Implementation of a Multi-disciplinary Wake-up Stroke (WUS) Protocol at a Comprehensive Stroke Center in a Diverse Urban Community: 2-Year Experience
Asish Gulati1, Olivia Morgan2, Ryan Peterson3, Ranliang Hu3, Matthew Wheatley4, Diogo Haussen5, Samir Belagaje5, Michael Frankel5, Nirav Bhatt6
1Neurology, George Washington University, 2Pharmacy, Grady Health System, 3Radiology, 4Emergency Medicine, 5Neurology, Emory University School of Medicine, 6Neurology, University of Pittsburgh
Background:
AHA/ASA guidelines support the use of MRI DWI-FLAIR mismatch to determine eligibility for IV Alteplase (IVT) in suspected acute ischemic stroke (AIS) patients with an unknown time of onset. We report the results of a quality improvement (QI) initiative aimed to address barriers and streamline workflow using a rapid MRI protocol.
Design/Methods:
The WUS Protocol was a QI initiative implemented in July 2020 that encompassed Vascular Neurology, Emergency Medicine, Pharmacy, Nursing and Radiology at Grady Memorial Hospital. We reviewed patients between July 2020 and July 2022 who met criteria based on AHA/ASA guidelines. A modified 5-minute rapid sequence MRI protocol evaluated DWI-FLAIR mismatch for eligibility of IVT administration. We report treatment times and safety metrics, length of stay (LOS), NIHSS and discharge mRS.
Results:
Thirty-one patients met criteria for the protocol, of whom 21 were African American and 10 were Caucasian. The median age was 63 (IQR 53.5-71). A history of hypertension was seen in 77.5%, atrial fibrillation in 6.5%, diabetes mellitus in 38.7%, and prior stroke in 12.9% of patients. The median NIHSS on arrival was 7 (IQR 5-11.5) and median mRS was 0. Median time of arrival to CT scan was 16 minutes (IQR 7-25.5) and MRI scan was 77 minutes (IQR 60-92). Twenty-one patients (67.7%) had ischemic strokes on MRI with 10 (32.2%) qualifying for IVT. The median time of arrival to IVT was 86.5 minutes (IQR 74.5-111). None who received IVT had a symptomatic ICH. Median LOS was 4 days (IQR 2-9), median discharge mRS was 1 (IQR 0-3) and NIHSS was 2 (IQR 0-4).
Conclusions:
Our results mirror those in previously published randomized clinical trials and reflects a real-world experience and success of a multi-disciplinary QI initiative that addresses barriers and minimizes delays in providing treatment to diverse AIS patients at a comprehensive stroke center.