MINDtime: Keeping an Eye on the Clock
Krupp S, Lewandowski C, Miller D, Brady M, Scozzarri D, and Shah K. MINDtime: Keeping an eye on the clock. Acad Emerg Med 2018; 25:S119.
Acad Emerg Med
Background: During an ischemic stroke, time is brain. Patients arriving within 4.5 hours of Last Known Well (LKW) are eligible for treatment with intravenous tissue plasminogen activator (t-PA) based on their respective inclusion/exclusion criteria. It is well established that the benefits of IV t-PA are time-dependent, thus published guidelines recommend a door-to-needle treatment time of 60 minutes. More recently, there has been a nationwide push to treat 50% of t-PA patients within 45 minutes. Numerous steps have been implemented to facilitate rapid decision making and treatment; however, challenges remain. At our Comprehensive Stroke Center, we proposed a simple and non-invasive tool to help expedite the door-to-needle times by attaching a stopwatch to the t-PA eligible patient's bed in an effort to remind all members of the care team that “the clock was ticking.”
Methods: Data was collected on all patients who received IV t-PA from 5/29/17 - 11/27/17. Dates ending in an odd number were designated the intervention group, where eligible patients would have a large digital clock attached to their bed that counted upwards from their arrival time. The even number days were the control group, where patients would be assessed and treated based on established hospital protocol. The outcome was measured in minutes.
Results: A total of 68 patients were treated with IV t-PA during the pre-specified time period. All patients that met either the 3 hour or 4.5 hour IV t-PA criteria were included in the study. There were 39 patients (50%) treated during the “odd” days with the stopwatch present. The median door-to-needle time was 52 minutes [IQR 43 - 72] for this cohort, while the median door-to-needle time was 49 minutes [IQR 42 - 70] for the other group (p = 0.79). Conclusion: Our study did not demonstrate a significant difference in door-to-needle time between the two groups. We believe there are some possible reasons for these findings. During our study period, there were several simultaneous improvement processes occurring, which could have diluted our study results. We believe that the concept of displaying time to the members of the care team can assist in expediting door-to-needle times. This resource-limited and relatively simple intervention may be attractive to Acute Stroke Ready Hospitals (ASRHs) and some Primary Stroke Centers (PSCs).