Dr. David Lombardi, Dr. John Chen, Dr. Vu Huynh, Kimberly Dyer BSN RN SCRNOrange County Global Medical Center

Stroke – Time is Brain!Stroke – Time is Brain!

* Door times include ALL tPA patients. This takes into account those who required priority care before administration (ie. BP augmentation, Respiratory/Cardiac support or resuscitation) and includes all in-patient strokes using the time the code was called as the door time.

“Time is Brain”That’s a saying we all know. There have been multiple studies that prove it is beneficial to restore blood flow to the brain in a timely manner. Nearly 2 million cells die every minute from a lack of oxygen delivery. The most notable initiative is Target: Stroke from the American Heart Association/American Stroke Association. Tissue Plasminogen Activator (tPA) had been recommended as the only FDA approved medication to treat Acute Ischemic Strokes (AIS’s), however, in 2010 less than 30 percent of U.S. patients were being treated with this medication within the recommended 60-minute window from hospital arrival. The first goal was to reach a performance goal of 50% of AIS patients being treated with tPA within 60 minutes of arrival. (Fonarow, 2011)This initiative was successful and in 2015, Target: Stroke Phase II was introduced. The primary goal was treating 75% of patients within 60 minutes from arrival and the secondary goal was treating 50% of patients within 45 minutes of arrival. Orange County Global Medical Center:Orange County Global Medical Center (OCGMC) was founded as Santa Ana Hospital in 1902 and developed the Santa Ana Hospital Training School for Nurses in 1904. The hospital was originally surgery and obstetrics oriented and in the early 1920’s grew into Santa Ana Valley Hospital. Orange County, CA has grown considerably since then and Santa Ana now enjoys a population of 334,217 people. 62.5% of the Santa Ana population is between 18 and 64 in age, 6.8% over 65 years old, 48.9% female, and 78.2% Hispanic or Latino.In 2009, OCGMC was deemed a Stroke Neurology Receiving Center (SNRC) by Orange County Emergency Medical Services (OCEMS). There are a total of 9 SNRC’s in the county that is 719 square miles in size and all have comprehensive stroke care capabilities. In 2010, OCGMC was certified by the Joint Commission as a Primary Stroke Center and in 2017 was certified by Hospital Facilities Accreditation Program as a Comprehensive Stroke Center.While OCGMC has always offered excellent care to the patients it serves, we identified room for improvement in our tPA administration times. It was also expected that improvement in tPA administration times would also improve patient outcomes.Baseline:In 2016: Stroke Volume (# of patients with d/c dx of AIS): 191tPA administration volume: 38 (20% treatment rate)Door times*:Mean (Average): 85 minutes; Median: 62 minutes; Range: 223 minutes

INTRODUCTION

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MAXIMUM: 250 MINUTES

THIRD QUARTILE: 93 MINUTES

MEDIAN: 62 MINUTES

FIRST QUARTILE: 55 MINUTES

MINIMUM: 27 MINUTES

2016 tPA Times

Early administration of tPA is FDA approved for the treatment of AIS. Every minute 1.9 million brain cells die from lack of oxygen. It has been shown that an improvement in tPA administration of 15 minutes greatly improves patient outcomes.It is important for hospitals who treat stroke patients to be diligent in their practices. This requires regular review of the processes in place to identify areas that may be improved.Improvement does not happen overnight and by implementing a change theory, the likelihood of changes being successful long-term are improved.

The changes that led to improvement of tPA treatment rates and times at OCGMC were implemented over a year. Additional improvement opportunities have been identified for 2018 and are well underway. The only thing constant is change.

References:Fonarow, G. C., et al. “Improving Door-to-Needle Times in Acute Ischemic Stroke: The Design and Rationale for the American Heart Association/American Stroke Associations Target: Stroke Initiative.”Stroke, vol. 42, no. 10, Jan. 2011, pp. 2983–2989., doi:10.1161/strokeaha.111.621342.Target: Stroke Phase II. (n.d.). Retrieved from www.heart.org/en/professional/quality-improvement/target-stroke/ introducing-target-stroke-phase-ii

CONCLUSIONSA thorough review of the tPA evaluation process was conducted. This included the following areas: tPA inclusion and exclusion criteria, patient flow

Utilizing Charles Lewin’s change theory of unfreezing-change-refreeze, the following two phases were implemented:

Phase 1:• Unfreezing: Education conducted with all members of the Stroke Response Team.• Change: Update of the tPA inclusion/exclusion criteria to reflect the current FDA contraindications and the Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke publication from the American Heart Association/American Stroke Association. This led to administration of tPA to a larger patient population.• Refreezing: Holding to the new inclusion/exclusion criteria and monitoring for compliance and patient outcome.• Outcome: We began administering tPA to patients with lower NIHSS’s, patients who may be showing improvement, but have not improved back to baseline, and patients over 80 years old.

Phase 2:• Unfreezing: Educating the stroke response team as to the importance of early tPA administration and breaking free from the “Golden Hour” time frames. Changing the focus away from times and towards a patient specific focus. This phase also included a multi-disciplinary investigation of the patient flow and identified areas for improvement.

• Change: The easiest change to make was to begin overhead announcing “Incoming” strokes when we were alerted to these individual’s pre-arrival by EMS.

• Refreezing: Solidifying the process of announcing “Incoming” strokes, monitoring the process and resolving any concerns or workflow changes.

• Outcome: tPA administration times improved markedly.

Phase 3:• Unfreezing: Demonstrating improvements in tPA administration times by sharing the results from Phase 2 with staff. Reiterating the purpose for making changes and the potential benefits to patients by further advancing our processes and improving patient outcomes. The ED staff champions began walking and timing the various steps of getting patients to the CT scanner and identified further area for improvement.

• Change: In collaboration with EMS, we implemented a “pit-stop” in the ED. The patient is not off-loaded from the gurney or changed to the facility cardiac monitoring. The blood glucose and EKG from EMS is accepted for treatment purposes. Only one attempt to start any needed IVs is attempted during the time the ED Physician and staff received report from EMS and the ED Physician cleared the patient for CT. The patient is taken to CT on the EMS gurney, and off-loaded directly on the scanner. This is when the patient is be changed to the facility monitoring equipment, attempts for IV access are made if necessary. After the imaging is completed, the patient is transferred to a facility weighted gurney and returned to the Emergency Department for tPA decisions.

• Refreezing: The process and flow was perfected over time and consistency between day and night shifts were solidified. ED times were monitored and evaluated for improvement.

METHODS

Outcome: The EMS crews were released faster than they were previousto the change. The time from arrival to CT was improved and the time totPA was reduced.

In 2017:Stroke Volume: 199tPA administration volume: 77 (39% treatment rate)Door times*:Mean (Average): 55 minutesMedian: 47 minutesRange: 144 minutes

RESULTS

2017

39%

2016

20%

2017 tPA Times

2016–2017 Times Compared

MAXIMUM: 161 MINUTES

THIRD QUARTILE: 67 MINUTES

MEDIAN: 47 MINUTES

FIRST QUARTILE: 35 MINUTES

MINIMUM: 17 MINUTES

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60

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300

250

200

150

100

50

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MAXIMUM: 89 MINUTES

THIRD QUARTILE: 26 MINUTES

MEDIAN: 15 MINUTES

FIRST QUARTILE: 20 MINUTES

MINIMUM: 10 MINUTES

2016

2017

tPA Treatment Rate Improvements

tPA Treatment Rates Improved by Nearly 100% in 2017