Improving Time to Neuro imaging in Suspected Stroke: A two cycle Quality Improvement Project

Introduction

Strokes predominantly affect older adults, in whom atypical presentation, cognitive impairment and unwitnessed symptom onset may contribute to a delay in recognition. Timely access to neuroimaging is essential, as the benefit from thrombolysis is strongly time dependent. The National Stroke Service Model recommends neuroimaging within 20 minutes of hospital arrival. We aimed to improve the proportion of patients with suspected strokes meeting this standard at Sunderland Royal Hospital. 

Method

We undertook a two-cycle quality improvement project. Our baseline measurement consisted of 268 patients (October to December 2025). Education sessions were then delivered to the emergency department clinicians and to Stroke Nurse Practitioners, focusing on recognition and imaging indications, aiming to shorten the clinician-dependent delay. Cycle two included 144 patients (March 2026 and May 2026). Arrival time, CT request time, CT completion time, and thrombolysis status were collected for both cycles.

Results

Median arrival to CT time decreased from 54 to 47 minutes (Mann–Whitney U, p=0.031), although attainment of the 20-minute standard increased only from 7% to 9% (p=0.61). The proportion of patients with CT requested within the standard increased from 57% to 67%  (median request time decreased from 14 to 11 minutes). Whereas request to completion performance was unchanged (23% to 24.8% meeting the standard). Among thrombolysis candidates in cycle two 95.8% had imaging requested within the standard (increased from 83% in cycle 1), but only 45.8% had imaging completed within 20 minutes. 

Conclusion

Although imaging times improved this improvement was confined to the clinician dependent phase, with imaging capacity representing the principal barrier to achieving the 20 minute standard. Process mapping of the request to completion interval and implementation of a direct Stroke Nurse Practitioner telephone line for pre alerted patients will be reviewed in the next cycle.