Improving Door to CT Times for Stroke Patients using EMS Pre-Notification

Abstract

Purpose: The American Heart Association/American Stroke Association’s Target Stroke initiative, recommends an expedited process for the transport of stroke patients by EMS directly to CT. The ultimate goal is to achieve a Door to Needle (thrombolytic therapy) Time of less than 60 minutes. The objective of this project was to optimize our pre-notification process and decrease the Door to CT time for stroke patients arriving by EMS to the Emergency Department as part of an initiative to decrease Door to Needle Time. Design: This was a quality improvement project designed to expedite the care of potential stroke patients that arrived to the Emergency Department via ambulance. The objective was to design a pre-hospital notification tool for EMS to utilize and communicate directly to the ED physician on duty. This would initiate a stroke alert prior to the patient's arrival in the ED. The patient would then be expedited directly to the CT scanner which would save valuable minutes should they then become eligible to receive tPA. Setting: A community hospital with 200 inpatient beds and 31 Emergency Department Beds. Participants/Subjects: ALL ED staff, radiology staff, members of the stroke team, and EMS agencies participated in this initiative. Methods: The PDCA methodology was employed. The Emergency Department (ED) team in collaboration with local EMS agencies, redesigned and implemented the EMS Stroke Screen1, a pre-notification tool that is used to communicate potential stroke cases en route to the ED. Education of ED and EMS staff occurred in August 2016, followed by a September 12th implementation date. Upon dispatch, the paramedic now speaks directly to the ED physician on duty, conveying the information captured by the tool, and a pre-hospital stroke code is initiated. By consistently using this tool and method of pre-notification, patients are received immediately upon arrival, quickly assessed by the ED physician, and expedited to the CT scanner. Results/Outcomes: Baseline data for the five month period 4/1/16-9/11/16 reflects a median Door to Stroke Code time of 2 minutes and a median Door to CT Initiated time of 16 minutes. The five month period post-implementation, reveals a more efficient process of Stroke Codes called 4 minutes prior to ED arrival (-4) and Door to CT Initiated at 8 minutes. This translates to a 300% decrease in median time for Door to Stroke Code and a 50% reduction in median time for Door to CT Initiated. Data for following quarters showed sustained improvement, door to stroke code times through the last quarter of 2017 ranged from 2 minutes to -3 minutes and door to CT times from 7-8 minutes. Implications: By implementing a pre-notification tool with local EMS agencies and introducing a direct to CT process, we were able to significantly reduce both Stroke Code and CT Initiation times. Additionally, EMS pre-notification calls have increased from between two to five per quarter prior to the initiative, to ten in Q1 2017 demonstrating their engagement, collaboration and commitment, both to the revised process and providing high-quality and timely stroke care.