WHAT ABSOLUTE LAZY FUCKING BULLSHIT! You're not even trying for 100% recovery! Do you ever talk to survivors about their goals? YOU need to get involved and get this changed! They mention 'care' 18 times which survivors don't give a flying fuck about! THEY WANT RESULTS AND RECOVERY! I'd fire everyone involved!
30/60/90 National Stroke Targets
By 2030
• National median endovascular clot retrieval door to puncture time
<30mins for transfers
• National median thrombolysis door to needle time <60mins
• National median door in door out time for endovascular clot retrieval <60mins
in metro hospitals*
• National median endovascular clot retrieval door to puncture time <90mins for
primary presenters
• Certified stroke unit care provided to >90% of patients with primary stroke diagnosis
*Where same-crew ambulance door-in and -out transfer is possible. Regional services retrieving via road should
aim for a DIDO time of 75 minutes (hospitals requiring aero-retrieval service are not included in this target).
These targets have been developed in consultation with leading Australian stroke
clinicians and researchers, and are endorsed by the following organisations:
1
306090 National Stroke Targets - Action Plan2
Introduction
The Australian Stroke Coalition (ASC) 30/60/90 National Stroke Targets focus on stroke
unit access 1 and expedited reperfusion therapies.2,3 These were identified as the acute
stroke Key Performance Indicators (KPIs), most likely, if optimised, to have the greatest
impact on patient outcomes. This document has distilled national and international 4 best
practice opinion and guidelines to assist stroke hospitals and state stroke networks in
meeting these targets.
1. Stroke Unit Access and National System Organisation
To ensure all patients have the ability to access stroke unit care and reperfusion
treatments, all hospitals in the country should be designated as one of these five stroke
hospital categories, according to the 2023 Stroke Foundation National Acute Stroke
Services Framework.5
1. Comprehensive Stroke Centre (CSC) - a hospital providing 24/7 endovascular therapy
(EVT) and neurosurgical services.
2. Primary Stroke Centre (PSC) - a hospital providing 24/7 thrombolysis and stroke unit care.
3. Stroke Capable Regional General Hospital (SCRGH) - a hospital geographically
distant from metropolitan centres which provides 24/7 thrombolysis and stroke care
approximating stroke unit care, but from which routine transfer to a large PSC or CSC is
infeasible, due to distance.
4. Telestroke Thrombolysis Centre (TTC) - a hospital providing telestroke-enabled
thrombolysis, ideally 24/7, but not providing stroke unit care.
5. General Hospital (GH) - a hospital which does not provide either thrombolysis or stroke
unit care, but which should have protocols for patients presenting with stroke, to ensure
rapid transfer to hospitals with thrombolysis and stroke unit care occurs.
We recommend the following actions, at Department of Health, Stroke Network and
Local Hospital Network levels, to ensure that every Australian with acute stroke is
provided with an opportunity to access certified stroke unit care:
1. Map every private and public hospital in Australia to determine whether they are
a current or potential CSC, PSC, SCRGH, TTC or GH.
2. Support current and potential CSCs, PSCs and SCRGHs in meeting Australian Stroke
Coalition stroke unit certification criteria and gaining certification.
3. Identify and support potential TTCs in joining State or Interstate telestroke networks.
4. Support GHs in developing triage and transfer protocols to ensure patients
presenting with stroke directly can access reperfusion and stroke unit care.
5. Work with ambulance and retrieval services to ensure all patients with potential
stroke are transferred to hospitals which can provide appropriate acute stroke care.
6. Provide each patient presenting with stroke to Australian TTCs and GHs with the
opportunity to access stroke unit care via a CSC, PSC or SCRGH.
7. Facilitate system-wide stroke data collection to monitor stroke hospitalisation
processes and outcomes.
306090 National Stroke Targets - Action Plan3
2. Reperfusion optimisation strategies
The American Heart Association (AHA) “Target: Stroke” initiative advocates the
adoption of key best practice strategies for expediting reperfusion therapies for acute
ischaemic stroke.6-9 These AHA strategies have been workshopped and modified slightly
for an Australian context by Australian stroke leaders.
While many strategies are common both to CSCs and other thrombolysing Centres
(PSCs, SCRGHs and TTCs), for clarity and ease of use, two versions of these Strategies
are provided.
a. Reperfusion optimisation strategies for PSCs, SCRGHs and TTCs
These strategies facilitate rapid assessment and neuroimaging of patients
with suspected stroke, and, if indicated, administration of thrombolytic
(+/- transfer out for EVT):
1. Systematic, coordinated ambulance bypass of all suspected stroke (following use
of validated stroke screening tools or stroke-capable ambulance assessment +/- ambulance-
based neuroimaging) to stroke-thrombolysis capable hospitals and severely affected
suspected stroke patients to endovascular-capable hospitals where locally indicated
(depending on local door to needle, door-in-door out times and transfer distance10-12
).
2. Ambulance code stroke team prenotification – (e.g., time last known well,
anticoagulant use, venous access etc). The code stroke team at a minimum includes CT
(or MR) radiographer staff, and medical and nursing stroke team members. Move towards
transmitting electronically reliable identifying data pre-arrival - in the interim, use
unknown patient protocols if patient cannot be identified and pre-registered pre-arrival.
3. Use of stroke toolkits (including medications commonly used during acute code stroke)
4. Rapid triage and direct transfer from ambulance to CT – acceptance of paramedic
observations as sufficient without requiring repetition during triage process, followed by
transfer directly from triage to CT on the same ambulance stretcher without off-loading,13
if deemed medically stable by ambulance, triage and clinical staff. The presence of
Advanced Life Support-trained staff is NOT required for otherwise stable stroke patients.
5. Attach timer or clock to chart, clip board, or bed. Acute ischaemic stroke care
including EVT requires an accurate, timely, coordinated and systematic evaluation of the
patient. A universal clock visible to the ED and stroke teams is an enabling tool for improving
the timeliness and quality of care and should be considered for recording critical stages.8
6. Pre-consent using verbal-only discussions about potential reperfusion therapy
(if informed consent not possible due to stroke deficits, emergency treatment provision
is acceptable if next of kin unreachable (reasonable to attempt for up to 5 minutes)).
7. Rapid acquisition of neuroimaging – pre-prepare and connect IV contrast prior to
patient arrival to CT. Following direct transfer on the ambulance stretcher, proceed swiftly
and directly to multi-modal neuroimaging (non-contrast CT (NCCT), arch to vertex CT
angiography (CTA) and CT perfusion (CTP)) unless known contrast allergy. Multimodal
imaging should be used for all stroke patients who meet an institutional threshold for clinical
stroke severity.14 Image interpretation and decision-making is supported by automated
CT perfusion analysis software.15 Multi-modal imaging should not delay administration of
thrombolytic or contact with the ENI (Endovascular Neuro-interventional) team. An arterial
phase CTA from the CTP can be manually sent to PACS to identify large vessel occlusion
(LVO) early, where feasible.
306090 National Stroke Targets - Action Plan4
8. Blood draw for rapid laboratory +/- point of care INR testing but proceed to
thrombolytic administration without awaiting results unless indicated by clinical or past
medical history.
9. Rapid access to and administration of thrombolytic – have immediately at hand prior to CT.
10. Swift imaging availability should be facilitated via IT services for the stroke consultant
within minutes of acquisition to enable prompt decision making in conjunction with onsite
personnel. Pre-notify the consultant decision-maker of the pending NCCT.
11. Administration of thrombolytic on the imaging table following non-contrast imaging,
where appropriate – supported by hospital policies to permit this.
12. Team-based approach – parallel workflows for clinical assessment, obtaining venous
access, ordering diagnostic tests and commencing treatment.
13. Streamlined door-in door-out protocols should be developed by all non-endovascular
capable hospitals receiving acute stroke patients to enable swift door-in-door-out times.
Consider commencing Endovascular Neurointervention (ENI) team notification as soon
as treatment-eligible LVO is probable (e.g. following a clear hyperdense MCA in LVO
syndrome patients). For metropolitan sites the same inbound ambulance crew should
be used for the outbound journey.10 For regional sites decision about the level of medical
escort required should be promptly made in conjunction with the stroke physician to
prevent unnecessary delay.
14. Prompt data feedback should be provided to both hospital and ambulance staff.
Accurately measuring and tracking door to needle times and key time-markers along
this pathway allows the treating teams to identify areas for improvement and take
appropriate action. A data monitoring and feedback system (such as the Australian Stroke
Clinical Registry) creates a process for providing timely feedback and recommendations
for improvement on a case-by-case basis and in hospital aggregate. This system helps
identify specific preventable delays, devise strategies to overcome them, set targets,
and monitor progress on a case-by-case basis.7,8
306090 National Stroke Targets - Action Plan5
b. Reperfusion optimisation strategies for Comprehensive Stroke Centres
These strategies facilitate rapid assessment and neuroimaging of patients with
suspected stroke, and, if indicated, administration of thrombolytic and provision of EVT.
1. Systematic, coordinated ambulance bypass of all suspected stroke (following use of
validated stroke screening tools or stroke-capable ambulance assessment +/- ambulance-
based neuroimaging) to stroke-thrombolysis capable hospitals and severely affected
suspected stroke patients to endovascular-capable hospitals where locally indicated
(depending on local door to needle, door-in-door out times and transfer distance10-12
).
2. Ambulance code stroke team prenotification – (e.g., time last known well,
anticoagulant use, venous access etc). The code stroke team at a minimum includes
CT (or MR) radiographer staff, and medical and nursing stroke team members. Move
towards transmitting electronically reliable identifying data pre-arrival - in the interim, use
unknown patient protocols if patient cannot be identified and pre-registered pre-arrival.
3. Use of stroke toolkits (including medications commonly used during acute code stroke)
4. Rapid triage and direct transfer from ambulance to CT – acceptance of paramedic
observations as sufficient without requiring repetition during triage process, followed by
transfer directly from triage to CT on the same ambulance stretcher without off-loading,13
if deemed medically stable by ambulance, triage and clinical staff. The presence of
Advanced Life Support-trained staff is NOT required for otherwise stable stroke patients.
5. Attach timer or clock to chart, clip board, or bed. Acute ischaemic stroke care including
endovascular therapy requires an accurate, timely, coordinated and systematic evaluation
of the patient. A universal clock visible to the ED and stroke (+/- ENI) team is an enabling
tool for improving the timeliness and quality of care and should be considered for
recording critical stages.8
6. Pre-consent using verbal-only discussions about potential reperfusion therapy
(if informed consent not possible due to stroke deficits, emergency treatment provision
is acceptable if next of kin unreachable (reasonable to attempt for up to 5 minutes)).
7. Rapid acquisition of neuroimaging – pre-prepare and connect IV contrast prior
to patient arrival to CT. Following direct transfer on the ambulance stretcher, proceed
swiftly and directly to multi-modal neuroimaging (non-contrast CT, arch to vertex CT
angiography and CT perfusion) unless known contrast allergy. Multimodal imaging should
be used for all stroke patients who meet an institutional threshold for clinical stroke
severity.14 Image interpretation and decision making is supported by automated CT
perfusion analysis software.15 Multi-modal imaging should not delay administration
of thrombolytic or contact with the ENI team. An arterial phase CTA from the CTP can
be manually sent to PACS to identify large vessel occlusion (LVO) early, where feasible.
8. Blood draw for rapid laboratory +/- point of care INR testing but proceed to
thrombolytic administration without awaiting results unless indicated by clinical or past
medical history.
9. Rapid access to and administration of thrombolytic – have immediately at hand prior to CT.
10. Swift imaging availability should be facilitated via IT services for the stroke consultant
within minutes of acquisition to enable prompt decision making in conjunction with onsite
personnel. Pre-notify consultant decision-maker of pending NCCT.
11. Administration of thrombolytic on the imaging table following non-contrast imaging,
where appropriate – supported by hospital policies to permit this.
306090 National Stroke Targets - Action Plan6
12. Team-based approach – parallel workflows for clinical assessment, obtaining venous
access, ordering diagnostic tests and commencing treatment.
13. Prompt data feedback should be provided to both hospital and ambulance staff.
Accurately measuring and tracking door to needle times and key time-markers along
this pathway allows the treating teams to identify areas for improvement and take
appropriate action. A data monitoring and feedback system (such as the Australian Stroke
Clinical Registry) creates a process for providing timely feedback and recommendations
for improvement on a case-by-case basis and in hospital aggregate. This system helps
identify specific preventable delays, devise strategies to overcome them, set targets,
and monitor progress on a case-by-case basis.7,8
IN ADDITION: for CSCs these Endovascular Neurointervention-specific
strategies should be implemented:
1. Pre-notification and rapid activation of the ENI team: The ENI team should be
alerted immediately if a possible candidate for thrombectomy is identified based upon
a pre-specified clinical severity threshold, or non-contrast imaging suggesting a large
vessel occlusion. If a patient is being transferred for potential endovascular therapy,
the ENI team should receive pre-notification and an estimated time of arrival.16,17
2. Rapid availability of the ENI team: The hospital should have a policy in place
specifying the expected call-arrival times to the ENI suite (preferably ≤30 minutes)
that the ENI team on call (neurointerventionalist, radiologist, nurses) need to fulfill.18
3. Expedite transferred patients with known LVO directly from triage to the ENI Suite:
Guided by prespecified protocols, eligible stroke patients, transferred to the
thrombectomy-capable centre from a referral site, should routinely bypass the
Emergency department directly to the ENI suite.17 Exceptions may include patients with
cardiorespiratory instability requiring immediate stabilisation, and patients with significant
improvement to non-disabling symptoms, following long-distance (>3 hour) transfer.14
4. Transfer of patients with newly-identified LVO directly from neuroimaging to the
ENI Suite: Directly-presenting stroke patients eligible for endovascular therapy should be
directly transported from the CT/MR imaging suites to the ENI suite, if ready to receive
the patient, without returning to the Emergency Department.19
5. Endovascular therapy-ready ENI suite: policies and protocols should ensure the ENI
suite is, at all times, in an endovascular therapy-ready state. This includes standardised,
pre-prepared equipment tray/cart for endovascular therapy cases that includes all
necessary equipment for the case (e.g. BRISK: Brisk Recanalization Ischemic Stroke Kit,
with drapes, tubing, syringes, catheters, and devices). Noting that the first-line approach
might not always be possible, institutions should have an agreed routine first-line
endovascular technique (consensus between operators) so that there is less need
for nursing staff to vary equipment/tools based on the person on call.16,18
6. Team-based ENI approach: Parallel workflows by Emergency Department Team,
stroke team, and ENI team, including the neurointerventionalist, interventional
radiographer, anaesthetist and nursing staff, should be utilised to facilitate rapid
angiography and, when indicated, endovascular therapy.16-18,20
7. Anaesthesia access and protocols: Rapid anaesthetic support should be available. General
anaesthesia is not required in non-agitated compliant patients. If general anaesthesia is employed,
induction should be swift and done without allowing a drop in blood pressure (ideally to maintain
systolic blood pressure above 140mm Hg)21,22 while minimising any delay to procedure start. These
workflow recommendations should be tailored to meet the needs of individual institutions.18,23,24
8. Prompt ENI team data feedback: ENI performance metrics should be promptly shared with
appropriate staff utilising thrombolysis data feedback principles stated above.7,8,25
Conclusion
These strategies, if implemented,(Means you're leaving survivors disabled; NOT RECOVERED!) will lead to substantial improvements(So you're trying to normalize your failures?) in stroke unit
access and timely ischaemic stroke reperfusion. Strategies will be reviewed at annual
scientific meetings of the Australian and New Zealand Stroke Organisation (ANZSO), and
further refinements will provide additional assistance in meeting the 30/60/90 National
Stroke Targets, as well as forming a foundation for subsequent system improvements.
