Time is critical when it comes to stroke, and early treatment is
associated with better outcomes. According to the Screening with MRI for
Accurate and Rapid stroke Treatment (SMART) study, small changes in
quality improvement procedures enabled clinicians to use MRI scans to
diagnose stroke patients before giving acute treatment, within 60
minutes of hospital arrival. MRI scans provide detailed images but take
longer to complete than CT scans, which are commonly used in most
centers. The findings, published in
Neurology, were supported in part by the National Institutes of Health's National Institute of Neurological Disorders and Stroke (NINDS).
"By making small changes to our processes, we were able to scan
suspected stroke patients with MRI and appropriately treat patients
within a goal time of 60 minutes. This is an important finding for
hospitals, healthcare providers and the public," said Amie Hsia, M.D.,
medical director of the Comprehensive Stroke Center at MedStar
Washington Hospital Center, Washington D.C., and senior author of the
study. "Not only does MRI provide more precise and complete information
than the traditionally used CT scan, now we've also demonstrated that it
is feasible to use from a time perspective."
National guidelines suggest that stroke patients should receive
treatment within 60 minutes of arriving at the hospital. (Why so slow?)The majority of
hospitals rely on rapid CT scans to determine if an individual is
eligible for intravenous tPA, the only FDA-approved treatment for
ischemic strokes, those caused by blood clots in the brain. If a CT scan
shows the patient is having a bleeding, or hemorrhagic, type of stroke,
tPA cannot be used as treatment. For many years CT scans were the only
imaging tool available in most hospitals, but now MRIs are becoming more
widely available.
Clinicians at MedStar Washington Hospital Center and Suburban
Hospital, Bethesda, Maryland, routinely work with physician-scientists
from NIH and have access to their cutting-edge medical protocols and
technologies. The two hospitals use MRI instead of CT scans to screen
stroke patients. Although MRI scans can take up to 15 minutes longer
than CT scans, they provide clinicians with more detailed information
about what is happening in a patient's brain. Using MRI, clinicians can
see early changes taking place during the stroke. In this way, they can
see what tissue is at risk and identify blocked blood vessels or subtle
bleeding that cannot be picked up by CT.
To
reduce the door to treatment time, multidisciplinary teams at both
hospitals carefully examined the existing processes to identify
time-consuming bottlenecks or duplicative methods. By using "lean
process interventions," they found a number of steps that could be
eliminated or changed. For example, at MedStar Washington Hospital
Center, a lengthy MRI screening form was simplified to three questions;
at Suburban Hospital, tPA was put into the medication cart in the MRI
suite so that it could be given immediately to patients after scanning
instead of returning them to the Emergency Department for treatment.
Once the changes were implemented, Dr. Hsia's team examined whether
they had an impact on treatment times for patients. The results
indicated that door to treatment time was reduced from 93 to 55 minutes,
a difference of 40 percent. Over a two year period, the percentage of
patients treated within 60 minutes increased from 13 to 61.5 percent.
Further analysis revealed that these changes were due to faster MRI
start times.
"There was no difference in the patient characteristics. It was clear
the improvements were due to the changes we made in the processes at
these two hospitals," said Dr. Hsia.
"A number of the changes that Dr. Hsia's team assessed were not
specific for MRI scans, but were related to general procedures of
getting patients ready for imaging as quickly as possible. This suggests
that these findings are relevant even in hospitals that do not have
emergency access to MRI scanners," said Walter Koroshetz, M.D., acting
director of NINDS. "We will persist in evaluating best practices for
acute stroke care to ensure that the greatest number of patients receive
treatment as early as possible following stroke."
Dr. Hsia and her colleagues will continue to monitor the door to
treatment times, to ensure they are sustainable. In addition, they plan
to continue to evaluate best practices for acute stroke care and look
for other improvements to further decrease door-to-treatment times for
patients.
Source:
NIH/National Institute of Neurological Disorders and Stroke
