Approximately two million neurons are lost every minute during an ischemic stroke. University of Colorado has a median time of 71 minutes for door to tissue plasminogen activator (tPA) administration. The American Stroke Association (ASA) sets a goal of 60 minutes or less from initial Emergency Department (ED) triage to intravenous thrombolysis for patients with ischemic stroke. That difference corresponds to the loss of approximately 20.9 million neurons.
We hypothesize that applying quality improvement principles, including datadriven process maps and plandostudyact (PDSA) cycles, will allow for identification of inefficiencies in the current tPA administration process amenable to intervention.
Baseline data from March 2010 to March 2011 were analyzed. All patients presenting to the emergency department (ED) with signs and symptoms consistent with ischemic stroke were included. The primary outcome is median time to tPA administration. Secondary outcomes include time to stroke alert activation, commutedtomography (CT) scanning, stroke team arrival to patient bedside, and interpretation of CT images. The median time to tPA was 71 minutes and 19% of patients received tPA in under 60 minutes. Stroke alerts in which tPA was not administered were slower at every measured step. For tPA alerts, the median time to CT, CT results, and tPA was 11 minutes, 43 minutes, and 71 minutes, respectively while nontPA cases had a median time to CT of 60 minutes. No patient received tPA beyond 3 hours and 10 minutes of symptom onset. Based on this data, several targeted interventions were initiated July 15, 2011: (1) stroke alert criteria revision to only include patients who are tPA candidates in order to increase stroke alert urgency, (2) stroke alert protocol revision to streamline efficiency in the process and allow events after noncontrast CT to occur in parallel rather than in sequence, (3) pharmacy to be present or available at all alerts to reduce time from tPA order to administration, and (4) real time data collection to allow datadriven modifications of processes in subsequent PDSA cycles. Revised stroke alert criteria and streamlined activation process were implemented using inservice educational forums.
This project demonstrates that quality improvement strategies, specifically process mapping and PDSA cycles, can be applied to stroke alert procedures in an academic medical center in order to successfully identify inefficiencies and design interventions to address them. Ongoing data collection will be used to refine the process map, identify strategies of further improvement, and generate new interventions in subsequent PDSA cycles.
To cite this abstract:Graves A, TadY D, Levin D, Harry E, Cumbler E, Glasheen J, Sweigart J, Reichelt K, Price L, Hudak M. Striving to Save 21 Million Neurons Through Quality Improvement. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97749. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/striving-to-save-21-million-neurons-through-quality-improvement/. Accessed November 20, 2019.