Quality assurance data for regional drip-and-ship strategies- gearing up the transfer process

BACKGROUND

Stroke patients with large vessel occlusion (LVO) require endovascular therapy (EVT) provided by comprehensive stroke centers (CSC). One strategy to achieve fast stroke symptom 'onset to treatment' times (OTT) is the preclinical selection of patients with severe stroke for direct transport to CSC. Another is the optimization of interhospital transfer workflow. Our aim was to investigate the dynamics of the OTT of 'drip-and-ship' patients as well as the current 'door-in-door-out' time (DIDO) and its determinants at representative regional German stroke units.

METHODS

We determined the numbers of all EVT treatments, 'drip-and-ship' and 'direct-to-center' patients and their median OTT from the mandatory quality assurance registry of the federal state of Hesse, Germany (2012-2019). Additionally, we captured process time stamps from primary stroke centers (PSC) in a consecutive registry of patients referred for EVT in our regional stroke network over a 3 months period.

RESULTS

Along with an increase of the EVT rate, the proportion of drip-and-ship patients grew steadily from 19.4% in 2012 to 31.3% in 2019. The time discrepancy for the median OTT between 'drip-and-ship' and 'direct-to-center' patients continuously declined from 173 to 74 min. The largest share of the DIDO (median 92, IQR 69-110) is spent with the organization of EVT and consecutive patient transfer.

CONCLUSIONS

'Drip-and-ship' patients are an important and growing proportion of stroke patients undergoing EVT. The discrepancy in OTT for EVT between 'drip-and-ship' and 'direct-to-center' patients has been reduced considerably. Further optimization of the DIDO primarily aiming at the processes after the detection of LVO is urgently needed to improve stroke patient care.

[The effect of age on the spread of spinal anesthesia using isobaric 2% mepivacaine]

In the elderly, anaesthesia and surgery are associated with higher perioperative mortality and morbidity as compared to younger patients. There is some evidence that spinal anaesthesia may improve the postoperative state of elderly patients. A prospective study was performed to elucidate the effects of age on the characteristics of spinal anaesthesia with isobaric 2% mepivacaine. METHODS. Forty-six patients aged between 17 and 39 years and 48 elderly patients aged between 76 and 87 years having operations on the lower extremities or lower abdomen were investigated. All patients received 4.5 ml plain mepivacaine 2% (90 mg) as a subarachnoid injection in the L3-4 interspace in the sitting position. The patients were turned supine immediately after the injection. Time of onset, extent and duration of analgesia, motor block, and cardiovascular responses were assessed. The segmental level of sensory loss was tested using the pin-prick method. RESULTS. It was found that the time to maximal motor blockade was significantly decreased in the older age group compared to the younger group (7.9 vs 11.5 min). In the older group, the time to maximum spread was significantly shorter (11.4 vs 13.6 min). A significantly higher sensory block was obtained in the older group (T8 vs T10). The mean duration of analgesia or motor blockade did not differ significantly (200.7 vs 192.8 min). There were no unacceptably high degrees of spinal blockade. In the older group there was a tendency to a greater decrease in systolic arterial pressure as compared to preanaesthetic values (23.7% vs 16.3%) and greater falls in diastolic blood pressure were observed in the older group (22.1% vs 14.4%). A greater volume of lactated Ringer's solution was necessary in the older group (14.8 vs 10.3 ml/kg). Postspinal headache was encountered in 3 patients in the younger group and 2 in the older group. DISCUSSION. It is concluded that there was a tendency for greater spread of spinal analgesia with isobaric 2% mepivacaine in the elderly. The clinical significance of this finding is limited. In elderly patients hypotension is more common than in younger patients, but might not be related solely to age or extent of the neural blockade.