Reducing Door to Needle Times and Expediting Transfer for Endovascular Care for Acute Ischemic Stroke Patients

Williamsport Regional Medical Center (WRMC) in Williamsport, PA, is the only designated Primary Stroke Center within the UPMC Susquehanna four-hospital health system. WRMC partnered with Specialists on Call (SOC), the largest provider of teleneurology care, to improve door to needle times (DTN) for administering a thrombolytic agent, or “clot buster” (tPA). They also established a relationship with Lehigh Valley Cedar Crest (LV), a respected regional medical center, for transferring patients who met the criteria for endovascular intervention.

The Challenges:

1. Delays in tPA administration were putting stroke patients at risk for functional deficits. There were several reasons for these delays—from waiting for lab results for the neurological assessment to take place, to not having the tPA pulled from the medication management locker, to not having supplies to administer the medication at the bedside.

2. Delays in patient transfers for endovascular care were causing a negative impact on patient flow in the endovascular suite at LV and putting patients at risk for functional deficits as a result of delays in intervention.
3. Delays in the transport of stroke patients deemed candidates for endovascular intervention at Lehigh Valley Cedar Crest were posing a risk for patients who arrived at LV outside the window of eligibility (six hours).

The Action Plan:

WRMC created an interdisciplinary process improvement team comprised of multiple organizations: their own Emergency Department (ED) nurses, a Clinical Nurse Specialist and the Director of Medical Operations for Neuroscience from LV, and the Regional Director at Geisinger Medical Center's LifeFlight. EMS personnel serving WRMC's ED were also on the team. They identified four areas for improvement and redesigned their workflows:

1. The tPA Alert Process

   • The alert system begins with EMS, if the patient comes to the ED by ambulance
   • Issue a hospital tPA alert for all patients suspected of stroke coming to the ED presenting with stroke like symptoms, and a Time Last Known Well (without signs or symptoms of current stroke) of 4.5 hours or less
2. Expediting the Neurological Assessment

   • Instead of calling and relaying information over the phone, ED nursing staff initiate SOC “SpeedPass”, a web-based intake application that creates an emergent consult in the SOC queue
   • This gives high-priority designation for suspected stroke patients deemed possible candidates for tPA administration; using SpeedPass helps decrease the wait time for a teleneurologist evaluation
   • Also ensure an SOC telemedicine cart is immediately placed into the patient room

3. Breaking the 60 Minute Barrier

   • Stroke team proactively pulls tPA from the medication management locker and places it at the bedside
   • A “tPA supply box” of all materials for administering the medication is also placed at the bedside

4. Endovascular Intervention

   • SOC neurologists help identify endovascular intervention candidates by reviewing CT scans and CT angiograms and providing necessary guidance on which patients are appropriate candidates
   • Once patients are identified as endovascular candidates, the WRMC stroke nurses make simultaneous calls to LV to alert and coordinate endovascular care and to LifeFlight to arrange for air transport

The Results:

With new guidelines and Joint Commission protocols, the quality and safety/stroke team at WRMC has continued to make strides in improving the delivery of emergency stroke care through the implementation of new, standardized processes and the development of close partnerships with regional healthcare systems.

The utilization of SOC's teleNeurology program has expedited the assessment of patients coming into the ED with suspected stroke symptoms. DTN times greatly improved and more stroke patients received comprehensive assessments and administration of tPA in a timely manner to improve outcomes.

This process helped WRMC better meet the time metric of the SOC evaluation to tPA administration of approximately 30 minutes. According to Mondell, “The utilization of the tPA SpeedPass through SOC had a huge impact on improving our door to needle times.”

WRMC has seen DTN times improve significantly between 2015 and 2016, with 36% more patients receiving tPA within 60 minutes. With the transfer process for endovascular candidates standardized, WRMC staff is able to act swiftly to initiate the transfer to Lehigh Valley's endovascular suite through Geisinger Medical Center's LifeFlight air transport, with a 29% improvement in DIDO times between 2015 and 2016.

For more detailed information on the WRMC TeleStroke program, or SOC's SpeedPass, please visit www.specialistsoncall.com.