To meet the latest guidelines on promptness from the American Heart Association (AHA) and American Stroke Association (ASA), providers must image suspected stroke patients within 20 minutes of their arrival. For a brain deprived of oxygen by a blood clot, every second counts. It is critical to quickly determine whether the patient needs such treatment as a clot-busting injection of tissue plasminogen activator (tPA) or a mechanical thrombectomy.
The stroke center at 425-bed Washington Regional Medical Center (WRMC) in Fayetteville, Ark., is beating that door-to-scan benchmark with minutes to spare. Meanwhile, its all-important initial stroke-check scans—head CT without contrast—are getting interpreted, largely by subspecialized neuroradiologists, at an average of only 6.53 minutes.
Put those numbers together, and the center is achieving a door-to-interpretation time of under 25 minutes. That’s more than 20 minutes faster than the 45 minutes AHA and ASA call for in their key best-practice strategies.
Perhaps the most impressive aspect of WRMC’s speedy stroke turnaround times is the newness of its program. The institution only launched the stroke center in 2014. The very next year, the Joint Commission gave the program its Gold Seal of Approval, while the AHA and ASA recognized it with their Heart-Check mark representing advanced certification for primary stroke centers.
Today the WRMC stroke center is the referral center of choice for four hospital systems across five counties in Northwest Arkansas. And soon it will apply for Joint Commission designation as a Comprehensive Stroke Center. This will confirm its ability to provide complex and demanding stroke services, including endovascular procedures, any time of day or night.
How did the center go from starting blocks to success story in well under five years? Short answer: by aiming high, planning well and collaborating constantly. Some details of its journey so far should be instructive to any provider organization thinking about shooting for something similar.
Targeting Turnaround Times
Amy LeSieur, VP of ancillary services, recalls the early days of WRMC’s stroke program as a time of tweaking existing ways of doing things, all with an eye on reducing door-to-intervention turnaround times.
After finalizing the best prioritization model for their workflows, the team developed a standard work process for submitting the images to the radiologist. This could be one of the eight radiologists at WRMC, one of whom is subspecialized in neuro, or a collaborator at vRad, which has supplied the institution with teleradiology services since the mid-aughts.
“We have an interdisciplinary stroke committee,” LeSieur says. “During the first few years, as we were developing this program, we met one day a week at 7 a.m. and reviewed every single case that had come through the door over the preceding week. We wanted to make sure that everybody’s role in our set of processes was hard-wired.”
The organization’s CT technologists are all trained on CT perfusion and CT angiography as well as non-contrast CT, so the staff’s competence was never in question, LeSieur says. “It was more of a focus on process,” she says, “making sure we do the right thing and do it the same, standardized way every time.”
Today the team is hitting that goal on 99 percent of suspected stroke cases coming into the center.
No ER Waits for Stroke Patients
Jamie Batey, lead CT technologist, says a key first collaborative step was reaching out to the six emergency medical services (EMS) companies that serve the community and transport to WRMC. Any time a medical first responder encountered a patient exhibiting signs of stroke, that EMS worker would alert the center so that Batey’s team of techs could reserve and set up a CT scanner while—or before—the patient was en route.
“We don’t have patients with a possible stroke waiting in the hall,” Batey says, underscoring that this takes some doing at a high-volume, level 2 trauma center. And indeed, WRMC’s emergency department saw some 61,000 ER visits in 2017. “The challenge for us as CT technologists is providing care to our emergency population without any delay for stroke patients when they arrive.”
This takes LeSieur to what the accomplishment has meant to the communities WRMC serves.
“Prior to our having the advanced stroke program, patients and their families would have to be sent two to three hours away,” she says, adding that the travel was not only inconvenient but also wasteful of precious time. “Being the only primary stroke center in the area, we’re now able to be there for a lot of people in the community.”
Faster turnaround times translate to better outcomes, Batey underscores. “Don’t forget, time is brain,” he says. “If you live in Northwest Arkansas, you now have a greater likelihood of surviving and recovering from stroke than you ever did before.”
And your chances are even better for those blazing fast read times supplied by the radiologists of WRMC and vRad.
Subspecialized Stroke Readers
All WRMC’s radiologists read CTs, including head scans for stroke, but the gold standard is subspecialized neuroradiologists reading neuro imaging studies. In addition, “we have a relatively small group here, one that obviously can’t cover 24/7,” LeSieur explains. “We rely heavily on vRad after normal business hours, even for complex studies such as cerebral CT perfusion. Our radiologists take some calls for emergencies or for times when they need to come in and do an interventional procedure, but otherwise vRad is there to be the eyes and ears of our radiology group after hours.”
And after hours is a crucial time for stroke preparedness, as research has shown that strokes are most likely to occur during two two-hour periods: 6 to 8 in the morning and 6 to 8 in the evening.
“Throughout the past couple of years, vRad has added or credentialed more neuroradiologists,” Batey observes. “As our volumes have increased, they’ve increased their capacity to read those studies for us. So we’ve kind of grown together.”
Doug Chambers, RIS/PACS coordinator, has seen the same.
“Early on we did some research to make sure vRad had enough radiologists who were credentialed for stroke and could handle the volume that we were likely going to be sending,” Chambers recalls. “That was kind of an unknown. And vRad has exceeded our expectations in that regard.”
13 ‘Really Significant’ Minutes
It’s not by chance that vRad’s 75+ neuroradiologists are reading noncontrast head CTs for stroke in under seven minutes on average. The 500-plus-physician practice, a MEDNAX company, provides over 73,000 stroke interpretations annually using proprietary auto-routing technology, an auto-dialer for critical findings, study-specific workflows and many other features designed for speed. Today, the vRad team serves more than 20 percent of certified stroke centers as well as non-stroke hospitals in the U.S., according to company materials.
For her part, LeSieur credits a new component in vRad’s stroke-service protocol as one of the most decisive factors behind the dramatic reduction of turnaround times at the WRMC stroke center. Named “Call on Open,” it requires the vRad radiologist to call the ordering physician as a first action item after opening a stroke study and before spending time finalizing the report. The radiologist can either click to call or the system will autodial the physician after seven minutes.
Another key factor is WRMC’s time-saving protocol to send the Non-contrast Head CT, the study upon which all else hinges, to vRad the moment the images are available. This allows the vRad neuroradiologist to get a diagnosis to the ED without getting slowed down with image sets that are less time sensitive. LeSieur says the uniform protocol and Call on Open have slashed 25% off WRMC stroke center’s turnaround times on CT head without and 13 minutes off cerebral CT perfusion studies. “That’s really significant,” she says.
And speaking of CT perfusion, Batey notes that WRMC is performing more of these studies because the stroke center recently expanded its definition of acute stroke patients to include all who have presented stroke symptoms within the previous 24 hours. It used to be just a seven-hour lookback for acute stroke. These patients receive a full workup, which goes beyond the initial noncontrast CT to include CT angiography head and neck as well as CT perfusion.
Interestingly, the surge in head CT perfusion studies correlates with what vRad has seen, as the practice is on track to see a year-over-year increase in these reads of 200 percent to over 3,000 studies this year.
Finally, the WRMC stroke center has met with much success in not much time because it has made reducing turnaround times part of its culture: Speed in stroke care is top of mind for all who have a hand in any related activities.
“One of our main points of emphasis for every new technologist coming on board is making sure they understand the importance of fast turnaround times on stroke CT scanning,” Batey says. “We make sure they are able to perform the various head CT scans for stroke and quickly submit the images to the radiologist. They see right away that this is very important to us as a primary stroke center.”
They also see it in the many ways the center reminds the community to be ever watchful for signs of stroke. Regular promotions include an annual stroke education event, heart and stroke fundraising walks and a drop-in—by helicopter—of WRMC stroke neurologist Margaret Tremwel, MD, PhD, at a “Strike Out Stroke” baseball game of the Northwest Arkansas Naturals (the Double-A affiliate of the Kansas City Royals).
The center has even partnered with local pharmacies and coffee shops to get the word out about “FAST”—Facial drooping, Arm weakness, Speech difficulties and Time to call emergency services.
It’s paying off.
“Using the images that we acquire, a doctor can isolate which vessel in the brain the clot is in,” Batey says. “And when you see a success story, where they’re able to remove that clot and a patient who couldn’t move their arm gets discharged and gets to go home two or three days later—fully functioning—that is quite rewarding. It’s good just knowing that you are a part of making that happen.”