Date of Graduation

Summer 8-7-2018

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Nancy Taquino



Problem: Decreasing the time to assess acute ischemic stroke patients impacts the patients’ well-being. The clinical benefit of intravenous Alteplase for ischemic stroke patients results in better outcomes. Intravenous thrombolysis success is dependent on narrowing time to treat (Fonarow et al., 2014). Decreasing the time to intravenous thrombolysis for acute ischemic stroke patients augments the ability of patients to improve the quality of life by minimizing disability and improving health outcomes (Speirs & Mitchell, 2015).

Context: The microsystem chosen for this evidence-based change of practice project change takes place in the Northern California emergency department (ED). The ED provides care for patients in life-threatening situations, acute, and chronic conditions. The ED also serves as a health care safety net for the Northern California community. The ED is a high functioning, stressful environment, that when there is an increase of patients and not enough resources this impacts on the Altepase administration timing.

Interventions: The description of changes to test includes daily stroke team assignments, stroke kits, education through electronic modules, and stroke code simulation. At the start of every shift the assistant nurse manager (ANM) will choose the stroke team for each shift. Implementing stroke kits and placing them on top of the Telestroke Cisco Cart (video telemedicine platform) will help support the DTN time. Stroke kits will include a hard copy of a stroke check off list and intravenous (IV) start kit and IV tubing. We will also share current goals of AIS patients receiving Alteplase, which may include having staff watch modules. The team will initiate monthly simulation Stroke Codes. Test workflows during simulation Stroke Codes will be implemented at least three times day on various shifts.

Measures: One of the ED-specific metrics that matter is the Stroke Alteplase door-to-needle (DTN) time, which should be less than or equal to 30 minutes. The quality gap in ED is not having enough resources for increase census and not meeting the monthly metrics measures baseline of 50%. Given that the number of patients arriving to the ED can impact the duration of time of Alteplase administration, the typical time is longer than 30 minutes.

Results: Significantly, there is an improvement from January 2017 to April 2018. The DTN Alteplase administration to less and equal to 30 minutes increased from 43% prior to intervention to 55% after the intervention were implemented. Since the intervention, there was an increase on the ED DTN response time. However, there is not enough data that points to say that there is a trend in the process. The percentage of staff members completing modules in Health Connect (HC) is 90%. (Quality and Operations Support: The Permanente Medical Group, 2017).

Conclusion: This project has been a great success and opportunity for staff to understand the importance of assessing AIS patients, documentation, simulations, electronic education modules and the importance of close loop communication, influence safe, quality stroke care outcomes. By administering Alteplase in a timely manner, fulfills Northern California Hospital’s vision as a leader in creating an overall improvement of living a quality life for patients and their families. Decreasing the time to intervention benefits AIS patients and their families by reducing disability, improving self-confidence, and quality care.