No abstract

Objectives To identify barriers to inpatient alteplase administration and implement an interdisciplinary program to reduce time to systemic thrombolysis. Patients and Methods Compared with patients presenting to the emergency department with an acute ischemic stroke (AIS), inpatients are delayed in receiving alteplase for systemic thrombolysis. Institutional AIS metrics were extracted from the electronic medical records of patients presenting as an inpatient stroke alert. All patients who received alteplase for AIS were included in the analysis. A gap analysis was used to assess institutional deficiencies. An interdisciplinary intervention was initiated to address these deficiencies. Efficacy was measured with pre- and postintervention surveys and institutional AIS metric analysis. Statistical significance was determined using the Student t test. We identified 5 patients (mean age, 73 years; 100% (5/5) male; 80% (4/5) white) who met inclusion criteria for the preintervention period (January 1, 2017, to December 31, 2017) and 10 patients (mean age, 71 years; 50% male; 80% white) for the postintervention period (October 31, 2018, to July 1, 2020). Results We found barriers to rapid delivery of thrombolytic treatment to include alteplase availability and comfort with bedside reconstitution. Interdisciplinary intervention strategies consisted of stocking alteplase on additional floors as well as structured education and hands-on alteplase reconstitution simulations for resident physicians. The mean time from stroke alert to thrombolysis was shorter postintervention than preintervention (57.4 minutes vs 77.8 minutes; P =.03). Conclusion A coordinated interdisciplinary approach is effective in reducing time to systemic thrombolysis in patients experiencing AIS in the inpatient setting. A similar program could be implemented at other institutions to improve AIS treatment.

Introduction: Acute ischemic stroke treatment is time sensitive especially for large vessel occlusion (LVO) strokes with the goal to achieve early cerebral reperfusion. Research suggests standardized protocols incorporate early notification to reduce time from arrival to mechanical thrombectomy (MT). The MT workflow at a certified stroke center required multiple phone calls to mobilize staff and resources resulting in treatment delays. The average time from neurosurgery notification (NN) to case start (CST) was 60.4 minutes (min) resulting in average door-to-puncture (DTP) time of 124.8 min further delaying early reperfusion. Purpose: Standardize MT workflows and incorporate a 1-step notification system to reduce average NN to CST by 20% to 45 min to achieve 90 min average DTP time by 90 days post implementation. Methods: Baseline data for MT cases admitted 1/1/18 - 9/2/19 arriving in the emergency room (ER) and occurring inpatient were abstracted from stroke alert logs and the electronic health record. MT transfers were excluded. A multidisciplinary group of key stakeholders completed both high level process and workflow analysis maps and mock simulations to identify gaps. Both an analysis of variance and Tukey-Kramer’s T Test were performed revealing NN to CST was most statistically significant (p<.0001) and largest root cause for overall increased DTP times. New service-specific workflows were developed including 1-step notification activated via an existing group paging system used for other purposes. Activation notified on call staff of the MT case and patient location. Data points collected were NN to CST (ED and inpatient) and DTP (ED only). Results: Average NN to CST time was 26.7 min (33.3 min decrease or 55.1%; p<.0001, n=12) resulting in DTP average of 83.4 min (41.4 min decrease or 35.3%, n=10) 90 days post-implementation. The paging system was cost-neutral due to existing licensing agreements. Conclusion: In conclusion, streamlined workflows incorporating 1-step notification reduced time from notification to staff response so MT procedures could start sooner. A multidisciplinary approach along with key stakeholder buy-in was instrumental in successful project implementation.

ObjectiveTo ensure prime blood pressure management and intracerebral hemorrhage (ICH) score documentation within 6 hours of arrival and/or before any intervention in patients admitted to Mayo Clinic Hospital with acute ICH.Patients and MethodsA quality improvement initiative was conducted between September 29, 2015, and May 30, 2017, following the Define-Measure-Analyze-Improve-Control methodology. Our prespecified goals for the first 8 months postintervention were that at least 80% of patients with ICH will have systolic blood pressure (SBP) control as per guideline-based recommendations (SBP ≤140 mm Hg) and at least 80% will have ICH score documented within 6 hours postadmission. Neurovascular stakeholders' feedback was included in the process development. Practice gaps and their leading causes were identified and served rational interventions' planning. Education and admission order-set modifications were chosen as intervention methods.ResultsAt 4 (first measurement, n=13) and 8 months (second measurement, n=15) postintervention, 92.3% and 100% of patients with ICH, respectively, reached the target SBP, compared with 50% in the preintervention group (comparison group, n=26); 84.6% and 85.7% of the patient population had the ICH score documented at the first and second outcome measurement, respectively, compared with 42.3% in the preintervention group. Stakeholders reported good satisfaction with the novel applications. Sustainability plans and future directions were established.ConclusionEffective education methods enhance the introduction of guideline-based clinical practices. This quality improvement project has the potential to impact patient outcomes, staff efficiency, and stroke centers' maintenance of certification and quality care recognition. This initiative warrants implementation at hospitals across all Mayo Clinic campuses and nationwide.