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Kate Zimmerman, DO, FACEP
We know that in the case of stroke, time is neurons. Each minute that a large vessel occlusion stroke is untreated, the average patient loses 1.9 million neurons.[1] Every minute counts. Finding ways to increase efficiency in the recognition and treatment of stroke plays a crucial role in patient outcomes. National guidelines call for completion of neuroimaging within 25 minutes of a suspected acute stroke patient’s arrival to the Emergency Department (ED).[2] For patients that arrive by EMS, time to CT can be shortened by taking these patients directly to the CT scanner upon ED arrival. To make this happen, pre-notification from EMS needs to occur for patients who meet pre-defined criteria for a pre-established Direct-to-CT pathway.
The first step in in a Direct-to-CT pathway is early hospital notification. EMS, following a set of guidelines/checklist, can notify the hospital of an incoming stroke patient that would potentially qualify for thrombolytics and potentially thrombectomy. With advanced notification, the CT scanner can be cleared and ready to receive the patient, registration can be prepared to meet the patient at the door for quick registration, supplies readied to gain IV access (if not already done by EMS) and to draw labs. The lab can be prepared to receive the specimens for expedited processing. Upon patient arrival, the emergency medicine physician should meet the patient at the door to perform a brief screening exam to assure medical stability prior to CT (e.g. no resuscitative efforts need to be made prior to CT). The radiologist should be prepared to immediately review the CT and provide the treating physician with the read. If possible, the patient should be weighed via a lift-type scale while being moved between the CT and stretcher so that, if indicated, the proper dose of thrombolytics can be ordered. The parallel processing is crucial for efficiency. I can save minutes, which translates to millions of neurons.
Establishing a Direct-to-CT program requires collaboration. EMS, the emergency department (nursing, physicians, registration and ancillary staff), radiology (CT techs and radiologist), pharmacy, and lab, all need to be part of the planning process. Mock patient scenarios should be run to test the system and identify vulnerabilities in the pathway to allow for modifications. Consistent quality improvement and case reviews should be performed to assure that educational opportunities are identified and that the program goals are met.
There are many hospitals that have launched successful Direct-to-CT programs and would be happy to share their experiences with you. EMS clinicians, if there are hospitals that you take patients to without a Direct-to-CT program, please encourage them start one. Our goal is to reduce the number of minutes to definitive treatment for our acute stroke patients – every minute counts.
[1] Saver, JL (2005, December 8) Time is brain-quantified. Stroke. Retrieved August 26, 2022 from https://www.ahajournals.org/doi/abs/10.1161/01.STR.0000196957.55928.ab [2] Jauch, EC (2013, Jan 31) Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the AHA/ASA Retrieved May 20, 2023 from https://www.ahajournals.org/doi/10.1161/str.0b013e318284056a