A review of acute ischemic stroke triage protocol evidence: a context for discussion

Chartrain, Alexander G; Shoirah, Hazem; Jauch, Edward C.; Mocco, J

doi:10.1136/neurintsurg-2018-013951

Cited by 7 publications

(3 citation statements)

References 53 publications

(28 reference statements)

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“…Little evidence is available from clinical studies on triage strategies. 29 The DIRECT-MT trial (Direct Intraarterial Thrombectomy in Order to Revascularize Acute Ischemic Stroke Patients with Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals: a Multicenter Randomized Clinical Trial) recently showed that EVT alone was noninferior compared with EVT with prior IVT administered within 4.5 hours after symptom onset, which supports the strategy to bypass primary stroke centers when the likelihood of LVO is high. 30 Results from the STRATIS registry (Systematic Evaluation of Patients Treated with Neurothrombectomy Devices for Acute Ischemic Stroke) showed that direct transportation of LVO patients to an intervention center, especially when within 20 miles, may lead to better clinical outcomes.…”

Section: Discussionmentioning

confidence: 93%

Prehospital Triage Strategies for the Transportation of Suspected Stroke Patients in the United States

Venema

Burke

Roozenbeek

et al. 2020

Stroke

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Background and Purpose: Ischemic stroke patients with large vessel occlusion (LVO) could benefit from direct transportation to an intervention center for endovascular treatment, but non-LVO patients need rapid IV thrombolysis in the nearest center. Our aim was to evaluate prehospital triage strategies for suspected stroke patients in the United States. Methods: We used a decision tree model and geographic information system to estimate outcome of suspected stroke patients transported by ambulance within 4.5 hours after symptom onset. We compared the following strategies: (1) Always to nearest center, (2) American Heart Association algorithm (ie, directly to intervention center if a prehospital stroke scale suggests LVO and total driving time from scene to intervention center is <30 minutes, provided that the delay would not exclude from thrombolysis), (3) modified algorithms with a maximum additional driving time to the intervention center of <30 minutes, <60 minutes, or without time limit, and (4) always to intervention center. Primary outcome was the annual number of good outcomes, defined as modified Rankin Scale score of 0–2. The preferred strategy was the one that resulted in the best outcomes with an incremental number needed to transport to intervention center (NNTI) <100 to prevent one death or severe disability (modified Ranking Scale score of >2). Results: Nationwide implementation of the American Heart Association algorithm increased the number of good outcomes by 594 (+1.0%) compared with transportation to the nearest center. The associated number of non-LVO patients transported to the intervention center was 16 714 (NNTI 28). The modified algorithms yielded an increase of 1013 (+1.8%) to 1369 (+2.4%) good outcomes, with a NNTI varying between 28 and 32. The algorithm without time limit was preferred in the majority of states (n=32 [65%]), followed by the algorithm with <60 minutes delay (n=10 [20%]). Tailoring policies at county-level slightly reduced the total number of transportations to the intervention center (NNTI 31). Conclusions: Prehospital triage strategies can greatly improve outcomes of the ischemic stroke population in the United States, but increase the number of non-LVO stroke patients transported to an intervention center. The current American Heart Association algorithm is suboptimal as a nationwide policy and should be modified to allow more delay when directly transporting LVO-suspected patients to an intervention center.

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Section: Discussionmentioning

confidence: 93%

Prehospital Triage Strategies for the Transportation of Suspected Stroke Patients in the United States

Venema

Burke

Roozenbeek

et al. 2020

Stroke

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“…In fact, an analysis of data from 984 patients enrolled in the Systematic Evaluation of Patients Treated with Stroke Devices for Acute Ischemic Stroke (STRATIS) Registry showed that development of an appropriate triage model with a 20-mile radius for direct to endovascular center care would delay IV tPA administration by only an average of 7 min, but would improve thrombectomy delivery by 94 min 19. This has been demonstrated in multiple other studies, both within and outside the United States 20. Stroke patients would likely be better served if stroke systems aligned more closely with the trauma model, designating regionalized centers of excellence, as was well reviewed in a recent paper in the journal Stroke 21.…”

Section: The Crisis For Stroke Patientsmentioning

confidence: 91%

Stroke patients can’t ask for a second opinion: a multi-specialty response to The Joint Commission’s recent suspension of individual stroke surgeon training and volume standards

Arthur

Mocco

Linfante

et al. 2018

J NeuroIntervent Surg

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“…State-wide and county-wide protocols for EMS systems that include a bypass strategy for patients with suspected LVO have been implemented in the United States 15 16. A lot of efforts have also been made to shorten the time interval from symptoms' onset to reperfusion by EVT 17–19…”

Section: Introductionmentioning

confidence: 99%

Redistributing medical resources for a bypass strategy for large vessel occlusion: a community-based study

Liu

Wang

Chiang

et al. 2019

J NeuroIntervent Surg

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BackgroundA bypass strategy for large vessel occlusion (LVO) benefits patients receiving endovascular thrombectomy (EVT), but may delay some patients from receiving IV thrombolysis. However, patient centralization has been shown to improve outcomes.ObjectiveTo understand the current coverage of medical services for patients with stroke, and to identify the best coverage under different medical resource redistribution to help balance medical equality and patient centralization.MethodsThis 6-year geographic study of 7679 on-scene patients with suspected stroke with a positive Cincinnati Prehospital Stroke Scale (CPSS) score identified 4037 patients with all three CPSS items who were suspected as having an LVO. Geographic, population, and patient coverage rates for hospitals providing IV thrombolysis and those providing EVT were identified according to hospital service areas, defined as geographic districts with access to a hospital within a ≤15 min off-peak driving time estimated using Google Maps. Moreover, we estimated the effects on resource redistribution when implementing a bypass strategy.ResultsGeographic coverage rates for hospitals providing IV thrombolysis and those providing EVT were 64.75% and 56.62%, respectively, and population coverage rates were 97.30% and 92.72%, respectively. The service areas of hospitals providing IV thrombolysis covered 93.77% of patients with suspected stroke, and those of hospitals providing EVT covered 87.89% of patients with suspected LVO. The number of hospitals providing IV thrombolysis and those providing EVT could be reduced to six and two hospitals, respectively, without affecting hospital arrival time when implementing a bypass strategy.ConclusionHospitals providing IV thrombolysis and EVT could be reduced without reducing medical equality.

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A review of acute ischemic stroke triage protocol evidence: a context for discussion

Cited by 7 publications

References 53 publications

Prehospital Triage Strategies for the Transportation of Suspected Stroke Patients in the United States

Prehospital Triage Strategies for the Transportation of Suspected Stroke Patients in the United States

Stroke patients can’t ask for a second opinion: a multi-specialty response to The Joint Commission’s recent suspension of individual stroke surgeon training and volume standards

Redistributing medical resources for a bypass strategy for large vessel occlusion: a community-based study

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