Implementation of an institution-wide acute stroke algorithm: Improving stroke quality metrics
CONTEXT Although tissue plasminogen activator (tPA) is an effective treatment for stroke patients, it typically must be administered within 3 hours of symptom onset to substantially reduce morbidity and mortality. Because of this limited treatment window, it is essential for healthcare professionals to properly identify and quickly triage stroke patients. OBJECTIVE To determine if implementation of a stroke alert protocol coupled with a limited education program will reduce arrival time to computed tomography scan time and treatment time for stroke patients in the emergency department (ED). METHODS This prospective pilot study took place at Geisinger Medical Center in Danville, Pennsylvania, and included a formal stroke protocol based partly on The Joint Commission's stroke center recommendations. The major feature was integration of various hospital departments to quickly and accurately identify and triage stroke patients; included was a limited education program for residents and attending staff. Patients who presented between November 1, 2007, to October 31, 2008, comprised the study group (ie, after protocol implementation). A retrospective analysis of patient records from November 1, 2006, to October 31, 2007, for stroke morbidity, mortality, and tPA administration was employed as a control group (ie, prior to protocol implementation). Inclusion criteria consisted of patients aged 18 years or older who arrived at the ED with stroke-like symptoms. Exclusion criteria consisted of previous hemorrhagic stroke, seizure at stroke onset, internal bleeding, intracranial hemorrhage, recent surgery, platelet count of less than 100 × 10(3)/μL, untreated blood pressure greater than 185/110 mm Hg, symptoms lasting for longer than 6 hours, and vascular malformation. Patients with a history of ischemic stroke were included in the study. RESULTS The study included a total of 233 stroke patients, 132 of whom presented to the ED prior to stroke protocol implementation and 101 of whom presented after stroke protocol implementation. For patients who arrived at the ED within 3 hours from symptom onset, median time to completion of a computed tomography (CT) scan was reduced from 65.5 minutes (interquartile range, 41.0-101.0) prior to the new protocol to 54.0 minutes (interquartile range, 25.0-54.0) after implementation (P<.004). Regarding patients who arrived in the ED 3 to 6 hours after symptom onset, median time from ED arrival to CT time decreased from 94.5 minutes (interquartile range, 68.0-136.0) before the new protocol to 48.5 minutes (interquartile range, 33.0-89.0) following implementation (P<.002). Of the 79 patients who arrived at the ED within 3 hours of symptom onset in the year after protocol implementation, 12 were treated with tPA, compared to 4 out of 86 treated in the year prior to protocol implementation. Mean time from ED arrival to tPA treatment was reduced from 85.5 minutes in the preprotocol group to 48.9 minutes in the postprotocol group. CONCLUSION By coupling a formal stroke protocol with a limited education program, door-to-treatment time of stroke patients was reduced.