Using Team Alerts to Reduce Time to Treatment for Acute Stroke Patients

Background

Strokes occur frequently in the United States, with more than 795,000 people suffering a new or repeat stroke each year.1 It’s a common cause of death in this country and a major cause of disability. Luckily, timely treatment of acute ischemic stroke has been shown to significantly reduce disability and mortality. 

In-hospital mortality was significantly lower among acute stroke patients who were treated with intravenous tissue plasminogen activator (tPA) within 60 minutes of ED arrival, compared with those who were treated after more than 60 minutes.2 One study found no benefit to tPA when administered 4.5 hours or more after symptom onset; beyond the 4.5-hour mark, the risks associated with the therapy may outweigh the potential benefits.3 

Current treatment recommendations emphasize the need for rapid evaluation and treatment of patients presenting with symptoms of acute stroke. Joint American Heart Association/ American Stroke Association guidelines call for interpretation of the CT scan within 45 minutes of ED arrival and treatment initiation within 60 minutes.4 

Not every organization can meet these challenging goals. To assist in achieving them, in 2000 the Brain Attack Coalition recommended the development of primary stroke centers to deliver standardized acute stroke care.5 

As of February 2022, there are more than 1,400 certified primary stroke centers across the country.6 Experts have identified key elements of these focused treatment centers that are associated with improved outcomes, including certification by an independent entity and identification of an acute stroke team that can be mobilized to the bedside within 15 minutes of patient presentation.5

However, operationalizing a coordinated rapid team response on a 24/7/365 basis can be a daunting administrative task and a significant barrier to providing timely acute stroke treatment. 

Staff at one hospital and medical center have built a reliable process for rapidly evaluating and treating patients with acute stroke—and have seen their door-to-treatment times decline steeply and the number of patients treated with tPA increase substantially. Single-call notification of the acute stroke team with PerfectServe Clinical Collaboration is central to this process.

Challenges

The hospital is a 772-bed acute care hospital located in Michigan. Known for its leadership in several clinical areas, the hospital was in the process of preparing for The Joint Commission certification as a primary stroke center in the late 2000s. The Director of Neuroscience for the health system was charged with reconfiguring the program to meet certification standards. 

Along with a multidisciplinary team of physicians and other staff from neurology, the ED, and neurosurgery, the director identified single-call team notification as an important priority. 

“We were looking for a mechanism to contact both the neurologist and the neuroendovascular physician at the same time,” the director said. “We realized that PerfectServe—which we were in the process of setting up for all providers— would let us alert more than one person at a time, provide a backup, and track calls.” 

According to her, there were a number of shortcomings in the acute stroke treatment process prior to the overhaul.

“We had no system for escalation or backup if the neurologist didn’t call back quickly. We had to update the on-call list in the ED continually,” she said. “The neurologists couldn’t easily tell if an incoming call was routine or related to a stroke. We couldn’t track calls. And we didn’t have a mechanism for easily tracking patients who were evaluated for acute stroke but discharged with a different diagnosis.” 

The Chief of Neurology & Stroke Program Director at the hospital recalls that identifying the correct physician to contact was a major issue.

“The ED staff never knew who was on call. The schedule wouldn’t get disseminated properly or it would get lost. A few times, the wrong physician was contacted because the staff was looking at the schedule for the correct month but from a previous year,” the chief said. “Nobody knew who to contact, let alone when, how, why, and where. Sometimes a particular neurology group might be assigned to take stroke calls, but until you called their answering service, waited on hold, and finally spoke with someone, you wouldn’t know who was on call that day. It was a major bottleneck.” 

According to the Vice Chief of Emergency Medicine, the lack of an automated escalation system for callbacks added extra work for the ED physician.

“We had written policies on escalation, but they were all driven by physicians in the ED,” the vice chief said. “I might become busy, then remember that the neurologist I paged 25 minutes ago hadn’t called back. The clerk would try him again and then the next neurologist on the list. A busy ED physician shouldn’t have to remember that.”

He also pointed to challenges with collecting and extracting data regarding calls and call times, difficulty altering the call schedule (a task that required up to 10 phone calls to inform others of the change), and delays in treatment initiation due to a lack of timely communication. He also saw a great deal of variability in the timeliness of treatment. 

“If the ED physician was very motivated and the ED wasn’t too busy, he or she could make the calls, set up the CT scan, and speak with the radiologist,” he said. “But the ED physician had to create the protocol on the fly every time. A problem in any one of those steps could cause a delay.”

Solution

The planning group at the hospital and medical center listed several priorities for the future treatment program: a dedicated neurologist on call for acute stroke, integration with the interventional group and the radiology department, and a simple team communication system that would be consistent 24/7 and could easily be updated by users. The group chose PerfectServe because of the success other clinical areas within the medical center had experienced with the solution. 

After getting commitment from the neurology groups regarding a call system for acute stroke and achieving buy-in from primary care physicians that the designated on-call neurologist would be contacted for acute stroke patients, the group launched the treatment program, which was dubbed “Code Stroke.” 

The group initiated a weekly meeting to review data and identify bottlenecks in the system. Over time, they refined the process into a highly efficient system.

Implementation

Acute stroke treatment at the hospital is now a standardized process built on reliable, rapid team notification. First, the ED staff makes a single call to PerfectServe. After that, on-call schedules are automatically analyzed, and the appropriate team members are identified. The entire acute stroke care team is contacted simultaneously based on the individual preferences of team members and the specific rules established for the team. 

Because team members are immediately aware of the reason for the call, they respond quickly. If needed, repeat call backs and escalation occur automatically. Users can easily change the call schedule via phone, web, or mobile app. Changes are reflected in real time. 

The new process also eliminated the need for ED staff to refer to printed schedules. Now, schedules are built into the PerfectServe platform, and messages route automatically to the appropriate clinician. 

Finally, team members can easily track and analyze call times and patient data. Using this data, the team can identify and address areas of concern to drive continuous process improvement.

Results

By deploying the new process, the team was able to reduce on-call neurologist response time by 90%—from 22 to two minutes.

Using the revised process, staff administered tPA to three times more patients with acute ischemic stroke in the year after implementation.

The process also reduced the door-to-CT completion time by 41%—from 78 to 46 minutes.

During this study period, the number of patients with acute stroke remained relatively flat.

With the new process in place, the team achieved a significant reduction in time to treatment for acute stroke patients. 

As the graphic above indicates, neurologists on call for acute stroke now respond to ED calls in an average of two minutes, which represents a 90% improvement from the previous average of 22 minutes. 

“Because the notification is immediate and because the neurologist knows the call is coming from the ED, they respond quickly. I rarely get backup calls anymore because the notification system works so well,” the Chief of Neurology said. 

The door-to-CT completion time averaged 78 minutes before the notification system was implemented. That number is now 46 minutes. 

Although the number of patients diagnosed with acute ischemic stroke at the hospital has remained stable, the Vice Chief of Emergency Medicine said the number who receive tPA has increased substantially. 

“We were below the national average before, and now we’re way above average—and getting better all the time,” he added.

Conclusion

“The Joint Commission wants to see that we’ve collected 95% or more of the data, not 70%,” he said. “Using PerfectServe, we can get these numbers in an automated fashion in very close to real time.” 

He also noted the benefits of the new program for both patients and physicians. “The notification system has made stroke management easier for the ED doctor, which is great for patients. It reduces the frustrations of the ED physician and frees them up to care for patients. We have a really busy and fast-growing emergency department, so it’s important that we have a system that works well for us.” 

The Director of Neuroscience agreed. “PerfectServe really helped us to affect a practice change, making treatment better and safer for patients and easier for ED staff.” 

The Chief of Neurology recalled the importance of rapid treatment for a particular patient. “I remember a patient who came in with a lack of blood supply to his brain stem—a very important part of the brain. He was treated quickly and effectively, and the speed of treatment helped to ensure that he would walk out of the hospital almost completely normal.” 

He credits the PerfectServe notification system as being an essential factor in the team’s ability to treat patients quickly.