Introduction: The American Heart and American Stroke Associations released their new Target: Stroke goal of IV tPA administration in under 45 minutes from arrival for all eligible patients. While many hospitals have improved with prompt IV tPA initiation, further analysis is necessary to determine reasons for ongoing delays in order to continue to improve door- to-needle (DTN) times. Hypothesis: We hypothesized that identifying trends in IV tPA initiation delays could guide development of process improvement (PI) geared toward decreasing DTN times. Methods: A retrospective cohort of 2,417 patients presenting to a five hospital campus system from January 2013 to March 2015 were studied to identify trends in IV tPA delays. Inclusion criteria: all patients presenting to the emergency department (ED) for which a code stroke was activated and IV tPA was initiated with DTN times greater than 60 minutes from arrival. Exclusion criteria: patients presenting to the ED for which a code stroke was activated but IV tPA was not administered, or IV tPA was initiated within 60 minutes of arrival. Results: Sixty-seven patients met the inclusion criteria, and the following trends were identified: seven patients (10%) required management for other life threatening conditions prior to IV tPA, such as intubation or cardioversion; IV tPA was delayed in 28 patients (42%) due to an inability to determine eligibility. This was based on waxing and waning symptoms and/or uncertainty of last time known well (LKWT). Twenty patients (30%) required IV medications for hypertension and twelve (18%) patients and/or family members initially refused the drug. Conclusion: This study revealed that 90% of IV tPA initiation delays were due to potential modifiable factors. Indicating that through implementation of PI changes, hospital systems may be able to prevent similar delays from occurring. Examples include: collaboration with emergency medical services to transport witnesses to the ED for assistance with prompt identification of LKWT, earlier management of hypertension, and a streamlined approach for risk and benefit discussions between clinicians, patients and/or family to assist in a rapid informed consent process.

Introduction: American Stroke Association guidelines recommend pre-hospital stroke code notification via EMS to facilitate prompt treatment decision for acute ischemic stroke (AIS) patients. Despite pre-notification to the stroke team, treatment decisions are often delayed until medical history and last known well times are established. Hypothesis: We hypothesized that screening for IV Alteplase candidacy and obtaining pertinent medical history from a witness or patient during a pre-hospital stroke code activation prior to hospital arrival would decrease door to needle (DTN) times. Methods: A retrospective analysis was conducted on 193 patients presenting to the emergency department (ED) at a Comprehensive Stroke Center (CSC) from February 2016 through July 2016. A process improvement (PI) event was initiated between the CSC and two fire stations with a catchment time of > 10 minutes. For pre-hospital activated stroke codes, the witness or patient was provided the contact card and encouraged to call the centralized number to the Neurologist. Inclusion criteria: All patients presenting to the ED with EMS pre-hospital stroke code activation. Exclusion criteria: Patients presenting to the ED with stroke code initiated after arrival, or medic response events which did not lead to a pre-hospital stroke code activation. Results: After applying criteria, 126 met inclusion and exclusion criteria. A total of 19 patients arrived via the 2 fire stations with pre-hospital stroke code initiations and serve as our intervention group, while 107 patients underwent standard of care. Contact cards were provided to 11 patients (58%) in the intervention group prior to arrival. IV Alteplase was initiated for 3 of 11 patients (27.3%) in the intervention group vs. 19 of 107 patients (17.8%) in the standard of care group. Mean and median DTN times in the intervention group was 36 minutes as compared to a mean of 46.1 minutes and median time of 40 minutes receiving standard of care. Conclusions: Preliminary data suggest that DTN times can be decreased when medical history is obtained prior to hospital arrival to screen for IV Alteplase eligibility. This study warrants further investigation in pre-acquisition of history for pre-hospital stroke code patients.

Introduction: The American Heart and American Stroke Associations’ revised guidelines for acute ischemic stroke recommend rapid transfer of patients with large vessel occlusions (LVO) eligible to receive mechanical endovascular procedures (MEP) if initial receiving facility does not offer MEP. Initiating the transfer process to MEP capable facilities is often delayed until LVO is confirmed on imaging. Hypothesis: We hypothesized that initiating a pre-notification process (PNP) by which emergency medical system (EMS) is notified of patients arriving to the emergency department (ED) with symptoms of LVO would reduce transfer turn-around-times (TATs). Methods: A pre- and post-interventional study involving 735 patients presenting to 2 EDs in a 5 campus hospital system from January 2014-June 2015. Both EDs began a PNP to alert EMS of potential MEP candidates. EMS then dispatched a critical care transport (CCT) ambulance with a CCT nurse to the ED to await transfer decision. Transfer TATs pre- and post-process change were reviewed. Inclusion criteria: patients with stroke code (SC) initiations in the ED who were transferred for possible MEP, or had PNP to EMS initiated. Exclusion criteria: patients with SC initiations that were not transferred or did not have PNP initiated. Results: Sixty patients met inclusion criteria; 52 were transferred pre-process change, and 8 were transferred post-process change with PNP initiated. Median time from decision to EMS arrival in the ED decreased from 22.5 minutes to -1 minute, with ambulance arriving to ED prior to decision. Median time of decision to EMS departure from ED decreased from 56 to 39 minutes, and overall median transfer TATs to MEP capable facility decreased from 78 to 69.5 minutes. Of the 8 patients with PNP to EMS, 6 (75%) were transferred to MEP capable facility. Conclusions: Pre-notification from ED to EMS of patients arriving with symptoms of LVO can reduce transfer times to an MEP capable facility. This study highlights the importance of early EMS involvement upon initial recognition of potential LVO patients, and implementation of rapid transfer protocols. Additional opportunities may exist to streamline care within the ED to further reduce transfer TATs.