Improve Indoor Research Articles

Abstract TP32: Continuous Quality Improvement Implementation Across A Stroke Network

Background and Purpose: One of the network missions is to improve quality of care through an evidence-based, standardized approach. In 2014 with 24 affiliate hospitals (25% certified stroke centers), a formalized continuous quality improvement process began and it continues through today with 37 affiliate hospitals (51% certified stroke centers). Methods: Over the years, the quality process has been enhanced to include additional abstraction training/support, individual data points for improved data analysis and a newly developed data report with built in logic and automatically populated graphs. Data is aggregated for network analysis and an annual scorecard is published that is utilized for benchmarking. Performance improvement (PI) goals are established as a network. Results: In 2014, 88% (21 of 24) affiliates submitted stroke data, compared to 91% (32 of 35) in 2022 fiscal year (Note: two affiliates are pending training). In 2022, 80% of non-certified stroke centers submitted data, compared to 100% for certified stroke centers. For Thrombolytic Therapy (STK-4), 79% compliance rate in 2014, compared to 89% in 2022; Thrombolytic Therapy (ASR-OP-1), 66% compliance rate in 2021, compared to 88% in 2022. For Dysphagia Screening (STK[PM]-7), 58% of the affiliates submitted data in 2014 with average of 92% compliance, compared to 89% in 2022 with an average of 87%. For Order Set Usage, in 2018 61% of the affiliates submitted data with an 87% compliance rate, compared to 89% of the affiliates submitted data with an 87% compliance rate in 2022. From 2018 to FY2022, the network had a 10% improvement in Door to Needle (≤ 60 minutes) from 66% compliance to 76%. Conclusions: The network showed improvement with the CQI program in: data submission rates, Door to Needle Time, and Thrombolytic Therapy. This is a success overall, particularly with the non-certified stroke centers. Though there are many confounding factors, this is in correlation with our focused improvement efforts such as individual follow-ups, data abstraction training, quarterly review of data, sharing best practices, updating program documents, monthly quality insights and education with affiliates.

Tenecteplase use in the management of acute ischemic stroke: Literature review and clinical considerations.

Several research articles have been published within the last decade comparing the use of tenecteplase to alteplase in ischemic stroke management. Prior reporting on the comparative therapeutic efficacy and safety profiles of tenecteplase and alteplase is reviewed. Tenecteplase is a variant of native tissue-type plasminogen activator, which rapidly promotes thrombolysis by catalyzing formation of the serine protease plasmin. Tenecteplase has theoretical advantages over alteplase as it has greater fibrin specificity and has a longer half-life than alteplase. This allows the administration of a single bolus over 5 to 10 seconds, as opposed to a bolus followed by a 1-hour infusion with alteplase. While currently approved by the Food and Drug Administration for the treatment of ST-segment elevation myocardial infarction, tenecteplase has also been studied in the treatment of acute ischemic stroke and has extensive data for this off-label indication. The most comprehensive trials to date evaluating the use of tenecteplase in acute ischemic stroke include the TNK-S2B, Australian TNK, ATTEST, Nor-Test, and EXTEND-IA TNK trials. Findings from these randomized controlled studies suggest that tenecteplase is at least as efficacious as alteplase in terms of neurological outcomes. The majority of these studies also reported a trend toward improved safety profiles with the use of tenecteplase. Current clinical evidence shows that tenecteplase is not inferior to alteplase for the treatment of ischemic stroke and suggests that tenecteplase may have a superior safety profile. Furthermore, tenecteplase also has practical advantages in terms of its administration. This can potentially lead to a decrease in medication errors and improvement in door to thrombolytic time.

Ongoing Improvement in Acute Ischemic Stroke Therapy Per Concurrent Guidelines and Easily Implementable Quality Improvement Protocol

Background: Despite proven efficacy of intravenous tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT) in acute ischemic stroke, there has been slow administration of these therapies in the real world practice. We examined the ongoing quality improvement in acute stroke care at our comprehensive stroke center. Methods: Consecutive patients with acute ischemic stroke from 2013 to 2018 were studied. Patients were managed using Code Stroke algorithm per concurrent AHA guidelines and a simple quality improvement protocol implemented in 2015. Demographics and clinical data were collected from Get-With-The-Guideline-Stroke registry and electronic medical records. Patients were divided into 3 groups per admission and implementation date of quality improvement initiatives. Quality measures, including rates of intravenous tPA and EVT, door-to-needle (DTN) time, and door-to-puncture (DTP) time, were analyzed with general mean linear regression models and Jonckheere-Terpstra test. Results: Of the 1,369 eligible patients presenting within 24 hours of symptom onset or wakeup stroke, the rate of intravenous tPA was 20%, 30% and 22%, respectively, in 2013-2014, 2015-2016, and 2017-2018. In contrast, EVT rate was 9%, 14% and 15%, respectively. Based on Jonckheere-Terpstra test, there was significant ongoing improvement in the median DTN time (57, 45, 39 minutes; p < 0.001) and DTP time (172, 130, 114 minutes; p =0.009) during the 3 time periods, with DTN time ≤ 60 and ≤45 minutes in 80% and 63% patients, respectively, in 2017-2018. Conclusions: Getting with the guidelines and simple quality improvement initiatives are associated with satisfactory rates of acute stroke therapy and ongoing improvement in door to treatment times.

Abstract P483: Immediate Feedback to Emergency Medical Services Reduce Door to Angiogram and Transfer Time for Endovascular Treatment of Large Vessel Occlusion Ischemic Strokes

Background: The morbidity of acute ischemic Stroke (AIS) caused by a large vessel occlusion (LVO) can be significantly reduced with endovascular intervention. However, delay in diagnosis can exclude a patient from therapy.Rapid Arterial Occlusion evaluation (RACE) score of five or more have an 85% chance of being LVO acute ischemic stroke. Pre-arrival notification of potential LVO cases by EMS (Emergency Medical Service) is an important factor to reduce door-to-transfer time from a Primary Stroke Center (PSC) to a Comprehensive Stroke center (CSC). We hypothesize that immediate feedback to EMS teams on their pre-hospital RACE score reporting will improve prehospital recognition of LVO strokes. Therefore, reducing the Door to Needle CTA (CT Angiogram) and/or Door to Transfer Time for endovascular treatment. Methods: Our inclusion criteria included patients with a diagnosis of AIS brought in by EMS with a RACE score of five or more, was given IV thrombolytics, or transferred to a comprehensive stroke center for endovascular treatment. A 5-item feedback form was developed for each case and was reviewed biweekly with our EMS liaison. Feedback included compliance with RACE score reporting, presence of IV access, CTA time, and TPA/Transfer time. Direct feedback was verbally given to the EMS transport team. Results: Comparison of data from a twelve-month preintervention period (n=29) to a four-month postintervention period (n=12) was conducted through direct comparison. This showed a decrease in mean Door-to-CTA time from 212.14 (CI ±83.3) to 97.08 (CI ±54.92) minutes with a p-value of 0.0126 in a one-tailed t-Test, a 54% reduction and a reduction in door to transfer time (305 minutes to 132 minutes, a 56.7 % reduction ). Conclusion: A pilot project focused on providing immediate feedback to EMS regarding accurate prehospital notification of RACE score showed a statistically significant improvement in door to CTA time and door to transfer time. Extension of the post study period is needed to confirm the significance of transfer time. This study demonstrates the importance of collaboration between a PSC and EMS to ensure prompt diagnosis and transfer for endovascular treatment of AIS caused by LVO.

Abstract TMP67: Prehospital Cath Lab Activation Based on EMS Large Vessel Occlusion Screen Cancelled

Background: Current guidelines indicate reduced time to reperfusion with thrombectomy is strongly associated with better outcomes. Validated screening tools for large vessel occlusions are available for the prehospital setting. Objective: To reduce door to access times for patients arriving by EMS to an urban 487 bed quaternary hospital. Methods: Starting in January of 2016, EMS crews screened all stroke patients with the Cincinnati - Stroke Triage Assessment Tool (C-STAT) and communicated results to the ED prior to arrival (PTA). In 2017, a team consisting of Neurology, ED, Cath Lab, Neuro Interventional leadership and stroke coordinator agreed to a 6-month pilot project of activating the Cath Lab when EMS radioed a patient was C-STAT positive. Any ED staff who might take EMS radio report were educated on the new process. Instructions were added to the existing Stroke Patient Checklist. Cath Lab and EMS staff were notified of the pilot project. During the pilot period, feedback was provided to EMS and ED leadership if an issue was identified for a specific case and trends were discussed. Results: During the pilot period, median door to access time for C-STAT positive patients who had Cath Lab activated PTA was 66 minutes compared to the 104 minutes the previous year (37% reduction). Unexpectedly, the median door to needle time for these patients also improved from 45 minutes the previous year to 28 minutes (38% reduction). The Cath Lab was activated PTA 16 times for patients EMS reported as C-STAT positive; Only 5 went on to have a thrombectomy. Overcalls were due to lack of C-STAT specificity (n=6) or C-STAT not scored correctly (n=5). In practice as well as when cases associated with assessment errors are removed, C-STAT demonstrated a low specificity for LVO (37.5% and 40% respectively). Lastly, internal process issues lead to 5 additional PTA Cath Lab activations for patients EMS did not report as being C-STAT positive. Conclusions: It was felt additional education would not be enough to make this initiative sustainable given the low specificity. In conclusion, despite marked improvement in door to access and door to needle times, the overactivation of Cath Lab lead to the initiative being cancelled.

P1764Quality criteria for STEMI care - a national perspective

Abstract Introduction The definition of quality criteria in health care is essential to implement structural organization strategies that ensure that patients (P) receive the best care according to the most updated recommendations available at the time they are treated. Quality indicators have recently been defined with regard to the approach and treatment of STEMI in the European Guidelines published in 2017. Objective The authors intend to characterize the level of care provided to P with STEMI inserted into a national multicenter registry since 2011 in order to establish a relationship with international recommendations. Population and methods Descriptive study based on a national multicenter registry. A total of 2051 P admitted to the hospital with the diagnosis of STEMI were included, 1266 P for the year 2011 and 785 P for the year 2016. Results The P of the year 2011 and 2016 presented similar age (64±14 vs 63±13). There was a higher percentage of P admitted by STEMI fast track managed care system in 2016 (36.9% vs 22.2%, p<0,001) and less from the Emergency Department (31.6% vs 56.8%; p<0,001). Regarding the transport to the Hospital, there was an increase in patients transported by prehospital medical teams (28% vs 21%; p<0,001) and less by own means (35.7% vs 45.6%; p<0,001). Regarding in-hospital therapy, it was found that in 2016 more patients received loading doses of P2Y12 inhibitors – Clopidogrel (78.1% vs 70.3% P<0,001) and Ticagrelor (54.7% vs 0.7% P<0,001). In post-discharge therapy, there was also a slight improvement in care in 2016, with more P being treated with P2Y12 inhibitor (96.2% vs 92.4%; p=0.03) and beta-blocker (84.4% vs 78.7%; p<0,001). Regarding the type of reperfusion, there was an increase in angioplasty (95.5% vs 92.2%; p<0,001) and a decrease in fibrinolysis (4.5% vs 7.8%; p=0.03) in 2016. There was a slight worsening of the prehospital delay in 2016 (median 163min vs 120min) and an improvement in door to reperfusion time (median 60min vs 70min). There was also an increase in angioplasties performed in 2016 (87.1% vs 85.1%; p<0,001) as well as an increase in the percentage of left ventricular function evaluation before discharge (98.2% vs 93.9%; p<0,001). Conclusion The results presented demonstrate a slight improvement in the quality of the care provided to STEMI P. However, there are areas for improvement, in accordance with international recommendations, in particular with regard to reperfusion times.

Abstract WP507: Improvement in Door to Needle Time to Intravenous Thrombolysis With on Site Stroke Activation Nurse

Introduction: Effectiveness of stroke thrombolysis is highly dependent on early initiation of therapy, and strategies have been developed to reduce the door-to-needle time (DTN). Aim: To determine the impact on DTN after introduction of stroke activation nurse (SAN) in a teaching hospital. Methods: Our hospital is the comprehensive stroke center serving western Singapore and admits about 900 acute ischemic stroke patients per year. Previously thrombolysis was commenced after evaluation in the Emergency Department (ED) and admission to the Neurology high-dependency unit, causing considerable delay to treatment. From May 2015, a SAN joined the stroke code and evaluated all thrombolytic candidates, obtained NIHSS scores, calculated the dose and prepared the tPA for administration in ED. From September 2016, addition of a second SAN allowed faster response, especially in simultaneous stroke activations. From a prospective database of our patients treated with thrombolysis, we compared patient characteristics and DTN during three 16-month periods before and after SAN participation: Jan 2014-Apr 2015 (Baseline), May 2015-Aug2016 (Period 1), and Sep 2016-Dec 2017 (Period 2). Results: A total of 555 patients received thrombolysis, with mean age 67.5 years, 41% female, 73% hypertension, 35% diabetes mellitus, 55% hyperlipidemia and 31% atrial fibrillation. More patients were thrombolysed after SAN participation in the stroke code, from 146 (14%) at baseline, to 191 (17.6%) in Period 1 and 218 (18.8%) in Period 2. The median (range) NIHSS scores during these periods were 16 (2-32), 13 (1-33) and 12 (2-35) respectively. Mean (SD) and median DTN at baseline was 80 ( ±32) and 77 mins, which decreased to 63 ( ±32) and 57 mins in Period 1, and 58 ( ±29) and 52 mins in Period 2 . Percentages of patients thrombolysed within 60 mins improved from 25.3% at Baseline to 56.5% and 67% during Periods 1 and 2 respectively. Conclusions: Our results showed that involvement of SAN was associated with decrease in DNT and enabled more patients to be treated with intravenous thrombolysis.

Abstract TP352: Work Flow Optimization in Acute Stroke Therapy in a Community Based Comprehensive Stroke Center

Background and Purpose: In acute stroke therapy, faster reperfusion leads to better outcome. We analyzed optimization steps to reduce treatment delays at a comprehensive stroke center in a non-academic tertiary hospital. Methods: Consecutive patients with ischemic stroke treated with either IV tPA, endovascular therapy or both were analyzed. Patient metrics were divided into two periods: pre-optimization period and post-optimization period. Key interventions of this workflow included: (1) addition of pre notification by EMS to ER and stroke team; (2) dividing stroke alert to level 1 (potential IV/IA candidate) vs. level 2; (3) direct transportation of level 1 stroke patients to brain CT imaging; (4) limitation of non-essential interventions; (5) 24/7 code stroke response by an in house trained vascular midlevel (NP/PA) and vascular neurologist (either in house or through telestroke network);(6) earlier notification of IR team; (7) CT to angiosuite direct transportation for LVO; (8) multidisciplinary monthly meetings to discuss delayed cases. Door to needle time and door to puncture time were used as target metrics in order to measure improvement. Results: A total of 279 patients were identified (101 in the pre-optimization and 178 in the post- optimization periods). No significant differences in any of the patient’s baseline characteristics were documented in the two observation periods. Almost all metrics favored the post-optimization period with a remarkable improvement in door to puncture time (64 (IQR 36-86) vs. 47 (IQR 20-62) min, p=0.002). Although non-statistically significant, we observed an increased percentage of good clinical outcomes in the post-optimization group (60.1% vs 54.8%, p=0.500). Conclusions: For patients undergoing acute reperfusion therapies, significant reductions in workflow time-frames can be achieved after simple optimization steps in a non-academic community based hospital.

Abstract WP411: Evaluation of Strategies to Reduce Time to Revascularization in Acute Ischemic Stroke

Background: There is growing support for the need for process improvement surrounding treatment of acute ischemic stroke, specifically, reducing time to reperfusion in endovascular therapy (EVT). Streamlining protocols from patient presentation to revascularization can lead to improved timelines to treatment and functional outcomes. Purpose: The purpose of this study was to identify the impact on specific hospital based process improvement strategies in the acute ischemic stroke patient population undergoing endovascular therapy with specific intent to decrease median arrival to revascularization time, thus increasing the potential for good functional outcome. Methods: The study includes a pre- and post-intervention retrospective review of patients 18 years or older, hospital admission between January 1, 2014 and December 31, 2015, who underwent EVT for treatment acute ischemic stroke. The primary outcome variable was time from arrival to revascularization during the acute ischemic stroke admission. The secondary outcome variables were specific to functional outcome analysis in the acute ischemic stroke patient. The data points were collected from the local America Heart Association’s Get with the Guidelines-Stroke (GWTG) dataset. Results: Twenty eight consecutive endovascular ischemic stroke patients were reviewed, pre process improvement (PI) (Group 1, n=10) and post PI (Group 2, n=18). There were no significant differences between baseline characteristics between the groups. The primary outcome analysis revealed significant improvement in door to revascularization between the pre and post PI groups, 2:56 and 2:11 (p=.002) respectively, a 45 minute decrease in time to treatment. Rates of good clinical outcomes (modified Rankin Scale 0-2 at 3 months) were similar in both groups, 33.3% pre PI and 46.2% post PI (p=0.59). Conclusions: Hospital based PI initiatives including: early notification, streamlined transport process, and utilization of feedback tool significantly improve door to revascularization times and can potentially lead to improved functional outcomes in the acute ischemic stroke patient undergoing EVT.

Improving Door to Needle Thrombolysis in Acute ST-Elevation Myocardial Infarction

Background: Although primary percutaneous coronary intervention is the recommended method of reperfusion for ST-segment elevation myocardial infarction patients, thrombolytic therapy should still be given to ST-segment elevation myocardial infarction patients when anticipated delay in percutaneous coronary intervention is more than 120 minutes from first medical contact.
 Objective: The aim of this study is to assess improvement of door to needle time in cases of ST-segment elevation myocardial infarction after applying new clinical pathway for cases of ST-segment elevation myocardial infarction presenting to Emergency Department at King Abdulaziz University Hospital over one year period.
 Methods: A prospective study conducted at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, in patients with ST-segment elevation myocardial infarction who underwent thrombolysis from November 2012 to October 2013 to compare door to needle time obtained from this study with door to needle time from previous records during October 2010 till September 2011.
 Results: A total of 93 patients with ST-segment elevation myocardial infarction received thrombolytic in Emergency Department. Mean age 50 years. Median door to Electrocardiogram 3 minutes, median Electrocardiogram to thrombolytic 25 minutes and door to needle time 30 minutes. 54.8% of patients received thrombolytic within 30 minutes or less.
 Conclusions: Improvement in door to needle time for thrombolysis of cases of ST-segment elevation myocardial infarction has been achieved at King Abdulaziz University Hospital during the period of the study compared to previous data.

Reinventing Emergency Department Flow via Healthcare Delivery Science.

Healthcare system flow resulting in emergency departments (EDs) crowding is a quality and access problem. This case study examines an overcrowded academic health center ED with increasing patient volumes and limited physical space for expansion. ED capacity and efficiency improved via engineering principles application, addressing patient and staffing flows, and reinventing the delivery model. Using operational data and staff input, patient and staff flow models were created, identifying bottlenecks (points of inefficiency). A new flow model of emergency care delivery, physician-directed queuing, was developed. Expanding upon physicians in triage, providers passively evaluate all patients upon arrival, actively manage patients requiring fewer resources, and direct patients requiring complex resources to further evaluation in ED areas. Sustained over time, ED efficiency improved as measured by near elimination of "left without being seen" patients and waiting times with improvement in door to doctor, patient satisfaction, and total length of stay. All improvements were in the setting on increased patient volume and no increase in physician staffing. Our experience suggests that practical application of healthcare delivery science can be used to improve ED efficiency.

Abstract T P336: Pursuit of Door to Needle Reductions through Enhanced Partnerships: A Paradigm Shift

Purpose: Ischemic stroke patients, who meet criteria to be administered t-PA, should receive a patient-focused effort that advocates for quality, efficacious treatment. It’s essential to continuously evaluate the impact that a model of care delivery has on clinical outcomes. Healthcare reform may dictate utilization of current resources and often allocation of those resources are re-aligned to meet financial targets. The model of care delivery referenced in this study includes primary responders on a code stroke team that have transitioned from a unit based resource to an emergency room resource. Quality outcomes are a priority and overcoming obstacles to prevent delays in meeting the national benchmark of door to needle time in less than 60 minutes requires enhanced partnerships. The purpose of this study was to determine the effects that a model of care delivery for acute stroke response had on door to needle time and identify the impact from utilization of value stream mapping. Methods: Retrospective chart reviews were conducted on stroke patients that received t-PA over a 5 year period. Comparative analysis of all response times were reviewed for trends and opportunities that may have also been impacted by the model of care delivery. Immediate review and feedback on every case served as a catalyst for quality improvement, engaging all providers to implement changes that would improve door to needle times. Response time data was analyzed to determine if there was statistical significance, such that all opportunities for improvement to reduce needle to door time to < 60 minutes could be addressed with action plans. Results: Percentage compliance of door to needle time within 60 minutes increased from 17% to 63% during the study period. Opportunities to further reduce door to needle times reveal potential decrease of key response times by approximately 20 minutes. This is evidenced by continued improvement in the average door to needle time by 15 minutes during the study period. Conclusion: Transition of care delivery models with ownership and team engagement can result in a paradigm shift that indicates effective action plans for quality improvement in door to needle times. Further insight from value mapping serves as a guide for lean processes.

Abstract T P272: Improvement in Door to Thrombolytic Time in a Rural Community Hospital

Background: Receiving thrombolytic therapy as soon as possible from stroke onset improves chance of complete or near complete neurologic recovery and reduces risk of bleeding. McLaren Northern Michigan (MNM) is a 213 bed nonacademic, regional referral hospital servicing 22 counties. The decision to give thrombolytic therapy at MNM has been the responsibility of the on-site neurologist. Neurological assessment, completion of inclusion/exclusion checklist and verification of stroke onset time were the responsibilities of the Code Stroke neurologist after arrival from home or office. Hypothesis: In a rural community hospital door to thrombolytic time can be reduced by using telephone neurology consultation and a revised multidisciplinary approach to treatment. Methods: Reviewed select Code Stroke data from 2012 to 2013 by a multidisciplinary team: Notification to neurologist arrival in ED Neurologist arrival to decision to treat Decision to treat to start of thrombolytic bolus Door to start of thrombolytic bolus Results: Identified delays: Neurology travel from home or office to ED Completed inclusion exclusion checklist, verification of onset time and neuro assessment by on-site neurologist Mixing of thrombolytic agent by nursing Revised the Code Stroke protocol to shift responsibilities from on-site neurologist to onsite ED nurses and ED physician. Provided with phone consultation with neurology: Documentation and verification ”Last Known Well” time Initial NIH Stroke Scale score and major deficits Results of Inclusion / Exclusion checklist Revised Code Stroke protocol to include a pharmacist at bedside to mix thrombolytic. Conclusion: Door to thrombolytic time was significantly decreased by shifting Code Stroke responsibilities and incorporating a pharmacist at the bedside. There were no major bleeds or adverse events

Abstract T P277: “The July Effect” in Ischemic Stroke Patients Receiving tPA

Objective: Each July thousands begin residencies and acquire increased responsibility for patient care. There is disagreement in the medical literature about whether a so-called July Effect, actually exists. There is paucity of data specifically looking at ischemic stroke patients receiving tPA. Approximately 1.9 million neurons die each minute from the onset of ischemia so we tried to evaluate if there is improvement in door to needle times for tPA administration from July to June. Methods: A Retrospective Review of patients admitted with symptoms of stroke to the Neurology department at our hospital from July 2013 to June 2014. Inclusion Criteria were all patients who met the criteria and received IV tPA. Results: During the study period, 60 patients met the criteria. The average tPA door to needle time in the month of July 2013 was 74.5 minutes and it increased to 93.5 minutes in the month of August 2013. The average door to needle time in the month of June 2014 was 45 minutes. There was significant decrease in the door to needle times form the month of July 2013 to June 2014 (p= 0.015). Please see figure 1 below for the average door to needle time over the year starting from July 2013 to June 2014. Discussion: The average door to need time is significantly lower in June 2014 when compared to July 2013 (P=0.015). It could be due to multiple factors including the new residents in the Emergency Department(ED) and Neurology residents taking call, as door to needle time includes the time when stroke alert was called after patient arrives in the ED, time taken by the neurology resident to examine the patient, time taken for the imaging, time taken for the decision to be made to give tPA, time taken by the pharmacy to get tPA ready and time to start tPA. Close supervision of the new residents with senior housestaff and adequate training including mock stroke activations may be helpful in overcoming this variation.

Abstract W P355: Emergency Room Stroke Nurse Facilitator Improves Door to Needle IV rtPA Time in a Rural Hospital

The National Institute of Neurological Disorders and Stroke benchmark treatment time for acute ischemic stroke with intravenous rtPA door to needle time is 60 minutes or less. Hospitals identified as Primary Stroke Centers will be required to treat 50% of their patients who qualify for rtPA within that time frame. Acute stroke care requires the skills of a multidisciplinary stroke team with nursing playing a pivotal role in the emergency room setting, including meeting the benchmark for IV rtPA administration. Review of the literature reveals that nurses comprehend the importance of and have a desire to provide timely and quality acute stroke care but there may be barriers to achieving that end including; lack of proficiency with the NIH stroke screen assessment, other emergency department demands and staffing challenges that affect stroke care. As part of the ongoing process improvement program at our 180 bed primary stroke care center in rural northwestern Pennsylvania, we hypothesized a need for an emergency room stroke nurse facilitator to meet the 60 minute door to needle IV rtPA time. Our hospital treated an average of 14 patients per year with IV rtPA from 2010 to 2013. We used a sample population of 31 participants representing all those presenting to the emergency department qualifying for IV rtPA: 13 patients from January to November 2013 before starting the stroke nurse facilitator role, 18 patients from December 2013 to May 2014 after starting the stroke nurse facilitator role. Data was collected from Get with the Guidelines stroke data base. Results revealed that before starting the role of the stroke nurse facilitator, the average door to needle IV rtPA time was 68 minutes with mean time of 70 minutes. After starting the role of the stroke nurse facilitator the average IV rtPA door to needle time was 60 minutes with a mean time of 47 minutes. In conclusion, a stroke nurse facilitator appears to provide improvement of door to needle IV rtPA time in the emergency room setting. Our goal is to maintain the stroke nurse facilitator and follow outcomes to determine if this improvement is sustainable.

Abstract W P217: Improvement of Door to Needle Times and IV rt-PA Utilization with the Application of TARGET:STROKE Recommendations to an Urban Integrated Tele-Medicine System

Background and Objectives: Tele-medicine (TM) has been proven to provide quality acute stroke care. The type of consultation and services provided by TM vendors vary. None seem to provide a comprehensive service to the receiving center that includes methods on how to improve door to needle times (DTN). We hypothesized that creating a comprehensive TM solution in an integrated medical system using TARGET: STROKE (TS) principles would improve DTN times and IV rt-PA utilization. Methods: Five urban Joint Commission certified primary stroke center community hospitals in a Southern California integrated healthcare system participated. Prior to initiation of TM services, each hospital had two separate meetings with the TM provider (two vascular neurologists). The first meeting was with emergency room physicians, explaining the need to have a low threshold to call a tele-code stroke within 4.5 hours of last seen normal regardless of inclusion/exclusion criteria and prior to obtaining the head CT. The second meeting included a multi-disciplinary group to outline the TS principles and organize a stroke team with a focused goal to improve DTN. The 10 TARGET: STROKE best practice strategies were implemented. Data regarding the key time interval goals were gathered and reviewed with each hospital on a bi-weekly basis. The TM providers worked with each hospital to improve specific time intervals where necessary by providing proven strategies, and assisting in their implementation. Data were analyzed using a parallel time period at each hospital comparing pre-TM to post-TM, the longest period being 11 months. Results: Twenty-eight patients were given rt-PA pre-TM compared to 50 patients post-TM. The percent of patients who received rt-PA ≤ 60 minutes (min) pre-TM was14% vs. 42% post-TM (p=0.02). The median pre-TM DTN was 78 min (IQR 68-116) compared to a post-TM DTN of 67 min (IQR 56-78), an absolute difference of 11 min (p=0.007). Conclusion: Application of TARGET: STROKE guidelines can be implemented successfully via an integrated TM system of stroke care to improve DTN and rt-PA utilization.

Abstract T P288: Improvement of Door to Groin Time for Endovascular Therapy in Acute Ischemic Stroke Using Quality Improvement Methods

Objective: Time has been identified as a key variable to the success endovascular treatment of acute ischemic stroke. This project was designed to reduce the time from patient arrival to groin puncture for these treatments at a single academic hospital. Methods: Using Plan-Do-Study-Act (PDSA) quality improvement methodology, a multidisciplinary team was created to identify ways to reduce time from patient presentation to groin puncture. A comparison of pre-intervention and post-intervention times was performed. Pre-intervention patients were retrospectively identified using existing databases and post-intervention patients were prospectively identified. Process maps were created to identify areas of delay. Debriefs helped to indentify future process improvements. Four PDSA cycles have been completed. Stroke neurologists instituted an early notification of IR physicians and a unified imaging protocol. Other interventions included a group paging system, standardized order sets, education within each discipline, improved communication, standardized stroke tray set-up, and streamlining preparation of the patients prior to transportation from the ED. Results: The median time from presentation to groin puncture was reduced from 126 minutes to 92 minutes. MRI imaging was associated with a long pre-intervention time to groin puncture, with a median of 182 minutes that was reduced to 99 minutes. Procedures outside of normal business hours were associated with long time to groin puncture, with a median time of 149 minutes that was reduced to 125 minutes. Conclusions: A reduction of time from presentation to groin puncture is possible using PDSA cycles. This QI project decreased time to groin puncture by 26%, showing that a systematic evaluation of institutional-specific workflow can improve the process preceding a time-sensitive procedure.

AS-020 Improvement in Door to Balloon time for Acute ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention after appointment of Emergency Heart Disease Specialized Center

AS-020 Improvement in Door to Balloon time for Acute ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention after appointment of Emergency Heart Disease Specialized Center

Improvement in Door to Balloon Times in Management of Acute STEMI via the Initiation of “Code AMI”

Improvement in Door to Balloon Times in Management of Acute STEMI via the Initiation of “Code AMI”