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Background: Efficient emergency department (ED) code stroke processes lead to improved door-to-needle (DTN) times for the administration of IV tissue plasminogen activator (tPA) for qualifying acute ischemic stroke (AIS) patients. A code stroke initiation in the ED activates a cascade of actions involving multiple steps and can result in variations of processes, consequently leading to delayed treatment. Hypothesis: We sought to implement an efficient, standardized tPA ordering method, called Direct Pharmacy Ordering Process (DPOP), as part of our code stroke process to improve DTN times. Methods: A retrospective review of 401 records from our internal code stroke database was completed prior to and post implementation (June, 2013 to December, 2013 and April, 2014 to April, 2015, respectively) of DPOP. DPOP allows the ED physician to call for tPA directly to the pharmacist, who then calculates dosage, mixes and dispenses the medication. Charts were reviewed for patients’ time of ED arrival, time of CT scan results, time of tPA orders, and time of tPA administration. Inclusion criteria: AIS patients for whom an ED code stroke was initiated and who received tPA. Exclusion criteria: code strokes initiated after hospital administration, ED code stroke patients not receiving tPA, and patients receiving tPA but for whom process times could not be determined. Results: After applying criteria, a total of 46 patients’ records were included (16 pre-DPOP and 30 post-DPOP). There was a substantial reduction in all turn-around-times when pre-DPOP and post-DPOP data were compared. Mean time from CT results to time pharmacy received tPA requests decreased from 38 minutes to 17; mean time from CT results to administration of tPA, decreased from 52 minutes to 36, with a decreased median time from 54 minutes to 34. Additionally, DPOP eliminated illegible orders and orders with omissions, further improving timeliness. Conclusion: We implemented an improvement process for ordering IV tPA that led to substantial reductions in time for our code stroke process. Additionally, DPOP eliminated problems inherent to written prescriptions, thus leading to reductions in median time of tPA administration from the time of reported CT results by >20 minutes for most AIS cases receiving tPA.

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