Code Stroke: Effects of a Protocol Revision: A Quality Improvement Project

Introduction: Acute strokes in the inpatient setting comprise 6-15% of all strokes annually and are associated with worse functional outcomes and a larger financial burden than those with outpatient onset (Blacker, 2003; Cumbler, 2015; Bekelis, Missios, Coy, & Mackenzie, 2016). Approximately 32,000 neurons die every second during an acute stroke and preservation of function following reperfusion therapy is highly time dependent (Saver, 2006; Fransen et al., 2016; Stefanovic et al., 2017). Objective: To analyze the effects of a quality improvement project on alert-to-CT (ATC) times for suspected acute inpatient stroke (Code Stroke) in a large tertiary care facility. Methods: Alert-to-CT and alert-to-intervention (ATI) times were analyzed for a two year period before and one year after the implementation of a new Code Stroke protocol. We also analyzed the rates of ATC times exceeding 25 minutes. Results: Approximately one year after implementing a new Code Stroke protocol, ATC times were analyzed and a reduction in median times from 24 to 22 (IQR 18.5 to 27.5; P = 0.01) minutes was found, along with a 16% reduction in ATC times exceeding the goal of 25 minutes (P = 0.01). Alert-to-intervention times did not change significantly. Conclusion: The results of this study demonstrate that the implementation of the new Code Stroke protocol was associated with greater efficiency of inpatient stroke response and a reduction in neuroimaging times, which is an important first step in evaluation and treatment of acute stroke. This protocol clearly defines roles for Code Stroke team members and may serve as a model for institutions wishing to develop or improve an inpatient stroke response process.