Abstract Details

Title Delaying tPA Decision Impacts Overall Stroke Alert Efficiency: A Quality Improvement Initiative to Improve tPA Door to Needle Times

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) P4 - Poster Session 4 (5:30 PM-6:30 PM)

Poster/Presentation
Number 4-011

Objective

Identify barriers to timely intravenous (IV) tissue plasminogen activator (tPA) administration in the emergency department (ED) of one academic medical center in urban Philadelphia.

Background Early reperfusion therapy with thrombolysis via IV tPA and/or clot retrieval for patients with acute ischemic stroke (AIS) improves functional outcomes and reduces morbidity and mortality. Current guidelines mandate efficient tPA administration as measured by door to needle times, though several barriers prevent consistent adherence to these guidelines. At present, it is unclear which barriers are amenable to targeted quality improvement (QI) interventions that would address delays.

Design/Methods We interviewed Neurology and Emergency Medicine physicians, nurses, advanced practice practitioners, and pharmacists to identify a root cause analysis for delayed tPA administration defined as door to needle time >45 minutes. We then analyzed our institution’s event times dataset for all AIS ED patients between January 1, 2019 and August 22, 2019 to quantify the time each identified barrier contributed to the stroke alert.

Results Interviewees identified variably timed communication from Neurology as a consistent contributor to delayed tPA administration. During the observation period, 22 patients received tPA; 15 patients had documented the time Neurology communicated a tPA decision. Delayed tPA cases had a median Neurology arrival to tPA decision communication time of 22 minutes compared to 11 minutes in non-delayed tPA cases (p=0.09). Furthermore, there was a positive association between median times to tPA decision communication and median times between tPA decision and tPA administration (additional 40 minutes in delayed tPA cases versus 20 minutes in non-delayed tPA cases; R²=0.14).

Conclusions Our results suggest that Neurology tPA decision times predict downstream efficiency with overall tPA administration. Variability in tPA decision time reflects ranging levels of Neurology engagement with acute care decision-making and patient complexity. An intervention that successfully decreases Neurology’s tPA decision-making time is expected to have cumulative downstream effects.

Authors/Disclosures
Daniel Cristancho, MD (University of Pennsylvania) PRESENTER	Dr. Cristancho has nothing to disclose.
Hannah C. Machemehl, MD (Austin Neuromuscular Center)	No disclosure on file

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Abstract Details