Authors (including presenting author) :
Karin Chow (1), Michael FU (1), Members of NTWC – Coordinating Committee on Neuroscience (2)
Affiliation :
Acute Stroke Unit, Department of M&G (1), Department of DR & NM and Accident & Emergency in Tuen Mun Hospital (2), New Territories West Cluster, Hospital Authority.
Introduction :
The benefits of intravenous tissue plasminogen recombinant activator (IV-tPA) in acute ischemic stroke are highly time dependent. Because of the importance of rapid treatment, international guidelines recommend a door-to-needle )DTN) time of < 60 minutes.
Objectives :
Yet prior studies suggested fewer than 30% of IV-tPA treated were meeting this goal. To address this shortfall, Tuen Mun Hospital stroke team followed the “Target: Stroke” organized by the AHA/ASA to increase the proportion of stroke patients with DTN times < 60 minutes.
Methodology :
The expert members of NTWC committee review on improving DTN times and identified the keys evidence-based strategies associated with timely stroke treatment that could be most rapidly, feasibly, and cost effectively adopted in NTWC stroke center. Target: Modified Stroke key best practice strategies 1. Rapid triage protocol in AED and direct upgrade patient to CT-suite 2. Single call activation system 3. Use of stroke toolkit including guidelines and hospital-specific algorithms, standardized communication tools for critical pathways 4. Rapid acquisition and interpretation of brain imaging, communication via HA chat for rapid case discussion amongst interventionist 5. Rapid access to IV-tPA medication in AED 6. Rapid data feedback to stroke team on each patient’s DTN time and other performance data including patient-time-trackers. 7. Intensive stroke nursing management training through weekly case discussion, train-the-trainer, 3-tiers advanced stroke nursing training
Result & Outcome :
Data retrieved from 2018 to 2019 by TMH stroke nursing team. We analyzed door-to-CT time, DTN time, and CT to IV rt-PA time in consecutive patients treated with IV rt-PA 12 months pre-implementation and 12 months post-implementation. 98 patients were included in the pre-implementation and 75 in the post-implementation group. We found no significant difference between the groups in demographics, comorbidities, anticoagulation status, after-hours arrival, or in stroke etiology, but excluded those have different if needed prethrombolysis hypertension treatment. After implementation, median DTN time improved from 68 (interquartile range [IQR]: 30-156) to 59 (IQR: 34-121) minutes (P < .001). Door-to-CT time decreased from 21 (9-110) to 19 (7-55) minutes (P = .016), and CT-to-IV rt-PA time improved from 47 (IQR: 13-142) to 39 (IQR: 9-108) minutes (P < .001). Percentage of average D-T-N ≤ 60 min improved from 41.8% to 65.3%.
Conclusion
Hospital gap analysis identifies targeted interventions that lead to rapid and sustained improvement in treatment times.
Expertise has to exhibit a patient-centred and highly collaborative relationship to advance common goals of stroke care. Capacity to plan, deliver and evaluate high quality acute stroke services is essential for improvement of health care delivery and patient outcomes.
