title: The 'pit-crew' model for improving door-to-needle times in endovascular stroke therapy: a Six-Sigma project.
abstract: BACKGROUND
  Delays in delivering endovascular stroke therapy adversely affect outcomes. Time-sensitive treatments such as stroke interventions benefit from methodically developed protocols. Clearly defined roles in these protocols allow for parallel processing of tasks, resulting in consistent delivery of care.
  
  
  OBJECTIVE
  To present the outcomes of a quality-improvement (QI) process directed at reducing stroke treatment times in a tertiary level academic medical center.
  
  
  METHODS
  A Six-Sigma-based QI process was developed over a 3-month period. After an initial analysis, procedures were implemented and fine-tuned to identify and address rate-limiting steps in the endovascular care pathway. Prospectively recorded treatment times were then compared in two groups of patients who were treated 'before' (n=64) or 'after' (n=30) the QI process. Three time intervals were measured: emergency room (ER) to arrival for CT scan (ER-CT), CT scan to interventional laboratory arrival (CT-Lab), and interventional laboratory arrival to groin puncture (Lab-puncture).
  
  
  RESULTS
  The ER-CT time was 40 (±29) min in the 'before' and 26 (±15) min in the 'after' group (p=0.008). The CT-Lab time was 87 (±47) min in the 'before' and 51 (±33) min in the 'after' group (p=0.0002). The Lab-puncture time was 24 (±11) min in the 'before' and 15 (±4) min in the 'after' group (p<0.0001). The overall ER-arrival to groin-puncture time was reduced from 2 h, 31 min (±51) min in the 'before' to 1 h, 33 min (±37) min in the 'after' group, (p<0.0001). The improved times were seen for both working hours and off-hours interventions.
  
  
  CONCLUSIONS
  A protocol-driven process can significantly improve efficiency of care in time-sensitive stroke interventions.
authors: Department of Radiology, Neurology and Neurosurgery, West Virginia University, Morgantown, West Virginia, USA.
authors: Ansaar T
authors: AT
authors: Rai
authors: Department of Neurology, West Virginia University, Morgantown, West Virginia, USA.
authors: Matthew S
authors: MS
authors: Smith
authors: Interventional Neuroradiology, West Virginia University, Morgantown, West Virginia, USA.
authors: SoHyun
authors: S
authors: Boo
authors: Interventional Neuroradiology, West Virginia University, Morgantown, West Virginia, USA.
authors: Abdul R
authors: AR
authors: Tarabishy
authors: Department of Statistics, West Virginia University, Morgantown, West Virginia, USA.
authors: Gerald R
authors: GR
authors: Hobbs
authors: Interventional Neuroradiology, West Virginia University, Morgantown, West Virginia, USA.
authors: Jeffrey S
authors: JS
authors: Carpenter
mesh_terms: D000046:Academic Medical Centers / Q000592:standards; D000368:Aged; D000369:Aged, 80 and over; D004632:Emergency Medical Services / Q000379:methods* / Q000592:standards; D057510:Endovascular Procedures / Q000379:methods* / Q000592:standards; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009339:Needles; D020521:Stroke / Q000000981:diagnostic imaging* / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000379:methods* / Q000592:standards; D013997:Time Factors; D061665:Time-to-Treatment / Q000592:standards; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage; D014057:Tomography, X-Ray Computed / Q000379:methods / Q000592:standards
chemical_list: D010959:Tissue Plasminogen Activator
keywords: Standards; Stroke