Kaiser Permanente's coordinated telemedicine response workflow slashes ‘door-to-needle’ time for stroke patients.
Telemedicine is at the heart of a complete workflow redesign of the way stroke alerts are handled across Kaiser Permanente's 21 Northern California hospitals, resulting in new stroke patients being treated twice as fast as the national average, according to a study.
American Heart Association and American Stroke Association guidelines recommend a "door-to-needle" time of 60 minutes or less for administering intravenous r-tPA, also known as alteplase, a drug that dissolves the stroke-causing clot and restores blood flow to the brain.
A study in the journal Stroke compared door-to-needle times for six months before implementation of the telemedicine program to a six-month calendar period after implementation. It showed that across the 21 hospitals, the average treatment time for intravenous r-tPA was 34 minutes. The study also showed that:
- 87% of stroke patients were treated in 60 minutes or less
- 73% were treated in 45 minutes or less
- 41% were treated in under 30 minutes
The Stroke EXPRESS (EXpediting the PRrocess of Evaluating and Stopping Stroke) program was redesigned in 2015 to help speed evaluation and treatment of patients, even though there aren’t enough stroke neurologists to go around all 21 centers, says Mai Nguyen-Huynh, MD, MAS, vascular neurologist and research scientist with the Kaiser Permanente Northern California Division of Research.
How it works
Nguyen-Huynh says her team asked itself, "How do we streamline our system to really expedite the evaluation of these stroke patients" to determine when patients aren’t having a hemorrhagic stroke and, therefore, are good candidates for intravenous r-tPA.
Although the system offered telemedicine for a couple of services, there was nothing standardized in place until the Stroke EXPRESS program.
"We found that the only way that we could really do this is standardize and centralize things," Nguyen-Huynh says. "There needs to be one system, one protocol."
Now, all Kaiser Permanente EDs in Northern California are equipped with telestroke carts, which include a video camera and access to scans and test results, enabling an on-call stroke specialist to conduct a patient's neurologic physical exam from a remote location, whether it’s another facility or even their own home.
In fact, Nguyen-Huynh said part of the IT team’s extensive work on implementing the program included traveling to each of the stroke neurologists’ homes to set up their systems so someone can be on-call 24/7.
In addition to the telemedicine carts themselves, Kaiser Permanente also changed the process for evaluating and treating patients as they come in.
"One of the best things we did was eliminate the whole waiting thing," Nguyen-Huynh says.
New protocol
She’s referring to the old process for evaluating stroke patients, which used to occur in a series, one step after another, waiting for each step to finish before starting the next. First an ED doctor would evaluate, then they’d call a neurologist, etc.
"All of these things takes time," she says. "We saw a lot of waste in that."
Now, all the steps happen in tandem, with the whole team working on a patient and every member of the team performing their tasks at once, while the stroke neurologist oversees the process via telemedicine.
"We think of the stroke team nowadays as a pit crew," Nguyen-Huynh says.
Paramedics provide advance notification to the ED that a stroke patient is on the way. A "stroke alert" notifies a stroke neurologist, who meets the patient upon arrival, in person or via video, to coordinate the stroke alert.
Pharmacists prepare the clot-busting medication early so it is ready to be administered once a radiologist has read neuroimaging and confirmed that the patient is a good candidate for intravenous r-tPA.
"Our focus becomes much more on whether the patient is a candidate for the drug," Nguyen-Huynh says. "We don’t get distracted by anything else … we decide very quickly, literally within the first ten minutes."
Nguyen-Huynh also says that they call a stroke alert on all cases of acute stroke, just so they don’t miss any r-tPA candidates.
"We know it’s going to be a big overcall," she says, but it’s worth having a stroke neurologist be on the call every time.
"We took it upon ourselves to do the canceling if it’s not appropriate rather than potentially missing an acute stroke patient," she says.
In fact, Nguyen-Huynh says they ultimately cancel about 50% of the stroke alerts, noting that across the 21 centers from January 2016 through June 2017, the team had about 3,000 stroke alerts seen through the Stroke EXPRESS program. Of those, 1,271 were treated with alteplase.
Nguyen-Huynh also says despite the cancelation rate, it’s actually more efficient for the stroke neurologist to lay eyes on the patient, focus on medication criteria, and make an immediate decision.
When the patient can receive the drug, the stroke neurologist stays on the call from start to finish, including doing the handoff to where the patient will be transferred.
Ongoing 'maintenance'
Such a big overhaul of an existing protocol took a lot of work and training, from the IT team to the stroke neurologists who were all trained in every aspect of the program, including participating in mock stroke alerts with observation and feedback, "even if you think you already know" how to do it, Nguyen-Huynh says.
Now, Nguyen-Huynh says the program is in a "maintenance" phase, and they’re constantly parsing the data to ensure that the process is working the way it’s supposed to. When it doesn’t, they examine why.
"The key things that really stood out was the whole coordination piece with the standardized protocol," she says. "We watch these numbers and we watch these processes in place."
Nguyen-Huynh also encourages other health systems to look to their model as one that they can implement in their own systems.
"We think there are some certain steps in this whole process that are essentially important for centers to keep in mind in order for these processes to work," she says. "We think this should be shared with other systems around the country."
Alexandra Wilson Pecci is an editor for HealthLeaders.
