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Bluhm S, Schramm P, Spreen-Ledebur Y, Bluhm S, Münte TF, Eiersted MR, Wolfram F, van Hooff RJR, Wienecke T, Royl G. Potential effects of a mobile stroke unit on time to treatment and outcome in patients treated with thrombectomy or thrombolysis: A Danish-German cross-border analysis. Eur J Neurol 2024:e16298. [PMID: 38682808 DOI: 10.1111/ene.16298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 03/04/2024] [Accepted: 03/26/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND AND PURPOSE A mobile stroke unit (MSU) reduces delays in stroke treatment by allowing thrombolysis on board and avoiding secondary transports. Due to the beneficial effect in comparison to conventional emergency medical services, current guidelines recommend regional evaluation of MSU implementation. METHODS In a descriptive study, current pathways of patients requiring a secondary transport for mechanical thrombectomy were reconstructed from individual patient records within a Danish (n = 122) and an adjacent German region (n = 80). Relevant timestamps included arrival times (on site, primary hospital, thrombectomy centre) as well as the initiation of acute therapy. An optimal MSU location for each region was determined. The resulting time saving was translated into averted disability-adjusted life years (DALYs). RESULTS For each region, the optimal MSU location required a median driving time of 35 min to a stroke patient. Time savings in the German region (median [Q1; Q3]) were 7 min (-15; 31) for thrombolysis and 35 min (15; 61) for thrombectomy. In the Danish region, the corresponding time savings were 20 min (8; 30) and 43 min (25; 66). Assuming 28 thrombectomy cases and 52 thrombolysis cases this would translate to 9.4 averted DALYs per year justifying an annual net MSU budget of $0.8M purchasing power parity dollars (PPP-$) in the German region. In the Danish region, the MSU would avert 17.7 DALYs, justifying an annual net budget of PPP-$1.7M. CONCLUSION The effects of an MSU can be calculated from individual patient pathways and reflect differences in the hospital infrastructure between Denmark and Germany.
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Affiliation(s)
- Susanna Bluhm
- Department of Neurology, University of Lübeck, Lübeck, Germany
- St Vinzenz-Hospital, Köln, Germany
| | - Peter Schramm
- Department of Neuroradiology, University of Lübeck, Lübeck, Germany
- Neurovascular Center, University Hospital Schleswig-Holstein, Lübeck, Germany
| | | | | | - Thomas F Münte
- Department of Neurology, University of Lübeck, Lübeck, Germany
- Neurovascular Center, University Hospital Schleswig-Holstein, Lübeck, Germany
| | | | - Frauke Wolfram
- Department of Radiology, Zealand University Hospital, Roskilde, Denmark
| | - Robbert-Jan Roderick van Hooff
- Department of Neurology, Zealand University Hospital, Roskilde, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Troels Wienecke
- Department of Neurology, Zealand University Hospital, Roskilde, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Georg Royl
- Department of Neurology, University of Lübeck, Lübeck, Germany
- Neurovascular Center, University Hospital Schleswig-Holstein, Lübeck, Germany
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Tsiftsis D, Manioti EA, Touris G, Kyriakakis E, Tsamopoulos N, Gamvroudi M. Detecting Stroke at the Emergency Department by a Point of Care Device: A Multicenter Feasibility Study. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2024; 17:107-112. [PMID: 38476129 PMCID: PMC10928921 DOI: 10.2147/mder.s445075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/28/2024] [Indexed: 03/14/2024] Open
Abstract
Purpose To evaluate if the Strokefinder MD 100 by Medfield Diagnostics AB can be used as a point of care device in overcrowded Emergency Departments (ED). Patients and Methods We used the strokefinder MD 100 by Medfield Diagnostics AB in two Greek National Health System (NHS) Hospitals Emergency Departments. Our research protocol was approved by local scientific and ethics committees. We prospectively enrolled 71 adult patients from two NHS emergency departments in whom stroke was included as a differential diagnosis after triage. The feasibility of using the Strokefinder MD 100 by Medfield Diagnostics AB in various emergency department settings was evaluated through a structured questionnaire. Results The strokefinder MD 100 was used on 71 patients in various settings in the Emergency Department. In every case, the test was completed at the patient bedside without interfering with other ongoing and diagnostic and resuscitation procedures. There was no additional delay to patient care caused by performing the test when compared with current local Emergency Department practice and protocol. In almost 90% of the cases, a clear result was produced by the device. Conclusion The Strokefinder MD 100 can be safely used as a point of care device by all trained healthcare professionals, in the most overcrowded emergency department, in various ED locations. MeSH terms Point of Care Systems, Cerebrovascular Stroke, Proof of Concept Study.
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Affiliation(s)
- Dimitrios Tsiftsis
- Emergency Department, “Agios Panteleimon” General Hospital, Nikaia, Greece
| | | | - Georgios Touris
- Emergency Department “Konstantopouleio - Patision” General Hospital, Nea Ionia, Greece
| | | | | | - Maria Gamvroudi
- Emergency Department “Konstantopouleio - Patision” General Hospital, Nea Ionia, Greece
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Schuler FAF, Ribó M, Dequatre‐Ponchelle N, Rémi J, Dobrocky T, Goeldlin MB, Gralla J, Kaesmacher J, Meinel TR, Mordasini P, Seiffge DJ, Fischer U, Arnold M, Kägi G, Jung S. Geographical Requirements for the Applicability of the Results of the RACECAT Study to Other Stroke Networks. J Am Heart Assoc 2023; 12:e029965. [PMID: 37830330 PMCID: PMC10757535 DOI: 10.1161/jaha.123.029965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/11/2023] [Indexed: 10/14/2023]
Abstract
Background The RACECAT (Transfer to the Closest Local Stroke Center vs Direct Transfer to Endovascular Stroke Center of Acute Stroke Patients With Suspected Large Vessel Occlusion in the Catalan Territory) trial was the first randomized trial addressing the prehospital triage of acute stroke patients based on the distribution of thrombolysis centers and intervention centers in Catalonia, Spain. The study compared the drip-and-ship with the mothership paradigm in regions where a local thrombolysis center can be reached faster than the nearest intervention center (equipoise region). The present study aims to determine the population-based applicability of the results of the RACECAT study to 4 stroke networks with a different degree of clustering of the intervention centers (clustered, dispersed). Methods and Results Stroke networks were compared with regard to transport time saved for thrombolysis (under the drip-and-ship approach) and transport time saved for endovascular therapy (under the mothership approach). Population-based transport times were modeled with a local instance of an openrouteservice server using open data from OpenStreetMap.The fraction of the population in the equipoise region differed substantially between clustered networks (Catalonia, 63.4%; France North, 87.7%) and dispersed networks (Southwest Bavaria, 40.1%; Switzerland, 40.0%). Transport time savings for thrombolysis under the drip-and-ship approach were more marked in clustered networks (Catalonia, 29 minutes; France North, 27 minutes) than in dispersed networks (Southwest Bavaria and Switzerland, both 18 minutes). Conclusions Infrastructure differences between stroke networks may hamper the applicability of the results of the RACECAT study to other stroke networks with a different distribution of intervention centers. Stroke networks should assess the population densities and hospital type/distribution in the temporal domain before applying prehospital triage algorithms to their specific setting.
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Affiliation(s)
- Florian A. F. Schuler
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Marc Ribó
- Stroke Unit, Department of NeurologyVall d’Hebron University HospitalBarcelonaSpain
| | | | - Jan Rémi
- Department of NeurologyUniversity Hospital, Ludwig‐Maximilians‐UniversityMunichGermany
| | - Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Martina B. Goeldlin
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Thomas R. Meinel
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
- Network RadiologyKantonsspital St. GallenSt. GallenSwitzerland
| | - David J. Seiffge
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Urs Fischer
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
- Department of NeurologyUniversity Hospital Basel, University of BaselSwitzerland
| | - Marcel Arnold
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Georg Kägi
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
- Department of NeurologyKantonsspital St. GallenSt. GallenSwitzerland
| | - Simon Jung
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
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Paolucci M, Biguzzi S, Cordici F, Romoli M, Altini M, Agnoletti V, Fabbri A, Francesconi R, Menarini M, Perin T, Ruggiero M, Longoni M. Drip-and-ship toward mothership model for mechanical thrombectomy during COVID-19 pandemic: a retrospective analysis. Neurol Sci 2023; 44:1-7. [PMID: 35099642 PMCID: PMC8802255 DOI: 10.1007/s10072-022-05903-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 01/14/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION During the first wave of the COVID-19 pandemic in spring 2020, our stroke network shifted from a drip-and-ship strategy (transport of acute ischemic stroke patients to the nearest primary stroke centers) toward a mothership model (direct transportation to the Comprehensive Stroke Center). We retrospectively analyzed stroke network performances comparing the two models. PATIENTS AND METHODS All spoke-district patients treated with endovascular thrombectomy (EVT) between 15th March-15th June 2019 (drip-and-ship) and 2020 (mothership) were considered. We compared onset-to-groin time (OGT) and onset-to-needle time (ONT) between the two periods. Secondarily, we investigated other performances parameters (percentage of IV thrombolysis, timing of diagnostic and treatment) and clinical outcome (3-month modified Rankin Scale). RESULTS Twenty-four spoke-district patients in 2019 (drip-and-ship) and 26 in 2020 (mothership) underwent EVT. The groups did not differ for age, sex, risk factors, pre-stroke mRS 0-1, NIHSS, and ASPECTS distribution. The MS model showed a significant decrease of the OGT (162.5 min vs 269 min, p = 0.001) without significantly affecting the ONT (140.5 min vs 136 min, p = 0.853), ensuring a higher number of IV thrombolysis in combination with EVT (p = 0.030). The mothership model showed longer call-to-door time (median + 23 min, p < 0.005), but shorter door-to-needle (median - 31 min, p = 0.001), and door-to-groin time (- 82.5 min, p < 0.001). We found no effects of the stroke network model on the 3-month mRS (ordinal shift analysis, p = 0.753). CONCLUSIONS The shift to the mothership model during the COVID-19 pandemic guaranteed quicker EVT without significantly delaying IVT.
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Affiliation(s)
- Matteo Paolucci
- Neurology Unit, "M. Bufalini" Hospital, AUSL Romagna, Viale Giovanni Ghirotti, 286, Cesena, 47521, FC, Italy.
- Headache and Neurosonology Unit, Campus Bio-Medico University, Rome, Italy.
| | - Sara Biguzzi
- Neurology Unit, "M. Bufalini" Hospital, AUSL Romagna, Viale Giovanni Ghirotti, 286, Cesena, 47521, FC, Italy
| | - Francesco Cordici
- Neurology Unit, "M. Bufalini" Hospital, AUSL Romagna, Viale Giovanni Ghirotti, 286, Cesena, 47521, FC, Italy
| | - Michele Romoli
- Neurology Unit, "M. Bufalini" Hospital, AUSL Romagna, Viale Giovanni Ghirotti, 286, Cesena, 47521, FC, Italy
| | | | - Vanni Agnoletti
- Intensive Care Unit, "M. Bufalini" Hospital, AUSL Romagna, Cesena, FC, Italy
| | - Andrea Fabbri
- Emergency Department, "Morgagni-Pierantoni" Hospital, AUSL Romagna, Forlì, FC, Italy
| | | | - Maurizio Menarini
- Centrale Operativa 118 Romagna E Emergenza Territoriale Della Provincia Di Ravenna, AUSL Romagna, Ravenna, Italy
| | - Tiziana Perin
- Emergency Department, "Infermi" Hospital, AUSL Romagna, Rimini, RN, Italy
| | - Maria Ruggiero
- Neuroradiology Unit, "M. Bufalini" Hospital, AUSL Romagna, Cesena, FC, Italy
| | - Marco Longoni
- Neurology Unit, "M. Bufalini" Hospital, AUSL Romagna, Viale Giovanni Ghirotti, 286, Cesena, 47521, FC, Italy
- Neurology Unit, "Morgagni-Pierantoni" Hospital, AUSL Romagna, Forlì, FC, Italy
- Neurology Unit, "Infermi" Hospital, AUSL Romagna, Rimini, RN, Italy
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Krebs S, Sykora M, Krammel M, Girsa M, Auer A, Greisenegger S, Neumann C, Beisteiner R, Lang W, Roth D. Prehospital triage optimization of patients with large vessel occlusion by Austrian Prehospital Stroke Scale. Acta Neurol Scand 2022; 146:246-251. [PMID: 35596547 DOI: 10.1111/ane.13654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 05/06/2022] [Accepted: 05/11/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The Austrian Prehospital Stroke Scale (APSS) score was developed to predict large vessel occlusion (LVO) and improve prehospital transportation triage. Its accuracy has been previously analyzed retrospectively. We now aimed to investigate the accuracy, as well as the impact of the implementation of a triage strategy using this score on treatment times and outcome in a prospective study. MATHERIAL & METHODS Prospective diagnostic test accuracy and before-after interventional study. EMS prospectively evaluated APSS in patients suspected of stroke. Accuracy was compared with other LVO scores. Patients with APSS ≥4 points were brought directly to the comprehensive stroke center. Treatment time frames, neurological, and radiological outcome before and after the APSS implementation were compared. RESULTS A total of 307 patients with suspected stroke were included from October 2018 to February 2020. Treatable LVO was present in 79 (26%). Sensitivity of APSS to detect those was 90%, specificity 79%, positive predictive value 66%, negative predictive value 95%, and area under the curve 0.87 (95% CI 0.83-0.91). This was similar to in-hospital NIHSS (AUC 0.89 95% CI 0.89-0.92, p = .06) and superior to CPSS (AUC 0.83 95% CI 0.78-0.87, p = .01). Implementation of APSS triage increased direct transportation rate for LVO patients (21% before vs. 52% after; p < .001) with a significant time benefit (alert to groin puncture time benefit: 51 min (95% CI 28-74; p < .001). Neurological and radiological outcome did not differ significantly. CONCLUSIONS Austrian Prehospital Stroke Scale triage showed an accuracy comparable with in-hospital NIHSS, and lead to a significant optimization of prehospital workflows in patients with potential LVO.
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Affiliation(s)
- Stefan Krebs
- Department of Neurology St. John's Hospital Vienna Austria
| | - Marek Sykora
- Department of Neurology St. John's Hospital Vienna Austria
- Medical Faculty Sigmund Freud University Vienna Austria
| | | | | | | | | | | | | | - Wilfried Lang
- Department of Neurology St. John's Hospital Vienna Austria
- Medical Faculty Sigmund Freud University Vienna Austria
| | - Dominik Roth
- Department of Emergency Medicine Medical University of Vienna Vienna Austria
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Allen M, Pearn K, Ford GA, White P, Rudd AG, McMeekin P, Stein K, James M. National implementation of reperfusion for acute ischaemic stroke in England: How should services be configured? A modelling study. Eur Stroke J 2021; 7:28-40. [PMID: 35300255 PMCID: PMC8921787 DOI: 10.1177/23969873211063323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 10/25/2021] [Accepted: 10/29/2021] [Indexed: 11/21/2022] Open
Abstract
Objectives To guide policy when planning thrombolysis (IVT) and thrombectomy (MT) services for acute stroke in England, focussing on the choice between ‘mothership’ (direct conveyance to an MT centre) and ‘drip-and-ship’ (secondary transfer) provision and the impact of bypassing local acute stroke centres. Design Outcome-based modelling study. Setting 107 acute stroke centres in England, 24 of which provide IVT and MT (IVT/MT centres) and 83 provide only IVT (IVT-only units). Participants 242,874 emergency admissions with acute stroke over 3 years (2015–2017). Intervention Reperfusion delivered by drip-and-ship, mothership or ‘hybrid’ models; impact of additional travel time to directly access an IVT/MT centre by bypassing a more local IVT-only unit; effect of pre-hospital selection for large artery occlusion (LAO). Main outcome measures Population benefit from reperfusion, time to IVT and MT, admission numbers to IVT-only units and IVT/MT centres. Results Without pre-hospital selection for LAO, 94% of the population of England live in areas where the greatest clinical benefit, assuming unknown patient status, accrues from direct conveyance to an IVT/MT centre. However, this policy produces unsustainable admission numbers at these centres, with 78 out of 83 IVT-only units receiving fewer than 300 admissions per year (compared to 3 with drip-and-ship). Implementing a maximum permitted additional travel time to bypass an IVT-only unit, using a pre-hospital test for LAO, and selecting patients based on stroke onset time, all help to mitigate the destabilising effect but there is still some significant disruption to admission numbers, and improved selection of patients suitable for MT selectively reduces the number of patients who would receive IVT at IVT-only centres, challenging the sustainability of IVT expertise in IVT-only centres. Conclusions Implementation of reperfusion for acute stroke based solely on achieving the maximum population benefit potentially leads to destabilisation of the emergency stroke care system. Careful planning is required to create a sustainable system, and modelling may be used to help planners maximise benefit from reperfusion while creating a sustainable emergency stroke care system.
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Affiliation(s)
- Michael Allen
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Kerry Pearn
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Gary A Ford
- Radcliffe Department of Medicine, Oxford University and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Phil White
- Translational and Clinical Research Institute, Newcastle University and Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Anthony G Rudd
- Kings College London and Guy’s and St Thomas, NHS Foundation Trust, London, UK
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle Upon Tyne, UK
| | - Ken Stein
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Martin James
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
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Wheaton A, Fok PT, Holodinsky JK, Vanberkel P, Volders D, Kamal N. Optimal Transport Scenario With Rotary Air Transport for Access to Endovascular Therapy Considering Patient Outcomes and Cost: A Modeling Study. Front Neurol 2021; 12:768381. [PMID: 34975727 PMCID: PMC8718632 DOI: 10.3389/fneur.2021.768381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/24/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: For an ischemic stroke patient whose onset occurs outside of the catchment area of a hospital that is capable of Endovascular Treatment (EVT) and whose stroke is suspected to be caused by a large vessel occlusion (LVO), a transportation dilemma exists. Bypassing the nearest stroke hospital will delay Alteplase but expedite EVT. Not bypassing allows for confirmation of an LVO diagnosis before transfer to an EVT-enabled facility, but ultimately delays EVT. Air transport can reduce a patient's overall time to treatment however, it is costly. We expanded on an existing model to predict where Drip-and-Ship vs. Mothership provides better outcomes by including rotary air transport, and we also included prediction of where either the transport method was most cost effective. Methods: An existing model predicts the outcome of patients who screen positive for an LVO in the field based on how they were transported, Drip-and-Ship (alteplase-only facility first, then EVT-enabled facility) or Mothership (direct to EVT-enabled facility). In our model, the addition of rotary wing transportation was conditionally applied to inter-facility transfer scenarios where it provided a time advantage. Both patient outcome and transport cost functions were developed for Mothership and Drip-and-Ship strategies including transfers via either ground or air depending on the conditional probabilities. Experiments to model real world scenarios are presented by varying the driving time between the alteplase-only and EVT-enabled facility, time to treatment efficiencies at the alteplase-only facility, and EVT eligibility for LVO patients. Patient outcome and transport costs were evaluated for Mothership and Drip-and-Ship strategies. Results: The results are presented in temporospatial diagrams that are color coded to indicate which strategy optimizes the objectives. In most regions, there was overall agreement between the optimal solution when considering patient outcomes or transport costs. Small regions exist where outcome and cost are divergent; however, the difference between the divergence in Mothership and Drip-and-Ship in these regions is marginal. Conclusions: The optimal transport method can be optimized for both patient outcomes and transport costs.
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Affiliation(s)
- Ashlee Wheaton
- Department of Industrial Engineering, Dalhousie University, Halifax, NS, Canada
| | - Patrick T. Fok
- Division of Emergency Medical Services (EMS), Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Jessalyn K. Holodinsky
- Department of Clinical Neurosciences, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Peter Vanberkel
- Department of Industrial Engineering, Dalhousie University, Halifax, NS, Canada
| | - David Volders
- Department of Diagnostic Radiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, NS, Canada
- Department of Clinical Neurosciences, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
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Klingman JG, Alexander JG, Vinson DR, Klingman LE, Nguyen‐Huynh MN. Potential accuracy of prehospital NIHSS-based triage for selection of candidates for acute endovascular stroke therapy. J Am Coll Emerg Physicians Open 2021; 2:e12441. [PMID: 33969354 PMCID: PMC8087906 DOI: 10.1002/emp2.12441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 03/11/2021] [Accepted: 03/29/2021] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Whether patients with acute stroke and large vessel occlusion (LVO) benefit from prehospital identification and diversion by emergency medical services (EMS) to an endovascular stroke therapy (EST)-capable center is controversial. We sought to estimate the accuracy of field-based identification of potential EST candidates in a hypothetical best-of-all-worlds situation. METHODS In Kaiser Permanente Northern California, all acute stroke patients arriving at its 21 stroke centers between 7:00 am and midnight from January 2016 to December 2019 were evaluated by teleneurologists on arrival. Initial National Institutes of Health Stroke Scale (NIHSS) score, presence of LVO, and referral for EST were obtained from standardized teleneurology notes. Factors associated with LVO were evaluated using generalized estimating equations accounting for clustering by facility. RESULTS Among 13,377 patients brought in by EMS with potential stroke, 7168 (53.6%) were not candidates for acute stroke interventions. Of the remaining 6089 cases, 2,573 (42.3%) had an NIHSS score >10, the cutoff with a higher association for LVO. Only 703 patients (27.3% with NIHSS score >10) were ultimately diagnosed with LVO and referred for EST. Across all NIHSS scores, only 884 (6.6%) suspected acute stroke patients had LVO and EST referral. CONCLUSIONS Even if field-based tools were as accurate as NIHSS scoring and predictions by stroke neurologists, only about 1 in 4 acute stroke patients diverted to EST-capable centers would benefit by receiving EST. Depending on geography and stroke center performance on door-to-needle time, many systems may be better served by focusing on expediting evaluation, treatment with intravenous thrombolysis, and transfer to EST-capable centers.
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Affiliation(s)
- Jeffrey G. Klingman
- Department of NeurologyKaiser Permanente, Northern CaliforniaWalnut CreekCaliforniaUSA
| | - Janet G. Alexander
- Division of ResearchKaiser Permanente, Northern CaliforniaOaklandCaliforniaUSA
| | - David R. Vinson
- Division of ResearchKaiser Permanente, Northern CaliforniaOaklandCaliforniaUSA
- Department of Emergency MedicineKaiser Permanente, Northern CaliforniaRosevilleCaliforniaUSA
| | | | - Mai N. Nguyen‐Huynh
- Department of NeurologyKaiser Permanente, Northern CaliforniaWalnut CreekCaliforniaUSA
- Division of ResearchKaiser Permanente, Northern CaliforniaOaklandCaliforniaUSA
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Stefanou MI, Stadler V, Baku D, Hennersdorf F, Ernemann U, Ziemann U, Poli S, Mengel A. Optimizing Patient Selection for Interhospital Transfer and Endovascular Therapy in Acute Ischemic Stroke: Real-World Data From a Supraregional, Hub-and-Spoke Neurovascular Network in Germany. Front Neurol 2020; 11:600917. [PMID: 33343500 PMCID: PMC7746873 DOI: 10.3389/fneur.2020.600917] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/10/2020] [Indexed: 11/18/2022] Open
Abstract
Background: Interhospital transfer for endovascular treatment (EVT) within neurovascular networks might result in transfer of patients who will not undergo EVT (futile transfer). Limited evidence exists on factors associated with the primary patient selection for interhospital transfer from primary stroke centers (PSCs) to comprehensive stroke centers (CSCs), or EVT-workflow parameters that may render a transfer futile. Methods: A prospective, registry-based study was performed between July 1, 2017 and June 30, 2018, at a hub-and-spoke neurovascular network in southwest Germany, comprising 12 referring PSCs and one designated CSC providing round-the-clock EVT at the University Hospital Tübingen. Patients with acute ischemic stroke due to suspected large artery occlusion (LAO) were included upon emergency interhospital transfer inquiry (ITI). Results: ITI was made for 154 patients, 91 (59%) of whom were transferred to the CSC. Non-transferred patients (41%) had significantly higher premorbid modified Rankin scale scores (mRS) compared to transferred patients [median (IQR): 2 (1–3) vs. 0 (0–1), p < 0.001]. Interhospital transfer was denied due to: distal vessel occlusion (44.4%), or non-verifiable LAO (33.3%) in computed tomography angiography (CTA) upon teleconsultation by CSC neuroradiologists; limited Stroke-Unit or ventilation capacity (9.5%), or limited neuroradiological capacity at the CSC (12.7%). The CT-to-ITI interval was significantly longer in patients denied interhospital transfer [median (IQR): 43 (29–56) min] compared to transferred patients [29 (15–55), p = 0.029]. No further differences in EVT-workflow, and no differences in the 3-month mRS outcomes were noted between non-transferred and transferred patients [median (IQR): 2 (0–5) vs. 3 (1–4), p = 0.189]. After transfer to the CSC, 44 (48%) patients underwent EVT. The Alberta stroke program early CT score [ORadj (95% CI): 1.786 (1.573–2.028), p < 0.001] and the CT-to-ITI interval [0.994 (0.991–0.998), p = 0.001] were significant predictors of the likelihood of EVT performance. Conclusion: Our findings show that hub-and-spoke neurovascular network infrastructures efficiently enable access to EVT to patients with AIS due to LAO, who are primarily admitted to PSCs without on-site EVT availability. As in real-world settings optimal allocation of EVT resources is warranted, teleconsultation by experienced endovascular interventionists and prompt interhospital-transfer-inquiries are crucial to reduce the futile transfer rates and optimize patient selection for EVT within neurovascular networks.
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Affiliation(s)
- Maria-Ioanna Stefanou
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Centre for Neurovascular Diseases Tübingen, ZNET: Zentrum für neurovaskuläre Erkrankungen Tübingen, Tübingen, Germany
| | - Vera Stadler
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Centre for Neurovascular Diseases Tübingen, ZNET: Zentrum für neurovaskuläre Erkrankungen Tübingen, Tübingen, Germany
| | - Dominik Baku
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Centre for Neurovascular Diseases Tübingen, ZNET: Zentrum für neurovaskuläre Erkrankungen Tübingen, Tübingen, Germany
| | - Florian Hennersdorf
- Centre for Neurovascular Diseases Tübingen, ZNET: Zentrum für neurovaskuläre Erkrankungen Tübingen, Tübingen, Germany.,Department of Diagnostic & Interventional Neuroradiology, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Ulrike Ernemann
- Centre for Neurovascular Diseases Tübingen, ZNET: Zentrum für neurovaskuläre Erkrankungen Tübingen, Tübingen, Germany.,Department of Diagnostic & Interventional Neuroradiology, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Centre for Neurovascular Diseases Tübingen, ZNET: Zentrum für neurovaskuläre Erkrankungen Tübingen, Tübingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Centre for Neurovascular Diseases Tübingen, ZNET: Zentrum für neurovaskuläre Erkrankungen Tübingen, Tübingen, Germany
| | - Annerose Mengel
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Centre for Neurovascular Diseases Tübingen, ZNET: Zentrum für neurovaskuläre Erkrankungen Tübingen, Tübingen, Germany
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10
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Langhorne P, Audebert HJ, Cadilhac DA, Kim J, Lindsay P. Stroke systems of care in high-income countries: what is optimal? Lancet 2020; 396:1433-1442. [PMID: 33129394 DOI: 10.1016/s0140-6736(20)31363-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/31/2020] [Accepted: 06/09/2020] [Indexed: 01/19/2023]
Abstract
Stroke is a complex, time-sensitive, medical emergency that requires well functioning systems of care to optimise treatment and improve patient outcomes. Education and training campaigns are needed to improve both the recognition of stroke among the general public and the response of emergency medical services. Specialised stroke ambulances (mobile stroke units) have been piloted in many cities to speed up the diagnosis, triage, and emergency treatment of people with acute stroke symptoms. Hospital-based interdisciplinary stroke units remain the central feature of a modern stroke service. Many have now developed a role in the very early phase (hyperacute units) plus outreach for patients who return home (early supported discharge services). Different levels (comprehensive and primary) of stroke centre and telemedicine networks have been developed to coordinate the various service components with specialist investigations and interventions including rehabilitation. Major challenges include the harmonisation of resources for stroke across the whole patient journey (including the rapid, accurate triage of patients who require highly specialised treatment in comprehensive stroke centres) and the development of technology to improve communication across different parts of a service.
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Affiliation(s)
- Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Royal Infirmary, Glasgow, UK.
| | - Heinrich J Audebert
- Department of Neurology and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Dominique A Cadilhac
- Monash University, Department of Medicine, School of Clinical Sciences at Monash Health, Clayton, VIC, Australia
| | - Joosup Kim
- Monash University, Department of Medicine, School of Clinical Sciences at Monash Health, Clayton, VIC, Australia
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11
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Venema E, Burke JF, Roozenbeek B, Nelson J, Lingsma HF, Dippel DWJ, Kent DM. Prehospital Triage Strategies for the Transportation of Suspected Stroke Patients in the United States. Stroke 2020; 51:3310-3319. [PMID: 33023425 PMCID: PMC7587242 DOI: 10.1161/strokeaha.120.031144] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background and Purpose: Ischemic stroke patients with large vessel occlusion (LVO) could benefit from direct transportation to an intervention center for endovascular treatment, but non-LVO patients need rapid IV thrombolysis in the nearest center. Our aim was to evaluate prehospital triage strategies for suspected stroke patients in the United States. Methods: We used a decision tree model and geographic information system to estimate outcome of suspected stroke patients transported by ambulance within 4.5 hours after symptom onset. We compared the following strategies: (1) Always to nearest center, (2) American Heart Association algorithm (ie, directly to intervention center if a prehospital stroke scale suggests LVO and total driving time from scene to intervention center is <30 minutes, provided that the delay would not exclude from thrombolysis), (3) modified algorithms with a maximum additional driving time to the intervention center of <30 minutes, <60 minutes, or without time limit, and (4) always to intervention center. Primary outcome was the annual number of good outcomes, defined as modified Rankin Scale score of 0–2. The preferred strategy was the one that resulted in the best outcomes with an incremental number needed to transport to intervention center (NNTI) <100 to prevent one death or severe disability (modified Rankin Scale score of >2). Results: Nationwide implementation of the American Heart Association algorithm increased the number of good outcomes by 594 (+1.0%) compared with transportation to the nearest center. The associated number of non-LVO patients transported to the intervention center was 16 714 (NNTI 28). The modified algorithms yielded an increase of 1013 (+1.8%) to 1369 (+2.4%) good outcomes, with a NNTI varying between 28 and 32. The algorithm without time limit was preferred in the majority of states (n=32 [65%]), followed by the algorithm with <60 minutes delay (n=10 [20%]). Tailoring policies at county-level slightly reduced the total number of transportations to the intervention center (NNTI 31). Conclusions: Prehospital triage strategies can greatly improve outcomes of the ischemic stroke population in the United States, but increase the number of non-LVO stroke patients transported to an intervention center. The current American Heart Association algorithm is suboptimal as a nationwide policy and should be modified to allow more delay when directly transporting LVO-suspected patients to an intervention center.
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Affiliation(s)
- Esmee Venema
- Department of Neurology (E.V., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands.,Department of Public Health (E.V., H.F.L.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - James F Burke
- Department of Neurology, University of Michigan, Ann Arbor, MI (J.F.B.)
| | - Bob Roozenbeek
- Department of Neurology (E.V., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (B.R.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Jason Nelson
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston, MA (J.N., D.M.K.)
| | - Hester F Lingsma
- Department of Public Health (E.V., H.F.L.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology (E.V., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston, MA (J.N., D.M.K.)
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12
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McTaggart RA, Holodinsky JK, Ospel JM, Cheung AK, Manning NW, Wenderoth JD, Phan TG, Beare R, Lane K, Haas RA, Kamal N, Goyal M, Jayaraman MV. Leaving No Large Vessel Occlusion Stroke Behind: Reorganizing Stroke Systems of Care to Improve Timely Access to Endovascular Therapy. Stroke 2020; 51:1951-1960. [PMID: 32568640 DOI: 10.1161/strokeaha.119.026735] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ryan A McTaggart
- Department of Diagnostic Imaging (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurology (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (R.A.M., R.A.H., M.V.J.)
| | - Jessalyn K Holodinsky
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (J.K.H.)
| | - Johanna M Ospel
- Department of Clinical Neurosciences, University of Calgary, Canada (J.M.O., M.G.).,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Switzerland (J.M.O.)
| | - Andrew K Cheung
- Department of Neurointervention, Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Department of Neurointervention, Liverpool Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Ingham Institute for Applied Medical Research, Sydney, Australia (A.K.C., N.W.M., J.D.W.)
| | - Nathan W Manning
- Department of Neurointervention, Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Department of Neurointervention, Liverpool Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Ingham Institute for Applied Medical Research, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (N.W.M., J.D.W.)
| | - Jason D Wenderoth
- Department of Neurointervention, Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Department of Neurointervention, Liverpool Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Ingham Institute for Applied Medical Research, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (N.W.M., J.D.W.)
| | - Thanh G Phan
- Department of Neurology, Monash Health and School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia (T.G.P.)
| | - Richard Beare
- Department of Medicine, Peninsula Health and Central Clinical School, Monash University and Murdoch Children's Research Institute Melbourne Australia (R.B.)
| | - Kendall Lane
- Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI
| | - Richard A Haas
- Department of Diagnostic Imaging (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurology (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (R.A.M., R.A.H., M.V.J.)
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, Nova Scotia, Canada (N.K.)
| | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Canada (J.M.O., M.G.).,Department of Radiology, Seaman Family MR Research Centre, Foothills Medical Centre, Calgary, Canada (M.G.)
| | - Mahesh V Jayaraman
- Department of Diagnostic Imaging (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurology (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (R.A.M., R.A.H., M.V.J.)
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13
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Schlemm L, Endres M, Nolte CH. Bypassing the Closest Stroke Center for Thrombectomy Candidates. Stroke 2020; 51:867-875. [DOI: 10.1161/strokeaha.119.027512] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background and Purpose—
Patients with acute ischemic stroke who have large vessel occlusion benefit from direct transport to a comprehensive stroke center (CSC) capable of endovascular therapy. To avoid harm for patients without large vessel occlusion from delayed access to intravenous thrombolysis (IVT), it has been suggested to only redirect patients with high likelihood of large vessel occlusion for whom the additional delay to intravenous thrombolysis (IVT) caused by transport to the CSC is below a certain threshold. However, which threshold achieves the greatest clinical benefit is unknown.
Methods—
We used mathematical modeling to calculate additional-delay-to-IVT thresholds associated with the greatest reduction in disability-adjusted life years in abstracted 2-stroke center and multiple-stroke center scenarios. Model parameters were extracted from recent meta-analyses or large prospective cohort studies. Uncertainty was quantified in probabilistic and 2-way univariate sensitivity analyses.
Results—
Assuming ideal treatment time performance metrics, transport to the nearest CSC was the preferred strategy irrespective of additional delay-to-IVT when the transfer time between primary stroke center and CSC was <40 minutes (95% credible interval: 25–66 minutes); otherwise, the optimal additional delay-to-IVT-threshold ranged from 28 to 139 minutes. In multiple-stroke center scenarios, optimal additional-delay-to-IVT thresholds were 30 to 54 minutes in urban and 49 to 141 minutes in rural settings; use of optimal thresholds as compared with a 15 minute-threshold saved 0 to 0.11 and 0 to 0.37 disability-adjusted life years per triage case, respectively. Assuming slower treatment times at primary stroke centers and CSCs yielded longer permissible additional delays.
Conclusions—
Our results suggest that patients with acute ischemic stroke with suspected large vessel occlusion should be redirected to a CSC if the additional delay to IVT is <30 minutes in urban and 50 minutes in rural settings.
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Affiliation(s)
- Ludwig Schlemm
- From the Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin, Germany (L.S., M.E., C.H.N.)
- Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
| | - Matthias Endres
- From the Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin, Germany (L.S., M.E., C.H.N.)
- Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany (M.E., C.H.N.)
- DZNE (German Center for Neurodegenerative Diseases), Partner Site Berlin, Germany (M.E., C.H.N.)
| | - Christian H. Nolte
- From the Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin, Germany (L.S., M.E., C.H.N.)
- Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany (M.E., C.H.N.)
- DZNE (German Center for Neurodegenerative Diseases), Partner Site Berlin, Germany (M.E., C.H.N.)
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14
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Ernst M, Schlemm E, Holodinsky JK, Kamal N, Thomalla G, Fiehler J, Brekenfeld C. Modeling the Optimal Transportation for Acute Stroke Treatment: The Impact of the Drip-and-Drive Paradigm. Stroke 2019; 51:275-281. [PMID: 31735142 DOI: 10.1161/strokeaha.119.027493] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background and Purpose- Health systems are faced with the challenge of ensuring fast access to appropriate therapy for patients with acute stroke. The paradigms primarily discussed are mothership and drip and ship. Less attention has been focused on the drip-and-drive (DD) paradigm. Our aim was to analyze whether and under what conditions DD would predict the greatest probability of good outcome for patients with suspected ischemic stroke in Northwestern Germany. Methods- Conditional probability models based on the decay curves for endovascular therapy and intravenous thrombolysis were created to determine the best transport paradigm, and results were displayed using map visualizations. Our study area consisted of the federal states of Lower Saxony, Hamburg, and Schleswig-Holstein in Northwestern Germany covering an area of 64 065 km2 with a population of 12 703 561 in 2017 (198 persons per km2). In several scenarios, the catchment area, that is, the region that would result in the greatest probability of good outcomes, was calculated for each of the mothership, drip-and-ship, and the DD paradigms. Several different treatment time parameters were varied including onset-to-first-medical-response time, ambulance-on-scene time, door-to-needle time at primary stroke center, needle-to-door time, door-to-needle time at comprehensive stroke center, door-to-groin-puncture time, needle-to-interventionalist-leave time, and interventionalist-arrival-to-groin-puncture time. Results- The mothership paradigm had the largest catchment area; however, the DD catchment area was larger than the drip-and-ship catchment area so long as the needle-to-interventionalist-leave time and the interventionalist-arrival-to-groin-puncture time remain <40 minutes each. A slowed workflow in the DD paradigm resulted in a decrease of the DD catchment area to 1221 km2 (2%). Conclusions- Our study suggests the largest catchment area for the mothership paradigm and a larger catchment area of DD paradigm compared with the drip-and-ship paradigm in Northwestern Germany in most scenarios. The existence of different paradigms allows the spread of capacities, shares the cost and hospital income, and gives primary stroke centers the possibility to provide endovascular therapy services 24/7.
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Affiliation(s)
- Marielle Ernst
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F., C.B.), University Medical Center Hamburg-Eppendorf, Germany
| | - Eckhard Schlemm
- Department of Neurology (E.S., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Jessalyn K Holodinsky
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.K.H.)
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, Canada (N.K.)
| | - Götz Thomalla
- Department of Neurology (E.S., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Jens Fiehler
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F., C.B.), University Medical Center Hamburg-Eppendorf, Germany
| | - Caspar Brekenfeld
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F., C.B.), University Medical Center Hamburg-Eppendorf, Germany
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15
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Schlemm L, Endres M, Scheitz JF, Ernst M, Nolte CH, Schlemm E. Comparative Evaluation of 10 Prehospital Triage Strategy Paradigms for Patients With Suspected Acute Ischemic Stroke. J Am Heart Assoc 2019; 8:e012665. [PMID: 31189395 PMCID: PMC6645624 DOI: 10.1161/jaha.119.012665] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background The best strategy to identify patients with suspected acute ischemic stroke and unknown vessel status (large vessel occlusion) for direct transport to a comprehensive stroke center instead of a nearer primary stroke center is unknown. Methods and Results We used mathematical modeling to estimate the impact of 10 increasingly complex prehospital triage strategy paradigms on the reduction of population‐wide stroke‐related disability. The model was applied to suspected acute ischemic stroke patients in (1) abstract geographies, and (2) 3 real‐world urban and rural geographies in Germany. Transport times were estimated based on stroke center location and road infrastructure; spatial distribution of emergency medical services calls was derived from census data with high spatial granularity. Parameter uncertainty was quantified in sensitivity analyses. The mothership strategy was associated with a statistically significant population‐wide gain of 8 to 18 disability‐adjusted life years in the 3 real‐world geographies and in most simulated abstract geographies (net gain −4 to 66 disability‐adjusted life years). Of the more complex paradigms, transportation of patients with clinically suspected large vessel occlusion based on a dichotomous large vessel occlusion detection scale to the nearest comprehensive stroke center yielded an additional clinical benefit of up to 12 disability‐adjusted life years in some rural but not in urban geographies. Triage strategy paradigms based on probabilistic conditional modeling added an additional benefit of 0 to 4 disability‐adjusted life years over less complex strategies if based on variable cutoff scores. Conclusions Variable stroke severity cutoff scores were associated with the highest reduction in stroke‐related disability. The mothership strategy yielded better clinical outcome than the drip‐‘n'‐ship strategy in most geographies.
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Affiliation(s)
- Ludwig Schlemm
- Klinik und Hochschulambulanz für NeurologieCharité—Universitätsmedizin BerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinGermany
- Berlin Institute of Health (BIH)BerlinGermany
| | - Matthias Endres
- Klinik und Hochschulambulanz für NeurologieCharité—Universitätsmedizin BerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinGermany
- Berlin Institute of Health (BIH)BerlinGermany
- DZHK (German Center for Cardiovascular Research)BerlinGermany
- DZNE (German Center for Neurodegenerative Diseases)BerlinGermany
| | - Jan F. Scheitz
- Klinik und Hochschulambulanz für NeurologieCharité—Universitätsmedizin BerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinGermany
- Berlin Institute of Health (BIH)BerlinGermany
- DZHK (German Center for Cardiovascular Research)BerlinGermany
| | - Marielle Ernst
- Medizinische FakultätUniversität HamburgGermany
- Abteilung für diagnostische und interventionelle NeuroradiologieUniversitätsklinikum Hamburg‐EppendorfHamburgGermany
| | - Christian H. Nolte
- Klinik und Hochschulambulanz für NeurologieCharité—Universitätsmedizin BerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinGermany
- Berlin Institute of Health (BIH)BerlinGermany
- DZHK (German Center for Cardiovascular Research)BerlinGermany
- DZNE (German Center for Neurodegenerative Diseases)BerlinGermany
| | - Eckhard Schlemm
- Medizinische FakultätUniversität HamburgGermany
- Klinik und Poliklinik für Neurologie, Kopf‐ und NeurozentrumUniversitätsklinikum Hamburg‐EppendorfHamburgGermany
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