Background: In response to the pandemic, our facility recognized the need to safely decompress ICUs to create space for critically ill COVID-19 patients. Stroke leadership identified select recipients of Alteplase to have care safely de-escalated from ICU to stepdown status earlier than the traditional protocol allowed. Per previous protocol, all stroke patients recovered in ICU for 24 hours post- Alteplase with 36 neurological and vital sign assessments completed. Acting upon the need to ensure patient safety and create inpatient ICU bed availability, the multidisciplinary stroke leadership team created the Fast Track Alteplase Protocol. Goals: Project goals included decreasing ICU utilization and minimizing nursing encounters at the patient bedside to decrease potential COVID-19 exposures. Methods: Protocol qualifications include both pre-Alteplase NIH Stroke Scale scores less than 10 and no large vessel occlusions or flow limiting stenosis present on imaging. Once in the protocol, to qualify for transfer out of ICU, an NIH Stroke Scale score less than 10 throughout ICU stay, noncontrast head CT or MRI to evaluate infarct burden, not require continuous anti-hypertensive medications to maintain systolic blood pressure cap, and not demonstrate hemodynamic or respiratory concerns must be achieved and completed. We developed education for nurses and physicians in ED, ICU, and stepdown patient care areas and tip sheets to guide nursing care and documentation associated with the new protocol. Electronic orders were quickly developed and integrated as a new subphase specific to the Fast Track Alteplase Protocol within an existing stroke order set. Results: The protocol decreased the number of encounters between nursing and patients from 36 to 12 interactions (66.7%) and planned time in the ICU from 24 to 12 hours (50%). The median time comparison of ICU length of stay for Fast Track vs. traditional protocol was 12 hours and 26 min vs35 hours and 15 minutes respectively. Conclusion: The protocol achieved both goals of decreasing the amount of time stroke patients arein the ICU and number of nursing encounters reducing the possibility of patient and staff exposure toCOVID-19.
Ready, set, go! Covid-19 pandemic drives creation of fast track alteplase protocol