Stroke of Genius
Meredith Thompson, Jennifer Smith, Mary Williams, Stephanie Barker, Layne Singletary
Abstract
Description of the Issue: The time it takes for a
patient who reports to the emergency department
with stroke symptoms to receive brain scan results
should be within 45 minutes of arrival. Memorial
Regional Medical Center has an average rate of
65% of patients meeting this time standard, which
is lower than the national average of 72% (Medicare.gov).
Data Analysis: Data was made available on the
Medicare.gov hospital comparison site.
Root Cause: A lack of understanding of specific
roles, processes, and materials needed in a Code
Stroke are all factors that affect the delay in time
from ED presentation to CT results.
Proposed Solution: We propose to implement
mock codes to help streamline the Code Stroke
process and to help prevent any role confusion.
Conclusion: Implementing mock codes will help
MRMC to exceed the national average of stroke to
CT time in one year time.
Introduction and Description
of the Issue
Macro Description: Time is an essential aspect in the
successful treatment of strokes and any delays in care can lead
to poor health outcomes for patients to include irreversible
neurological damage and even death (Barbour & Thakore, 2017). National
standards indicate patients who present to the emergency
department with stroke symptoms should receive brain scan
results within 45 minutes of their arrival time.
Micro Description: Sixty five percent of patients who
presented with stroke symptoms to the emergency
department at Memorial Regional Medical Center met the
national standard. The national average is 72% (Medicare.gov).
Multiple factors affect delays in time from ED presentation and
CT results and pose a challenge to the facility. We believe a lack
of education on specific roles, processes, materials, and
equipment for a Code Stroke is the root cause of delay.
Bon Secours Memorial College of Nursing
Data and Analysis of the Issue
● It is essential to initiate a CT scan within 25 minutes of
arrival and complete interpretation of the CT scan within 45
minutes to exclude intracranial hemorrhage prior to
administration of intravenous rt-PA (American Stroke Association, 2010).
● Data collected quarterly between 10/1/18 and 9/30/19
available on the Medicare.gov hospital comparison website
shows a lower than national average for MRMC ED response
times for patients presenting with stroke symptoms.
● Current ED administration reports:
○ The use of American Heart/American Stroke Association
Target Stroke Phase III goals, an initiative with more
aggressive time targets for timely treatment of strokes
with IV alteplase (American Heart Association, 2020).
■ Door-to-needle within 60 minutes for 85% of acute
ischemic stroke patients
■ Door-to-thrombectomy device times within 90
minutes in 50% of direct arriving eligible acute
ischemic stroke patients requiring endovascular
therapy
○ MRMC ED nurses required to take an 8 hour Basic Stroke
course, complete the National Institute Stroke
Certification, and participate in ongoing required
educational modules.
● Ajmi et al.(2019), Kalnins et al. (2017), and Nalleballe et al.
(2020), conducted studies that resulted in a decrease in
door to needle time when implementing education
interventions such as mock codes.
● Additional information desired by our group:
○ Process of code stroke
○ How is time being tracked?
○ Are staff roles clearly defined?
○ How often and how are mock Code Strokes conducted?
Root Cause
Proposed Solution
By implementing mock code stroke simulations and the use of a
visible time tracker in the emergency department of MRMC, we
aim to decrease the time it takes suspected stroke patients to
complete a CT scan. Literature reviews have shown that
performing and observing mock codes can lead to a better
understanding of role clarity, process streamlining, and improve
patient outcomes.
Logistics
-Employee education
-Coordinating time and place to run mock code
strokes
-Barriers include: nurse educator covering 2.5
facilities, need to conduct multiple simulations to
facilitate all staff participation
Stakeholders
-Patients
-Nurses
-Hospital Administration
-Hospital Educators
Potential costs
-Time: 4 hours simulation planning, staff presence
during 30 minute mock code, multiple and
consistent simulation times for staff
-Equipment: timer to attach to bed/IV pole
6/$14.99
Timeline
-Implementation of mock Code Strokes to begin
within the next 6 months and occur 4 times
covering both day/night and weekday/weekend
shifts each quarter thereafter.
Data Collection
-After 3 months we will evaluate the effectiveness of
changes suggested through surveys, staff discussion
and staff response. BSMH quality abstraction team
will be consulted to determine percentage of
patients that received CT within 45 minutes.
Conclusion
● MRMC currently does not conduct mock codes, nor have a
visible time tracking system in place.
● Implementing mock codes as additional education will
ensure that health care professionals are fully prepared to
carry out their roles during Code Stroke which will result in a
decrease in time from onset of of symptoms to CT reading.
● Providing a visual timer during a Code Stroke response will
help emergency department see time elapsed from the
initial presentation of a patient with stroke symptoms.
References
● Ajmi, S.C., Advani, R., Fjetland L., et al. (2019) Reducing door-to-needle times in
stroke thrombolysis to 13 min through protocol revision and simulation
training: a quality improvement project in a Norwegian stroke centre. BMJ
Quality & Safety 28, 939-949. doi: 10.1136/bmjqs-2018-009117.
● American Heart Association. (2020). Target: Stroke Phase III.
https://www.heart.org/en/professional/quality-improvement/target-
stroke/introducing-target-stroke-phase-iii.
● American Stroke Association. (2010).
http://www.strokeassociation.org/idc/groups/heart-
public/@wcm/@hcm/@gwtg/documents/downloadable/ucm_308277.pdf
● Barbour, V., & Thakore, S. (2017). Improving door to CT scanner times for potential
stroke thrombolysis candidates - The emergency department's role. BMJ
Quality Improvement Reports, 6(1),
https://doi.org/10.1136/bmjquality.u211470.w4623.
● Kalnins, A., Mickelsen, L.J., March, D., et al. (2017) Decreasing stroke code to CT
time in patients presenting with stroke symptoms. RadioGraphics. 37, 1559-
1568. doi: 10.1148/rg.2017160190.
● Medicare.gov (n.d) Hospital compare: Data sources.
https://www.medicare.gov/hospitalcompare/details.html?msrCd=prnt2grp5
● Nalleballe, K., Brown, A., Sharma, R., et al. (2020). When telestroke programs work,
hospital size really does not matter. Journal of Neurosciences in Rural Practice,
11(3), 403-406. http://doi.org/10/1055/s-0040-1709362.
● Sadeghi-Hokmabadi, E., Taheraghdam, A., Hashemilar, M., et al. (2016). Simple
in-hospital interventions to reduce door-to-CT time in acute stroke.
International Journal of Vascular Medicine, 2016, 1-6.
https://doi.org/10.1155/2016/1656212.