Table 1.
A summary of improvement measures implemented with details provided for each measure
| Measures | Details |
|---|---|
| Chief of hospital engagement | The chief of the hospital was engaged in the introduction process of the measures to facilitate improving stroke workflow |
| Pre-notification | A pre-notification system was established via referral hospital doctors to communicate a history of patients from the next of kin and assess thrombectomy treatment benefits and risks for suspected ischemic large vessel occlusion patients |
| Training | Multiple training sessions were provided for stroke and emergency nurses to promptly recognize stroke signs and symptoms |
| Priority | Suspected ischemic stroke patients were prioritized for triage by an emergency doctor |
| CT was prioritized for suspected ischemic stroke patients | |
| CTA or MRA for suspected ischemic stroke large vessel occlusion patients within 24 h of onset was prioritized | |
| When CTA was performed, CTA images were reconstructed by radiologists in real-time to facilitate rapid imaging interpretation | |
| CT was primarily used for all patients, but MRI/MRA/CTP/MRP was prioritized for suspected ischemic stroke patients | |
| Neurointerventionalist availability for emergency procedures was prioritized for patients with intracranial occlusion | |
| Reduce procedures | Implementation of a modified direct-to-Digital Subtraction Angiography approach, bypassing CTA for selected patients with a clinical suspicion of large vessel occlusion and lack of intracranial hemorrhage on initial CT |
| More rapid acquisition of consent with support of other providers | |
| Neuro-interventionists team cooperation | Cooperation of two experienced neuro-interventionists, with one discussing with patients’ family members to acquire consent for thrombectomy, and the other preparing patients for thrombectomy |
| Green light route | Medical department decision in the best interest of the patient to whether thrombectomy could be performed in critical or emergency situations if a patient family member could be contacted |
| Surgery was provided without delays for hospital fees payment for all patients | |
| Prepare in advance | Preparation of the medications and required devices for thrombectomy in advance by an interventional nurse once the notification is received |
| Feedback | Holding monthly stroke meetings to analyze the etiology of DPT-delayed cases by hospital chief and the ED staff, neurology, and radiology department staff |
| Reward | Rewarding participation of intervention center, ED staff, neurology, and radiology departments financially if DPT was performed less than or equal to 120 min and if patient outcomes were above satisfactory level |
| Public education | Increasing the awareness of the public about the signs and symptoms of acute stroke and thrombectomy by using local newspapers, television programs and the Internet platform by Regional Health Bureau and Media Department of the hospital |
Abbreviations- CT Computerized tomography, CTA Computed tomography angiography, CTP Computed tomography perfusion, DPT Door-to-puncture time, ED Emergency department, MRA Magnetic resonance angiography, MRP Magnetic resonance perfusion