Abstract P589: Pediatric Thrombectomy: Design And Workflow Lessons From Two Experienced Centers

Abstract

Introduction: While clinical trials have demonstrated the remarkable efficacy of endovascular thrombectomy (EVT) for treating adult patients suffering from acute ischemic stroke (AIS), benefits reaped from advances in adult stroke care have unfortunately not occurred in parallel with pediatric stroke care. Randomized trials of EVT in childhood stroke are unlikely given the low incidence of stroke in children compared to adults, and despite promising outcomes in small case reports and series, EVT in children remains an off-label procedure lacking established consensus guidelines. Along with a clear need to collect prospective pediatric EVT outcome data, there is a need to enhance pediatric stroke care infrastructure to provide high-quality care to children experiencing stroke. Methods: In this work, we review two successful pediatric thrombectomy programs, examining key workflow design features that are likely to be important for other programs that aspire to implement pediatric EVT capability. Discussion: While pediatric EVT workflows will vary between centers, we identify several key elements of programmatic success shared between the two reviewed stroke programs that may serve as foundational design considerations for centers aiming to develop their own pediatric EVT programs. These elements include a formalized protocol and workflow, integration with an adult EVT workflow, simplification and automation of workflow steps, pediatric adaptations of stroke imaging, advocacy of pediatric stroke care, and collaboration between providers, among others. These essential features transcend any single hospital environment and may provide an important foundation for other pediatric centers that aim to enhance the care of children with stroke. Conclusion: EVT shows promise in reducing stroke-associated morbidity in children. To maximize the efficacy of this intervention, workflow optimizations discussed here should be implemented by centers seeking to develop local pediatric EVT capability.

Pediatric hospital proximity to endovascular thrombectomy centers in the United States

“…As a result, few pediatric hospitals currently provide EVT, and most instead rely upon inter-hospital transport to an EVT center. 8 Though this care paradigm is widely used, the proximity of EVT hospitals to pediatric hospitals has not previously been characterized. We found that the majority of pediatric hospitals are within reasonable proximity of an EVT center.…”

“…Several of these opportunities have been highlighted in a recent publication describing strategies to improve coordination between pediatric and EVT hospitals. 8 One particularly relevant suggestion of this work is the introduction of adult-optimized workflows into pediatric stroke setting so that pediatric patients can benefit from well-rehearsed adult stroke workflows.…”

“…[5][6][7] Since few pediatric hospitals currently have the necessary infrastructure and expertise to provide EVT in-house, pediatric access to EVT often relies on proximity to adult EVT centers. 8 No studies to date characterize the proximity of pediatric hospitals to EVT centers. In this cross-sectional study, we quantify the travel time and distance by road and aerial routes between pediatric hospitals and their nearest certified EVT centers throughout the contiguous United States to determine the feasibility of transporting children to a nearby EVT center.…”

Stroke in Children

“…16 Additional publications offer guidance on devices and other technical considerations, workflow, and pediatric stroke center requirements. [17][18][19]…”

Challenges of implementation of the RCPCH paediatric stroke guidelines (acute management component) and how they can be overcome

“…Often, ambulances with adult stroke calls are diverted to these centres for acute management. If this is the case in your hospital, it is worthwhile engaging with the adult stroke specialists and their HASUs who will have expertise on implementation of adult stroke protocols 5. Some hospitals have already agreed to admit young people from 16 years (or younger in some cases) and up to the HASU for management if there is paediatric neurology input.…”