Optimizing workflow of urgent stroke endovascular intervention: A focused lean six sigma project.

INTRODUCTION: Urgent endovascular intervention is currently accepted as the primary and critical therapeutic approach to patients whose acute ischemic stroke results from a large arterial occlusion (LAO). In this context, one of the quality metrics most widely applied to the assessment of emergency systems performance is the "door-to-puncture" (D-P) time. We undertook a project to identify the subinterval of the D-P metric causing the most impact on workflow delays and created a narrowly focused project on improving such subinterval. METHODS: Using the DMAIC (i.e., define, measure, analyze, improve and control) approach, we retrospectively reviewed our quality stroke data for calendar year (CY) 2021 (i.e., baseline population), completed a statistical process control assessment, defined the various subintervals of the D-P interval, and completed a Pareto analysis of their duration and their proportional contribution to the D-P interval. We retooled our workflow based on these analyses and analyzed the data resulting from its implementation between May and December 2022 (i.e., outcome population). RESULTS: The baseline population included 87 patients (44 men; mean age = 67.2 years). Their D-P process was uncontrolled, and times varied between 35-235 minutes (Mean = 97; SD = 38.40). Their door to angiography arrival (D-AA) subinterval was significantly slower than their arrival to puncture (AA-P) (73.4 v. 23.5 minutes; p < 0.01), accounted for 73% of the average length of the D-P interval. The group page activation to angiography arrival (GP-AA) subinterval accounted for 41.5% of the entire D-AA duration, making it the target of our project. The outcome population originally consisted of 38 patients (15 men; mean age = 70.3 years). Their D-P process was controlled, its times varying between 43-177 minutes (Mean = 85.8; SD = 34.46), but not significantly difference than the baseline population (p = 0.127). Their target subinterval GP-AA varied between 0-37 minutes and was significantly improved from the baseline population (Mean = 13.21 v. 29.68; p < 0.001). CONCLUSIONS: It seems feasible and reasonable to analyze the subinterval components of complex quality metrics such as the D-P time and carry out more focused quality improvement projects. Care must be exercised when interpreting the impact on overall system performance, due to unexpected variations within interdependent subprocesses. The application of a robust and comprehensive LSS continuous quality improvement process in any CSC will have to include individualized focused projects that simultaneously control the different components of overall system performance.

Acute Intramyocardial Right Ventricular Hematoma After Coronary Artery Bypass Graft.

A 50-year-old woman underwent coronary artery bypass graft (CABG) for multivessel coronary artery disease. Due to hemodynamic instability, the patient could not be weaned from cardiopulmonary bypass without mechanical support, even after multiple attempts. Subsequently, a right ventricular intramyocardial hematoma (IH) was found during postoperative coronary angiography. The IH was felt to be the main contributing factor leading to right ventricular failure and cardiogenic shock, which, to the authors' knowledge, has not been previously reported after CABG. An IH is a rare complication postoperatively that often requires a high level of suspicion to identify on transesophageal echocardiogram. It should be suspected when there is hemodynamic instability intraoperatively or postoperatively in the intensive care unit that cannot be explained easily. There currently is no standard treatment. Treatment often is based on the individual patient and degree of hemodynamic instability.

Normoglycemic Diabetic Ketoacidosis in a Pregnant Patient with Type II Diabetes Mellitus Presenting for Emergent Cesarean Delivery.

The development of acute abdominal pain in a laboring parturient after a previous cesarean delivery is of concern and may be the result of a potentially life-threatening condition such as uterine rupture. We present a case of a parturient with type II diabetes mellitus, who had undergone 2 previous cesarean deliveries and now presented in labor with increasing abdominal pain. An emergency cesarean delivery was performed for probable uterine rupture. Intraoperatively, the patient was noted to be severely hypocarbic with significant metabolic acidosis, and the diagnosis of diabetic ketoacidosis was established.