Background The efficacy of endovascular therapy (EVT) as the standard of care for acute ischemic stroke attributable to vessel occlusion improves when delivered quickly. Time metrics have been proposed in order to facilitate quality assurance and there are numerous strategies to streamline workflow. The concept of a combined CT-Angiography-surgical (hybrid) suite in close proximity to the emergency room has been proposed as an innovative and multidisciplinary opportunity to reduce the time required for diagnosis and treatment of neurovascular disease including stroke. We describe our interval times for the endovascular treatment of stroke from patient arrival in the emergency room (door) and imaging (CT) to initiation of treatment (arterial access) before and after two interventions: first, a multifaceted but intuitive quality improvement initiative and second, the opening of an interdisciplinary hybrid operating room composed of a sliding CT scanner, a robotic C-arm and both sterile and non-sterile functionality.
Methods Data are from a single center’s neurointerventional database from January 2017 to July 2019, excluding in-house stroke patients and patients who had imaging at an outside hospital. Workflow metrics acquired were: door to arterial access (DTA) and CT first image acquisition to arterial access (ITA). Data are described by calendar year and half-years and subdivided by two different angiography suites: the usual neuroangiography biplane suite (BS) located distant to the emergency room (ER) and the hybrid suite (HS) immediately adjacent to the ER. The details of the quality improvement initiative were obtained from internal organizational documents as were the details of the training required for the opening of the hybrid room and the subsequently encountered problems.
Results After the launch of a modest stroke quality improvement initiative in January 2018 until July 2019 (n=208), both average DTA and ITA decreased every 6 months in the BS, from 116 to 81 minutes and 86 to 64 minutes, respectively. Despite extensive training and preparation, the opening of the HS in the second half of 2018 showed worse DTA and ITA not only for the first 6 months (18 patients) but also for the first half of 2019 (33 patients) compared to the BS although improvement was demonstrated over the first year of operation. Several setbacks and challenges were associated with the HS most notably with the monoplane robotic C-arm and monitor.
Conclusion A workflow quality improvement initiative had a durable effect on reducing EVT treatment times overall and particularly in the existing, geographically distant biplane suite, however, the new lower times were not reproducible within the complicated infrastructure of a new modern hybrid suite next to the ER.
Disclosures K. Blackham: None. G. Karwacki: None. D. Zumofen: None. T. Schubert: None. M. Psychogios: None.
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