ABSTRACT
Background and Objectives: Endovascular therapy (EVT) for stroke has emerged as an important therapy for selected stroke patients, and shorter times to clot removal improve functional outcomes. EVT requires the close coordination of multiple departments and poses unique challenges to care coordination in large hospitals. We present the results of our quality improvement project that aimed to improve our door-to-groin puncture (DTP) times for patients who undergo EVT after direct presentation to our emergency department. Methods: We conducted time-motion studies to understand the full process of an EVT activation and conducted Gemba walks in multiple hospitals. We also reviewed the literature and interviewed stakeholders to create interventions that were implemented over 4 Plan-Do-Study-Act (PDSA) cycles. We retrospectively collected data starting from baseline and during every PDSA cycle. During each cycle, we studied the impact of the interventions, adjusted the interventions, and generated further interventions. A variety of interventions were introduced targeting all aspects of the EVT process. This included parallel processing to reduce waiting time, standardization of protocols and training of staff, behavioral prompts in the form of a stroke clock, and push systems to empower staff to facilitate the forward movement of the patient. A novel role-based communication app to facilitate group communications was also used. Results: Eighty-eight patients spanning across 22 months were analyzed. After the final PDSA cycle, the median DTP time was reduced by 36.5% compared with baseline (130 minutes (interquartile range [IQR] 111-140) to 82.5 minutes (IQR 74.8-100)). There were improvements in all phases of the EVT process with the largest time savings occurring in EVT decision to patient arrival at the angiosuite. Interventions that were most impactful are described. Discussion: EVT is a complex process involving multiple processes and local factors. Analysis of the process from all angles and intervening on multiple small aspects can add up to significant improvements in DTP times.
ABSTRACT
Instrumenting physical assessments in people with Parkinson's disease can provide valuable and sensitive information. This study aimed to investigate whether variables derived from a Kinect-based system can provide incremental value over standard habitual gait speed (HGS) and timed up and go (TUG) variables by evaluating associations with (1) motor and (2) postural instability and gait difficulty (PIGD) subscales of the Unified Parkinson's Disease Rating Scale (UPDRS). Sixty-two individuals with Parkinson's disease (age 66 ± 7 years; 74% male) undertook an instrumented HGS and modified TUG tests, in addition to the UPDRS. Multivariable regression models were used to evaluate the associations of the Kinect measures with UPDRS motor and PIGD scores. First step length during the TUG and average step length and vertical pelvic displacement during the HGS were significantly associated with the PIGD subscale (P < 0.05). The only Kinect-derived variable showing additive benefits over the standard measures for the PIGD association was HGS vertical pelvic displacement. The only standard or Kinect-derived variable significantly associated with the motor subscale was first step length during the TUG (P < 0.01). This study provides preliminary evidence to support the use of a low-cost, non-invasive method of instrumenting gait and TUG tests in people with Parkinson's disease. Graphical abstract á .
