How to reduce delays when seconds count
Your door-to-needle time for administration of thrombolytic therapy to stroke patients should be less than 90 minutes, says Patricia Kunz Howard, RN, MSN, CCRN, CEN, EMS training coordinator for the Lexington (KY) Fayette Urban County Government Division of Fire and Emergency Services and former ED director and stroke team coordinator at Central Baptist Hospital, also in Lexington.
"The sooner the drug is given, the better," she emphasizes.
ED nurses have a comfort level with thrombolytics for cardiac indications but might be hesitant to use it for stroke, thus causing delays in treatment, says Janice Fitzgerald. MS, RN, CEN, clinical practice guidelines coordinator at Baystate Medical Center in Springfield, MA. "Just as we say time is muscle’ with cardiac conditions, the same rule applies to stroke. Time is also brain."
Every second counts, Fitzgerald emphasizes. "Everybody who has contact with moving the patient through the system must do it as quickly as possible, knowing that the clock is ticking."
Here are ways to reduce your door-to-needle times:
• Take advantage of having first contact with the patient.
You might be the first provider to do an in-depth assessment that might flag the patient as a potential candidate for treatment, says Fitzgerald. "Any patient who comes in with stroke symptoms should be considered a candidate."
• Include standing orders for nurses.
Protocols should give the nurse "standing orders" to initiate diagnostic procedures based on the patient’s clinical presentation and specific risk factors, without an examination by a physician, nurse practitioner, or physician’s assistant, says Howard. "It should also allow nurses to start other interventions, such as IV access."
• Investigate delays.
Delays also can be overcome by frequent quality assurance audits, says Nanette H. Hock, RN, MSN, program coordinator for the Stanford Stroke Center in Palo Alto, CA. "Find out what caused the delay, and immediately implement an action plan."
Hold periodic staff meetings to evaluate delays in door-to-needle times, says DeLemos. "Ask, What is our door to needle time? What are the hang-ups? How long does it take to get a CT scan interpreted? How long does it take for an ED physician to see the patient?’ These are all things that can make a huge difference."
• Assess whether the patient needs to be transferred.
Identify the delays that cannot be controlled or overcome, Hock recommends. If the cause of the delay is beyond the institution’s capacity to change or overcome, such as the absence of a competent physician who can direct the treatment or the absence of an ICU bed, the institution should transfer the patient to a more competent hospital, she says.
• Make stroke care a priority.
A common cause of delay is a disorganized or busy ED with multiple patients and conflicting priorities, says Hock. In this case, the team needs to make a concerted effort to reprioritize stroke or transport the patient immediately to the ICU for thrombolytic therapy, she advises.
"Whatever the cause of the delay may be, the key is to make a concerted and authoritative decision to change and better the system," Hock emphasizes.
• Educate emergency medical services (EMS) providers about making stroke a priority.
Inservicing EMS providers is essential so they can alert you of an incoming stroke patient and begin gathering needed information, Howard says. "While many places today assume that everyone knows about rapid recognition and treatment of stroke, it is simply not true."
EMS providers need special training on stroke recognition, says Howard. "Many emergency medical technicians and paramedics were not trained under this framework, so in some cases they are part of the delay to care." For example, paramedics might not transport a patient whose only complaint is numbness or double vision, Howard adds.
"It is a recognized fact that patients brought in by ambulance receive evaluation more quickly than patients walking through the front door," Howard says.
Also, EMS providers should begin the thrombolytic checklist as they do for an acute myocardial infarction, says Howard. "EMS should have their own stroke protocol, so they can do things such as administer an aspirin and manage hypertension." (See brain attack inservice for EMS, p. 96.)
• Identify individual staff members to take specific actions.
"You need a point’ person to take charge and hammer down the cascade of events that are to take place instantly, such as obtaining rapid CT, ultrastat labs, reading the CT, and instantly screening the patient for potential t-PA treatment or other interventions," advises Hock. These events must be a closed loop, she says. "If one or two pathways don’t work, the effort and outcome are not as smooth."
• Use protocols.
Stroke protocols in ED provide the guideline for rapid and organized treatment for acute stroke, says Hock. At a minimum, protocols should cover recognition of signs and symptoms of stroke, proposed response time, and specific roles and responsibilities in a stroke code, she says. (See protocol for thrombolytic therapy and thrombolytic therapy standing orders, inserted in this issue.)
"The protocols will help minimize delay in triage and treatment by defining the algorithm and pathway for care," Hock says.
For more information about reducing door-to-needle times, contact:
• Janice Fitzgerald. MS, RN, CEN, Baystate Medical Center, 759 Chestnut St., Springfield MA 01199. Telephone: (413) 794-2531. Fax: (413) 794-8866. E-mail: [email protected].
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content