Identifying and Addressing Barriers to Systemic Thrombolysis for Acute Ischemic Stroke in the Inpatient Setting: A Quality Improvement Initiative

• Published in: Mayo Clinic proceedings. Innovations, quality & outcomes Vol. 4; no. 6; pp. 657 - 666
• Main Authors: Pines, Andrew R., Das, Devika M., Bhatt, Shubhang K., Shiue, Harn J., Dawit, Sara, Vanderhye, Vanesa K., Sands, Kara A.
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Inc 01.12.2020; Elsevier
• Subjects: Original; NIHSS; PCCU; AIS; EMR; STN; IV; RRN; CT; DTB; AMDC; AHA; RN; ED; RRN, rapid response nurse; PCCU, progressive cardiac care unit; EMR, electronic medical record; STN, stroke-alert-to-needle; IV, intravenous; DTB, decision-to-treat-to-bolus; AHA, American Heart Association; CT, computerized tomography; ED, emergency department; NIHSS, National Institutes of Health Stroke Scale; RN, registered nurse; AIS, acute ischemic stroke; AMDC, automated medication dispensing cabinet
• ISSN: 2542-4548; 2542-4548
• DOI: 10.1016/j.mayocpiqo.2020.07.009

To identify barriers to inpatient alteplase administration and implement an interdisciplinary program to reduce time to systemic thrombolysis. Compared with patients presenting to the emergency department with an acute ischemic stroke (AIS), inpatients are delayed in receiving alteplase for systemic thrombolysis. Institutional AIS metrics were extracted from the electronic medical records of patients presenting as an inpatient stroke alert. All patients who received alteplase for AIS were included in the analysis. A gap analysis was used to assess institutional deficiencies. An interdisciplinary intervention was initiated to address these deficiencies. Efficacy was measured with pre- and postintervention surveys and institutional AIS metric analysis. Statistical significance was determined using the Student t test. We identified 5 patients (mean age, 73 years; 100% (5/5) male; 80% (4/5) white) who met inclusion criteria for the preintervention period (January 1, 2017, to December 31, 2017) and 10 patients (mean age, 71 years; 50% male; 80% white) for the postintervention period (October 31, 2018, to July 1, 2020). We found barriers to rapid delivery of thrombolytic treatment to include alteplase availability and comfort with bedside reconstitution. Interdisciplinary intervention strategies consisted of stocking alteplase on additional floors as well as structured education and hands-on alteplase reconstitution simulations for resident physicians. The mean time from stroke alert to thrombolysis was shorter postintervention than preintervention (57.4 minutes vs 77.8 minutes; P=.03). A coordinated interdisciplinary approach is effective in reducing time to systemic thrombolysis in patients experiencing AIS in the inpatient setting. A similar program could be implemented at other institutions to improve AIS treatment.