When it comes to a stroke, every second counts. For patients with ischemic strokes, getting medication as quickly as possible to break up clots and restore blood flow to the brain is critical because every passing minute means more brain cells are deprived of oxygen and possibly lost.
While the evidence-based practice is often clearly understood – the coordination required to improve timely delivery of clot-busting medication presents unique implementation challenges for healthcare delivery systems.
Now, a new study from neurology researchers and implementation scientists at Intermountain Health demonstrates that when a systemwide stroke protocol is implemented with a degree of local tailoring across a health system, treatment time for stoke patients at all impacted hospitals significantly improves giving patients a better chance at survival and recovery.
For the study, neurology leaders at Intermountain worked to empower each of the Intermountain hospitals – rural and urban, large and small – to customize the implementation of protocols to fit that hospital’s unique environment and patient population.
Nearly all participating hospitals saw a dramatic drop in the gap between when a patient calls for help, and when clot-busting medication, tPA, is administered. Several hospitals improved by more than 20 minutes – which translates into a lot of brain cells saved.
Findings from the new study examining the systemwide implementation are published this month in the journal, Circulation: Cardiovascular Quality and Outcomes.
“We want to provide the same high quality stroke care throughout our entire healthcare system, whether you come into our flagship urban hospital, or a small rural hospital that might only see patients who need tPA medication once or twice a year,” said Kathleen McKee, MD, co-lead author of the study and associate medical director of neurosciences research at Intermountain Healthcare. “This research shows we’re getting closer to that reality.”
“The delivery of acute stroke care is complex within an emergency department. This can present challenges for clinicians seeking to deliver high quality care for each patient. In this study, we found that defining centrally ‘what’ needed to happen across all emergency departments, while providing each site with flexibility or tailoring to their local circumstances led to better care across all sites,” said Andrew Knighton, PhD, an implementation scientist and co-lead author on the study.
The study involved 21 Intermountain Health emergency departments in Utah and Idaho, with four being dedicated stroke centers. For the study, each hospital site received acute stroke care implementation strategies to get tPA medication to appropriate patients as soon as possible, as previous research has shown that tPA given within six hours of a stroke significantly increases the chance of someone surviving a stroke and reduces chances of disability.
Each hospital worked with a central Intermountain Health team to brainstorm what implementation strategies would work best for deployment of the protocol within their emergency department. This led to each emergency department coming up with unique implementation solutions specifically tailored to their and their patients’ needs for timely tPA delivery.
In the study, researchers tracked the effectiveness of the acute stroke care program’s implementation from January 2018 to February 2020. During that time, those hospital emergency departments had 855,474 patient encounters, with 5,325 code stroke activations. Of those, 615 patients received tPA in less than three hours of symptom onset.
The research team measured door-to-needle (DTN) times—or the time from when a patient arrives in the emergency department to the time the intravenous needle delivers tPA.
The study demonstrated that the percentage of DTN times under 60 minutes increased from 72.5% to 86.1%. Researchers also found the biggest improvement in rural and frontier non-stroke center emergency departments.
“This suggests further contextual differences may exist between non-stroke center emergency departments that need to be better understood, driven perhaps by differences in patient volumes, site leadership and decision-making, team dynamics, and resources,” said Knighton.
Overall, the Intermountain researchers say the study demonstrates that a centrally led but locally customized approach can be utilized to improve acute stroke care across very diverse emergency departments.
About Intermountain Health
Headquartered in Utah with locations in six states and additional operations across the western U.S., Intermountain Health is a nonprofit system of 34 hospitals, 400 clinics, medical groups with some 4,600 employed physicians and advanced care providers, a health plans division called Select Health with more than one million members, and other health services. Helping people live the healthiest lives possible, Intermountain is committed to improving community health and is widely recognized as a leader in transforming healthcare by using evidence-based best practices to consistently deliver high-quality outcomes at sustainable costs. For more information or updates, see https://intermountainhealthcare.org/news.
