Background: Recent emergence of evidence for the effectiveness of intra-arterial treatment (IAT) of acute ischemic stroke secondary to large vessel occlusion (LVO) has prompted hospitals to examine the efficiency of their initial evaluation process. Mount Sinai Hospital has taken an interdisciplinary approach to hyper acute stroke care. It streamlined its process focusing on rapid triage of stroke, stroke team assessment, IV tPA administration and detection of LVO.
Rapid Acute Stroke Protocol (RASP), including early stroke team activation by the triage nurse was implemented in December 2014. Triage nurses were trained in the identification of stroke and stroke team activation. Feedback was provided to nursing leadership and individual participants on every treated case. A ‘team member of the month’ was established to promote ongoing enthusiasm and team rapport.
We hypothesized that the combination of new evidence and the introduction of RASP would increase the number of patients treated, decrease time to stroke team assessment and door to puncture (DTP) time.
Method: In this retrospective review of 51 consecutive patients with AIS treated with IAT from January 2014 until July 2015, the population was divided into two cohorts. Cohort 1 included patients treated from January 2014 through November 2014, prior to RASP initiation. Cohort 2 included patients treated from December 2014 through July 2015. Outcomes included number of patients treated, arrival to stroke team assessment, and DTP time.
Results: In cohort 1, .9 cases per month were treated with IAT compared to 5.1 per month in cohort 2, a 5.2 fold increase. A greater percentage of these patients arrived in the ED via inter-hospital transfer 56% vs 30%. There was a decrease in arrival time to stroke team assessment for cohort 2 vs cohort 1 (3 vs 9 minutes) and a reduction of 46.6% from DTP time (79 minutes vs 148 minutes p=<.001).
Conclusion: These findings demonstrate how an interdisciplinary approach to hyper acute care can have a dramatic effect on the stroke patient. Improved prenotification by EMS or the originating hospital contributed to immediate stroke team availability. However, key to RASP was empowering the triage nurse with the responsibility of stroke recognition and activation of the stroke code.