Abstract
Background: Stroke is a leading cause of death and disability among adults in the United States. Alteplase and thrombectomy are the only two FDA approved interventions for acute ischemic stroke. These interventions are time sensitive. Guidance from the American Heart Association (AHA) encourages EMS providers to triage acute stroke patients to thrombectomy capable stroke centers if there is clinical concern for a large vessel occlusion (LVO). Through the use of LVO scales and effective communication patterns, institutions are better informed prior to EMS arrival and able to active a stroke pre-alert and prepare for timely intervention.
Problem Statement: Quality metrics at academic medical center (AMC) demonstrated opportunities for improvement in stroke pre-alert times and other quality stroke metrics to more closely mirror national benchmarks.
Aim: Framed in Donabedian’s (2005) structure-process-outcome, the aim of this QI project was to educate emergency department (ED) staff and medical communication center (MEDCOM) dispatchers at an AMC, and EMS providers at select agencies to use, chart, and report the Vision Aphasia Neglect scale (VAN); an LVO scale., with a goal of improved pre-alert and quality stroke metrics.
Methods: A training curriculum that added VAN to EMS’s stroke assessment, charting, and reporting protocols was presented by a DNP student to EMS providers (at Agency A, B &C), dispatchers, and ED nursing staff throughout the academic medical center’s service area. Post education and VAN implementation data was compared to a historic sample. The outcomes of the VAN project were measured using the stroke care metrics of pre-alert, door to alert, door to team, door to CT, and door to needle times.
Results: 245 EMS, ED, and MEDCOM providers were trained to use VAN during the project. The highest percentage of EMS providers trained in VAN were at Agency A, who also had a significant increase in percentage of pre-alert from 15.4% to 66.7% (p=.015). Aggregate improvements were demonstrated by an 18.9% increase in the percentage of stroke pre-alert (p=.051) and 5:51 minute reduction in door to team time (p=.207).
Conclusion: Interdisciplinary integration and synchronization of LVO assessment and reporting into EMS stroke protocols can improve systemic response to the care of stroke patients as evidenced in some stroke quality care metrics. This project highlights not only the opportunity to enhance quality stroke metrics but also the novel role of the DNP-prepared clinician in incorporating evidence into practice through the establishment of joint efforts among community EMS providers and academic medical center clinicians. Such collaborative interventions improve efficiency, augment care performance and reduce siloed approaches.
