Save a Brain- Getting your ED ready for Comprehensive Stroke Certification

Abstract

Session D presented Thursday, September 27, 2:30-3:30 pm Purpose: Stroke is the 5th leading cause of death in the U.S. Our health system is located in the Southeastern part of the United States in the middle of the Stroke belt/buckle. Our hospital has been designated as a primary stroke center since 2007. In preparation for Comprehensive Stroke survey our Stroke CPI committee initiated subgroups to address our performance improvement plans. One of these major initiatives was to improve our door to puncture times for patients arriving to ED by EMS. Design: This EBP project was triggered by a LEAN initiative. This LEAN team was comprised of staff from multidisciplinary departments. Setting: This LEAN project was conducted in an ED designated Level II Trauma Center with greater than 110,000 patient visits per year. Due to our southeastern location in the U.S. we activate greater than 1,000 code strokes per year. Participants/Subjects: All EMS patients presenting to the ED as a Code Stroke (0-8 hours of last know well) were included. All ED staff was educated on the new Code Stroke standardization process and participated in this project. Methods: A multidisciplinary team was established to analyze our door to puncture process. The team completed an A3 lean analysis of current door to puncture process and identified areas for process improvement. Areas identified for improvement included; parallel work at time of patient arrival ( obtain patient weight, tPA administration, advanced imaging), improved handoff from ED to IR, and parallel work between anesthesia and IR. at time of procedure. With these findings we implemented a Code Stroke cart in CT with necessary supplies (cardiac monitor, laptop, IV supplies, foleys) to prevent unnecessary transfer back and forth to ED and radiology. Neuro-hospitalist were advised to order CTA's immediately after CT Head on patient's with Large Vessel Occlusion symptoms. In addition, education was completed with the pharmacist to respond to all Code Strokes and mix tPA in CT for eligible patients. EMS was also involved to began starting 2 large bore IVs prior to arrival. A tool was developed to show each team member's role and the expected time of completion. Staff received a in-service and tour of the IR department with new expectations of transporting patients to IR upon activation. Audits were completed for each patient and feedback given to all staff members involved. Results/Outcomes: While preparing for our Comprehensive Stroke Certification and working on our process improvement plan, our team was able to make huge impacts on our Door to Puncture and Door to Needle Times. Our average Door to Puncture Time decreased from 140 minutes to 85 minutes. Inadvertently, Door to Needle Time decreased from 50 minutes to 35 minutes with the change in process of tPA being administered in CT.. Implications: The A3 LEAN process has impacted both door to puncture and door to needle times positively effecting patient outcomes. In addition this LEAN process developed standard of work for care of the Acute Stroke patient.