University of Michigan Health in Grand Rapids has dramatically improved metrics for stroke treatment, using communication tools to connect EMS teams with specialists in neurology, radiology, nursing, laboratory, and pharmacy.
The improved communication enables the hospital to activate the appropriate personnel in the ED before stroke patients arrive. Paramedics use a secure messaging app on their smartphones to send prearrival notifications with contextual patient information, such as name, age, medical record number, and state of health, to members of the hospital’s stroke team.
The efforts have resulted in a 46% improvement in median door-to-groin time, a decrease from 114 minutes to 62 minutes. Door-to-needle time is down 46%, from 53 minutes to 28 minutes.
The American Heart Association and American Stroke Association urge prompt treatment for acute ischemic stroke care, particularly by reducing door-to-needle times for eligible patients treated with tPA.
Their guidelines recommend a door-to-needle time of 60 minutes or less, but research has shown that less than 30% of U.S. patients are treated that quickly. The goal for door-to-needle time is 45 minutes in at least half of stroke patients.1
The health system had been looking at the adoption of a secure messaging app. Once leaders discovered a solution, it was piloted in the stroke center, says Dillon Fassett, process improvement coordinator for the Comprehensive Stroke Center at Metro Health, part of University of Michigan Health. (Metro Health uses a messaging product from Vocera in San Jose, CA. Many similar secure messaging apps are available from other companies.)
The stroke program began by creating a roadmap of the process flow through the ED, determining how the messaging app could be used more effectively than the paging system in the EMR and other contact methods that were in use.
One benefit in the new app is the physician call schedule is embedded. The system automatically contacts the right doctor without someone in the ED first consulting a schedule to see who is available, Fassett explains.
“It streamlines the process of getting the right people in the room when we have a stroke patient come in,” he says. “In the first month, we were around 50 minutes for door-to-needle. That was too high. The messaging helped us bring that time way down, as well as the door-to-recanalization type for tPA patients.”
Fassett says the new technology streamlines the notification process. Previously, the ED staff would activate a button in the Epic system that would send a page to the clinician, who would then have to call the ED to find the patient’s history and other information. Now, paramedics in route to the hospital can use the app to bring up a template and fill out information about the patient. One click sends that information to all members of the stroke team currently on call.
“As soon as our stroke team receives that information, they are able to immediately assess the important data, such as last known well, age, [and] other inclusion and exclusion criteria for intervention,” Fassett says.
“We have our stroke team at the ED doors and waiting with all this information already, whereas otherwise it was kind of a game of phone tag getting medical history and other necessary information,” he continues. “It enables us to have a game plan when the patient arrives that we can execute right away.”
Introducing any new process or technology can be difficult, and there was some initial resistance to the Michigan plan. There was a window of about 60 days in which Metro Health used both the old and new systems, partly because they were wary of cell coverage dead zones that might impair using the smartphone app.
There turned out to be no problems with dead zones or other impediments. Metro Health found that in most cases the new messaging app was making contact with clinicians before the old version of paging. “The overall process is smoother. There is a lot of communication and a lot of people involved,” Bassett says. “Our stroke team, myself, and a few other members get the information, and then it’s a multidisciplinary group chat that goes on. They can get images and start discussing options while the patient is still on the way to the ED.”
Metro Health has since expanded use of the messaging app after its success in the stroke program. This allows staff to be alerted to a wide range of incoming patients. For instance, clinicians can use the information to decide whether to accept a transfer long before the patient would have arrived at the hospital.
“The app takes away a lot of chances for error that could interfere with the treatment process and slow down processes, like reading a call schedule wrong or typing in the wrong phone number,” Fassett says. “It’s a good avenue for enabling the entire multidisciplinary team to discuss the case without being in the same room, and as soon as the information is made available.”
- American Heart Association. Target: Stroke Phase III.
- Dillon Fassett, Process Improvement Coordinator, Comprehensive Stroke Center at Metro Health, University of Michigan Health, Grand Rapids, MI. Phone: (616) 252-7200.