TOPIC REVIEW – QUALITY IMPROVEMENT IN ISCHEMIC STROKE
TREATMENT
Saharsh Dass
Loma Linda University
HLIF 526: Quality and Performance Improvement
Professor Cloutier
November 5, 2024
TOPIC
Advancing Ischemic Stroke Treatment – Application of Lean/Six Sigma Principles for the
Effectiveness of Endovascular Intervention in Patients with Varying Ischemic Core Growth
Rates and Treatment Time Windows
EXECUTIVE SUMMARY
The literature outlined in this paper document the advances in understanding how to better
address acute ischemic stroke treatment with endovascular thrombectomy (EVT) for enhancing
treatment protocols, patient outcomes and how the lean/six sigma principles were applied to each
specific publication. The guidelines from the multiple stroke care societies established an
optimized workflow and timely EVT eligibility decisions derived from the DAWN and DEFUSE
trials. The expansion of the treatment window is also an important factor that relies on image-
based selection also shows promise for improved recovery rates with more eligible patients.
Studies also document that a faster ischemic core growth rate can be more beneficial for
recovery outcomes after EVT and should be prioritized to minimize delays. Other meta-analyses
further confirms that each hour of delay in treatment can lead to unfavorable events. Thus,
applying tools from the lean six sigma process from process mapping to value stream analysis,
reduction of door-to-treatment times can better support quality of care and patient recovery.
ANNOTATED BIBLIOGRAPHY
1. From the American Association of Neurological Surgeons (AANS), American Society of
Neuroradiology (ASNR), Cardiovascular and Interventional Radiology Society of Europe
(CIRSE), Canadian Interventional Radiology Association (CIRA), Congress of Neurological
Surgeons (CNS), European Society of Minimally Invasive Neurological Therapy (ESMINT),
European Society of Neuroradiology (ESNR), European Stroke Organization (ESO), Society
for Cardiovascular Angiography and Interventions (SCAI), Society of Interventional
Radiology (SIR), Society of NeuroInterventional Surgery (SNIS), and World Stroke
Organization (WSO), Sacks, D., Baxter, B., Campbell, B. C. V., Carpenter, J. S., Cognard,
C., Dippel, D., Eesa, M., Fischer, U., Hausegger, K., Hirsch, J. A., Hussain, M. S., Jansen,
O., Jayaraman, M. V., Khalessi, A. A., Kluck, B. W., Lavine, S., Meyers, P. M., Ramee, S.,
Rüfenacht, D. A., … Vorwerk, D. (2018). Multisociety Consensus Quality Improvement
Revised Consensus Statement for Endovascular Therapy of Acute Ischemic Stroke. AJNR.
American journal of neuroradiology, 39(6), E61–E76. https://doi.org/10.3174/ajnr.A5638
- In this publication, the authors have formed a comprehensive guideline by generating a
statement in collaboration with a variety of society’s that participate in stroke care. The
guidelines focus on the techniques used in the procedures, post-procedure care, and the
function of endovascular therapy. The authors also paid close attention to quality
improvement metrics with respect to improving patient outcomes, their workflow efficiency,
and finding ways to leverage advanced imaging techniques making EVT eligibility decisions
in a timely fashion. One Lean principle focused on reducing waste and enhancing patient
workflow which can fall under process mapping and standardization. Being able to track
procedural times and outcomes. There were some improvements put in place which included
having a triage process, better imaging protocols and pre-procedural preparations. The
authors emphasized widespread use of CT perfusion and MRI to better identify patients who
would benefit from EVT. Some of the results achieved include adoption of the guidelines
which improved the outcomes of the patients based on evidence-based studies of DAWN and
DEFUSE. Organizations the follow these protocols have better practices and quality of care.
2. Albers G. W. (2018). Late Window Paradox. Stroke, 49(3), 768–771.
https://doi.org/10.1161/STROKEAHA.117.020200
- In this article the authors emphasizes that there increased efficacy in treatment patients
experiencing acute ischemic stroke beyond the set 6-hour treatment window with
thrombectomy. CT perfusion and MRI help with identification of brain tissue beyond the
window. Furthermore, the article challenges some of the assumptions on the irreversibility of
brain damage. This article uses some specific data driven analytical approaches that are
drawn from the DAWN and DEFUSE 3 clinical trial to identify opportunities for
improvement. A root-cause analysis of understanding the reasons to why patients respond
well to thrombectomy during the late period is an improvement area. This article highlights a
potential shift in treatment guidelines based on image-based findings instead of the strict 6-
hour window period. Thus, there is room for more improvement within an expanded 24-hour
period to increase the number of eligible patients. Some of the results achieved included
broader treatment eligibility criteria
3. Jadhav, A. P., Haussen, D. C., et al. (2018). Thrombectomy 6 to 24 hours after stroke with a
mismatch between deficit and infarct. New England Journal of Medicine, 378(1), 11–21.
https://doi.org/10.1056/NEJMoa1706442
- This article particularly looks at the efficacy of performing a thrombectomy between the 6–
24-hour window period as compared to the standard period within 0-6 hours. The participants
were put into either the thrombectomy and standard therapy group or the standard medical
therapy group alone. The authors found that the patients in the thrombectomy group had a
better Rankin scale assessment indicating a favorable outcome. There was no significant
difference in the adverse events experienced between the two groups as well. Although this
was more of a focus on clinical procedure outcome versus lean/six sigma tools analysis, there
can be broader applications for this research for process mapping to streamline clinical
protocols and guidelines for treatment of future patients. The improvements put in place
include the protocol changes. The results achieved are promising in terms of the Rankin
score and the safety and adverse event profile.
4. Lin, L., Zhang, H., Chen, C., Bivard, A., Butcher, K., Garcia-Esperon, C., Spratt, N. J., Levi,
C. R., Parsons, M. W., Li, G., & INSPIRE Study Group (2021). Stroke Patients With Faster
Core Growth Have Greater Benefit From Endovascular Therapy. Stroke, 52(12), 3998–4006.
https://doi.org/10.1161/STROKEAHA.121.034205
- In this study, the authors look at how the rate at which the ischemic core growth influences
the results from EVT. This was a retrospective study that looked at various clinical trials and
observational studies. Stroke patients had their ischemic core growth rate measured before
treatment using imaging data and the outcomes were evaluated using the Rankin score. The
findings from the study showed that patients with faster ischemic growth rate had better
improvements in their post-EVT outcomes. Thus, it is concluded that patients who have a
faster ischemic growth rate and greater potential for improvement should be prioritized in
treatment with EVT as they will most likely benefit from it. I think a good process flow
analysis is done recommending better identification of patients who can benefit from it which
goes into a pareto analysis to identify and prioritize factors that impact delays in EVT. The
improvements suggested focus on the prioritization of certain patients. The results showed
that there are better functional recovery outcomes for patients with faster growth rates and
the reduction of time between when the patient is admitted to when they have a procedure
done is an important operational area to consider improving.
5. Saver, J. L., Goyal, M., van der Lugt, A., Menon, B. K., Majoie, C. B., Dippel, D. W.,
Campbell, B. C., Nogueira, R. G., Demchuk, A. M., Tomasello, A., Cardona, P., Devlin, T.
G., Frei, D. F., du Mesnil de Rochemont, R., Berkhemer, O. A., Jovin, T. G., Siddiqui, A. H.,
van Zwam, W. H., Davis, S. M., Castaño, C., … HERMES Collaborators (2016). Time to
Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-
analysis. JAMA, 316(12), 1279–1288. https://doi.org/10.1001/jama.2016.13647
- In this publication, the authors seek to investigate the effectiveness of the treatment time and
how that relates to the EVT efficacy while identifying the time window that makes the best
impact. A meta-analysis of several clinical trials and observational studies was utilized. The
functional independence of patients were identified at 90 days after the procedure. Mortality
rates and symptomatic intracranial hemorrhage were noted as an outcome. It was recognized
that every hour delay contributed to decreased odds of having favorable outcomes, although
treatment up to 24 hours in certain cases can also be favorable. Like some of the previous
articles here the main tools used revolve around value stream mapping and process flow
diagrams. The stages of the process from having symptoms onset to when the EVT is
performed can be mapped out in addition to identifying the steps the patient goes through
from pre-hospital to being a patient admitted for acute ischemic stroke. There are ways that
this publication focused on improvements for triaging and rapid identification of the patients
which enables better decision making and coordination of emergency services. The results
also showed that there a direct relationship between being treated faster and better outcomes.
With this application of the lean/six sigma tools, there can be decreased door-to-treatment
times and better coordination of care with the emergency medical services within the
hospital.
