improving door-to-needle time: ems/emergency dept stroke...
TRANSCRIPT
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Improving Door-to-Needle Time:
EMS/Emergency Dept Stroke Care 10th Annual Cerebrovascular Symposium
Swedish Medical Center
Benjamin Seo, MD Swedish Cherry Hill Emergency Dept
May 5, 2016
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Swedish Medical Center
Cherry Hill Campus
> Neurosciences/Cardiovascular
> Comprehensive Stroke Center
> GWTG Stroke Gold Plus
> Emergency Department
• Full service department
• 15 beds
• Approx 25k visits per year
• [] “code strokes”, approx []% tPA
cases
• Target Stroke Honor Roll Elite Plus
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Rationale for Improving DTN Times
Second leading cause of death globally behind heart disease
> Fifth leading cause of death in the U.S.
• 129,000 deaths per year (one every 4 minutes)
• 795,000 strokes annually in the U.S. (one every 40 seconds)
Leading cause of serious long term disability in the U.S.
• National Stroke Association: 40% of patients w/ impairment requiring
special care after discharge
• 10% will require nursing home level care,14% will experience another
stroke within the first year
• Estimated total cost of care $71.6 billion in 2012
• Projected to triple to $184 billion by 2030
(Mozafarrian et al, 2015)
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Time is Brain
1.9 million neurons are lost per minute (Saver, 2006)
• 14 billion synapses, 7.5 miles of myelinated fiber per minute
• Equivalent of aging 3.6 years per hour without treatment
Every 15 min reduction in DTN estimated to add 1 month of
disability free life (Meretoja et al., 2014)
• 1.8 days added per 1 min reduction in DTN time overall
• 0.6 days added for 80yo and NIHSS 20 | 0.9 days 80yo and NIHSS 4
• 2.7 days added for 50yo and NIHSS 20 | 3.5 days 50yo and NIHSS 4
Every 15 min reduction in DTN estimated to lower odds of
mortality by 5% (Fonarow et al., 2011)
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National Backdrop
1996: FDA approval of IV-tPA 0-3 hours onset
2003: AHA/ASA creation of Primary Stroke Center designation
> Get With the Guidelines Stroke Registry created
2009: AHA/ASA recommendation of 4.5 hour IV-tPA window
*2010: Target Stroke Campaign initiated
2012: Comprehensive Stroke Center designation created
2015: AHA/ASA updated guidelines for endovascular treatment FOOTER 5
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Target Stroke
AHA/ASA national campaign to improve DTN times
> Campaign launched Jan 2010
• Goal of DTN w/in 60min for at least 50% of patients
> Studies at the time reported less than 30% of patient receiving IV-tPA
w/in 60min*
> 2010 national median DTN time of 78 minutes (GWTG Registry)
> Phase II started in 2015: DTN w/in 60min for 75% of patients, 45min
for 50%
*(Fonarow et al, 2011)
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.
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Our Story 2010 Median DTN Time of 74 minutes (GWTG Registry)
> Stroke care very linear:
• EMS arrives and gives report
• Patient is moved to ED bed, weighed, placed on monitor, IV access, blood
glucose, EKG, registered
• MD takes EMS report, interviews and examines patient, initiates Code
Stroke, orders labs/CT, Neurology paged.
• Patient returns from CT, and is examined by Neurology.
• CT report from Radiology
• Labs reviewed
• Decision to give tPA made. Ordered. Mixed in Pharmacy and brought to
the bedside.
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How to Utilize Lean Principles at CH?
What part of the pathway is of
actual value to the patient?
> How do we reduce or eliminate
everything else
> How do we create flow?
> How do we reduce
variability/outliers?
> How do we change a linear
process to a parallel process?
> How do we maintain
quality/safety?
IMAGE FROM LEAN.ORG 9
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Our Experience
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*Data from Swedish GWTG Registry
0
10
20
30
40
50
60
70
80
2010(n=17)
2011(n=25)
2012(n=22)
2013(n=28)
2014(n=39)
2015(n=38)
2016(n=7)
74
65
55
47
40 38 34
74 76
59
52
45 40 39
Nu
mb
er
of
Cas
es
Cherry Hill Door to IV Alteplase Times
Median
Mean
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General Concepts
Multi-departmental / multi-institutional effort
Successful models
• STEMI care, Trauma
• Swedish Denver, Helsinki University Central Hospital
Standardization
• Stroke Protocol and order-sets / STAT stroke labs and head CT
• Hospital-based Neurology service dedicated to stroke care
• Staff training and experience
How much can be done before rooming the patient?
• Coordination with Seattle Medic One / local EMS
• Door-to-CT Pilot Project
Continuous QI and refinement of processes / PDSA Model
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EMS
Standards:
• 9-1-1 Dispatch within 90 sec of receiving call
• EMS response time within 8 minutes
• On-scene time less than 15 minutes
• Rapid transport to nearest designated stroke center (PSC vs CSC)
• Currently drip and ship model (Pervez et al, 2010)
Pre-Hospital Activation and care
• “the key is to do as little as possible after the patient has arrived in the
emergency room and as much as possible before that” (Meretoja 2012)
Experimental
• MSTUs
• Neuroprotective agents – animal studies have not translated to benefit in
human trials yet (e.g., FAST-MAG)
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EMS (cont)
Door-to-CT Project:
• Met with Seattle Medic One and other local EMS stakeholders
• Model of successful STEMI system
• King County EMS stroke training and education revamp in 2015-16
Prehospital Assessment
• LKN
• FAST: sensitivity 79-85%, specificity 68%, misses 38% posterior strokes (Nor et al, 2004; Purrucker et al., 2015; Harbison et al., 2003)
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EMS (cont.)
PreHospital Assessment (cont)
> LAMS: new Seattle protocol for
late 2016
• sensitivity 81%, specificity 85%
for LVO with score of 4 or higher
(7 fold higher risk)
> Comparable with sNIHSS (Naziel
et al., 2008; Llanes et al., 2004)
FROM: JEMS VOLUME-40. ISSUE-1 14
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Pre-Hospital Pre-notification of Code Stroke
• LKN and ETA
• Witness contact info/cell phone (or transport with patient)
ALS ambulances (Medic One, unstable patients)
• Blood glucose
• Attempt at IV placement (not to delay transport)
• EKG/rhythm strip (not to delay transport)
BLS ambulances (local agencies, majority of incoming strokes)
• Blood glucose
ED:
• CT notified to keep scanner clear
• ED weight bed and monitor parked in Radiology
• Team assembles in Ambulance Bay
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Pre-ED Room Avoid rooming patient if stable
• Patient met in Ambulance Bay
• Expedited MD assessment, ABC*
• Blood glucose (tech)*
• ID Band (registration)*
• One attempt at IV line (RN)
EMS takes patient to CT
• Weight obtained
• CT scan reviewed right away by ED MD / Neurology
• Pharmacy called to pre-mix tPA
• Neurology contacts witnesses/family
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ED Room Value Added Time
• Patient assessed by Neurology upon return
• Two lines placed (RN)
• EKG performed if not done already (tech)
• Consent process
• Safety pause and IV-tPA administration
• Post-tPA protocol initiated
Post-tPA
• Admission to ICU or taken to Radiology by Neurology for Code IR
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Continuous Process Quality review
• Continuous staff education
• Debriefs with staff/EMS
• Data reviewed monthly
• Protocols refined based on feedback, outlier cases (e.g., BP management
protocol implemented)
Results
• 30-40min reduction in DTN times
• No increase in symptomatic hemorrhage
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No Increase in Symptomatic Hemorrhage
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0%
5%
10%
15%
20%
2014(n=57)
2015(n=55)
2016Jan-Feb(n=8)
5%4%
0%Percen
tage
CherryHillSymptoma cHemorrhagicComplica onw/in36hrsofIVAlteplase
(DatafromtPARegistry)
0%
5%
10%
15%
20%
2014(n=16)
2015(n=39)
2016(n=3)
0% 0% 0%Perce
ntage
CherryHillSymptoma cHemorrhagicComplica onw/in36hrsofIVAlteplase
(DatafromGWTG)
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Future Considerations Code IR
> Protocol for MRI/MRA changed to default of CTA/P
> CTA upfront had previously led to delays in DTN times
> CT relocated to same level as ED in spring 2016
> CTA upfront? tPA in CT?
Misc
> POC Testing
> Where should tPA be mixed?
> Patient weight
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Summary
2010: Median DTN Time of 74 minutes (GWTG Registry)
• Internal goal of 45 minutes
• Standardization of stroke protocol, order-sets
• Dedicated stroke service expansion
• Telestroke to reduce response time for after hours cases
2013-2014: Next Phase
• Door-to-CT Pilot Project initiated
• Meetings and coordination with local EMS, Radiology, Pharmacy and
other stakeholders to revamp stroke protocols
• BP protocol, pre-mixing tpa, ED review of Imaging
2016: 30 minute reduction in DTN times
• Continuous refinement
• Better integration of Code IR with arrival of new CT scanner
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References
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References
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