Effect of Workflow Improvements on Time to Endovascular Thrombectomy for Acute Ischemic Stroke in the MR CLEAN Registry

BACKGROUND: Insight in the effect of workflow improvements can help to minimize the time between onset of ischemic stroke and start of endovascular thrombectomy (EVT). The authors aimed to assess the implementation of EVT workflow strategies and their effect on time to treatment. METHODS: The authors used data from the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) registry and included patients with acute ischemic stroke in the anterior circulation, who underwent EVT between March 2014 and November 2017. Data on implementation of 20 predefined workflow improvement strategies during the study period were collected from each intervention center. Multilevel linear regression with a random intercept for center was used to quantify the effect of each strategy on door-to-groin puncture time, with adjustment for calendar time, for directly presented and transferred patients separately. RESULTS: The authors included 2633 patients who were treated in 14 intervention centers. Of the 20 predefined strategies, 18 were actually implemented in >= 1 centers during the study period. In directly presented patients (n=1157), the intervention with the largest effect on door-to-groin puncture time was a strategy to avoid sedation during EVT compared with standard use of general anesthesia, which led to a reduction of 29% (95% CI, 6-46; P=0.02), corresponding to a decrease of 26 minutes (95% CI, 5-42). In transferred patients (n=1476), the interventions with the largest decrease in door-to-groin puncture time were a strategy to make the decision for patient transfer to the angiosuite after 1 stroke physician assessed the imaging, instead of both interventionist and neurologist (47% [95% CI, 5-70]; 19 minutes [95% CI, 2-29]) (P=0.03), and a strategy to perform neurological assessment at the angiosuite instead of the emergency department (32% [95% CI, 19-43]; 13 minutes [95% CI, 8-17]) (P<0.001). CONCLUSION: Intervention centers have implemented multiple new strategies to improve their workflow. Such workflow improvements lead to substantial reductions in time to EVT and may thereby improve the outcome of patients with acute ischemic stroke.