A SYSTEMS-APPROACH TO IMMEDIATE EVALUATION AND MANAGEMENT OF HYPERACUTE STROKE - EXPERIENCE AT 8 CENTERS AND IMPLICATIONS FOR COMMUNITY PRACTICE AND PATIENT-CARE

Background and Purpose With the approval by the Food and Drug Administ ration of recombinant tissue plasminogen activator (rt-PA) for acute i schemic stroke within 180 minutes of symptom onset, patients and preho spital and hospital systems will now have to treat stroke as a medical emergency. It is thus critical to develop efficient hospital-based me thods for hyperacute stroke patient evaluation and intervention at bot h community-based and tertiary care academic centers. Methods We descr ibe how the eight centers in the National Institute of Neurological Di sorders and Stroke rt-PA Stroke Trial developed systems for enrolling patients within 3 hours of symptom onset. The actual methodology and p ractical sequence of events are detailed. Deming principles of system organization were applied, and each center developed a flowchart of ac ute stroke patient screening, assessment, and treatment. We divided th e process into the following: clinical center background and preparati on, screening, stroke team response, data needed before treatment, CT of the head, pharmacy, patient treatment, and monitored care. Critical features, both unique to a given center and shared by several centers (common at four or more centers), were summarized. Results Phase I of the trial included several months of preparation with review of every detail involved in the process of acute stroke care at each site, All centers worked closely with emergency medical sen ices. Community str oke awareness and education programs were developed. A stroke team was initiated and worked closely with the emergency department physicians and nurses. Rapid and efficient communication systems and protocols w ere established to reduce time to complete each task, Standardized str oke examinations and protocols for blood pressure management and intra cranial hemorrhage detection as well as nursing flowcharts were used. Conclusions Hyperacute stroke treatment can be initiated, often within 55 minutes of patient arrival at the hospital, in both community and academic settings when all aspects of stroke carl processes are identi fied, streamlined, and built into the day-to-day operations of the pre hospital and hospital healthcare delivery system.