CLINICAL
MEET ME IN COMPUTED TOMOGRAPHY SUITE: DECREASING TISSUE PLASMINOGEN ACTIVATOR DOOR-TO-NEEDLE TIME FOR ACUTE ISCHEMIC STROKE PATIENTS Authors: Lauri Speirs, MSN, ACNS-BC, PCCN, CNRN, SCRN, and Anne Mitchell, MSN, ACNS-BC, CEN, CCRN, Ft. Worth, TX, Mesa, AZ Introduction
Since the introduction of intravenous (IV) recombinant tissue plasminogen activator (tPA) as a treatment for ischemic stroke patients, stroke has declined from the third to the fourth leading cause of death in the United States. 1 The effectiveness of thrombolysis for acute ischemic stroke is beyond debate, 2 but the benefit of tPA is strongly time dependent. 3 For each minute during which a large-vessel ischemic stroke is untreated, 1.9 billion neurons and 13.8 billion synapses are lost. 4 For each hour the stroke is untreated, the same neuronal loss develops that would occur in 3.6 years of normal aging. 4 Current recommendations are to administer IV tPA within 60 minutes of arrival to the emergency department for 50% of ischemic stroke patients or more. 5 Additional measures for treatment of acute ischemic stroke include door-to-physician time within 10 minutes, door–to–computed tomography (CT) examination within 25 minutes, and door–to–CT interpretation time within 45 minutes. 6 Although the treatment window has expanded from 3 to 4.5 hours, 7 patients treated within the first 90 minutes after symptom onset show almost twice the improvement without increased hemorrhage than patients receiving tPA 91 to 180 minutes after symptom onset. 8–10 Patients treated within 181 to 270 minutes still show improvement but to a lesser degree than those treated within 90 minutes. 2 For every 15-minute reduction in door-to-needle (DTN) time, the risk-adjusted
in-hospital mortality rate decreases by 5%. 10 For every 15-minute decrease in the time from symptom onset to treatment, patients have 4% greater odds of walking independently, 3% greater odds of being discharged home, and 4% lower odds of death and hemorrhagic transformation. 10 Time to treatment with tPA is an important determinant of 90-day and 1-year functional outcomes for patients with ischemic stroke. 10 A shorter delay from symptom onset to tPA can make the difference between being independent and being dependent. 11 Despite the proven effectiveness of timely tPA administration, the rate of tPA use in the United States for ischemic stroke patients remains low at 5.2% or less. 12 Fonarow et al. 9 reported that just 27% of patients with ischemic stroke arriving to the emergency department within 3 hours of symptom onset received tPA within the 60-minute goal. They noted that these patients were more likely to present to the emergency department on Monday through Friday, between the hours of 7 am and 5 pm. Patients arriving quickly to the emergency department after the onset of stroke symptoms tend to have more severe strokes but the DTN time may actually be longer for these patients. 3,9 Researchers have reported that the longest DTN times occurred in patients arriving to the emergency department within 30 minutes of symptom onset. 9,13 They speculated that making the decision to treat with tPA takes time as long as time is available. 9,13 Prehospital Improvement Strategies
Lauri Speirs is Neuroscience Clinical Nurse Specialist, JPS Health, Ft. Worth, TX. Anne Mitchell is Clinical Nurse Specialist, Emergency Department and Intensive Care Unit, Banner Baywood Medical Center, Mesa, AZ. For correspondence, write: Lauri Speirs, MSN, ACNS-BC, PCCN, CNRN, SCRN, JPS Health, 1500 S. Main Street, Ft. Worth, TX 76104; E-mail: [email protected]. J Emerg Nurs 2015;41:381-6. Available online 18 March 2015 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.01.005
September 2015
VOLUME 41 • ISSUE 5
Many potential barriers contribute to delays in DTN time for ischemic stroke patients. No pre-notification of the impending arrival of a stroke patient, a protracted triage process, location of the CT scanner outside the emergency department, lack of a dedicated stroke team process, and standardized stroke treatment protocols are hurdles to timely stroke identification and tPA administration. 3,11 Best-practice recommendations include minimizing the impact of these barriers by developing processes that allow rapid identification of stroke patients and timely tPA administration for eligible patients.
WWW.JENONLINE.ORG
381
CLINICAL/Speirs and Mitchell
In considering the onset of symptoms–to–treatment time (OTT), most time is lost in the prehospital setting primarily because patients delay seeking medical attention. Data from the Centers for Disease Control and Prevention indicate that fewer than half of stroke patients arrive to the emergency department within 2 hours of symptom onset. 14 Factors associated with earlier arrival after symptom onset include more severe symptoms, male sex, younger age, white race, higher educational status, living with a mate, and history of atrial fibrillation. 15,16 A factor strongly associated with shorter OTT is emergency medical services (EMS) transport to the emergency department. 10,17 Enhanced training of EMS providers in stroke recognition and development of a prehospital notification system reduce time to treatment. 10,14 In a European community, investigators equipped an ambulance with a neurologist, a radiographer, a CT scanner, and point-of-care (POC) laboratory diagnostics plus EMS personnel to determine the effect on DTN times. 18 Most patients, after confirmation of ischemic stroke, received tPA in the ambulance, resulting in a DTN time of 58 minutes. 18 Meretoja et al. 19 instituted changes in the pre-notification and assessment process by EMS. The hospital pre-notification call was made directly to the mobile phone of the on-call regional stroke physician. The pre-notification call included a conversation between the stroke physician and the on-scene next of kin or bystander. To gather additional event history, EMS then transported that individual, if possible, to the hospital with the patient. 19 Orders for laboratory tests and the CT examination were entered into the computer while the patient was en route to the emergency department, and the blood glucose level was measured by EMS. This prehospital strategy reduced DTN times to 20 minutes. Meretoja et al. 20 implemented a similar optimized tPA protocol in a different hospital system, showing a reduction in average DTN times from 61 to 46 minutes.
In-Hospital Strategies
In addition to streamlining EMS identification of, treatment of, and ED notification regarding stroke patients before arrival, strategies focusing on timely diagnosis and treatment after hospital arrival are part of the “Stroke Chain of Survival.” 21 Olson et al. 22 interviewed members of stroke teams in top-performing hospitals regarding management of ischemic stroke patients. They found that creating and training stroke teams, implementing preapproved standardized treatment protocols, obtaining administrative support, and monitoring performance are associated with early tPA use.
382
JOURNAL OF EMERGENCY NURSING
Investigators in large and small hospitals have reported improvements in DTN times and the number of patients receiving tPA after implementation of a standardized stroke response and treatment protocol. 23,24 In a small community hospital, Tveiten et al. 23 provided EMS personnel screening criteria for tPA treatment. If criteria were met, the emergency department and neurologist were notified and the CT scanner was made available at the time of patient arrival. Approximately 40% of ischemic stroke patients arriving to the emergency department within 3 hours received tPA. 23 A non-contrast CT scan of the head is essential before tPA administration. According to Rose et al. 25 only 11.5% of patients with stroke symptoms receive a CT scan within 25 minutes of hospital arrival. Significant predictors of CT scan delay include a delay from symptom onset to hospital arrival, non-EMS transport, being female or African American, and a presumed transient ischemic attack (TIA) diagnosis. 25 In an effort to decrease door-to-CT times for stroke patients, Hoegerl et al. 24 educated staff and implemented a stroke protocol providing for immediate examination, rapid CT, laboratory testing, and early notification of neurology. A year after protocol implementation, the door-to-CT time decreased to 10.5 minutes, the number of tPA-eligible patients receiving tPA increased from 4 to 12, and the DTN time decreased from 85.5 to 48.9 minutes. After analyzing how stroke patients were identified and determined to be eligible for tPA therapy, Ford et al. 26 listed 3 barriers associated with delayed tPA administration: (1) inefficient patient flow, (2) serial processing of multiple tasks, and (3) delayed laboratory results for patients taking anticoagulants. After streamlining the approach by taking the patient directly to the CT suite on arrival, performing required tasks simultaneously, and adopting POC testing for patients who have undergone anticoagulation, the average DTN time decreased from 60 to 39 minutes and the percentage of patients receiving tPA increased from 52% to 78%. 26 A second group of researchers also sought to improve door–to–CT examination times by delivering the EMS patient directly to the CT table. 19 A stroke physician performed a rapid neurologic evaluation, and laboratory specimens were obtained in the CT suite; the CT scan was then completed. This strategy resulted in door-to-CT times of 5 to 10 minutes and DTN times of 20 minutes. Comparable improvements in DTN times were achieved when the same researcher replicated similar process changes, including delivering the patient directly to the CT suite, in a different health care system. 27 Binning et al. 20 expedited tPA administration for eligible stroke patients by implementing pre-notification by EMS to the neurologic ED team and delivering the patient directly to the CT suite rather than an ED room. The average door-to-CT time was 11.8
VOLUME 41 • ISSUE 5
September 2015
Speirs and Mitchell/CLINICAL
TABLE
Best-practice recommendations for tPA administration Training of EMS personnel to recognize stroke using validated screening tools Advanced hospital notification by EMS Rapid triage protocol with stroke team notification Single-call stroke activation system Stroke tools/protocols Rapid acquisition and interpretation of brain imaging Rapid laboratory testing (including point of care if indicated) Mixing of tPA before patient arrival by EMS Rapid access to IV tPA Team-based approach to stroke patient Prompt data feedback Placement of CT scanner near or in emergency department CT scan ordered as soon as facility is made aware of incoming patient Delivery of patients to certified stroke center Continuous data collection to drive system improvement The recommendations are based on the findings of Fonarow et al.,9 Saver et al.,10 Kruyt et al.,11 Lin et al.,17 and Rose et al.25 CT, Computed tomography; EMS, emergency medical services; IV, intravenous; tPA, tissue plasminogen activator.
minutes, and the DTN time decreased by 67%. Walter et al. 28 reconfigured the entire stroke laboratory analysis to a POC system, reporting a decrease in door–to–therapy decision times from 84 to 40 minutes after POC implementation. Numerous studies have indicated that DTN times can be effectively shortened with multiple simple interventions (Table), and when the DTN time is reduced, more ischemic stroke patients can be treated with thrombolytic therapy.
Methods
As part of a multistate health care system located in a large metropolitan area, our facility treats 1,000 to 1,200 TIA and stroke patients per year, averaging 450 to 500 stroke alerts annually. Over the years since initiation of the stroke program and certification as a stroke center by The Joint Commission in 2008, most recommendations for best practice regarding tPA administration were gradually incorporated into the stroke process, resulting in some improvement in stroke measures. An established stroke team responds around the clock to stroke alerts announced by overhead paging, using a standardized stroke protocol to initiate care. For stroke alerts occurring in the emergency
September 2015
VOLUME 41 • ISSUE 5
department, the emergency physician responds to stroke alerts as a team member. EMS personnel pre-notify the emergency department of the pending arrival of a patient with a positive finding on the Cincinnati Stroke Scale. The CT scanner is located within the emergency department and made available when a stroke alert occurs. A “stroke box” fully stocked with all necessary supplies for tPA administration is available in the emergency department. All ED beds are capable of providing accurate patient weights using a simple button function. Neurology consultation is available 24 hours per day. Ongoing concurrent monitoring and data reporting provide timely feedback on performance and stroke target measures, identifying opportunities for improvement. Despite the implementation of these measures, DTN times remained greater than 60 minutes. From January through May 2013, the door–to–CT examination time averaged 21.76 minutes, the door–to–CT result time averaged 35.41 minutes, and the DTN time averaged 75.41 minutes. A DTN time of 60 minutes or less was achieved only 29.4% of the time. To improve the percentage of patients receiving tPA within 60 minutes of EMS arrival, the facility stroke committee reviewed each component of the stroke alert process and the associated time increments. A literature review provided information regarding additional strategies that successfully reduced DTN times in other stroke programs. Even though the average door-to-CT time and door–to– CT result times met established recommendations, analysis indicated that additional time could be saved within these 2 parameters, which could potentially translate to shorter DTN times and a higher percentage of patients receiving tPA within 60 minutes. Typically, when EMS arrived, the patient was placed in an ED room and connected to the cardiac monitor and a second IV line was initiated. A 12-lead electrocardiogram and laboratory specimens were obtained. The stroke team met the patient in the ED room and completed a physical examination and assessment using the National Institutes of Health Stroke Scale. After completion of these tasks, the patient was transported to the CT suite for scanning and returned to the ED room. The results of the analysis determined the critical elements required for the tPA decision and included the CT scan, quick assessment, history and medication list, platelet count, and for select patients, prothrombin time results. Other steps such as placing the patient in the room, connecting the patient to the cardiac monitor, starting a second IV line, and completing a thorough assessment could be performed during the time between CT completion and CT result. A “direct to CT” approach for the EMS-transported stroke patient and postponement of nonessential tasks until after CT examination were adopted. A decrease of 8 to 10 minutes in DTN time was anticipated as
WWW.JENONLINE.ORG
383
CLINICAL/Speirs and Mitchell
Average Door to CT Completed Pre and Post Intervention (minutes)
Average Door to CT Result (minutes)
40.00 35.00 30.00 25.00 20.00 15.00 10.00 5.00 0.00
25.00 20.00 15.00 10.00 5.00 0.00 pre (Jan '13-Jun '13)
pre (Jan '13-Jun '13)
post (Jul '13-Jun'14)
post (Jul '13-Jun'14)
FIGURE 2 FIGURE 1 Average door–to–computed tomography (CT) time (in minutes) before intervention (pre) and after intervention (post).
a result of delivering the patient directly to the CT suite. EMS, CT and laboratory personnel, emergency physicians, nursing staff, and stroke responders received education on the new process. Modification of the overhead announcement of stroke alerts incorporated broadcasting the CT suite as the meeting location rather than the ED room number. The new process was implemented in June 2013.
Results
One year after implementation of the change, the door-to-CT, door–to–CT result, and DTN times all improved. The door-to-CT time decreased by 9.71 minutes, from 21.76 to 12.05 minutes after implementation (Figure 1), and the door– to–CT result time decreased by 11.68 minutes, from 35.41 to 23.73 minutes after implementation (Figure 2). The DTN time declined by 7.63 minutes, from 75.41 to 67.78 minutes after implementation (Figure 3). By June 2014, 57.9% of patients received tPA within 60 minutes compared with 29.4% in 2013 prior to meeting in the CT suite (Figure 4). Meeting the EMS-transported stroke patient in the CT suite successfully reduced the door-to-CT, door–to–CT result, and DTN times for ischemic stroke patients eligible for thrombolytic therapy.
Discussion
Shorter DTN times are strongly linked to decreased hemorrhage and mortality rates, and tPA administration within 90 minutes of symptom onset improves patient outcomes. 8–10 The American Stroke Association (ASA) recommends that 50% of acute ischemic stroke patients
384
JOURNAL OF EMERGENCY NURSING
Average door–to–computed tomography (CT) result time (in minutes) before intervention (pre) and after intervention (post).
receive tPA within 60 minutes of arrival. 5 Despite CT times that met national benchmarks and the implementation of most of the ASA recommendations for acute stroke management, 3 our facility’s average DTN time exceeded the 60-minute goal by 15 minutes. The directto-CT strategy was incorporated into the facility stroke alert process based on reported improvements in DTN times when EMS-transported stroke patients are delivered directly to the CT suite. 19,20,27 One year after process modification, from June 2013 through June 2014, 34 patients received tPA and door-to-CT, door–to–CT result, and DTN times all improved. The door–to–CT result time showed the greatest decrease, followed by the door-to-CT time. Though improved, the DTN time achieved the smallest gain, decreasing by 7.63 minutes, as compared with 9.71 minutes and 11.68 minutes for door-to-CT time and door–to–CT result time, respectively. The time improvements did not translate equally within the 3 parameters; the decrease in door–to–CT result time of nearly 12 minutes did not reduce the DTN time by 12 minutes. This may be related to the time taken to make the tPA decision even though data were available more quickly. Occasionally, family members extended the tPA decision time, being reluctant to commit to a treatment strategy, but the incidence of indecision appeared similar before and after implementation. POC testing was initially considered by the stroke committee as a potential improvement tactic. Given the anticipated decrease in the DTN time as a result of the direct-to-CT approach, POC testing was not included as a recommendation. Although the lower DTN times achieved by Meretoja et al. 19,20 were not realized, the number of patients receiving tPA within 60 minutes nearly doubled. This represents a substantial improvement and meets the
VOLUME 41 • ISSUE 5
September 2015
Speirs and Mitchell/CLINICAL
Percentage of Patients Receiving tPA within 60 minutes
Average Door To Needle Pre and Post Intervention (minutes) 76.00
60.00%
74.00
50.00%
72.00 70.00
40.00%
68.00
30.00%
66.00
20.00%
64.00
10.00%
62.00 pre (Jan '13-Jun '13)
post (Jul '13-Jun'14)
0.00% pre (Jan '13-Jun '13)
post (Jul '13-Jun'14)
FIGURE 3 Average door-to-needle time (in minutes) before intervention (pre) and after intervention (post).
Target: Stroke goal of tPA in less than 60 minutes for 50% of ischemic stroke patients or more. For many communities, making a stroke neurologist available 24/7 by phone to a network of EMS providers transporting stroke patients, as well as transporting witnesses to stroke events to local emergency departments, may not be a feasible strategy even though substantial reductions in DTN times were achieved by Meretoja et al. Moreover, equipping a stroke ambulance with a stroke neurologist, a CT scanner, and tPA, as Weber et al. 18 did, is not likely to be a realistic strategy for the majority of communities. Since these European studies were published, a Texas facility has been investigating the effect on DTN times using an ambulance outfitted with a CT scanner for the transport of possible stroke patients. 29 Implications for Practice and Conclusion
Optimum reduction in DTN time delays is not achievable by any single intervention but rather results from continuous analysis of data and improvement of the stroke process as a whole. Achieving door-to-CT and door–to–CT result benchmark times may not be sufficient to meet the DTN target of 60 minutes or less. However, delivering the EMS-transported stroke patient directly to the CT suite instead of first placing the patient in the ED room can result in substantial gains in CT times and increase the percentage of patients receiving tPA within 60 minutes. Postponing nonessential components of care until after completion of the CT scan does not appear to result in any harm to the patient or interfere with routine CT operations. Even if CT scan and result times meet recommended targets, implementation of a direct-to-CT approach as a single improvement strategy appears effective in reducing DTN times and improving the percentage of patients receiving tPA within 60 minutes.
September 2015
VOLUME 41 • ISSUE 5
FIGURE 4 Percentage of patients receiving tissue plasminogen activator (tPA) within 60 minutes before intervention (pre) and after intervention (post).
REFERENCES 1. Towfighi A, Saver J. Stroke declines from third to fourth leading cause of death in the United States. Stroke. 2011;42:2351-2355. 2. Lees K, Bluhmki E, van Kummer R, et al. Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet. 2010;375:1695-1703. 3. Fonarow G, Smith G, Saver J, et al. Improving door-to-needle times in acute ischemic stroke. The design and rationale for the American Heart Association/American Stroke Association’s Target: Stroke initiative. Stroke. 2011;42:2983-2989. 4. Saver J. Time is brain. Stroke. 2006;37:263-266. 5. Target: Stroke. http://www.strokeassociation.org/STROKEORG/ Professionals/Target-Stroke_UCM_314495_SubHomePage.jsp. Accessed July 30, 2014. 6. Jauch E, Saver J, Adams H, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870-947. 7. Zoppo G, Saver J, Jauch E, Adams H. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator. Stroke. 2009;40:2945-2948. 8. Ahmed N, Wahlgren N, Grond M, et al. Implementation and outcome of thrombolysis with alteplase 3–4.5 hours after an acute stroke: an updated analysis from SITS-ISTR. Lancet Neurol. 2010;9:866-874. 9. Fonarow G, Smith E, Saver J, et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-toneedle times within 60 minutes. Circulation. 2011;123:750-758. 10. Saver J, Fonarow G, Smith E, et al. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA. 2013;309:2480-2488. 11. Kruyt N, Nederkoorn P, Dennis M, et al. Door-to-needle time and the proportion of patients receiving intravenous thrombolysis in acute
WWW.JENONLINE.ORG
385
CLINICAL/Speirs and Mitchell
ischemic stroke. Uniform interpretation and reporting. Stroke. 2013;44:3249-3253. 12. Adeoye O, Hornung R, Khatri P, Kleindorfer D. Recombinant tissuetype plasminogen activator use for ischemic stroke in the United States. Stroke. 2011;42:1952-1955. 13. Strbian D, Patrik M, Ringleb P, et al. Relationship between onset-todoor time and door-to-thrombolysis time. Stroke. 2013;44:2808-2813.
resuscitation and emergency cardiovascular care. Circulation. 2010;122:S818-1828. 22. Olson D, Constable M, Britz G, et al. A qualitative assessment of practices associated with shorter door-to-needle time for thrombolytic therapy in acute ischemic stroke. J Neurosci Nurs. 2011;43:329-336.
14. Kue R, Steck A. Prehospital diagnosis and management of patients with acute stroke. Emerg Med Clin North Am. 2012;30:617-635.
23. Tveiten A, Mygland A, Ljostad U, Thomassen L. Intravenous thrombolysis for ischemic stroke: short delays and high communitybased treatment rates after organisational changes in a previously inexperienced centre. Emerg Med. 2009;26:324-326.
15. Iosif C, Papathanasiou M, Staboulis E, Gouliamos A. Social factors influencing hospital arrival time in acute ischemic stroke patients. Neuroradiology. 2012;54:361-367.
24. Hoegerl C, Goldstein F, Sartorius J. Implementation of a stroke alert protocol in the emergency department: a pilot study. J Am Osteopath Assoc. 2011;111:21-27.
16. Tong D, Reeves M, Hernandez A, et al. Times from symptom onset to hospital arrival in the Get with the Guidelines—Stroke Program 2002 to 2009: temporal trends and implications. Stroke. 2012;43:1912-1917.
25. Rose K, Rosamond W, Huston S, Murphy C, Tegeler C. Predictors of time from hospital arrival to initial brain-imaging among suspected stroke patients: the North Carolina Collaborative Stroke Registry. Stroke. 2008;39:3262-3267.
17. Lin C, Peterson E, Smith E, et al. Emergency medical service hospital pre-notification is associated with improved evaluation and treatment of acute ischemic stroke. Circulation. 2012;5:514-522. 18. Weber J, Ebinger M, Rozanski M, et al. Pre-hospital thrombolysis in acute stroke. Results of the PHANTOM-S pilot study. Neurology. 2013;80:163-168. 19. Meretoja A, Strbian D, Mustanoja S, et al. Reducing in-hospital delay to 20 minutes in stroke thrombolysis. Neurology. 2012;79:306-313. 20. Meretoja A, Weir L, Ugalde M, et al. Helsinki model cut stroke thrombolysis delays to 25 minutes in Melbourne in only 4 months. Neurology. 2013;81:1071-1076. 21. Jauch J, Icchiara B, Opeolu A, et al. Part II: adult stroke: 2010 American Heart Association guidelines for cardiopulmonary
386
JOURNAL OF EMERGENCY NURSING
26. Ford A, Williams J, Spencer M, et al. Reducing door-to-needle times using Toyota’s manufacturing principles and value stream analysis. Stroke. 2012;43:3395-3398. 27. Binning M, Sanfillippo G, Rosen W, et al. The neurological emergency room and prehospital stroke after: the whole is greater than the sum of the parts. Neurosurgery. 2014;74:281-285. 28. Walter S, Haass A, Grasu M, et al. Point-of-care laboratory halves doorto-therapy-decision time in acute stroke. Ann Neurol. 2011;69:581-586. 29. Fitzgerald S. Nation’s first ‘Stroke Ambulance’ debuts in Houston: new data from models in Germany. http://journals.lww.com/neurotodayonline/ Fulltext/2014/05150/Nation_s_First__Stroke_Ambulance__Debuts_in. 1.aspx. Accessed December 23, 2014.
VOLUME 41 • ISSUE 5
September 2015
MEET ME IN COMPUTED TOMOGRAPHY SUITE: DECREASING TISSUE PLASMINOGEN ACTIVATOR DOOR-TO-NEEDLE TIME FOR ACUTE ISCHEMIC STROKE PATIENTS Authors: Lauri Speirs, MSN, ACNS-BC, PCCN, CNRN, SCRN, and Anne Mitchell, MSN, ACNS-BC, CEN, CCRN, Ft. Worth, TX, Mesa, AZ Introduction
Since the introduction of intravenous (IV) recombinant tissue plasminogen activator (tPA) as a treatment for ischemic stroke patients, stroke has declined from the third to the fourth leading cause of death in the United States. 1 The effectiveness of thrombolysis for acute ischemic stroke is beyond debate, 2 but the benefit of tPA is strongly time dependent. 3 For each minute during which a large-vessel ischemic stroke is untreated, 1.9 billion neurons and 13.8 billion synapses are lost. 4 For each hour the stroke is untreated, the same neuronal loss develops that would occur in 3.6 years of normal aging. 4 Current recommendations are to administer IV tPA within 60 minutes of arrival to the emergency department for 50% of ischemic stroke patients or more. 5 Additional measures for treatment of acute ischemic stroke include door-to-physician time within 10 minutes, door–to–computed tomography (CT) examination within 25 minutes, and door–to–CT interpretation time within 45 minutes. 6 Although the treatment window has expanded from 3 to 4.5 hours, 7 patients treated within the first 90 minutes after symptom onset show almost twice the improvement without increased hemorrhage than patients receiving tPA 91 to 180 minutes after symptom onset. 8–10 Patients treated within 181 to 270 minutes still show improvement but to a lesser degree than those treated within 90 minutes. 2 For every 15-minute reduction in door-to-needle (DTN) time, the risk-adjusted
in-hospital mortality rate decreases by 5%. 10 For every 15-minute decrease in the time from symptom onset to treatment, patients have 4% greater odds of walking independently, 3% greater odds of being discharged home, and 4% lower odds of death and hemorrhagic transformation. 10 Time to treatment with tPA is an important determinant of 90-day and 1-year functional outcomes for patients with ischemic stroke. 10 A shorter delay from symptom onset to tPA can make the difference between being independent and being dependent. 11 Despite the proven effectiveness of timely tPA administration, the rate of tPA use in the United States for ischemic stroke patients remains low at 5.2% or less. 12 Fonarow et al. 9 reported that just 27% of patients with ischemic stroke arriving to the emergency department within 3 hours of symptom onset received tPA within the 60-minute goal. They noted that these patients were more likely to present to the emergency department on Monday through Friday, between the hours of 7 am and 5 pm. Patients arriving quickly to the emergency department after the onset of stroke symptoms tend to have more severe strokes but the DTN time may actually be longer for these patients. 3,9 Researchers have reported that the longest DTN times occurred in patients arriving to the emergency department within 30 minutes of symptom onset. 9,13 They speculated that making the decision to treat with tPA takes time as long as time is available. 9,13 Prehospital Improvement Strategies
Lauri Speirs is Neuroscience Clinical Nurse Specialist, JPS Health, Ft. Worth, TX. Anne Mitchell is Clinical Nurse Specialist, Emergency Department and Intensive Care Unit, Banner Baywood Medical Center, Mesa, AZ. For correspondence, write: Lauri Speirs, MSN, ACNS-BC, PCCN, CNRN, SCRN, JPS Health, 1500 S. Main Street, Ft. Worth, TX 76104; E-mail: [email protected]. J Emerg Nurs 2015;41:381-6. Available online 18 March 2015 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.01.005
September 2015
VOLUME 41 • ISSUE 5
Many potential barriers contribute to delays in DTN time for ischemic stroke patients. No pre-notification of the impending arrival of a stroke patient, a protracted triage process, location of the CT scanner outside the emergency department, lack of a dedicated stroke team process, and standardized stroke treatment protocols are hurdles to timely stroke identification and tPA administration. 3,11 Best-practice recommendations include minimizing the impact of these barriers by developing processes that allow rapid identification of stroke patients and timely tPA administration for eligible patients.
WWW.JENONLINE.ORG
381
CLINICAL/Speirs and Mitchell
In considering the onset of symptoms–to–treatment time (OTT), most time is lost in the prehospital setting primarily because patients delay seeking medical attention. Data from the Centers for Disease Control and Prevention indicate that fewer than half of stroke patients arrive to the emergency department within 2 hours of symptom onset. 14 Factors associated with earlier arrival after symptom onset include more severe symptoms, male sex, younger age, white race, higher educational status, living with a mate, and history of atrial fibrillation. 15,16 A factor strongly associated with shorter OTT is emergency medical services (EMS) transport to the emergency department. 10,17 Enhanced training of EMS providers in stroke recognition and development of a prehospital notification system reduce time to treatment. 10,14 In a European community, investigators equipped an ambulance with a neurologist, a radiographer, a CT scanner, and point-of-care (POC) laboratory diagnostics plus EMS personnel to determine the effect on DTN times. 18 Most patients, after confirmation of ischemic stroke, received tPA in the ambulance, resulting in a DTN time of 58 minutes. 18 Meretoja et al. 19 instituted changes in the pre-notification and assessment process by EMS. The hospital pre-notification call was made directly to the mobile phone of the on-call regional stroke physician. The pre-notification call included a conversation between the stroke physician and the on-scene next of kin or bystander. To gather additional event history, EMS then transported that individual, if possible, to the hospital with the patient. 19 Orders for laboratory tests and the CT examination were entered into the computer while the patient was en route to the emergency department, and the blood glucose level was measured by EMS. This prehospital strategy reduced DTN times to 20 minutes. Meretoja et al. 20 implemented a similar optimized tPA protocol in a different hospital system, showing a reduction in average DTN times from 61 to 46 minutes.
In-Hospital Strategies
In addition to streamlining EMS identification of, treatment of, and ED notification regarding stroke patients before arrival, strategies focusing on timely diagnosis and treatment after hospital arrival are part of the “Stroke Chain of Survival.” 21 Olson et al. 22 interviewed members of stroke teams in top-performing hospitals regarding management of ischemic stroke patients. They found that creating and training stroke teams, implementing preapproved standardized treatment protocols, obtaining administrative support, and monitoring performance are associated with early tPA use.
382
JOURNAL OF EMERGENCY NURSING
Investigators in large and small hospitals have reported improvements in DTN times and the number of patients receiving tPA after implementation of a standardized stroke response and treatment protocol. 23,24 In a small community hospital, Tveiten et al. 23 provided EMS personnel screening criteria for tPA treatment. If criteria were met, the emergency department and neurologist were notified and the CT scanner was made available at the time of patient arrival. Approximately 40% of ischemic stroke patients arriving to the emergency department within 3 hours received tPA. 23 A non-contrast CT scan of the head is essential before tPA administration. According to Rose et al. 25 only 11.5% of patients with stroke symptoms receive a CT scan within 25 minutes of hospital arrival. Significant predictors of CT scan delay include a delay from symptom onset to hospital arrival, non-EMS transport, being female or African American, and a presumed transient ischemic attack (TIA) diagnosis. 25 In an effort to decrease door-to-CT times for stroke patients, Hoegerl et al. 24 educated staff and implemented a stroke protocol providing for immediate examination, rapid CT, laboratory testing, and early notification of neurology. A year after protocol implementation, the door-to-CT time decreased to 10.5 minutes, the number of tPA-eligible patients receiving tPA increased from 4 to 12, and the DTN time decreased from 85.5 to 48.9 minutes. After analyzing how stroke patients were identified and determined to be eligible for tPA therapy, Ford et al. 26 listed 3 barriers associated with delayed tPA administration: (1) inefficient patient flow, (2) serial processing of multiple tasks, and (3) delayed laboratory results for patients taking anticoagulants. After streamlining the approach by taking the patient directly to the CT suite on arrival, performing required tasks simultaneously, and adopting POC testing for patients who have undergone anticoagulation, the average DTN time decreased from 60 to 39 minutes and the percentage of patients receiving tPA increased from 52% to 78%. 26 A second group of researchers also sought to improve door–to–CT examination times by delivering the EMS patient directly to the CT table. 19 A stroke physician performed a rapid neurologic evaluation, and laboratory specimens were obtained in the CT suite; the CT scan was then completed. This strategy resulted in door-to-CT times of 5 to 10 minutes and DTN times of 20 minutes. Comparable improvements in DTN times were achieved when the same researcher replicated similar process changes, including delivering the patient directly to the CT suite, in a different health care system. 27 Binning et al. 20 expedited tPA administration for eligible stroke patients by implementing pre-notification by EMS to the neurologic ED team and delivering the patient directly to the CT suite rather than an ED room. The average door-to-CT time was 11.8
VOLUME 41 • ISSUE 5
September 2015
Speirs and Mitchell/CLINICAL
TABLE
Best-practice recommendations for tPA administration Training of EMS personnel to recognize stroke using validated screening tools Advanced hospital notification by EMS Rapid triage protocol with stroke team notification Single-call stroke activation system Stroke tools/protocols Rapid acquisition and interpretation of brain imaging Rapid laboratory testing (including point of care if indicated) Mixing of tPA before patient arrival by EMS Rapid access to IV tPA Team-based approach to stroke patient Prompt data feedback Placement of CT scanner near or in emergency department CT scan ordered as soon as facility is made aware of incoming patient Delivery of patients to certified stroke center Continuous data collection to drive system improvement The recommendations are based on the findings of Fonarow et al.,9 Saver et al.,10 Kruyt et al.,11 Lin et al.,17 and Rose et al.25 CT, Computed tomography; EMS, emergency medical services; IV, intravenous; tPA, tissue plasminogen activator.
minutes, and the DTN time decreased by 67%. Walter et al. 28 reconfigured the entire stroke laboratory analysis to a POC system, reporting a decrease in door–to–therapy decision times from 84 to 40 minutes after POC implementation. Numerous studies have indicated that DTN times can be effectively shortened with multiple simple interventions (Table), and when the DTN time is reduced, more ischemic stroke patients can be treated with thrombolytic therapy.
Methods
As part of a multistate health care system located in a large metropolitan area, our facility treats 1,000 to 1,200 TIA and stroke patients per year, averaging 450 to 500 stroke alerts annually. Over the years since initiation of the stroke program and certification as a stroke center by The Joint Commission in 2008, most recommendations for best practice regarding tPA administration were gradually incorporated into the stroke process, resulting in some improvement in stroke measures. An established stroke team responds around the clock to stroke alerts announced by overhead paging, using a standardized stroke protocol to initiate care. For stroke alerts occurring in the emergency
September 2015
VOLUME 41 • ISSUE 5
department, the emergency physician responds to stroke alerts as a team member. EMS personnel pre-notify the emergency department of the pending arrival of a patient with a positive finding on the Cincinnati Stroke Scale. The CT scanner is located within the emergency department and made available when a stroke alert occurs. A “stroke box” fully stocked with all necessary supplies for tPA administration is available in the emergency department. All ED beds are capable of providing accurate patient weights using a simple button function. Neurology consultation is available 24 hours per day. Ongoing concurrent monitoring and data reporting provide timely feedback on performance and stroke target measures, identifying opportunities for improvement. Despite the implementation of these measures, DTN times remained greater than 60 minutes. From January through May 2013, the door–to–CT examination time averaged 21.76 minutes, the door–to–CT result time averaged 35.41 minutes, and the DTN time averaged 75.41 minutes. A DTN time of 60 minutes or less was achieved only 29.4% of the time. To improve the percentage of patients receiving tPA within 60 minutes of EMS arrival, the facility stroke committee reviewed each component of the stroke alert process and the associated time increments. A literature review provided information regarding additional strategies that successfully reduced DTN times in other stroke programs. Even though the average door-to-CT time and door–to– CT result times met established recommendations, analysis indicated that additional time could be saved within these 2 parameters, which could potentially translate to shorter DTN times and a higher percentage of patients receiving tPA within 60 minutes. Typically, when EMS arrived, the patient was placed in an ED room and connected to the cardiac monitor and a second IV line was initiated. A 12-lead electrocardiogram and laboratory specimens were obtained. The stroke team met the patient in the ED room and completed a physical examination and assessment using the National Institutes of Health Stroke Scale. After completion of these tasks, the patient was transported to the CT suite for scanning and returned to the ED room. The results of the analysis determined the critical elements required for the tPA decision and included the CT scan, quick assessment, history and medication list, platelet count, and for select patients, prothrombin time results. Other steps such as placing the patient in the room, connecting the patient to the cardiac monitor, starting a second IV line, and completing a thorough assessment could be performed during the time between CT completion and CT result. A “direct to CT” approach for the EMS-transported stroke patient and postponement of nonessential tasks until after CT examination were adopted. A decrease of 8 to 10 minutes in DTN time was anticipated as
WWW.JENONLINE.ORG
383
CLINICAL/Speirs and Mitchell
Average Door to CT Completed Pre and Post Intervention (minutes)
Average Door to CT Result (minutes)
40.00 35.00 30.00 25.00 20.00 15.00 10.00 5.00 0.00
25.00 20.00 15.00 10.00 5.00 0.00 pre (Jan '13-Jun '13)
pre (Jan '13-Jun '13)
post (Jul '13-Jun'14)
post (Jul '13-Jun'14)
FIGURE 2 FIGURE 1 Average door–to–computed tomography (CT) time (in minutes) before intervention (pre) and after intervention (post).
a result of delivering the patient directly to the CT suite. EMS, CT and laboratory personnel, emergency physicians, nursing staff, and stroke responders received education on the new process. Modification of the overhead announcement of stroke alerts incorporated broadcasting the CT suite as the meeting location rather than the ED room number. The new process was implemented in June 2013.
Results
One year after implementation of the change, the door-to-CT, door–to–CT result, and DTN times all improved. The door-to-CT time decreased by 9.71 minutes, from 21.76 to 12.05 minutes after implementation (Figure 1), and the door– to–CT result time decreased by 11.68 minutes, from 35.41 to 23.73 minutes after implementation (Figure 2). The DTN time declined by 7.63 minutes, from 75.41 to 67.78 minutes after implementation (Figure 3). By June 2014, 57.9% of patients received tPA within 60 minutes compared with 29.4% in 2013 prior to meeting in the CT suite (Figure 4). Meeting the EMS-transported stroke patient in the CT suite successfully reduced the door-to-CT, door–to–CT result, and DTN times for ischemic stroke patients eligible for thrombolytic therapy.
Discussion
Shorter DTN times are strongly linked to decreased hemorrhage and mortality rates, and tPA administration within 90 minutes of symptom onset improves patient outcomes. 8–10 The American Stroke Association (ASA) recommends that 50% of acute ischemic stroke patients
384
JOURNAL OF EMERGENCY NURSING
Average door–to–computed tomography (CT) result time (in minutes) before intervention (pre) and after intervention (post).
receive tPA within 60 minutes of arrival. 5 Despite CT times that met national benchmarks and the implementation of most of the ASA recommendations for acute stroke management, 3 our facility’s average DTN time exceeded the 60-minute goal by 15 minutes. The directto-CT strategy was incorporated into the facility stroke alert process based on reported improvements in DTN times when EMS-transported stroke patients are delivered directly to the CT suite. 19,20,27 One year after process modification, from June 2013 through June 2014, 34 patients received tPA and door-to-CT, door–to–CT result, and DTN times all improved. The door–to–CT result time showed the greatest decrease, followed by the door-to-CT time. Though improved, the DTN time achieved the smallest gain, decreasing by 7.63 minutes, as compared with 9.71 minutes and 11.68 minutes for door-to-CT time and door–to–CT result time, respectively. The time improvements did not translate equally within the 3 parameters; the decrease in door–to–CT result time of nearly 12 minutes did not reduce the DTN time by 12 minutes. This may be related to the time taken to make the tPA decision even though data were available more quickly. Occasionally, family members extended the tPA decision time, being reluctant to commit to a treatment strategy, but the incidence of indecision appeared similar before and after implementation. POC testing was initially considered by the stroke committee as a potential improvement tactic. Given the anticipated decrease in the DTN time as a result of the direct-to-CT approach, POC testing was not included as a recommendation. Although the lower DTN times achieved by Meretoja et al. 19,20 were not realized, the number of patients receiving tPA within 60 minutes nearly doubled. This represents a substantial improvement and meets the
VOLUME 41 • ISSUE 5
September 2015
Speirs and Mitchell/CLINICAL
Percentage of Patients Receiving tPA within 60 minutes
Average Door To Needle Pre and Post Intervention (minutes) 76.00
60.00%
74.00
50.00%
72.00 70.00
40.00%
68.00
30.00%
66.00
20.00%
64.00
10.00%
62.00 pre (Jan '13-Jun '13)
post (Jul '13-Jun'14)
0.00% pre (Jan '13-Jun '13)
post (Jul '13-Jun'14)
FIGURE 3 Average door-to-needle time (in minutes) before intervention (pre) and after intervention (post).
Target: Stroke goal of tPA in less than 60 minutes for 50% of ischemic stroke patients or more. For many communities, making a stroke neurologist available 24/7 by phone to a network of EMS providers transporting stroke patients, as well as transporting witnesses to stroke events to local emergency departments, may not be a feasible strategy even though substantial reductions in DTN times were achieved by Meretoja et al. Moreover, equipping a stroke ambulance with a stroke neurologist, a CT scanner, and tPA, as Weber et al. 18 did, is not likely to be a realistic strategy for the majority of communities. Since these European studies were published, a Texas facility has been investigating the effect on DTN times using an ambulance outfitted with a CT scanner for the transport of possible stroke patients. 29 Implications for Practice and Conclusion
Optimum reduction in DTN time delays is not achievable by any single intervention but rather results from continuous analysis of data and improvement of the stroke process as a whole. Achieving door-to-CT and door–to–CT result benchmark times may not be sufficient to meet the DTN target of 60 minutes or less. However, delivering the EMS-transported stroke patient directly to the CT suite instead of first placing the patient in the ED room can result in substantial gains in CT times and increase the percentage of patients receiving tPA within 60 minutes. Postponing nonessential components of care until after completion of the CT scan does not appear to result in any harm to the patient or interfere with routine CT operations. Even if CT scan and result times meet recommended targets, implementation of a direct-to-CT approach as a single improvement strategy appears effective in reducing DTN times and improving the percentage of patients receiving tPA within 60 minutes.
September 2015
VOLUME 41 • ISSUE 5
FIGURE 4 Percentage of patients receiving tissue plasminogen activator (tPA) within 60 minutes before intervention (pre) and after intervention (post).
REFERENCES 1. Towfighi A, Saver J. Stroke declines from third to fourth leading cause of death in the United States. Stroke. 2011;42:2351-2355. 2. Lees K, Bluhmki E, van Kummer R, et al. Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet. 2010;375:1695-1703. 3. Fonarow G, Smith G, Saver J, et al. Improving door-to-needle times in acute ischemic stroke. The design and rationale for the American Heart Association/American Stroke Association’s Target: Stroke initiative. Stroke. 2011;42:2983-2989. 4. Saver J. Time is brain. Stroke. 2006;37:263-266. 5. Target: Stroke. http://www.strokeassociation.org/STROKEORG/ Professionals/Target-Stroke_UCM_314495_SubHomePage.jsp. Accessed July 30, 2014. 6. Jauch E, Saver J, Adams H, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870-947. 7. Zoppo G, Saver J, Jauch E, Adams H. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator. Stroke. 2009;40:2945-2948. 8. Ahmed N, Wahlgren N, Grond M, et al. Implementation and outcome of thrombolysis with alteplase 3–4.5 hours after an acute stroke: an updated analysis from SITS-ISTR. Lancet Neurol. 2010;9:866-874. 9. Fonarow G, Smith E, Saver J, et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-toneedle times within 60 minutes. Circulation. 2011;123:750-758. 10. Saver J, Fonarow G, Smith E, et al. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA. 2013;309:2480-2488. 11. Kruyt N, Nederkoorn P, Dennis M, et al. Door-to-needle time and the proportion of patients receiving intravenous thrombolysis in acute
WWW.JENONLINE.ORG
385
CLINICAL/Speirs and Mitchell
ischemic stroke. Uniform interpretation and reporting. Stroke. 2013;44:3249-3253. 12. Adeoye O, Hornung R, Khatri P, Kleindorfer D. Recombinant tissuetype plasminogen activator use for ischemic stroke in the United States. Stroke. 2011;42:1952-1955. 13. Strbian D, Patrik M, Ringleb P, et al. Relationship between onset-todoor time and door-to-thrombolysis time. Stroke. 2013;44:2808-2813.
resuscitation and emergency cardiovascular care. Circulation. 2010;122:S818-1828. 22. Olson D, Constable M, Britz G, et al. A qualitative assessment of practices associated with shorter door-to-needle time for thrombolytic therapy in acute ischemic stroke. J Neurosci Nurs. 2011;43:329-336.
14. Kue R, Steck A. Prehospital diagnosis and management of patients with acute stroke. Emerg Med Clin North Am. 2012;30:617-635.
23. Tveiten A, Mygland A, Ljostad U, Thomassen L. Intravenous thrombolysis for ischemic stroke: short delays and high communitybased treatment rates after organisational changes in a previously inexperienced centre. Emerg Med. 2009;26:324-326.
15. Iosif C, Papathanasiou M, Staboulis E, Gouliamos A. Social factors influencing hospital arrival time in acute ischemic stroke patients. Neuroradiology. 2012;54:361-367.
24. Hoegerl C, Goldstein F, Sartorius J. Implementation of a stroke alert protocol in the emergency department: a pilot study. J Am Osteopath Assoc. 2011;111:21-27.
16. Tong D, Reeves M, Hernandez A, et al. Times from symptom onset to hospital arrival in the Get with the Guidelines—Stroke Program 2002 to 2009: temporal trends and implications. Stroke. 2012;43:1912-1917.
25. Rose K, Rosamond W, Huston S, Murphy C, Tegeler C. Predictors of time from hospital arrival to initial brain-imaging among suspected stroke patients: the North Carolina Collaborative Stroke Registry. Stroke. 2008;39:3262-3267.
17. Lin C, Peterson E, Smith E, et al. Emergency medical service hospital pre-notification is associated with improved evaluation and treatment of acute ischemic stroke. Circulation. 2012;5:514-522. 18. Weber J, Ebinger M, Rozanski M, et al. Pre-hospital thrombolysis in acute stroke. Results of the PHANTOM-S pilot study. Neurology. 2013;80:163-168. 19. Meretoja A, Strbian D, Mustanoja S, et al. Reducing in-hospital delay to 20 minutes in stroke thrombolysis. Neurology. 2012;79:306-313. 20. Meretoja A, Weir L, Ugalde M, et al. Helsinki model cut stroke thrombolysis delays to 25 minutes in Melbourne in only 4 months. Neurology. 2013;81:1071-1076. 21. Jauch J, Icchiara B, Opeolu A, et al. Part II: adult stroke: 2010 American Heart Association guidelines for cardiopulmonary
386
JOURNAL OF EMERGENCY NURSING
26. Ford A, Williams J, Spencer M, et al. Reducing door-to-needle times using Toyota’s manufacturing principles and value stream analysis. Stroke. 2012;43:3395-3398. 27. Binning M, Sanfillippo G, Rosen W, et al. The neurological emergency room and prehospital stroke after: the whole is greater than the sum of the parts. Neurosurgery. 2014;74:281-285. 28. Walter S, Haass A, Grasu M, et al. Point-of-care laboratory halves doorto-therapy-decision time in acute stroke. Ann Neurol. 2011;69:581-586. 29. Fitzgerald S. Nation’s first ‘Stroke Ambulance’ debuts in Houston: new data from models in Germany. http://journals.lww.com/neurotodayonline/ Fulltext/2014/05150/Nation_s_First__Stroke_Ambulance__Debuts_in. 1.aspx. Accessed December 23, 2014.
VOLUME 41 • ISSUE 5
September 2015
