Clinical challenge
An audit revealed that the BVH stroke services is still underperforming on the door to needle time target in thrombolysing AIS. There is still significant number of patients who might benefit from very early reperfusion therapy. Furthermore, the recent report from the Sentinel Stroke National Audit Programme (SSNAP) (2017) also showed that BVH stroke services were still sitting at “D” level for thrombolysis domain. All the domains in the audit is given a performance level from A to E, where “A” is the benchmark for the best standard while “E” is the least favoured outcome. Due to these reasons, the idea of restructuring the current stroke thrombolysis pathway was proposed in order to meet the national standard and improve the current door to needle time.

Solution

• Stroke thrombolysis pathway was restructured utilising the 2222 emergency call out for all stroke patients who might be eligible for thrombolysis.
• All FAST positive patients with definite onset time within 4.5 hrs and has met the inclusion criteria are included in the pilot study.
• A  core stroke team (Stroke Consultant, Stroke Registrar/Medical Registrar, Tr. Adv. Practitioner, CT Radiographer and Bed Manager) was created who will respond to 2222 call out and attend (as necessary) to patient from arrival in ED to admission to SU. Involvement of the bed management team ensures that a stroke bed is ready to directly admit the patient to the stroke unit.
• Stroke team activation is initiated prior to patients arrival to ED thereby giving time for the team to review patients’ hospital records.
• Thrombolysis  is initiated in CT department during core hours once intracranial bleed has been ruled out and inclusion and exclusion criteria have been met.

Impact
Results showed a vast reduction in DTN in core hours. The data gathered showed that during core hours 100% of Stroke patients eligible for thrombolysis were treated in less than 45 minutes with a median door to needle time of 21 minutes. In contrast, during out of hours Only 29% of eligible patients were thrombolysed within 60 minutes and with a door to needle time average of 80 minutes. Although a similar method of pathway was used during core hours and out of hours, during out of hours only the stroke nurse, CT radiographer and an on-call  medical registrar receives the activation call and only the stroke nurses are able to attend to the patient in ED as the on-call medical registrar also covers all the other areas in the hospital. BTHFT has no stroke consultant on site during out of hours and reliant to the telestroke consultant covering the region.

It could also be noted that most patients who were not eligible for thrombolysis in this pathway were scanned and admitted to SU within 60 minutes.

Feedback
Some comments from patients and family 
“I feel like a VIP with the stroke team waiting for my arrival”
"what a fantastic service, quick and systematic”.

CT manager commented 
“We have been doing our own audit of time to scan from time of activation … as you can see the results are really good and the awareness/completion of the forms has improved significantly since the 2222 bleep was introduced”.

Other staff comments
“This is a fantastic outcome and most certainly a benchmark for other organisations to aspire too”
“amazing achievements, particularly in current pressures”

Reflection
The success of implementing an evidence-based project is highly dependent on the success of behavioural change.  Quality improvement requires the will, the ideas and the execution of those ideas; however, interventions can lead to wasted effort if there is no system or concrete plan in place. Similarly, no matter how robust the pathway or the system is, if there is lack of manpower to execute the process then the positive outcome expected cannot be attained.

The result of this project leads us to formulate a more robust stroke plan and take action on the identified areas where we are not meeting the desired stroke quality standard. A proposal will also be submitted to look at covering weekends with a stroke specialist advanced practitioner  or stroke specialist doctor who will assist the stroke nurses and the on call telestroke consultant in assessing, diagnosing and treating acute stroke and not be reliant to the on-call medical registrars.

This case study was written by Mark Delabajan, Trainee Advanced Practitioner at Stroke Unit Blackpool Victoria Hospital


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