Optimizing Door-to-Groin Puncture Time: The Mayo Clinic Experience

India Rangel; Paolo Palmisciano; Vanesa K Vanderhye; Tarek Y El Ahmadieh; Waseem Wahood; Bart M Demaerschalk; Kara A Sands; Cumara B O'Carroll; Chandan Krishna; Richard S Zimmerman; Brian W Chong; Bernard R Bendok; Ali H Turkmani

doi:10.1016/j.mayocpiqo.2022.05.009

Optimizing Door-to-Groin Puncture Time: The Mayo Clinic Experience

Mayo Clin Proc Innov Qual Outcomes. 2022 Jun 27;6(4):327-336. doi: 10.1016/j.mayocpiqo.2022.05.009. eCollection 2022 Aug.

Authors

Affiliations

¹ Mayo Clinic Alix School of Medicine, Scottsdale, AZ.
² Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy.
³ Department of Neurology, Mayo Clinic, Phoenix, AZ.
⁴ Department of Neurological Surgery, Mayo Clinic, Phoenix, AZ.
⁵ Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York City, NY.
⁶ Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, FL.
⁷ Department of Radiology, Mayo Clinic, Phoenix, AZ.

Abstract

Objectives: To provide a better understanding of methods that can be used to improve patient outcomes by reducing the door-to-groin puncture (DTP) time and present the results of a stroke quality improvement project (QIP) conducted by Mayo Clinic Arizona's stroke center.

Methods: We conducted a systematic literature search of Ovid MEDLINE(R), Ovid EMBASE, Scopus, and Web of Science for studies that evaluated DTP time reduction strategies. Those determined eligible for the purpose of this analysis were assessed for quality. The strategies for DTP time reduction were categorized on the basis of modified Target: Stroke Phase III recommendations and analyzed using a meta-analysis. The Mayo Clinic QIP implemented a single-call activation system to reduce DTP times by decreasing the time from neurosurgery notification to case start.

Results: Fourteen studies were selected for the analysis, consisting of 2277 patients with acute ischemic stroke secondary to large-vessel occlusions. After intervention, all the studies showed a reduction in the DTP time, with the pooled DTP improvement being the standardized mean difference (1.37; 95% confidence interval, 1.20-1.93; τ²=1.09; P<.001). The Mayo Clinic QIP similarly displayed a DTP time reduction, with the DTP time dropping from 125.1 to 82.5 minutes after strategy implementation.

Conclusion: Computed tomography flow modifications produced the largest and most consistent reduction in the DTP time. However, the reduction in the DTP time across all the studies suggests that any systematic protocol aimed at reducing the DTP time can produce a beneficial effect. The relative novelty of mechanical thrombectomy and the consequential lack of research call for future investigation into the efficacy of varying DTP time reduction strategies.

Keywords: AIS, acute ischemic stroke; CT, computed tomography; DTP, door-to-groin puncture; ED, emergency department; LVO, large-vessel occlusion; MT, mechanical thrombectomy; QIP, quality improvement project; SMD, standardized mean difference.