Faster Stroke Care When the Clock Is Ticking … Literally

A large alarm clock kept stroke team members on their toes and led to timelier stroke management at one German center, researchers showed in a randomized trial.

Installed in a dedicated stroke room connected to the angiography suite, the stroke clock kept track of time elapsed since the patient was admitted and required clinicians to clock in at every step of stroke care, according to Klaus Fassbender, MD, of Saarland University Medical Center in Homburg, Germany, and colleagues.

This resulted in improved times from door to:

• Therapy decision (end of all indicated diagnostic work-up): 16.73 vs 26.00 minutes (P<0.001)
• End of neurological examination: 7.28 vs 10.00 minutes (P<0.001)
• End of CT: 11.17 vs 14.00 minutes (P=0.002)
• End of CT angiography: 14.00 vs 17.17 minutes (P=0.001)
• End of point-of-care laboratory testing: 12.14 vs 20.00 minutes (P<0.001)
• Start of IV thrombolysis: 18.83 vs 47.00 minutes (P=0.o16)

Fassbender’s group reported their findings in the October 2020 issue of Stroke.

“This study showed that the use of a stroke clock demanding active feedback significantly improves acute stroke management metrics and, thus, represents a potential low-cost strategy for streamlining time-sensitive stroke treatment,” they said.

However, the stroke clock did not significantly improve door-to-groin puncture times and functional outcome at 90 days, though this “may be explained by the fact that the study was not powered to detect statistical significance for these secondary end points,” according to the investigators.

A large display kept the stroke clock in view in the stroke room. Alarms were set to sound when time ran out on certain targets (e.g., neurological exam completed by 15 minutes, CT scanning and INR determination completed by 25 minutes, IV thrombolysis started by 30 minutes).

The responsible stroke physician had to press a buzzer before time ran out to avoid each alarm.

No important deviations from proper stroke management were seen with stroke clock use, supporting the safety of this protocol, according to the study authors.

Fassbender’s team included 107 patients at a German comprehensive stroke center who were randomized by day of admission in weekly blocks. The group was split between those assigned to management with the stroke clock (n=51) and usual care (n=56).

Baseline characteristics were similar between groups.

Median times from symptom onset to door were similar as well (90 vs 85 minutes).

Stroke clock patients and controls received thrombolysis in 21.6% and 12.5% of cases, respectively, and thrombectomy in 17.6% and 10.7%. These differences between groups did not reach statistical significance.

“The improvement of the stroke-management metrics may be explained by the synergistic combination of increase in the participants’ awareness of the passing time by the stroke clock combined with the demand for active feedback by pressing the buzzer at target times,” according to Fassbender and colleagues.

“Although it cannot be excluded that the intervention would also be effective without buzzing, however, a slight pressure by the soon anticipated alarm and the required feedback might have contributed to the acceleration of acute stroke management,” they continued.

Stroke team members reported that the stroke clock “provided support” by tracking time but raised stress levels “slightly.”

Limiting the generalizability of the trial was the fact that it only included patients admitted during normal weekday business hours and those no more than 8 hours into their stroke symptoms.

Additionally, the findings may not apply to hospitals with different stroke management pathways, such as those lacking dedicated stroke rooms.