22. European Stroke Conference 609 Acute stroke: emergency management, stroke units and complications Developing a Rapid Stroke Thrombolysis Pathway in a District General Hospital: Implement-ing Value Stream Mapping to Improve Onset-to-Needle Times. J.G.G. Penge1, K. Xu2, V. Umachandran3, G. Zachariah4 Broomfield Hospital, Chelmsford, UNITED KINGDOM1, Broomfield Hospital, Chelmsford, UNITED KINGDOM2, Broomfield Hospital, Chelmsford, UNITED KINGDOM3, Broomfield Hos-pital, Chelmsford, UNITED KINGDOM4 Background Value stream mapping (VSM) derived from lean manufacturing principles, first developed by the motor industry, has been successfully applied to stroke services in the setting of a large American teaching hospital. As existing evidence strongly indicates that earlier thrombolysis treatment in-creases efficacy, we believed it important to examine whether the application of similar principles could significantly improve delays to thrombolysis in a European District General Hospital (DGH). Methods A VSM was created to identify areas of the stroke thrombolysis pathway which could be stream-lined. Inefficient patient flow, use of staff and unnecessary procedures were addressed. Important elements included introduction of an ambulance pre-alert system, removal of the emergency depart-ment from the pathway with direct notification of the stroke team and rapid acquisition of brain im-aging. Door-to-needle (DTN) and onset-to-needle (OTN) times were examined prior to the implementation of changes between April 2010 and September 2011 and post streamlining between November 2011 and May 2012. Ambulance timings were also examined for a 1 month period pre and post change. Results Median DTN time was reduced from 65 minutes (n=80) to 41 minutes (n=38) representing a 37% reduction (p= <0.001). Ambulance median call-to-door times showed a non-statistically significant (p=0.55) improvement from 64 minutes (n=32) to 60 minutes (n=31). Of concern was that only 64% of calls were categorised as being of highest urgency (Category A). Median OTN time fell from 150 minutes (n=80) to 113 minutes (n=38) representing a 25% reduc-tion (p= <0.01) with streamlining of the stroke thrombolysis pathway. Conclusion Thrombolysis times can be improved by the application of VSM to streamline services in the setting of a European DGH. Further application of VSM and resources are required to improve the pre-hospital pathway in order to make further significant reductions in OTN times. 668 © 2013 S. Karger AG, Basel Scientific Programme 610 Acute stroke: emergency management, stroke units and complications The Human Factor in Thrombolysis. The Innsbruck Thrombolysis Registry. M. Knoflach1, R. Pechlaner2, B. Matosevic3, M. Ruecker 4, A. Zangerle5, J. Willeit6, S. Kiechl7 Department of Neurology, Medical University Innsbruck, Innsbruck, AUSTRIA1, Department of Neurology, Medical University Innsbruck, Innsbruck, 2, Department of Neurology, Medical Uni-versity Innsbruck, Innsbruck, 3, Department of Neurology, Medical University Innsbruck, Innsbruck, 4, Department of Neurology, Medical University Innsbruck, Innsbruck, 5, Department of Neurology, Medical University Innsbruck, Innsbruck, 6, Department of Neurology, Medical University Inns-bruck, Innsbruck7 Background: Short onset-to-treatment time is key for a good clinical outcome in intravenous throm-bolysis for ischemic stroke. The door-to-needle time (DNT) is the standard benchmark for the qual-ity of in-hospital processes in acute stroke care and significantly contributes to the onset-to-treat-ment. We aim to assess the human factor i.e. differences in the DNT between different stroke specialists in a single stroke unit. Methods: The neurology department of the medical university Innsbruck (Austria) is primary and secondary referral hospital and houses a comprehensive stroke unit. Thrombolysis is administered in the neurological emergency department or the stroke unit, which are staffed with a stroke specialist. We assessed the DNT of all patients treated with i.v. thrombolysis since approval of rtPA in Europe and analyzed relevant determinants including in individual process measures and patient characteris-tics. Results: Between Oct 2002 and Dec 2012, 625 patients were treated in our department by 16 stroke specialists. A total of 11 have treated more than 20 and were considered in the analysis. After con-trolling for age and sex of the patient, onset-to-door time, NIHSS upon admission, primary imaging modality and clinical syndrome, median DNT differed between stroke specialists. When considering the experience of the stroke physicians, ascertained by the overall number of thrombolysis therapies performed, the differences largely disappeared. Conclusions: Inter-individual variability of the DNT in our center was mainly explained by differ-ences in patient characteristics and differences in individual process measures. Still our data indi-cates that a human factor i.e. inter-individual difference exist between stroke physicians and reflect the respective experience in acute stroke care. A close monitoring and discussion of process mea-sures as well as individual factors leading to possible delays in the application of thrombolysis in acute stroke care is recommended.
Karger_ESC London_2013
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