Department of Stroke Medicine, Queen's Hospital, Barking, Harvering and Redbridge University Hospitals NHS Trust

Clinical challenge
The shorter door to needle time for thrombolysis increases the higher and quicker chance for reperfusion and lesser damage to brain tissue. In an aim to analyse delayed thrombolysis and an eligible group which didn’t receive thrombolysis from SSNAP placed in Mortality and morbidity meeting of stroke governance.

Solution
This is a retrospective analysis audit carried out for the four months period from December 2016 till March 2017. Initial data were gathered from the SSNAP sheet and case notes – ICP were analysed based on SSNAP information. The two main focus areas were missed thrombolysis and delayed thrombolysis. This revealed an average door to needle time in BHRUT of 51 minutes. We aspire to London standard time of 30 minutes.

We acquired the impact of these individual team-wide discussions on the door to needle time. 
Every team member was asked to raise an incident (IR) if thrombolysis was delayed more than 30 minutes and a robust discussion took place.

Impact
Two top most reasons for delayed thrombolysis were CT scanner occupied with another patient (system factors) and 2 blue calls at the same time (human factors).

Another important point noted was inadequate data entry in the case notes for SSNAP to clarify about eligibility for thrombolysis and reasons for the delay.

Following this, action plans were suggested to medical staff and SSNAP administrators.

A re-audit was carried out for the period of August to November 2017. The outcome of this re-audit has shown significant improvement in the door to needle: 31 minutes from 51 minutes. Also, there was no major mismatch between the submitted SSNAP data and the ideal missed and delayed thrombolysis data.

Reflection
Individual case discussion of delayed thrombolysis and missed thrombolysis are now placed in Morbidity&mortality Meeting agenda. The awareness generated by SSNAP data and use of IR system (incident reporting system) has led to a significant reduction in door to needle time and better understanding of factors causing delay. This project has enabled us to better understand the impact of delays to treating patients, but has also had a knock on effect of improving the “access to stroke unit in 4 hours” target, which leads to better outcomes for patients. We are also reviewing the mismatch in data collection in an attempt to understand the cause and to enable us to provide more robust and accurate data going forward.