Reducing door-to-puncture times for intra-arterial stroke therapy: a pilot quality improvement project.
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.


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.
Division of Interventional Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., R.V.C., D.L.B., J.A.H., J.D.R., A.J.Y.) Department of Neurology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., N.S.R., L.H.S.).
Brijesh P
BP
Mehta
Division of Interventional Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., R.V.C., D.L.B., J.A.H., J.D.R., A.J.Y.) Department of Neurology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., N.S.R., L.H.S.).
Thabele M
TM
Leslie-Mazwi
Division of Interventional Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., R.V.C., D.L.B., J.A.H., J.D.R., A.J.Y.).
Ronil V
RV
Chandra
Division of Interventional Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., R.V.C., D.L.B., J.A.H., J.D.R., A.J.Y.).
Donnie L
DL
Bell
Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.H.J.S.).
Chung-Huan J
CH
Sun
Division of Interventional Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., R.V.C., D.L.B., J.A.H., J.D.R., A.J.Y.).
Joshua A
JA
Hirsch
Division of Interventional Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., R.V.C., D.L.B., J.A.H., J.D.R., A.J.Y.).
James D
JD
Rabinov
Department of Neurology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., N.S.R., L.H.S.).
Natalia S
NS
Rost
Department of Neurology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., N.S.R., L.H.S.).
Lee H
LH
Schwamm
Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (J.N.G.).
Joshua N
JN
Goldstein
Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, MA (W.C.L.).
Wilton C
WC
Levine
Wellstar Neurosurgery, Kennestone Hospital, Marietta, GA (R.G.).
Rishi
R
Gupta
Division of Diagnostic Neuroradiology, Massachusetts General Hospital, Boston, MA (A.J.Y.) Division of Interventional Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., R.V.C., D.L.B., J.A.H., J.D.R., A.J.Y.).
Albert J
AJ
Yoo
D000368:Aged; D000369:Aged, 80 and over; D000761:Anesthesia Department, Hospital / Q000592:standards; D003299:Cooperative Behavior; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D007261:Infusions, Intra-Arterial; D033183:Interdisciplinary Communication; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team / Q000592:standards; D010865:Pilot Projects; D017064:Process Assessment, Health Care / Q000592:standards*; D015397:Program Evaluation; D011677:Punctures; D058996:Quality Improvement / Q000592:standards*; D019984:Quality Indicators, Health Care / Q000592:standards*; D012189:Retrospective Studies; D020521:Stroke / Q000175:diagnosis / Q000628:therapy*; D017131:Thrombectomy / Q000592:standards*; D015912:Thrombolytic Therapy / Q000592:standards*; D013997:Time Factors; D013996:Time and Motion Studies; D061665:Time-to-Treatment / Q000592:standards*; D016896:Treatment Outcome; D057188:Workflow
D005343:Fibrinolytic Agents
acute ischemic stroke; endovascular stroke thrombectomy; quality improvement; stroke process improvement