Door to needle time

We break the entire process down into several elements. First are the goals. Door to Doctor( ER DOC )(10 minutes), Door to Labs/CT done (20 Minutes), Door to Labs/CT results/neuro consult (45 minutes), Door to drug. (60 Minutes) We allocate 15 minutes for drug prep ie getting the drug, mixing, tubing, ivac, inclusion/exclusion/consent.

Then we went through each case to see what our times were.

First thing we had to do was get CT time frame down. CT is now alerted as soon as ER knows a case is coming in. They then start making a scanner available and send their transport team to the ER.

Lab time was way too long. Why? One was the actuall ordering of labs, obtaining labs, getting them to lab, getting them ran and then results. Had the ordering software changed so that all the staff has to put in is Stroke Alert and the labs, ct etc are all ordered hyper stat automatically. Lab sends a runner to pick up the blood and tag it as stroke alert.

Then we looked at who did what and when. We now do a fast assessment to confirm symptoms and then draw labs/place 2nd IV prior to going to CT. CT either takes the pt for chest xray or sends portable along with pt back to ER to do it there. ECG is then done and the NIHSS. A warning call goes out to the stroke team when pt first hits ER. Then they are called in if symptoms and history = acute stroke so that they arrive just after CT results and as lab results come in. The NIHSS is done so they just do a quick exam and follow inclusion/exclusion criteria and we are ready to rock and roll.

CT and Lab were able to adjust fairly fast. Training the ER crew to get labs first was the big time saver. Now all we have to do is go back over each case and review the specific time slots and then critique the response so we can see how to organize the approach. We also worked with EMS to get that early warning call. That allowed the ER to be ready when the pt hit the door. We recognized that as a key aspect to starting the case off on the right course. The next thing I will introduce is the team noting the time frame at 10 minute intervals so they can see if they are falling behind and try to expedite the next phase. hope that helps.