Coagulation

The protocol that proved a game changer for door-to-needle times at one Qld hospital


A Queensland hospital has dramatically reduced door-to-needle times to 25 minutes by changing the acute management of suspected ischaemic stroke.

Presenting latest data at the Stroke 2018 conference in Sydney on 8 August, Dr Darshan Shah, Stroke Consultant at Princess Alexandra Hospital, Brisbane, said the hospital’s implementation of its own “Code Stroke protocol” in 2016 had driven down the median time from arrival at hospital to thrombolysis from 92 minutes in 2015 to 25 minutes in 2017.

Since the protocol, 93% of patients eligible for thrombolysis were treated in the so-called “golden hour”, meaning the hospital’s treatment timeframes are now above national standards and comparable to international benchmarks.

His presentation drew on a retrospective observational study of prospectively collected data in the Princess Alexandra Hospital stroke database comparing data from January 2010 to September 2016 (pre Code Stroke), and from October 2016 to June 2017 (post Code Stroke).

Over this period the median door-to-CT time improved from 31 to seven minutes, and median door-to-needle time improved from 92 to 25 minutes.

Out of 50 code stroke activations 64% patients had a final diagnosis of ischaemic stroke and 40% of Code Stroke patients with ischaemic stroke received thrombolysis.

The study found the overall thrombolysis rate (including after hours, non-Code Stroke) for ischaemic stroke substantially increased to 58/247 (23.5%) compared to pre-protocol rates of 127/952 (13.3%). To compare, the national rate for thrombolysis currently sits at 13%.

Before 2016, the hospital used a traditional stroke pathway and median door to needle times were 95 minutes in 2010, 105 minutes in 2011 and 91 minutes in 2012.

In September 2016 the hospital introduced Code Stroke – which is based on the ‘Code Blue’ concept – for use on Monday to Friday between 8 am to 5 pm.

“It means that the moment the ambulance calls the ED triage staff and if they have FAST positive patient, ED triage staff will call a Code Stroke – a single pager system – that will go to every member of the stroke team, radiology team. Each member of stroke team then will go down to the emergency department straightaway,”said Dr Shah.

While waiting for the patient to arrive, a radiographer in the ED prepares the CT scanner and the stroke team look up the patient’s medical history through the state-wide hospital medical records system in order to help guide decision making.

“The moment they arrive our team will be at the triage desk and take the patient to the CT scanner, on the ambulance stretcher”

“While we are walking to the CT scanner we perform a NIH stroke scale and then the patient transfers direct to CT. They get CT, CT perfusion and CT angiogram and ideally we will thrombolyse in the CT scanner.”

The innovative protocol uses elements of the Helsinki Model, which has been shown to reduce door-to-needle times at the Royal Melbourne Hospital, though Dr Shah believes it is an appropriate model for any, “less well resourced” hospital.

“You need that team approach and one person to run the show,” he said.

There is a downside, as each Code Stroke case takes on average 30 to 60 minutes and PAH’s data shows one third of cases are not stroke. “But we are happy because two thirds do need specialist input,” Dr Shah said.

In another presentation at the Stroke 2018 meeting, a national snapshot of patient access to thrombolysis  showed Australia was lagging behind international comparators, with only a third of patients thrombolised in the “golden hour” compared to more than half in the US and UK.

Dr Monique Kilkenny, a senior research fellow at the Stroke and Ageing Research Group (STAR) in the School of Clinical Sciences at Monash Health, said Australia was “heading in the right direction” when it came to improving access to thrombolysis but there was more work to be done.

The research looked at changes to access to the thrombolysis between 2015 and 2017 in hospitals across Australia, finding that the total proportion of ischaemic stroke patients receiving thrombolysis was up to 13% from 8% in 2015.

The study drew from data from audits of over 8000 clinical cases and an organisational survey completed by 127 hospitals in 2015 and 185 hospitals in 2017, 73% of which offered thrombolysis.

The number of  patients who received thrombolysis within 4.5 hours of symptom onset increased up to 38% from 24% in 2015, but there was little change in door-to-needle times, with 30% thrombolised within 60 minutes, up from 26% in 2015.

“One in three are receiving TpA within an hour of arrival but we do have room for improvement,” Dr Kilkenny told the conference.

“If you look at what’s happening around the world… we have fallen behind: 59% [of patients] in the US are getting thrombolysed within 60 minutes of arrival to hospital and in the UK [it’s] 62 minutes.”

However, the time from onset of symptoms to thrombolysis was reduced by 18 minutes between 2015 and 2017, Dr Kilkenny told the conference. She noted the data represented a small number of cases – approximately 30 to 40 per hospital – and should be interpreted with caution.

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