Stroke Center Reduces Door-to-Needle Times to Less Than 30 Minutes

VBCN - May 2015 Volume 2, No 1

Washington, DC—When a stroke occurs, every second counts. A minute may feel like a lifetime, or, to a neurologist, like 1.9 million neurons—the average loss of neurons per minute during which a patient with stroke goes untreated.

Despite the urgency of stroke care, in 2009 less than one-third of US hospitals had a mean door-to-needle time of less than 60 minutes. According to a study presented at the 2015 annual meeting of the American Academy of Neurology, however, a stroke center in metropolitan Denver is making the seemingly impossible a reality: door-to-needle times that have bested the 15-minute mark.

“There is plenty of substantiation in the literature that patients’ outcomes are improved with faster door-to-needle times,” said Judd M. Jensen, MD, Swedish Medical Center, Englewood, CO. “I think it’s well-established that whatever we do to our stroke patients, we have to do it fast.”

With a team of 8 neurologists who specialize in the treatment of patients with stroke, Dr Jensen’s Joint Commission–certified Comprehensive Stroke Center in metropolitan Denver annually treats more than 1000 patients who have been diagnosed with stroke. Despite the center’s impressive door-to-needle times with respect to the national average, once these times were examined for efficiency, Dr Jensen observed an all too linear process that was almost painstakingly sequential.

Patients were moved from room to room, visiting with nurses, emergency department physicians, and, finally, a neurologist, who would wait for confirmation from the computed tomography (CT) scanner before contacting a pharmacist, who would then begin the process of mixing tissue plasminogen activator (tPA).

“There seemed to be a lot of wasted time,” Dr Jensen acknowledged. “So, with the advice, consent, and enthusiasm of our emergency room physicians, we reevaluated our process and took several steps to improve our stroke alert process.”

First Initiative: Increasing Emergency Medical Service Prehospital Alert Rate

“We made a concerted effort to get our EMS [Emergency Medical Service] providers to notify us as soon as they were en route to our hospital,” Dr Jensen explained, which allowed the hospital’s stroke team to receive advanced notice of an incoming patient.

Creating a launchpad in the back of the emergency department specifically designated for the treatment of patients suspected of having a stroke was the next step, which was crucial to allow for procedures to occur simultaneously upon the patient’s arrival.

“A bunch of people descend on the patient,” said Dr Jensen. “Someone registers the patient; the neurologist is there getting history; NIHSS [National Institutes of Health Stroke Scale] is performed; a stroke coordinator is there. A lot of things happen all at once. EMS hopefully gives us a good history about last normal.”

If the patient is suspected of having ischemic stroke, the pharmacist is instructed from the launchpad to mix tPA before the patient is transferred to the CT scanner. A CT scan of the brain is then performed and interpreted by the neurologist. If tPA is indicated, it is given intravenously in the CT room.

Door-to-Needle Time: 30-Minute Average

Dr Jensen and colleagues evaluated the protocol in a study of 262 patients diagnosed with acute ischemic stroke whose mean initial NIHSS was 12. Starting in 2013 at 39 minutes, the median door-to-needle time fell to 31 minutes after only 1 year (P<.001). There were significant changes in treatment time windows, too.

“Almost 50% of patients are getting tPA within less than 30 minutes, and nearly all of them receive tPA in less than 60 minutes,” reported Dr Jensen. “We had a number of patients under 15 minutes, with 11 minutes being the fastest time.”

Faster door-to-needle times also led to a marked improvement in outcomes, Dr Jensen observed. Overall, 46% of patients had “excellent” discharge modified Rankin Scale values at the end of the study, marking a significant improvement. Drawing conclusions from the center’s success, Dr Jensen stressed that the multidisciplinary team effort needed to sustain such coordinated precision.

“Everyone has to be on board and enthusiastic,” he said. “Radiology has to clear the deck on the CT scanner when a stroke alert is coming in. Pharmacy has to be ready to mix tPA at a moment’s notice…and, very important, ED [emergency department] physicians and nurses have to be invested in this.”

As is often the case with teamwork, sacrifice is required.

“This is a disruption of their workflow,” he said. “It changes the way they do things. In particular, the ED physicians have to be comfortable with the fact that you are giving tPA to their patient in a CT scanner, because, at that point, the patient is registered as an ED patient. [The ED physicians] are the ones responsible for the patient, and yet you are giving a potentially lethal drug to their patient somewhere else.”

Finally, given the extraordinary value of time in the treatment of patients diagnosed with stroke, where a reduction of minutes can be tantamount to millions of neurons saved, Dr Jensen’s takeaway was a simple but powerful reminder of the importance of streamlining.

“It’s really about the elimination of unnecessary steps,” he concluded, “and thinking of doing things simultaneously instead of sequentially.”

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