Reducing door-to-puncture times for intra-arterial stroke therapy: A pilot quality improvement project

Brijesh P. Mehta, Thabele M. Leslie-Mazwi, Ronil V. Chandra, Donnie L. Bell, Chung-Huan J. Sun, Joshua A. Hirsch, James D. Rabinov, Natalia S. Rost, Lee H. Schwamm, Joshua N. Goldstein, Wilton C. Levine, Rishi Gupta, Albert J. Yoo

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Background-Delays to intra-arterial therapy (IAT) lead to worse outcomes in stroke patients with proximal occlusions. Little is known regarding the magnitude of, and reasons for, these delays. In a pilot quality improvement (QI) project, we sought to examine and improve our door-puncture times. Methods and Results-For anterior-circulation stroke patients who underwent IAT, we retrospectively calculated in-hospital time delays associated with various phases from patient arrival to groin puncture. We formulated and then implemented a process change targeted to the phase with the greatest delay. We examined the impact on time to treatment by comparing the pre- and post-QI cohorts. One hundred forty-six patients (93 pre- vs. 51 post-QI) were analyzed. In the pre-QI cohort (ie, sequential process), the greatest delay occurred from imaging to the neurointerventional (NI) suite ("picture-suite": median, 62 minutes; interquartile range [IQR], 40 to 82). A QI measure was instituted so that the NI team and anesthesiologist were assembled and the suite set up in parallel with completion of imaging and decision making. The post-QI (ie, parallel process) median picture-to-suite time was 29 minutes (IQR, 21 to 41; P < 0.0001). There was a 36-minute reduction in median door-to-puncture time (143 vs. 107 minutes; P < 0.0001). Parallel workflow and presentation during work hours were independent predictors of shorter door-puncture times. Conclusions-In-hospital delays are a major obstacle to timely IAT. A simple approach for achieving substantial time savings is to mobilize the NI and anesthesia teams during patient evaluation and treatment decision making. This parallel workflow resulted in a > 30-minute (25%) reduction in median door-to-puncture times.

Original languageEnglish
Article numbere000963
Number of pages9
JournalJournal of the American Heart Association
Issue number6
Publication statusPublished - 17 Dec 2014
Externally publishedYes


  • Acute ischemic stroke
  • Endovascular stroke thrombectomy
  • Quality improvement
  • Stroke process improvement

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