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This study analyzed the efficacy and safety of the “drip, ship, and retrieve (DSR)” approach used to improve patient access to thrombectomy for acute stroke. Methods: The study participants were 45 patients who underwent thrombectomy following intravenous tissue plasminogen activator between September 2013 and August 2015. Patients were divided into two groups according to whether they were transferred from another hospital (DSR group; n = 33) or were brought in directly (Direct group; n = 12). The two groups were compared based on their baseline characteristics, time from stroke onset to reperfusion, outcome, and adverse events. Results: There were no significant differences in baseline characteristics. Time from onset until admission to our facility was significantly shorter in the Direct group (56.9 min) than in the DSR group (163.5 min) (P <0.0001). Conversely, time from arrival at the hospital to arterial puncture was significantly shorter in the DSR group (25.0 min) than in the Direct group (109.5 min) (P <0.0001). Time from onset to reperfusion did not differ significantly between the groups. There was no significant difference in patient outcomes, with a modified Rankin scale score of 0–2 (44.8% in DSR group versus 48.7% in Direct group). Moreover, there was no difference in the incidence of adverse events. Discussion: Despite the time required to transfer patients in the DSR group between hospitals, reducing the time from arrival until commencement of endovascular therapy meant that the time from onset to reperfusion was approximately equivalent to that of the Direct group. Conclusion: Time-saving measures need to be taken by both the transferring and receiving hospitals in DSR paradigm.
Background: Quality indicators (QIs) are an accepted tool for measuring a hospital’s performance in routine care. We examined national trends in adherence to the QIs developed by the Close The Gap-Stroke program by combining data from the health insurance claims database and electronic medical records, and the association between adherence to these QIs and early outcomes in patients with acute ischemic stroke in Japan. Methods: In the present study, patients with acute ischemic stroke who received acute reperfusion therapy in 351 Close The Gap-Stroke-participating hospitals were analyzed retrospectively. The primary outcomes were changes in trends for adherence to the defined QIs by difference-in-difference analysis and the effects of adherence to distinct QIs on in-hospital outcomes at the individual level. A mixed logistic regression model was adjusted for patient and hospital characteristics (eg, age, sex, number of beds) and hospital units as random effects. Results: Between 2013 and 2017, 21 651 patients (median age, 77 years; 43.0% female) were assessed. Of the 25 defined measures, marked and sustainable improvement in the adherence rates was observed for door-to-needle time, door-to-puncture time, proper use of endovascular thrombectomy, and successful revascularization. The in-hospital mortality rate was 11.6%. Adherence to 14 QIs lowered the odds of in-hospital mortality (odds ratio [95% CI], door-to-needle <60 min, 0.80 [0.69–0.93], door-to-puncture <90 min, 0.80 [0.67–0.96], successful revascularization, 0.40 [0.34–0.48]), and adherence to 11 QIs increased the odds of functional independence (modified Rankin Scale score 0–2) at discharge. Conclusions: We demonstrated national marked and sustainable improvement in adherence to door-to-needle time, door-to-puncture time, and successful reperfusion from 2013 to 2017 in Japan in patients with acute ischemic stroke. Adhering to the key QIs substantially affected in-hospital outcomes, underlining the importance of monitoring the quality of care using evidence-based QIs and the nationwide Close The Gap-Stroke program.
Introduction: The effectiveness of endovascular thrombectomy for acute cerebral large vessel occlusion (LVO) was proved, but many patients did not received such interventions because capable operators were not placed at all hospitals. If the type of stroke [large vessel occlusion, subarachnoid hemorrhage (SAH), intracranial hemorrhage (ICH), other cerebral infarction (CI)] was predicted at prehospital, better access to appropriate interventions were capable. We, thus, developed the clinical prediction rules to classify the type of stroke who were suspected to suffer acute stroke at prehospital, and validated them. Methods: We analyzed consecutive 1,229 patients who were suspected to suffer acute stroke from June, 2015 to March 2016. We obtained the history and physical signs at prehospital from paramedics and final diagnosis from hospital transferred. We constructed multivariate logistic regression models for 1) LVO, 2) SAH, 3) ICH, 4) CI, and developed the clinical prediction rules for each type. We prospectively validated the rules with another consecutive patients from August 2016 to July 2017 using mobile application. Results: In the derivation cohort, 104 LVO, 57 SAH, 169 ICH, and 183 CI were observed. The area under the receiver operating curve (AUC) of the rules were 0.90 for LVO, 0.90 for SAH, 0.85 for ICH, and 0.65 for CI. The validation cohort of 932 patients showed the sensitivity and specificity of the rules were 0.53 and 0.95 for LVO, 0.73 and 0.96 for SAH, 0.52 and 0.85 for ICH, 0.63 and 0.70 for CI. The AUCs of LVO, SAH, ICH, and CI were 0.85, 0.96, 0.77, and 0.67, respectively. Conclusions: The clinical prediction rule calculated by paramedics at prehospital can easily classify the patients who suspected to have stroke into LVO, SAH, ICH, and CI with excellent performance. By applying the rules, more patients would receive appropriate interventions without unnecessary delay. <!--EndFragment-->
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