Reducing Door-to-Reperfusion Time for Mechanical Thrombectomy With a Multitiered Notification System for Acute Ischemic Stroke

Abstract

ObjectiveTo reduce door-to-angiographic reperfusion (DTR) time to 120 minutes for patients presenting with acute ischemic stroke attributed to anterior circulation large-vessel occlusion amenable to endovascular mechanical thrombectomy.Patients and MethodsPatients treated with mechanical thrombectomy before (April 10, 2015, through April 11, 2016) and after (April 12, 2016, through May 10, 2017) implementation of a multitiered notification system were studied. Lean process mapping was used to assess inefficiencies with multidisciplinary triage. A 3-tiered paging platform, which rapidly alerts essential personnel of the acute ischemic stroke team at advancing decision points, was introduced.ResultsSixty-two patients were analyzed before and after implementation (34 vs 28, respectively). Following intervention, DTR time was reduced by 43 minutes (mean DTR, 170 minutes vs 127 minutes; P=.02). At 90-day follow up, 5 of the 28 patients in the postintervention cohort (19%) had excellent neurologic outcomes, defined as a modified Rankin Scale score of 0, compared to 0 of 34 (0%) in the preintervention cohort (P=.89). Reductions were also seen in the length of stay on the neurocritical care service (mean, 6 vs 3 days; P=.006), and total hospital charges for combined groups (mean, $100,083 vs $161,458; P<.001).ConclusionThe multitiered notification system was a feasible solution for improving DTR within our institution, resulting in reductions of overall DTR time, neurocritical care service length of stay, and total hospital charges.

Pre- and Interhospital Workflow Times for Patients With Large Vessel Occlusion Stroke Transferred for Endovasvular Thrombectomy

“…Ever since EVT has become standard care for patients with LVO stroke and its effect has been shown to be highly time-dependent ( 7), many studies have examined measures to improve EVT-related logistics inside the CSC, leading to a fairly streamlined in-hospital workflow (8)(9)(10)(11)(12)(13). However, the workflow prior to arrival at the CSC-pre-and interhospital workflow-has only recently started to gain attention (14-16), and is currently considered one of the main "bottlenecks" in acute stroke management (17,18).…”

“…Timely initiation of EVT is of vital importance, because it increases the chance of good clinical outcome (7). Multiple studies have reported in detail on EVT-related time intervals after arrival at the CSC, such as door-to-CT and door-to-groin time (8)(9)(10)(11), and innovations to shorten these time intervals have been studied and successfully implemented (9)(10)(11)(12)(13). In recent years, several measures to improve the prehospital and interhospital workflow prior to EVT have also been proposed (14)(15)(16).…”

Developments in hybrid operating room, neurointensive care unit, and ward composition and organization for stroke management

“…[13] Additional factors that augment the initiation of stroke treatment include rapid availability of IV tPA in the emergency department as well as organizing a large-vessel occlusion alert to simultaneously notify multiple key players in the event of an intracranial large-vessel occlusion. [14]…”

Value of brain computed tomographic angiography to predict post thrombectomy final infarct size and clinical outcome in acute ischemic stroke

“…This is likely since our onset-to-recanalization time is prolonged with meantime 354.9 min (±173.9 SD). Some published results [24][25][26][27] show that good clinical outcomes may not be obtained even where TICI 2b/3 is achieved if the onset to recanalization time window is prolonged. Moreover, the present results show higher hemorrhagic transformation than previous data, [28] and there are only 44.2% of the patients in our study that have had good collateral status, which may also affect the clinical outcome.…”