P027: Development of a physician assistant lead stroke protocol to provide timely and equitable access to hyperacute stroke care in a telestroke community hospital

Abstract

Background: The Brant Community Healthcare System (BCHS) has consistently been well above the recommended 30 minute benchmark for door-to-needle (DTN) for eligible acute stroke patients. As a large community hospital with no neurologists, and like many other hospitals internationally, we rely on telestroke support for every stroke case. This is a time-consuming process that requires a multitude of phone calls, and pulls physicians from other acutely ill patients. We sought to develop a system that would streamline our approach and care for hyperacute stroke patients by targeting improvements in DTN. Aim Statement: We will decrease the door-to-needle (DTN) time for stroke patients arriving at the BCHS Emergency Department (ED) who are eligible for tissue plasminogen activator (tPA) by 25% from a median of 87 minutes to 50 minutes by March 31, 2018 and maintain that standard. Measures & Design: Outcome Measures: Door-to-needle time for acute stroke patients receiving tPA Process Measures: Door-to-triage time, Door-to-CT time, Door-to-CTA time; INR collection-to-verification time, telestroke callback time Balancing Measures: Number of stroke protocol patients per month Model Design: We simultaneously designed and implemented a robust program to train physician assistants in hyperacute stroke care. Evaluation/Results: Through vast stakeholder engagement and implementing a multitude of change ideas, by March of 2018 we had achieved an average DTN of 53 minutes. Our door-to-triage time went from an average of 7 minutes to 3 minutes. Our door-to-CT time decreased from 17 minutes to 7 minutes and our time between CT and CTA from an average of 13 minutes to 3 minutes. One and a half years later, our average DTN is maintained at 55 minutes and physician assistants continue to effectively lead and liaise with telestroke neurologists and stroke patients. Discussion/Impact: Prior to this program, acute stroke care was a very contentious topic at our local community hospital. Creating a program that streamlined the care and standardized the work has proven successful, and not only allowed for improved DTN times but also freed up physicians to better simultaneously care for other acutely ill patients.