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Day J, Simmonds RL, Shaw L, Price CI, McClelland G, Ford GA, James M, White P, Stein K, Pope C. Healthcare professional views about a prehospital redirection pathway for stroke thrombectomy: a multiphase deductive qualitative study. Emerg Med J 2024; 41:429-435. [PMID: 38729751 PMCID: PMC11228204 DOI: 10.1136/emermed-2023-213350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 04/10/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Mechanical thrombectomy for stroke is highly effective but time-critical. Delays are common because many patients require transfer between local hospitals and regional centres. A two-stage prehospital redirection pathway consisting of a simple ambulance screen followed by regional centre assessment to select patients for direct admission could optimise access. However, implementation might be challenged by the limited number of thrombectomy providers, a lack of prehospital diagnostic tests for selecting patients and whether finite resources can accommodate longer ambulance journeys plus greater central admissions. We undertook a three-phase, multiregional, qualitative study to obtain health professional views on the acceptability and feasibility of a new pathway. METHODS Online focus groups/semistructured interviews were undertaken designed to capture important contextual influences. We purposively sampled NHS staff in four regions of England. Anonymised interview transcripts underwent deductive thematic analysis guided by the NASSS (Non-adoption, Abandonment and Challenges to Scale-up, Spread and Sustainability, Implementation) Implementation Science framework. RESULTS Twenty-eight staff participated in 4 focus groups, 2 group interviews and 18 individual interviews across 4 Ambulance Trusts, 5 Hospital Trusts and 3 Integrated Stroke Delivery Networks (ISDNs). Five deductive themes were identified: (1) (suspected) stroke as a condition, (2) the pathway change, (3) the value participants placed on the proposed pathway, (4) the possible impact on NHS organisations/adopter systems and (5) the wider healthcare context. Participants perceived suspected stroke as a complex scenario. Most viewed the proposed new thrombectomy pathway as beneficial but potentially challenging to implement. Organisational concerns included staff shortages, increased workflow and bed capacity. Participants also reported wider socioeconomic issues impacting on their services contributing to concerns around the future implementation. CONCLUSIONS Positive views from health professionals were expressed about the concept of a proposed pathway while raising key content and implementation challenges and useful 'real-world' issues for consideration.
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Affiliation(s)
- Jo Day
- NIHR Applied Research Collaboration South West Peninsula, Health and Community Sciences, University of Exeter, Exeter, Devon, UK
| | | | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher I Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Graham McClelland
- North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne, UK
- Northumbria University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Gary A Ford
- Oxford University Hospitals NHS Foundation Trust and Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Martin James
- Royal Devon University Healthcare NHS Foundation Trust and University of Exeter, University of Exeter, Exeter, Devon, UK
| | - Phil White
- Stroke Research Group, Clinical and Translational Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ken Stein
- NIHR Applied Research Collaboration South West Peninsula, University of Exeter, Exeter, Devon, UK
| | - Catherine Pope
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Weddell J, Parr E, Knight S, Muddegowda G, Natarajan I, Chembala J, Ferdinand P, Ahmad N, Pencz Z, Rana S, Warusevitane A, Jadun C, Nayak S, Hashim Z, Augustine A, Sim J, Roffe C. Mechanical thrombectomy: can it be safely delivered out of hours in the UK? BMC Neurol 2020; 20:326. [PMID: 32873250 PMCID: PMC7461259 DOI: 10.1186/s12883-020-01909-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 08/24/2020] [Indexed: 12/15/2022] Open
Abstract
Background Mechanical thrombectomy was approved by NICE as a treatment for stroke in 2016. However, most of the evidence is from studies conducted during working hours. Only few centres in the UK perform thrombectomies out-of-hours. The Royal Stoke University Hospital (RSUH) has offered thrombectomies over 24 h (24/7) since 2010. The aim of this service review is to compare the outcomes for patients treated in regular working hours to those treated outside normal working hours within this unit. Methods This retrospective service analysis includes all patients treated with mechanical thrombectomy at RSUH since the start of the service in January 2010 to June 2019. Data on key demographics, timings, procedural complications, and long-term outcomes including death and disability at 90 days were collected. In-hours was defined as the time between 8:00–17:00 h, Monday to Friday; out-of-hours was defined as any time outside this period. Results In total, 516 mechanical thrombectomies were performed in this time period; data were available on 501 of these. Successful recanalization (TICI 2b/3) was achieved in 86% of patients. By 90 days 96 (19%) had died and 234 (47%) were functionally independent (modified Rankin Scale score ≤ 2). 211 (42%) of the procedures were performed in-hours and 290 (58%) out-of-hours. Door-to-CT and door-to-groin times were significantly longer out-of-hours than in-hours, but thrombectomy duration was significantly shorter. There were no significant differences in complications and short- and long-term outcomes. Conclusion Mechanical thrombectomy was delivered safely and effectively 24/7 in this UK hospital, with no difference in clinical outcomes.
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Affiliation(s)
- Jake Weddell
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK.
| | - Emma Parr
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Stacey Knight
- School of Medicine, Keele University, Newcastle-under-Lyme, ST5 5BG, UK
| | - Girish Muddegowda
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Indira Natarajan
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Jayan Chembala
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Phillip Ferdinand
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Nasar Ahmad
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Zoltan Pencz
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Saad Rana
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Anushka Warusevitane
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Changez Jadun
- Department of Radiology, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Sanjeev Nayak
- Department of Radiology, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Zafar Hashim
- Department of Radiology, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Albin Augustine
- Department of Anaesthetics, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Julius Sim
- School of Medicine, Keele University, Newcastle-under-Lyme, ST5 5BG, UK
| | - Christine Roffe
- Department of Stroke Medicine, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK.,School of Medicine, Keele University, Newcastle-under-Lyme, ST5 5BG, UK
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