A Massachusetts Team Achieves a “F.A.S.T.”-er Stroke Response

Overview

When a person is having a stroke, recognizing the signs and symptoms quickly is important to survival. During a stroke, as the minutes tick away, brain tissue in the areas that aren’t getting the blood and nutrients they need will die. Treating the patient quickly reduces the risk of serious disability or death.

Stroke treatment works best if the stroke is recognized and treatment begins within 3 hours of the first symptoms. One way to remember the signs and symptoms of stroke is to think F.A.S.T.: face drooping, arm weakness, speech slurred, time to call 9-1-1.

Coordination and teamwork across the stroke system of care—from ambulance to hospital to rehabilitation—are the keys to timely treatment. That’s why Mercy Medical Center and Mercy Rehabilitation teamed up to reduce the time it was taking for staff at Mercy Rehabilitation to recognize that a patient might be having a stroke and transport them to the medical center.

With support from the Massachusetts Coverdell Program, a team that included the medical center’s stroke committee and stroke coordinator and staff from the rehabilitation facility was created. The team:

• Reviewed the records of patients who had a stroke while at the rehabilitation facility.
• Identified areas of improvement in procedures and training that could improve stroke response times.
• Recommended that Mercy Rehabilitation develop a rapid response stroke alert protocol that clearly defined the roles and responsibilities of all staff members in cases of suspected stroke.

“The Mercy staff wanted a more coordinated approach to ensure that everyone knew what they should do and to ensure that the next caregiver in the response relay would be fully informed when they received the patient.”

Challenge and Approach

The team set an ambitious goal of 30 minutes from when a possible stroke is first recognized at the rehabilitation facility to the time the patient receives a computed tomography (CT) scan at the medical center. A CT scan can show whether the patient is having a stroke, what type of stroke it is, and whether the clot-busting medicine alteplase should be given.

The team felt the 30-minute goal could be met because the rehabilitation facility is connected to the medical center by a tunnel. Patients suspected of having a stroke are transported through the tunnel to the medical center for emergency care without the need for an ambulance ride.

The team reviewed recent stroke data on patients suspected of having a stroke and the associated response times. They used the PDSA (Plan-Do-Study-Act) quality improvement tool to create and continually evaluate the effectiveness of the new protocol.

This tool helped the team:

• Plan out the details of the new protocol.
• Conduct a small-scale test.
• Gather data.
• Analyze the effect of the change.
• Make any needed changes to the process.
• Put the protocol into action in the rehabilitation facility.

The new stroke protocol outlined the responsibilities of all rehabilitation facility staff, including a clinical team made up of a doctor, nurse, and rapid response team. All rehabilitation staff were trained on the new protocol, including using the acronym “F.A.S.T.” to recognize the signs and symptoms of stroke and how to respond.

The doctor first uses the National Institutes of Health Stroke Scale (NIHSS) to assess the severity of the stroke symptoms. The doctor then orders that the patient be transferred to the medical center, calls the stroke code, and determines whether a CT scan is needed. The doctor and nurse also tell the staff at the medical center about any medicines the patient is receiving, especially medicines to prevent blood clots. The nurse records the time when the patient was last known to be well, an important measure in deciding whether the patient is eligible for alteplase.

Information about the stroke protocol and NIHSS are posted in the rehabilitation facility where staff can see them. Clinical staff regularly take tests on how to recognize and respond to a possible stroke. All staff take part in “mock codes,” a type of medical fire drill in which staff practice responding to a suspected stroke.

As a result of the new protocol, potential stroke patients got faster care, which likely improved their outcomes. The rehabilitation staff recognized the importance of faster recognition and treatment for their stroke patients and embraced the changes.

“The team created this new process, but they understand that you can’t just say, ‘Okay, we’re done with that, let’s move on to the next thing,’ ” said Van Dusen. “They have to keep constantly assessing and reevaluating, and they continue to do that.”

Accomplishments

Seven stroke alerts were called from August to December 2020, after the new protocol was established at Mercy Rehabilitation. Only two of the seven patients were found to have had a stroke. The false alarms are expected to occur and staff consider it better to send someone to the hospital and be wrong than to delay treatment for a patient who could suffer serious disability or death if not treated quickly.

The new procedures and training resulted in faster response times for the seven stroke codes called. Specifically:

• Time to CT scan was reduced from 3 hours to 41.5 minutes. Three patients received a CT scan in less than 30 minutes.
• The time the person was last known to be well was less than 1 hour for all seven patients.
• The average time for the stroke alert call was 4.5 minutes.

“They were beyond excited by the impact of the new protocol,” said Van Dusen. “And what was so critical to their success was that they didn’t do this in a silo, but worked as a team.”

Lessons Learned

Education and training, including practice in mock codes, were key to helping staff understand their responsibilities and recognize the importance of a fast response.

Posting information about the stroke response protocol and NIHSS where staff could continually see and review them was also helpful. Sharing the successes that resulted from the new protocol has reinforced the staff’s efforts.

Partnerships were important and showed the value of the stroke care continuum. This continuum includes the care patients receive from the time they have a stroke, during transport to the medical center and in the medical center, and through their discharge and recovery. Collaboration across the rehabilitation facility, the medical center, and the Massachusetts Coverdell Program allowed staff to make high-level decisions about their stroke care protocol, identify gaps, and find solutions.

The principles outlined by Mercy Medical Center and Mercy Rehabilitation can be applied to help other prehospital, in-hospital, and posthospital settings develop protocols to better coordinate care for patients. Hospital case managers already work with staff at facilities and agencies that are part of the continuum of care. These relationships can help build and strengthen stroke care partnerships with emergency medical services and rehabilitation centers.

“We try to emphasize every opportunity to move away from silos and show agencies how their collaboration is essential to getting the patient the best care as quickly as possible.”

Additional Information

• CDC: Paul Coverdell National Acute Stroke Program
• CDC: Stroke Systems of Care Framework
• Massachusetts Department of Public Health: Massachusetts Coverdell Stroke Systems of Care
• Agency for Healthcare Research and Quality: Plan-Do-Study-Act (PDSA) Directions and Examples