Improving telestroke treatment times through a quality improvement initiative in a Singapore emergency department

• Published in: Singapore medical journal Vol. 60; no. 2; pp. 69 - 74
• Main Authors: Mong, Rupeng, Tiah, Ling, Wong, Michelle, Tan, Camlyn
• Format: Journal Article
• Language: English
• Published: Singapore Singapore Medical Association 01.02.2019
• Subjects: Adult; Aged; Aged, 80 and over; Emergency Service, Hospital - organization & administration; Female; Humans; Interprofessional Relations; Intracranial Hemorrhages - prevention & control; Male; Middle Aged; Original; Quality Improvement; Severity of Illness Index; Singapore; Stroke - therapy; Telemedicine - methods; Telemedicine - organization & administration; Telemedicine - standards; Thrombolytic Therapy - methods; Time; Tissue Plasminogen Activator - therapeutic use; Treatment Outcome; Singapore; telemedicine; stroke; door-to-needle time; quality improvement
• DOI: 10.11622/smedj.2018083
• ISSN: 0037-5675

Telestroke allows for remote determination of suitability for treatment with thrombolysis in patients with acute ischaemic stroke. However, this approach is time-dependent and most centres have yet to achieve the recommended treatment times. We describe a quality improvement initiative aimed at improving the telestroke workflow and treatment times at our centre. A multidisciplinary workgroup comprising clinicians, stroke case managers and radiology staff was formed to oversee the initiative. A phase-by-phase review of the existing workflow was done to identify the reasons for delay. Phase-specific measures were then introduced to address these delays, and a data-monitoring system was established to track the impact of these measures. The initiatives were implemented through four Plan-Do-Study-Act cycles. The door-to-needle (DTN) times for thrombolysis and clinical outcomes before and after the interventions were compared. A total of 104 patients were evaluated. The median DTN time improved from 96 minutes to 78 minutes post implementation of initiatives (p = 0.003). Fewer patients had symptomatic intracranial haemorrhages (8.5% vs. 24.2%; p = 0.03), and more patients had improvements in their National Institutes of Health Stroke Scale score (47.9% vs. 25.0%; p = 0.031) after the initiatives were introduced. The quality improvement initiative resulted in a reduction in median DTN time. Our approach allowed for a systematic method to resolve delays within the telestroke workflow. This initiative is part of an ongoing effort aimed at providing thrombolysis safely to eligible patients in the shortest possible time.