A successful treatment strategy is about analyzing process and identifying missed eligible patients
Understanding measures and outcomes of a high performing stroke institution
The first step in identifying areas for improvement is prioritizing
and analyzing stroke quality metrics. Doing so will prompt the
necessary steps to implement change over time. Although change
involves the entire multidisciplinary stroke team, stroke
coordinators, given their unique role, are well-positioned to
spearhead performance enhancements and process improvements.
Methodically review reasons for non-treatment:
- Review all patients with a discharge diagnosis of AIS
- Investigate reasons for non-treatment
- Assess areas for potential process and protocol change
- Develop a strategy to improve process
- Communicate and implement strategy
Continue to assess. Given that only a minority of all AIS patients receive Activase, 3 monitoring processes such as door-to-needle (DTN) time and evaluating all-AIS patients to identify missed eligible patients may facilitate advancement of care.
Based on your metrics, what is the most common reason for not treating with Activase?
Door-to-Needle (DTN) time
AIS is a serious medical emergency. It’s critical to assess and manage AIS patients as soon as they arrive in the emergency department (ED) to achieve optimal DTN time.
Learn how to achieve DTN in ≤60 minutes and beyond. 2,15,16
a Initiate treatment with Activase as soon as possible
but within 3 hours after symptom onset.
b Advanced or additional imaging, such as MRI, should not delay Activase treatment. 2
What’s your DTN target?
When assessing opportunities to decrease DTN time, consider the following questions:
- What are the trends or outliers in your process?
- How does your process compare to benchmarks?
- What steps may be a source of delay?
- Are delays attributed to certain team members?
- What action plans are already in place and are they effective?
Find out if your team is aligned with time-saving recommendations from Target: Stroke 17
Five time-saving strategies employed by world-class hospitals to reduce DTN time include 18:
- Overall emergency medical services prenotification
- Neurology evaluation via secure telecommunication en route
- Transfer directly to imaging – multiple assessments occur in parallel and patient bypasses ED bed
- Point-of-care laboratory testing
- Activase immediately after CT excludes a
What institutions are doing to improve their process: door-to-needle time (DTN)
Top stroke institutions are constantly striving to find new ways to better their process, such as moving from a serial (or sequential steps) to a parallel (or concurrent steps) model. Consider the following example:
CODE FAST 14
- The CODE FAST protocol was a quality improvement project, undertaken by the Kennestone Hospital of Marietta, Georgia, with the aim to reduce DTN times
- Prior to CODE FAST patients were brought to the emergency room (ER) without pre-notification, evaluated by an ER physician, given a CT scan, and an on-call neurologist was contacted, all in a sequential manner
process was evaluated for improvements with parallel
- Compared with the serial approach (02/01/2014–09/08/2014),
after CODE FAST implementation (09/09/2014–02/28/2015):
- The number of patients receiving Activase increased from 41 (of 414 total AIS admissions) to 52 (of 397 total AIS admissions)
- There was a significant reduction in DTN times: median DTN
time from 62 to 25 min (P <0.0001) and median
door-to-imaging time from 16 to 8 min (P
CODE FAST Protocol
Adapted by permission from BMJ Publishing Group
Ltd. J Neurointerv Surg, Busby L, Owada K, Dhungana S, et al,
volume 8 (7), page 661-664, copyright notice 2016.
- Learn more about the CODE FAST Program
- Use the Parallel Process Questionnaire to identify measures for improving your institution's stroke processes
Are there bottlenecks? Where can you identify areas for improvement at your institution?
Identifying missed eligible patients
Evaluating all patients with AIS is a better way to view and
understand the full AIS patient pool at your institution. Healthcare
professionals may have differing criteria when evaluating
appropriateness for Activase treatment, based on:
- The label Indication, Contraindications, and Warnings and Precautions
- Individual hospital protocols
- Personal treatment philosophy
Constant evaluation of processes implemented within an institution can have a meaningful impact in identifying missed eligible patients.
How do you use metrics to identify missed eligible patients? What tools do you use?
Use stroke program initiatives to track all-AIS
Tracking every patient discharged from your hospital with a confirmed AIS diagnosis, tracking all-AIS, is a way to increase knowledge of the patient pool. It can provide valuable insights into understanding why patients at your institution may or may not be treated and help identify potential gaps.
- What are the most common reasons for not treating with Activase and how do these reasons align with Activase prescribing information-based eligibility criteria?
- Does this report reflect the institution's current stroke treatment protocol?
- How does your pool of AIS patients fit within protocol and guidelines criteria?
Reach out to your Get With The Guidelines (GWTG) representative for help with GWTG reports
Reasons for non-treatment may already be tracked at your institution. Hospitals using GWTG must document reasons for non-treatment for all AIS patients who did not receive Activase. Considering evaluating GWTG reports such as, Reasons for no intravenous Activase, which is illustrated in the sample below, as they can provide insights into critical trends regarding your patient pool.
When evaluating all AIS, does patient eligibility reflect
what is currently in your hospital protocol? Is anything