A System-Based Intervention to Improve Access to Hyperacute Stroke Care

Abstract

Background: Hyperacute stroke is a time-sensitive emergency for which outcomes improve with faster treatment. When stroke systems are accessed via emergency medical services (EMS), patients are routed to hyperacute stroke centres and are treated faster. But over a third of patients with strokes do not come to the hospital by EMS, and may inadvertently arrive at centres that do not provide acute stroke services. We developed and studied the impact of protocols to quickly identify and move "walk-in" patients from non-hyperacute hospitals to regional stroke centres (RSCs). Methods and Results: Protocols were developed by a multi-disciplinary and multi-institutional working group and implemented across 14 acute hospital sites within the Greater Toronto Area in December of 2012. Key metrics were recorded 18 months pre-and post-implementation. The teams regularly reviewed incident reports of protocol non-adherence and patient flow data. Transports increased by 80% from 103 to 185. The number of patients receiving tissue plasminogen activator (tPA) increased by 68% from 34 to 57. Total EMS transport time decreased 17 minutes (mean time of 54.46 to 37.86 minutes, p < 0.0001). Calls responded to within 9 minutes increased from 34 to 59%. Conclusions: A systems-based approach that included a multi-organizational collaboration and consensus-based protocols to move patients from non-hyperacute hospitals to RSCs resulted in more patients receiving hyperacute stroke interventions and improvements in EMS response and transport times. As hyperacute stroke care becomes more centralized and endovascular therapy becomes more broadly implemented, the protocols developed here can be employed by other regions organizing patient flow across systems of stroke care.RÉSUMÉ: Une intervention systémique pour améliorer l'accès aux soins pour les patients atteints d'un accident vasculaire cérébral suraigu. Contexte: L'accident vasculaire cérébral (AVC) suraigu nécessite un traitement d'urgence dont les résultats sont d'autant meilleurs que le traitement est administré plus rapidement. Le facteur temps est donc critique. Quand l'accès aux systèmes de prévention de l'AVC se fait par les services médicaux d'urgence (SMU), les patients sont dirigés vers des centres de traitement de l'AVC suraigu et sont traités plus rapidement. Cependant, plus du tiers des patients atteints d'un AVC ne sont pas conduits à l'hôpital par les SMU et peuvent être dirigés par inadvertance vers des centres qui ne fournissent pas de tels soins. Nous avons élaboré et étudié l'impact de protocoles pour identifier et transporter rapidement les patients qui se présentent à un centre où des soins suraigus ne sont pas offerts vers un centre régional de traitement de l'AVC. Méthodologie et résultats: Un groupe de travail multidisciplinaire et multi-institutionnel a élaboré des protocoles qui ont été déployés dans 14 hôpitaux de soins aigus dans la grande région de Toronto en décembre 2012. Les indicateurs clés ont été comptabilisés 18 mois avant et 18 mois après leu...

Impact and sustainability of centralising acute stroke services in English metropolitan areas: retrospective analysis of hospital episode statistics and stroke national audit data

“…Research in several countries including the US, Canada, the Netherlands, Denmark, and Australia suggests that this approach may improve provision of evidence based care processes for all stroke patients, by increasing access to specialist care and thrombolysis where appropriate 910 11 12 13 14 Although improved clinical outcomes among patients admitted to organised inpatient stroke care are well documented, relatively little evidence exists to show whether centralising acute stroke care to a small number of high volume specialist centres produces better clinical outcomes at the system level across all stroke patients 1516 Our previous research showed reductions in mortality after the centralisation of stroke services in London (see below).…”

“…Ethical approval: The study received ethical approval in September 2011 from the London East NHS Research Ethics Committee (ref 11/LO/1396).…”

Gestão em rede no atendimento ao acidente vascular cerebral: revisão integrativa de literatura

“…Houve eficiência da pré-notificação hospitalar (Kendall;Dutta;Brown, 2015), maio acesso a centros de AVC (Hsieh et al, 2016) e redução da mortalidade (Hsieh et al, 2016;Kodankandath et al, 2017). Houve aumento da taxa da população a 30 minutos de um centro de AVC (Swartz et al, 2017), redução de internações em centros que costumam ter uma carga excessiva de trabalho (Tan et al, 2017), mantendo os pacientes mais próximos de casa (Jewett et al, 2017) e melhorando a qualidade de vida dos que vivem em área rural (Klingner et al, 2018). Potencialização da colaboração entre níveis de saúde e entre profissionais (Jewett et al, 2017;Kodankandath et al, 2017) e favorecimento da integração de capital humano, tecnologia e procedimentos, universalizando os cuidados de saúde (Kodankandath et al, 2017).…”

The Impact of Systems of Care on International Health Security

“…In several countries, acute stroke services are being centralized into "hub and spoke" systems in which hospital providing different levels of care work together to create a centralized system in which all patients with acute ischemic stroke are taken to specialized centers, rather than the nearest hospital [60]. Research suggests that in countries where such models exist (e.g., the United States, Canada, the Netherlands, Denmark, and Australia), there is greater provision of evidence-based therapies by increasing access to specialist care and thrombolysis [61][62][63]. Other countries, such as the United Kingdom, have found decreases in mortality and hospital length-of-stay where hyperacute stroke services were centralized to a small number of highly specialized, highvolume centers [64].…”