Observational study on the impact of feedback to Scottish Ambulance Service personnel to compliance with Stroke care bundle and ED management.
Introduction:
There is a drive to improve care of patients with acute stroke presenting to the Scottish Ambulance Service. Guidelines are clear, aiming to reduce time to attendance in the ED and hence time from onset of symptoms to thrombolysis. We wanted to look at using targeted feedback to guide ambulance personnel and subsequent impact on the ED management of these patients.
Methods:
We prospectively collected data on all patients from October 1st 2017 to March 31st 2018 with a pre alert for potential stroke. We reviewed pre hospital and emergency medicine department documentation and reviewed final diagnosis as per hospital discharge letter. Compliance with the key areas of the pre-hospital stroke care bundle were reviewed including FAST status; measurement of blood glucose and blood pressure. A note was made of both time from call to hospital (aim < 60 minutes) and on scene time (aim < 20 minutes) and arrival in the ED to scan time. Individual feedback was given to SAS staff via team leaders detailing compliance with stroke bundle and outcome for patient during the audit period.
Results:
A total of 222 patients were pre alerted as a potentially thrombolysable stroke over this 6 month period - median age 72.5yrs, IQR1 66 yr; IQR3 81yrs, minimum 15yrs; maximum 98yrs.
On reviewing the pre-hospital bundle compliance, there was a steady improvement from 82% in October 2017 to 100% compliance by March 2018. Time from call to hospital admission within 60 minutes improved from 68% to a maximum of 85% of cases in January 2018 falling to 70% in March 2018, which may reflect difficulties with extreme weather conditions. There was no corresponding improvement in scene time.
Overall, 48 patients were potentially thrombolysable and had immediate CT imaging performed. Of these 27 were thrombolysed. Time to CT scan from attendance to ED for these cases improved from average 29.4 minutes in October 2017 to 15.5 minutes in March 2018.
There was no difference in recognition of patients suitable for thrombolysis during this period. However, it was noted that 45 cases (20.3%) had resolving symptoms or mild symptoms on arrival to the ED; 41 cases (18.5%) had no clear onset time and 9 had onset time outwith thrombolysis delivery. Current pre hospital guidelines advise ambulance personnel to give a pre alert for all of these cases.
Discussion and Conclusion:
Giving feedback to key ambulance personnel appears to have increased awareness of the stroke care bundle showing improved pre-hospital documentation and improved transfer times.
An improved understanding of key information/bundle compliance and therefore handover quality has helped the Emergency Department team expedite CT for appropriate patients and improved door to CT time with consequent reduction in time to thrombolysis.
Ongoing work highlights the importance of minimising on scene delays, and modifying SAS guidelines to target patients who may derive maximum benefit from thrombolysis.
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