Short and long-term impact of four sets of actions on acute ischemic stroke management in Rhône County, a population based before-and-after prospective study

Abstract

Background Optimizing access to recanalization therapies in acute ischemic stroke patients is crucial. Our aim was to measure the short and long term effectiveness, at the acute phase and 1 year after stroke, of four sets of actions implemented in the Rhône County. Methods The four multilevel actions were 1) increase in stroke units bed capacity and development of endovascular therapy; 2) improvement in knowledge and skills of healthcare providers involved in acute stroke management using a bottom-up approach; 3) development and implementation of new organizations (transportation routes, pre-notification, coordination by the emergency call center physician dispatcher); and 4) launch of regional public awareness campaigns in addition to national campaigns. A before-and-after study was conducted with two identical population-based cohort studies in 2006–7 and 2015–16 in all adult ischemic stroke patients admitted to any emergency department or stroke unit of the Rhône County. The primary outcome criterion was in-hospital management times, and the main secondary outcome criteria were access to reperfusion therapy (either intravenous thrombolysis or endovascular treatment) and pre-hospital management times in the short term, and 12-month prognosis measured by the modified Rankin Scale (mRS) in the long term. Results Between 2015–16 and 2006–7 periods ischemic stroke patients increased from 696 to 717, access to reperfusion therapy increased from 9 to 23% (p < 0.0001), calls to emergency call-center from 40 to 68% (p < 0.0001), first admission in stroke unit from 8 to 30% (p < 0.0001), and MRI within 24 h from 18 to 42% (p < 0.0001). Onset-to-reperfusion time significantly decreased from 3h16mn [2 h54-4 h05] to 2h35mn [2 h05-3 h19] (p < 0.0001), mainly related to a decrease in delay from admission to imaging. A significant decrease of disability was observed, as patients with mild disability (mRS [0–2]) at 12 months increased from 48 to 61% (p < 0.0001). Pre-hospital times, however, did not change significantly. Conclusions We observed significant improvement in access to reperfusion therapy, mainly through a strong decrease of in-hospital management times, and in 12-month disability after the implementation of four sets of actions between 2006 and 2016 in the Rhône County. Reducing pre-hospital times remains a challenge.

Temporal Trend of Transient Ischemic Attack Management over a 10-Year Period: Data from the Rhône County, France

“…We conducted a before-and-after study with two identical population-based cohort studies in the Rhône County. For this purpose, we used data from AVC69 and STROKE69, two population-based cohort studies, including all patients aged over 18 years with a suspected acute stroke or TIA and admitted to any emergency or neurologic department of the Rhône county over a 7-month period [8, 9]. AVC69 was conducted from November 6, 2006, to June 6, 2007, while STROKE69 was conducted from November 6, 2015, to June 6, 2016.…”

Optimising medical retrieval processes and outcomes in remote areas in high‐income countries: A scoping review

“…Study populations included adult patients with trauma, burn injuries, strokes, cardiac conditions, infections and respiratory illnesses and children requiring neurosurgical emergency management. Five studies were conducted in Australia [11][12][13][14][15] ; six in Canada 7,[16][17][18][19][20] ; four in USA [21][22][23][24] ; eight in Europe [25][26][27][28][29][30][31][32] ; and one in Taiwan region, China. 33 The outcome indicators included various mortality metrics (in-hospital death; mortality during transport; mortality within 1 h of the emergency department [ED] admission; 90-day/30-day mortality; mortality at 12 months and increased/decreased risk to mortality), 7,11,12,16,17,20,22,27,33 survival rates (survival to hospital discharge/Intensive Care Unit [ICU] discharge), 11,22,29,31 length of hospital stay, 16 time to treatment (prehospital time; activation time; approach times; on scene time; time to treatment/care; in-hospital management times), 15,21,[23][24][25]…”

“…Study populations included adult patients with trauma, burn injuries, strokes, cardiac conditions, infections and respiratory illnesses and children requiring neurosurgical emergency management. Five studies were conducted in Australia 11–15 ; six in Canada 7,16–20 ; four in USA 21–24 ; eight in Europe 25–32 ; and one in Taiwan region, China 33 …”

“…The outcome indicators included various mortality metrics (in‐hospital death; mortality during transport; mortality within 1 h of the emergency department [ED] admission; 90‐day/30‐day mortality; mortality at 12 months and increased/decreased risk to mortality), 7,11,12,16,17,20,22,27,33 survival rates (survival to hospital discharge/Intensive Care Unit [ICU] discharge), 11,22,29,31 length of hospital stay, 16 time to treatment (prehospital time; activation time; approach times; on scene time; time to treatment/care; in‐hospital management times), 15,21,23–26,30 number of retrievals and number of unnecessary retrievals, 13,14,28 number of cases of clinical deterioration, 19 cost savings, 13,14 percentage of patients benefiting from an intervention (e.g. number of patients receiving definitive treatment or benefiting from point‐of‐care tests) 17,18,22,23,25,26 and number of telehealth consultations 28 …”

Temporal Trends of Intravenous Thrombolysis Utilization in Acute Ischemic Stroke in a Prospective Cohort From 1998 to 2019: Modeling Based on Joinpoint Regression

“…Other effective improvement strategies are the transport of patients by EMS directly to the scanner and rapid registration of patients (25,27). Furthermore, there is cumulating evidence that pre-hospital interventions aimed to optimize workflow contributed to reducing pre-hospital and in-hospital delays (28,29).…”