Every year around 400-500 stroke patients are rushed to Intermountain Medical Center’s ED, where about 100 receive alteplase, a hyper-acute, recombinant tissue-type plasminogen activator designed to dissolve the blood clot that caused the stroke. The American Stroke Association recommends that patients receive alteplase in less than 60 minutes from when they arrive in an ED (or less than 45 minutes if the hospital is already achieving the 60-minute goal), which is known as door-to-needle time.
Intermountain Medical Center’s door-to-needle time was already very good. “We were already delivering alteplase in less than 45 minutes,” says Gabe Fontaine, PharmD. “But a patient who’s having a stroke loses 2,000,000 brain cells each minute until blood flow is restored to the brain, which is facilitated by alteplase, and every minute of delay increases the risk of permanent brain damage, disability, or death. So we wanted to be even better.”
Gabe and his colleagues who worked on a multidisciplinary Continuous Improvement project created a standardized alteplase kit that would be ready whenever a stroke patient was heading to Intermountain Medical Center, and also refined their communication structure facilitating alteplase ordering and delivery to the patient’s bedside. Then they focused on shaving minutes from each phase of care that happens between when a stroke patient arrives in the ED and when they get alteplase. Those phases included:
- The time it takes patients to see a physician, which is known as door-to-physician time
- Their door-to-stroke-team time
- Their door-to-initiation of a CT scan
- Their door-to-CT interpretation time
- The time between when alteplase is ordered and when it’s given
And the results?
Compared to door-to-needle times of 41 minutes before the new process was implemented, Intermountain Medical Center’s door-to-needle time dropped to 33 minutes. “That’s statistically significant and clinically outstanding,” says Elizabeth McKnight, director of systems improvement for the Central Region.
“Figuring that we treat about 100 patients a year, that improvement means we can expect a 2 percent reduction in mortality, which means two patients will live as a result of this Continuous Improvement process who otherwise would have died,” says Gabe. “One less patient would suffer from a brain bleed, which is a complication of alteplase administration, and five more patients would have improved functional outcomes, which means they’re less likely to suffer disability as a result of their stroke.
“Those are really excellent results, and given our focus to work as ‘One Intermountain,’ we’ll share the process via Intermountain’s TeleStroke service to share these improved outcomes with stroke patients throughout the Intermountain Healthcare service area.”