Improving “door to needle time” is critical in treating stroke at emergency departments. Now, Kaiser Permanente hospitals in Northern California have developed a way to treat stroke patients with clot-busting medication at more than twice the national average speed.

An article in the journal Stroke details the effect of regionwide adoption of an integrated telemedicine program. Kaiser Permanente researchers tout the study as one of the first to prove that standardized treatment protocols and telemedicine in a large, integrated hospital system can significantly reduce time to acute ischemic stroke treatment with intravenous r-tPA.

“When a stroke happens, minutes matter,” explained lead author Mai Nguyen-Huynh, MD, MAS, vascular neurologist and research scientist with the Kaiser Permanente Division of Research. “Faster treatment with intravenous r-tPA, which dissolves the stroke-causing clot and restores blood flow to the brain, is strongly associated with better functional outcomes for stroke patients.”

While national guidelines call for door-to-needle times of less than an hour for intravenous r-tPA, in reality fewer than 30% of acute ischemic stroke patients in the United States are currently being treated within this window, recent research suggests.

At Kaiser Permanente's 21 Northern California hospitals, however, 87% of stroke patients were treated in 60 minutes or less, 73% in 45 minutes or less, and 41% in less than 30 minutes. In fact, the article points out, the average treatment time for intravenous r-tPA was 34 minutes at those facilities.

The key, according to study authors, is the EXpediting the PRocess of Evaluating and Stopping Stroke (EXPRESS) program. As part of that, all Kaiser Permanente EDs in Northern California were provided with telestroke carts, which include a video camera and access to scans and tests results; that enabled a stroke specialist to conduct each patient's neurologic physical exam remotely.

The protocol assigns specific tasks to each member of the healthcare response team:

• Paramedics provide advance notification to the ED that a stroke patient is en route.
• A stroke alert notifies a neurologist, who meets the patient upon arrival, in person or via video, to coordinate treatment.
• Pharmacists prepare clot-busting medication early, so it is ready to be administered when required.
• A radiologist evaluates neuroimaging and confirms that the patient is not having a hemorrhagic stroke and, therefore, is a good candidate for intravenous r-tPA.

Researchers compared Kaiser Permanente members treated with intravenous r-tPA in the nine months before September 2015 implementation with those treated in the nine months afterward.