March 9, 2015
EDMONTON — Many local stroke patients are receiving a clot-busting drug faster than ever, significantly improving their chances for a full recovery.
Median door-to-needle (DTN) time – the total time from when a patient enters the emergency room, is given a stroke diagnosis and receives a clot-busting drug – has been reduced to
40 minutes from 79 minutes three years ago at the University of Alberta Hospital, one of two main stroke centres in the city. The improvements are the result of a quality improvement project initiated at the Alberta Health Services facility in March 2012.
About 1,200 stroke patients are treated at the hospital every year.
“There are approximately 20 different processes that need to be executed from the time a patient arrives in the emergency department to the time the clot-busting drug is administered,” says
Dr. Thomas Jeerakathil, a neurology physician at the University of Alberta Hospital.
“A delay of just one minute in each of these steps could result in a massive loss of brain cells.”
On average, a stroke patient loses 1.9 million brain cells every minute that passes until the clot is cleared and regular blood flow can return to the brain. Typically, the clot is cleared using a drug called tPA (tissue plasminogen activator).
Canadian Best Practice Recommendations for Stroke indicates DTN time should be 60 minutes or less. Edmonton’s other major stroke centre, the Grey Nuns Community Hospital, also has a median DTN time of less than 60 minutes.
A stroke can result in paralysis, loss of muscle control, pain, difficulty with language and speaking, and trouble with memory and thinking. Administering tPA within 60 minutes of a stroke has been shown to reduce mortality, reduce complications of the treatment, lessen disabilities and shorten inpatient hospital stays.
Last month, Richard Grynoch tried to get out of bed but the 68-year-old Edmonton man couldn’t see and had lost control of his left arm and leg. EMS transported him to the University of Alberta Hospital emergency department, the stroke team was paged, staff tested Grynoch’s blood and used a CT scan to confirm his stroke diagnosis.
He received tPa 27 minutes after he arrived in the emergency department.
“I would call my recovery miraculous,” says Grynoch, who was released from hospital after three days. “I started improving within 10 minutes of receiving the drug – my vision cleared and my limbs stopped thrashing. I have a small visual field defect in my right eye, and some short-term memory loss, but that’s getting better. I don’t have any motor defects. I know how much worse it could have been.”
Protocol improvements included the emergency department immediately paging all members of the stroke team and diagnostic imaging when the patient is triaged, ensuring the CT scanner is available for quick use, and creating visual cues for the lab to indicate the urgency of the patient’s blood tests.
The departments continue to meet, troubleshoot problem areas, and look for areas of improvement.
“If you don’t measure, you can’t make change,” says Dr. Jeerakathil. “Everyone is an expert in their own process, so it was essential to present the teams with the numbers and engage them to think about what we could all do better. We determined if anything could be eliminated or simplified, and which processes could run in parallel, rather than in sequence.”
The University of Alberta Hospital’s protocol improvements and ideas are being shared with the other stroke centres across Alberta.
“The DTN improvement initiative is one of the best examples we have of multidisciplinary teams working together to make a difference in the care patients receive, and subsequently their recovery and quality of life,” says Shy Amlani, Edmonton Zone Stroke Program manager. (http://www.albertahealthservices.ca/edmstroke.asp)
Not all stroke patients are candidates for tPA.
Patients who have a high risk of hemorrhage, and those who arrived in an emergency department too long after the initial stroke, may not be candidates for tPA.
Alberta Health Services is the provincial health authority responsible for planning and delivering health supports and services for more than four million adults and children living in Alberta. Its mission is to provide a patient-focused, quality health system that is accessible and sustainable for all Albertans.
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