The ‘pit-crew’ model for improving door-to-needle times in endovascular stroke therapy: a Six-Sigma project

Abstract

BackgroundDelays 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.ObjectiveTo present the outcomes of a quality-improvement (QI) process directed at reducing stroke treatment times in a tertiary level academic medical center.MethodsA 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).ResultsThe 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.ConclusionsA protocol-driven process can significantly improve efficiency of care in time-sensitive stroke interventions.

Interfacility Transfer Directly to the Neuroangiography Suite in Acute Ischemic Stroke Patients Undergoing Thrombectomy

“…8 With an emphasis on parallel workflow, preset time goals, and continuous feedback, several centers have now demonstrated improved treatment times with quality-initiative projects. 17,18 Based on their meta-analysis, Saver et al 8 advocate for the following time metrics: 50 minutes for brain imaging-to-arterial puncture time, 75 minutes for ED door-to-arterial puncture time, and 110 minutes for ED door-to-reperfusion time.…”

Decreasing procedure times with a standardized approach to ELVO cases

“…This has also held true in the modern embolectomy era 7. Workflow optimization to ensure rapid triage of patients with severe stroke and efficient in-hospital processes are vital to optimize time to angiography 8 9. Our aim was to standardize what happened intraprocedurally once the patient arrived in the angiography suite and to examine how this impacted time from groin puncture to first deployment and recanalization.…”

A standardized neurointerventional thrombectomy protocol leads to faster recanalization times

“…Mehta et al 16 reported a median (IQR) door to puncture time of 107 (87–124) min post quality improvement protocol. In addition, Rai et al 20 demonstrated a mean (SD) door to puncture time of 75 (18) min post quality improvement protocol. Our pre-implementation median door to puncture time was 66 min and decreased to 47 min post-implementation.…”

“…Both of these previously mentioned studies applied lean methodology in order to eliminate wasteful steps, create an action plan to implement a new protocol, and continuously evaluate changes made. Lean methodology helped to establish an early NI activation system, including preparing the angiography suite in advance and clearly defining clinician roles 16 20. Early activation allowed them to reduce time from CT to angiography suite or door to puncture through parallel work of various team members 16 20.…”