A Low-Tech Approach to Expediting Stroke Care

You don’t always have to spend big money to make a difference. A low-cost, low-tech, decidedly simple mechanism in St. Louis is proving a novel way get faster help to stroke victims.

It’s a basic business card that says this:

We Need Your Help

Please call 314-362-9123

Your friend or loved one may be having a stroke and is being taken to the Barnes-Jewish Hospital Emergency Room.

When the operator answers, please say, “Hello, I am calling with an ambulance stroke card. May I speak to the stroke doctor?”

A Washington University stroke specialist will assist you.

With that minimalist mechanism—a simple statement of concise instructions given to a witness or bystander when someone’s had a stroke—an ambulance crew can get a patient en route to Barnes-Jewish, the city’s sole comprehensive stroke center; that person can pass on key information directly to the treatment team while the patient is being transported; and informed BJH clinicians can expedite the process to treat patients faster.

“When we went through and looked at our processes,” says Scott Gilmore, MD, EMT-P, FACEP, medical director for the St. Louis Fire Department and an assistant professor of emergency medicine at the Washington University School of Medicine (Barnes-Jewish is part of Washington University Medical Center), “we identified that while EMS is driving from the scene to the hospital, we’re losing valuable time that might be better spent in another process.”

The solution, devised in conjunction with WU stroke physicians, is to let crews get off scene faster by employing witnesses (often friends and family) to relay key information to the hospital.

The card is carried with the glucometer, and a crew member will give it to the bystander and ask them to follow its instructions before following to the hospital. The specialist they speak with gathers a brief medical history and, if possible, the last-known-normal time. At the same time, medics in transit alert Barnes-Jewish to activate its stroke team.

Without much data yet it’s hard to draw conclusions on the card program’s effect on treatment intervals, but from 2014 to 2015, BJH’s average door-to-bolus time for ED administration of IV tPA dropped by 25% (from 40 minutes to 30), and its number of IV tPA patients jumped by about 50%.

Overall, Barnes-Jewish has worked to streamline its processes, and its stroke barometers have been trending positively for more than a decade. From 2005–2015, the hospital’s average door-to-bolus time fell by 53% (from 64 to 30 minutes); arrival-to-CT-completed times fell by 53% (from 17 minutes to 8); and the number of IV tPA patients roughly quadrupled.

Multiple factors have contributed to the improvements, including best practices like starting the drug before the patient is removed from the CT scanner. “But what set that up,” notes Gilmore, “was these witnesses and bystanders calling in ahead of time and talking to the neurologist, so the neurologist can get a lot of the inclusionary and exclusionary criteria out of the way. So as soon as the patient hits the door, we can do a quick stroke scale, scan ’em, finish it up and make a decision, right then and there.”

A remaining challenge is to increase the recipients’ call-in rate, which has thus far been just 35%–45%. But the card program is expanding to St. Louis University Hospital, meaning it now covers half the city’s stroke hospitals. Discussions are planned with the other two.

“The biggest thing I hope people take from this is, there are many opportunities for improving stroke care, and not everything has to be high-tech or expensive,” says Gilmore. “The biggest advantage we’ve found is actually looking at our stroke process itself and seeing how you can change just a few little things here and there and make huge differences in the grand scheme.”

Scott Gilmore spoke about this program at the Gathering of Eagles in last February. Visit gatheringofeagles.us for information on the 2017 conference.