Data shows written protocols may improve emergency stroke care performance

New data from Vanderbilt University Medical Center (VUMC) helps prove that written care protocols can significantly improve the overall emergency care pathway for stroke, the fourth leading cause of death in the U.S. The findings were announced at this year’s Society of NeuroInterventional Surgery (SNIS) 11th Annual Meeting in Colorado Springs, Colorado.

Over the last decade, an accumulation of evidence has affirmed that, for
stroke, reducing the time that elapses from patient presentation to
treatment is critical to procedural success and improved patient
outcomes. Accordingly, the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO), the regulating agency that certifies
primary and comprehensive stroke centers, requires that these
institutions establish written care protocols to guide performance in
the emergency care of acute ischemic stroke.

This study details a
2012 initiative by VUMC, an advanced certification comprehensive stroke
centre, to significantly revise its stroke care protocol.

"Our
ultimate goal was to develop an enhanced protocol that eliminates
variability in our process, streamlines care to achieve necessary
efficiencies, and improves time delays to improve the potential for
better patient outcomes," said J. Mocco, MD, associate professor of
neurosurgery at Vanderbilt University Medical Center.

The new
protocol specifies three phases of activities involved in patient
assessment and treatment decisions, as well as corresponding
communication to relevant physicians at every phase. Specific
measurements that map to the three phases include: time from patient
arrival to CT scanning; time from patient arrival to neurology
evaluation of diagnostics; and time from patient arrival to treatment
with Intravenous tissue Plasminogin Activator (IV tPA).

Data was
obtained over four separate three-month time periods pre- and
post-protocol for comparison (pre-implementation of protocol: January –
March 2012, and post-implementation of protocol: August – October, 2012;
January – March, 2013; and September – November, 2013).

"These
categories had been measured as part of our original protocol,"
continued Mocco, "however, we saw an opportunity to focus attention on
some of the sub-processes within each that typically don't command
attention, but, if addressed, could make a meaningful difference in
quality improvement and the overall result."

Post-implementation
of the protocol, an analysis across all categories showed notable
progress, with average time from patient arrival to CT scanning
decreasing from 40.4 to 13 minutes; average time from patient arrival to
neurology evaluation of diagnostics decreasing from 34.3 to 8.3
minutes; and average time from patient arrival to IV tPA treatment
decreasing from 67.6 to 46.5 minutes. The latter means that VUMC has
successfully met the JCAHO-stipulated metric of 60 minutes for "patient
arrival to IV tPA."

"The success of this new protocol can truly
be attributed to a multi-disciplinary effort on the part of all of our
physicians and other clinicians who work within the always complex and
dynamic environment of emergency stroke care with ever-changing
variables, all for the purpose of providing the best care for our stroke
patients," said Scott Zuckerman, a senior neurosurgery resident who
helped plan and lead the implementation of the protocol.

When
reflecting on the implications of the study, Mocco added, "First and
foremost, it illustrates the value of customized written protocols that
consider all of the nuances associated with any one hospital's emergency
stroke care process. Ours is certainly not a one-size fits all
solution. Every stroke center has to tailor its protocols to it own
culture and resources. But, ultimately, we hope our experience will be
of benefit to other stroke centers that are considering or just
beginning a written protocol initiative to fulfill their mission of
offering the highest standard of stroke care to their patients."

Founded
in 1992, the Society of NeuroInterventional Surgery (SNIS) is
represented by physicians who specialize in minimally invasive
techniques to treat neurovascular conditions, including stroke,
aneurysms, carotid stenosis and spinal abnormalities. Drawing on diverse
backgrounds and expertise including interventional neuroradiology,
neurosurgery and neurology, these physicians are continuing to forge new
pathways in the development of the distinct specialty of
neuro-intervention.