Abstract 161: Lean Process Improvements Reduce Door to CT and Door to Needle Times for Acute Ischemic Stroke Patients

2017 ◽  
Vol 10 (suppl_3) ◽  
Author(s):  
Cory McCann ◽  
Aleks Tkach ◽  
Adam de Havenon ◽  
Joel Loosli ◽  
Jamie Troyer ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Improve Patient Safety ◽  
Post Intervention ◽  
Process Improvements ◽  
Slowing Down ◽  
Before And After ◽  
Ct Brain ◽  
Student’S T ◽  
First Time

Background: In late 2015, we assembled a multi-disciplinary team to analyze current emergency department (ED) processes and identify improvement opportunities in the current “brain attack” (BA) protocol. Using lean process engineering tools, including time study analysis, gemba walks, and cause and effect diagrams, we mapped our baseline state and identified delaying activities that did not add value to the BA process. We defined a new BA process (see Figure 1) to eliminate waste and improve team communication, including 3 Time Outs to ensure that increased speed didn’t decrease safety. Methods: To determine the effect of our intervention, we retrospectively reviewed patients who were admitted to our ED as a BA for evaluation of possible acute ischemic stroke and had a CT brain after ED arrival between April 2015 and August 2016. ED arrival was defined as the time that patients physically arrived at the ED and “time to CT” was the time from ED arrival to the first time stamp of the CT brain. The time from ED arrival to tPA bolus was also measured for "door to needle" time. The time to CT and door to needle times were compared between BA patients before and after lean process improvements using Student’s T-test. Results: Our cohort included 239 patients who presented to the ED as a BA. We included 116 BA patients from before the intervention and 123 from afterwards. The mean±SD time to CT prior to the intervention was 19.0±13.9 minutes. After our lean process improvements the time to CT was 14.2±15.6 minutes. The delta of 4.8 minutes resulted in a significant reduction in time to CT, p = 0.012. There were 14 patients who received tPA prior to the intervention and 9 afterwards, for a total of 23 door to needle times (10% of cohort). Door to needle time was significantly shortened post-intervention (46±13 minutes versus 32±12 minutes, p=0.013). Conclusions: Lean process improvement methodology significantly reduces door to CT and door to needle times, supporting current AHA Target: Stroke goals and allowing faster treatment of patients with acute ischemic stroke. Incorporating time-outs into standardized processes that aim to deliver care more quickly may improve patient safety without substantially slowing down DTN times. Further investigation is required to determine whether the new process improved safety and clinical outcomes.

Abstract WP57: Utility of Flat Panel CT Perfusion for Physiologic Assessment of Acute Ischemic Stroke in the Angiography Suite

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Robert W Ryan ◽  
Paula Eboli ◽  
Michael J Alexander ◽  
Shlee S Song ◽  
Marcel M Maya ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Perfusion Defect ◽  
Ct Perfusion ◽  
Endovascular Intervention ◽  
Flat Panel ◽  
Post Intervention ◽  
Angiography Suite ◽  
Before And After

Introduction The decision to perform endovascular intervention in patients with acute ischemic stroke (AIS) may be guided by physiologic imaging such as CT perfusion (CTP) demonstrating a salvageable penumbra, but such studies can delay transfer to the angiography suite. Flat Panel Detector CT (FPD-CT) allows pre, intra and post-procedural physiologic assessment using rotational images acquired on the angiography table; however these measurements have not been correlated with conventional perfusion techniques. We began a prospective, observational comparison of standard, multi-slice CTP with FPD-CT perfusion for AIS interventions, and report our initial results. Methods Patients with AIS that are candidates for endovascular intervention and have standard CTP images available were enrolled in the study after obtaining informed consent and following the IRB approved protocol. FPD-CTP images were obtained with aortic contrast injection and commercially available workstation image assessment (Siemens, Erlangen, Germany) before and after intervention, and compared with standard CT perfusion and follow up images. Results A total of 3 cases have been enrolled. All demonstrated anatomic correlations between perfusion defects in the standard CTP and the FPD-CTP. Case example: A 58 year old man developed left sided hemiplegia and standard CTP demonstrated a right MCA defect with a small core infarction (Fig 1 A). Pre-intervention FPD-CTP showed the same defect pattern (Fig 1 B), and successful mechanical thrombectomy was performed (Fig 1 C,D). Post-intervention FPD-CT showed reversal of perfusion defect outside the core infarct (Fig 1 E). The patient had good clinical recovery and only small infarct on follow up CT (Fig 1 F). Conclusions Early experience with FPD-CTP imaging shows correlation with standard CTP images and reversal of perfusion defect following successful recanalization, suggesting it may be a valuable aid for decision making in AIS intervention.

Abstract T P288: Improvement of Door to Groin Time for Endovascular Therapy in Acute Ischemic Stroke Using Quality Improvement Methods

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Jennifer R Simpson ◽  
Alexandra Graves ◽  
Annie N Burrus ◽  
David E Case ◽  
Christina J Denton ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Median Time ◽  
Systematic Evaluation ◽  
Mri Imaging ◽  
Post Intervention ◽  
Imaging Protocol ◽  
Process Improvements ◽  
Set Up

Objective: Time has been identified as a key variable to the success endovascular treatment of acute ischemic stroke. This project was designed to reduce the time from patient arrival to groin puncture for these treatments at a single academic hospital. Methods: Using Plan-Do-Study-Act (PDSA) quality improvement methodology, a multidisciplinary team was created to identify ways to reduce time from patient presentation to groin puncture. A comparison of pre-intervention and post-intervention times was performed. Pre-intervention patients were retrospectively identified using existing databases and post-intervention patients were prospectively identified. Process maps were created to identify areas of delay. Debriefs helped to indentify future process improvements. Four PDSA cycles have been completed. Stroke neurologists instituted an early notification of IR physicians and a unified imaging protocol. Other interventions included a group paging system, standardized order sets, education within each discipline, improved communication, standardized stroke tray set-up, and streamlining preparation of the patients prior to transportation from the ED. Results: The median time from presentation to groin puncture was reduced from 126 minutes to 92 minutes. MRI imaging was associated with a long pre-intervention time to groin puncture, with a median of 182 minutes that was reduced to 99 minutes. Procedures outside of normal business hours were associated with long time to groin puncture, with a median time of 149 minutes that was reduced to 125 minutes. Conclusions: A reduction of time from presentation to groin puncture is possible using PDSA cycles. This QI project decreased time to groin puncture by 26%, showing that a systematic evaluation of institutional-specific workflow can improve the process preceding a time-sensitive procedure.

Abstract WP24: Improvement In Collateral Score And Level Of Occlusion Are Early Angiographic Indicators Of The Degree of Infarction In Acute Ischemic Stroke

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Matthew R Amans ◽  
Maya Vella ◽  
Daniel L Cooke ◽  
Steven W Hetts
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Brain Infarction ◽  
Arterial Occlusion ◽  
Brain Parenchyma ◽  
Post Intervention ◽  
Vessel Occlusion ◽  
Post Procedure ◽  
Before And After ◽  
Cerebral Arterial Occlusion

INTRODUCTION: Brain parenchyma contrast staining on CT after recanalization therapy and digital subtraction angiography (DSA) in large vessel occlusion acute ischemic stroke (LVO-AIS) patients has been demonstrated to be a marker for significant brain injury, possibly indicating blood brain barrier breakdown or no-reflow phenomena at the capillary level. Most often stained parenchyma undergoes infarction. We evaluated several DSA parameters in order to determine if findings on DSA at the time of LVO-AIS intervention can predict postintervention parenchymal contrast staining on CT and, thus, serve as early prognostic factors for brain infarction. HYPOTHESIS: Point of cerebral arterial occlusion, TICI score, and degree of pial collateraliation correlate with presence of parenchymal contrast staining on post-intervention CT in LVO-AIS patients. METHODS: Our institution’s CHR approved this analysis of imaging and patient charts. We reviewed 17 years of LVO-AIS intervention at our institution, and 67 patients met inclusion criteria. Angiograms were evaluated for level of occlusion, TICI scores before and after intervention, and level of collateralization before and after intervention. Statistical analysis was performed using Fisher’s exact test and ANOVA. RESULTS: More proximal sites of cerebral arterial occlusion were more likely patients to have post-intervention staining (p=0.08). Preprocedure TICI, postprocedure TICI and improvement in TICI score did not predict contrast staining on post procedure CT (p=0.34, 0.54, and 0.52). Preprocedure collateral score, post procedure collateral score were similarly not predictive (p=0.28 and 0.93). Decreasing collateral score (i.e., increased antegrade flow with decreased need for collateral supply) was predictive of contrast staining (p=0.09). CONCLUSION: Improvement in pial collateral score was more predictive of postprocedure contrast staining than was change in TICI grade, and thus may serve as a complement to TICI in the assessment of revascularization efficacy at the time of stroke intervention.

scholarly journals Treatment with Delipid Extracorporeal Lipoprotein Filter from Plasma after Intravenous Thrombolysis for Acute Ischemic Stroke: A Single-Center Experience

2020 ◽  
Vol 10 (3) ◽  
pp. 148-158
Author(s):  
Yu Cui ◽  
Zhong-He Zhou ◽  
Xiao-Wen Hou ◽  
Hui-Sheng Chen
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Low Density Lipoprotein ◽  
Density Lipoprotein ◽  
Intravenous Thrombolysis ◽  
Single Center Experience ◽  
Before And After ◽  
Prospective Trials ◽  
Symptomatic Intracranial Hemorrhage ◽  
Rate Of Improvement

<b><i>Introduction:</i></b> The delipid extracorporeal lipoprotein filter from plasma (DELP) has been approved for the treatment of acute ischemic stroke (AIS) by the China Food and Drug Administration, but its effectiveness and mechanism are not yet fully determined. The purpose of this study was to evaluate the effect of DELP treatment on AIS patients after intravenous thrombolysis. <b><i>Methods:</i></b> A retrospective study was performed on AIS patients with no improvement within 24 h after intravenous thrombolysis who were subsequently treated with or without DELP. Primary outcome was the proportion with a modified Rankin scale (mRS) of 0–1 at 90 days. Secondary outcomes were changes in National Institute of Health Stroke Scale (NIHSS) score from 24 h to 14 days after thrombolysis, and the rate of improvement in stroke-associated pneumonia (SAP). The main safety outcomes were the rates of symptomatic intracranial hemorrhage and mortality. To investigate its mechanisms, serum biomarkers were measured before and after DELP. <b><i>Results:</i></b> A total of 252 patients were recruited, 63 in the DELP group and 189 matched patients in the NO DELP group. Compared with the NO DELP group, the DELP group showed an increase in the proportion of mRS 0–1 at 90 days (<i>p</i> = 0.042). More decrease in NIHSS from 24 h to 14 days (<i>p</i> = 0.024), a higher rate of improvement in SAP (<i>p</i> = 0.022), and lower mortality (<i>p</i> = 0.040) were shown in DELP group. Furthermore, DELP decreased levels of interleukin (IL)-1β, E-selectin, malondialdehyde, matrix metalloprotein 9, total cholesterol, low-density lipoprotein, and fibrinogen, and increased superoxide dismutase (<i>p</i>&#x3c; 0.05). <b><i>Conclusions:</i></b> DELP following intravenous thrombolysis should be safe, and is associated with neurological function improvement, possibly through multiple neuroprotective mechanisms. Prospective trials are needed.

scholarly journals 2D Parametric Parenchymal Blood Flow as a Predictor of the Hemorrhagic Events after Endovascular Treatment of Acute Ischemic Stroke: A Single-Center Retrospective Study

2018 ◽  
Vol 7 (6) ◽  
pp. 522-532 ◽  
Author(s):  
Nada Elsaid ◽  
Ahmed Saied ◽  
Krishna Joshi ◽  
Jessica Nelson ◽  
John Baumgart ◽  
...  
Keyword(s):  
Blood Flow ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Dual Energy Ct ◽  
Anterior Circulation ◽  
Brain Scans ◽  
Increased Risk ◽  
Significant Difference ◽  
Hemorrhagic Events ◽  
Ct Brain

Background and Purpose: Intracranial hemorrhage (ICH) is one of the major adverse events related to the endovascular management of acute ischemic stroke. It is important to evaluate the risk of ICH as it may result in clinical deterioration of the patients. Development of tools which can predict the risk of ICH after thrombectomy can reduce the procedure-related morbidity and mortality. 2D parenchymal blood flow could potentially act as an indicator for ICH. Methods: 2D parenchymal blood flow was used to evaluate pre- and postthrombectomy digital subtraction angiography series of patients with acute ischemic stroke in the anterior circulation. A recently developed software allows the separation of the vascular filling and parenchymal blush signals using band-pass and band-reject filtering to allow for greater visibility of the parenchyma offering a better visual indicator of the effect of treatment. The “wash-in rate” was selected as the parameter of interest to predict ICH. Results: According to the presence or absence of signs of intracranial parenchymal hemorrhage in the follow-up dual-energy CT brain scans, the patients were classified into a hemorrhagic and nonhemorrhagic group (15 patients each). The only significant difference between the groups is the calculated wash-in rate after thrombectomy (p = 0.024). The cutoff value of the wash-in rate after thrombectomy was suggested to be 11,925.0, with 60% sensitivity to predict the hemorrhage and 93.3% specificity. Conclusions: Elevated parametric parenchymal blood flow wash-in rates after thrombectomy may be associated with increased risk of hemorrhagic events.

Abstract NS2: Effect of Volume-Viscosity Swallow Test (V-VST) in Acute Ischemic Stroke Patients With Dysphagia: A Hospital-Based Case-Control Study

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Ting Ye ◽  
Yi Dong ◽  
Shengyan Huang
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Case Control Study ◽  
Tube Feeding ◽  
Case Control ◽  
Stroke Patients ◽  
Post Intervention ◽  
Post Stroke ◽  
Volume Viscosity ◽  
Control Study

Background: The dysphagia screening in acute ischemic stroke plays an important role in patients with risk of dysphagia. The aim of this hospital-based case-control study is to explore if V-VST, as a new nurse-driven dysphagia screening tool for AIS patients, might help to reduce the rate of post-stroke pneumonia and early withdraw of feeding tube. Methods: 1598 acute ischemic stroke patients were enrolled in this study. The standard protocol in AIS patients were assessed by WST (before intervention and plus with V-VST after intervention). The V-VST assessment were be trained in two senior nurses and all AIS patients were assessed by V-VST during July 1and Dec 30 th , 2017. Among 299 AIS patients with suspected, all clinical data were analyzed. The comparison of their rate of pneumonia in hospital and withdraw rate of tubefeeding before discharge were performed between patients post-intervention (January 1, 2018-June 30, 2019)and those admitted before the intervention (January 1, 2016-June 30, 2017). Results: The baseline characteristics of the pre- and post- intervention AIS groups were similar in age, gender, NIHSS. The implementation of V-VST have a statistically significant reducing the risk of pneumonia with an adjusted HR (0.60, 95% CI 0.43-0.84, P=0.003). Additionally, follow-up V-VST were likely to be associated the withdraw rate of tube-feeding at discharge (29/168 vs 38/131 P=0.016).There is also a trend of length of tube-feeding decreasing (8.32±12.27 vs 6.84±8.61 P=0.241). Conclusion: In our study, the V-VST is a feasible bedside tool. The implemental might be associated with the reduction of post-stroke pneumonia. Therefore, it meets the requirements of a clinical screening test for dysphagia in acute stroke patients at bedside. Large prospective interventional study is needed to confirm our findings. V-VST: Volume-viscosity Swallow Test WST: Water Swallow Test AIS: Acute Ischemic Stroke HR: hazard ratio

‘Stroke Room': Diagnosis and Treatment at a Single Location for Rapid Intraarterial Stroke Treatment

2015 ◽  
Vol 40 (5-6) ◽  
pp. 251-257 ◽  
Author(s):  
Andreas Ragoschke-Schumm ◽  
Umut Yilmaz ◽  
Panagiotis Kostopoulos ◽  
Martin Lesmeister ◽  
Matthias Manitz ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Treatment Time ◽  
Diagnosis And Treatment ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Single Location ◽  
Before And After ◽  
Therapeutic Procedures ◽  
Therapeutic Measures

Background: For patients with acute ischemic stroke, intra-arterial treatment (IAT) is considered to be an effective strategy for removing the obstructing clot. Because outcome crucially depends on time to treatment (‘time-is-brain' concept), we assessed the effects of an intervention based on performing all the time-sensitive diagnostic and therapeutic procedures at a single location on the delay before intra-arterial stroke treatment. Methods: Consecutive acute stroke patients with large vessel occlusion who obtained IAT were evaluated before and after implementation (April 26, 2010) of an intervention focused on performing all the diagnostic and therapeutic measures at a single site (‘stroke room'). Result: After implementation of the intervention, the median intervals between admission and first angiography series were significantly shorter for 174 intervention patients (102 min, interquartile range (IQR) 85-120 min) than for 81 control patients (117 min, IQR 89-150 min; p < 0.05), as were the intervals between admission and clot removal or end of angiography (152 min, IQR 123-185 min vs. 190 min, IQR 163-227 min; p < 0.001). However, no significant differences in clinical outcome were observed. Conclusion: This study shows for the, to our knowledge, first time that for patients with acute ischemic stroke, stroke diagnosis and treatment at a single location (‘stroke room') saves crucial time until IAT.

Sign in / Sign up

Export Citation Format

Share Document