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Quality of Stroke Care for Arkansans

IV rt-PA Arrive by 2 Hours, Treat by 3 Hours

Current Value

79.2%

2018

Definition

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Story Behind the Curve

As discussed previously, timely diagnosis and treatment is imperative to optimize outcomes in stroke patients. Areas of the brain are not receiving adequate oxygenated blood during an acute stroke1. This problem is addressed with IV tissue plasminogen (rt-PA) activator which helps return blood flow to the affected regions of the brain. However, before rt-PA can be administered, the patient must arrive at the hospital and be diagnosed by medical professionals2.

The metric IV rt-PA arrive by 2 hours, treat by 3 hours takes this series of events into consideration. It is the percent of acute ischemic stroke patients who arrive at the hospital within 2 hours after last known well time (LKWT) and also received rt-PA within 3 hours of LKWT.  The American Heart Association has set a benchmark that 85% of acute ischemic stroke patients meet these time constraints. 

As demonstrated by the Arkansas Stroke Registry (ASR), Arkansas has been improving drastically over the past several years in regards to this metric. This metric was met in 79.2% of stroke patients in 2018, which is up from a low of 38.0% in 2012. It is likely that Arkansas will meet the 85% benchmark if this trend continues.


Source: 1Saver, J. (2006). Time Is Brain—Quantified. Stroke, 37, 263-266. Retrieved April 25, 2019.

Source: 2Robinson, T., Zaheer, Z., & Mistri, A. K. (2011). Thrombolysis in acute ischaemic stroke: an update. Therapeutic advances in chronic disease, 2(2), 119-31.

Partners

• Acute Stroke Care Task Force
• American College of Cardiology 
• Arkansas Department of Health Tobacco Cessation and Prevention Branch 
• Arkansas Department of Health Trauma Branch – Stroke and STEMI Section 
• Arkansas Department of Health Chronic Disease Branch 
• Heart Disease and Stroke Prevention Coalition 
• Mercy Telestroke System 
• UAMS Center for Distance Health - AR SAVES (Arkansas Stroke Assistance through Virtual Emergency Support)

What Works

Evidence has repeatedly demonstrated that following American Heart Association (AHA) guidelines for rapid reperfusion is beneficial for the patient. There is a strong association between timely reperfusion and positive patient outcome after acute stroke. This includes mortality as well as functional outcomes. This particular study found that with every 10-minute delay in thrombolysis within the 3-hour window, 0.9 fewer patients had an improved disability outcome. Additionally, for every 15 minutes that rt-tPA was initiated sooner, patients demonstrated having a 4% greater odds of walking indecently at discharge, a 3% greater odds of being discharged to home, and a 4% lower odds of death before discharge1. These results stress the need for action to meet the IV rt-PA arrive by 2 hours, treat by 3 hours benchmark established by the AHA.


Source: 1Saver JL, Fonarow GC, Smith EE, et al. Time to Treatment With Intravenous Tissue Plasminogen Activator and Outcome From Acute Ischemic Stroke. JAMA. 2013;309(23):2480–2488. doi:10.1001/jama.2013.6959

Action Plan

The Arkansas Department of Health has implemented quality improvement initiatives to help target this metric. One such initiative begins with a series of questions discussed with Arkansas hospitals’ stroke teams which include:

  1. Is IV-tPA given in the ED?
    1.  If no, were reasons for not giving IV-tPA documented?
    2. Is tele-medicine used to administer IV tPA? 
  2. Is the lack of adherence to the measure related to delays in administration?
    1. Is there pre-notification? 
    2. Are stroke symptoms not identified in the initial assessment? 
  3. Is-there documentation of ineligibility for IV tPA use?
    1. Do you use provider forms/EMR to document ineligibility? 
    2. Are addendum notes used to document exclusions for IV tPA use? If so, with this measure, the addendum note must be done prior to the patient’s discharge. 

There are two ways to miss this measure. One is that the patient is eligible by time, not given IV-tPA and the ineligibility is not documented. Or, the IV-tPA administration time extends beyond 3 hours. The Arkansas Department of Health State Stroke Nurse Coordinator assist hospitals’ stroke coordinator to conduct a PDSA cycle to improve adherence to this measure by developing an algorithm that will look to the documented dated and time of onset of symptoms and then compare this to the date and time of IV t-PA administration on the MAR along with the pharmacy delivery time to associated to the IV t- PA to determine if the patient arrived within 2 hours of symptom onset and if t-PA was administered within 3 hours. Also, the State Stroke Nurse Coordinator assist hospitals’ stroke coordinators/teams to review current Acute Stroke Assessment Flowsheet and ensure that this flowsheet aligns stroke measures used for Get With the Guidelines-Stroke Stroke, develop a Stroke Performance Improvement Tracking Form, (this is form that can be used in real time one-on-one staff improvement action as it relates to not effectively adhering to various stroke measures and missed documentation), and create a drop-down Stroke Narrative Box (this Stroke Narrative box will immediately drop down when the nurse checked “acute stroke” indicator box located on the Acute Stroke Assessment Flowsheet The Stroke Narrative Box will provide nurses with a list of required documentation for Acute Stroke Patient). The Stroke Narrative Box replaces the need for hard-stops throughout the Acute Stroke Assessment Flowsheet. 

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