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Ospel JM, Dmytriw AA, Regenhardt RW, Patel AB, Hirsch JA, Kurz M, Goyal M, Ganesh A. Recent developments in pre-hospital and in-hospital triage for endovascular stroke treatment. J Neurointerv Surg 2023; 15:1065-1071. [PMID: 36241225 DOI: 10.1136/jnis-2021-018547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 10/05/2022] [Indexed: 11/04/2022]
Abstract
Triage describes the assignment of resources based on where they can be best used, are most needed, or are most likely to achieve success. Triage is of particular importance in time-critical conditions such as acute ischemic stroke. In this setting, one of the goals of triage is to minimize the delay to endovascular thrombectomy (EVT), without delaying intravenous thrombolysis or other time-critical treatments including patients who cannot benefit from EVT. EVT triage is highly context-specific, and depends on availability of financial resources, staff resources, local infrastructure, and geography. Furthermore, the EVT triage landscape is constantly changing, as EVT indications evolve and new neuroimaging methods, EVT technologies, and adjunctive medical treatments are developed and refined. This review provides an overview of recent developments in EVT triage at both the pre-hospital and in-hospital stages. We discuss pre-hospital large vessel occlusion detection tools, transport paradigms, in-hospital workflows, acute stroke neuroimaging protocols, and angiography suite workflows. The most important factor in EVT triage, however, is teamwork. Irrespective of any new technology, EVT triage will only reach optimal performance if all team members, including paramedics, nurses, technologists, emergency physicians, neurologists, radiologists, neurosurgeons, and anesthesiologists, are involved and engaged. Thus, building sustainable relationships through continuous efforts and hands-on training forms an integral part in ensuring rapid and efficient EVT triage.
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Affiliation(s)
- Johanna M Ospel
- Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Neurointerventional Program, Departments of Medical Imaging & Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
| | | | - Aman B Patel
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Martin Kurz
- Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Mayank Goyal
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Aravind Ganesh
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Yu AY, Bravata DM, Norrving B, Reeves MJ, Liu L, Kilkenny MF. Measuring Stroke Quality: Methodological Considerations in Selecting, Defining, and Analyzing Quality Measures. Stroke 2022; 53:3214-3221. [DOI: 10.1161/strokeaha.122.036485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Knowledge about stroke and its management is growing rapidly and stroke systems of care must adapt to deliver evidence-based care. Quality improvement initiatives are essential for translating knowledge from clinical trials and recommendations in guidelines into routine clinical practice. This review focuses on issues central to the measurement of the quality of stroke care, including selection and definition of quality measures, identification of the eligible patient cohorts, optimization of data quality, and considerations for data analysis and interpretation.
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Affiliation(s)
- Amy Y.X. Yu
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (A.Y.X.Y.)
| | - Dawn M. Bravata
- VA HSR&D Center for Health Information and Communication (CHIC)‚ Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B.)
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis (D.M.B.)
- Regenstrief Institute, Indianapolis, IN (D.M.B.)
| | - Bo Norrving
- Department of Clinical Sciences (Neurology), Lund, Lund University, and Neurology, Skåne University Hospital Lund/Malmö, Sweden (B.N.)
| | - Mathew J. Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (L.L.)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (L.L.)
| | - Monique F. Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (M.F.K.)
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (M.F.K.)
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Bulmer T, Volders D, Blake J, Kamal N. Discrete-Event Simulation to Model the Thrombolysis Process for Acute Ischemic Stroke Patients at Urban and Rural Hospitals. Front Neurol 2021; 12:746404. [PMID: 34777215 PMCID: PMC8586711 DOI: 10.3389/fneur.2021.746404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/30/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Effective treatment with tissue plasminogen activator (tPA) critically relies on rapid treatment. Door-to-needle time (DNT) is a key measure of hospital efficiency linked to patient outcomes. Numerous changes can reduce DNT, but they are difficult to trial and implement. Discrete-event simulation (DES) provides a way to model and determine the impact of process improvements. Methods: A conceptual framework was developed to illustrate the thrombolysis process; allowing for treatment processes to be replicated using a DES model developed in ARENA. Activity time duration distributions from three sites (one urban and two rural) were used. Five scenarios, three process changes, and two reductions in activity durations, were simulated and tested. Scenarios were tested individually and in combinations. The primary outcome measure is median DNT. The study goal is to determine the largest improvement in DNT at each site. Results: Administration of tPA in the imaging area resulted in the largest median DNT reduction for Site 1 and Site 2 for individual test scenarios (12.6%, 95% CI 12.4–12.8%, and 8.2%, 95% CI 7.5–9.0%, respectively). Ensuring that patients arriving via emergency medical services (EMS) remain on the EMS stretcher to imaging resulted in the largest median DNT improvement for Site 3 (9.2%, 95% CI 7.9–10.5%). Reducing both the treatment decision time and tPA preparation time by 35% resulted in a 11.0% (95% CI 10.0–12.0%) maximum reduction in median DNT. The lowest median and 90th percentile DNTs were achieved by combining all test scenarios, with a maximum reduction of 26.7% (95% CI 24.5–28.9%) and 17.1% (95% CI 12.5–21.7%), respectively. Conclusions: The detailed conceptual framework clarifies the intra-hospital logistics of the thrombolysis process. The most significant median DNT improvement at rural hospitals resulted from ensuring patients arriving via EMS remain on the EMS stretcher to imaging, while urban sites benefit more from administering tPA in the imaging area. Reducing the durations of activities on the critical path will provide further DNT improvements. Significant DNT improvements are achievable in urban and rural settings by combining process changes with reducing activity durations.
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Affiliation(s)
- Tessa Bulmer
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - David Volders
- Interventional and Diagnostic Neuroradiology, QEII Health Sciences Centre, Nova Scotia Health, Halifax, NS, Canada.,Department of Radiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - John Blake
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
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Heemskerk JL, Domingo RA, Tawk RG, Vivas-Buitrago TG, Huang JF, Rogers A, Quinones-Hinojosa A, Abode-Iyamah K, Freeman WD. Time Is Brain: Prehospital Emergency Medical Services Response Times for Suspected Stroke and Effects of Prehospital Interventions. Mayo Clin Proc 2021; 96:1446-1457. [PMID: 33714603 DOI: 10.1016/j.mayocp.2020.08.050] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/17/2020] [Accepted: 08/24/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To compare prehospital time for patients with suspected stroke in Florida with the American Stroke Association (ASA) time benchmarks, and to investigate the effects of dispatch notification and stroke assessment scales on prehospital time. PATIENTS AND METHODS A retrospective analysis was performed using data from Florida's Emergency Medical Services Tracking and Reporting System database. All patients with suspected stroke transported to a treatment center from January 1, 2018, through December 31, 2018, were analyzed. Time intervals from 911 call to hospital arrival were evaluated and compared with ASA benchmarks. RESULTS In 2018, 11,577 patients with suspected stroke were transported to a hospital (mean age, 71.5±15.7 years; 51.5% women). The median alarm-to-hospital time was 33.98 minutes (27.8 to 41.4), with a total emergency medical services (EMS) time of 32.30 minutes (26.5 to 39.478). The on-scene time was the largest time interval with a median of 13.28 minutes (10.0 to 17.4). Emergency medical services encounters met the ASA benchmarks for time in 58% to 62% of the EMS encounters in Florida (recommended 90%; P<.001). The total EMS time was reduced when a stroke notification was reported by the dispatch center (32.00 minutes vs 32.62 minutes; P=.006) or when a stroke assessment scale was used by the EMS personnel (31.88 minutes vs 32.96 minutes; P=.005). CONCLUSION This study reveals a substantial opportunity for improvement in stroke care in Florida. Two prehospital EMS stroke interventions seem to reduce prehospital time for patients with suspected stroke. Adoption of these interventions might improve the stroke systems of care.
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Affiliation(s)
| | | | - Rabih G Tawk
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL
| | | | | | - Ashley Rogers
- Department of Neurology, Mayo Clinic, Jacksonville, FL
| | | | | | - William D Freeman
- Department of Neurological Surgery, Neurology, and Critical Care Medicine, Mayo Clinic, Jacksonville, FL.
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Röther J, Busse O, Berlis A, Dörfler A, Groden C, Hamann G, Jansen O, Meixensberger J, Müller O, Regelsberger J, Steinmetz H, Vatter H, Weber W, Hänggi D, Nabavi D. [Interdisciplinary neurovascular networks: state of the art]. DER NERVENARZT 2020; 91:902-907. [PMID: 32930814 DOI: 10.1007/s00115-020-00991-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In order to treat the complete spectrum of neurovascular diseases at a high level of quality, which goes beyond the purely acute treatment of stroke, the German Stroke Society (DSG) together with the German Societies for Neurosurgery and Neuroradiology developed a certification procedure for neurovascular networks (NVN). Structurally, a NVN consists of a coordinating center with at least three neurovascular network partners with a certified stroke unit. From 2018 to 2020 a total of 15 NVN have so far been audited and certified according to this new standard. OBJECTIVE How efficient are the NVN? Are high standards maintained? MATERIAL AND METHODS The reports of the audits were analyzed. The data were taken from the period 2017-2019. RESULTS The 15 NVN treated a total of 86,510 stroke patients in the years examined and were networked with a total of 107 partner clinics, which were situated an average of 25 km from the coordinating center and transferred a total of 2726 patients. The coordinating centers performed 2463 thrombectomies and treated 2383 patients with nontraumatic intracerebral bleeding. In 712 patients with acute aneurysmatic subarachnoid hemorrhages endovascular treatment was carried out and clipping in 401. The audit was successful in the majority of the NVN. CONCLUSION The certification process of NVN has been successfully established and the audits proved to be a useful instrument for quality control and improvement. The 15 NVN are highly efficient and treat more than one quarter of stroke patients in German stroke units.
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Affiliation(s)
- J Röther
- Kopf- und Neurozentrum, Neurologische Abteilung mit überregionaler Stroke Unit, Neurophysiologie und Neurologischer Intensivmedizin, Asklepios Klinik Hamburg Altona, Asklepios Campus Hamburg der Semmelweis Universität, Paul-Ehrlich-Straße 1, 22763, Hamburg, Deutschland.
| | - O Busse
- Deutsche Schlaganfall-Gesellschaft, Reinhardtstraße 27C, 10117, Berlin, Deutschland
| | - A Berlis
- Diagnostische und Interventionelle Radiologie und Neuroradiologie, Universitätsklink Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
| | - A Dörfler
- Neuroradiologische Abteilung, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Schwabachanlage 6 (Kopfkliniken), 91054, Erlangen, Deutschland
| | - Ch Groden
- Universitätsklinikum Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - G Hamann
- Klinik für Neurologie und Neurologische Rehabilitation, Bezirkskrankenhaus Günzburg der Bezirkskliniken Schwaben, Ludwig-Heilmeyerstr. 2, 89312, Günzburg, Deutschland
| | - O Jansen
- Klinik für Radiologie und Neuroradiologie, Universitätsklinikum Schleswig-Holstein Campus Kiel, Arnold-Heller Str. 3, 24105, Kiel, Deutschland
| | - J Meixensberger
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Deutschland
| | - O Müller
- Klinik für Neurochirurgie, Klinikum Dortmund, Münsterstr. 240, 44145, Dortmund, Deutschland
| | - J Regelsberger
- Neurochirurgische Klinik, Universitätsklinikum Hamburg Eppendorf, Martinistr 52, 20251, Hamburg, Deutschland
| | - H Steinmetz
- Klinik für Neurologie, Universitätsklinikum, Goethe-Universität Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Deutschland
| | - H Vatter
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - W Weber
- Institut für Diagnostische und Interventionelle Radiologie, Neuroradiologie und Nuklearmedizin, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, In der Schornau 23-25, 44892, Bochum, Deutschland
| | - D Hänggi
- Neurochirurgische Klinik / Department of Neurosurgery, Universitätsklinikum Düsseldorf / Düsseldorf University Hospital, Heinrich-Heine-Universität, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - D Nabavi
- Klinik für Neurologie, Vivantes Klinikum Neukölln, Rudower Str. 48, 12351, Berlin, Deutschland
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Psychogios MN, Maier IL, Tsogkas I, Hesse AC, Brehm A, Behme D, Schnieder M, Schregel K, Papageorgiou I, Liebeskind DS, Goyal M, Bähr M, Knauth M, Liman J. One-Stop Management of 230 Consecutive Acute Stroke Patients: Report of Procedural Times and Clinical Outcome. J Clin Med 2019; 8:jcm8122185. [PMID: 31835763 PMCID: PMC6947228 DOI: 10.3390/jcm8122185] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/04/2019] [Accepted: 12/06/2019] [Indexed: 12/18/2022] Open
Abstract
Background and purpose: Rapid thrombectomy for acute ischemic stroke caused by large vessel occlusion leads to improved outcome. Optimizing intrahospital management might diminish treatment delays. To examine if one-stop management reduces intrahospital treatment delays and improves functional outcome of acute stroke patients with large vessel occlusion. Methods: We performed a single center, observational study from June 2016 to November 2018. Imaging was acquired with the latest generation angiography suite at a comprehensive stroke center. Two-hundred-thirty consecutive adults with suspected acute stroke presenting within 6 h after symptom onset with a moderate to severe National Institutes of Health Stroke Scale (≥10 in 2016; ≥7 since January 2017) were directly transported to the angiography suite by bypassing multidetector CT. Noncontrast flat-detector CT and biphasic flat-detector CT angiography were acquired with an angiography system. In case of a large vessel occlusion patients remained in the angiography suite, received intravenous rtPA therapy and underwent thrombectomy. As primary endpoints, door-to-reperfusion times and functional outcome at 90 days were recorded and compared in a case-control analysis with matched prior patients receiving standard management. Results: A total of 230 patients (123 women, median age of 78 years (Interquartile Range (IQR) 69–84)) were included. Median symptom-to-door time was 130 min (IQR 70–195). Large vessel occlusion was diagnosed in 166/230 (72%) patients; 64/230 (28%) had conditions not suitable for thrombectomy. Median door-to-reperfusion time for M1 occlusions was 64 min (IQR 56–87). Compared to 43 case-matched patients triaged with multidetector CT, median door-to-reperfusion time was reduced from 102 (IQR 85–117) to 68 min (IQR 53–89; p < 0.001). Rate of good functional outcome was significantly better in the one-stop management group (p = 0.029). Safety parameters (mortality, sICH, any hemorrhage) did not differ significantly between groups. Conclusions: One-stop management for stroke triage reduces intrahospital time delays in our specific hospital setting.
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Affiliation(s)
- Marios-Nikos Psychogios
- Department of Neuroradiology, University Medical Center Goettingen, 37075 Goettingen, Germany; (I.T.); (A.C.H.); (A.B.); (D.B.); (K.S.); (M.K.)
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, 4031 Basel, Switzerland
- Correspondence: ; Tel.: +41-613-28-6370
| | - Ilko L. Maier
- Department of Neurology, University Medical Center Goettingen, 37075 Goettingen, Germany; (I.L.M.); (M.S.); (M.B.); (J.L.)
| | - Ioannis Tsogkas
- Department of Neuroradiology, University Medical Center Goettingen, 37075 Goettingen, Germany; (I.T.); (A.C.H.); (A.B.); (D.B.); (K.S.); (M.K.)
| | - Amélie Carolina Hesse
- Department of Neuroradiology, University Medical Center Goettingen, 37075 Goettingen, Germany; (I.T.); (A.C.H.); (A.B.); (D.B.); (K.S.); (M.K.)
| | - Alex Brehm
- Department of Neuroradiology, University Medical Center Goettingen, 37075 Goettingen, Germany; (I.T.); (A.C.H.); (A.B.); (D.B.); (K.S.); (M.K.)
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, 4031 Basel, Switzerland
| | - Daniel Behme
- Department of Neuroradiology, University Medical Center Goettingen, 37075 Goettingen, Germany; (I.T.); (A.C.H.); (A.B.); (D.B.); (K.S.); (M.K.)
| | - Marlena Schnieder
- Department of Neurology, University Medical Center Goettingen, 37075 Goettingen, Germany; (I.L.M.); (M.S.); (M.B.); (J.L.)
| | - Katharina Schregel
- Department of Neuroradiology, University Medical Center Goettingen, 37075 Goettingen, Germany; (I.T.); (A.C.H.); (A.B.); (D.B.); (K.S.); (M.K.)
| | | | - David S. Liebeskind
- Neurovascular Imaging Research Core and Stroke Center, Department of Neurology, University of California Los Angeles, Los Angeles, CA 90095, USA;
| | - Mayank Goyal
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB 2500, Canada;
| | - Mathias Bähr
- Department of Neurology, University Medical Center Goettingen, 37075 Goettingen, Germany; (I.L.M.); (M.S.); (M.B.); (J.L.)
| | - Michael Knauth
- Department of Neuroradiology, University Medical Center Goettingen, 37075 Goettingen, Germany; (I.T.); (A.C.H.); (A.B.); (D.B.); (K.S.); (M.K.)
| | - Jan Liman
- Department of Neurology, University Medical Center Goettingen, 37075 Goettingen, Germany; (I.L.M.); (M.S.); (M.B.); (J.L.)
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