Door to CT: Stalk the stroke
Background
Delayed diagnosis in patients with acute ischemic stroke still represents a blind spot in the assessment of quality health care indicators.
Study Aim
To evaluate a fast track program to reduce door to CT time and thrombolytic therapy in patients with suspected stroke admitted to emergency departments.
Materials & Methods
A retrospective archive study was conducted between 2015 and 2016. We collected clinical data on all stroke patients (n=577) admitted to the emergency department (ED) and compared the adherence to clinical guidelines before (n=309) and after (n=268) the intervention program was implemented.
The program comprised of four steps:
1. The ED nurse and neurologist receive an announcement of the imminent arrival of a stroke patient.
.2The staff wait for the patients in the shock room.
3. The neurologist performs a rapid assessment according to the NIHSS and simultaneously the nurse assesses the vital signs and takes a blood tests.
4. The nurse contacts the CT unit.
5. A rapid exit (less than 15 minutes) from the shock room.
Results
After implementing the intervention program, the median time to CT was 31 minutes compared to 51 minutes (p<.001); 109 patients (35.2%) received thrombolytic therapy compared to only 79 patients (29.4%) (p=.04); 61 patients (56%) vs. 50 (63.2%) underwent reperfusion with IV rt-PA (p=.003). Mechanical clot disruption was performed for 21 (19.2%) and 15 (18.9%) (P=.12) patients post- compared to pre- intervention, respectively. Integrated approach, namely, IV rt-PA and mechanical clot disruption was performed in 14 (17.7%) in 2015 and in 27 patients (24.7%) in 2016, before and after intervention, respectively (p=.02).
After implementing the intervention, more patients received a neurologist evaluation within 10 minutes (72.3%) compared to pre- intervention (56.6%) (p=0.04); and more patients stayed in the ED for less than 60 minutes (68.2% and 41.7%, respectively, p=0.001). It clearly appears that when comparing post- to pre-intervention, less time lags (in minutes) were measured in patients whose clinical guidelines were not achieved before the program.
Conclusion
Attaching a case manager to perform a rapid assessment of patients with acute ischemic stroke reduced the time for patients to receive at CT. These findings have significant implications for the quality of care for patients with suspected stroke admitted to an ED.
These findings also encourage further such interventions to achieve better outcomes in the critical assessment of stroke patients in the ED.
