Improving Door to Groin Puncture Time for Mechanical Thrombectomy via Iterative Quality Protocol Interventions

Introduction: Delays in door to groin puncture time (DGPT) for patients with ischemic stroke caused by acute large vessel occlusions (LVO) are associated with worse clinical outcomes. We present the results of a quality improvement protocol for endovascular stroke treatment at the University of California, San Diego (UCSD) that aimed to minimize DGPT.

Materials and Methods: Our stroke team implemented a series of quality improvement measures to decrease DGPT, with a target of 90 minutes or less. Sixty-three patients treated at our center were retrospectively divided into three groups based on the date of their intervention as a proxy for the implementation of process improvement protocols: 23 patients treated from July to December 2015, 24 patients treated from January to July 2016, and 16 patients treated from July 2016 to December 2016. Multivariate log-linear and logistic regression analyses were used to assess the predictors of prolonged DGPT and compliance with target DGPT (<90 min), respectively.

Results: Date of intervention—a proxy for the implementation of process improvement protocols—was predictive of compliance with target DGPT. Patients treated from July 2016 to December 2016—after the full implementation of process improvements—were 3.2 times more likely to meet or exceed the target DGPT compared to patients treated from July 2015 to December 2015 (p=0.011). When adjusting for potential confounders in a multivariate analysis, patients in the final cohort were associated with shorter DGPT (Exp(B)=0.61, p=0.013) and remained significantly more likely to achieve the DGPT goal (OR=14.2, p=0.007).

Conclusion: An iterative quality improvement process can significantly improve DGPT. This analysis demonstrates the utility of a formal quality improvement system at an academic comprehensive stroke center.

Abstract 050: Improvements in Door to Groin Puncture Time for Surgical Stroke After Quality Protocol Interventions at the University of California, San Diego

Introduction: Delays in door to groin puncture time (DGPT) for patients with ischemic stroke caused by acute large vessel occlusion (LVO) correlate with worse clinical outcomes. Stroke centers aim to minimize DGPT to facilitate prompt intervention and limit ischemic brain injury. In this study, we present the results of a comprehensive quality assessment at the University of California, San Diego (UCSD). From 2015 to 2016, institutional implementation of a quality improvement protocol significantly reduced DGPT.

Materials and Methods: Beginning July 2015, the UCSD interdisciplinary stroke team implemented a series of quality improvement measures to decrease DGPT, with a target of 90 minutes or less. After each case, areas of inefficiency were identified and changes were implemented based on direct feedback from neurointerventional physicians and ancillary staff. Changes included: 1) creation of a pager group notification system to activate the entire neurointerventional team simultaneously, 2) consistently involving anesthesia with each neurointervention, 3) streamlining communication between the vascular neurology and neurointervention teams, and 4) structuring parallel workflows to enhance mobilization speed. R statistical software was utilized to compare DGPT before and after implementation of these process improvements. Patients were divided into three groups based on the date of their intervention as follows: 23 patients treated from July-December 2015, 24 patients treated from January-July 2016, and 14 patients treated from July 2016-December 2016. A multivariable univariate binary logistic regression model was constructed to capture predictors of compliance with our target DGPT (<90 min). Variables analyzed included: date of intervention, mode of patient admission (i.e. transfer, direct admit from ED, inpatient), hospital location, age, and gender.

Results: 61 patients underwent mechanical thrombectomy for treatment of acute LVO from July 2015 to December 2016. In our analysis, date of intervention—as a proxy for implementation of process improvement protocols—and mode of admission were predictive of compliance with target DGPT. Patients who were treated from July 2016 to December 2016—after full implementation of process improvements— were 9.5 times more likely to meet or exceed the target DGPT compared to patients treated July 2015 to December 2015 (p=0.01). Additionally, arrival via transfer from an outside hospital was determined to be an independent predictor of meeting DGPT goals. (p=0.02).

Conclusion: UCSD’s quality improvement process effected dramatic, statistically significant improvement in DGPT. This analysis demonstrates the utility of a formal quality improvement system at a large, academic comprehensive stroke center.

Abstract TP298: Rapid Response Team Utilization for Inpatient Stroke Codes

Introduction: Rapid response teams (RRTs) are a way to provide rapid assessment and early intervention for inpatients with clinical deterioration, including those with acute stroke. The goal of this study is to examine the accuracy and outcomes of inpatient stroke code RRT activations within a hospital system.

Methods: A retrospective chart review was performed for all RRT activations called for inpatient stroke codes within the UC San Diego Healthcare System from January 1, 2014 to November 30, 2015. Relevant variables included: clinical symptoms at the time of RRT initiation, neuroimaging modality (CT, CTA, MRI), IV rt-PA and/or endovascular therapy (ET), event diagnosis, and discharge disposition. We compared patients with diagnosis of stroke (AIS, ICH, SAH, other) versus non-stroke diagnosis. Diagnosis was determined by independent adjudication of provider documentation and corresponding acute and follow-up neuroimaging.

Results: 285 of 2336 (12.2%) RRT activations were for stroke code. Ultimately, 31.2% (n=89) were diagnosed with stroke (61 AIS [68.5%], 17 ICH [19.1%], 2 SAH [2.3%], 2 epidural [2.3%] and 7 subdural hematomas [7.9%]). Of stroke codes, neuroimaging was used more often in patients diagnosed with stroke including CT (97.8% vs 89.3%, p=0.03), CTA (42.7% vs 29.6%, p=0.04), and MRI (28.1% vs 16.3%, p=0.03). Discharge disposition was home in 18.0% vs. 36.2% (p=0.001), skilled nursing facility in 22.5% vs. 27.6% (p=0.001), and inpatient rehabilitation in 11.2% vs. 3.6% (p=0.001). In-hospital mortality was higher in those with stroke (22.5% vs 10.7%, p=0.001). Only 18 patients (6.3%) received acute recanalization therapies (4 IV rt-PA, 12 ET, 2 both).

Conclusions: Relatively few RRT stroke code activations diagnosed acute stroke and few received IV rt-PA and ET. Further studies are needed to better quantify the benefit of RRT in stroke code, explore additional benefits beyond acute recanalization therapies, and consider more targeted assessment for better resource utilization.