Time is Brain: Redesigning Stroke Care at Kaiser Permanente Northern California


Jeffrey G Klingman, MD


Introduction: Stroke is the number one cause of adult disability. Reduction of time of arrival to the emergency room to administration of alteplase has been shown to reduce mortality and morbidity, and reduce poststroke disability. Endovascular stroke treatment has also been shown to dramatically improve outcomes in patients with large vessel occlusion in a time-senisitve manner, necessitating rapid identification of large vessel occlusion and rapid transfer after alteplase treatment. In 2015, Kaiser Permanente (KP) Northern California (KPNC) redesigned acute stroke treatment at all 21 hospitals to facilitate very rapid alteplase treatment and rapid identification and transfer of patients for endovascular stroke therapy.
Methods: The stroke alert process was redesigned with the introduction of initial evaluation of all acute stroke patients by teleneurologists as well as significant workflow changes. Changes include prenotification of the teleneurologist, rapid assessment, immediate ordering of critical care ambulance service when a large vessel occlusion is suspected, ordering of alteplase before computed tomography, administration of alteplase in the scanner after a safety check, and performance of computed tomography angiogram immediately after starting intravenous alteplase infusion. Systematic simulation work in partnership with local Medical Centers completed the culture change required.
Results: After implementation, median door-to-needle time was reduced from 61 minutes to 39 minutes. The complication rate of symptomatic intracerebral hemorrhage is 4.2%, pre-implementation rate of 4.5%. National averages are 4% to 6%.
Discussion: KP leads the nation in stroke care. The national average for door-to-needle in 30 minutes or less is 17%; KPNC was 63% for June 2017. All KPNC Medical Centers have received the highest stroke award from the American Heart Association. Multiple patients have received alteplase with positive outcomes, enabling return to a fulfilling life vs years in a nursing home.


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