how to reduce time between patient arrival and puncture
TRANSCRIPT
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Vipul GuptaNeurointerventional SurgeryArtemis Hospital, Gurgaon
How to reduce time between patient arrival and puncture-
Hospital flow and protocol
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MR CLEAN TrialNetherlands, 2015
ESCAPE TrialCanadian, 2015
EXTEND-IA TrialAustralian, 2015
SWIFT PRIME TrialUSA, 2015
REVASCAT TrialSpanish, 2015
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The most significant factor that can influence positive outcomes is development of a multidisciplinary stroke team and a high level of communication between the emergency room, the neurointerventional team, and the neurology team, along with a concurrent rapid, highly efficient, protocol-based approach to acute stroke management.
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•The Interventional Management of Stroke pilot trials tested combined IV/IA therapy onset.
•Among the 54 cases, only time to angiographic reperfusion and age independently predicted good clinical outcome after angiographic reperfusion.
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Every 30-min delay in angiographic reperfusion reduced the relative likelihood of a good clinical outcome by 12% in adjusted analysis.
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For each 1-hour increase in stroke onset to final digital subtraction angiography (or TICI 2b/3) time, odds of good clinical outcome decreased by 38%.
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Beating the Bullet!!!!
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TIME for recanalization• Onset to door time
• Door to Imaging/picture
• Picture to puncture (P2P)
• Puncture to recanalization time
Hospital processes
Technical skills
• Onset to puncture/groin time
• Onset to recanalization time
• Door to Puncture (D2P)
• Picture to recanalization (P2R)
Society infrastructure
Ultimate predictor
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Onset to groin/reperfusion time
In IMS III, the endovascular arm had a mean onset-to-groin puncture time of 208 minutes and onset to reperfusion was 325 min.
MR RESCUE trial, the mean time from imaging to groin puncture alone was 124 minutes.
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Onset to door time-- Hurdles
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The worst clinical outcomes were noted with door-to-puncture times of 136 minutes or greater
( J Am Heart Assoc. 2014;3:e000859
N=478
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• Parallel Processing, Trust, and Teamwork
• Fast Minimalist Clinical Examination
• Fast, Minimalist Imaging Based on a Decision- Based Paradigm; No Complex Post Processing of Imaging
• No General Anesthesia
• Use the CT Angiography to Plan the Procedure
• Setting Up the Angiography Room
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One hundred forty-six patients (93 pre- vs. 51 post-QI) were analyzed.
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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). The post-QI (ie, parallel process) median picture-to-suite time was 29 minutes (IQR, 21 to 41; P<0.0001).
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P2P Challenges
• CT vs MRI
• Availability of the angiosuite SOS
• 24x 7 neurointerventionist, anaesthetist, technician, nurse
• Team of like minded people
• Overcoming the Financial Barrier
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Imaging…
• CT vs MRI • CT & CTA is the standard • In previous institution – CTP • In current – MRI DW• However, we should have Indian
guideline – CT , CTA. Training of radiologists and neurologists in interpretation
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Stroke protocol
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Lab..
ANGIO SUITE•Biplane lab• Aneurysm, AVM, CAS•Close –co-operation with cardiologist •Lab near the radiology
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Services…• Round the clock services • INR - Three faculty – two radiology and one from
stroke neurology background . We also provide emergency services to selected centres
• The stroke neurologist INR takes care of all stroke patients
• Overlapping – neurology-stroke-INR team• Based on group practice • One fellow – Stroke-INR fellowship
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Technician•Encouraged to stay nearby •Training program
Anesthesia and critical care •NI program is part of clinical neurosciences•Active – neurovascular program – SAH•Neuroanesthesia provide cover as for HI etc hn
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Financial barrier•Most patients don’t have insurance •They have to be explained in simple clear terms •Major stroke, MVO, we can try to save brain, 70% recanalization; 50% good outcome at 3-months; risk of bleed /decompression •Based on written commitment • Show them pictures•Detailed counseling everyday on written form
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Promoting stroke intervention program – In hospital
• Buy-in from fellow neurology and neurosurgery – group practice model
• Hospital admin – all acute neurological emergency , branding
• Common protocol• Protocol presentation and training – neurology,
neurosurgery, emergency, radiology, neurocritical care, all other critical care
• Testimonials • Monitor the results
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Promoting stroke intervention program – outside hospital
• Stroke training program for physicians• Encouraged to take opinions • Neurology services to selected centers • Public lectures – Rotary, Lion clubs• Stroke week • Media
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Rapid Triage Protocol and Stroke Team Notification
Single Call Activation System
Changes at our hospital
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Door time recording by CCTV footage
Door to CT• No dress change
• No valuable transfer
• No consent for CT
• 18 gauge cannula
Transfer Directly to CT
Rapid Acquisition and Interpretation of Brain Imaging
Multimodal imaging protocol (CTA/CTP)
Changes …
•
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Parallel approach
Clinical assessment ‘en route’ to Imaging.Access line and blood investigations (POC)Prepare IV tPAAlert Angio suite/ Lab personnelFinancial considerations/ undertakingConsent – pre written
Changes …
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Times pre and post implementation of parallel processing:
• Picture to Puncture time:• PRE Mean: 80 minutes (21 – 260)• POST Mean: 60 minutes (30 – 140)
(Median – 50 minutes)30 minutes reduction
• Puncture to reperfusion
• POST Median 42 minutes (12 – 120)
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Case
• 60 year old man• History of sudden onset weakness on right
side at 6:30 AM• Arrived in emergency at 8:05AM (95 min)• Global aphasia• NIHSS 16 • Known case of mitral valve replacement• On Acitrom
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8:22 AM (17 min)8:27AM (22 min)
8:31AM ( 26 min)
Patient on acitrom
INR came (8:45 AM)-2.6
IV tpa ruled out
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9:10 AM(65 min) 9:22 AM 9:27 AM( 77 Min)
Door to recanalization time< 90 minImaging to recanlization time< 60 minComplete recovery
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Hospital Layout
TRIAGE
CT Room
DSA Room
Ground Floor
Third Floor
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There was a significant difference between groups for door-to-reperfusion timing,favoring patients admitted during normal business hours (146 versus 165 min, p = 0.02).
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CT to groin puncture was 127 minutes (n=341; IQR 51 minutes) compared with 142 minutes during nighttime (n=63;IQR 60 minutes; P=0.0012)
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Centers performing more than 50 endovascular intra-arterial stroke interventions annually were designated as HV centers.
Patients treated at HV centers were more likely to have a good clinicaloutcome (OR 1.86, 95% CI 1.11 to 3.10, p<0.018) and successful reperfusion (OR 1.82, 95% CI 1.16 to 2.86, p<0.008)
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Puncture to Recanlization time
• Planning on CT angiography
• Local anaesthesia
• No groin preparation
• Putting Foley’s after deploying stent
• Standardized stroke kit that is ready to go
• Use of balloon guide catheter
• Push & Fluff technique
(Stroke. 2014;45:e252-e256.)
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Conclusion
• Improving door to puncture time may be the key
SNIS – 2015 …
• Target Door to puncture < 60 min
Door to recanalization <90 min
• Small steps make a big difference!!!
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Thank you ….