Reducing Door-to-Puncture Times for Mechanical Thrombectomy in a Large Tertiary Hospital

You have massively failed at delivering tPA in 3 minutes. What is your followup to still meet the goal of 100% recovery for all? NONE? Then you don't belong in stroke, get the hell out and let better people actually solve stroke!

Electrical 'storms' and 'flash floods' drown the brain after a stroke

 In this research in mice the needed time frame for tPA delivery is 3 minutes for full recovery.

The latest here:

Reducing Door-to-Puncture Times for Mechanical Thrombectomy in a Large Tertiary Hospital

Zhenghong Liu, MBBS, MRCEM https://orcid.org/0000-0003-3361-3818, Man Qing Leong, BSc https://orcid.org/0000-0002-6299-1685, Nanlan Li, BA, MPP https://orcid.org/0009-0009-3886-2400, Miqi Mavis Teo, MBBS, MMEd (Anaes) https://orcid.org/0000-0003-2759-2563, Wei- Li Rachel Leong, MBBS, MMEd (Anae) https://orcid.org/0000-0003-2329-4235, Steve Chen Pong Wong, MBBS, MMed (Diag Rad), FRCR (UK) https://orcid.org/0000-0003-2936-4054, Jing Si Chew, BN, MN https://orcid.org/0009-0000-6871-0496, Seyed Ehsan Saffari, PhD https://orcid.org/0000-0002-6473-4375, Yee Hau Pang, MBBS, MRCP(UK) https://orcid.org/0000-0002-3957-471X, and Ghim Song Chia, MD, FRCR, MMed (Diag Rad) https://orcid.org/0000-0002-1305-2753Authors Info & Affiliations

October 2024 issue

14 (5)

https://doi.org/10.1212/CPJ.0000000000200325

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Abstract

Background and Objectives

Endovascular therapy (EVT) for stroke has emerged as an important therapy for selected stroke patients, and shorter times to clot removal improve functional outcomes. EVT requires the close coordination of multiple departments and poses unique challenges to care coordination in large hospitals. We present the results of our quality improvement project that aimed to improve our door-to-groin puncture (DTP) times for patients who undergo EVT after direct presentation to our emergency department.

Methods

We conducted time-motion studies to understand the full process of an EVT activation and conducted Gemba walks in multiple hospitals. We also reviewed the literature and interviewed stakeholders to create interventions that were implemented over 4 Plan-Do-Study-Act (PDSA) cycles. We retrospectively collected data starting from baseline and during every PDSA cycle. During each cycle, we studied the impact of the interventions, adjusted the interventions, and generated further interventions. A variety of interventions were introduced targeting all aspects of the EVT process. This included parallel processing to reduce waiting time, standardization of protocols and training of staff, behavioral prompts in the form of a stroke clock, and push systems to empower staff to facilitate the forward movement of the patient. A novel role-based communication app to facilitate group communications was also used.

Results

Eighty-eight patients spanning across 22 months were analyzed. After the final PDSA cycle, the median DTP time was reduced by 36.5% compared with baseline (130 minutes (interquartile range [IQR] 111–140) to 82.5 minutes (IQR 74.8–100)). There were improvements in all phases of the EVT process with the largest time savings occurring in EVT decision to patient arrival at the angiosuite. Interventions that were most impactful are described.(So nowhere near fast enough to deliver 100% recovery!)

Discussion

EVT is a complex process involving multiple processes and local factors. Analysis of the process from all angles and intervening on multiple small aspects can add up to significant improvements in DTP times.

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