Abstract TP292: Impact of Structured Feedback on Emergency Department Physician Culture to Reduce Door-to-Telestroke Activation Times

Abstract

Introduction: Emergency Department (ED) Physicians typically consult with a specialist after pertinent results are gathered. In the case of acute stroke, delays in neurologist consultation equate to valuable time lost for treatment. When Telestroke went live in June 2015 at our 148-bed regional medical center, the physician norm was challenged because Telestroke protocol stipulates activation of the system before the CT scan. Despite education about the importance of calling early, ED physicians continued to activate Telestroke after gathering results. Hypothesis: Implementation of timely, structured feedback to ED physicians will change ED physician culture to reduce Door-to-Telestroke Activation (DTA) times. Methods: In February 2017, monthly feedback was initiated with ED physicians. Graphs showing current performance related to activation times were discussed, goals were reviewed, small improvements were acknowledged, and physicians were encouraged to share their successes. Using a prospective observational study design and a REDCap database, data from June 2015 to February 2017 were compared to data from March 2017 to July 2018. Results: From June 10, 2015 to July 18, 2018 Telestroke was activated 246 times in the ED. After the feedback initiation, the median DTA of 20 m (n=145) was significantly lower than the baseline median of 32 m (n=101, p<0.0001) and the percentage of activations prior to the CT scan rose significantly from 20% to 46% (p=0.0003). Also, Door-to-Needle (DTN) time decreased to a median of 48 m (n=27), compared to the baseline of 56 m (n=19, p=0.15) and the percentage of ischemic stroke patients treated with IV Alteplase increased to 17.7% from 13.4%. Median Door-to-CT (DTCT) remained unchanged at 17 m both pre and post intervention, demonstrating consistent ED processes. Conclusions: Timely ED physician feedback led to faster Door-to-Telestroke Activation times. While statistically insignificant, post intervention DTN times rose from a baseline of 63% (n=19) to 81% (n=27, p=0.29) which met the primary Target: Stroke Phase II goal to treat 75% of patients within 60 minutes. Faster activation resulted in faster treatment and ultimately improved chances of a better outcome.