Once upon a time, long, long ago, physician progress notes were a way of recording the patient's condition and your treatments in the patient's chart in order to communicate and...
- When a patient has a stroke, every minute matters. The quicker the stroke is recognized by either the patient or their family, the quicker the emergency squad can get the patient to the emergency department, and the quicker the ER physician can evaluate the patient and administer intravenous t-PA, the better the patient will do.
t-PA has it’s greatest benefit if given within 3 hours of the onset of stroke symptoms. If given between 3 and 4 1/2 hours, it loses some of it’s beneficial effects but patients still do better than if they do not receive t-PA. After 4 1/2 hours, t-PA can actually cause more harm than good by increasing the risk of bleeding into the brain and making a stroke larger.
In the hospital, we only have control over the time between when the patient arrives in the ER until the time that the blood clot dissolving medication, t-PA, is given. For a hospital to be a designated stroke center, that time has to be less than 60 minutes, we call that the “door-to-needle” time. On the surface, 60 minutes seems like a long time and many people would wonder why it would ever take that long to given an IV medication after a patient comes to the ER.
The problem is that you first have to diagnose a possible stroke and this can be difficult when patients walk in the door with very non-specific symptoms. For example, is the patient’s had numbness from a stroke or did they sleep on their arm wrong, compressing the brachial nerve causing the hand to “feel asleep”? Or is the patient’s slurred speech due to a stroke or are they intoxicated? Second, the doctor has to get a head CT scan to be sure that the stroke is not hemorrhagic, that is bleeding into the brain – if the stroke is hemorrhagic, then t-PA can make it worse, not better. Third, there needs to be an evaluation by a stroke specialist to analyze the patient’s situation and determine if t-PA would be beneficial. In our case, we do this with “tele-stroke” where we have video communication with a stroke specialist available 24 hours a day. This stroke specialist is on-call for many hospitals in Ohio via tele-stroke technology.
In order to get all of this done within 60 minutes, the following are the guidelines for time intervals once a patient comes through the ER door created by the American Heart Association and the American Stroke Association:
- Evaluation by a physician – 10 minutes
- Stroke specialist contacted – 5 minutes
- Head CT scan completed – 10 minutes
- Head CT scan interpreted – 20 minutes
- Intravenous t-PA started – 15 minutes
- TOTAL = 60 minutes
There are several reasons why you would not want to give t-PA to someone having a stroke. For example, if their blood pressure is too high or if you cannot verify that the initial onset of stroke symptoms was < 4.5 hours, then you can make the patient worse with t-PA.
In order to meet these time intervals, the ER has to change the work flow for patients with stroke compared to other patients. Here are our tactics:
- Nurse activated internal stroke alerts. Rather than waiting for the ER physician to evaluate the patient to determine if there might be a stroke, we have empowered our nurses in the triage area to make that initial assessment. If they suspect stroke based on the patient’s symptoms, then they will activate the stroke process. We anticipate an increase in false alarms but the benefit should be a 10 minute savings.
- Initiation of the tele-stroke consultation immediately after the non-contrast CT scan. In our hospital, the protocol is for patients with suspected stroke to get a series of 3 CT scans: a non-contrast head CT, a CT angiogram of the brain, and a CT perfusion scan of the brain. The first CT dictates whether t-PA can be given safely and the second two help guide the use of other treatments, such as neurosurgical treatments. The problem is that the patient has to remain in the CT scanner after the first CT scan for 9 minutes while getting the other two CT scans. By not waiting for the second two scans, the benefit should be a 9 minute savings.
- The ER physician does the tele-stroke consult in the CT scan room. Usually, after the CT scans are completed, the patient is taken off of the CT scan table, transferred to a gurney, and then transported back to a regular ER exam room to do the tele-stroke video consult with the stroke neurologist. By taking the tele-stroke equipment into the CT scan room, we can eliminate the transfer and transportation time – the benefit should be a 5 minute savings.
- Stock t-PA in the emergency department Pyxis machine. In the past, when there was a stroke alert, our pharmacist would have to go from wherever in the hospital they were at the time, down to the pharmacy in the basement of the hospital to get the t-PA, and then back up to the emergency department. By stocking the t-PA in the ER, the ER nurses can pull the t-PA out of the Pyxis and have it ready at the bedside. This saves the pharmacist from having to first go to the pharmacy to get the drug and so she/he can go directly to the ER to reconstitute the medication for IV administration. The benefit should be a 6 minute savings.
- All stroke alerts go to the hospital medical director’s pager. Currently, I get receive pages for all STEMI alerts and all code blue alerts, 24-hours a day. If I am in the hospital, I go to all of these to help ensure that the hospital’s response is timely and effective. If I am at home or in the clinic, I can call in or check on-line through our electronic medical record to be sure that everything is running smoothly. The advantage is that it shows an institutional priority for good code blue responses and rapid STEMI “door-to-balloon” times. With this same personal response to all internal stroke alerts, we can emphasize that a stroke alert should activate the same sense of urgency as a code blue or STEMI. The benefit should be a 5 minute time savings.
- Mock stroke alerts. We do all sorts of drills the hospital: mock code blues, massive transfusion protocol drills, disaster drills, fire drills, etc. The purpose of drills is to be sure that when the real thing happens, everyone knows their role and is able to perform their role efficiently and effectively. By doing stroke drills, my hope is that we can achieve all of the above time savings to shave a total of 35 minutes off our our door-to-needle times.
Completing the evaluation and initiating treatment of patients with a stroke is truly a team effort involving the ER nurses, the ER physician, the tele-stroke neurologist, the radiology technician, the radiologist, and the pharmacist. In order to consistently get the door-to-needle time under 60 minutes, it requires every member of the team to be prepared, to be practiced, and to prioritize the patient.
June 25, 2017