Someone suffers a stroke every 40 seconds in the United States, and every four minutes a stroke-related death occurs. Previous research has shown that shortening time to restoration of blood flow, or reperfusion, improves clinical outcomes for patients with acute ischemic stroke (AIS). Studies have also demonstrated that there are ways to improve stroke care at every point along the care pathway--from transport times, to better prioritization of resources, improved staff training, and use of evidence-based stroke protocols.

A new study in Interventional Neuroradiology¹ demonstrates improved patient outcomes and significantly shorter time-to-treatment for AIS patients undergoing endovascular treatment (EVT) with the use of a multipronged program called STEPS-T: Stroke Triage Education, Procedure Standardization, and Technology. The authors analyzed the success of this team-based program over five years, looking at a total of 230 patients.

What is the STEPS-T program?

The STEPS-T program is an integrated team approach designed to reduce the amount of time from when a stroke patient arrives at the hospital, known as “door time,” to recanalization, or restoration of blood flow.

STEPS-T is organized to optimize speed and quality of care by focusing on three key domains: procedure workflow, technologies, and education.

Procedure workflow standardization

Key to the STEPS-T program is the stroke team dividing up responsibilities and tasks and running them in parallel to shorten time to recanalization. Once a patient is diagnosed with large vessel occlusion or distal occlusion, the first tech sets up the room, prepares the devices, and preps the patient after they arrive. At the same time, a second tech retrieves the patient data and begins recording. Once the patient is draped, the nurse retrieves the drugs required for the procedure and begins monitoring the patient. Parallel to these tasks, the physician talks with the patient’s family and obtains consent. The physician then focuses on proper table positioning. During the procedure, the first tech will prep devices as needed; the second tech continues monitoring and recording; the nurse monitors the patient and continues pulling drugs as needed; and the physician focuses on performing the catheterization and thrombectomy safely and efficiently.

Technologies

The STEPS-T program utilizes a biplane angiographic system, the Innova IGS 630 from GE Healthcare, equipped with 30cm-by-30cm flat panel detectors and advanced imaging capabilities such as cone beam computed tomography (CT), according to the study authors. The technology affords ergonomic and workflow efficiencies by utilizing a centralized joystick to provide optimal control at the table side using one hand. It also features automatic exposure control to deliver high image quality with minimal radiation doses.

The program integrates “digital objects,” also called macro-enabled systems. This digital technology connects staff in the care pathway and records each step in the workflow. The time for the completion of each step was recorded as a digital object. Researchers recorded time stamps for: patient arrival at the center; arrival at angiography suite; groin puncture; acquisition of first digital subtraction angiography (DSA); placement of microcatheter; and recanalization.

Education

A multiphase implementation helped the new program go smoothly. For the first thirty days, staff received integrated daily training, and the process was customized to the hospital’s needs. After the first month, advanced training happened monthly. Over the first six months, the process was optimized. After that time, processes were monitored and refined as needed.

Staff members were required to participate in training. New staff members were required to participate in peer-to-peer training for three to six months. During this time, they would shadow on-call procedures.

The program included monthly training for all team members as well as support from the information technology department and the hospital administration. It was part of a wider initiative that included naming a “stroke champion” in the emergency department, a staff member dedicated to stroke care, who was trained to speed triage to CT, administer thrombolysis if needed, and make sure that stroke patients were transferred to the angiography suite as quickly as possible.

How did the STEPS-T program improve outcomes?

Over the five-year study period, the median total intervention time—time from arrival in the biplane suite to recanalization—decreased significantly, from 121 to 52 minutes. The time from door-to-biplane suite did not change significantly (66 minutes). All steps of the procedure were shortened significantly, including set-up, groin puncture to first DSA, first DSA to microcatheter placement, and clot retrieval time. Taken together, total intervention and recanalization times were improved by a median of 57 percent.

Annual recruitment also increased from 12 patients in the first year to 66 patients in years four and five.

Clinical outcomes, measured by modified Rankin Score between 0 and 2, increased from 36 percent to 59 percent over the study period, a significant improvement.

There was no significant change in recanalization rates during the study period--88 percent of patients had a successful recanalization over the five years of the study.

What are the potential next steps for the STEPS-T program?

The strength of this approach compared to other stroke workflow programs is that it focuses on more than staff training, adding digital technology that further improves workflow efficiency. Ongoing education and training addresses questions from clinical staff and performance variability, but the combination of education and standardized protocols helps reduce cognitive load for staff and allows them to focus on patient treatment.

The success of the STEPS-T program suggests that other hospitals may want to adopt it to improve their outcomes for stroke patients as well. Once adopted, the program can be customized to apply to non-acute procedures as well. In a lower-volume center, implementation of STEPS-T may take longer than in this trial.

Next steps will include standardizing digital objects and staff training to further improve quality of care at all steps along the care pathway.

1. Endovascular treatment outcomes using the Stroke Triage Education, Procedure Standardization, and Technology (STEPS-T) program. Interventional Radiology. http://journals.sagepub.com/doi/abs/10.1177/1591019917740100 Last accessed August 30, 2018.