Background: Patient selection for endovascular treatment in a 325 bed PSC located near two CSCs was based on subjective findings only.
Purpose: The project scope was to streamline evaluation and treatment of acute ischemic stroke patients. The goals were to improve identification of large vessel strokes, transfer patients who could benefit from endovascular intervention, and minimize unnecessary transfers.
Method: A flow diagram was created using objective selection criteria and advanced imaging. The criteria consisted of assessment findings, symptom onset time, and renal function to guide vascular imaging. Completed images were electronically sent to the CSC. The algorithm was implemented in June 2015, and the stroke team was educated on the new process. After algorithm implementation, data on utilization, endovascular candidates, and patient outcomes were presented monthly at the multidisciplinary Neuro QI meetings.
Results: Five months prior to algorithm implementation, 16% (34/213) met the screening criteria for having advanced imaging. Of those, only four were transferred for possible endovascular treatment with two receiving interventions. Patient discharge dispositions were 26% home, 15% rehab, 29% SNF, 26% hospice, and 3% expired. After algorithm implementation, in the initial two months 19% (13/68) met screening criteria for advanced imaging. Of the 13 patients, six transferred for endovascular treatment with two receiving intervention. Three had advanced imaging and avoided unnecessary transfer. The remaining four received only IV tPA, family chose no treatment, or not identified in ED. Patient discharge dispositions were 38% home, 46% rehab, 0% SNF, 8% hospice, and 8% expired.
Conclusions: By using objective criteria to aid identification of potential large vessel occlusions and incorporating vascular imaging, appropriate transfers are occurring more consistently and patient outcomes are improving. The defined criteria has increased awareness and identification of potential large vessel occlusions. However the implementation of vascular imaging has been slow to put into practice, requiring educational reinforcement. When utilized at the facility, candidates are selected more appropriately for higher levels of care.