Gulf Coast Medical Center

Emergency department nurses reduce time to tPA administration for ischemic stroke patients

TEAM: Emergency Department
ENTRY SUBMITTED BY: Gregg MacDonald, MS, RN, CEN, PHRN, EMT-P, certified emergency nurse

The emergency nursing staff at Gulf Coast Medical Center created a new initiative that demonstrated a significant impact on the quality of life of ischemic stroke patients.

A stroke has the potential to be a devastating, if not fatal, occurrence. Aggressive recognition of the symptoms through a simple algorithm, rapid presentation at the Emergency Department (ED) within the first few hours of symptoms, and determination of eligibility to receive t-Plasminogen activator (tPA) has the potential to completely reverse the permanent disabilities. The American Stroke Association had a 60 minute benchmark for tPA administration from the time the patient arrives at the hospital to the administration of the drug. This period of time is known as the door to needle time (DTN).

We are a comprehensive stroke center that fastidiously analyzes the door to needle performance of its emergency department staff. A nursing-led process change program was developed and implemented that demonstrated remarkable improvements in DTN during 2014 and 2015.

Each stakeholder that is involved in the initial moments after the arrival of a stroke patient were brought together for a session that delineated each specific job. These jobs then had a step by step job instruction (JI) created that maximized time efficiency while maintaining the highest quality care and safety.

Overall this was a very successful nursing-led collaboration effort that included representatives from emergency nursing, emergency physicians, neurology, laboratory, radiology CT technicians, radiologists, EMS, patient care liaisons (ED department secretaries), hospital administration, and registration. Each representative group realized the importance of implementing the changes and they were enthusiastically rolled out to their staff. The new stroke Lean Transformation Stroke Alert program was launched in January 2013 and immediately there were significant changes in the DTN.

Recently the American Stroke Association lowered their benchmark time for tPA administration to 45 minutes. During 2014 and the first six months of 2015 there were 87 patients that received tPA at GCMC. The average DTN during 2014 was 48 minutes and the first six months of 2015, it was 39 minutes, with the fastest tPA administration time being 13 minutes. The average tPA time is currently 50% less than the rate before the launch of the Lean Transformation Stroke Alert program. The rate of tPA related complications has also remained within expected limits. This data was presented at the International Stroke Conference meeting in February 2016.

It is an honor have this data recognized as innovative by the American Stroke Association at the International Stroke Conference in Los Angeles. The true benefit of this initiative is that nursing can take charge of a quality issue, and through true inter-professional collaboration can have a significant impact on the quality of care. The truly remarkable benefit of this nursing-led team project is the ability to witness debilitating stroke symptoms disappear and watch a patient return to their normal baseline.

Our emergency nurses are now recognized as one of the leading facilities in the world ford treating ischemic stroke patients. This project has worldwide implications by educating emergency departments on a method to drastically reduce door to needle time for stroke patients. It is estimated that stroke patients lose 1,000,000 brain cells per minute. Our nursing team has demonstrated that our project will significantly impact the quality of lives for thousands of individuals in the years ahead.

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