The diagnostic workup for a patient with signs and symptoms of a stroke include a thorough medical history, physical exam, laboratory tests, and imaging. Imaging modalities include Computer Tomography (CT) and Magnetic Resonance Imaging (MRI).  Both CT and MRI are effective in different scenarios, however the CT scan is the primary and most widely used initial imaging modality for suspected stroke victims. CT is important to evaluate for presence of ischemic stroke and also if there is any evidence of hemorrhage, which could dictate treatment options. Rapid imaging and resulting treatment of stroke are important steps in ensuring the best possible outcome for the patient¹.

This metric measures the percentage of patients in which less than 25 minutes lapses from when the patient enters the emergency department to when the CT scan is initiated. The American Heart Association has varying door to CT times depending on when the stroke symptoms started, which is refereed to as last known well time (LKWT). The American Stroke Association has established a series of benchmarks regarding how quickly imaging is completed. The most important of these benchmarks is the initial CT occuring no more than 25 minutes after triage in the emergency department. The American Heart Association benchmark for percentage of stroke patients that meet this time is 100%².

Arkansas has not met this benchmark in the eight years of data that have been collected on this metric. The most recent data shows that only 51% of sampled patients underwent a CT scan in 25 minutes or less after entering the emergency department. Although this is low, the overall trend has been upward since 2011 when it was shown that 20.4% of patients met the benchmark. 

Source: ¹Birenbaum, D., Bancroft, L. W., & Felsberg, G. J. (2011). Imaging in acute stroke. The western journal of emergency medicine, 12(1), 67-76.

Source:² Stroke Fact Sheet. Accessed April 2, 2019 from https://www.heart.org/idc/groups/ahaecc-public/@wcm/@gwtg/documents/downloadable/ucm_491528.pdf

• Acute Stroke Care Task Force
• American College of Cardiology 
• Arkansas Department of Health Tobacco Cessation and Prevention Branch 
• Arkansas Department of Health Trauma Branch – Stroke and STEMI Section 
• Arkansas Department of Health Chronic Disease Branch 
• Heart Disease and Stroke Prevention Coalition 
• Mercy Telestroke System 
• UAMS Center for Distance Health - AR SAVES (Arkansas Stroke Assistance through Virtual Emergency Support)

Acute stroke occurs when an area of the brain no longer is receiving blood flow. Therefore, the ultimate treatment is to restore blood flow to these regions that are in danger of damage. The more time passes, the more damage is done which follows the phrase "Time is Brain"¹. The first step to treatment is diagnosis, which is most commonly done through CT scans. It has been demonstrated that a rapid CT scan is a necessary step in ensuring the best possible outcome for the patient².

Source: ¹Saver, J. (2006). Time Is Brain—Quantified. Stroke, 37, 263-266. Retrieved April 25, 2019.

Source: ² Birenbaum, D., Bancroft, L. W., & Felsberg, G. J. (2011). Imaging in acute stroke. The western journal of emergency medicine, 12(1), 67-76.

This metric has been improved by Arkansas hospitals’ stroke teams and EMS agencies collaborative efforts to use several evidence-based quality improvement initiatives offered by the Arkansas Department of Health Stroke Nurse Coordinator to rapidly identify and assess stroke symptoms with accuracy, with more clinical details, and in a timely manner. These quality improvement initiatives include:

1. Call CT room and hold for stroke patient
2. If greater than 3 hours from LKW, the physician makes the decision for an expedited CT
3. Increasing the number of patients transported by EMS through community awareness and education
4. Improving EMS’s accuracy toward identifying acute stroke systems and providing a timely stroke pre-notification, providing time for ED staff to prepare for the Code Stroke
5. Ensuring EMS and hospitals’ stroke teams to perform mock stroke codes monthly or weekly more frequency if needed as an active role toward improving door to CT times; these mock stroke set-ups allow hospital and EMS team to identify true stroke symptoms verses stroke mimics through prehospital assessment and questioning
6. Ensuring that EMS and hospitals’ stroke teams are continuously performing monthly or quarterly audits of EMS stroke run sheets, both collaboratively and individually to verify adherence to stroke protocol and documentation of stroke performance metrics on the run sheets. 

If the adherence continues to be below expectations, conduct a PDSA cycle to collaborate with the ED and EMS providers to decrease door to CT time. For example, consider transporting suspected stroke patients directly to CT. Hospitals’ Stroke Nurse Coordinator/Educator provides one-on-one training with Emergency and Radiology Departments’ staff to improve the Code Stroke process. Once on the CT table and the CT is read by the ED physician/Telemedicine Neurologist as non-hemorrhagic, the initial bolus IV-tPA is delivered while the patient is still on the CT table. Efforts are made so that all hospitals’ stroke team to integrate ED physicians and staff in all improvement projects. Up-to-date, evidence-based resources and quality improvement plan of actions to assist with improving your hospital’s door-to-CT and door-to-needle times are regularly emailed. They are assisted with using a team-approach to conduct a PDSA to develop or create a standardized stroke pathway and/or revised protocols to enhance the number of eligible patients treated and reducing time to treatment in stroke. Because of the evidence to support this initiatives, hospitals’ stroke nurse coordinators are asked to develop an interdisciplinary collaborative team (including EMS) to assist with stroke performance improvement efforts. This internal stroke team should frequently meet, including serving EMS providers to review hospitals’ processes, quality care initiatives, acute stroke patient protocols and safety parameters, and clinical outcomes, as well as make recommendations for improvement. Before implementing plans for QI initiatives, assistance is given to hospitals’ stroke team set goals, for example, 95% of suspected stroke patients will have a CT imaging within 25 minutes and 90% will receive tPA within 60 minutes of ED arrival and gradually increasing this percentage until their hospital’s stroke team has attained an adherence rate of 100%. Up-to-date quality improvement initiatives are introduced annually to Arkansas Stroke Registry (ASR) hospitals during the Program Review, which is organized and facilitated by the Arkansas Department of Health State Stroke Nurse Coordinator. ASR hospitals and EMS agencies collaborate using the PDSA template to implement all QI on a small scale with a timeframe between 2-3 months.