Strokes are the second leading cause of death in the world and the number one cause of disability. Prompt treatment responses are imperative. Rush University Medical Center is certified as a comprehensive stroke center by The Joint Commission and strives to improve the time stroke patients receive intravenous (IV) thrombolytics to promote rapid revascularization.
The American Heart Association aims to reduce the average time from patients entering the emergency department (ED) door to receiving IV thrombolytic within 60 minutes for 85% or more of patients with an acute ischemic stroke. The medical center program aimed to achieve the American Heart Association’s Target Stroke Honor Roll by decreasing the average door-to-needle (IV thrombolytic) times to within 60 minutes for at least 85% of eligible patients.
The interdisciplinary stroke performance improvement committee and comprehensive stroke program team monitor the monthly door-to-needle times. The teams were concerned that the medical center was not meeting the honor roll target. In October 2023, the average door-to-needle time was 73 minutes, exceeding the time required to achieve honor roll status. An interdisciplinary team of nurse leaders, clinical nurses, physicians, pharmacists and radiologists convened to analyze the data and plan process improvements to reduce the average door-to-needle time (minutes) for acute ischemic stroke patients presenting to the ED.
Due to the urgent need to address the issues, several initiatives were introduced simultaneously as a bundled approach. Nick Cozzi, MD, medical director of EMS, Laurel Cherian, MD, MS medical director of the Comprehensive Stroke Program, Giles Slocum, PharmD, Kristen Fisher, DNP, APN, AGACCNS-BC, CCRN-K, nurse-stroke coordinator, Rahul Patwari, MD; Margie Huerta-Mukite, BA, director of patient access and Amie Porcelli, MSN, RN, CEN, TCRN, nurse–assistant unit director in the ED, collaborated to implement the following improvements in the Emergency Department, with the Chicago Fire Department (CFD) and medical center registration department:
- Partnered with the Chicago Fire Department (CFD) to streamline the arrival process.
- CFD to radio a priority call from the field.
- ED RN announces the “code stroke from EMS, arrival time in XX minutes” overhead paging system.
- Hard stop at the registration desk upon arrival.
- Occurs immediately at the ambulance bay doors.
- Patient access team members participate.
- The clock starts a 60-minute countdown by the patient care technician, traveling everywhere with the patient.
- A portable monitor for vital signs remains on the patient in the CT scanner area, allowing for frequent vital sign measurements, as well as prompt treatment of hypertension to ensure candidacy for IV thrombolysis.
- Interdisciplinary stroke huddles are called within 30 minutes of the patient’s arrival. Led by the neurology team, the group discusses a plan for IV thrombolysis and mechanical thrombectomy, ensures all team members are aware of the plan of care, and provides the opportunity for team members to observe the consent process together.
The go-live for these new system processes was November 30, 2023. By December 2024, there was an 18% decrease in the mean door-to-needle time for stroke patients. Because of the comprehensive stroke program's strong interprofessional collaboration to implement evidence-based interventions and streamline care processes, the team achieved honor roll success of “elite” status, meeting the average door-to-needle time within 60 minutes for 85% of all ischemic stroke patients.