Abstract T P247: An Interdisciplinary Approach Using a Root Cause Analysis to Decrease Door to IV tPA Times

Abstract

Background and Issues: The benchmark goal for stroke treatment is door to IV tPA in 60 minutes. In 2010, average door to IV tPA treatment time for acute stroke patients at our acute care, tertiary teaching hospital was 87 minutes. Purpose: As a TJC certified primary stroke center, our purpose was to improve door to IV tPA times. Methods: Causes for lengthy tPA treatment times were identified by the stroke interdisciplinary team using a root cause analysis approach. Identified delays included: lab turn-around times, order entry, clinical decision making time, and tPA preparation, delivery, and administration. Process improvement initiatives for order entry included revisions to electronic order sets to auto-populate and enhance efficiency and safety of order entry. Lab audits revealed that the BMP took the most time to process, resulting in initiation of point of care testing. For clinical decision making delays by neurology, immediate feedback was provided to the neurologist after each tPA administration. A year end summary was compiled showing door to tPA times for each attending neurologist. In addition, 3 APNs completed a neurovascular advanced practice fellowship program. Pharmacy instituted a tracking log to audit prep-to-delivery time which encouraged earlier notification and faster delivery times. Mixing of tPA was changed from (2) 50mg vials to reconstitution of (1) 100mg vial. Nurses who administer tPA were re-competencied using a simulation lab. Patients were triaged to a room in ED closer to the CT scanner. And, a count-down clock was initiated upon patient arrival to ED to enhance time awareness for all stroke team members. Results: Average door to tPA time has decreased from 87 minutes in 2010 to 50 minutes YTD 2013, a 37 minute improvement. In addition, volume increased by 25 more tPA administrations in 2012. Chi square comparisons of discharge dispositions showed no statistical differences for 2010 vs 2013 (p=.56) or 2012 vs 2013 (p= .18). Our hospital has received the American Stroke Association’s Target Stroke award for the past 2 years. Conclusions: An interdisciplinary approach using a root cause analysis is effective in identifying and implementing process improvements, ultimately leading to decreased door to IV tPA times.