Document Type

DNP Project

Publication Date


Degree Name

Doctor of Nursing Practice

Faculty Advisor

Dorothea Esposito, DNP, MSN/ed, APRN, FNP-BC

Practice Mentor

Janet Parkosewich, DNSc, RN, FAHA


Introduction: Delays in door to skin puncture time for patients with ischemic stroke are associated with worse clinical outcomes. The following quality improvement study was conducted at Greenwich Hospital which aimed to decrease door to skin puncture time for endovascular stroke treatment. Greenwich Hospital began its new stroke program in January 2020 and opened thrombectomy capable interventional radiology (IR) services. Delays to door to skin puncture times existed with average time being 100 minutes with a goal time of 90 minutes or less for 50% or more of patients directly arriving to the hospital and 60 minutes or less for 50% or more of patients transferred from another hospital.

Materials and Methods: Our stroke team implemented a series of quality improvement measures to decrease door to skin puncture time with a target of 90 minutes or less. A monthly interdisciplinary stroke committee meeting was utilized to identify and remedy delays to timely treatment with thrombectomy using the theoretical framework of Plan, Do, Study, Act (PDSA) cycles. Each monthly meeting reviewed the previous month’s thrombectomy cases in the format of a stroke report card which analyzed door to skin puncture times for each case. 9 thrombectomies were performed at Greenwich Hospital from July to December 2021. PDSA cycles were used to identify delays in door to skin puncture times and garner solutions for delays.

Results: Mean door to skin puncture times decreased 19.5 minutes to 80.5 minutes in 71% of patients directly arriving to Greenwich hospital. The following solutions were implemented during the data collection period: appropriate IV catheter placement size by EMS prior to arrival to hospital to save time in cat scan, stroke clinical pathway created in EPIC, heparinized saline bags stocked in Interventional Radiology procedural area and a nurse navigator was hired in October.

Conclusion: A thorough quality improvement process can significantly improve door to skin puncture times. This analysis demonstrates the effectiveness of a formal quality improvement system at a thrombectomy capable hospital.


A DNP project submitted in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice, Sacred Heart University Davis & Henley College of Nursing.

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Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License
This work is licensed under a Creative Commons Attribution-NonCommercial-Share Alike 4.0 International License.



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