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Shaving minutes off stroke treatment

An article in Stanford Medicine magazine examines how Stanford Health Care cut half an hour off its stroke treatment time, helping patients.

The record is nine minutes. In that time, Stanford Hospital's emergency department registered, weighed and scanned a stroke patient; inserted an intravenous line; reviewed medical records; and administered a clot-busting drug, tissue plasminogen activator, also known as tPA.

Quality managers at the hospital start counting whenever a stroke patient arrives because time matters: Every minute, 1.9 millions neurons die. A short amount of time can make the difference between living alone and relying on a caregiver, walking or using a wheelchair.

"When we are able to administer tPA quickly, that translates into saved neurons, saved independence and saved health care costs," said Nirali Vora, MD, an associate professor of neurology and a stroke specialist.

Just a few years ago, the average door-to-tPA time at Stanford Hospital was 66 minutes, typical for a U.S. hospital. Today, it's 26 minutes. As I describe in my story for Stanford Medicine magazine:

Shaving so much time from a process, in a department already primed for quick action, required months of research, years of changing work habits and a good dose of diplomacy.

In 2012, fellows at Stanford's Clinical Excellence Research Center, which studies ways to improve health outcomes while lowering costs, looked at stroke treatment. They recommended ways to reduce time, largely by eliminating unnecessary steps and performing many of the necessary steps simultaneously.

One of the fellows, Waimei Amy Tai, MD, now a neurologist at Christiana Care Health System in Delaware, stayed on at Stanford Hospital to implement the recommendations. Tai and her team observed what happened when stroke patients arrived, looking for ways to rejigger the process. They ran mock stroke emergencies, shaving off minute by minute.

For Tai, the work demanded, above all, humility:

At a meeting, I would suggest inserting the IV while we were waiting for CT scans, and no one would say anything. Then I would email reference papers around, and someone at the next meeting would say, 'Why can't we insert the IV in the CT scanner?' and I'd say, 'That's an awesome idea!'

Ensuring that door-to-treatment times remain low is an ongoing job for everyone involved: nurses, physicians, pharmacists, registration specialists and paramedics. But it's Eric Bernier, RN, quality director for Stanford Health Care, who keeps track. When he receives a notice on his cell phone that a stroke patient is arriving, he heads upstairs to the emergency department to oversee the process. He watches to ensure that every step is taken, and he times it.

"I'm the grumpy guy in the basement who asks why things are taking so long," he said.

Illustration by Jeffrey Decoster

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