AAN: Finding ways to improve door-to-needle times in stroke treatment

WASHINGTON – A streamlined emergency care service and a low-cost, tablet-based mobile telestroke system are two examples of shortening the time it takes for acute ischemic stroke patients to receive thrombolytic therapy that were presented at the annual meeting of the American Academy of Neurology.

American Heart Association/American Stroke Association guidelines recommend a door-to-needle (DTN) time of 60 minutes or less and set a goal for participating hospitals to administer tissue plasminogen activator (TPA) to at least 50% of their patients with acute ischemic stroke within 60 minutes of arriving at the hospital.

^{©Jack Cote/UVA}

A neurologist uses the iTREAT mobile telestroke system to evaluate a student acting as a patient with stroke symptoms.

Dr. Judd Jensen described the efforts of Swedish Medical Center, Englewood, Colo. to streamline the emergency care of patients suspected of having an acute ischemic stroke after a task force determined that their previous “sequential, step-by-step process” wasted time. The median DTN time at the hospital’s stroke center had dropped from 46 minutes in 2010 to 39 minutes in 2013, which was better than the national average, “but we felt we could do better,” said Dr. Jensen, a neurologist at the hospital.

The process was modified so that more of the activities take place simultaneously, which includes immediately sending patients for a CT scan before entering the emergency department and administering IV TPA in the CT area to eligible patients, he explained. Previously, these patients were taken to a bed in the ED on arrival, registered, then examined by the emergency physician and neurologist and transported for a CT scan and then transported back to the ED where TPA was administered, if indicated, after several other steps were completed, including interpreting the CT scan, deciding about treatment, acquiring consent, and contacting the pharmacy to mix the TPA.

This process was improved by increasing pre-hospital notification by emergency medical services (EMS) and establishing a “launchpad” area in the back of the ED where the stroke team meets after EMS notification. On arrival, patients are transferred directly to the CT room where they are examined. The pharmacy is instructed to mix the TPA if an ischemic stroke is suspected, and the TPA is brought to the CT room where a stroke neurologist evaluates the CT scan and TPA is administered if indicated.

The impact of the revised process was evaluated in a prospective study of 262 acute ischemic stroke patients who received IV TPA between January 2010 and December 2014 at the hospital. They had a mean age of 73 years, 44% were male, and 84% were white. Their mean initial National Institutes of Health Stroke Scale (NIHSS) score was 12. The median DTN times dropped to a median of 31 minutes in 2014, Dr. Jensen said.

In 2014, almost 50% of the patients received TPA in 30 minutes or less, compared with about 25% in 2011, 2012, and 2013, he added, noting that 11 minutes was the fastest DTN time in 2014. Patients with an excellent discharge modified Rankin Scale (mRS) score (0 or 1) improved from 31% in 2010 and 30% in 2013 to 46% in 2014. During the time period studied, two patients had a symptomatic intracerebral hemorrhage, one in 2010 and another in 2012.

Dr. Jensen described the process as a multidisciplinary team effort, noting that it is important that emergency room physicians feel comfortable with the administration of TPA in the CT scan area, “because it is still their patient being administered a potentially fatal drug outside of the ED.”

At the meeting, Matthew Padrick, a medical student at the University of Virginia, Charlottesville, presented the results of a pilot study that targeted the EMS transport time as an “untapped treatment window” to improve the time to thrombolytic treatment using a low-cost mobile telestroke system to evaluate patients in the ambulance on their way to the hospital.

Because the catchment area covered by UVA includes a large rural area, transport times to the stroke center can be as long as 30 to 60 minutes, Mr. Padrick said.

In the “Improving Treatment with Rapid Evaluation of Acute Stroke via mobile Telemedicine” (iTREAT) study, he and his associates evaluated the feasibility and reliability of performing acute stroke assessments (with the NIHSS) in the ambulance. The iTREAT system, which includes an Apple iPad with retina display attached to the patient stretcher with an extendable clamp, a secure video conferencing application, a high-speed 4G LTE modem, a magnetic antenna on top of the ambulance, and the regional cellular network, “providing seamless connectivity,” he said. At a total cost of under $2,000, the system is designed so that the neurologist can evaluate the patient remotely, via the iPad.