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

Abstract

Introduction: 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.

Methods: 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.

Results: 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.

Conclusion: 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.

Keywords: door-to-needle time; quality improvement; stroke; telemedicine.

Fig. 1

Diagram shows initial target timings and audit findings, and the new target timings proposed by the workgroup. CT: computed tomography; ED: emergency department; tPA: tissue plasminogen activator

Fig. 2

Summary of quality improvement initiatives. CT: computed tomography; ED: emergency department; EMS: emergency medical service; FAST: face-arm-speech-test; NIHSS: National Institutes of Health Stroke Scale; NNI: National Neuroscience Institute; tPA: tissue plasminogen activator

Fig. 3

Box and whisker plot shows the time taken for each phase of telestroke before and after the initiatives.