Reducing Door‐to‐Puncture Times for Intra‐Arterial Stroke Therapy: A Pilot Quality Improvement Project

• Published in: Journal of the American Heart Association Vol. 3; no. 6; pp. e000963 - n/a
• Main Authors: Mehta, Brijesh P., Leslie‐Mazwi, Thabele M., Chandra, Ronil V., Bell, Donnie L., Sun, Chung‐Huan J., Hirsch, Joshua A., Rabinov, James D., Rost, Natalia S., Schwamm, Lee H., Goldstein, Joshua N., Levine, Wilton C., Gupta, Rishi, Yoo, Albert J.
• Format: Journal Article
• Language: English
• Published: England Blackwell Publishing Ltd 11.11.2014
• Subjects: acute ischemic stroke; Aged; Aged, 80 and over; Anesthesia Department, Hospital - standards; Cooperative Behavior; endovascular stroke thrombectomy; Female; Fibrinolytic Agents - administration & dosage; Humans; Infusions, Intra-Arterial; Interdisciplinary Communication; Male; Middle Aged; Original Research; Patient Care Team - standards; Pilot Projects; Process Assessment (Health Care) - standards; Program Evaluation; Punctures; quality improvement; Quality Improvement - standards; Quality Indicators, Health Care - standards; Retrospective Studies; Stroke - diagnosis; Stroke - therapy; stroke process improvement; Thrombectomy - standards; Thrombolytic Therapy - standards; Time and Motion Studies; Time Factors; Time-to-Treatment - standards; Treatment Outcome; Workflow; endovascular stroke thrombectomy; stroke process improvement; acute ischemic stroke; quality improvement
• ISSN: 2047-9980; 2047-9980
• DOI: 10.1161/JAHA.114.000963

Background Delays to intra‐arterial therapy (IAT) lead to worse outcomes in stroke patients with proximal occlusions. Little is known regarding the magnitude of, and reasons for, these delays. In a pilot quality improvement (QI) project, we sought to examine and improve our door‐puncture times. Methods and Results For anterior‐circulation stroke patients who underwent IAT, we retrospectively calculated in‐hospital time delays associated with various phases from patient arrival to groin puncture. We formulated and then implemented a process change targeted to the phase with the greatest delay. We examined the impact on time to treatment by comparing the pre‐ and post‐QI cohorts. One hundred forty‐six patients (93 pre‐ vs. 51 post‐QI) were analyzed. In the pre‐QI cohort (ie, sequential process), the greatest delay occurred from imaging to the neurointerventional (NI) suite (“picture‐suite”: median, 62 minutes; interquartile range [IQR], 40 to 82). A QI measure was instituted so that the NI team and anesthesiologist were assembled and the suite set up in parallel with completion of imaging and decision making. The post‐QI (ie, parallel process) median picture‐to‐suite time was 29 minutes (IQR, 21 to 41; P<0.0001). There was a 36‐minute reduction in median door‐to‐puncture time (143 vs. 107 minutes; P<0.0001). Parallel workflow and presentation during work hours were independent predictors of shorter door‐puncture times. Conclusions In‐hospital delays are a major obstacle to timely IAT. A simple approach for achieving substantial time savings is to mobilize the NI and anesthesia teams during patient evaluation and treatment decision making. This parallel workflow resulted in a >30‐minute (25%) reduction in median door‐to‐puncture times.