Background: Five recently published randomized trials of endovascular therapy versus medical management, including intravenous thrombolysis, demonstrated strong positive data in support endovascular thrombectomy procedures. The American Heart Association/American Stroke Association released a focused update to specifically incorporate the findings of these trials. Implementing the care these studies show as beneficial requires a mechanism to rapidly transfer large vessel occlusion patients from primary stroke centers to those offering thrombectomy.
Purpose: The purpose of the project was to streamline stroke work-up across the various levels of stroke hospitals and to apply rapid routing practices when transferring stroke patients between facilities. We evaluated the changes in stroke systems of care, with an emphasis on the role of pre-hospital stroke triage, inter-hospital transfer, and the two main levels of stroke center certification (primary and comprehensive).
Methods: The system stroke steering team, defined four primary processes to reduce transfer times. These included 1) benchmarks for hospital door in to door out times of transferring centers 2) scripted transfer verbiage to designated time critical patients 3) large vessel stroke criteria definitions 4) pre-notification of the endovascular team to treat potential patients presenting with stroke. A reduction in time between initial patient contact and arterial puncture times and measures of patient outcomes were used as indicators of effectiveness.
Results: The implementation of four process improvements for large vessel stroke patients was associated with improved treatment times. Mean door to recanalization times decreased from 224 minutes in 2014 to 112 minutes, thus far in 2016. Stroke treatment rates for tPA increased from 19.8% in 2013 to 22.7% in 2016, and endovascular treatment rates of 14.6% to 18.1% in the same time period. Conversely, complication rates from stroke treatment declined within the same period from 7.4% to 3.8%.
Conclusion: Within a metropolitan health system, using the above multimodal approach to streamline the transfer of patients from primary to comprehensive centers decreases latency to treatment and is associated with improved outcomes.