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  • Endovascular Stroke Evaluation and Treatment Process Improvement to Reduce the Door to Revascularization (D2R) Times in Acute Ischemic Stroke (AIS) Received via Inter-Facility Transfer

    Final Number:

    Justin Singer MD; Abhishek Ray MD; Addison Barnett; Nicholas C. Bambakidis MD; Robert Tarr MD; Jeffery Sunshine MD; Julie Fussner RN; Sophie Sundararajan MD; Megan Louttit; Tinatin Gumberidze; Cathy Sila MD

    Study Design:

    Subject Category:
    Ischemic Stroke

    Meeting: AANS/CNS Cerebrovascular Section 2016 Annual Meeting

    Introduction: Neurologic and functional outcome following AIS are dependent on time to revascularization and size of core infarction. MRI diffusion-weighted imaging is more sensitive for determining core infarct volume(CIV) than CT and CT Perfusion(CTP). Due to time delay, lack of 24-hour availability, and patient monitoring challenges, MRI screening is infrequently used at stroke centers. Quality improvement processes, including implementation of workflow algorithms, clinical practice guidelines(CPG), work-sampling and lean analysis can be used to improve endovascular therapy(ET) D2R.

    Methods: We performed a multi-step quality improvement process at our comprehensive stroke center on all patient admitted via transfer with AIS and evaluated for ET. Neuro-interventionalists and stroke providers established a consensus on a CPG and neuroimaging algorithm to rapidly screen AIS patient’s for ET with MRI and established a set of consensus criteria based on patient characteristics, size of CIV and location of vessel occlusion. Patients deemed suitable for ET received emergent imaging evaluation and were then referred for ET if CIV and vessel occlusion met ET criteria. The imaging algorithm and ET criteria were published and distributed to stroke team members. Next, work-sampling and LEAN analysis was performed. 14 front-line providers were interviewed and extensive task analysis was obtained by observing intake of 5 AIS patients.

    Results: Implemented improvements included prehospital completion of MRI safety checklist, pre-registration, standardization of data paged to team, streamlined evaluation and transport to MRI. AIS transfer D2R time reduced by 17.7 % (33 min) from baseline (183 min) after implementation of neuro-imaging CPG and initiation of throughput efficiencies. Functional outcomes(mRS) were improved, with no deaths and no severe disability following complete implementation.

    Conclusions: Quality improvement processes can improve D2R times in AIS. Decreasing D2R in AIS may lead to superior neurologic outcomes, with decreased incidence of severe disability and death.

    Patient Care: Process improvement initiatives are valuable tools to improve the process of stroke care and decrease door to revascularizations times. This is particularly pertinent in spoke and hub model comprehensive systems where the majority of stroke patients are referred via inter-facility transfer, which inherently delays to time until revascularization and definitive treatment.

    Learning Objectives: By occlusion of this sessions participants should understand 1)The value of QI processes in reducing D2R 2)Importance of team consensus and CPG 3)Value stream mapping and implementation of efficies


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