4/28/2016
Improving Door-to-Needle Time:
EMS/Emergency Dept Stroke Care
10th Annual Cerebrovascular Symposium
Swedish Medical Center
Benjamin Seo, MD
Swedish Cherry Hill Emergency Dept
May 5, 2016
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Swedish Medical Center
Cherry Hill Campus
> Neurosciences/Cardiovascular
> Comprehensive Stroke Center
> GWTG Stroke Gold Plus
> Emergency Department
• Full service department
• 15 beds
• Approx 25k visits per year
• [] “code strokes”, approx []% tPA
cases
• Target Stroke Honor Roll Elite Plus
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Rationale for Improving DTN Times
Second leading cause of death globally behind heart disease
> Fifth leading cause of death in the U.S.
• 129,000 deaths per year (one every 4 minutes)
• 795,000 strokes annually in the U.S. (one every 40 seconds)
Leading cause of serious long term disability in the U.S.
• National Stroke Association: 40% of patients w/ impairment requiring
special care after discharge
• 10% will require nursing home level care,14% will experience another
stroke within the first year
• Estimated total cost of care $71.6 billion in 2012
• Projected to triple to $184 billion by 2030
(Mozafarrian et al, 2015)
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Time is Brain
1.9 million neurons are lost per minute (Saver, 2006)
• 14 billion synapses, 7.5 miles of myelinated fiber per minute
• Equivalent of aging 3.6 years per hour without treatment
Every 15 min reduction in DTN estimated to add 1 month of
disability free life (Meretoja et al., 2014)
• 1.8 days added per 1 min reduction in DTN time overall
• 0.6 days added for 80yo and NIHSS 20 | 0.9 days 80yo and NIHSS 4
• 2.7 days added for 50yo and NIHSS 20 | 3.5 days 50yo and NIHSS 4
Every 15 min reduction in DTN estimated to lower odds of
mortality by 5% (Fonarow et al., 2011)
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National Backdrop
1996: FDA approval of IV-tPA 0-3 hours onset
2003: AHA/ASA creation of Primary Stroke Center designation
> Get With the Guidelines Stroke Registry created
2009: AHA/ASA recommendation of 4.5 hour IV-tPA window
*2010: Target Stroke Campaign initiated
2012: Comprehensive Stroke Center designation created
2015: AHA/ASA updated guidelines for endovascular treatment
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Target Stroke
AHA/ASA national campaign to improve DTN times
> Campaign launched Jan 2010
• Goal of DTN w/in 60min for at least 50% of patients
> Studies at the time reported less than 30% of patient receiving IV-tPA
w/in 60min*
> 2010 national median DTN time of 78 minutes (GWTG Registry)
> Phase II started in 2015: DTN w/in 60min for 75% of patients, 45min
for 50%
*(Fonarow et al, 2011)
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Our Story
2010 Median DTN Time of 74 minutes (GWTG Registry)
> Stroke care very linear:
• EMS arrives and gives report
• Patient is moved to ED bed, weighed, placed on monitor, IV access, blood
glucose, EKG, registered
• MD takes EMS report, interviews and examines patient, initiates Code
Stroke, orders labs/CT, Neurology paged.
• Patient returns from CT, and is examined by Neurology.
• CT report from Radiology
• Labs reviewed
• Decision to give tPA made. Ordered. Mixed in Pharmacy and brought to
the bedside.
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How to Utilize Lean Principles at CH?
What part of the pathway is of
actual value to the patient?
> How do we reduce or eliminate
everything else
> How do we create flow?
> How do we reduce
variability/outliers?
> How do we change a linear
process to a parallel process?
> How do we maintain
quality/safety?
IMAGE FROM LEAN.ORG
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Our Experience
Cherry Hill Door to IV Alteplase Times
Number of Cases
80
74
76
74
65
70
59
60
55
52
47
50
40
40
45
38
40
39
34
Median
Mean
30
20
10
0
2010
(n=17)
2011
(n=25)
2012
(n=22)
2013
(n=28)
2014
(n=39)
2015
(n=38)
2016
(n=7)
*Data from Swedish GWTG Registry
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General Concepts
Multi-departmental / multi-institutional effort
Successful models
• STEMI care, Trauma
• Swedish Denver, Helsinki University Central Hospital
Standardization
• Stroke Protocol and order-sets / STAT stroke labs and head CT
• Hospital-based Neurology service dedicated to stroke care
• Staff training and experience
How much can be done before rooming the patient?
• Coordination with Seattle Medic One / local EMS
• Door-to-CT Pilot Project
Continuous QI and refinement of processes / PDSA Model
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EMS
Standards:
• 9-1-1 Dispatch within 90 sec of receiving call
• EMS response time within 8 minutes
• On-scene time less than 15 minutes
• Rapid transport to nearest designated stroke center (PSC vs CSC)
• Currently drip and ship model (Pervez et al, 2010)
Pre-Hospital Activation and care
• “the key is to do as little as possible after the patient has arrived in the
emergency room and as much as possible before that” (Meretoja 2012)
Experimental
• MSTUs
• Neuroprotective agents – animal studies have not translated to benefit in
human trials yet (e.g., FAST-MAG)
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EMS (cont)
Door-to-CT Project:
• Met with Seattle Medic One and other local EMS stakeholders
• Model of successful STEMI system
• King County EMS stroke training and education revamp in 2015-16
Prehospital Assessment
• LKN
• FAST: sensitivity 79-85%, specificity 68%, misses 38% posterior strokes
(Nor et al, 2004; Purrucker et al., 2015; Harbison et al., 2003)
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EMS (cont.)
PreHospital Assessment (cont)
> LAMS: new Seattle protocol for
late 2016
• sensitivity 81%, specificity 85%
for LVO with score of 4 or higher
(7 fold higher risk)
> Comparable with sNIHSS (Naziel
et al., 2008; Llanes et al., 2004)
FROM: JEMS VOLUME-40. ISSUE-1
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Pre-Hospital
Pre-notification of Code Stroke
• LKN and ETA
• Witness contact info/cell phone (or transport with patient)
ALS ambulances (Medic One, unstable patients)
• Blood glucose
• Attempt at IV placement (not to delay transport)
• EKG/rhythm strip (not to delay transport)
BLS ambulances (local agencies, majority of incoming strokes)
• Blood glucose
ED:
• CT notified to keep scanner clear
• ED weight bed and monitor parked in Radiology
• Team assembles in Ambulance Bay
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Pre-ED Room
Avoid rooming patient if stable
• Patient met in Ambulance Bay
• Expedited MD assessment, ABC*
• Blood glucose (tech)*
• ID Band (registration)*
• One attempt at IV line (RN)
EMS takes patient to CT
• Weight obtained
• CT scan reviewed right away by ED MD / Neurology
• Pharmacy called to pre-mix tPA
• Neurology contacts witnesses/family
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ED Room
Value Added Time
• Patient assessed by Neurology upon return
• Two lines placed (RN)
• EKG performed if not done already (tech)
• Consent process
• Safety pause and IV-tPA administration
• Post-tPA protocol initiated
Post-tPA
• Admission to ICU or taken to Radiology by Neurology for Code IR
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Continuous Process
Quality review
• Continuous staff education
• Debriefs with staff/EMS
• Data reviewed monthly
• Protocols refined based on feedback, outlier cases (e.g., BP management
protocol implemented)
Results
• 30-40min reduction in DTN times
• No increase in symptomatic hemorrhage
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No Increase in Symptomatic
Hemorrhage
Cherry Hill Symptoma c Hemorrhagic
Complica on w/in 36 hrs of IV Alteplase
Percentage
(Data from tPA Registry)
20%
15%
10%
5%
0%
5%
4%
0%
2014
(n=57)
2015
(n=55)
2016 Jan-Feb
(n=8)
Cherry Hill Symptoma c Hemorrhagic
Complica on w/in 36 hrs of IV Alteplase
Percentage
(Data from GWTG)
20%
15%
10%
5%
0%
0%
2014
(n=16)
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0%
2015
(n=39)
0%
2016
(n=3)
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Future Considerations
Code IR
> Protocol for MRI/MRA changed to default of CTA/P
> CTA upfront had previously led to delays in DTN times
> CT relocated to same level as ED in spring 2016
> CTA upfront? tPA in CT?
Misc
> POC Testing
> Where should tPA be mixed?
> Patient weight
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Summary
2010: Median DTN Time of 74 minutes (GWTG Registry)
• Internal goal of 45 minutes
• Standardization of stroke protocol, order-sets
• Dedicated stroke service expansion
• Telestroke to reduce response time for after hours cases
2013-2014: Next Phase
• Door-to-CT Pilot Project initiated
• Meetings and coordination with local EMS, Radiology, Pharmacy and
other stakeholders to revamp stroke protocols
• BP protocol, pre-mixing tpa, ED review of Imaging
2016: 30 minute reduction in DTN times
• Continuous refinement
• Better integration of Code IR with arrival of new CT scanner
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References
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References
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Purrucker JC, Hametner C, Engelbrecht A, et al. Comparison of stroke recognition and stroke severity scores for stroke detection in a
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Qureshi AI, Chaudhry SA, Rodriguez GJ, Suri MF, Lakshminarayan K, Ezzeddine MA. Outcome of the ‘drip-and-ship’paradigm among
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