Background The prehospital phase is critical in ensuring that stroke treatment is delivered quickly and is a major source of time delay. This study sought to identify and examine prehospital stroke workflow optimizations (PSWOs) and their impact on improving health systems, reperfusion rates, treatment delays, and clinical outcomes. Methods The authors conducted a systematic literature review and meta‐analysis by extracting data from several research databases (PubMed, Cochrane, Medline, and Embase) published since 2005. We used appropriate key search terms to identify clinical studies concerning prehospital workflow optimization, following Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. Results The authors identified 27 articles that looked at the impact of prehospital workflow optimizations on time and treatment parameters; 26 were included in the meta‐analysis. The PSWO were subgrouped into three categories: improved intravenous thrombolysis (IVT) triage, large‐vessel occlusion (LVO) bypass, and mobile stroke unit (MSU). The salient findings are as follows: improved IVT triage led to significantly improved rates of IVT (relative risk [RR] = 1.80, 95% confidence interval [CI] = 1.18 to 2.75); however, MSU did not (RR = 1.22, 95% CI = 0.98 to 1.52). Improved IVT triage (standard mean difference [SMD] = –0.82, 95% CI = –1.32 to –0.32), LVO bypass (SMD = –0.80, 95% CI = –1.13 to –0.47), and MSU (SMD = –0.87, 95% CI = –1.57 to –0.17) were found to significantly reduce door‐to‐needle time for IVT. MSU was found to significantly reduce call‐to‐needle (SMD = –1.41, 95% CI = –1.94 to –0.88) and onset‐to‐needle (SMD = –1.15, 95% CI = –1.74 to –0.56) times for IVT. MSU additionally demonstrated significant reduction in door‐to‐perfusion (SMD = –0.72, 95% CI = –1.32 to –0.12) as well as call‐to‐perfusion (SMD = –0.73, 95% CI = –1.08 to –0.38) times for EVT. Finally, PSWO did not demonstrate significant improvements in rates of good functional outcome (RR = 1.04, 95% CI = 0.97 to 1.12) or mortality at 90 days (RR = 1.00, 95% CI = 0.76 to 1.31). Conclusions This systematic review and meta‐analysis found that PSWO significantly improves several time metrics related to stroke treatment leading to improvement in IVT reperfusion rates. Thus, the implementation of these measures in stroke networks is a promising avenue to improve an often‐neglected aspect of the stroke response. However, the limited available data suggest functional outcomes and mortality are not significantly improved by PSWO; hence, further studies and improvement strategies vis‐à‐vis PSWOs are warranted.

The therapeutic goal for acute ischaemic stroke (AIS) patients is to achieve timely restoration of cerebral blood flow to the ischaemic brain tissue at risk of infarction and reduce neurological complications. 1 Current literature supports the efficacy and use of intravenous thrombolysis (IVT) with tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT) in the treatment of AIS, with EVT proven to be more efficacious in patients presenting with large vessel occlusion (LVO). 2-5 When tPA and EVT are administered within their therapeutic time window of ≤4.5 and ≤6 hours, respectively, both therapies improve both recovery and clinical outcome of stroke patients. 2-6 Results from the DAWN trial have proposed extending the therapeutic time window for EVT to 24 hours due to improved efficacy and similar safety profiles. 7 Time to treatment is arguably the most important determinant of the efficacy of reperfusion

Objectives The value of in‐hospital systems‐based interventions in streamlining treatment delays associated with reperfusion therapy delivery in acute ischaemic stroke (AIS), in the emergency department (ED), is poorly understood. This systematic review and meta‐analysis aimed to assess and quantify the value of in‐hospital systems‐based interventions in streamlining reperfusion therapy delivery following AIS. Material & Methods Articles from the following databases were retrieved: Medline, Embase and Cochrane Central Register of Controlled Trials. The primary endpoint was in‐hospital time metrics between the intervention and control group. The secondary endpoint included the rate of good functional outcome at 90 days. Results 393 Systems intervention studies published after 2015 were screened, and 231 full articles were then read. In total, 35 studies with 35,815 patients were included in the final systematic review and 26 studies with 7,089 patients were used in the meta‐analysis. The greatest time reductions from in‐hospital system interventions were achieved in door‐to‐needle (DTN) time (SMD: −2.696, 95% CI: −2.976, −2.416, z = 3.03, p = 0.002). Systems interventions were also associated with a statistically significant improvement in mortality (RR: 0.25, 95% CI: 0.18, 0.38), rate of symptomatic intracerebral haemorrhage (RR: 0.07, 95% CI: 0.04, 0.1) and ≤60‐minute reperfusion rates (RR: 0.63, 95% CI: 0.51, 0.79). Conclusions The use of in‐hospital workflow optimization is imperative to expedite reperfusion therapy delivery and improving patient outcomes. To reduce the morbidity and mortality of stroke globally, in‐hospital workflow guidelines should be adhered to and incorporated including the optimal elements identified in this study.