Abstract TP3: What Hospital Characteristics Drive Faster Thrombectomy For Emergent Large Vessel Occlusion (ELVO)?

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jason Tarpley ◽  
Lindsay Lucas ◽  
Joseph T Ho ◽  
Renee Ovando ◽  
Elizabeth Baraban
Keyword(s):  
Arrival Time ◽  
High Volume ◽  
Reperfusion Therapy ◽  
Multivariate Logistic Regression Model ◽  
Vessel Occlusion ◽  
Stroke Registry ◽  
Primary Stroke Center ◽  
Treatment Volume ◽  
Transferred Patients ◽  
Stroke Center

Introduction: Recent thrombectomy trials for ELVO have reverberated the importance of speed in reperfusion therapy. Identifying hospital practices and features associated with faster door to thrombectomy times is critical to evolving our hospital systems to effectively deliver this powerful therapy. Methods: A multi-hospital, Get with the Guidelines stroke registry was used to identify AIS patients who received intra-arterial (IA) intervention between January 2012 and May 2016. Transferred patients were excluded since their door to reperfusion times don’t typically include a primary evaluation. Patients were categorized as having door to reperfusion (Door-to-IA) time over 135 minutes or Door-to-IA time below or equal to 135 minutes. A multivariate logistic regression model was used to identify which of the following variables were associated with Door-to-IA times over 135 minutes: age, gender, IV alteplase treatment, admit NIHSS score, patient arrival time to hospital, hospital certification (primary stroke center (PSC) versus comprehensive stroke center (CSC)), hospital annual IA treatment volume, and hospital annual percentage of transfers for thrombectomy. Results: We identified 229 AIS patients from ten hospitals who received IA intervention between January 2012 and May 2016. Of those, 49% (n=113) had Door-to-IA times over 135 minutes and 51% (n=116) had Door-to-IA time below or equal to 135 minutes. Patients with Door-to-IA times over 135 minutes were more likely to be older (adjusted odds ratio (AOR) = 1.02 per year; p=.040), treated at a PSC (AOR = 2.26; p=.028), and treated at a hospital with a higher percentage of transfers (AOR = 1.08 per percentage point; p<.001). IV-alteplase treatment, gender, NIHSS, patients’ arrival time and volume were not significant. Conclusion: Comprehensive stroke centers had shorter Door-to-IA times than Primary Stroke Centers in our system. However, hospital annual IA treatment volume did not impact Door-to-IA and centers with larger transfer volume actually had worse Door-to-IA times for patients evaluated and treated locally. This suggests that high volume centers with a larger volume of transferred patients may have tuned their practices to treating transfers rather than treating local ELVO patients.

scholarly journals Shortening time to reperfusion after transfer from a primary to a comprehensive stroke center

2019 ◽  
Vol 9 (5) ◽  
pp. 417-423 ◽  
Author(s):  
Denis Sablot ◽  
Geoffroy Farouil ◽  
Alexandre Laverdure ◽  
Caroline Arquizan ◽  
Alain Bonafe
Keyword(s):  
Clinical Characteristics ◽  
Mechanical Thrombectomy ◽  
High Volume ◽  
Reperfusion Therapy ◽  
Mri Imaging ◽  
Interhospital Transfer ◽  
Primary Stroke Center ◽  
Speed Up ◽  
Comprehensive Stroke Center ◽  
Stroke Center

BackgroundThis study assessed whether a quality improvement (QI) process to streamline transfer from a primary stroke center (PSC) to a comprehensive stroke center (CSC) could reduce the delay of reperfusion by mechanical thrombectomy (MT).MethodsFrom 2015 to 2017, a QI process was implemented with specific interventions to reduce door-in-to-door-out (DIDO) time in a high volume PSC, and speed up interhospital transfer and inhospital processes at the CSC. Clinical characteristics and time metrics were compared in the QI (2015–2017; n = 157) and pre-QI cohorts (2012–2014; n = 121).ResultsDuring the QI process, the median symptom onset to reperfusion time was reduced by 50 minutes (367 vs 417 minutes in the pre-QI cohort, p < 0.04), with a substantial 40-minute DIDO reduction (78 vs 118 minutes, p < 0.01), related to the faster administration of IV thrombolysis (median door-to-needle time: 49 vs 82 minutes, p = 0.0001). The door-to-door time was shortened (170 vs 205 minutes, p = 0.002), but not the transfer time (92 vs 87 minutes, p = 0.5). The QI process had no effect on the prehospital phase (77 vs 76 minutes, p = 0.83) and on the time from MRI imaging at the PSC to reperfusion (252 vs 288 minutes, p = 0.12). The rate of modified Rankin Scale score 0–2 at 90 days was comparable in the pre-QI and QI cohorts.ConclusionsA QI process can reduce the reperfusion therapy delay in a distant CSC; however, we could not demonstrate that it can also improve the outcome of patients who undergo MT.

Abstract 1122‐000137: Characteristics and Utilization of Acute Reperfusion Therapy after Transfer of In‐Hospital LVO Strokes

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Rahul Rao ◽  
Conor Kelly ◽  
Shashvat Desai ◽  
Ashutosh Jadhav
Keyword(s):  
Tertiary Care ◽  
Reperfusion Therapy ◽  
Artery Occlusion ◽  
Basilar Artery Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Primary Stroke Center ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Introduction : Acute repercussion therapy for acute ischemic stroke is a crucial tool in the tertiary care setting for patients presenting with large vessel occlusion (LVO). While strokes that present from the community have favorable outcomes compared to in‐hospital strokes, it is unclear if this is because of greater access to endovascular therapy. We aim to characterize the utilization of endovascular reperfusion therapy for in‐house LVO and compare outcomes of in‐house LVOs to those presenting from the community. Methods : From the period of December 2013 to December 2019, all stroke patients with an LVO who presented to a primary stroke center (“spoke” hospital) who were transferred to a comprehensive stroke center (“hub”) were analyzed. Univariate and multivariate analyses were performed to compare baseline characteristics and clinical outcomes. Results : A total of 181 in‐house strokes were transferred from a peripheral center to our comprehensive stroke center. About 16% (29) received IV‐tPA at the OSH and 2 additional patients received IV‐tPA at the CSC [17%; n = 31]. 163 patients harbored an intracranial acute vessel occlusion. Anterior LVO (ICA, M1,M2) and basilar artery occlusion was observed in 64% (n = 116) patients and 6% (n = 11) patients, respectively [Total LVO‐ 70%; n = 127]. 20% (n = 27) of LVO received IV‐tPA and 72% (n = 91) of LVO underwent thrombectomy. Reasons for not receiving included symptoms improved (25%), repeat imaging made reperfusion inadvisable (72.2%) and poor baseline (2.8%). Rates of mRS 0–2 in patients with ICA/M1/M2 receiving EVT were 13% (13/100) and the mortality rate was 45% (46/103). Rates of mRS 0–2 were significantly lower [13% vs 38%, p<0.01] and mortality was significantly higher [45% vs 18%, p<0.01] amongst anterior LVO in‐house transfer patients receiving EVT compared to all anterior LVO patients receiving EVT in the given time period. Conclusions : A relatively large proportion of in‐house LVO stroke patients underwent thrombectomy (70%). Most common cause of not receiving thrombectomy was imaging findings showing completed or large infarct. Compared to their community stroke counterparts, in‐house LVO strokes had lower efficacy outcomes and higher mortality. Further study in required to understand these findings.

Abstract P147: Unanticipated Benefits of a Large Vessel Occlusion Screening Tool in a Primary Stroke Center

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Amanda Werner ◽  
Brian L Kaiser
Keyword(s):  
Screening Tool ◽  
Complication Rates ◽  
Alert System ◽  
Vessel Occlusion ◽  
Primary Stroke Center ◽  
Implementation Time ◽  
Transferred Patients ◽  
Stroke Center ◽  
Transfer Times ◽  
Geographically Isolated

Introduction: Use of an LVO screening tool to triage patients suspected of having an LVO and expedite transfer to an endovascular capable stroke center (ESC) has some benefit for patients within 15 minutes of an ESC. The benefits of using an LVO screening tool amongst Primary Stroke Centers (PSC) that are geographically isolated from an ESC is of less clear benefit. Methods: The implementation of the Vision, Aphasia, Neglect (VAN) LVO screening tool at a regional series of PSCs and freestanding emergency departments was accomplished in anticipation of pursuing thrombectomy-capable certification at one of the facilities. The use of VAN was incorporated into a tiered stroke alert system to identify patients eligible for endovascular treatment up to 24 hours. Retrospective data was collected and assessed for pre and post implementation time metrics: workflow timestamps, volume of treated and transferred patients, mimic and complication rates, median door-to-needle times, and median door-in-door-out times. Results: The 12-month calendar year prior to and immediately following VAN implementation was reviewed and included final diagnosed ischemic (n=469) and hemorrhagic (n=96) patient volumes. Implementation of VAN was associated with reductions in median door-to-transfer times from 143 to 122 minutes and median door-to-needle times from 48 to 38 minutes. Thrombolytic treatment rates increased by 5%, mimic rate decreased by 5%, without significant changes in thrombolytic complications. Conclusions: In conclusion, use of VAN as an LVO screening tool in a Primary Stroke Center which is geographically isolated from an ESC was associated with an unanticipated improvement of multiple program metrics including reduced door to transfer times, reduced door to needle times, increased percentage of patients treated with thrombolytics, and increased staff satisfaction and engagement. These unanticipated benefits are likely the result of a combination of factors including increased staff awareness of stroke symptoms and optimization of regional stroke alert workflows that occurred in conjunction with LVO implementation.

scholarly journals Progression of cerebral infarction before and after thrombectomy is modified by prehospital pathways

2021 ◽  
pp. neurintsurg-2020-017155
Author(s):  
Alexander M Kollikowski ◽  
Franziska Cattus ◽  
Julia Haag ◽  
Jörn Feick ◽  
Alexander G März ◽  
...  
Keyword(s):  
Patient Characteristics ◽  
Large Vessel ◽  
Stroke Severity ◽  
Large Vessel Occlusion ◽  
Time Intervals ◽  
Vessel Occlusion ◽  
Before And After ◽  
Transferred Patients ◽  
Stroke Center

BackgroundEvidence of the consequences of different prehospital pathways before mechanical thrombectomy (MT) in large vessel occlusion stroke is inconclusive. The aim of this study was to investigate the infarct extent and progression before and after MT in directly admitted (mothership) versus transferred (drip and ship) patients using the Alberta Stroke Program Early CT Score (ASPECTS).MethodsASPECTS of 535 consecutive large vessel occlusion stroke patients eligible for MT between 2015 to 2019 were retrospectively analyzed for differences in the extent of baseline, post-referral, and post-recanalization infarction between the mothership and drip and ship pathways. Time intervals and transport distances of both pathways were analyzed. Multiple linear regression was used to examine the association between infarct progression (baseline to post-recanalization ASPECTS decline), patient characteristics, and logistic key figures.ResultsASPECTS declined during transfer (9 (8–10) vs 7 (6-9), p<0.0001), resulting in lower ASPECTS at stroke center presentation (mothership 9 (7–10) vs drip and ship 7 (6–9), p<0.0001) and on follow-up imaging (mothership 7 (4–8) vs drip and ship 6 (3–7), p=0.001) compared with mothership patients. Infarct progression was significantly higher in transferred patients (points lost, mothership 2 (0–3) vs drip and ship 3 (2–6), p<0.0001). After multivariable adjustment, only interfacility transfer, preinterventional clinical stroke severity, the degree of angiographic recanalization, and the duration of the thrombectomy procedure remained predictors of infarct progression (R2=0.209, p<0.0001).ConclusionsInfarct progression and postinterventional infarct extent, as assessed by ASPECTS, varied between the drip and ship and mothership pathway, leading to more pronounced infarction in transferred patients. ASPECTS may serve as a radiological measure to monitor the benefit or harm of different prehospital pathways for MT.

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 WP455: Memorial Hermann Hospital System Stroke Coordinators: Working as One

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Sandi G Shaw ◽  
Isabel Gonzales ◽  
Hari Indupuru ◽  
Nicole Harrison ◽  
Sean Savitz ◽  
...  
Keyword(s):  
Best Practice ◽  
Quality Care ◽  
High Volume ◽  
Work Load ◽  
Joint Commission ◽  
Large Hospital ◽  
Hospital System ◽  
Primary Stroke Center ◽  
Stroke Center ◽  
The Joint Commission

Background: Many hospital stroke programs fail to meet or maintain the certification requirements of The Joint Commission (TJC) as a Primary Stroke Center (PSC) or Comprehensive Stroke Center (CSC). The most common reason is the absence of a dedicated stroke program coordinator. There are opportunities for improvement to promote stroke coordinator growth and retention. Purpose: We created The Memorial Hermann Hospital System Stroke Coordinator Alliance to combine resources, reduce workload, and support stroke coordinators in order to promote adherence to best practice and maintain TJC stroke certification. Methods: The Memorial Hermann Hospital System Stroke Coordinator Alliance was developed in 2015. It includes 14 nurses who represent 11 acute care hospitals within a large hospital system in Houston (Figure1). Four of the hospitals are CSCs, five are PSCs, and two are not certified. Monthly meetings are conducted to create standardized access to resources, stroke coordinator orientation, education, medical power plans, process improvement, and data development. Coordinator work groups, a central email and shared drive, biweekly data meetings, and a buddy system were created to reduce work load, improve electronic communication, and streamline data review procedures. A partnership was created to onboard new coordinators and to prepare for mock and real time survey visits. In 2018 data abstraction was standardized across hospitals with use of a homegrown database Stroke Program Registry (REGIS). Results: Of the 14 Stroke Coordinators in place during fiscal years 2015 - 2019, retention was 100%. A total of 19 stroke surveys were completed and recognized as successful by The Joint Commission. A total of 17,148 stroke patients were received with PSC measures averaging greater than 95% and CSC measures above 90%. Conclusion: Implementing program development support for stroke coordinators improves retention and quality care in a high volume stroke system.

Characteristics and management of stroke in Korea: 2014–2018 data from Korean Stroke Registry

2019 ◽  
Vol 15 (6) ◽  
pp. 619-626 ◽  
Author(s):  
Han-Yeong Jeong ◽  
Keun-Hwa Jung ◽  
Heejung Mo ◽  
Chan-Hyuk Lee ◽  
Tae Jung Kim ◽  
...  
Keyword(s):  
Risk Factors ◽  
Reperfusion Therapy ◽  
Lifestyle Changes ◽  
Large Artery ◽  
Stroke Subtype ◽  
Vessel Occlusion ◽  
Stroke Registry ◽  
Aging Populations ◽  
Care Patterns ◽  
Ischemic Attack

Background Lifestyle changes and evolving healthcare practices in Korea have influenced disease patterns and medical care. Since strokes have high disease burden in countries with aging populations, it is necessary to evaluate the associated recent disease characteristics and patient care patterns. The Korean Stroke Registry is a nationwide, multicenter, prospective, hospital-based stroke registry in Korea used to monitor these changes across the population. Aims We aimed to evaluate the recent status of clinical characteristics and management of stroke cases in order to identify changes in the Korean population across time. Methods This study used Korean Stroke Registry data from patients experiencing ischemic stroke or transient ischemic attack patients, between 2014 and 2018. We analyzed data on demographics, risk factors, stroke subtypes, and treatments that included thrombolysis. Results A total of 39,291 patients (mean age 68.0 ± 13.0, 58.3% male) were analyzed. The proportions of hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, and prior stroke were 63.4%, 30.9%, 27.7%, 19.4%, and 17.1%, respectively. In the stroke subtype analysis, the frequency of large artery atherosclerosis was highest (32.6%), followed by cardioembolism (21.3%) and small vessel occlusion (19.9%). Acute reperfusion therapy was conducted in 15.3% of cases (11.7% using intravenous tPA and 7.3% using intra-arterial thrombectomy). Intra-arterial thrombectomy also demonstrated a steep increasing trend over time (RR 1.095 (1.060–1.131), p < 0.001). Conclusions This study provided analysis of nationwide, hospital-based, quality-controlled data from the Korean Stroke Registry database regarding changes in the characteristics, risk factors, and treatments of strokes in Korea.

scholarly journals Effect of Interhospital Transfer on Endovascular Treatment for Acute Ischemic Stroke

Stroke ◽  
2019 ◽  
Vol 50 (4) ◽  
pp. 923-930 ◽  
Author(s):  
Esmee Venema ◽  
Adrien E. Groot ◽  
Hester F. Lingsma ◽  
Wouter Hinsenveld ◽  
Kilian M. Treurniet ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Functional Independence ◽  
Modified Rankin Scale ◽  
Interhospital Transfer ◽  
Primary Stroke Center ◽  
Transferred Patients ◽  
Stroke Center

Background and Purpose— To assess the effect of inter-hospital transfer on time to treatment and functional outcome after endovascular treatment (EVT) for acute ischemic stroke, we compared patients transferred from a primary stroke center to patients directly admitted to an intervention center in a large nationwide registry. Methods— MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry is an ongoing, prospective, observational study in all centers that perform EVT in the Netherlands. We included adult patients with an acute anterior circulation stroke who received EVT between March 2014 to June 2016. Primary outcome was time from arrival at the first hospital to arterial groin puncture. Secondary outcomes included the 90-day modified Rankin Scale score and functional independence (modified Rankin Scale score of 0–2). Results— In total 821/1526 patients, (54%) were transferred from a primary stroke center. Transferred patients less often had prestroke disability (227/800 [28%] versus 255/699 [36%]; P =0.02) and more often received intravenous thrombolytics (659/819 [81%] versus 511/704 [73%]; P <0.01). Time from first presentation to groin puncture was longer for transferred patients (164 versus 104 minutes; P <0.01, adjusted delay 57 minutes [95% CI, 51–62]). Transferred patients had worse functional outcome (adjusted common OR, 0.75 [95% CI, 0.62–0.90]) and less often achieved functional independence (244/720 [34%] versus 289/681 [42%], absolute risk difference −8.5% [95% CI, −8.7 to −8.3]). Conclusions— Interhospital transfer of patients with acute ischemic stroke is associated with delay of EVT and worse outcomes in routine clinical practice, even in a country where between-center distances are short. Direct transportation of patients potentially eligible for EVT to an intervention center may improve functional outcome.

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