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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 FOOTER 5

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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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.

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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 9

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Our Experience

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*Data from Swedish GWTG Registry

0

10

20

30

40

50

60

70

80

2010(n=17)

2011(n=25)

2012(n=22)

2013(n=28)

2014(n=39)

2015(n=38)

2016(n=7)

74

65

55

47

40 38 34

74 76

59

52

45 40 39

Nu

mb

er

of

Cas

es

Cherry Hill Door to IV Alteplase Times

Median

Mean

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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 14

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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

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0%

5%

10%

15%

20%

2014(n=57)

2015(n=55)

2016Jan-Feb(n=8)

5%4%

0%Percen

tage

CherryHillSymptoma cHemorrhagicComplica onw/in36hrsofIVAlteplase

(DatafromtPARegistry)

0%

5%

10%

15%

20%

2014(n=16)

2015(n=39)

2016(n=3)

0% 0% 0%Perce

ntage

CherryHillSymptoma cHemorrhagicComplica onw/in36hrsofIVAlteplase

(DatafromGWTG)

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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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