Your hyperacute stroke unit's median door-to-needle time is 68 minutes against a national target of 45. Outline how you would lead a project to improve it.

Question

You are the neurology registrar with an interest in stroke. The stroke consultant has asked you to lead the improvement work and report to the regional stroke network.

Accepted Answer

Door-to-needle is an aggregate of four intervals, so I would begin by measuring each of them separately rather than the total: pre-alert to arrival, arrival to CT, CT to thrombolysis decision, and decision to needle. In almost every unit the delay is concentrated in one interval, usually CT to decision, and finding which one turns a vague problem into a fixable one. I would process map the pathway with the people who work it — the ambulance crews, the ED nurses, the radiographers, the stroke nurses and the on-call registrars — and segment the data by in-hours versus out-of-hours, pre-alert versus self-presenter, and day of week. My aim would be SMART: to reduce median door-to-needle time from 68 to under 45 minutes within six months. My outcome measure would be median door-to-needle plotted on a run chart, with process measures for each interval, and balancing measures of symptomatic intracranial haemorrhage and the proportion of thrombolysed patients who turn out to be stroke mimics, because pressure on speed can push people into treating without adequate assessment. I would then test changes in small PDSA cycles, favouring parallel processing over sequential steps: taking the patient directly to CT on the ambulance trolley rather than through a bay, keeping the thrombolysis drug in the scanner room, obtaining bloods and consent during the scan, and a single pre-alert call that activates the radiographer, the stroke nurse and the registrar simultaneously. I would use in-situ simulation to rehearse it and feed individual case times back to the team weekly in a non-punitive way, which is what actually shifts behaviour. For sustainability I would embed the pathway in the SOP and in induction, keep the run chart going, name an owner before I rotate, and report to the network so it can spread.

Reducing Door-to-Needle Time in Thrombolysis

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