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

Abstract

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.

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“…Recently, the results of an interventional study aimed at reducing the delays before IAT were reported [23] . This intervention, based on a protocol for early alert of the neurointerventional radiology team about arriving patients with suspicion of stroke even before image acquisition and a consequent parallel work flow, allowed the researchers to reduce median door-to-groin puncture times from 143 to 107 min.…”

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