BackgroundDelays 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 ResultsFor 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.ConclusionsIn‐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.
Confronted with the coronavirus disease 2019 (COVID-19) pandemic, New York City Health + Hospitals, the city's public health care system, rapidly expanded capacity across its eleven acute care hospitals and three new field hospitals. To meet the unprecedented demand for patient care, NYC Health + Hospitals redeployed staff to the areas of greatest need and redesigned recruiting, onboarding, and training processes. The hospital system engaged private staffing agencies, partnered with the Department of Defense, and recruited volunteers throughout the country. A centralized onboarding team created a singlesource portal for medical care providers requiring credentialing and established new staff positions to increase efficiency. Using new educational tools focused on COVID-19 content, the hospital system trained twenty thousand staff members, including nearly nine thousand nurses, within a two-month period. Creation of multidisciplinary teams, frequent enterprisewide communication, willingness to shift direction in response to changing needs, and innovative use of technology were the key factors that enabled the hospital system to meet its goals.
Background and Purpose-The aim of this study was to correlate CT angiography-source image (CTA-SI) parenchymal hypoattenuation with clinical outcome in patients with vertebrobasilar occlusion treated with intra-arterial thrombolysis. Methods-In 16 patients with vertebrobasilar occlusion treated with intra-arterial thrombolysis, we graded CTA-SI parenchymal hypoattenuation in the medulla, pons, midbrain, thalamus, cerebellum, occipital lobe, inferior parietal lobe, and medial temporal lobe. The grading scale was: 0, no hypoattenuation; 1, Ͻ50% hypoattenuation; and 2, Ͼ50% hypoattenuation. On CTA, we assessed clot location and length and collaterals. Outcome was measured with modified Rankin score. Results-Mean patient age was 68.3 years (range, 47 to 86 years), National Institutes of Health Stroke Scale was 28 (range, 11 to 40), time to CTA was 5.2 hours (range, 0.69 to 15.32), and time from CTA to intra-arterial thrombolysis was 5 hours (range, 2.25 to 10.38 hours). There were 4 basilar, 2 vertebral, and 10 combined occlusions. Eleven patients had near complete, 4 had partial, and one had no recanalization. Independent outcome predictors measured as modified Rankin score at 3 months were CTA-SI pons and midbrain scores (cumulative rϭ0.81, PϽ0.001). For outcome dichotomized into death versus survival, the CTA-SI pons score (Pϭ0.0037) was the only independent predictor. Conclusion-Hypoattenuation Materials and Methods Patient SelectionSixteen patients with VBO underwent CTA before IAT between January 2003 and October 2006. Four patients received intravenous tissue plasminogen activator before IAT. For IAT, 13 patients were treated with wire manipulation and urokinase, 4 of 13 underwent additional angioplasty, and one of 4 was also treated with the Merci device: one with wire manipulation alone, one with the Merci device and urokinase, and one with the Merci device, wire manipulation, and angioplasty. Image Acquisition and AnalysisCTA acquisitions were performed with multidetector CT scanners (LightSpeed; GE Healthcare, Milwaukee, Wis) as previously published. 5 Two neuroradiologists graded CTA source images for hypoattenuation bilaterally in the medulla, pons, midbrain, thalamus, cerebellum, occipital lobe, inferior parietal lobe, and medial temporal lobe. Each side was graded: 0, no hypoattenuation; 1, Ͻ50% hypoattenuation; or 2, Ͼ50% hypoattenuation.The CTA was assessed for clot location: proximal basilar arteryvertebrobasilar junction to anterior inferior cerebellar artery origins; middle basilar artery-anterior inferior cerebellar artery to superior cerebellar artery origins; distal basilar artery-superior cerebellar artery origins to basilar tip. For thrombus length, one point was assigned to each basilar segment and intracranial vertebral artery with clot. Presence of posterior communicating arteries (collaterals) was recorded.Recanalization was graded on angiography following IAT using the Mori scale: 0, unchanged; 1, thrombus movement without Clinical MeasuresNIHSS scores at admission and modified Rankin...
BACKGROUND AND PURPOSE:Sacral insufficiency fractures are a common cause of severe low back pain and immobilization in patients with osteoporosis or cancer. Current practice guideline recommendations range from analgesia and physical therapy to resection with surgical fixation. We sought to assess the safety and effectiveness of sacroplasty, an emerging minimally invasive treatment.
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