Background: Time critical care in the Emergency Department is important for a patient’s survival and recovery. Reductions in disability are attributed to rapid triage and treatment for patients with both small and large vessel strokes. Current guidelines provide recommendations in clinical practice but do not delineate which type of stroke patients should receive heightened levels of triage when they arrive in the ED simultaneously.
Purpose: To decrease unintentional care delays by classifying patients who are in need of intravenous tPA, endovascular therapy, or patients receiving no therapy in the initial assessment. Additionally, the number of activations of over 4,000 since 2014 was leading to stroke fatigue and we sought to decrease this fatigue with a tiered triage approach.
Methods: Performance improvement initiatives were used to eliminate under used resources while also accounting for overburden of multiple patients in a very busy stroke center. The project prioritized code stroke activations based on acuity into RED, YELLOW and GREEN stroke alerts. RED signified a patient as a possible candidate for IV tPA, YELLOW prioritized the patient as possible endovascular candidate, and GREEN prioritized the patient as having a longer symptom onset initially.
Results: The ultimate goal was to improve stroke treatment times while also decreasing activation fatigue. In the RED activations, the door to needle (DTN) time decreased from a mean of 46 minutes in 2014 to a mean of 34 minutes in 2016. In the YELLOW activations, the door to groin puncture mean decreased from 155 minutes to 72 minutes in the same time period. Prioritizing stroke based on acuity has demonstrated efficiency in team members’ time and improved stroke treatment times and treatment rates.
Conclusions: Despite the increased influx of stroke patients into comprehensive stroke for endovascular consideration, the patients who were candidates for tPA could be prioritized to minimize delays in tPA treatment. Furthermore, patients with potential treatment for endovascular could be further prioritized and treatment times could also improve. Decreasing activation fatigue and fine tuning flow process helped manage multiple stroke patients at one time and favored improved patient outcomes.