Poster - #VH-54852 - Keywords: stroke quality improvement american heart association

Getting With The Guidelines: A QI/PI Project to Enhance Stroke Care

Megan Sterling DO[1], Dakota Rodgers MD[1], Merrill Moe MD[2], Matthew Blattner MD[2], Juan Fernandez MD[2]
1. Internal Medicine Residency, Department of Medicine, Tripler Army Medical Center, Honolulu, HI 2. Neurology Division, Department of Medicine, Tripler Army Medical Center, Honolulu, HI

ABSTRACT:
Introduction: The American Heart Association (AHA) has five evidence-based time metrics for patients presenting to the hospital with acute stroke-like symptoms that improve patient outcomes: door-to-initial MD evaluation within 10 minutes, door-to-stroke team notification within 15 minutes, door-to-CT scan and CT interpretation within 25 and 45 minutes respectively, and door-to-IV thrombolytic therapy within 60 minutes. In 2019, our facility conducted a root cause analysis after a missed opportunity for thrombolytic therapy in a stroke patient. From 2020 through 2022, we recorded these five AHA metrics, and data revealed that our hospital missed the mark in each metric by 20 minutes or more. As a result, we formed a quality improvement/performance improvement (QI/PI) committee to record and analyze these five AHA metrics, to improve institutional stroke care, and to become active members of the Hawaii Stroke Coalition (HSC). Methods: To improve adherence to AHA metrics, we adopted the Plan-Do-Study-Act (PDSA) methodology and formed the "Code Stroke Performance Improvement Committee" (PIC). We developed a hospital stroke protocol outlining activation criteria, education was standardized to identify patients requiring rapid intervention, and an activation system was developed that notified essential parties. We included patients presenting with acute stroke symptoms within 24 hours and identified the five AHA metrics as our target measures. Neurologists and rapid-response nurses independently recorded metrics in every stroke patient for internal reliability. The PIC lead neurologist reviewed findings and presented data quarterly to stakeholders from November 2022 to January 2024. The PIC identified performance gaps and developed countermeasures based on the best available evidence, expert opinion, and specific needs within our healthcare system. Results: There was an average of 25 stroke activations per quarter. Comparison of target measures at project closeout to pre-PIC formation demonstrated significant improvement in metrics: time-to-initial MD eval occurred within 3 minutes (from 30 minutes), the stroke team was activated within 8 minutes (from 32 minutes), time-to-CT scan occurred within 22 minutes (from 42 minutes), and CT interpretation occurred within 35 minutes (from 52 minutes). At 82 minutes (from 75 minutes), door-to-needle time was often delayed due to relative contraindications; however, a small sample size (n=16) and outliers heavily influenced this metric. Notably, since the implementation of standardized stroke recognition education and PIC formation, there has been sustained stroke recognition and activation, and all thrombolytic candidates received therapy, a 95% improvement. Before this time, less than ¼ of patients experiencing acute stroke-like symptoms were recognized. Study limitations included a small sample size and limited data reliability collected before the PIC was formed. Conclusion: PDSA methodology and the formation of the Code Stroke PIC significantly improved institutional care and adherence to AHA metrics in patients experiencing acute stroke-like symptoms. Continuous evaluation of countermeasures was instrumental in this process. The PIC had a measurable impact on stroke metrics, a likely positive impact on patient outcomes and improved communication across departments. These benefits led to the decision to continue data collection and form a hospital "Stroke Committee." The attainment of HSC membership and the potential for stroke certification demonstrates the success of this project.