Reducing Door-to-Reperfusion Time for Mechanical Thrombectomy With a Multitiered Notification System for Acute Ischemic Stroke

OBJECTIVE

To reduce door-to-angiographic reperfusion (DTR) time to 120 minutes for patients presenting with acute ischemic stroke attributed to anterior circulation large-vessel occlusion amenable to endovascular mechanical thrombectomy.

PATIENTS AND METHODS

Patients treated with mechanical thrombectomy before (April 10, 2015, through April 11, 2016) and after (April 12, 2016, through May 10, 2017) implementation of a multitiered notification system were studied. Lean process mapping was used to assess inefficiencies with multidisciplinary triage. A 3-tiered paging platform, which rapidly alerts essential personnel of the acute ischemic stroke team at advancing decision points, was introduced.

RESULTS

Sixty-two patients were analyzed before and after implementation (34 vs 28, respectively). Following intervention, DTR time was reduced by 43 minutes (mean DTR, 170 minutes vs 127 minutes; P=.02). At 90-day follow up, 5 of the 28 patients in the postintervention cohort (19%) had excellent neurologic outcomes, defined as a modified Rankin Scale score of 0, compared to 0 of 34 (0%) in the preintervention cohort (P=.89). Reductions were also seen in the length of stay on the neurocritical care service (mean, 6 vs 3 days; P=.006), and total hospital charges for combined groups (mean, $100,083 vs $161,458; P<.001).

CONCLUSION

The multitiered notification system was a feasible solution for improving DTR within our institution, resulting in reductions of overall DTR time, neurocritical care service length of stay, and total hospital charges.

Chronic ventilator dependence in elderly patients

Long-term ventilator dependence is the need for mechanical ventilation for more than 6 h/d for more than 21 days. Long-term ventilator dependence complicates 9% to 20% of the episodes of mechanical ventilation treated in the intensive care units of acute care hospitals; it is associated with an average mortality rate of 40%. Unlike acute respiratory failure, the risk for which does not increase with age, long-term ventilator dependence falls disproportionately to patients aged 70 years or older. During the past 2 decades, a profusion of care sites for patients with long-term ventilator dependence has evolved, largely as the product of the prospective payment system for health services introduced by the Health Care Financing Administration in 1983. The outcome of long-term ventilator dependence in elderly patients across this health care continuum is addressed.

Missouri rural adolescent pregnancy project (MORAPP)

The purpose of this study was to investigate the pregnancy outcomes and services available to adolescent women in Missouri, comparing rural and urban residents. A secondary analysis of a large public use data set obtained from the Missouri Department of Health was done for the 5-year period 1992 to 1996. Data were collected by county, with each of the 114 counties of the state classified as rural or urban. The SAS program was used for analysis. Results demonstrated definite patterns of similarity and dissimilarity among the teen mothers based on residence, when age and race were controlled. There were over 54,000 births to adolescent mothers in the 5-year study period. Among the outcomes of pregnancy studied were: abortion rates, inadequate weight gain, intrauterine growth retardation, and low-birthweight (LBW) infants. Among the services available to the young mothers that were studied were fertility services, WIC (women, infants, and children supplemental nutrition) program, food stamps, and Medicaid coverage for pregnancy and infant care. The outcomes are probably generalizable to Midwestern, rural/urban states similar to Missouri.