Speedy stroke treatment and feedback

An academic medical center reduces door-to-needle time dramatically.

Where: University of California, San Francisco (UCSF), a 600-bed academic medical center.

The issue: Reducing door-to-needle time in stroke patients.


Since 2011, the stroke team at UCSF has known exactly how long it takes their patients to get to thrombolysis treatment. “We had done a lot of work looking at our processes and measuring different steps of the process—the time it takes from when the patient arrives to when the Code Stroke alert goes out, the time it takes from when the patient arrives to get to the CT scanner, or the time it takes from when a patient arrives to get laboratory test results back,” said Anthony S. Kim, MD, assistant professor of neurology and medical director of the UCSF Stroke Center.

But despite efforts to speed each component, the median time to intravenous tissue-type plasminogen activator (tPA) was still over the recommended hour. “Things were happening correctly in the right order, and things were moving reasonably quickly, but there wasn't this overall sense of urgency, and also there wasn't sharing of what the specific time goal for that patient was. Everyone just knew that we shouldn't delay,” said Dr. Kim.

He and his colleagues wondered if their existing Code Stroke alert system could be used to coordinate a team effort to improve the situation. “That initial stroke alert is a system that we had in place that sends a message to all of the key players—radiology, neurology, ICU bed requests, the attendings, the fellows, the residents … about 20 people—pulling this big red lever down saying there is a patient with a suspected stroke,” he said.

How it works

Under UCSF's new system, the Code Stroke, which is delivered through a group-texting system, is followed up with a message letting the team know how well the system worked for each patient. The real-time feedback alert says whether a patient received tPA, and if so, how long it took to get from door to needle.

Other forms of rapid feedback were also added. If a patient doesn't get thrombolysis within an hour of arrival, the case is reviewed within 24 to 72 hours to identify any issues that slowed down care. The whole stroke team also receives biweekly updates on the hospital's door-to-needle times.

Door-to-needle time had already been an important outcome for the hospital, but relaying results to involved clinicians more quickly was an important change for a team that includes many residents. Under the old system, “they may not get the feedback until after they've left the rotation, which is too late to institute a change,” said Dr. Kim.


Significant changes did result from the new feedback system, according to an analysis published in the December 2014 Stroke. The hospital's average door-to-needle time dropped from 82 minutes in 94 patients treated during the 3 years before implementation to 56 minutes in the 108 patients treated after.

The gains have stayed in place since the end of the study in April 2014, Dr. Kim noted. “It was a pretty dramatic change,” he said.

Of course, the team had always wanted to treat patients rapidly, but the instant feedback added a collective sense of urgency, according to Dr. Kim. “People were moving more quickly and people were talking to each other about ‘OK, the patient came in this time, this is our goal,’” he said. “The very same things were happening but more quickly, in a fashion that I think is more typical of what you see in a trauma response.”

Words of wisdom

The new feedback system “was just so easy to implement” at UCSF, because the group notification system and data collection were already in place, Dr. Kim noted. The project leaders also benefited from certainty at the start that it was possible for their team to treat patients in under an hour. “We knew we could do it, because we had been able to do it in the past, but just not as consistently,” Dr. Kim said.

Other hospitals might not have an established method for rapidly communicating feedback to a whole team. On the other hand, they might not have as many problems with rapid turnover of team members who are residents. “There might be aspects of our situation that might not necessarily generalizable,” said Dr. Kim.

But almost any program could benefit from speeding up their feedback loop. “A lot of places might have meetings every month or every couple of weeks,” he said. “This is, literally, you get feedback as it's happening.”

Next steps

Researchers at UCSF are working on a number of other projects aimed at minimizing stroke symptom onset-to-treatment times, including developing a prehospital video system to reduce door-to-groin puncture and door-to-recanalization times for endovascular strokes and looking at mobile stroke units with built-in CT scanners on the ambulance rig. “I think increasingly there's going to be more structural innovations in how we provide this care quickly,” said Dr. Kim.