A systems approach to immediate evaluation and management of hyperacute stroke. Experience at eight centers and implications for community practice and patient care. The National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stroke Study Group

Abstract

Background and purpose: With the approval by the Food and Drug Administration of recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke within 180 minutes of symptom onset, patients and prehospital and hospital systems will now have to treat stroke as a medical emergency. It is thus critical to develop efficient hospital-based methods for hyperacute stroke patient evaluation and intervention at both community-based and tertiary care academic centers.

Methods: We describe how the eight centers in the National Institute of Neurological Disorders and Stroke rt-PA Stroke Trial developed systems for enrolling patients within 3 hours of symptom onset. The actual methodology and practical sequence of events are detailed. Deming principles of system organization were applied, and each center developed a flowchart of acute stroke patient screening, assessment, and treatment. We divided the process into the following: clinical center background and preparation, screening, stroke team response, data needed before treatment, CT of the head, pharmacy, patient treatment, and monitored care. Critical features, both unique to a given center and shared by several centers (common at four or more centers), were summarized.

Results: Phase I of the trial included several months of preparation with review of every detail involved in the process of acute stroke care at each site. All centers worked closely with emergency medical services. Community stroke awareness and education programs were developed. A stroke team was initiated and worked closely with the emergency department physicians and nurses. Rapid and efficient communication systems and protocols were established to reduce time to complete each task. Standardized stroke examinations and protocols for blood pressure management and intracranial hemorrhage detection as well as nursing flowcharts were used.

Conclusions: Hyperacute stroke treatment can be initiated, often within 55 minutes of patient arrival at the hospital, in both community and academic settings when all aspects of stroke care processes are identified, streamlined, and built into the day-to-day operations of the prehospital and hospital healthcare delivery system.