Simple Text-Messaging Intervention Is Associated With
Improved Door-to-Needle Times for Acute Ischemic Stroke
Molly M. Burnett, MD; Lara Zimmermann, MD; Zlatan Coralic, PharmD;
Tina Quon, RN, MSN, CEN, BC; William Whetstone, MD; Anthony S. Kim, MD, MAS
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Background and Purpose—Timely administration of intravenous tissue-type plasminogen activator (IV tPA) is associated
with improved outcomes for acute ischemic stroke; yet, developing processes to consistently provide prompt treatment
remains a challenge. We developed and evaluated a simple quality improvement intervention designed to improve doorto-needle (DTN) times for resident-led Code Stroke teams at an academic medical center.
Methods—We evaluated a simple text-messaging based intervention with real-time feedback to improve DTN times for
intravenous tissue-type plasminogen activator. We used the rank-sum test and linear regression to evaluate for a change
in DTN times that was temporally associated with the rollout of the intervention.
Results—A total of 202 patients received intravenous tissue-type plasminogen activator; 94 preintervention and 108
postintervention. The median DTN time was significantly lower in the postintervention period (56 minutes [interquartile
range 44–71] versus 82 minutes [IQR 68–103], P<0.0001) and a significantly higher proportion of patients were treated
within 60 minutes (61% versus 16%, P<0.001).
Conclusions—A simple real-time text-messaging intervention was associated with a significant improvements in DTN
times for acute ischemic stroke. (Stroke. 2014;45:3714-3716.)
Key Words: door-to-treatment time ◼ quality improvement ◼ stroke ◼ thrombolytic therapy
T
Methods
hrombolysis for acute ischemic stroke is most effective
when administered soon after symptom onset, and this
efficacy declines with time.1–4 Therefore, improving door-toneedle (DTN) times for intravenous tissue-type plasminogen
activator (IV tPA) has been a major goal for ongoing quality
improvement efforts.
Current guidelines recommend administering IV tPA within
60 minutes of arrival to the emergency department,5 and
recent reports have demonstrated that median DTN times of
20 minutes are achievable.6 The American Heart Association’s
Target: Stroke initiative has highlighted this focus on DTN
time and has been associated with improvements in this process measure at a national level,7 although there continue to be
opportunities for improvement.8
At our academic medical center, we found that components of the Code Stroke response such as door-to-computed
tomography scan or door-to-laboratory times often individually met performance goals. However, we were concerned
that the frequent turnover of residents and fellows every few
weeks contributed to a shorter institutional memory for best
practices and a diffusion of accountability for the overall
DTN performance. Therefore, we developed, implemented,
and evaluated a simple text-messaging–based intervention to
provide real-time feedback to improve DTN times.
We developed and implemented a quality improvement intervention
to improve DTN times with 3 components:
Real-time feedback: For each Code Stroke activation, the team
leader was required to report whether IV tPA was administered
and the DTN time to the entire Code Stroke team in real-time
via a group text page.
Process for improvement: Any cases with DTN time >60 minutes
were formally reviewed within 24 to 72 hours to identify and
address any systemic barriers to timely IV tPA administration.
Sharing performance data: A DTN dashboard was distributed to
the team on a biweekly basis. This included midpoint feedback
for on-service residents, as well as data on the prior performance-to-date for incoming residents before the start of their
clinical rotation.
To evaluate the impact of the intervention, we compiled longitudinal
data on consecutive adults treated with IV tPA for acute ischemic
stroke that presented to the emergency department at our tertiary care
center from January 2008 to April 2014. This analysis period encompassed the experience for ≈3 years before and 3 years after the intervention was implemented in April 2011.
Code Stroke responses are activated by group text page for suspected stroke within 12 hours of symptom onset. Teams are led by a
rotating neurology resident and include fellows and attendings; emergency department nurses, residents, pharmacists, and attendings; neuroradiologists; and radiology and laboratory technicians. Eligibility
Received September 2, 2014; final revision received September 25, 2014; accepted September 25, 2014.
From the Departments of Neurology (M.M.B., L.Z., A.S.K.), Emergency Medicine (T.Q., W.W.), and Clinical Pharmacy (Z.C.), University of California,
San Francisco.
Correspondence to Anthony S. Kim, MD, MAS, UCSF Department of Neurology, 675 Nelson Rising Lane, Room 411B, San Francisco, CA 94158.
E-mail [email protected]
© 2014 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.114.007294
3714
Burnett et al Improved DTN Times With Text Messaging 3715
criteria for IV tPA were based on 2007 and 2009 American Heart
Association guidelines.2,9
We used descriptive statistics and Fisher exact test to evaluate univariate and bivariate associations. We evaluated for a secular trend in
DTN times during the preintervention period by visual inspection, as
well as with linear regression. We used the rank-sum test to evaluate
changes in median DTN times and linear regression to evaluate for
changes in the slope or intercept of the linear trend associated with the
intervention or potential cointerventions (an ED pharmacist service was
initiated 14 months before the intervention, and an electronic medical
record system with computerized physician order entry went live and
the requirement for an INR result in patients without a known history
of anticoagulant use was dropped 14 months after the intervention.)
Results
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A total of 94 patients were treated in the preintervention
period and 108 patients were treated in the postintervention
period (Table). There was no significant linear trend for DTN
times during the preintervention period (slope=–0.17 minutes/
mo, 95% CI –0.66 to 0.31, P=0.47).
The median DTN time was significantly lower in the
postintervention period compared with the preintervention
period (56 minutes [IQR 44–71] versus 82 minutes [IQR
68–103], rank-sum P<0.001) and a significantly higher proportion of patients were treated within 60 minutes (63% versus 16%, P<0.001; Figure). Based on the linear trend, we
observed a 14.9-minute improvement in DTN time (95%
CI 0.56–29.3, P=0.04) that coincided with the rollout of the
intervention but not with the potential cointerventions listed
above (data not shown).
Table. Characteristics of Patients With Acute Ischemic Stroke
Treated With IV tPA Before and After Implementation of a Quality
Improvement Intervention to Improve Door-to-Needle Times
Preintervention Postintervention P
n=94
n=108
Value
Age, mean (SD)
73.2 (15.2)
73.6 (15.6)
0.83
Female sex, n (%)
48 (51.1)
58 (53.7)
0.78
Initial NIHSS, median (IQR)
10 (4–15)
10 (4–17)
0.74
Stroke subtype, n (%)
Large vessel, anterior circulation
63 (67)
65 (60)
0.38
Large vessel, posterior circulation
6 (6)
10 (9)
0.60
Small vessel
4 (4)
12 (11)
0.12
Multifocal
3 (3)
9 (8)
0.15
Watershed
1 (1)
0 (0)
0.47
Mimic or undetermined
17 (18)
11 (10)
0.15
Diabetes mellitus, n (%)
21 (22)
24 (22)
0.99
Hypertension, n (%)
73 (78)
90 (83)
0.25
Dyslipidemia, n (%)
40 (43)
56 (52)
0.47
Atrial fibrillation, n (%)
39 (41)
46 (43)
0.86
CAD, n (%)
21 (22)
21 (19)
0.83
CHF, n (%)
17 (18)
17 (16)
0.99
Smoking, n (%)
20 (21)
12 (11)
0.16
Prior stroke/TIA, n (%)
31 (33)
28 (26)
0.70
CAD indicates coronary artery disease; CHF, congestive heart failure; IV,
intravenous; NIHSS, National Institute of Health Stroke Scale; TIA, transient
ischemic attack; and tPA, tissue-type plasminogen activator.
Figure. Door-to-needle times for intravenous tissue-type plasminogen activator before and after a text-messaging–based
quality improvement intervention was implemented at month 0
(April 2011) at a single academic medical center. Dashed lines
show the linear trend during the preintervention and postintervention periods.
There were no significant differences in the incidence of
symptomatic intracranial hemorrhage (4% pre and post;
P=0.99), stroke mimics (10% pre versus 8% post; P=0.81),
and in-hospital death (13% pre versus 6% post; P=0.15).
Discussion
A simple text-messaging–based quality improvement intervention that provided real-time DTN time feedback was temporally associated with a significant improvement in DTN
times at our academic medical center.
Our intervention was designed to focus the team on a
specific performance goal and to provide timely feedback
on performance against that goal but did not require a large
investment of resources or staff time, or changes in existing
protocols since we left it to team leaders to define how the
goal was to be achieved.
Quality improvement efforts that rely on retrospective
review can often provide feedback only weeks or months later.
In practice settings where staff rotate frequently, this feedback
can arrive too late to change clinical practice. In contrast, a
real-time reporting mechanism allows for a tighter feedback
loop while the clinical details of a particular case are still fresh
in the minds of team members. It may also serve to increase
accountability for DTN performance—an especially relevant
issue at centers where staff turnover can contribute to a diffusion of accountability.
Although the performance improvements we observed
were robust and temporally associated with our intervention, these data reflect the experience at a single center and
we cannot exclude the possibility that cointerventions or
unmeasured changes contributed to the observed improvements. Furthermore, although the particular components of
the intervention that may be most responsible for improvements are unknown and further improvements will require
additional structural changes to our infrastructure and protocols, our simple intervention could be readily implemented
at other centers and its impact has the potential to be generalizable to other practice settings.
3716 Stroke December 2014
Disclosures
Dr Kim receives support from the National Institutes of Health (the
National Institute of Neurological Disorders and Stroke and the
National Center for Advancing Translational Sciences). The other
authors have no disclosures to report.
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Simple Text-Messaging Intervention Is Associated With Improved Door-to-Needle Times
for Acute Ischemic Stroke
Molly M. Burnett, Lara Zimmermann, Zlatan Coralic, Tina Quon, William Whetstone and
Anthony S. Kim
Downloaded from http://stroke.ahajournals.org/ by guest on June 14, 2017
Stroke. 2014;45:3714-3716; originally published online October 28, 2014;
doi: 10.1161/STROKEAHA.114.007294
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