Clinical Audit of Head CT in Stroke Alert Cases: Role of Radiology Resident and CT Technologist Awareness in improving Head CT reporting time K Hooda, MBBS; D Hayashi, MBBS, PhD G Muro, MD; J Sapire, MD; Y Kumar, MD; N Parikh, MD Department of Radiology Yale New Haven Health System at Bridgeport Hospital, Bridgeport, CT

INTRODUCTION Ischemic stroke results from a sudden cessation of blood supply to the parts of the brain. An ischemic stroke typically presents with rapid onset neurological deficit. The symptoms often evolve over hours, and may worsen or improve, depending on the fate of the ischemic penumbra.

INTRODUCTION In many institutions with active stroke services which provide reperfusion therapies a so-called code stroke aimed at expediting diagnosis and treatment of patients include a non-contrast CT brain, CT perfusion and CT angiography. However, to initiate intravenous tPA, only non-contrast head CT is required to exclude any acute hemorrhage. Timely reporting of Head CT in stroke patients is very crucial for proper management.

INTRODUCTION The goals of CT in the acute setting are: To exclude intracranial hemorrhage, which would preclude thrombolysis; To look for any "early" features of infarction To exclude other intracranial pathologies that may mimic a stroke, such as tumor. Timely reporting of Head CT in stroke patients is very crucial for proper management.

INTRODUCTION Since “time is brain”, human nervous tissue is rapidly and irretrievably lost as stroke progresses and that therapeutic interventions should be emergently pursued. Thus, timely reporting of Head CT in stroke patients is very crucial for prompt and proper management.

Purpose To reduce time taken to report Head computed tomography (CT) for stroke alert cases by increasing radiology residents and CT technologists awareness. To improve adherence to the National Institute of Neurological Disorder and Stroke (NINDS) critical time goals for Head CT reporting time in stroke alert cases.

National Institute of Neurological Disorder and Stroke (NINDS) critical time goals Assuming the patient meets the treatment criteria, National Institute of Neurological Disorder and Stroke (NINDS) critical time goals include: • Time from door to doctor: 10 minutes • Time from door to CT scan: 25 minutes • Time from door to CT reporting: 45 minutes • Time from door to drug: 60 minutes • Time from door to monitored bed: 3 hours. Thus, time between CT scan completion and reporting should not exceed 20 minutes in acute stroke cases.

PDSA Cycle PLAN: Define the objective, questions and predictions. Plan data collections. DO: Carry out plan, collect the data, begin analysis of the data. STUDY: Complete the analysis of the data. Compare data to predictions. Summarize what was learned. ACT: Plan the next cycle, decide whether the change can be implemented.

PDSA Cycle Initial Audit September 2012 Analysis September 2012 Resident and CT technologist education Re Audit March 2014

Materials and Methods Using the stroke register, audit of time between completion of Head CT and informing the clinical team was performed within the Department of Radiology between 3/21/12 to 9/5/12. Average time to report was 11 minutes. Reporting time range was from 2 minutes to 33 minutes with median value of 10 minutes. Although average time adhered to NINDS critical time goals but was more than our hospital target of 10 minutes. In one case the reporting time of 33 minutes was more than NINDS goal of 20 minutes.

Materials and Methods Discussions were held among residents, CT technologists and attending radiologists. Reasons for above results were discussed, and were thought to be mainly related to lack of awareness of hospital stroke policy and NINDS goals. All the residents and CT technologists were made aware of hospital stroke policy and NINDS goals.

Materials and Methods Residents and CT technologists education resulted in the following strict departmental protocol in acute stroke cases: Call from CT technologist to the radiology resident with information about the stroke patient. Another call from CT technologist to the radiology resident at the start of examination. Better coordination between radiology resident and attending to read the examination as soon as possible. This included looking at the images while examination is in progress ( which most of the PACS systems allow). Finally, a phone call to the referring physician about the findings followed by final report.

Materials and Methods Therefore, we aimed to improve the reporting time by making residents and CT technologists aware of hospital policy and NINDS goals. Audit of time between completion of Head CT and informing the clinical team was again performed 9/13/12 to 2/9/13 and average and median reporting times were reassessed.

Results By educating residents and CT technologists about stroke treatment outcomes, hospital policy and NINDS goals, and enforcing strict guidelines about timely reporting; we were able to bring down Head CT reporting time in stroke patients from average of 11 minutes to 8 minutes and range from 2-33 minutes to 1-17 minutes. This resulted in strict adherence to National Institute of Neurological Disorder and Stroke critical time goals.

MEDIAN TIME

Mean Time

CONCLUSIONS By educating residents about stroke treatment outcomes and enforcing strict guidelines about timely reporting, we were able to bring down Head CT reporting time in stroke patients from average of 11 minutes to 8 minutes and range from 2-33 minutes to 1-17 minutes.

CONCLUSIONS This resulted in strict adherence to National Institute of Neurological Disorder and Stroke critical time goals. This in turn resulted in better patient care as early treatment in stroke patients has been confirmed as key to recovery in large randomized controlled clinical trials.

DISCLOSURES All authors have nothing to disclose.