Reducing Door-to-Needle Times for Ischaemic Stroke to a Median of 30 Minutes at a Community Hospital

Shand, Elaine; Swanson, R. Chad; Hill, Michael D.; Jeerakathil, Thomas; Imoukhuede, Oje; Heinrichs, Irvin; Bakker, Jackie; Stoyberg, Carol; Fowler, Luke; Duckett, S J; Holsworth, Scott; Mann, Balraj; Valaire, Shelley; Bestard, Jennifer

doi:10.1017/cjn.2018.368

Cited by 14 publications

(18 citation statements)

References 20 publications

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“…Their outcomes stress the importance of early symptom onset to treatment time and demonstrate significant adverse outcomes for even a 30‐minute delay 24 …”

Section: Comparison Of Procedural Timesmentioning

confidence: 97%

“…23 Their outcomes stress the importance of early symptom onset to treatment time and demonstrate significant adverse outcomes for even a 30-minute delay. 24 Instead of transferring AIS patients with LVO to EVT capable stroke centers more than an hour away, we propose community treatment by carotid stent capable IC working in collaboration with noninvasive neurologists (or remotely with telemedicine). 13,25 These three centers achieved competency in carotid artery ste- Abbreviations: EXTEND 1A, extending the time for thrombolysis in emergency neurological deficits intra-arterial; ESCAPE, endovascular treatment for small core and anterior circulation proximal occlusion with emphasis on minimizing CT to recanalization times; MR CLEAN, multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands; REVASCAT, randomized trial of revascularization with solitaire FR device versus best medical therapy in the treatment of acute stroke due to anterior circulation large vessel occlusion presenting within 8 hr of symptom onset; SWIFTPRIME, solitaire with the intention for thrombectomy as primary endovascular treatment.…”

Section: Moving Forwardmentioning

confidence: 99%

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Outcomes following endovascular therapy for acute stroke by interventional cardiologists

Bob‐Manuel

Hornung

Guidera

et al. 2020

Cathet Cardio Intervent

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Objectives: To summarize the outcomes of acute ischemic stroke (AIS) intervention by interventional cardiologists (IC) working on a stroke team. Background: There is a geographic maldistribution of dedicated neurointerventionalists (NI) to treat large vessel occlusion (LVO) AIS. Methods: Results of 166 consecutive patients who received endovascular therapy (EVT) for AIS due to LVO by IC at three centers between 2009 and 2019 are reported. A modified Rankin score (mRs) of ≤ 2 at 90 days after EVT was used as the primary measurement of a good neurological outcome. Univariate logistic regression was used to evaluate predictors of the mRS > 2 and mortality. Those variables with significance of p < .2 from the univariate analysis were included in a multivariate analysis. Results: All-cause mortality at 30 days was 22%. A favorable clinical outcome, mRS ≤ 2 at 90 days, was 49%. After multivariate analysis and controlling for confounders, a higher baseline NIHSS was predictive of 30-day mortality (OR 1.20 [95% CI 1.09-1.32] p < .001) and unfavorable clinical outcome (mRS > 2) at 90 days (OR 1.16 [95% CI 1.07-1.25] p < .001). Conclusion: Outcomes for carotid stent capable IC performing EVT for AIS are comparable to those achieved by NI physicians in major randomized clinical trials. Our data supports conducting a clinical trial of carotid stent capable IC working on multidisciplinary stroke teams to perform EVT for AIS due to LVO in communities and hospitals without timely access (<60 min by ground transport) to dedicated NI.

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“…Their outcomes stress the importance of early symptom onset to treatment time and demonstrate significant adverse outcomes for even a 30‐minute delay 24 …”

Section: Comparison Of Procedural Timesmentioning

confidence: 97%

Section: Moving Forwardmentioning

confidence: 99%

Outcomes following endovascular therapy for acute stroke by interventional cardiologists

Bob‐Manuel

Hornung

Guidera

et al. 2020

Cathet Cardio Intervent

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“…The Improvement Collaborative intervention has been used successfully for the improvement of acute stroke treatment in Alberta; a project led by the N. Kamal (NPI). 36 It successfully reduced door-toneedle times across Alberta to 36 minutes from 68 minutes; 37,38 Alberta was the first jurisdiction in the world to achieve this level of improvement across an entire population. However, it has not been used to improve access to stroke treatments, or to improve efficiency of EVT treatment.…”

Section: The Intervention Will Increase the Proportion Of Ischemic Stmentioning

confidence: 99%

Improving access and efficiency to treatment for stroke within 12 hours of onset in Atlantic Canada

Kamal

2020

http://isrctn.com/

Self Cite

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Background on Stroke Treatment: Revolutionary advances in stroke treatment have occurred over the past two decades from thrombolysis using IV (intravenous) alteplase in the mid-1990's 1,2 to the most recent groundbreaking trials showing the high efficacy of endovascular thrombectomy (EVT) in 2015. 3,4 Studies demonstrate that an additional 10% of patients receiving alteplase within 3 hours of stroke onset will have no disability compared to control, which translates to a number needed to treat (NNT) of 10. 5 EVT is even more efficacious, with studies showing that an additional 14% of patients will have no disability and 20% will be functionally independent (NNT=5). 3 These two synergistic therapies are used to treat acute ischemic stroke, which is the most common type of stroke, making up 85% of all strokes. EVT is provided to a subset of ischemic stroke patients with the most severe form of ischemic stroke due to a large vessel occlusion, while alteplase is appropriate for a larger proportion of ischemic stroke patients including those with both large and small vessel occlusions. Stroke is the leading cause of severe disability, 6 which has significant societal and economic impact. Stroke results in disability that increases the need for assistance with daily living tasks, 7 impedes return to the workplace, 8 and results in high hospital costs. These high hospital costs are related to extended hospitalization during the acute phase, prolonged in-patient rehabilitation, and the need for long-term care. 9 Therefore, because the therapies attenuate the severity of disability, the therapies reduce costs and provide significant societal benefit. Evidence-to-Practice Gap: Although alteplase and EVT are part of guideline care in Canada and around the world, 10,11 less than optimal utilization rates for both of these treatments are observed. This evidence-to-practice gap is not a new phenomenon; 12,13 however, the substantial economic and societal benefits of these therapies make it critical to pursue optimal uptake in Atlantic Canada and the rest of the country. This evidence-practice gap is exacerbated by the geo-political and socio-political divide. There is a split between urban and rural access to treatment. Emergency physicians are less comfortable with intravenous alteplase, 14-16 and they are often the only treating physician in rural hospitals, where access to stroke physicians or neurologists is limited. In fact, the Canadian Association of Emergency Physician only endorsed alteplase in 2015 (revised in 2018) and only to 3 hours after onset. 17 Atlantic Canada is especially challenged by access gaps. The Queen Elizabeth II Health Sciences Centre (QEII) provides guideline-and evidencebased treatment to the residents of metropolitan Halifax, where 22.8% of ischemic stroke patients received alteplase in 2018, but in rural Nova Scotia only 17.5% received alteplase. In New Brunswick, similar discrepancies exist with 15.7% receiving alteplase in Saint John and Moncton, and only 4.8% receiving alteplase outside of th...

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“…Since 2015, approximately 12 projects have been scaled across the province. Alberta's SCNs have helped improve appropriate antipsychotic use in dementia, 9 supported the implementation of enhanced recovery after surgery protocols [10][11][12][13][14] and the safe surgery checklist, 15 improved access to diagnosis for patients with breast cancer (https://albertahealthservices.ca/assets/about/scn/ahs-scn-reports-retrospective-2012-2018.pdf), and supported the implementation of a provincial stroke action plan (Stroke Care Alberta [16][17][18] ).…”

Section: (Continued)mentioning

confidence: 99%

Alberta’s Strategic Clinical Networks: A roadmap for the future

Manns

Strilchuk

Mork

et al. 2019

Healthc Manage Forum

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Clinical networks are groups of clinicians, patients, operational leaders, and other stakeholders who work together to solve health challenges, translate evidence into practice, and improve health outcomes and clinical care. Networks enable health, community, and academic partners to align their efforts, address priority issues, and advance quality improvements, health innovation, and transformational change on a local and system-wide scale. Clinical networks have existed in some countries for nearly 20 years. Alberta first implemented clinical networks in 2012 in specific areas of health. There are now 16 Strategic Clinical Networks (SCNs) in Alberta, embedded within a province-wide health system. The SCNs have developed an action plan that builds on their experience and identifies common areas of focus. This article describes the SCNs, their impact to date, and the objectives, areas of focus, and processes Alberta’s SCNs will use to improve health outcomes and health system performance over the next 5 years.

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Reducing Door-to-Needle Times for Ischaemic Stroke to a Median of 30 Minutes at a Community Hospital

Cited by 14 publications

References 20 publications

Outcomes following endovascular therapy for acute stroke by interventional cardiologists

Outcomes following endovascular therapy for acute stroke by interventional cardiologists

Improving access and efficiency to treatment for stroke within 12 hours of onset in Atlantic Canada

Alberta’s Strategic Clinical Networks: A roadmap for the future

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