Door to Needle

What is ‘Door to Needle?’

The earlier stroke thrombolytic therapy is given in acute ischaemic stroke the better the functional outcomes for the patient. 'Door to needle time' is an important key performance measure.


Overview

The Acute Stroke Service in the Mater Hospital developed a new streamlined stroke thrombolysis pathway aiming to shorten door to needle time for acute stroke thrombolysis in December 2013. The Project to develop this pathway, which is called ‘Door to Needle’ (DTN) was originally established by Professor Sean Murphy and a multidisciplinary team, both internal and external, with the goal to reduce the median Door to Needle time for Acute Ischemic Stroke patients attending the Mater Hospital Emergency Department from 80 minutes to 60 minutes. With the support of Prof Mary Day CEO Mater Hospital and Prof Conor O'Keane, it was agreed that the Project at the Mater should be supported by the Mater Lean Academy. The Mater Lean Academy was delighted to take the Lean Six Sigma helm of the Mater Lean ‘Door to Needle’ Project from March 2014 onwards and to support Professor Murphy, the Acute Stroke team and the frontline staff in supplying Lean Six Sigma guidance and support. The Project is now in the Control Phase.

The new pathway

Key new and enhanced features in this updated pathway include the following:

  • The Ambulance Service Paramedics who identify a possible acute stroke case using the Face Arm Speech Test continue, as previously, to pre-notify the Mater ED of an incoming FAST positive patient.
  • Patients are pre-registered on Patient Centre, ahead of arrival in ED, using a pseudo-MRN which allows pre-ordering of CT & CT angio. Registration staff amalgamate the pseudo-MRN with the patient's true MRN once the patient's details have been gathered.
  • Upon pre-notification of the ED of an incoming FAST positive patient, the on-call Stroke Consultant, Stroke or GIM SpR and CT are immediately alerted.
  • During normal working hours, the FAST positive patient is brought directly to CT upon arrival in ED Resus. The initial history taking and expedited clinical examination takes place on the CT table but without delaying acquisition of CT/CT angio.
  • Out of hours, the Stroke Consultant can utilise the telemedicine system to expedite off-site clinical assessment of the patient and to review the CT imaging on NIMIS.
  • The Stroke SpR or GIM SpR act as Team Leader during the initial expedited assessment of the FAST positive patient supported in person by the ED SpR.
  • Initial blood tests, from ED Resus, use the Red Stickers which signify to Laboratory staff the urgency of getting test results back.

Latest Results

door to needle result

Since baseline readings in December 2013 there has been a corresponding drop in median Door to needle time from 80 minutes to 45 minutes, an improvement of 44% in the thrombolysis administration time. Correspondingly, the median Door to CT time has decreased from 47 to 15 minutes, an improvement of 66% in the door to CT. These early indicators illustrate that this new pathway has made a big impact in expediting the acute initial assessment off suspected stroke patients in the Mater Emergency Department.
The Mater Lean Academy is delighted to have supported front Line staff in their continued consolidation of this Project since March 2014, and to have many of its Green Belt graduates directly involved in the Project Implementation. At the end of the day, the Project reflects the Mater ethos of Person Centred Care.
Sean MurphyThe enormous amount of work that was required and huge number of stakeholders that were consulted and encouraged to change the way they do things, took time, dedication, and energy by the whole team.”Prof. Sean Murphy, The Mater Misericordiae University Hospital