Workflow Intervals of Endovascular Acute Stroke Therapy During On- Versus Off-Hours

Abstract

Background and Purpose— Endovascular treatment (EVT) of patients with acute ischemic stroke because of large vessel occlusion involves complicated logistics, which may cause a delay in treatment initiation during off-hours. This might lead to a worse functional outcome. We compared workflow intervals between endovascular treatment–treated patients presenting during off- and on-hours. Methods— We retrospectively analyzed data from the MR CLEAN Registry, a prospective, multicenter, observational study in the Netherlands and included patients with an anterior circulation large vessel occlusion who presented between March 2014 and June 2016. Off-hours were defined as presentation on Monday to Friday between 17:00 and 08:00 hours, weekends (Friday 17:00 to Monday 8:00) and national holidays. Primary end point was first door to groin time. Secondary end points were functional outcome at 90 days (modified Rankin Scale) and workflow time intervals. We stratified for transfer status, adjusted for prognostic factors, and used linear and ordinal regression models. Results— We included 1488 patients of which 936 (62.9%) presented during off-hours. Median first door to groin time was 140 minutes (95% CI, 110–182) during off-hours and 121 minutes (95% CI, 85–157) during on-hours. Adjusted first door to groin time was 14.6 minutes (95% CI, 9.3–20.0) longer during off-hours. Door to needle times for intravenous therapy were slightly longer (3.5 minutes, 95% CI, 0.7–6.3) during off-hours. Groin puncture to reperfusion times did not differ between groups. For transferred patients, the delay within the intervention center was 5.0 minutes (95% CI, 0.5–9.6) longer. There was no significant difference in functional outcome between patients presenting during off- and on-hours (adjusted odds ratio, 0.92; 95% CI, 0.74–1.14). Reperfusion rates and complication rates were similar. Conclusions— Presentation during off-hours is associated with a slight delay in start of endovascular treatment in patients with acute ischemic stroke. This treatment delay did not translate into worse functional outcome or increased complication rates.

Association of Time of Day When Endovascular Therapy for Stroke Starts and Functional Outcome

“…Admission to groin puncture delays were significantly longer at night, which has been previously reported. 34 , 35 Corroborating the findings of the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry, this delay was not appreciable in our analysis regarding clinical outcome. We conjecture that working conditions for EVT paradoxically improves during the evening or night and may maintain good technical performance and offset fatigue partially because of less work burden or distractions.…”

Presentation outside office hours does not negatively influence treatment times for reperfusion therapy for acute ischemic stroke

“…While various studies have examined the off-hours effect for IVT, data on this topic for EVT are scarce. Previous studies did report prolonged treatment times for patients with EVT presenting outside office hours, but none of these found an effect on functional outcome at 90 days [8][9][10]17]. One of those studies used data of the MRCLEAN Registry, reporting on results of all patients treated with EVT between March 2014 and June 2016 in the Netherlands, also including patients from the Greater Amsterdam Area [10].…”

“…Previous studies did report prolonged treatment times for patients with EVT presenting outside office hours, but none of these found an effect on functional outcome at 90 days [8][9][10]17]. One of those studies used data of the MRCLEAN Registry, reporting on results of all patients treated with EVT between March 2014 and June 2016 in the Netherlands, also including patients from the Greater Amsterdam Area [10]. We, however, report results of patients that received EVT over a wider time span (March 2014 through January 2018), and in contrast, we found no differences in treatment times or functional outcome, regardless of presentation time.…”

“…Previous studies on the existence of such an "offhours effect" have yielded conflicting results, observing both longer and shorter treatment times for patients presenting outside office hours [4][5][6][7]. Moreover, these studies mostly focused on door-to-needle times (DNT) for IVT, and there are limited data available on door-to-groin times (DGT) for EVT [8][9][10].…”

Factors Associated with Failure of Reperfusion in Endovascular Therapy for Acute Ischemic Stroke

“…This study, however, did not find an association between time from symptom onset to final angiographic run and reperfusion result. A weekend effect has been described in the pre-EVT era and has been defined as a worse clinical outcome for patients treated for acute ischemic stroke outside of routine daytime hours [31] and has been reported for patients with EVT as well [32]; however, other studies focusing on patients treated with EVT did not describe such an effect [33][34][35].…”