambulance with concern for stroke and a last known normal time within 6 hours. All patients who received thrombolysis as part of their initial evaluation and treatment were included. No outliers were excluded. Median Door to CT and DTN times were compared using two sample Wilcoxon rank-sum (Mann-Whitney) tests. Results: The Mission Protocol cohort had 236 patients and the comparison cohort had 112 patients with results described in the table. The Mission Protocol was associated with a 10 minute faster median door to CT time (p&lt;0.00001), a 6 minute faster median DTN time (p=0.0046), a 22% increase in the proportion of patients treated within 45 minutes of hospital arrival (84% vs 62%), and a 12% increase in the proportion of patients treated within 60 minutes (92% vs 80%). There were 8 stroke mimics treated in the Mission Protocol cohort compared to 2 in the comparison cohort. Symptomatic intracranial hemorrhage only occurred in one Mission Protocol patient with an ischemic stroke. Conclusion: The EMS direct to CT based Mission Protocol was associated with faster median door to CT and DTN times. There was a 22% increase in the proportion of thrombolysis patients treated within 45 minutes or less. More stroke mimic patients received thrombolysis but symptomatic intracranial hemorrhage only occurred in one ischemic stroke patient.

Abstract WP289: Implementation of Secure Messaging System Reduces Response to Page Time in Telestroke Network

Introduction: Timeliness of a response to page by telestroke physicians is an important component in a telestroke network. Accrediting organizations such as the Joint Commission require telemedicine to be available within 20 minutes of the request. We implemented a secure messaging system to improve physician communication. We hypothesized that implementation of a secure messaging system would improve communication, reduce telestroke physician response to page and reduce door-to-needle (DTN) times compared to the previous pager-based system. Methods: We reviewed data collected as part of our telestroke quality program. We compared response to page times for one year before and after initiation of the secure messaging system. Additionally, we compared DTN times during the same epochs. Results: Seven hundred and sixty-five telestroke consults were completed in the year prior to implementation of the secure messaging system and 941 telestroke consults were completed in the year following implementation. Telestroke response to page time decreased significantly between pre ( mean rank 1005; median 4 min) and post ( mean rank 731 ; median 2 min) implementation of the secure messaging system ( U = 244,240 , p &lt; .001, r = .28). A significantly greater percentage of telestroke neurologist response times occurred within 20 minutes when using secure messaging 936/941 (99.5%) compared to pagers, 751/765 (98.2%), χ 2 (1, N = 1706) = 6.46, p = .01, φ = .06. DTN was lower when using secure messaging (64 min) compared to the prior paging system (66 min), but this difference was not statistically significant ( p = .74). Conclusions: In conclusion, implementation of a secure messaging system improved communication in our telestroke network and reduced telestroke response to page compared to our prior paging system. Implementation of the secure messaging system did not significantly reduce DTN times.

Abstract WP320: Coaching Stroke Quarterbacks in an Academic Medical Center to Improve Door to Treatment Times

Background: Rapid treatment for acute ischemic stroke (AIS) improves patient outcomes. In an academic medical center AIS treatment often involves a large team including trainees. A clear process allowing for rotating team members and varied experience in AIS care across disciplines is key for timely intervention. Purpose: To improve the percentage of patients with door to needle (DTN) and door to puncture (DTP) times within 45 and 90 minutes. Methods: A multidisciplinary team including EMS, Emergency Medicine (EM), Nursing, Radiology, Neurology, Neurosurgery, Pharmacy, Surgical Services, and Operations Excellence, along with residents from each specialty, convened for a Lean initiative to reduce door to treatment (DTT) times in an academic Comprehensive Stroke Center. An extensive process map was generated that identified 1) unclear role delineation for EM, Neurology, and Neurosurgery residents, and 2) uncertainty in optimizing the simultaneous processes of history-taking, NIHSS assessment and imaging determination. A model clarifying CT decision–making guidelines and designating a team leader or “Stroke Quarterback” was developed. A three month test of the process was conducted. Results: There was a 42% improvement in DTN within 45 minutes and 33.4% improvement in DTP within 90 minutes when compared to the same 3 month period one year prior to the test of change (figure 1). The rate of DTT within goal varied from month to month. Conclusions: Despite the varied levels of experience and training of providers at an academic hospital, the acute stroke response team must provide consistent and expeditious care in every instance. Identifying a team leader as a “stroke quarterback” allows for real-time decision-making (audibles), clear delegation of responsibilities (player assignments) based on experience, and utilization of structured processes (playbook). Our model is well-suited for the academic medical center environment and appears to reduce time to treatment.

Abstract TP293: Door to Needle Time Over Telestroke for Primary Stroke Center Spokes versus Non Primary Stroke Center Spokes

Background: Faster door to needle (DTN) times has been shown to lead to better functional outcome in patients with acute ischemic stroke. The implementation of telestroke networks has improved access to intravenous alteplase (tPA). In this study, we aim to compare DTN time between of tPA administered through telestroke in primary stroke center (PSC) spokes versus non-PSC spokes. Methods: A retrospective review of prospectively collected data on patients who received tPA through the Medical University of South Carolina telestroke program between July 2016 and March 2018. Collected data included baseline characteristics, baseline NIH stroke scale, door to CT times, door to telestroke consult time, symptom-onset to needle time, time between tPA decision and tPA administration, door to needle time, and 90-day modified Rankin scale (mRS). Wilcoxon Rank-sum (Mann-Whitney) test was used to compare median times between different groups. Results: During the study period, 399 patients received tPA through our telestroke network (314 received tPA at PSC spokes, and 85 received tPA at non-PSC spokes). PSC patients had more females (61.2%) compared to non-PSC patients (48.2%) (P=0.032). Other baseline characteristics including age and race were similar between both groups. Median NIHSS was 6 for both groups (IQR 4-9) (P=0.59). Mean times for all procedure measures were longer in non-PSC spokes; Door to CT: 8 min Vs. 5 min (P=0.029), Door to telestroke consult: 24 min Vs. 20.5 min (P=0.017), Symptom-onset to needle: 150 min Vs. 122 min (P=0.001), tPA decision to tPA administration: 20 min Vs. 10 min (&lt;0.001), and Door to needle: 65 min Vs. 54 min (P&lt;0.001). There was a trend towards having good functional outcome (90-day mRS 2 ) in the PSC group (79.1% and 75.7% of patients in PSC and non-PSC respectively, P=0.054) Conclusion: In our study, PSC spokes had better performance in the procedural measures for tPA administration than non-PSC spokes. Further research is needed to study the trend of these measures over time and to study the effect on the long-term functional outcome.