Effect of prehospital workflow optimization on treatment delays and clinical outcomes in acute ischemic stroke: A systematic review and meta‐analysis

Abstract

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.

Clinical and Functional Outcomes of Patients Receiving Cerebral Reperfusion Therapy: A Stroke Databank Study in Brazil

“…System-based approaches have improved in-hospital temporal parameters, maximized the utility of reperfusion therapies, and improved clinical benefits to patients (46). Several studies on prehospital stroke workflow optimization (PSWO) have implemented various strategies and shown success in reducing workflow time delays and patient treatment rates (47). Chowdhury et al showed that improved IVT triage is significantly associated with improved rates of IVT and thus can increase the number of potential IVT candidates.…”

In‐hospital systems interventions in acute stroke reperfusion therapy: a meta‐analysis

“…Our results nevertheless confirm that systems interventions improve time savings in the in‐hospital AIS workflow, meeting the aim of our study. Although our meta‐analysis focussed upon in‐hospital systems interventions, pre‐hospital systems interventions are also critical to AIS workflow, in reducing treatment times 13 …”

“…Despite several studies demonstrating efficacy in reducing treatment delay, it is yet to be determined if the benefits of systems interventions or workflow optimizations in the in‐hospital settings remain consistent in systematic review and meta‐analysis of pooled studies. Our recent study demonstrated that pre‐hospital stroke workflow optimization significantly improves reperfusion treatment‐related time metrics leading to improvement in IVT reperfusion rates 13 . The current study sought to examine the effect of in‐hospital system‐level optimization or systems‐based interventions on treatment delays, reperfusion rates within 1 hour of presentation to the Emergency Department (ED) and clinical outcomes in AIS patients treated with reperfusion therapy by performing a systematic review and meta‐analysis.…”

Optimising Prehospital Pathways to Improve Acute Stroke Reperfusion Therapy Delivery: Systems-Based Approaches

“…Prehospital pathways are critical to acute stroke organisation. Systems-level approaches to improving the process of care or prehospital acute stroke pathways have gained attention over the last decade [1][2][3][4]. The underlying principle is based on the fact that stroke systems of care, being a timecritical medical emergency, would benefit from streamlining the process of care or pathways by reducing time delays [1].…”

“…Recent studies aimed at improving the prehospital system are promising and demonstrate the value of such approaches [5]. However, it is yet to be established if the process improvements due to these interventions translate to the clinical benefit of stroke patients [3]. This article will provide an overview of current systems of acute stroke care with a focus on prehospital pathways and identify opportunities for improvement.…”