IMPROVING TELESTROKE CARE: DECREASING “DOOR -IN – DOOR- OUT” TIMES (DIDO) ANGELIQUA POCHERT MS 1 , ERIN EKSTROM RN BSN MBA 1 , JALEEN SMITH BS, 1 LEE CHUNG MD, 1,2 PETER HANNON MD, 1,2 AND JENNIFER J. MAJERSIK MD, MS 1,2 STROKE CENTER; 1 DIVISION OF VASCULAR NEUROLOGY, NEUROLOGY DEPARTMENT 2 UNIVERSITY OF UTAH C O N F I D E N T I A L
DISCLOSURES • No presenter or team member has a financial disclosure or conflict of interest. • Special thanks to our telestroke sites for providing the data, participating in discussion, and being excellent partners. C O N F I D E N T I A L
DOOR IN, DOOR OUT IMPROVEMENT PROJECT • It’s patient oriented. • It’s a critical metric associated with clinical Reduce Door- outcomes. In-Door-Out • It’s a statewide effort Times because led by Utah Stroke Task … Force. • Recommendation of transfers < 75 minutes. C O N F I D E N T I A L
BACKGROUND Certification UUHC Comprehensive Stroke Center Meets standards for Comprehensive Stroke Center Stroke Receiving Critical Access C O N F I D E N T I A L
C O N F I D E N T I A L
Simplified Process Map EMS pre- notification Teleconsult Departure Patient Assessment arrives in & decision ER making DIDO Time C O N F I D E N T I A L
DIDO - THE NEED FOR SPEED Why is this so important? Tissue reperfusion within 150 min of Last Known Well carries a ~91% probability of regaining functional independence. ( Curr Atheroscler Rep (2017) 19:52 ) Note: Reprinted from Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis by JL Saver, 2016. C O N F I D E N T I A L
January ‘17 – March ‘18 UTAH STROKE Baseline DIDO Times for UUHC Network TASKFORCE 500 RECOMMENDS A 400 Minutes GOAL OF 75 MIN! 300 200 100 0 DIDO 1 9 17 25 33 41 49 57 65 73 81 89 97 105 113 Average: Transfers 158.6 minutes! ≤ 90 min > 90 min C O N F I D E N T I A L
OUR 5 SELECTED SITES STATEWIDE C O N F I D E N T I A L
Root Cause Analysis Long Door to Transfer Times C O N F I D E N T I A L
Targeted Root Causes Empower nursing Why wait before staff to drive What we activating a BA? activations. have. Encourage ER 3 Why’s? physician to call Why wait to call 3 before having all the a tele consult? How’s? answers. What we want. Activate EMS as soon Why wait before as transfer is decided activating EMS? or tPA is given. C O N F I D E N T I A L
RESULTS (SELECTED SITES) Jan'17- Apr'18- Mar'18 July'19 Mean 148.5 min 115.9 min Median 123 min 99.5 min 25% Quartile 102 min 81.25 min 191.9 75% Quartile 176 min 139.5 min Two-tailed p- value 0.0024 C O N F I D E N T I A L
Survey Results for DIDO Results for DIDO Success Jun '18 Other (staff education, activation Weather protocol change, etc.) Care Team Process improved UUMC on divert Stroke Recognition EMS Availability EMS Availability Stroke Recognition Early Telestroke Activation Complications in Care 0 2 4 6 8 10 12 0 2 4 6 8 C O N F I D E N T I A L
DISCUSSION What were our 5 sites doing differently? They targeted barriers that could be easily changed while still yielding a high return. ED Physicians felt They improved Nurses were more comfortable communication with empowered to activating a tele EMS & activated activate BA’s in triage. consult. crews sooner. C O N F I D E N T I A L
What were we (UUHC) doing differently? We conducted visits We provided physician We followed up via We tracked and together with EMS to driven, individualized surveys, newsletters, recognized best DIDO each facility. education on site. and phone calls. times each month. C O N F I D E N T I A L
IMPROVING CLINICAL PROCESSES Take Away Key Points • Foster relationships • Set explicit DIDO goal • Standardize Brain Attack protocols • Provide visible support • Data Feedback and Recognition • Stay persistent C O N F I D E N T I A L
THANK YOU! Source: https://healthcare.utah.edu/publicaffairs/news/2014/images/hospital-university-2014.jpg C O N F I D E N T I A L
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