ISQUA18-0032Decrease Door-to-Needle Time (DNT) of Acute Ischemia Stroke with Quality Control Cycle

Abstract

Background and Objective: Comparing with the data of Europe and the United States, cerebrovascular disease in China has its own characteristic as higher morbidity (4-5 times) and mortality. Cerebrovascular disease is the first death cause in China, causing about 1.5 million death per year, accounting for 23% of all deaths. The high disability and recurrence rate brings 40 billion Yuan per year in medical cost. Acute ischemic stroke accounts for 70% of cerebrovascular disease, and the most effective treatment is recanalization in acute paroxysm phase, which including intravenous thrombolysis, intra-arterial thrombolysis and intravascular interventional mechanical treatment. Efficacy of thrombolysis with recombinant tissue plasminogen activator (rt-PA) is timedependent. Patients with DNT (Door-to-Needle Time) less than 60 minutes were confirmed with significantly lower mortality and symptomatic intracranial bleeding rate than the others. In order to eliminate delays, shorten thrombolysis time window and elevate recanalization rate, a multidisciplinary team was aimed at decreasing DNT and improving procedure of acute ischemic stroke diagnosis and treatment within a Medical alliance guided by a tertiary general hospital (Nanfang hospital) in South China. Method(s): 1. Multidisciplinary team including staffs from emergency, neurology, intervention, clinical laboratory, imaging diagnosis, information and quality management department was founded in tertiary hospital and performed improvement based 10 steps of Quality Control Circle. 2. The median DNT of acute ischemic stroke in Nanfang Hospital was 120 minutes(58 cases from January 2015 to June 2016, IQR: 93 minutes, 149 minutes).Only 18% of patients underwent thrombolysis therapy with DNT less than 60 minutes. 3. Several key factors were found through the whole team brainstorming and proven in practical work to be root causes of delays, such as lack of priority identification, postponing neurology consultation, timeconsuming transfer and admission, low efficient communication between doctor, patient and other medical staffs. 4. The following strategies were performed accordingly. First of all, multipoint crossover educating system was established, based on communitypre- hospital first aid-basic level hospital-tertiary general hospital alliance. Education contained residents early prevention -detection, pre- and inhospital seamless corporation mode, screening-diagnosis-transfer guideline of basic level hospitals. Secondly, based on operation strategy and responsibility division of medical, nursing, technical and management personnel, hierarchical professional training and exercise in practice were formed and conducted periodically. Capability assessment and key performance indicator carried out to establish a mechanism for supervision and continuous improvement. Thirdly, suspected acute ischemic stroke patients were whole-process priority identified and treated in multiple parallel processes. Evaluation and treatment in ER was in parallel with initial assessment of neurology physicians, signing informed consent was in parallel with checking laboratory and imaging results, recanalization strategy decision-making and implementation was in parallel with admission procedures. Once recanalization decision made, the intravenous thrombolysis launched in "one-stop" work pattern, no need to transfer out of imaging diagnosis department. The last but not the least, established time targeted management and team resources management mode. Any delay of nodes, as well as possible reasons of the delay should be collected in the minute to minute work-flow recording. Information was published and feedback timely through We-Chat, which can facilitate vulnerabilities disclosure so as to improve continuously. Result(s): After the above quality improvement procedure, the numbers of patients who got recanalization treatment in ischemia stroke acute paroxysm phase have been increased from 56 (from January 2015 to June 2016) to 185 (from July 2016 to December 2017), recanalization rate in emerge t outpatients with indication achieved at 80% vs 30% (the former). Meanwhile no increasing occurrence of therapy-related complications such as symptomatic intracranial bleeding was observed. Residence time in emergency department decreased from median 44 minutes (IQR: 30 minutes, 64 minutes) to 12 minutes (IQR: 6 minutes, 25 minutes), DNT decreased from 120 minutes to 45 minutes (IQR: 34 minutes, 60 minutes), DNT less than 60 minutes proportion increased from 18% to 86%. On basis of thrombolysis time window and cerebral semi-dark zone principle, series of standard operating procedures were established. Education in medical alliance facilitates earlier fist medical contact after episodes and further professional diagnosis in therapy time window. Evaluation and treatment procedure in emergency department shortens door to neurological consultant and imaging time. Computed tomography (CT)/Magnetic Resonance Imaging (MRI) multimodal imaging diagnosis strategy identifies indications and contraindications for optimal recanalization strategy. Recanalization treatment decision making principle is homogenized in medical alliance. A set of thrombolysis tool kit (including thrombolysis drugs, evaluating scales, informed consent paper, basic life support facilities) is developed to assure the convenience and safety of intravenous thrombolysis in "one-stop" work pattern. A medical service radius reaches around 30 kilometers, consisting of one centered tertiary hospital, several secondary hospitals and grassroots medical institutions. Residents get access to stroke risk assessment, standardized evaluation and intravenous thrombolysis in basic level hospitals, synchronized information sharing, followed by transferring to tertiary general hospital and conducting intravascular intervention, finally rehabilitation assessment and follow-up for discharge patients. Discussion(s): 1. Multidisciplinary team in tertiary hospital explores an optimal cooperation mode in treatment of complicated disease. Team resources management makes tidy link in the workflow connected tightly, so as to provide available and continuous medical service. 2. Medical alliance facilitates the formation of regional cooperation in ischemia stroke diagnosis and treatment. This dual referral, seamless corporation mode has obvious advantage in delivering integrative and continuous care for cerebrovascular disease, and optimal allocating of medical resources. 3. Our endeavor to quality improvement is strictly performed based on Plan-Do-Check-Act circle during 18-months practical work. Quality Control Circle, as a practical tool for quality management, plays important roles on staff motivation, data-based analysis, optimal strategy selection and continuous improvement. The achievement gets peer recognition and initiates a joint Quality Control Circle project, which involves 27 tertiary general hospitals scattering in Guangdong province to found a large-scale medical combination and promote the regional level of acute ischemia stoke diagnosis and treatment in Guangdong province, South China.