Quality Improvement in Acute Stroke Care: A Teleneurologist’s Perspective

When it comes to stroke care, we all know that time is brain. Every second that passes during an acute stroke is critical in determining a patient’s short- and long-term health, and efficiency and skill in acute ischemic stroke (AIS) treatment have direct and measurable benefits for patients. Developing efficiency in AIS care means identifying delays in treatment and following best practices to create opportunities for improvement. Efficiency in AIS treatment also relies on expert teamwork, from the teleneurologist to the on-site stroke staff. 

Telemedicine has become the standard of treatment in AIS care: telemedicine permits faster physician response times and maximizes physician resources during stroke treatment and thrombolytic administration. The increasing prevalence of telemedicine in healthcare positions teleneurologists at the crux of AIS treatment, and the expertise of the teleneurologist is essential in ensuring that acute stroke care is executed seamlessly.  

How do you improve stroke care outcomes for your patients and facilities? 

Enter Quality improvement. Quality improvement is a process that not only ensures better patient care but improves metrics for facilities by decreasing key treatment times to match industry standards. This, along with best practices, will demonstrably improve patient outcomes.    

What is Quality Improvement? 

Quality improvement is a framework used to improve patient care and standardize processes. It reduces variation, achieves predictable results, and improves outcomes for patients, healthcare systems, and organizations.

What will implementation of Quality Improvement for acute stroke treatment mean for facilities?

The single most important goal of quality improvement in treatment of acute ischemic stroke (AIS) is reducing door-to-needle times (for thrombolysis) and door-to-groin puncture times (for thrombectomy). The American Heart Association recommends door-to-need (DTN) times of less than 60 minutes and door-to-groin (DTG) puncture times of less than 90 minutes. Because some patients who undergo thrombectomy will first receive a thrombolytic, delays in DTN times can also result in delays in DTG times. Ultimately, reducing DTN times can improve outcomes for all acute stroke treatments.   

Quality Improvement focuses first on improving facilities’ DTN and DTG times. Improving these two simple stroke care metrics has widespread effects on improving stroke care in general, from increased efficiencies in the emergency department to improved downstream nursing, rehabilitation, and stroke prevention outcomes. 

Best Practices for Improved Stroke Care 

Implementing quality improvement processes and following best practices are key to improving door-to-needle (DTN) and door-to-groin (DTG) puncture times. Here are a few of the best practices that the AHA and TeleSpecialists recommend for reducing DTN and DTG times: 

  • Early and consistent stroke alert activation
  • Teleneurologist on-screen before the patient arrives in the emergency department
  • No ED room assignments for stroke alert patients 
  • Hallway stretcher with built-in scale (thrombolysis requires a quick and accurate weight)
  • Early preparation of thrombolytics 
  • Early administration of thrombolytics
  • If possible, thrombolytics are started before the patient leaves the CT scanner 
  • Monthly mock stroke alerts on all shifts to reinforce processes and protocols 

Best Practices for the Teleneurologist

Ensuring the best outcomes for AIS treatment requires a combination of quality improvement processes and teamwork from all members of the care team. During a stroke alert, the teleneurologist leads the care team by facilitating treatment that is given quickly and safely, guided by clinical expertise, and with attention to critical metrics (DTN and DTG times). The experience of the patient and family during treatment of an acute stroke treatment is also a priority, and the teleneurologist must, as much as possible, cultivate an environment that is calm and free of distractions. Interactions between care team members are respectful, and consensus medical advice is represented consistently by physicians and nurses alike. 


About TeleSpecialists

TeleSpecialists is a physician-owned management service organization committed to providing exceptional and comprehensive telemedicine patient care. Founded in 2013, TeleSpecialists has rapidly expanded to include over 100 board-certified physicians serving over 250 hospital locations across the US. ​TeleSpecialists is accredited by The Joint Commission and is an ISO 9001:2015 certified organization.

About the Author

Dr. Michelle Boudreau is board-certified in neurology and clinical neurophysiology. She obtained her master’s degree at Drexel University, completed medical school at Philadelphia College of Osteopathic Medicine, neurology residency at UCONN, and a fellowship in clinical neurophysiology at SUNY-Buffalo. Dr. Boudreau currently works at TeleSpecialists as a TeleNeurologist and Regional Medical Director.