Prehospital and Emergency Department-Focused Mission Protocol Improves Thrombolysis Metrics for Suspected Acute Stroke Patients

Debbie Y Madhok; Kevin J Keenan; Sara B Cole; Christine Martin; J Claude Hemphill 3rd

doi:10.1016/j.jstrokecerebrovasdis.2019.104423

Prehospital and Emergency Department-Focused Mission Protocol Improves Thrombolysis Metrics for Suspected Acute Stroke Patients

J Stroke Cerebrovasc Dis. 2019 Dec;28(12):104423. doi: 10.1016/j.jstrokecerebrovasdis.2019.104423. Epub 2019 Oct 9.

Authors

Debbie Y Madhok¹, Kevin J Keenan², Sara B Cole³, Christine Martin³, J Claude Hemphill 3rd⁴

Affiliations

¹ Department of Emergency Medicine, University of California, San Francisco, California; Department of Neurology, University of California, San Francisco, California. Electronic address: [email protected].
² Department of Neurology, University of California, Davis, California.
³ Department of Neurology, Zuckerberg San Francisco General Hospital.
⁴ Department of Neurology, University of California, San Francisco, California.

PMID: 31606319
DOI: 10.1016/j.jstrokecerebrovasdis.2019.104423

Abstract

Background: The Mission Protocol was implemented in 2017 to expedite stroke evaluation and reduce door-to-needle (DTN) times at Zuckerberg San Francisco General Hospital. The key system changes were team-based evaluation of suspected stroke patients at ambulance entrance by an Emergency Department (ED) physician, ED nurse, and neurologist and immediate emergency medical service (EMS) provider transport of patients to CT.

Methods: Patients were eligible for a Mission Protocol prehospital stroke activation if an EMS provider found a positive Cincinnati Prehospital Stroke Scale and a last known normal time within 6 hours. We retrospectively compared treatment metrics between the first year of Mission Protocol patients and patients from the year prior also brought in via ambulance with suspected stroke and a last known normal time within 6 hours. Median Door to CT and DTN times were compared using 2 sample Wilcoxon rank-sum (Mann-Whitney) tests.

Results: There were 236 patients in the Mission Protocol group and 112 in the comparison group. The Mission Protocol was associated with a 10 minutes faster median door to CT time (P < .00001), a 6 minutes faster median DTN time (P = .0046), a 22% increase in the proportion of patients treated within 45 minutes of arrival (84% versus 62%), and a 12% increase in the proportion of patients treated within 60 minutes (92% versus 80%). There were 8 stroke mimics treated in the Mission Protocol cohort compared to 2 in the comparison cohort. Symptomatic intracranial hemorrhage occurred in one Mission Protocol patient with an ischemic stroke.

Conclusions: The EMS direct to CT based Mission Protocol was associated with faster median door to CT and DTN times. There was a 22% increase in the proportion of thrombolysis patients treated within 45 minutes or less. More stroke mimic patients received thrombolysis but symptomatic intracranial hemorrhage only occurred in 1 ischemic stroke patient.

Keywords: Stroke; emergency medical service; ischemic stroke; prehospital.

Publication types

Comparative Study

MeSH terms

Aged
Aged, 80 and over
Brain Ischemia / diagnostic imaging
Brain Ischemia / drug therapy*
Clinical Protocols / standards*
Diagnosis, Differential
Emergency Medical Services / standards*
Emergency Service, Hospital / standards
Female
Fibrinolytic Agents / administration & dosage*
Fibrinolytic Agents / adverse effects
Humans
Male
Middle Aged
Outcome and Process Assessment, Health Care / standards*
Predictive Value of Tests
Quality Improvement / standards*
Quality Indicators, Health Care / standards*
Retrospective Studies
Stroke / diagnostic imaging
Stroke / drug therapy*
Thrombolytic Therapy / adverse effects
Thrombolytic Therapy / standards*
Time Factors
Time-to-Treatment / standards*
Tomography, X-Ray Computed / standards
Treatment Outcome

Substances

Fibrinolytic Agents