Abstract 205: Improving Door to Needle Time for IV Thrombolysis in Stroke

Background: Door to Needle Time (DNT) for IV tPA administration in acute stroke, has become an important quality metric. The rationale for this is based on evidence that earlier administration of IV tPA, improves patient outcomes.Methods: In 2010 we undertook a review of our hospital’s performance and process for administration of IV tPA for acute stroke. At the time, we were already using 7 elements of the AHA’s Target Stroke 10 best practices.We created a pocket card for our Brain Attack team to record the time at which each task in the process was completed. We found that the greatest delay was in the time between the decision to treat and administration of tPA. The factors that contributed were insertion of a Foley catheter (part of our order set at the time), blood pressure control, and mixing tPA.We instituted the 3 remaining Target Stroke best practices: activation of the Brain Attack team upon EMS advance hospital notification, mixing tPA ahead of time (right after CT scan), and prompt data feedback (case by case and aggregate).We also eliminated the Foley catheter insertion requirement from the order set, instituted a streamlined blood pressure control guideline, created an incentive pin awarded for treatment under 60 minutes, started timely case by case review and feedback, and included DNT on our department’s safety dashboard.Results: From 2007 to 2010, there were 5/43 (11.6%) patients with a DNT less than 60 minutes (DNTu003c60), and the average yearly median DNT was 80 min.After implementation: In 2011, DNTu003c60 was 5/14 (35.7%) and median DNT was 67 min.In 2012, DNTu003c60 was 11/28 (39%), DNTu003c45: 1/28 (3.6%),and median DNT was 67 min.In 2013, DNTu003c60 was 16/39 (41%), DNTu003c45: 3/39 (7.7%), and median DNT was 68 min.In 2014, DNTu003c60 was 19/39 (49%), DNTu003c45: 7/39 (18%), and median DNT was 61 min.Adjusted (aDNTu003c60) results based on the Get With The Guidelines accepted medical reasons for exclusion of the metric (released in the Fall of 2012).In 2013, aDNTu003c60 was 8/13 (61.5%) and median DNT was 55 min.In 2014, aDNTu003c60 was 9/10 (90%) and median DNT was 56 min.Conclusions: Efforts to reduce DNT are effective and create incremental improvement over time. The organization required to lower door to needle time, results in an increase of the number of patients treated. This may be a result of the greater efficiency needed to achieve fast administration of IV tPA, which in turn, improves recognition of stroke patients and efficiency of decision making.Our experience demonstrates that these gains are sustainable.