Every minute a stroke patient is left untreated, their brain loses 1.9 million neurons. In fact, every 15-minute delay in breaking up the clot to restore blood flow to the brain can decrease the chances the patient will be discharged home, walk independently again, or even survive.
But before patients can get that treatment—known as a tissue plasminogen activator (tPA)—they must first be evaluated with a computerized tomography (CT) scan.
“The head CT is the first major step and piece of data that neurology needs to determine the next steps of care,” said Andrew Jacobowitz, MS, PA-C, a physician assistant in Weill Cornell Medicine's Department of Emergency Medicine and at NewYork-Presbyterian/Weill Cornell Medical Center. “The goal is to get that head CT done as soon as possible.”
A fellow with United Hospital Fund and Greater New York Hospital Association’s Clinical Quality Fellowship Program, Mr. Jacobowitz set out to decrease the time it took patients to get a head CT when they arrived in the emergency room at NewYork-Presbyterian Lower Manhattan Hospital. While beneficial for all patients and hospital efficiency, Mr. Jacobowitz knew the project would specifically save critical minutes for patients eventually diagnosed with and treated for a stroke.
“For select patients who get that quicker head CT, a quicker neuro evaluation, and a quicker intervention—that’s who this project will make the greatest impact on,” he said.
The project hinged on a simple but innovative change in the emergency department’s workflow. Previously, staff would register patients at the triage station and bring them down the hall—walking past the CT scanner—to a patient room to insert an IV, draw labs, and perform a neuro examination before heading for the CT scan.
Mr. Jacobowitz noticed that precious time could be saved if patients were instead brought directly from triage to the scanner. This meant adding essential steps such as bringing the primary nursing and provider team to triage, to perform a rapid medical evaluation for stability and then finalizing the rest of the neuro exam in the patient room after the scan.
To make the shift, Mr. Jacobowitz and his team arranged triage with a computer on wheels, IV set ups, a stretcher and focused on educating staff about the change.
“Early on, we worked to highlight the benefits of this new process and the cases that went well to say, ‘When we do this right...it’s hugely valuable for stroke patient care,’” Mr. Jacobowitz said.
Eventually, the average time it took patients to start a head CT after arriving in the emergency room dropped by 13.6 percent. More than 170 patients were sent to get head CTs using the new approach over an eight-month period.
And perhaps most significantly, the proportion of those patients eventually diagnosed with a stroke who received a tPA treatment during a critical time window increased. After the new workflow was put in place, the ED saw an improvement of more than 120% in the number of patients receiving a tPA within 40 minutes of arrival. Plus, the median “door to tPA” time dropped by 11 minutes.
Given these results, the new triage-to-CT workflow has stayed in place since Mr. Jacobowitz’s project wrapped up at the end of 2022. The approach will be considered at NewYork-Presbyterian/Weill Cornell Medical Center’s emergency department, though with a workflow tailored to the larger hospital’s triage and CT layout.
Mr. Jacobowitz says the Clinical Quality Fellowship Program played an “enormous role” in the project’s success and in his career trajectory.
Since completing the fellowship, Mr. Jacobowitz took on a new role as an emergency medicine quality and patient safety specialist and is part of a team working on other quality improvement initiatives at NewYork-Presbyterian Lower Manhattan Hospital, including sepsis performance.
“I was interested in quality positions prior to doing CQFP, but I didn’t have any quality training,” Mr. Jacobowitz said. “Doing the fellowship directly led to me getting a new title in work that I’m really passionate about.”
Started in 2009, the Clinical Quality Fellowship Program has trained more than 300 mid-career physicians, nurses, and physician assistants from over 50 health care facilities in the New York metropolitan area to become quality improvement and patient safety leaders in their organizations. The 15-month program graduates a new class of these change-makers on the front lines of health care each year.