In-Hospital Delays in Stroke Thrombolysis: Every Minute Counts

Helicopter emergency medical services in Iceland between 2018 and 2022-A retrospective study

BACKGROUND

Helicopter emergency services (HEMS) are widely used to bring medical assistance to individuals that cannot be reached by other means or individuals that have time-critical medical conditions, such as chest pain, stroke or severe trauma. It is a very expensive resource whose use and importance depends on local conditions. The aim of this study was to describe flight and patient characteristics in all HEMS flights done in Iceland, a geographically isolated, mountainous and sparsely populated country, over a 5-year course.

METHODS

This retrospective study included all individuals requiring HEMS transportation in Iceland during 2018-2022. The electronic database of the Icelandic Coast Guard was used to identify the individuals and register flight data. Electronic databases from Landspitali and Akureyri hospitals were used to collect clinical variables. Descriptive statistics was applied.

RESULTS

The average number of HEMS transports was 3.5/10,000 inhabitants and the median [IQR] activation time and flight times were 30 min [20-42] and 40 min [26-62] respectively. The vast majority of patients were transported to Landspitali Hospital in Reykjavik. More than half of the transports were due to trauma, the most common medical transports were due to chest pain or cardiac arrests. Advanced medical therapy was provided for 66 (10%) of individuals during primary transports, 157 (24%) of individuals were admitted to intensive care, 188 (28%) needed surgery and 53 (7.9%) needed a coronary angiography.

CONCLUSION

In Iceland, the number of transports is lower but activation and flight times for HEMS flights are considerably longer than in other Nordic countries, likely due to geographical features and the structure of the service including utilizing helicopters both for HEMS and search and rescue operations. The transport times for some time-sensitive conditions are not within standards set by international studies and guidelines.

Delays in receiving Alteplase and related factors in patients with stroke referred to Shahid Beheshti Hospital in Kashan-Iran in 2020-2021

BACKGROUND

The benefits of using Alteplase are time-dependent. This study aimed to evaluate delays between the onset of symptoms and the administration of Alteplase and related factors in patients with acute ischemic stroke (AIS).

MATERIALS AND METHODS

In this cross-sectional study, 60 AIS patients receiving Alteplase were selected by census sampling from July 2020 to July 2021 from the eligible patients referred to Shahid Beheshti Hospital in Kashan, Iran. The data collection tool was a researcher-made questionnaire containing demographic information, time periods from the onset of symptoms to the injection of Alteplase, and associated factors. The required information was collected from the patients, their relatives, their health records, and Kashan Emergency Medical Service (EMS) information system. Data were analyzed in SPSS-16.

RESULTS

Eighty-five percent of the 60 patients participating in the study were transferred to the hospital by EMS ambulances. The mean time intervals between different phases were as follows: Onset-To-Door (OTD) time 81.35 ± 33.76 minutes; Door-To-CT (DTC) scan time 16.12 ± 17.46 minutes; Door-To-Needle (DNT) time 51.30 ± 26.14 minutes; and the overall Onset-To-Needle (ONT) time 133.75 ± 39.17 minutes. Also, the mean ONT in people transferred by EMS was about 129 minutes, and the longest prehospital delay in these patients was related to the time between the arrival of the EMS ambulance to the hospital. Marital status and geographical location where the stroke had occurred showed a significant relationship with prehospital delay and pre-hospital notification (PHN) by EMS But there was no relationship between underlying diseases or economic status and prehospital delays; also, the patient's diastolic blood pressure at the time of receiving Alteplase showed a significant relationship with in-hospital delay.

CONCLUSION

The findings of the study showed that the majority of people trust and use EMS ambulances to transfer to the hospital and the time spent in different stages, from the onset of symptoms to the injection of the thrombolytic drug, was in an acceptable range in the patients.

Variable parameters memory-type control charts for simultaneous monitoring of the mean and variability of multivariate multiple linear regression profiles

Variable parameters (VP) schemes are the most effective adaptive schemes in increasing control charts' sensitivity to detect small to moderate shift sizes. In this paper, we develop four VP adaptive memory-type control charts to monitor multivariate multiple linear regression profiles. All the proposed control charts are single-chart (single-statistic) control charts, two use a Max operator and two use an SS (squared sum) operator to create the final statistic. Moreover, two of the charts monitor the regression parameters, and the other two monitor the residuals. After developing the VP control charts, we developed a computer algorithm with which the charts' time-to-signal and run-length-based performances can be measured. Then, we perform extensive numerical analysis and simulation studies to evaluate the charts' performance and the result shows significant improvements by using  the VP schemes. Finally, we use real data from the national quality register for stroke care in Sweden, Riksstroke, to illustrate how the proposed control charts can be implemented in practice.

A hybrid strategy using an ambulance and a helicopter to convey thrombectomy candidates to definite care: a prospective observational study

BACKGROUND

Mechanical thrombectomy is the treatment of choice for large vessel occlusion strokes done only in comprehensive stroke centres (CSC). We investigated whether the transportation time of thrombectomy candidates from another hospital district could be reduced by using an ambulance and a helicopter and how this affected their recovery.

METHODS

We prospectively gathered the time points of thrombectomy candidates referred to the Tampere University Hospital from the hospital district of Southern Ostrobothnia. Primary and secondary transports were included. In Hybrid transport, the helicopter emergency medical services (HEMS) unit flew from an airport near the CSC to meet the patient during transport and continued the transport to definitive care. Ground transport was chosen only when the weather prevented flying, or the HEMS crew was occupied in another emergency. We contacted the patients treated with mechanical thrombectomy 90 days after the intervention and rated their recovery with the modified Rankin Scale (mRS). Favourable recovery was considered mRS 0-2.

RESULTS

During the study, 72 patients were referred to the CSC, 71% of which were first diagnosed at the PSC. Hybrid transport (n = 34) decreased the median time from the start of transport from the PSC to the computed tomography (CT) at the CSC when compared to Ground (n = 17) transport (84 min, IQR 82-86 min vs. 109 min, IQR 104-116 min, p < 0.001). The transport times straight from the scene to CT at the CSC were equal: median 93 min (IQR 80-102 min) in the Hybrid group (n = 11) and 97 min (IQR 91-108 min) in the Ground group (n = 10, p = 0.28). The percentages of favourable recovery were 74% and 50% in the Hybrid and Ground transport groups (p = 0.38) from the PSC. Compared to Ground transportation from the scene, Hybrid transportation had less effect on the positive recovery percentages of 60% and 50% (p = 1.00), respectively.

CONCLUSION

Adding a HEMS unit to transporting a thrombectomy candidate from a PSC to CSC decreases the transport time compared to ambulance use only. This study showed minimal difference in the recovery after thrombectomy between Hybrid and Ground transports.

The pre-hospital 12-lead electrocardiogram is associated with longer delay and worse outcomes in patients presenting to emergency medical services with acute stroke: a linked cohort study

Objectives

To investigate the association between pre-hospital 12-lead electrocardiogram (PHECG) use in patients presenting to emergency medical services (EMS) with acute stroke, and clinical outcomes and system delays.

Methods

Multi-centre linked cohort study. Patients with verified acute stroke admitted to hospital via EMS were identified through routinely collected hospital data and linked to EMS clinical records via EMS unique identifiers. Ordinal and logistic regression analyses were undertaken to analyse the relationship between having a PHECG and modified Rankin Scale (mRS); hospital mortality; pre-hospital time intervals; door-to-scan and door-to-needle times; and rates of thrombolysis.

Results

Of 1161 eligible patients admitted between 29 December 2013 and 30 January 2017, PHECG was performed in 558 (48%). PHECG was associated with an increase in mRS (adjusted odds ratio [aOR] 1.30, 95% confidence interval [CI] 1.01-1.66, p = 0.04) and hospital mortality (aOR 1.83, 95% CI 1.26-2.67, p = 0.002). There was no association between PHECG and administration of thrombolytic treatment (aOR 1.06, 95% CI 0.75-1.52, p = 0.73). Patients who had PHECG recorded spent longer under the care of EMS (median 49 vs 43 minutes, p = 0.006). No difference in times to receiving brain scan (median 28 with PHECG vs 29 minutes no PHECG, p = 0.32) or thrombolysis (median 46 vs 48 minutes, p = 0.37) were observed.

Conclusion

The PHECG was associated with worse outcomes and longer delays in patients with acute ischaemic stroke.

Direct admission of stroke in MRI room reduces in-hospital delays and improves recovery

PURPOSE

Efficacy of intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) is strongly time dependent in acute stroke management. We investigated the impact of a direct magnetic resonance imaging (MRI) room admission protocol in order to reduce in-hospital delays.

METHODS

We implemented a protocol of direct MRI room admission, bypassing the Emergency Department. We compared in-hospital delays, clinical and functional outcomes using National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores, between patients hospitalized via this protocol and those admitted via the standard workflow and treated by IVT and/or MT. The primary endpoint was the proportion of patients with door-to-needle time (DTN) ≤ 60minutes.

RESULTS

Among 308 consecutive patients included, 62 underwent direct MRI room admission. The proportion of patients with DTN ≤ 60minutes was higher in the intervention group compared to the control group (82.5% vs. 17.8%, P<0.001), and median DTN was lower (45min vs. 75min, P<0.001). Despite a functional benefit at discharge on dichotomized mRS (mRS [0-2, as independence]: 66.1% vs. 51.2%, P=0.003), the difference was no longer statistically significant at six months (68.4% vs. 57.4%, P=0.10).

CONCLUSION

Direct MRI room admission of stroke alerts is associated with an important reduction of treatment times and improves functional outcomes.

FeMA: Feature matching auto-encoder for predicting ischaemic stroke evolution and treatment outcome

Although, predicting ischaemic stroke evolution and treatment outcome provide important information one step towards individual treatment planning, classifying functional outcome and modelling the brain tissue evolution remains a challenge due to data complexity and visually subtle changes in the brain. We propose a novel deep learning approach, Feature Matching Auto-encoder (FeMA) that consists of two stages, predicting ischaemic stroke evolution at one week without voxel-wise annotation and predicting ischaemic stroke treatment outcome at 90 days from a baseline scan. In the first stage, we introduce feature similarity and consistency objective, and in the second stage, we show that adding stroke evolution information increase the performance of functional outcome prediction. Comparative experiments demonstrate that our proposed method is more effective to extract representative follow-up features and achieves the best results for functional outcome of stroke treatment.

Impact of Medical Community Model on Intravenous Alteplase Door-to-Needle Times and Prognosis of Patients With Acute Ischemic Stroke

Objective

In this study, we retrospectively analyzed 795 AIS patients who received intravenous alteplase for thrombolytic therapy in one third-class hospital or three second-class hospitals in Dongyang City and sought to evaluate the effects of the medical community model on intravenous alteplase door-to-needle time (DNT) and prognosis of patients with acute ischemic stroke.

Methods

According to whether the medical community model is established or not, 303 AIS patients (204 cases from the third-class hospital and 99 cases from three second-class hospitals) were assigned to control group unavailable to the medical community model and 492 AIS patients (297 cases from the third-class hospital, and 195 cases from three second-class hospitals) into observational group available to the medical community model.

Results

A higher thrombolysis rate, a shorter DNT, more patients with DNT ≤ 60 min and DNT ≤ 45 min, a shorter ONT, lower National Institutes of Health Stroke Scale (NIHSS) scores at 24 h, 7 d, 14 d, and modified Rankin scale (mRS) scores at 3 months after thrombolytic therapy, a shorter length of hospital stay, and less hospitalization expense were found in the observational group than the control group. Subgroup analysis based on different-class hospitals revealed that the medical community model could reduce the DNT and ONT to increase the thrombolysis rate of AIS patients, especially in low-class hospitals. After the establishment of the medical community model, the AIS patients whether from the third-class hospital or three second-class hospitals exhibited lower NIHSS scores at 24 h, 7 d, 14 d after thrombolytic therapy (p < 0.05). After a 90-day follow-up for mRS scores, a significant difference was only noted in the mRS scores of AIS patients from the third-class hospital after establishing the medical community model (p < 0.05). It was also found that the medical community model led to reduced length of hospital stay and hospitalization expenses for AIS patients, especially for the second-class hospitals.

Conclusion

The data suggest that the medical community model could significantly reduce intravenous alteplase DNT and improve the prognosis of patients with AIS.

Effectiveness and Predictors of Poor Prognosis Following Intravenous Thrombolysis in Patients with Wake-Up Ischemic Stroke Guided by Rapid MRI

PURPOSE

Our aim was to investigate the effectiveness and predictors of poor prognosis in WUIS patients who received alteplase thrombolysis under the guidance of diffusion-weighted imaging (DWI)-T2-weighted imaging (T2WI) mismatch.

PATIENTS AND METHODS

We recruited patients within 4.5 h of acute ischemic stroke (AIS) and WUIS patients with uncertain onset times from two stroke centers. To evaluate effectiveness, we compared National Institutes of Health Stroke Scale (NIHSS) scores between the two groups at admission and at 24 h, 3 days, and 1 week thereafter. We also compared the two groups with respect to the modified Rankin Scale (mRS) score at 90 days after thrombolysis. The WUIS patients were divided into a favorable prognosis group (mRS score: 0-1 points) and a poor prognosis group (mRS score ≥2 points). Data were compared between the two subgroups to identify factors that influence poor prognoses. The receiver operating characteristic (ROC) curve was used to evaluate the predictive value of factors related to poor prognosis.

RESULTS

A total of 114 patients with WUIS and 316 patients with AIS were enrolled in the study. There were no significant differences between the two groups in terms of NIHSS or 90-day mRS scores (p > 0.05). Baseline NIHSS score (odds ratio [OR] = 1.490, 95% confidence interval [CI] 1.248-1.779, p < 0.001) and atrial fibrillation (OR = 3.825, 95% CI 1.218-12.016, p = 0.022) were identified as independent predictors of poor prognosis following thrombolysis in WUIS patients. The combined ROC diagnosis of these two variables had an area under the curve of 0.850.

CONCLUSION

The DWI-T2WI sequence is an effective method to guide intravenous thrombolytic therapy for WUIS. Baseline NIHSS score and atrial fibrillation were identified as independent predictors of poor prognosis following thrombolysis in WUIS patients.

Thrombolytic DNT and fatality and disability rates in acute ischemic stroke: a study from Bigdata Observatory Platform for Stroke of China

OBJECTIVE

To evaluate whether shorter door-to-needle times (DNT) with intravenous tissue plasminogen activator (tPA) for acute ischemic stroke are associated with improved 1-year outcomes in Chinese patients.

METHODS

From August to September 2019, all first-ever ischemic stroke patients who were treated with intravenous tPA within 4.5 h of the time they were last known to be well from 232 hospitals in China were included. Patients were divided into four groups according to DNT time (≤ 45 min; 45-60 min; 60-90 min; > 90 min). All discharged patients would receive a telephone follow-up at 12-month after admission. Death and disability events were recorded.

RESULTS

Finally, 2370 patients were analyzed. The median age was 65 years, 66.6% were male, and 2.4% were of ethnic minorities. In the 1-year follow-up, 211 patients died (8.9%; 95%CI: 7.8-10.0%). The patients (53.1%) had DNT times of longer than 45 min, compared with those treated within 45 min, did not have significantly higher 1-year mortality (8.9% vs 8.9% [absolute difference, 0.03% {95% CI, - 0.05% to - 0.10%}, odd ratio {OR}, 1.00 {95% CI, 0.75 to 1.33}]). In addition, 385 patients (16.2%; 14.8-17.3%) out of those survivors had disability events. The patients had DNT times of longer than 45 min, compared with those treated within 45 min, did not have significantly higher 1-year disability rate (18.9% vs 16.7% [absolute difference, 1.9% {95% CI, 1.1% to 3.0%}, odd ratio {OR}, 1.22 {95% CI, 0.89 to 1.43}]).

CONCLUSIONS

The results did not show that shorter DNT for tPA administration was significantly associated with better 1-year outcomes.

Adverse consequences of immediate thrombolysis-related complications: a multi-centre registry-based cohort study of acute stroke

Complications following thrombolysis for stroke are well documented, and mostly concentrated on haemorrhage. However, the consequences of patients who experience any immediate thrombolysis-related complications (TRC) compared to patients without immediate TRC have not been examined. Prospectively collected data from the Sentinel Stroke National Audit Programme were analysed. Thrombolysis was performed in 451 patients (52.1% men; 75.3 years ± 13.2) admitted with acute ischaemic stroke (AIS) in four UK centres between 2014 and 2016. Adverse consequences following immediate TRC were assessed using logistic regression, adjusted for age, sex and co-morbidities. Twenty-nine patients (6.4%) acquired immediate TRC. Compared to patients without, individuals with immediate TRC had greater adjusted risks of: moderately-severe or severe stroke (National Institutes of Health for Stroke Scale score ≥ 16) at 24-h (5.7% vs 24.7%, OR 3.9, 95% CI 1.4-11.1); worst level of consciousness (LOC) in the first 7 days (score ≥ 1; 25.0 vs 60.7, OR 4.6, 95% CI 2.1-10.2); urinary tract infection or pneumonia within 7-days of admission (13.5% vs 39.3%, OR 3.2, 95% CI 1.3-7.7); length of stay (LOS) on hyperacute stroke unit (HASU) ≥ 2 weeks (34.7% vs 66.7%, OR 5.2, 95% CI 1.5-18.4); mortality (13.0% vs 41.4%, OR 3.7, 95% CI 1.6-8.4); moderately-severe or severe disability (modified Rankin Scale  score ≥ 4) at discharge (26.8% vs 65.5%, OR 4.7, 95% CI 2.1-10.9); palliative care by discharge date (5.1% vs 24.1%, OR 5.1, 95% CI 1.7-15.7). The median LOS on the HASU was longer (7 days vs 30 days, Kruskal-Wallis test: χ² = 8.9, p = 0.003) while stroke severity did not improve (NIHSS score at 24-h post-thrombolysis minus NIHSS score at arrival = - 4 vs 0, χ² = 24.3, p < 0.001). In conclusion, the risk of nosocomial infections, worsening of stroke severity, longer HASU stay, disability and death is increased following immediate TRC. The management of patients following immediate TRC is more complex than previously thought and such complexity needs to be considered when planning an increased thrombolysis service.

The Quest to Reduce Stroke Treatment Delays at A Melbourne Metropolitan Primary Stroke Centre over the Last Two Decades

BACKGROUND

Reducing door-to-needle time (DNT) for intravenous thrombolysis in acute ischaemic stroke can lead to improved patient outcomes. Long-term reports on DNT trends in Australia are lacking in the setting of extension of the thrombolysis time window, addition of mechanical thrombectomy and increasing presentations.

AIMS

To examine 17-year trends of DNT and identify factors associated with improved DNT at a high-volume, metropolitan primary stroke centre.

METHOD

Retrospective study between 2003 and 2019 of all thrombolysis cases using departmental stroke database. Since most strategies were implemented from 2012 onwards, intervention period has been defined as period 2012-2019. Factors associated with DNT reduction were examined by regression modelling.

RESULTS

15 strategies were identified including alterations to 'Code Stroke' processes. 1250 patients were thrombolysed, with 737 (58.8%) treated during the intervention period. The proportion of DNT ≤60- minutes rose from average of 22.5% during 2003-2012 to 63% during 2015-2018 and 71% in 2019. However, median DNT has only marginally improved from 58 to 51 minutes between 2015 and 2019. Faster DNT was independently associated with two modifiable workflow factors, 'Direct-to-CT' protocol (P < 0.001) and acute stroke nurse presence (P < 0.005). Over time, treated patients were older and less independent (P < 0.001), and the number of annual stroke admissions and 'Code Stroke' activations have risen by 4- and 10-fold to 748 and 1298 by 2019, respectively.

CONCLUSIONS

Targeted quality improvement initiatives are key to reducing thrombolysis treatment delays in the Australian metropolitan setting. Relative stagnation in DNT improvement is concerning and needs further investigation. This article is protected by copyright. All rights reserved.