Workflow Optimization for Ischemic Stroke in a Community-Based Stroke Center

Amin Aghaebrahim; Manuel F Granja; Guilherme J Agnoletto; Pedro Aguilar-Salinas; Gustavo M Cortez; Roberta Santos; Andre Monteiro; Wendy Camp; Jason Day; Scott Dellorso; Neeraj Naval; Mohamad Chmayssani; Richard Stromberg; Matthew C Rill; Eric Sauvageau; Ricardo Hanel

doi:10.1016/j.wneu.2019.05.127

Workflow Optimization for Ischemic Stroke in a Community-Based Stroke Center

World Neurosurg. 2019 Sep:129:e273-e278. doi: 10.1016/j.wneu.2019.05.127. Epub 2019 May 28.

Authors

Amin Aghaebrahim¹, Manuel F Granja², Guilherme J Agnoletto², Pedro Aguilar-Salinas², Gustavo M Cortez², Roberta Santos², Andre Monteiro², Wendy Camp², Jason Day², Scott Dellorso², Neeraj Naval², Mohamad Chmayssani², Richard Stromberg³, Matthew C Rill³, Eric Sauvageau², Ricardo Hanel²

Affiliations

¹ Baptist Neurological Institute, Lyerly Neurosurgery/Baptist Health, Jacksonville, Florida, USA. Electronic address: Amin.Aghaebrahim@bmcjax.com.
² Baptist Neurological Institute, Lyerly Neurosurgery/Baptist Health, Jacksonville, Florida, USA.
³ Emergency Department, Baptist Medical Center, Jacksonville, Florida, USA.

PMID: 31146041
DOI: 10.1016/j.wneu.2019.05.127

Abstract

Background: We analyzed the effect of specific optimization steps to reduce treatment delays in a nonacademic stroke hospital setting.

Methods: The data from patients with ischemic stroke who had been treated with intravenous tissue plasminogen activator or endovascular therapy, or both, were analyzed. The metrics were divided into 2 periods: preoptimization period (October 1, 2015 to September 30, 2016) and postoptimization period (October 1, 2016 to September 30, 2017). The key interventions were 1) notification by the emergency medical service to the emergency department and stroke team; 2) division of the stroke alert between level 1 (intravenous/intra-arterial candidate) and level 2; 3) direct transportation of level 1 patients to brain computed tomography; 4) limitation of nonessential interventions; 5) stroke orientation; 6) 24-hour, 7-day code stroke response by a vascular neurologist; 7) earlier notification of the interventional radiology team; 8) direct transportation from computed tomography to angiography suite for large vessel occlusion; and 9) multidisciplinary monthly meetings to discuss delayed cases.

Results: A total of 279 patients were identified. No significant differences in any of the baseline characteristics were documented. Almost all metrics favored the postoptimization period, with remarkable improvement in the door-to-puncture time (median, 64 minutes; interquartile range, 36-86; vs. 47 minutes; interquartile range, 20-62; P = 0.001). We observed an increased percentage of good clinical outcomes in the postoptimization group (60.1% vs. 54.8%; P = 0.500). We found an 8.4% increase in patients with good clinical outcomes in the postoptimization group compared with our previously reported work.

Conclusions: For acute reperfusion therapies, significant reductions in workflow intervals can be achieved after simple optimization methods in a nonacademic community-based hospital.

Keywords: Endovascular treatment; Reperfusion; Stroke; Thrombectomy; Workflow.

MeSH terms

Aged
Aged, 80 and over
Brain Ischemia / drug therapy
Brain Ischemia / therapy*
Endovascular Procedures / methods*
Female
Fibrinolytic Agents / therapeutic use*
Humans
Male
Middle Aged
Stroke / drug therapy
Stroke / therapy*
Thrombectomy / methods*
Time-to-Treatment
Tissue Plasminogen Activator / therapeutic use*
Treatment Outcome
Workflow*

Substances

Fibrinolytic Agents
Tissue Plasminogen Activator