Community Team Improves Door to CT Utilizing ESO Alerts
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A community team from Galveston Area Ambulance Authority (GAAA) and University of Texas Medical Branch (UTMB) worked to improve door-to-CT time for stroke patients. They identified that shorter treatment times are associated with better patient outcomes. Previously, valuable time was lost during patient registration and transfer to the CT scanner. The team developed a new process where GAAA would electronically notify UTMB of inbound stroke patients, allowing for pre-registration. This reduced delays, with door-to-CT times dropping significantly from August 2013 to October 2013. The collaboration between EMS and the hospital helped expedite stroke treatment and improved patient throughput and outcomes.
![Community Team Improves Door to CT Time for Stroke Patients
Trey Frankovich, LP; Edwin Smith Jr., RN, BSN; Valerie Brumfield, RN, MSN, CCRN, CNS
Galveston Area Ambulance Authority and University of Texas Medical Branch Galveston
Introduction
Recent studies in relation to stroke and best practices for the treatment of
stroke indicate some of the following:
Stroke kills almost 130,000 Americans each year thats 1 in
every 19 deaths1
About 87% of all strokes are ischemic2
Adults with acute ischemic stroke are candidates for
thrombolytic therapy within 4.5 hours of last seen normal.
Those treated sooner do significantly better than those treated
later.every 15 minutes shaved off the delay is associated with
a 4% drop in the odds of death in hospital.3
Emergency Departments should establish standard operating
procedures and protocols to triage stroke patients expeditiously
(Class 1, Level of Evidence B)4
Emergency Medical Services (EMS) providers should provide
early pre-notification to the receiving hospital when stroke is
recognized in the field. EMS pre-notification of hospitals can
significantly shorten time to brain imaging, reduce door-toneedle times with IV tPA5
Guided by pre-specified protocols, eligible stroke patients can,
if appropriate, be transported from the ED triage area directly
to the CT scanner5
At the minimum, the CT scan should be completed within 25
minutes of arrival (to the ED with stroke patient)5
An Interdisciplinary collaborative team is also essential for
successful stroke performance improvement efforts.5
Due to these studies and recommendations Galveston Area Ambulance
Authority (GAAA) and University of Texas Medical Branch (UTMB) teamed
together to improve the Door to CT time for stroke patients.
1.
2.
3.
4.
5.
Improved Method Continued
Outcome
The crew selects the ESO Alert tab at the bottom of their EMR and the
next screen allows them to select the type of alert and ETA. The alert is
sent and the hospital is notified of the inbound patient. The registration
clerk matches the patient to existing records or enters as a new patient
and registers with the patient status as in bound and the arm band is
printed and waiting for the arrival of the ambulance patient. The triage
nurse changes patient status to arrived in the EMR when the crew hits
the door, arm band applied and patient goes straight to CT where the
stroke team awaits their arrival due to prior activation from the EMS crew.
Discussion Continued
GAAAs change management was to mandate that crews send ESO Alerts
on all patients to expedite treatment and turnaround time as well as
developing the habit of notifying the hospital. With UTMB and GAAAs
system changes dramatic improvements were documented in a short
period of time as reflected in the graph below comparing August 2013 to
October 2013.
While Electronic Medical Records (EMRs) are excellent for gathering
information on patient outcomes and providing safety checks such as
potential allergic reactions, the EMRs dictate the patient must be
registered before treatment sets can be placed. The ambulance would
arrive at UTMBs ED and the crew would stop at the ambulance triage desk
and have to relate all the information gathered to the triage nurse and
registration clerk. The patient would then be placed in an ED room where
the physician would evaluate and place orders into the EMR for patient to
go to CT scan.
Valuable time was lost with repeated and unnecessary steps as reflected
by the door to CT graph below from August 2013.
The ESO patient status board shows patients as inbound in GREEN with an
ETA and those that are late in arriving as RED. Patients that have already
arrived are in WHITE.
Kochanek KD, Xu JQ, Murphy SL, Mini単o AM, Kung HC. Deaths: final
data for 2009 [PDF-2M]. National Vital Statistics Reports. 2011;60(3).
Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB,
et al. Heart disease and stroke statistics2012 update: a report from
the American Heart Association . Circulation. 2012;125(1):e2220.
Time to treatment with intravenous tissue plasminogen activator and
outcome from acute ischemic stroke. JAMA. 309(6):2480-8.
Comprehensive overview of nursing and interdisciplinary care of the
acute ischemic stroke patient: a scientific statement from the
American Heart Association. Stroke 2009;40;2911-2944
Target: Stroke Best Practice Strategies July 2012 update: a report
from the American Heart Association
All patients delivered in October were below the goal of equal to or less
than 24 minutes from door-to-CT.
GAAA was the first ambulance service in the United States to transmit a
patient alert to the hospital to expedite the registration process resulting
in improved patient throughput and positive patient outcomes.
Contact Information
Trey Frankovich, LP
Discussion
Improved Method
From October 2012 until October 2013, 122 patients with the primary
diagnosis of CVA were delivered to UTMBs ED for treatment from GAAAs
ambulances. Utilizing the American Heart Associations recommendations
for the rapid diagnosis and treatment of stroke patients to improve
outcomes the hospital and EMS began discussions on how to improve
patient flow.
The process had been for the EMS crew to immediately notify the 911
dispatcher to advise UTMB ER they had a stroke patient and then the
medics would gather patient information on the scene including the
patients demographics, onset of symptoms and record the Cincinnati
Stroke Scale. Treatment was instituted and the patient was rapidly
transported to the ED for further treatment.
GAAA contacted their EMR provider, ESO, and Beta tested an ALERT
process. Essentially GAAA was sending a draft of the EMR to the hospital
before arriving.
The crew now enters patient name, Social Security
number, birth date, weight and allergies. This information is essential for
matching the patient to the hospital records allowing for pre-registration
of the patient as in bound in the hospitals EMR system.
The hospital dispatcher may incorporate the ESO alerts into their own
emergency departments information system bed flow.
EMS Director
Galveston Area Ambulance Authority
P.O. Box 939, La Marque, TX 77568
Phone: 409.765-2524
Email: tfrankovich@gchd.org
www.linkedin.com/in/treyfrankovich
Contact Information
Edwin Smith, Jr., RN, BSN
Emergency Services Coordinator
Email: edhsmith@UTMB.EDU
Valerie Brumfield, RN, MSN, CCRN, CNS
Clinical Nurse Specialist
Email: vcbrumfi@UTMB.EDU
UTMB Galveston
301 University Blvd, Galveston, TX 77555-1173
409.772.1425
RESEARCH POSTER PRESENTATION DESIGN 息 2011
www.PosterPresentations.com](https://image.slidesharecdn.com/communityteamimprovesdoortoct-131121190010-phpapp02/85/Community-Team-Improves-Door-to-CT-Utilizing-ESO-Alerts-1-320.jpg)
Community Team Improves Door to CT Utilizing ESO Alerts
- 1. Community Team Improves Door to CT Time for Stroke Patients Trey Frankovich, LP; Edwin Smith Jr., RN, BSN; Valerie Brumfield, RN, MSN, CCRN, CNS Galveston Area Ambulance Authority and University of Texas Medical Branch Galveston Introduction Recent studies in relation to stroke and best practices for the treatment of stroke indicate some of the following: Stroke kills almost 130,000 Americans each year thats 1 in every 19 deaths1 About 87% of all strokes are ischemic2 Adults with acute ischemic stroke are candidates for thrombolytic therapy within 4.5 hours of last seen normal. Those treated sooner do significantly better than those treated later.every 15 minutes shaved off the delay is associated with a 4% drop in the odds of death in hospital.3 Emergency Departments should establish standard operating procedures and protocols to triage stroke patients expeditiously (Class 1, Level of Evidence B)4 Emergency Medical Services (EMS) providers should provide early pre-notification to the receiving hospital when stroke is recognized in the field. EMS pre-notification of hospitals can significantly shorten time to brain imaging, reduce door-toneedle times with IV tPA5 Guided by pre-specified protocols, eligible stroke patients can, if appropriate, be transported from the ED triage area directly to the CT scanner5 At the minimum, the CT scan should be completed within 25 minutes of arrival (to the ED with stroke patient)5 An Interdisciplinary collaborative team is also essential for successful stroke performance improvement efforts.5 Due to these studies and recommendations Galveston Area Ambulance Authority (GAAA) and University of Texas Medical Branch (UTMB) teamed together to improve the Door to CT time for stroke patients. 1. 2. 3. 4. 5. Improved Method Continued Outcome The crew selects the ESO Alert tab at the bottom of their EMR and the next screen allows them to select the type of alert and ETA. The alert is sent and the hospital is notified of the inbound patient. The registration clerk matches the patient to existing records or enters as a new patient and registers with the patient status as in bound and the arm band is printed and waiting for the arrival of the ambulance patient. The triage nurse changes patient status to arrived in the EMR when the crew hits the door, arm band applied and patient goes straight to CT where the stroke team awaits their arrival due to prior activation from the EMS crew. Discussion Continued GAAAs change management was to mandate that crews send ESO Alerts on all patients to expedite treatment and turnaround time as well as developing the habit of notifying the hospital. With UTMB and GAAAs system changes dramatic improvements were documented in a short period of time as reflected in the graph below comparing August 2013 to October 2013. While Electronic Medical Records (EMRs) are excellent for gathering information on patient outcomes and providing safety checks such as potential allergic reactions, the EMRs dictate the patient must be registered before treatment sets can be placed. The ambulance would arrive at UTMBs ED and the crew would stop at the ambulance triage desk and have to relate all the information gathered to the triage nurse and registration clerk. The patient would then be placed in an ED room where the physician would evaluate and place orders into the EMR for patient to go to CT scan. Valuable time was lost with repeated and unnecessary steps as reflected by the door to CT graph below from August 2013. The ESO patient status board shows patients as inbound in GREEN with an ETA and those that are late in arriving as RED. Patients that have already arrived are in WHITE. Kochanek KD, Xu JQ, Murphy SL, Mini単o AM, Kung HC. Deaths: final data for 2009 [PDF-2M]. National Vital Statistics Reports. 2011;60(3). Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, et al. Heart disease and stroke statistics2012 update: a report from the American Heart Association . Circulation. 2012;125(1):e2220. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA. 309(6):2480-8. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientific statement from the American Heart Association. Stroke 2009;40;2911-2944 Target: Stroke Best Practice Strategies July 2012 update: a report from the American Heart Association All patients delivered in October were below the goal of equal to or less than 24 minutes from door-to-CT. GAAA was the first ambulance service in the United States to transmit a patient alert to the hospital to expedite the registration process resulting in improved patient throughput and positive patient outcomes. Contact Information Trey Frankovich, LP Discussion Improved Method From October 2012 until October 2013, 122 patients with the primary diagnosis of CVA were delivered to UTMBs ED for treatment from GAAAs ambulances. Utilizing the American Heart Associations recommendations for the rapid diagnosis and treatment of stroke patients to improve outcomes the hospital and EMS began discussions on how to improve patient flow. The process had been for the EMS crew to immediately notify the 911 dispatcher to advise UTMB ER they had a stroke patient and then the medics would gather patient information on the scene including the patients demographics, onset of symptoms and record the Cincinnati Stroke Scale. Treatment was instituted and the patient was rapidly transported to the ED for further treatment. GAAA contacted their EMR provider, ESO, and Beta tested an ALERT process. Essentially GAAA was sending a draft of the EMR to the hospital before arriving. The crew now enters patient name, Social Security number, birth date, weight and allergies. This information is essential for matching the patient to the hospital records allowing for pre-registration of the patient as in bound in the hospitals EMR system. The hospital dispatcher may incorporate the ESO alerts into their own emergency departments information system bed flow. EMS Director Galveston Area Ambulance Authority P.O. Box 939, La Marque, TX 77568 Phone: 409.765-2524 Email: tfrankovich@gchd.org www.linkedin.com/in/treyfrankovich Contact Information Edwin Smith, Jr., RN, BSN Emergency Services Coordinator Email: edhsmith@UTMB.EDU Valerie Brumfield, RN, MSN, CCRN, CNS Clinical Nurse Specialist Email: vcbrumfi@UTMB.EDU UTMB Galveston 301 University Blvd, Galveston, TX 77555-1173 409.772.1425 RESEARCH POSTER PRESENTATION DESIGN 息 2011 www.PosterPresentations.com