key: cord-0810168-p9n4ogg8 authors: Chen, Yimin; Nguyen, Thanh N; Wellington, Jack; Mofatteh, Mohammad; Yao, Weiping; Hu, Zhaohui; Kuang, Qiuping; Wu, Weijuan; Wang, Xuejun; Sun, Yu; Ouyang, Kexun; Xu, Junmiao; Huang, Weiquan; Yang, Shuiquan title: Shortening Door-to-Needle Time by Multidisciplinary Collaboration and Workflow Optimization During the COVID-19 Pandemic date: 2021-10-20 journal: J Stroke Cerebrovasc Dis DOI: 10.1016/j.jstrokecerebrovasdis.2021.106179 sha: 1fb56001ca93815a64a1c3f898515e011d1df813 doc_id: 810168 cord_uid: p9n4ogg8 Objectives: This study aims to evaluate shortening door-to-needle time of intravenous recombinant tissue plasminogen activator of acute ischemic stroke patients by multidisciplinary collaboration and workflow optimization based on our hospital resources. Materials and Methods: We included patients undergoing thrombolysis with intravenous recombinant tissue plasminogen activator from January 1, 2018, to September 30, 2020. Patients were divided into pre- (January 1, 2018, to December 31, 2019) and post-intervention groups (January 1, 2020, to September 31, 2020). We conducted multi-department collaboration and process optimization by implementing 16 different measures in prehospital, in-hospital, and post-acute feedback stages for acute ischemic stroke patients treated with intravenous thrombolysis. A comparison of outcomes between both groups was analyzed. Results: Two hundred and sixty-three patients received intravenous recombinant tissue plasminogen activator in our hospital during the study period, with 128 and 135 patients receiving treatment in the pre-intervention and post-intervention groups, respectively. The median (interquartile range) door-to-needle time decreased significantly from 57.0 (45.3-77.8) minutes to 37.0 (29.0-49.0) minutes. Door-to-needle time was shortened to 32 minutes in the post-intervention period in the 3(rd) quarter of 2020. The door-to-needle times at the metrics of ≤30 min, ≤45 min, ≤60 min improved considerably, and the DNT>60min metric exhibited a significant reduction. Conclusions: A multidisciplinary collaboration and continuous process optimization can result in overall shortened door-to-needle despite the challenges incurred by the COVID-19 pandemic. The effect of thrombolysis is time-dependent. Intravenous recombinant tissue plasminogen activator (IV-rtPA) has significantly improved patient outcomes when administrated within 4.5 hours of symptom onset and in the extended time window [1] [2] [3] . To maximize clinical benefit, all efforts should be undertaken to shorten the treatment delay. [1] [2] [3] Patients affected by large vessel infarction lose approximately 1.9 million neurons every minute without reperfusion [4] . Previously, researchers at the Helsinki University Central Hospital implemented measures to reduce delays and shorten the median door-to-needle (DNT) to 20 minutes with an interquartile range (IQR) of 14-32 minutes [5] . However, less than 30% of patients had the recommended door-to-CT-time (DCT) of 20 minutes and DNT of 60 minutes by the American Medical Association (AMA) [7] . The Canadian Stroke Best Practices Recommendations (CSBPR) advised DNT for acute stroke should be reduced to a median of 30 minutes [6] . Committee (CSPPC) program of 380 Chinese stroke centers to be 48 minutes (add IQR if available) [8] . Previous studies demonstrated that door-to-needle time could be shortened in most centers by understanding the causes of delays to rapid treatment and the implementation of parallel workflow strategies [9] . Our hospital in Foshan, Guangdong province, China, is an 898-bed tertiary hospital. Suspected acute stroke patients arriving at our emergency department enter our stroke priority green pathway. Emergency physicians receive patients as a priority and request urgent neurological consultation. This study aimed to evaluate whether a multi-department collaboration and workflow optimization protocol could shorten the DNT of IV rt-PA in patients presenting with acute ischemic stroke. Our respective emergency department included patients undergoing thrombolysis with IV rt-PA from January 1, 2018, to September 30, 2020. All other patients diagnosed with ischemic stroke but who did not receive thrombolysis with IV rt-PA were excluded. In anticipation of stroke protocol changes that would be necessary at the beginning of the COVID-19 pandemic [10] , we continuously refined and disseminated our protocol since its implementation in January of 2020. Patients were divided into pre-intervention (from January 1, 2018, to December 31, 2019) and post-intervention groups (January 1, 2020, to September 31, 2020). It is worth mentioning that the post-intervention group coincided with the start of the COVID-19 pandemic. Patient demographics, including associated risk factors of stroke, NIHSS score on emergency department arrival, symptom onset-to-door time (ODT), DCT, CT-to-needle-time (CNT), DNT, onset-to-needle time (ONT), and intracranial hemorrhagic complications, were recorded. A comparison of outcomes between both groups was analyzed. The hospital ethics committee approved this study. To shorten DNT at our hospital via multidisciplinary and workflow optimization in prehospital, in-hospital, and feedback stages, we implemented the following Rewarding associated staff of emergency, neurology, and radiology departments financially if DNT was less than or equal to 60 minutes 15) Connecting with the regional Health Bureau and media department of the hospital to raise awareness and public education of acute stroke 16) Reinforcing standard procedures for acute stroke management after the post-intervention period to achieve a sustainable patient outcome. The results are reported as the median with IQR and the mean ± standard deviation or frequency (displayed in percentages). The relationships of the baseline characteristics and clinical factors between the pre-intervention and post-intervention groups were assessed using an independent sample t-test, Mann-Whitney U-test, Pearson chi-square test, or Nonparameter test. All statistical analyzes were performed using were considered significant. In our hospital, two hundred and sixty-three patients received IV rt-PA, with 128 and 135 patients receiving IV rtPA in the pre-intervention and post-intervention groups, respectively. The baseline characteristics of both patient groups are exhibited in Table 1 . When comparing baseline characteristics in both groups, the pre-intervention group consisted of a higher proportion of patients admitted with previous stroke (p-value = 0.001). Mean age, sex ratio, and median admission NIHSS scores showed no significant differences. Prior history of hypertension, atrial fibrillation, diabetes mellitus, coronary heart disease, hyperlipidemia, and thrombectomy displayed no difference between the two groups. The comparison of clinical outcomes is shown in Table 2 September is shown in table 3. Our study showed that multidisciplinary collaboration and workflow optimization could be considered an effective strategy to reduce DNT (Figure 1 This study consists of a single-center retrospective design with a lack of reporting of patients' outcomes at 90 days. Future multicenter studies, including patient outcomes, will be essential to monitor for continued stroke quality improvement. Our study demonstrated that multidisciplinary collaboration and process optimization could shorten DNT significantly during the COVID-19 pandemic period. Adaptations to workflow optimization and multidisciplinary case management may further benefit healthcare professionals during events of unforeseeable precedences, such as the COVID-19 pandemic and other emergencies in the future. Therefore, as healthcare professionals trained in the management of acute stroke, we should make every minute count, from prehospital to inpatient processing, alongside immediate clinical feedback. Yimin Not applicable. The data will be available upon request from the corresponding author. CT-to-needle time, ONT: onset-to-needle time. 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All authors have no conflict of interest.