“Time is brain”

When a person is having a stroke, getting treatment fast is critical because it can save brain tissue from permanent damage. About 75 to 85% of strokes are ischemic strokes, which are caused by a blockage of a blood vessel in the brain that leaves the surrounding tissue starved of blood. Restoring blood flow to the brain as soon as possible is crucial to give a person his or her best chance at a full recovery, like being able to walk and talk again.

Marc Lazzaro, MD, FAHA, an interventional neurologist at Froedtert & the Medical College of Wisconsin Froedtert Hospital and medical director of the hospital’s Comprehensive Stroke Center and Stroke and Neurovascular Program, said how each person tolerates a blocked blood vessel in the brain is different.

“For every 15 minutes after a stroke, we know there is a substantial decline in a person’s overall outcome,” Dr. Lazzaro said. “A person’s ability to be functionally independent and regain a good quality of life is reduced. This is why we say ‘time is brain.’”

A new target door-to-needle time

Hospitals measure how fast they provide treatment to stroke patients by what is called the door-to-needle time – the time it takes the team to deliver the medication that will dissolve the blood clot. The national standard, set by the American Heart Association/American Stroke Association, recommends patients receive the clot-busting medication, called IV thrombolytic, in less than 60 minutes. In 2017, the stroke team at Froedtert & MCW Froedtert Hospital set a more ambitious goal, putting protocols and processes in place to cut that time in half and targeting a 30 minute door-to-needle time.

“These very fast times are achievable,” Dr. Lazzaro said. “The real challenge is making them sustainable. We have spent a lot of time identifying areas for improvement, and our data shows it is possible for us.”

Teamwork leads to faster, more efficient treatment

The door-to-needle time for ischemic stroke patients at Froedtert & MCW Froedtert Hospital has steadily declined. For the past five years, our average door-to-needle time has been around 30 minutes. Dr. Lazzaro credits this success to the seamless coordination of care between everyone involved – from the paramedics in the field, to the hospital’s emergency medicine, neurology, radiology and pharmacy teams.

“It is a true multidisciplinary approach,” Dr. Lazzaro said. “We have studied and finessed every step of the process, from the moment an acute stroke patient is on their way to the hospital, and we have reorganized the sequence of events to allow for the most efficient treatment.”

Carrying out each step in the sequence with urgency and integrity is critical to achieving a faster door-to-needle time, made possible by a team with keen expertise and extensive experience in treating stroke patients. When a stroke patient is en route, the ambulance team notify the hospital. Upon arrival, the patient is immediately taken for brain scans to visualize the clot – changing into a hospital gown can wait. Parallel-processing is also crucial. For example, while the neurology team is evaluating the patient’s CT scan, the emergency department providers, pharmacy and nursing teams do their actions simultaneously so the IV thrombolytic medication can be given as soon as it is safe to do so.

“We always strive for continual improvement,” Dr. Lazzaro said. “We want to make a difference and advance stroke care. It’s part of our culture as an academic medical center to provide the highest caliber care possible.”

For more information on stroke care, visit: froedtert.com/stroke.

Don Herrmann

Is it reasonable to have off duty medical personnel "armed" with tPA in their med chest at home, or carried in a personal vehicle? My wife is a retired RN spending her last 22 years (of 43) in ICU. If she for example had immediete access to the med would it not serve to significantly reduce door-to-needle time for one who needs it now? What would it take to set this ability in place? Thank you. Don Herrmann.

Froedtert & MCW

Hi Don – Alteplase (TPA) needs to be provider-ordered and is not available outside of a health care facility (i.e. it cannot be purchased over the counter). The safest place to give TPA is in a certified stroke center, as the aftercare to reduce complications is also vital. TPA is only appropriate for patients with an ischemic stroke who do not have any contraindications. A CT (which could not be done at home) is needed to assure the patient is not bleeding in their brain. As the function of TPA is to break up clots, giving TPA to someone who is actively bleeding or has other contraindications that put them at higher risk for bleeding (i.e. who does not meet the scientific benefit guidelines) could cause more harm than good. At Froedtert Hospital, we have some of the fastest average arrival-to-TPA times in the nation. We have effectively provided TPA to eligible stroke patients in less than 30 minutes after they arrive (while still doing all the necessary tests and screening) with an after-treatment bleeding rate much lower than the national average.