Relatively simple changes to the management of suspected stroke patients can successfully reduce the time to thrombolysis without the risk of overtreatment.
A retrospective study at Westmead Hospital compared critical time to CT and time to treatment in patients presenting to the ED before and after introduction of a protocol change based on the Helsinki model.
Features of the protocol change included education of triage staff to contact stroke teams directly without waiting for medical review, stable patients arriving by ambulance transferred directly to CT on the paramedic stretcher, IV contrast does not wait for renal function tests and tPA is drawn up in radiology as soon as the decision to treat is made.
Other aspects of the Helsinki model such as stroke registrars interpreting CT scans as soon as they are performed, not waiting for advanced CT images, and having CT facilities close to the ED were already in place.
The study found 30 of 143 patients (21%) received thrombolysis after a Code Stroke was activated before the protocol change. After the Helsinki model was adopted, 14 of 134 patients (10.5%) received thrombolysis.
The total door-to-needle time reduced significantly from 76 minutes before the protocol change to 33 minutes afterwards.
Door-to-CT time did not change overall (23 v 22 minutes) but did reduce significantly in the subset of patients whose arrival to ED had been pre-notified by the ambulance (16 v 8 minutes).
CT to needle time also changed significantly from 55 to 26 minutes with the protocol change.
There were no significant differences between the groups in adverse events such as haemorrhagic transformation.
“Importantly, the changes persisted for the duration of the eight-month observation period, notwithstanding routine change in staff during the year. This was helped by repeated education sessions with each staff rotation, a process that will continue in to the future,” the study said.
The findings support those of a Queensland study reported in the limbic last year, which found the new model reduced door-to-thrombolysis time from 92 minutes to 25 minutes. However the proportion of patients receiving thrombolysis also increased in that study.
The Westmead study highlighted the important contribution of the pre-hospital setting in acute stroke management with first responders responsible for both pre-notifying the hospital and pre-registering patients to speed the process.
The researchers added that the protocol change did not require any structural change or any additional funding.