Impact of interhospital transfer on patients undergoing endovascular thrombectomy for acute ischaemic stroke in an Australian setting

Abstract

ObjectiveTo assess the impact of interhospital transfer on the interplay between functional outcome, mortality, reperfusion rates and workflow time metrics in patients undergoing endovascular thrombectomy (EVT) for acute ischaemic stroke due to large vessel occlusion (LVO) in the anterior cerebral circulation.Design, setting and participantsThis is an analysis of a prospective database of consecutive patients undergoing EVT for LVO presenting between January 2017 and December 2018 at a single Australian comprehensive stroke centre (CSC). Patients presented directly or were transferred to the CSC from 21 sites across New South Wales and the Australian Capital Territory.Main outcome measuresThe main outcome measures were rate of good 90-day functional outcome (modified Rankin Scale 0–2), successful reperfusion (Thrombolysis in Cerebral Infarction scale grade 2b or 3), symptomatic intracerebral haemorrhage (sICH) and 90-day mortality. Key workflow time metric milestones were examined.Results154 of 213 (72%) patients were interhospital transfers. There was no significant difference in baseline characteristics including age, National Institutes of Health Stroke Scale score, intravenous thrombolysis administration or procedure time between transferred and direct presenters (all p>0.05). Transferred patients had worse 90-day functional outcome (39.6% vs 61.0%, OR 0.42, 95% CI 0.23 to 0.78), higher mortality (25.3% vs 6.8%, OR 4.66, CI 1.59 to 13.70) and longer stroke onset to treatment (groin puncture) time (298 min vs 205 min, p<0.01). Successful reperfusion rates and sICH were similar between the cohorts (96.8% vs 98.3%, and 7.8% vs 3.4%).ConclusionInterhospital transfer is associated with longer stroke onset to treatment, worse 90-day functional outcome and higher mortality compared with patients presenting directly to the CSC.

TACTICS - Trial of Advanced CT Imaging and Combined Education Support for Drip and Ship: evaluating the effectiveness of an ‘implementation intervention’ in providing better patient access to reperfusion therapies: protocol for a non-randomised controlled stepped wedge cluster trial in acute stroke

“…12 Optimising the acute stroke workflow to improve access to EVT for regional and rural Australians In Australia, approximately two-thirds of thrombectomy patients are referred from other metropolitan or rural hospitals. 31 In rural areas, delays to the initiation of thrombectomy are generally between 4 and 6 hours. 32 Even in urban areas, interhospital transfers are often slow, with a median transfer time of 2 hours.…”

“…In Australia, approximately two-thirds of thrombectomy patients are referred from other metropolitan or rural hospitals 31. In rural areas, delays to the initiation of thrombectomy are generally between 4 and 6 hours 32.…”

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

“…Significant efforts have been put into optimizing the stroke workflow to minimize treatment delay in acute reperfusion therapy 11,12 . However, the prehospital setting remains a significant source of delay and an area in which workflow optimizations have been limited and where universal proven standards of care are lacking.…”

“…Significant efforts have been put into optimizing the stroke workflow to minimize treatment delay in acute reperfusion therapy. 11,12 However, the prehospital setting remains a significant source of delay and an area in which workflow optimizations have been limited and where universal proven standards of care are lacking. Several studies on prehospital stroke workflow optimization (PSWO) have implemented varying strategies and shown success in reducing workflow time delay and patient treatment rates.…”

“…However, the specialization resource intensiveness and cost of MSUs make its widespread adoption difficult 36. Moreover, It has been noted in several studies that LVO stroke patients who present directly at CSCs for EVT have significantly improved functional outcomes,11 providing support to the superior efficacy of the LVO bypass intervention. Only five studies provided data on functional outcomes; further studies are required Various prehospital optimizations investigated in the included studies Zhao et al20 (2020) Bath et al52 (2019) Abbreviations: IVT, intravenous thrombolysis; LVO, large-vessel occlusion; MSU, mobile stroke unit; PSC, primary stroke center.…”