Improving Door to Needle Times Strategies for Success: How to Maximize rtpa Administration from a Community Hospital s Perspective

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Lynn Haynes
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1 Improving Door to Needle Times Strategies for Success: How to Maximize rtpa Administration from a Community Hospital s Perspective

2 Presenter Disclosure Information FINANCIAL DISCLOSURE: Catherine Videtto, RN, MSN, ANP, CCRN, CPHQ No relevant financial relationship exists

3 Intravenous rtpa Studies 1995 National Institute of Neurological Disorders and Stroke (NINDS)- determined that patients who were given IV rtpa within 3 hours of symptoms were 30% more likely to have little or no disability at 3 months than patients given placebo Hacke,W, et al. Lancet. 2004; 363 (9411)

4 Goals of our Stroke Team St. Catherine of Siena Medical Center Provide excellence in Stroke/TIA Management Prevent missed opportunities for thrombolytic administration Develop protocols/policies to guide and support evidence based best practices for efficient administration of rtpa Demonstrate evidence of commitment to best practices by adherence to 10 CDC/COV Consensus Measures Deliver defect-free Stroke/TIA Management

5 Program Strengths Chief of Neurology = Physician champion role model/change agent advocating for improved compliance with evidence based best practices Chief of Emergency Service = strong advocate for effective use of IV rtpa for ED stroke patients Stroke Unit Nursing staff = committed to excellence in Stroke/TIA care 24 / 7 In-House Stroke Team lead by MLP trained in stroke management All stroke team members recognized for achievement of desired DTN times

6 The 1995 National Institute of Neurological Disorders and Stroke (NINDS) study determined that acute Ischemic Stroke patients who were given IV rtpa within 3 hours of symptom onset were 30% more likely to have little or no disability at 3 months than patients given placebo. 1. TRUE 2. FALSE 87% 13% 1 2

7 THE FASTER OUR STROKE TEAM MOVES, THE BETTER OUR PATIENT S CHANCE OF MOVING LATER In a typical middle cerebral artery ischemic stroke, 2 million nerve cells are lost each minute in which reperfusion has not been achieved. vonkummer,r, Holle,R et al. Radiology. 205 (2):

8 Target: STROKE initiative of the AHA/ASA was created: to help hospital teams to minimize doorto-needle (DTN) times and achieve door to IV rtpa bolus time of =/<60 minutes provide health care professionals with 10 Best Practice Strategies for improving DTN times includes wealth of resources and tools to assist in accomplishing this goal

9 Target: STROKE Best Practice Strategies Advance EMS Notification: shortens diagnostic times, provide educational programs to EMS acknowledging their contributions, Protector of Penumbra Award Rapid Triage Protocol: Stroke Alert Activation/ Triage RN competent and authorized to call Stroke Alert Single Call Activation System Stroke Tool Kit: specific order set, guidelines, algorithms, NIHSS, rtpa and administration guidelines Rapid Brain Imaging <25 minutes, results <45minutes: 2011 Annual Mean TAT CT=27 minutes result reported Rapid Lab Testing <45minutes, 2011 Annual Mean TAT Lab= 30 minutes

10 Target: STROKE Best Practice Strategies Preparation of rtpa Ahead of time: Weight based dosage guidelines and preprinted physician order sheet and storage of rtpa in ED Rapid Access to IV rtpa- incorporated into Thrombolytic Stroke Tool kit/pyxis Team Based Approach: Standardized pathway and protocols Prompt Data Feedback-Concurrent Monitoring, submission of GWTG PMT and timely feedback to all members of team Development of Stroke Alert lab panel to facilitate quick order entry

11 Success achieved in DTN Times Reduction through alignment with Target: Stroke Best Practices Each IV t-pa case analyzed in the Root Cause Analysis format All departments who impact IV rtpa (DTN) times discuss the process and believe they are accountable for each minute they are responsible for the care of that patient Team members present (Nursing, Radiology, Laboratory, Transport Team) identify barriers to minimizing DTN times and brain storm possible solutions Pin-point target areas for improvement and continue to strive to reach goal of achieving minimal DTN times (ie. develop tool kit, additional transport team hours)

12 IV tpa is a proven intervention in treatment of acute ischemic stroke resulting in improved neurologic outcomes at 90 days The relationship between DTN and clinical outcomes was reported during 6.5 year study time period (4/2003 9/2009) included 25,504 acute ischemic stroke patients who were treated with IV tpa within 3 hours of symptom onset at 1082 hospital sites Patients receiving intravenous tpa within 3 hours of symptom onset, showed a mean DTN time for tpa administration of 79.3 minutes There were 6790 (26.6%) patients with DTN times 60 minutes and 18,714 (73.4%) with DTN times >60 minutes. Fonarow G et al. Circulation 2011, 123:

13 Faster DTN time for tpa treated stroke patients was associated with: fewer tpa complications lower risk adjusted in-hospital mortality Short-term clinical outcomes were not compromised in those stroke patients receiving improved DTN times These links between process of care and outcomes support the use of DTN time 60 minutes Fonarow G et al. Circulation 2011, 123:

14 Which of the following statements is TRUE? 1. Target: STROKE was created to help hospital teams minimize DTN times. 82% 2. Goal is to achieve DTN rtpa administration times of <90 minutes. 3. If rtpa is prepared and not used, the hospital will not be reimbursed. 4. Faster DTN times were not associated with lower risk adjusted in-hospital mortality. 10% 3% 4%

16 The Whole is Even Greater Than the Sum of Its Parts The way a team plays as a whole determines its success. You may have the greatest bunch of individual stars in the whole world, but if they don t play together, the club won t be worth a dime -Babe Ruth

17 SCSMC Ischemic Stroke Management Improving Door-to-Needle (DTN) Times AHA/ASA Benchmark <60 minutes Mean DTN 2012 = 77 minutes n=6 Mean DTN 2011 = 66 minutes n=19 Mean DTN 2010 = 89minutes n=14 # M i n u t e s E l a p s e d T r i a g e T i m e t o r t P A B o l u s T i m e Trendline Benchmark <60 Difficulty obtaining consent family initially refused Penumbra Award Implemented 130 UCL 2SD= Consent delay? recent GI Bleed per family / 23/ 1 9/ 20/ 1 9/ 21/ 1 9/ 29/ 1 10/ 5/ 1 10/ 6/ 1 12/ 10/ 1 2/ 28/ 1 4/ 22/ 1 9/ 11/ 2 10/ 17/ 3/ 11/ 10 4/ 7/ 10 4/ 7/ 10 7/ 7/ 10 7/ 8/ 10 9/ 9/ 10 11/ 9/ 10 1/ 9/ 11 1/ 16/ 11 2/ 13/ 11 3/ 15/ 11 4/ 1/ 11 4/ 11/ 11 5/ 21/ 11 6/ 6/ 11 7/ 13/ 11 9/ 7/ 11 9/ 14/ / 5/ 2 11/ 16/ 2 12/ 14/ 12/ 25/ 1/ 10/ 2 1/ 23/ 2 2/ 28/ 2 3/ 20/ 2 4/ 8/ 20 4/ 14/ ?syncope, fell, large hematoma forehead & shoulder DTN

18 SCSMC Compliance with Achieving <60 minute Door to Needle Goal % c o m p l i a n c e < 6 0 m i n D T N n= n= n=6

19 Which of the following statements is NOT correct? 1. Faster DTN time for rtpa treated ischemic stroke patients was associated with fewer tpa complications. 2. Short-term clinical outcomes were not compromised in those patients receiving improved DTN times. 3. Utilization of a Thrombolytic Stroke Tool Kit can facilitate shorter DTN times. 4. Goal is to achieve Noncontrast Brain CT TAT times of <60 minutes. 57% 18% 15% 10%

20 Case Study #1 73 yo white female while shopping became weak, difficulty speaking; EMS activated; +Cincinnati Stroke Scale HPI: 26 minute PTA onset Right arm paresis and aphasia ED MD= 1 minute from triage time Neurologist activation=7 minutes from triage time triage= 11 PMH: CAD, HTN, Dyslipidemia Brain CT done=22 min, resulted=29minutes Labs result reported=34 minutes rtpa 34 minutes DTN time discharge= 2 minimal Right arm and Right leg drift, independent ambulation, speech clear, no apparent deficits Discharge to rehab program 5 day LOS 30 day post rehab d/c Internist office, no residual deficit

21 Case Study #2 82 yo White female arrived via EMS from home, ED 43 minutes from onset PMH: HTN, Dyslipidemia Stroke Alert Activation 2 minutes from triage NIHSS on admit= 18 (paresis, global aphasia); New onset AF on 4 minutes in triage Ambulation prior to admission independent Brain CT done=13 minutes; result reported=27minutes Labs resulted = 28 minutes rtpa bolus 54 minutes +DTN Goal Anticoagulation initiated, d/c d on full dose AC Rehabilitation SNF f/u with 45 days, MRS=0, NIHSS=3, minimal expressive aphasia, minimal Right arm and Right leg weakness

22 Thank You for your attention! Any questions?

TIME LOST IS BRAIN LOST. TARGET: STROKE CAMPAIGN MANUAL

TIME LOST IS BRAIN LOST. TARGET: STROKE CAMPAIGN MANUAL 2010, American Heart Association TARGET: STROKE CAMPAIGN MANUAL 01 INTRODUCTION Welcome to the Target: Stroke. The purpose of this manual is to provide