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Dr. Christopher Southwood awarded the Daniel M. Soref Fellowship for Clinical Neuroscience

Christopher Southwood, MDDr. Christopher Southwood, a fellow in Neuro-Critical Care, was awarded the Daniel M. Soref Fellowship for Clinical Neuroscience at the Medical College of Wisconsin for the 2019/2020 academic year in a competitive process. Clinical fellows from throughout Neurosciences are invited to submit research projects for consideration. Those projects are then judged by a group of researchers and leaders in Neurosciences. Dr. Southwood’s research on improving door-to-device times for acute ischemic stroke thrombectomy patients is being generously supported by the Daniel M. Soref Trust. Dr. Marc Lazzaro, a specialist in Vascular Neurology and Endovascular Surgical Neuroradiology and the Program Director of the Neurointervention fellowship program is serving as Dr. Southwood’s mentor.

Dr. Southwood’s Proposal

Stroke is the fifth leading cause of death in the United States and recognized as a leading cause of disability1. Treatment of acute ischemic stroke has undergone a revolution within the last half-decade with focuses on improving access to thrombolytic pharmacologic therapy and later overwhelming evidence supporting endovascular therapy (EVT). Treatment with pharmacological thrombolysis with alteplase (tPA) has also been refined to enhance access for more patients. Specifically, the American Heart Association/American Stroke Association has implemented a Target: Stroke initiative to streamline processes and efficiently deliver reperfusion therapy in a timely fashion. This initiative has successfully reduced Door-to-Needle times. Specifically, at Froedtert hospital we have been able to improve our door-to-needle times by 34 minutes over the last 5 years.

In 2015, EVT was firmly established within six hours to significantly improve functional recovery. Thrombectomy treatment for acute ischemic stroke has been further validated up to 24 hours, allowing for more stroke patients to attain functional independence. Now, the focus has turned to streamlining the endovascular therapy processes to improve efficiency and outcomes, deemed Door-to-Device (DTD) target times as has been supported by some of the thrombectomy trials2,3. The ESCAPE trial emphasized efficient workflow to achieve fast vessel recanalization2. As the Target: Stroke program enters phase III, the DTD will target 50% of patients in 90 minutes or less for patients entering Froedtert’s emergency room, and for DTD targeting less than 60 minutes for patients transferred from outside facilities4.

Aims

Hypothesis: Existing processes and workflows at Froedtert Hospital for patient management, care team activation, and transport in the Door-to-Device (DTD) phase of care contain inefficiencies leading to time delay, which can be improved with a systematic review, revision, and implementation of time-sensitive process updates.

Aim 1: Perform a retrospective analysis of previously collected time intervals for all patients with acute ischemic stroke who underwent thrombectomy.

Aim 2: Convene a multidisciplinary workgroup to review and compare time intervals with published data, identify areas for potential improvement, and propose a revised process for patient management in the DTD phase of care targeting a safe and meaningful reduction in time.

Aim 3: Perform Plan-Do-Study-Act (PDSA) cycles to implement and assess effectiveness of change, specifically for a safe and meaningful reduction in time.

Methods

To accomplish these aims, I will work closely with my mentor to complete a retrospective analysis of time intervals for patients undergoing acute stroke thrombectomy. This project will entail multiple Plan-Do-Study-Act (PDSA) cycles to streamline our DTD process for endovascular therapy. Specifically, there will be an in-depth analysis of our current state and examining our practices, standards, and identifying the stakeholders in this process including representatives from emergency medicine, radiology, stroke neurology, neurointervention, anesthesia, nurses, interventional radiology technologists, the Access Center, operators, and patient transport staff. In order to improve our process, it will be imperative to understand the challenges encountered across our multidisciplinary treatment team. This will require establishing metrics to accurately assess our current state and understanding national standards and targets to set and reach our goals. Changes concepts will aim to eliminate waste, improve workflow, optimize inventory, improve the work environment, reduce variation, and avoid errors. Through multiple PDSA cycles, it will be important to reduce waste and inefficiencies across every team members’ roles to improve our metrics. Future directions include taking patients directly from the CT scanner to the angiography suite without delaying for image interpretation, improving patient transport times to eliminate waste, working with anesthesia in parallel to avoid waste, standardizing a “stroke cart” so the radiology technologists can very quickly reach for the tools needed for any stroke case. The IV tPA door-to-needle times at Froedtert Hospital have already improved by 34 minutes using similar efforts to improve processes and workflow. The environment, multidisciplinary collaboration, and resources exist to make this a successful project.

Significance and potential Impact

Process and workflow inefficiencies may lead to unnecessary delays in delivering the critical and time-sensitive therapy of thrombectomy to acute ischemic stroke patients. Through improving the process of endovascular therapy for acute ischemic stroke, there is potential for significant impact for each patient treated around Wisconsin. The well-established mantra of “time in brain” remains true as the estimated rate of neuron death is 1.9 million for each minute in which stroke is untreated5. The aim to improve our metrics to meet the proposed goals in Target: Stroke phase III will undoubtedly improve each patients’ chances of recovery while reducing the burden of death and disability on our community. Similar projects are underway nationwide6, but it will be important to understand the unique challenges within the Froedtert health system to help patients in Wisconsin.