A Collaborative Approach to Improving Door-to-Needle Times in Patients with Acute Ischemic Stroke

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MR Cooper, Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, PA



Stroke remains a leading cause of disability and caregiver dependency in the United States. Alteplase is the only FDA approved drug to treat acute ischemic stroke (AIS). The benefits of alteplaseinclude improved functional outcome and reduction in dependency or disability, but these benefits are time dependent. National guidelines recommend a 60 minute door-to- needle (DTN) time for alteplase administrations for patients with AIS.


The purpose of this project is to establish a collaborative and seamless process that enables timely triage, diagnostic assessment, and treatment of a patient with AIS. The goal of this project was to achieve a DTN within 60 minutes of hospital arrival in at least 50 percent ofeligible patients to receive alteplase.


A retrospective data review of stroke protocol applications to alteplase-eligible patients in the emergency department (ED) from 2014 to 2016 was performed. Data were gathered through the organization’s electronic medical record to evaluate time intervals from patient arrival to alteplase administration. A review of measurable and immeasurable initiatives designed to achieve DTN within 60 minutes was conducted. External data were obtainedfrom the GetWithThe Guidelines (GWTG) StrokeRegistry.

Results Summary:

From 2014 to 2016 DTN time within 60 minutes of hospital arrival for alteplase eligible patients averaged 45percent. For 2016, the average was 40 percent. This project highlighted that while process measures are critical to achieving the desired DTN time goal, other incalculable issues such as ED physician’s comfort with alteplase therapy, patient education and other factors can have a major influence on performance.


Despite numerous efforts, the organizationfailed to achieve a DTN time within 60 minutes of hospital arrival for alteplase eligible patients in 50 percent of cases. Achieving an acceptable DTN time requires a complex clinical process that involves a high-performing, cross-functional team. Achieving a DTN time within 60 minutes in stroke care requiresin-depth analysis of bothmeasurable process metrics and other non-measurable factors.

Presentation: 29:19

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