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Sablot D, Leibinger F, Dumitrana A, Duchateau N, Van Damme L, Farouil G, Gaillard N, Lachcar M, Benayoun L, Arquizan C, Ibanez M, Coll F, Fadat B, Nguyen Them L, Desmond L, Allou T, Smadja P, Ferraro-Allou A, Mourand I, Dutray A, Pujol C, Tardieu M, Jurici S, Bonnec JM, Olivier N, Mas J, Costalat V, Bonafe A. Complications During Inter-Hospital Transfer of Patients with Acute Ischemic Stroke for Endovascular Therapy. PREHOSP EMERG CARE 2019; 24:610-616. [PMID: 31750753 DOI: 10.1080/10903127.2019.1695299] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Purpose: Few data are available on complications occurring during inter-hospital transfer from a primary stroke center (PSC) to a comprehensive stroke center (CSC) for endovascular treatment (EVT) after large vessel occlusion (LVO). Therefore, we prospectively studied data from consecutive patients transferred from our PSC to the next CSC during 4 years to determine the incidence and risk factors of complications during transfer. Methods: This observational, single-center study included consecutive patients transferred from January 1, 2015 to December 31, 2018. During inter-hospital transfer, all medical incidents were systematically recorded. A new complete clinical examination was performed on arrival at the CSC. Results: Among the 253 patients transferred to the CSC during the study period, 68 (26.9%) had one or more complications. In 11 patients (4.3%) these were life-threatening and required emergency intervention by a physician. Baseline characteristics were not different between patients with and without complications, except for the LVO location. Specifically, basilar artery (BA) occlusion was strongly associated with complications during the transport (p < 0.0005). Conclusion: Complications occurred in 26.9% of patients during transfer. Only BA occlusion could predict complication during transfer. Future studies should identify variables to help stratifying patients at high and low risk of complications during transportation.
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Leibinger F, Sablot D, Van Damme L, Gaillard N, Nguyen Them L, Lachcar M, Duchateau N, Arquizan C, Farouil G, Ibanez M, Pujol C, Fadat B, Allou T, Coll F, Benayoun L, Mas J, Smadja P, Ferraro-Allou A, Mourand I, Dutray A, Tardieu M, Jurici S, Bonnec JM, Olivier N, Cardini S, Aptel S, Marquez AM, Dumitrana A, Costalat V, Bonafe A. Which Patients Require Physician-Led Inter-Hospital Transport in View of Endovascular Therapy? Cerebrovasc Dis 2019; 48:171-178. [PMID: 31726450 DOI: 10.1159/000504314] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 10/23/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The current guidelines advocate the implementation of stroke networks to organize endovascular treatment (ET) for patients with acute ischemic stroke due to large vessel occlusion (LVO) after transfer from a Primary Stroke Centre (PSC) to a Comprehensive Stroke Centre (CSC). In France and in many other countries around the world, these transfers are carried out by a physician-led mobile medical team. However, with the recent broadening of ET indications, their availability is becoming more and more critical. Here, we retrospectively analysed data of patients transferred from a PSC to a CSC for potential ET to identify predictive factors of major complications (MC) at departure and during transport that absolutely require the presence of a physician during interhospital transfer. METHODS This observational, single-centre study included patients with evidence of intracranial LVO transferred for ET from Perpignan to a 156 km-distant CSC between January 1, 2015 and -December 31, 2018. We compared 2 groups: MC group (patients who required emergency intervention by the medical team due to life-threatening complications, including need of mechanical ventilation at departure) and non-MC group (all other patients who experienced no or only minor complications that could be managed by the emergency paramedics alone). RESULTS Among the 253 patients who were transferred to the CSC, 185 (73.1%) had no complication, 57 (22.6%) minor complications, and 11 (4.3%) had MC. In multivariate analysis, MC was associated with basilar artery (BA) occlusion (p < 0.0001), initial National Institute of Health Stroke Scale (NIHSS) score >22 (p < 0.005), and history of atrial fibrillation (p < 0.04). Among the 168 patients treated with intravenous thrombolysis (IVT), only 1 patient (0.6%) had MC due to an IVT-related adverse event during transfer. CONCLUSIONS Physician-led inter-hospital transports are warranted for patients with BA occlusion, initial NIHSS score >22, or history of atrial fibrillation. For the other patients, transfer without a physician may be considered, even if treated with IVT.
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Affiliation(s)
| | - Denis Sablot
- Department of Neurology, St. Jean Hospital, Perpignan, France, .,Regional Health Agency of Occitanie, Montpellier, France,
| | | | - Nicolas Gaillard
- Department of Neurology, St. Jean Hospital, Perpignan, France.,Department of Neurology, Gui-de-Chauliac Hospital, Montpellier, France
| | | | - Marlène Lachcar
- Department of Emergency, St. Jean Hospital, Perpignan, France
| | | | - Caroline Arquizan
- Department of Neurology, Gui-de-Chauliac Hospital, Montpellier, France
| | | | - Majo Ibanez
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | - Céline Pujol
- Department of Emergency, St. Jean Hospital, Perpignan, France
| | - Bénédicte Fadat
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | - Thibaut Allou
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | - Francis Coll
- Department of Emergency, St. Jean Hospital, Perpignan, France
| | | | - Julie Mas
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | - Philippe Smadja
- Department of Radiology, St. Jean Hospital, Perpignan, France
| | | | - Isabelle Mourand
- Department of Neurology, Gui-de-Chauliac Hospital, Montpellier, France
| | - Anais Dutray
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | - Maxime Tardieu
- Department of Radiology, St. Jean Hospital, Perpignan, France
| | - Snejana Jurici
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | | | - Nadège Olivier
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | - Sandra Cardini
- Department of Radiology, St. Jean Hospital, Perpignan, France
| | - Sabine Aptel
- Department of Radiology, St. Jean Hospital, Perpignan, France
| | | | | | - Vincent Costalat
- Department of Neuroradiology, Gui-de-Chauliac Hospital, Montpellier, France
| | - Alain Bonafe
- Department of Radiology, St. Jean Hospital, Perpignan, France.,Department of Neuroradiology, Gui-de-Chauliac Hospital, Montpellier, France
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Farouil G, Sablot D, Leibinger F, Van Damme L, Coll F, Gaillard N, Ibanez M, Smadja P, Benayoun L, Dutray A, Tardieu M, Nguyen Them L, Bonnec JM, Jurici S, Bensalah ZM, Olivier N, Desmond L, Fadat B, Bertrand JL, Mas J, Akouz A, Allou T, Mourand I, Ferraro-Allou A, Dumitrana A, Aptel S, Arquizan C, Costalat V, Bonafe A. Mechanical Recanalization after Transfer from a Distant Primary Stroke Center: Effectiveness and Future Directions. J Stroke Cerebrovasc Dis 2019; 28:104368. [PMID: 31537417 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/23/2019] [Accepted: 08/21/2019] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Little is known about the effectiveness of endovascular treatment (EVT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) admitted to a primary stroke center (PSC). The aim of this study was to assess EVT effectiveness after transfer from a PSC to a distant (156 km apart; 1.5 hour by car) comprehensive stroke center (CSC), and to discuss perspectives to improve access to EVT, if indicated. PATIENTS AND METHOD Analysis of the data collected in a 6-year prospective registry of patients admitted to a PSC for AIS due to LVO and selected for transfer to a distant CSC for EVT. The rate of transfer, futile transfer, EVT, reperfusion (thrombolysis in cerebral infarction score ≥2b-3), and relevant time measures were determined. RESULTS Among the 529 patients eligible, 278 (52.6%) were transferred and 153 received EVT (55% of transferred patients) followed by reperfusion in 115 (overall reperfusion rate: 21.7%). Median times (interquartile range) were: 90 minutes (76-110) for PSC-door-in to PSC-door-out, 88 minutes (65-104) for PSC-door-out to CSC-door-in, 262 minutes (239-316) for PSC-imaging to reperfusion, and 393 minutes (332-454) for symptom onset to reperfusion. At 3 months, rates of favorable outcome (modified Rankin Scale 0-2) were not significantly different between patients eligible for EVT (42.4%), transferred patients (49.1%) and patients who underwent EVT (34.1%). DISCUSSION AND CONCLUSIONS Our study suggests that transfer to a distant CSC is associated with reduced access to early EVT. These results argue in favor of on-site EVT at high volume PSCs that are distant from the CSC.
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Affiliation(s)
| | - Denis Sablot
- Regional Health Agency of Occitanie, Montpellier, France; Neurology Department, Perpignan, France.
| | | | | | | | - Nicolas Gaillard
- Neurology Department, Perpignan, France; Neurology Department, Montpellier, France
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Julie Mas
- Neurology Department, Perpignan, France
| | - Aziz Akouz
- Intensive Care Unit, Perpignan, France; Emergency Department, Perpignan, France
| | | | | | | | | | | | | | | | - Alain Bonafe
- Radiology Department, Perpignan, France; Neuroradiology Department, Montpellier, France
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Sablot D, Dumitrana A, Leibinger F, Khlifa K, Fadat B, Farouil G, Allou T, Coll F, Mas J, Smadja P, Ferraro-Allou A, Mourand I, Dutray A, Tardieu M, Jurici S, Bonnec JM, Olivier N, Cardini S, Damon F, Van Damme L, Aptel S, Gaillard N, Marquez AM, Nguyen Them L, Ibanez M, Arquizan C, Costalat V, Bonafe A. Futile inter-hospital transfer for mechanical thrombectomy in a semi-rural context: analysis of a 6-year prospective registry. J Neurointerv Surg 2018; 11:539-544. [DOI: 10.1136/neurintsurg-2018-014206] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/20/2018] [Accepted: 09/23/2018] [Indexed: 12/26/2022]
Abstract
Background and purposeInter-hospital transfer for mechanical thrombectomy (MT) might result in the transfer of patients who finally will not undergo MT (ie, futile transfers [FT]). This study evaluated FT frequency in a primary stroke center (PSC) in a semi-rural area and at 156 km from the comprehensive stroke center (CSC).MethodologyRetrospective analysis of data collected in a 6-year prospective registry concerning patients admitted to our PSC within 4.5 hours of acute ischemic stroke (AIS) symptom onset, with MR angiography indicating the presence of large vessel occlusion (LVO) without large cerebral infarction (DWI-ASPECT ≥5), and selected for transfer to the CSC to undergo MT. Futile transfer rate and reasons were determined, and the relevant time measures recorded.ResultsAmong the 529 patients screened for MT, 278 (52.6%) were transferred to the CSC. Futile transfer rate was 45% (n=125/278) and the three main reasons for FT were: clinical improvement and reperfusion on MRI on arrival at the CSC (58.4% of FT); clinical worsening and/or infarct growth (16.8%); and longer than expected inter-hospital transfer time (11.2%). Predictive factors of FT due to clinical improvement/reperfusion on MRI could not be identified. Baseline higher NIHSS (21 vs 17; P=0.01) and lower DWI-ASPECT score (5 vs 7; P=0.001) were associated with FT due to clinical worsening/infarct growth on MRI.ConclusionsIn our setting, 45% of transfers for MT were futile. None of the baseline factors could predict FT, but the initial symptom severity was associated with FT caused byclinical worsening/infarct growth.
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Sablot D, Gaillard N, Colas C, Smadja P, Gely C, Dutray A, Bonnec JM, Jurici S, Farouil G, Ferraro-Allou A, Jantac M, Allou T, Pujol C, Olivier N, Laverdure A, Fadat B, Mas J, Dumitrana A, Garcia Y, Touzani H, Perucho P, Moulin T, Richard C, Heroum C, Bouly S, Sagnes-Raffy C, Heve D. Results of a 1-year quality-improvement process to reduce door-to-needle time in acute ischemic stroke with MRI screening. Rev Neurol (Paris) 2017; 173:47-54. [PMID: 28131535 DOI: 10.1016/j.neurol.2016.12.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 09/20/2016] [Accepted: 12/20/2016] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To determine the effects of a 1-year quality-improvement (QI) process to reduce door-to-needle (DTN) time in a secondary general hospital in which multimodal MRI screening is used before tissue plasminogen activator (tPA) administration in patients with acute ischemic stroke (AIS). METHODS The QI process was initiated in January 2015. Patients who received intravenous (iv) tPA<4.5h after AIS onset between 26 February 2015 to 25 February 2016 (during implementation of the QI process; the "2015 cohort") were identified (n=130), and their demographic and clinical characteristics and timing metrics compared with those of patients treated by iv tPA in 2014 (the "2014 cohort", n=135). RESULTS Of the 130 patients in the 2015 cohort, 120 (92.3%) of them were screened by MRI. The median DTN time was significantly reduced by 30% (from 84min in 2014 to 59min; P<0.003), while the proportion of treated patients with a DTN time≤60min increased from 21% to 52% (P<0.0001). Demographic and baseline characteristics did not significantly differ between cohorts, and the improvement in DTN time was associated with better outcomes after discharge (patients with a 0-2 score on the modified rankin scale: 59% in the 2015 cohort vs 42.4% in the 2014 cohort; P<0.01). During the 1-year QI process, the median DTN time decreased by 15% (from 65min in the first trimester to 55min in the last trimester; P≤0.04) with a non-significant 1.5-fold increase in the proportion of treated patients with a DTN time≤60min (from 41% to 62%; P=0.09). CONCLUSION It is feasible to deliver tPA to patients with AIS within 60min in a general hospital, using MRI as the routine screening modality, making this QI process to reduce DTN time widely applicable to other secondary general hospitals.
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Affiliation(s)
- D Sablot
- Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France; Agence régionale de santé Languedoc-Roussillon et Midi-Pyrénées (ARS-LRMP), 28, parc club du Millénaire, 1025, avenue Henri-Becquerel, 34067 Montpellier, France.
| | - N Gaillard
- Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - C Colas
- Service d'accueil des urgences/SMUR 66, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - P Smadja
- Service de radiologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - C Gely
- Service d'accueil des urgences/SMUR 66, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - A Dutray
- Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - J-M Bonnec
- Service d'accueil des urgences/SMUR 66, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - S Jurici
- Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - G Farouil
- Service de radiologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - A Ferraro-Allou
- Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - M Jantac
- Service d'accueil des urgences/SMUR 66, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - T Allou
- Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - C Pujol
- Service d'accueil des urgences/SMUR 66, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - N Olivier
- Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - A Laverdure
- Service d'accueil des urgences/SMUR 66, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - B Fadat
- Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - J Mas
- Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - A Dumitrana
- Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - Y Garcia
- Service d'accueil des urgences/SMUR 66, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - H Touzani
- Service de neurologie, centre hospitalier, boulevard Dr-Lacroix, 11100 Narbonne, France
| | - P Perucho
- Service de la qualité, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - T Moulin
- Service de neurologie, CHU Minjoz, 3, boulevard A-Flemming, 25030 Besançon, France
| | - C Richard
- Agence régionale de santé Languedoc-Roussillon et Midi-Pyrénées (ARS-LRMP), 28, parc club du Millénaire, 1025, avenue Henri-Becquerel, 34067 Montpellier, France
| | - C Heroum
- Agence régionale de santé Languedoc-Roussillon et Midi-Pyrénées (ARS-LRMP), 28, parc club du Millénaire, 1025, avenue Henri-Becquerel, 34067 Montpellier, France
| | - S Bouly
- Agence régionale de santé Languedoc-Roussillon et Midi-Pyrénées (ARS-LRMP), 28, parc club du Millénaire, 1025, avenue Henri-Becquerel, 34067 Montpellier, France
| | - C Sagnes-Raffy
- Agence régionale de santé Languedoc-Roussillon et Midi-Pyrénées (ARS-LRMP), 28, parc club du Millénaire, 1025, avenue Henri-Becquerel, 34067 Montpellier, France
| | - D Heve
- Agence régionale de santé Languedoc-Roussillon et Midi-Pyrénées (ARS-LRMP), 28, parc club du Millénaire, 1025, avenue Henri-Becquerel, 34067 Montpellier, France
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