Field triage for endovascular stroke therapy: a population-based comparison

2019 ◽  
Vol 12 (3) ◽  
pp. 233-239 ◽  
Author(s):  
Mahesh V Jayaraman ◽  
Morgan L Hemendinger ◽  
Grayson L Baird ◽  
Shadi Yaghi ◽  
Shawna Cutting ◽  
...  
Keyword(s):  
Population Based ◽  
Stroke Severity ◽  
Matched Pairs ◽  
Inclusion Criteria ◽  
Stroke Therapy ◽  
Transport Time ◽  
Field Triage ◽  
Primary Stroke Center ◽  
Comprehensive Stroke Center ◽  
Stroke Center

BackgroundEndovascular therapy (EVT) for stroke improves outcomes but is time sensitive.ObjectiveTo compare times to treatment and outcomes between patients taken to the closest primary stroke center (PSC) with those triaged in the field to a more distant comprehensive stroke center (CSC).MethodsDuring the study, a portion of our region allowed field triage of patients who met severity criteria to a more distant CSC than the closest PSC. The remaining patients were transported to the closest PSC. We compared times to treatment and clinical outcomes between those two groups. Additionally, we performed a matched-pairs analysis of patients from both groups on stroke severity and distance to CSC.ResultsOver 2 years, 232 patients met inclusion criteria and were closest from the field to a PSC; 144 were taken to the closest PSC and 88 to the more distant CSC. The median additional transport time to the CSC was 7 min. Times from scene departure to alteplase and arterial puncture were faster in the direct group (50 vs 62 min; 93 vs 152 min; p<0.001 for both). Among patients who were independent before the stroke, the OR for less disability in the direct group was 1.47 (95% CI 1.13 to 1.93, p=0.003), and 2.06 (95% CI 1.10 to 3.89, p=0.01) for the matched pairs.ConclusionsIn a densely populated setting, for patients with stroke who are EVT candidates and closest to a PSC from the field, triage to a slightly more distant CSC is associated with faster time to EVT, no delay to alteplase, and less disability at 90 days.

scholarly journals Stroke Center Certification Is Associated With Improved Guideline Concordance

2019 ◽  
Vol 34 (6) ◽  
pp. 585-589
Author(s):  
Adam S. Jasne ◽  
Heidi Sucharew ◽  
Kathleen Alwell ◽  
Charles J. Moomaw ◽  
Matthew L. Flaherty ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Epidemiologic Study ◽  
Stroke Care ◽  
Population Based ◽  
Patient Demographics ◽  
Certification Programs ◽  
Primary Stroke Center ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Measurement of quality of stroke care has become increasingly important, but data come mostly from programs in hospitals that choose to participate in certification programs, which may not be representative of the care provided in nonparticipating hospitals. The authors sought to determine differences in quality of care metric concordance for acute ischemic stroke among hospitals designated as a primary stroke center, comprehensive stroke center, and non-stroke center in a population-based epidemiologic study. Significant differences were found in both patient demographics and in concordance with guideline-based quality metrics. These differences may help inform quality improvement efforts across hospitals involved in certification as well as those that are not.

scholarly journals Decision Analysis Model for Prehospital Triage of Patients With Acute Stroke

Stroke ◽  
2019 ◽  
Vol 50 (4) ◽  
pp. 970-977 ◽  
Author(s):  
Yaqian Xu ◽  
Neal S. Parikh ◽  
Boshen Jiao ◽  
Joshua Z. Willey ◽  
Amelia K. Boehme ◽  
...  
Keyword(s):  
Decision Analysis ◽  
Acute Stroke ◽  
Real World ◽  
Tissue Type ◽  
Decision Analysis Model ◽  
Transport Time ◽  
Primary Stroke Center ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Background and Purpose— We used a decision analysis approach to analyze triage strategies for patients with acute stroke symptoms while accounting for prehospital large vessel occlusion (LVO) screening methods and key time metrics. Methods— Our decision analysis compared anticipated functional outcomes for patients within the IV-tPA (intravenous tissue-type plasminogen activator) treatment window in the mothership and drip-and-ship frameworks. Key branches of the model included IV-tPA eligibility, presence of an LVO, and endovascular therapy eligibility. Our decision analysis evaluated 2 prehospital LVO screening approaches: (1) no formal screening and (2) the use of clinical LVO screening scales. An excellent outcome was defined as modified Rankin Scale scores 0–1. Probabilities and workflow times were guideline-based or imputed from published studies. In sensitivity analyses, we individually and jointly varied transport time to the nearest primary stroke center, additional time required to transport directly to a comprehensive stroke center, and LVO screening scale predictive probabilities. We evaluated 2 separate scenarios: one in which ideal time metrics were achieved and one under current real-world metrics. Results— In the ideal metrics scenario, the drip-and-ship strategy was almost always favored in the absence of formal LVO screening. For patients screened positive for an LVO, mothership was favored if the additional transport time to the comprehensive stroke center was <3 to 23 minutes. Under real-world conditions, in which primary stroke center workflow is slower than ideal, the mothership strategy was favored in more scenarios, regardless of formal LVO screening. For example, mothership was favored with an additional transport time to the comprehensive stroke center of <32 to 99 minutes for patients screened positive for an LVO and <28 to 39 minutes in the absence of screening. Conclusions— Joint consideration of LVO probability, screening, workflow times, and transport times may improve prehospital stroke triage. Drip-and-ship was more favorable when more ideal primary stroke center workflow times were modeled.

Effect of “drip-and-ship” and “drip-and-drive” on endovascular treatment of acute ischemic stroke with large vessel occlusion: a single-center retrospective study

2021 ◽  
pp. 028418512110068
Author(s):  
Yu Hang ◽  
Zhen Yu Jia ◽  
Lin Bo Zhao ◽  
Yue Zhou Cao ◽  
Huang Huang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Primary Stroke Center ◽  
Secondary Endpoints ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background Patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) were usually transferred from a primary stroke center (PSC) to a comprehensive stroke center (CSC) for endovascular treatment (drip-and-ship [DS]), while driving the doctor from a CSC to a PSC to perform a procedure is an alternative strategy (drip-and-drive [DD]). Purpose To compare the efficacy and prognosis of the two strategies. Material and Methods From February 2017 to June 2019, 62 patients with LVO received endovascular treatment via the DS and DD models and were retrospectively analyzed from the stroke alliance based on our CSC. Primary endpoint was door-to-reperfusion (DTR) time. Secondary endpoints included puncture-to-recanalization (PTR) time, modified Thrombolysis in Cerebral Infarction (mTICI) rates at the end of the procedure, and modified Rankin Scale (mRS) at 90 days. Results Forty-one patients received the DS strategy and 21 patients received the DD strategy. The DTR time was significantly longer in the DS group compared to the DD group (315.5 ± 83.8 min vs. 248.6 ± 80.0 min; P < 0.05), and PTR time was shorter (77.2 ± 35.9 min vs. 113.7 ± 69.7 min; P = 0.033) compared with the DD group. Successful recanalization (mTICI 2b/3) was achieved in 89% (36/41) of patients in the DS group and 86% (18/21) in the DD group ( P = 1.000). Favorable functional outcomes (mRS 0–2) were observed in 49% (20/41) of patients in the DS group and 71% (15/21) in the DD group at 90 days ( P = 0.089). Conclusion Compared with the DS strategy, the DD strategy showed more effective and a trend of better clinical outcomes for AIS patients with LVO.

How do treatment times impact on functional outcome in stroke patients undergoing thrombectomy in Germany? Results from the German Stroke Registry

2021 ◽  
pp. 174749302098526
Author(s):  
Juliane Herm ◽  
Ludwig Schlemm ◽  
Eberhard Siebert ◽  
Georg Bohner ◽  
Anna C Alegiani ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Odds Ratio ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
Poor Functional Outcome ◽  
Stroke Registry ◽  
Primary Stroke Center ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Center Time

Background Functional outcome post-stroke depends on time to recanalization. Effect of in-hospital delay may differ in patients directly admitted to a comprehensive stroke center and patients transferred via a primary stroke center. We analyzed the current door-to-groin time in Germany and explored its effect on functional outcome in a real-world setting. Methods Data were collected in 25 stroke centers in the German Stroke Registry-Endovascular Treatment a prospective, multicenter, observational registry study including stroke patients with large vessel occlusion. Functional outcome was assessed at three months by modified Rankin Scale. Association of door-to-groin time with outcome was calculated using binary logistic regression models. Results Out of 4340 patients, 56% were treated primarily in a comprehensive stroke center and 44% in a primary stroke center and then transferred to a comprehensive stroke center (“drip-and-ship” concept). Median onset-to-arrival at comprehensive stroke center time and door-to-groin time were 103 and 79 min in comprehensive stroke center patients and 225 and 44 min in primary stroke center patients. The odds ratio for poor functional outcome per hour of onset-to-arrival-at comprehensive stroke center time was 1.03 (95%CI 1.01–1.05) in comprehensive stroke center patients and 1.06 (95%CI 1.03–1.09) in primary stroke center patients. The odds ratio for poor functional outcome per hour of door-to-groin time was 1.30 (95%CI 1.16–1.46) in comprehensive stroke center patients and 1.04 (95%CI 0.89–1.21) in primary stroke center patients. Longer door-to-groin time in comprehensive stroke center patients was associated with admission on weekends (odds ratio 1.61; 95%CI 1.37–1.97) and during night time (odds ratio 1.52; 95%CI 1.27–1.82) and use of intravenous thrombolysis (odds ratio 1.28; 95%CI 1.08–1.50). Conclusion Door-to-groin time was especially relevant for outcome of comprehensive stroke center patients, whereas door-to-groin time was much shorter in primary stroke center patients. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03356392 . Unique identifier NCT03356392

Abstract 3313: Outcomes of “Drip-and-Ship” Paradigm Among Patients with Acute Ischemic Stroke. Results of a State Wide Study

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Saqib A Chaudhry ◽  
Gustavo J Rodriguez ◽  
M. Fareed K Suri ◽  
Adnan I Qureshi
Keyword(s):  
Ischemic Stroke ◽  
Recombinant Tissue Plasminogen Activator ◽  
Population Based ◽  
Primary Diagnosis ◽  
Hospital Charges ◽  
Stroke Patients ◽  
Frequency Distributions ◽  
Number Of Patients ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: “Drip-and-ship” denotes patients in whom intravenous (IV) recombinant tissue plasminogen activator (rt-PA) is initiated at the emergency department (ED) of a community hospital, followed by transfer within 24 hours to a comprehensive stroke center. Although drip-and-ship paradigm has the potential to increase the number of patients who receive IV rt-PA, comparative outcomes have not been assessed at a population based level. Methods: State-wide estimates of thrombolysis, associated in-hospital outcomes and mortality were obtained from 2008-2009 Minnesota Hospital Association (MHA) data. Patient numbers and frequency distributions were calculated for state-wide sample of patients hospitalized with a primary diagnosis of ischemic stroke. Patients outcomes were analyzed after stratification into patients treated with IV rt-PA through primary ED arrival or drip-and-ship paradigm. Results: Of the 21,024 admissions, 602 (2.86%) received IV rt-PA either through primary ED arrival (n=473) or drip-and-ship paradigm (n=129). The rates of secondary intracerebral or subarachnoid hemorrhage were higher in patients treated with IV rt-PA through primary ED arrival compared with those treated with drip-and-ship paradigm (8.5% versus 3.1, p=0.038). The in-hospital mortality rate was similar among ischemic stroke patients receiving IV rt-PA through primary ED arrival or drip-and-ship paradigm (5.9% versus 7.0%). The mean hospital charges were $65,669 for primary ED arrival and $47,850 for drip-and-ship treated patients (p<0.001). Conclusions: The results of drip-and-ship paradigm compare favorably with IV rt-PA treatment through primary ED arrival in this state-wide study.

Abstract 83: Etiology of Late Right-to-Left Shunting on Transcranial Doppler in Ischemic Stroke Patients

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Adam de Havenon ◽  
Anne Moore ◽  
Nicholas Freeberg ◽  
Ali Sultan-Qurraie ◽  
David Tirschwell
Keyword(s):  
Ischemic Stroke ◽  
Transcranial Doppler ◽  
Inclusion Criteria ◽  
Contrast Injection ◽  
Stroke Patients ◽  
Stroke Etiology ◽  
Standard Component ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Toast Classification

Background: An echocardiogram or transcranial Doppler (TCD) bubble study to test for a right-to-left shunt (RLS) is a standard component of an ischemic stroke workup. Because the pathway for an intracradiac RLS, such as a patent foramen ovale (PFO), is more direct, it has been proposed that the late appearance of a RLS suggests an extracardiac pathway. We sought to characterize a cohort of ischemic stroke patients with late RLS (LRLS) on TCD. Methods: We searched the medical record of a Comprehensive Stroke Center for patients with ischemic stroke who had a TCD and echocardiogram bubble study during 2011-2013. LRLS was defined as TCD bubbles appearing more than 18 cardiac cycles after contrast injection. TOAST stroke etiology classification was performed by a vascular neurologist blinded to TCD results. Results: 124 patients met inclusion criteria, of which 67/124 (54%) had RLS on TCD; and 32/67 (48%) had LRLS. In the 35/67 patients with normal RLS on TCD, 23% did not have RLS on echocardiography, consistent with prior reports of TCD’s superiority for detecting RLS. In the 32/67 patients with LRLS on TCD, 56% were negative for RLS by echocardiography. In the cohort of 124 patients, the percentage of TOAST classification 4 (stroke of other determined cause) was 26%, while in the 32 patients with LRLS the percentage of TOAST 4 was significantly higher at 52%(p=0.005) (Table 1). The increase in TOAST 4 in LRLS patients was created by an even distribution of decreases in the other TOAST categories. The most common TOAST 4 stroke etiology in LRLS patients was PFO with concurrent deep venous thrombosis. Conclusion: This preliminary data supports prior studies that have shown superiority of TCD over echocardiography for detection of RLS, and challenge the prevailing notion that extracardiac shunt, such as pulmonary AVM, is the most common cause of LRLS in ischemic stroke patients. This subgroup of patients warrants further research to clarify mechanisms of ischemic stroke in patients with RLS.

Abstract W P292: A Comparative Analysis of the Requirements for Certification of Stroke Programs, by Type and by Nationally Recognized Certifying Body

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Stacey Lang
Keyword(s):  
Selection Process ◽  
Evaluation Process ◽  
Program Leaders ◽  
Primary Stroke Center ◽  
Similarities And Differences ◽  
Certification Organizations ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Core Measures ◽  
Certification Requirements

Background and Purpose: There are currently three main, nationally recognized organizations that certify facilities as primary or comprehensive stroke centers. One of these organizations also offers a “Stroke Ready” designation. While each of these organizations share many of the same requirements, there are likewise many unique requirements between certifying bodies with respect to the certification requirements, process, performance, and on-going expectations. All should be considered when choosing a partner for certification by organizations that are committed to achieving an appropriate level of certification as determined by clinical capabilities. Differences in core measure requirements and definitions, data collection expectations and re-certification cycles among other factors are often overlooked when stroke program leaders are identifying the best certification partner for their particular organization. This poster will detail the similarities and differences among the various stroke program certifying organizations and present a detailed methodology to assist program leaders with the partner selection process. Methods: The three stroke program certifying organizations were examined for review cycles, levels of certification offered, requirements related to hospital certifications, and reportable core measures. Other factors such as cost, the actual certification process, and other considerations that may impact the successful achievement of certification within a particular organization were also reviewed. Results/Conclusion: While there are many similarities in the stroke center certification requirements and processes among the three certifying organizations, there are also significant differences. In order to ensure that the end product of a journey to certification will align with a hospital’s values, budget, and vision for the stroke program, an evaluation process in advance of certifying body selection is essential. Awareness of the similarities and differences among the stroke certification organizations can facilitate a hospital’s decision-making process for pursuit of certification as a stroke ready center, primary stroke center or comprehensive stroke center

Abstract WP389: Improving Systems of Care With Stroke Severity Adjusted EMS Triaging and Bypass Criteria Protocols to a Comprehensive Stroke Center

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Mary E Deleener ◽  
Brett Greenfield
Keyword(s):  
New Jersey ◽  
Near Infrared ◽  
Assessment Tool ◽  
Systems Of Care ◽  
Hospital Setting ◽  
Large Vessel ◽  
Atlantic City ◽  
Stroke Severity ◽  
Comprehensive Stroke Center ◽  
Stroke Center

A validated pre-hospital assessment tool to detect severe strokes including intracranial hemorrhages and large vessel occlusions along with protocols for bypassing to comprehensive stroke centers remains an ongoing debate. The long term goals align with the emphasis of developing formalized stroke severity adjusted EMS triaging and bypass protocols to recognize both large vessel ischemic and intracerebral hemorrhagic stroke patients early in the pre-hospital setting with the utilization of a recognized, validated assessment tool, formal bypass criteria protocols, and formalized training for emergency medical service personnel. These goals align with the topic of careful selection of patients who meet strict criteria for bypassing acute stroke ready and primary stroke centers throughout the Southeastern New Jersey region which includes one acute ready hospital and two primary stroke centers to the closest Comprehensive Stroke Center in Atlantic City, New Jersey. The first specific aim is to analyze the EMS field diagnostic accuracy completed by both AtlantiCare EMS ACLS providers and Mid Atlantic Medevac EMS personnel. A therapeutic bypass yield will be analyzed in order to determine the effectiveness of the formalized training to conduct effective stroke severity EMS triaging assessments and a formal bypass protocol to the Comprehensive Stroke Center in Atlantic City, New Jersey. Sensitivity results of the near-infrared (NIR) technology device as a pre-scanning tool for hemorrhages prior to CT scan and operator error will be analyzed. Final diagnosis, CT results, and the need for comprehensive services will serve as the sole factor for the therapeutic bypass yield analysis. The second aim is to analyze the percentage of bypassed patients to the Comprehensive Stroke Center that undergo comprehensive interventions or medical services. Policy/Protocol Design (refer to images) IRB Information : FWA#00011915 and RP# 15-039ex IRB

scholarly journals TRIAGE-STROKE: Treatment strategy In Acute larGE vessel occlusion: Prioritize IV or endovascular treatment—A randomized trial

2019 ◽  
Vol 15 (1) ◽  
pp. 103-108 ◽  
Author(s):  
Anne Behrndtz ◽  
Søren P Johnsen ◽  
Jan B Valentin ◽  
Martin F Gude ◽  
Rolf A Blauenfeldt ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Hospital Setting ◽  
Intravenous Thrombolysis ◽  
Large Vessel ◽  
Stroke Severity ◽  
Study Results ◽  
Primary Stroke Center ◽  
Stroke Center

Rationale For patients with acute ischemic stroke and large vessel occlusions, intravenous thrombolysis and endovascular therapy are standard of care, but the effect of endovascular therapy is superior to intravenous thrombolysis. If a severe stroke with symptoms indicating large vessel occlusions occurs in the catchment area of a primary stroke center, there is equipoise regarding optimal transport strategy. Aim For patients presenting with suspected large vessel occlusions (PASS ≥ 2) and a final diagnosis of acute ischemic stroke, we hypothesize that bypassing the primary stroke center will result in an improved 90-day functional outcome. Sample size We aim to randomize 600 patients, 1:1. Design A national investigator-driven, multi-center, randomized assessor-blinded clinical trial. The Prehospital Acute Stroke Severity Scale has been developed. It identifies most patients with large vessel occlusions in the pre-hospital setting. Patients without a contraindication for intravenous thrombolysis are randomized to either transport directly to a comprehensive stroke centers for intravenous thrombolysis and of endovascular therapy or to a primary stroke center for intravenous thrombolysis and subsequent transport to a comprehensive stroke centers for of endovascular therapy, if needed. Outcomes The primary outcome will be the 90-day modified Rankin Scale score (mRS) for all patients with acute ischemic stroke. Secondary outcomes include 90-day mRS for all randomized patients, all patients with ischemic stroke but without large vessel occlusions, and patients with hemorrhagic stroke. The safety outcomes include severe dependency or death and time to intravenous thrombolysis for ischemic stroke patients. Discussion Study results will influence decision making regarding transport strategy for patients with suspected large vessel occlusions.

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