Identify potential delays for acute intervention in our stroke alert process due to interruption of obtaining the NIHSS score during transfer of a patient to CT and completion of imaging in order to improve patient outcomes.

Ischemic stroke is a leading cause of morbidity and mortality in the U.S. Two acute stroke interventions exist – tissue plasminogen activator (tPA) and thrombectomy. Both are highly time sensitive in acute stroke and patient outcomes depend on rapid intervention.

The FOCUS-PDSA model was used to determine how our stroke alert process could be improved. An opportunity for improvement was identified in which the NIHSS score could be completed prior to imaging, outside the CT scanner. By eliminating interruptions in the examination, we hoped decisions for tPA and/or thrombectomy could be initiated soon after reviewing imaging. The protocol change was made in July 2020. Data was analyzed for 6 months before and after the protocol change to determine whether the new protocol improved times to tPA administration and thrombectomy.

Fifty-two patients received tPA prior to the protocol change and 36 received tPA after the change. Average times to tPA administration increased after the change, from 53.25 minutes to 63.20 minutes. In the >60 minute group, there were 12 patients (27.27%) pre-protocol change and 14 patients (40%) post-protocol change. There was a shift from the 46-60 minute group to the 31-45 minute group after the change. Time to thrombectomy improved from an average of 52.46 minutes to 43.63 minutes.

Door-to-needle times did not change significantly after allowing for completion of the NIHSS score prior to CT. However, time to thrombectomy did improve with this protocol change. A larger sample size is necessary to effectively address this clinical question. This should prompt additional analysis of the barriers to rapid tPA administration.