1. Improving Door to Needle Time In a Statewide Telestroke Program
Medical University of South Carolina
Improving Door to Needle Time In a Statewide Telestroke Program
Ellen Debenham, RN, CCRC Jessica Hannah, MD Christine Holmstedt, DO
David Jones, BSN, RN, CCRN, SCRN

2. Stroke in South Carolina
SC is located in the Buckle of the Stroke Belt
, SC had the 4th highest stroke mortality rate in the U.S.
5th leading cause of death in North America
3rd leading cause of death in South Carolina
Source: Centers for Disease Control and Prevention (2014)

3. Stroke in SC is BAD Telestroke in SC is GOOD!
Improves access to expert stroke care
Increases treatment with tPA
Provides evaluation for thrombectomy
Provides education and information exchange to promote stroke care and support for partner hospitals
Supports nurses and physicians across the state to keep patients closer to home
Enhances collaboration among hospitals
Improves overall resource utilization and cost savings

4. Program Overview 2008 - 6 hospitals - 87 consults
Expanded to 15 hospitals
3-4 Consults/day
2015 – 18 Partner sites, 7 Primary Stroke Centers (PSC)*
5-10 Consults/day
Expanded services -
Acute and scheduled general neuro consults
Post tPA tele rounds
Post stroke follow up tele clinic
2016 – 27 Partner sites, MUSC designated a Comprehensive Stroke Center (CSC)*, 9 PSCs, 3 seeking PSC
Ambulance pilot program to decrease treatment times
*Designation given by The Joint Commission

5. MUSC Telestroke Network 12/2015
19 Partner Sites
7078 Consults
1304 tPA
140 Thrombectomies

6. Population
50% < 65 years of age
28% < 55 years of age

7. Goal Develop a statewide telestroke program
Increase access to care
Improve quality and speed of treatment
An important marker of quality acute stroke care delivery is the Door-To-Needle (DTN)* time.
*Time from arrival in ED to administration of Alteplase (tPA)

8. Time Matters In one minute 1.9 million neurons are lost
14 billion synapses are lost
12 kilometers of myelinated fibers are lost
Patients treated within 60 minutes experience improved outcomes, including
lower in-hospital mortality and reduced long-term disability
Saver, J. Time is Brain – Quantified.
Stroke Jan;37(1):263-6.

9. Target Stroke - 2010 Initiative
Achieve a Door to Needle (DTN) Time within 60 minutes in at least 50% of ischemic stroke patients treated with IV tPA
© 2010 American Heart Association, Target Stroke Campaign 9

10. AHA/ASA Target Stroke Initiative
Sites
Year
2010 Phase I DTN
< 60 min Goal 50%
2015 Phase II DTN < 45 min Goal 50%
All
12% NA
2015
55%
26%
PSC (7sites)
65%
33%
2016*
57%
31%
70%
37%
*1st quarter only
2010, 2015 American Heart Association, Target Stroke Campaign

11. Methods 5/4/2008-12/31/2015 Door to Needle times (DTN) were reviewed
Of the 7,078 consults completed through 2015: Alteplase (tPA) was recommended in 1,304; DTN times were recorded in 916 instances
Data limited by incomplete time entries
For all sites, the yearly mean DTN time was calculated and a analysis of variance was determined with a one-way ANOVA.
*Hospital count varies by year

12. Mean & Minimum DTN Times
Using the One-Way ANOVA we found a significant decrease in DTN over time (p<0.0001)

13. MUSC Telestroke Program Time Points
All sites averages
# of t-PA recommended
ED door to Registration (min)
ED door to ATC call (min)
ATC call to MD Logon (min)
Consult start to t-PA decision (min)
t-PA decision to t-PA admin. (min)
Door to needle (min)
2008 28 35 10 33 24 99
2009 65 8 36 20
103
2010
125 32 45 31 18 93
2011
164 44 47 23 22 98
2012
190 40 26 25 91
2013
192 30 7 21 17 70
2014
201 5 16 74
2015
272 14 67
2016* 3 19
NINDS/MUSC Goals 15 60
*1st Quarter only

14. Results
Sample of mean DTN time trends in three of our partner sites

15. Biggest Challenges Locum physicians in the Emergency Department
Lack of management involvement
No dedicated stroke coordinator
Sites not tracking data
Sites not accountable to the standard of care
Lack of patient education
tPA kept in pharmacy causing delays in mixing and administration
Lack of Stroke Team plan in the Emergency Department

16. Best Practices Stroke – It’s a team event!
Every Team Member has a role -
EMS
Registration Staff
Physicians
Nurses
CT Technologists
Phlebotomists
Pharmacists
Family and Patient
They must understand their role in
the chain of survival
Stroke is an emergency!

17. Role of EMS - Early Recognition is Key
Best Practices
Role of EMS - Early Recognition is Key
If early signs are missed the opportunity to treat will be lost
Minimal scene time
ABC’s, Neuro Assessment, LKN, Medications, & Hx., Family Cell #
IV Access
2 Large Bore IV’s
Antecubital Vein for perfusion scanning
FSBS
Rapid Transport
Early encoding to ED

18. Best Practices Pre arrival notification by EMS
Response team ready and waiting
Allow nurses to initiate stroke calls
Sites allowing RN initiation demonstrate consistently faster time metrics
Rapid notification of Stroke Response Team by group page
CT Tech clears scanner
Call for telestroke consult prior to CT scan results
EMS &/or family give history to stroke consultant
Keep tPA in the ED, not pharmacy
Mixed and administered by nursing

19. Use of evidence based order sets, protocols and best practices
Expanded focus to support partner site’s stroke program development - PSC
Case review with Q and A
Highlight wins and recognize the team
Frequent stroke & tele-presenting education
Leads to quicker recognition of stroke patients
Increases comfort giving Alteplase (tPA) and assisting with exam
Use of evidence based order sets, protocols and best practices
Send monthly, quarterly & yearly data reports
Annual recognition of top performing organizations

20. Example of Monthly Data Report
Hospital Name
Consults
Ischemic Strokes
tPA Given
% tPA Given (Ischemic strokes)
# Transfers to MUSC
% Transfer to MUSC
NIR
# Transfers
No NIR
Feb Volumes 25 11 4
36%
16% 1 3
*All times reported as averages in minutes 
February Times For Each tPA Patient
Date of
Consult
ED Door to Registration
Registration to ATC Call
ATC Call to MD Logon
Consult Start to tPA Decision
tPA Decision to tPA Admin
Pt. Initials
2/25/2016 7 5
2/19/2016 6 2 15
2/28/2016 8 9
2/16/2016 10 17 29

21. Example of Monthly Data Graph

22. DTN Conclusion
Within a large statewide telestroke network, the mean DTN time can be reduced to meet the AHA/ASA Target Stroke Initiative goals. Continued process improvement, education, teamwork, and communication has been instrumental in the continued improvement and downward trend in DTN over the last 7 years, despite a rapidly growing call volume.

23. SC Telestroke Collaborative

24. Improved access to expert stroke care for vulnerable populations
30 min Drive w/out Telestroke
30 min Drive with Telestroke
60 min Drive with Telestroke
Black
29%
70% (+41%)
95% (+74%)
White
37%
71% (+34%)
96% (+59%)
Rural
15%
45% (+30%)
92% (+77%)
Medicaid
33%
70% (+37%)
96% (+63%)
Overall
35%
72% (+37%)
96% (+61%)

25. Drive Times

26. Current Research Projects

27. The Next Frontier
The MUSC Telestroke program has initiated a pilot study at one of our partner sites to evaluate the efficacy and feasibility of paramedics initiating the telestroke consult in the 911 setting to further decrease DTN times
How it will work:
EMS encodes ED from scene
ED initiates call to MUSC Stroke Consultant
Stroke Consultant begins exam via secure webcam in ambulance
Upon arrival in ED, patient is taken directly to CT
Exam & diagnostics complete – faster tPA treatment times

28. Database Extensive dataset Over 7000 patient encounters 78 data points
Outcomes information on all transfers (>1600)
Excellent resource for students, residents and researchers
Many publications and presentations
Please contact me for more information
Ellen Debenham, RN, CCRC

29. Emergency Medicine
Title: Relationship of Blood Pressure Guideline Adherence in Patients with Ischemic Stroke after Administration of tPA in the Prehospital Setting Principal Investigators: Jonathan C. King, David M. French

30. Aims
Assess how well strict blood pressure parameters are met during inter-hospital transfer following tPA administration at outside hospitals
Analyze whether blood pressure control adherence in the pre-hospital setting following tPA administration for ischemic stroke affects functional outcomes during hospitalization and at time of discharge from MUSC (e.g. whether hemorrhagic transformations take place, change in NIH Stroke Scale score, and disposition at time of discharge).

31. Do stroke coordinators at Telestroke sites improve site efficiency?
MANUEL calvo Gurry
Do stroke coordinators at Telestroke sites improve site efficiency?

32. Telestroke Data Source
7645 Telestroke consultations across 19 different sites
Demographic data
Socioeconomic data
Relevant Clinical data pertaining to Telestroke consultation
Relevant timeframes: ED to patient registration, door to needle etc.
Current + Previous Stroke coordinator status
ED Volume
Number of Beds
Annual Admissions

33. Overview Secondary data analysis Controlled factors Result:
ED presentation to Patient registration
Coordinator Status
Controlled factors
Hospital size
Rurality
ED volume
Result:
Door to registration time was min less on average when an institution has a coordinator (P=0.01, 95%CI 25.02,3.34).
Random effect was included to account for correlation between Telestroke consults at particular sites

34. Thank You ?