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Pre-hospital Triage of Acute Ischemic Stroke Patients-Importance of Considering More Than Two Transport Options.

ABSTRACT: Background: Patients with acute ischemic stroke (AIS) and large vessel occlusion benefit from rapid access to mechanical thrombectomy in addition to intravenous thrombolysis. Prehospital triage algorithms to determine the optimal transport destination for AIS patients with unknown vessel status have so far only considered two alternatives: the nearest comprehensive (CSC) and the nearest primary stroke center (PSC). Objective: This study explores the importance of considering a larger number of PSCs during pre-hospital triage of AIS patients. Methods: Analysis was performed in random two-dimensional abstract geographic stroke care infrastructure environments and two models based on real-world geographic scenarios. Transport times to CSCs and PSCs were calculated to define sub-regions with specific triage properties. Possible transport destinations included the nearest CSC, the nearest PSC, and any of the remaining PSCs that are not closest to the scene, but transport to which would imply a shorter total time-to-CSC-via-PSC. Results: In abstract geographic environments, the median relative size of the sub-region where a triage decision is required ranged from 34 to 92%. The median relative size of the sub-region where more than two triage options need to be considered ranged from 0 to 56%. The achievable reduction in time-to-thrombectomy ("benefit") exceeded the increase in time-to-thrombolysis ("harm") by a factor of 2 in 30.5-37.0% of the sub-region where more than two triage options need to be considered. Results were confirmed in geographic environments based on real-world urban and rural stroke care infrastructures. Conclusion: Pre-hospital triage algorithms for AIS patients that only take into account the nearest CSC and the nearest PSC as transport destinations may be unable to identify the optimal transport destination for a significant proportion of patients.

SUBMITTER: Schlemm L

PROVIDER: S-EPMC6503645 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Pre-hospital Triage of Acute Ischemic Stroke Patients-Importance of Considering More Than Two Transport Options.

Schlemm Ludwig L Schlemm Eckhard E Nolte Christian H CH Endres Matthias M

Frontiers in neurology 20190426

<b>Background:</b> Patients with acute ischemic stroke (AIS) and large vessel occlusion benefit from rapid access to mechanical thrombectomy in addition to intravenous thrombolysis. Prehospital triage algorithms to determine the optimal transport destination for AIS patients with unknown vessel status have so far only considered two alternatives: the nearest comprehensive (CSC) and the nearest primary stroke center (PSC). <b>Objective:</b> This study explores the importance of considering a larg ...[more]

PMID: 31114538

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Project description:Background and Purpose- Prehospital routing algorithms for patients with suspected stroke because of large vessel occlusions should account for likelihood of benefit from endovascular therapy (EVT), risk of alteplase delays, and transport times. We built a mathematical model to give a real-time, location-based optimal emergency medical service routing location based on local resources, transport times, and patient characteristics. Methods- Using location, onset time, age, sex, and prehospital stroke severity, we calculated odds of a favorable outcome for a patient with suspected large vessel occlusions under 2 scenarios: direct to EVT-capable hospital versus transport to the nearest alteplase-capable hospital with transfer to EVT-capable hospital if appropriate. We project lifetime outcomes incorporating disability, quality of life utility, and cost. Multiple parameter sets of center-specific times (eg, door to alteplase) were randomly selected within a clinically plausible range to account for the model sensitivity to these estimates; for each iteration, the optimal strategy was defined as the most cost-effective outcome (threshold, $100?000 per quality-adjusted life-years gained). After 1000 simulations, the most frequently occurring optimal strategy was the final recommendation, with its strength measured as the proportion of runs for which it was optimal. Results- Routing recommendations were highly sensitive to small changes in model input parameters. Under many scenarios, the recommendations for direct transfer to the EVT site increased with increasing stroke severity and geographic proximity but did not vary substantially with respect to sex, age, or onset time. Conclusions- We present a mathematical decision model that determines ideal prehospital routing recommendations for patients with suspected stroke because of large vessel occlusions, with consideration of patient characteristics and location at onset. This model may be further refined by incorporating real-time data on traffic patterns and actual EVT and alteplase timeliness performance. Further studies are needed to verify model predictions.

Project description:Background and purposePost hoc analyses of randomized controlled clinical trials evaluating mechanical thrombectomy have suggested that admission-to-groin-puncture (ATG) delays are associated with reduced reperfusion rates. Purpose of this analysis was to validate this association in a real-world cohort and to find associated factors and confounders for prolonged ATG intervals.MethodsPatients included into the BEYOND-SWIFT cohort (Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the Solitaire FR With the Intention for Thrombectomy; https://www.clinicaltrials.gov; Unique identifier: NCT03496064) were analyzed (n=2386). Association between baseline characteristics and ATG was evaluated using mixed linear regression analysis. The effect of increasing symptom-onset-to-admission and ATG intervals on successful reperfusion (defined as Thrombolysis in Cerebral Infarction [TICI] 2b-3) was evaluated using logistic regression analysis adjusting for potential confounders.ResultsMedian ATG was 73 minutes. Prolonged ATG intervals were associated with the use of magnetic resonance imaging (+19.1 [95% CI, +9.1 to +29.1] minutes), general anesthesia (+12.1 [95% CI, +3.7 to +20.4] minutes), and borderline indication criteria, such as lower National Institutes of Health Stroke Scale, late presentations, or not meeting top-tier early time window eligibility criteria (+13.8 [95% CI, +6.1 to +21.6] minutes). There was a 13% relative odds reduction for TICI 2b-3 (adjusted odds ratio [aOR], 0.87 [95% CI, 0.79-0.96]) and TICI 2c/3 (aOR, 0.87 [95% CI, 0.79-0.95]) per hour ATG delay, while the reduction of TICI 2b-3 per hour increase symptom-onset-to-admission was minor (aOR, 0.97 [95% CI, 0.94-0.99]) and inconsistent regarding TICI 2c/3 (aOR, 0.99 [95% CI, 0.97-1.02]). After adjusting for identified factors associated with prolonged ATG intervals, the association of ATG delay and lower rates of TICI 2b-3 remained tangible (aOR, 0.87 [95% CI, 0.76-0.99]).ConclusionsThere is a great potential to reduce ATG, and potential targets for improvement can be deduced from observational data. The association between in-hospital delay and reduced reperfusion rates is evident in real-world clinical data, underscoring the need to optimize in-hospital workflows. Given the only minor association between symptom-onset-to-admission intervals and reperfusion rates, the causal relationship of this association warrants further research. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03496064.

Project description:The emergency medical services (EMS) cover initiatives and services established to provide essential medical assistance in situations of acute illness. Triage-methods for systematic prioritizing of patients according to how urgent patients need care, including triage of requests of acute medical treatment, are adopted in hospitals as well as in the pre-hospital settings. This systematic review searched to identify available research on the effects of validated triage systems for use in the pre-hospital EMS on health outcomes, patient safety, patient satisfaction, user-friendliness, resource use, goal achievement, and the quality on the information exchange between the different settings of the EMS (for example the quality of documentation). The specific research questions were: 1) are pre-hospital triage systems effective, 2) is one triage system more effective than others, and 3) is it effective to use the same triage system in two or more settings of the EMS-chain? We conducted a systematic literature search in nine databases up to June 2012. We searched for systematic reviews (SRs), randomized controlled trials (RCTs), non-randomized controlled trials (non-RCTs), controlled before and after studies (CBAs) and interrupted time series analyses (ITSs). Two persons independently reviewed titles and abstracts, and the same persons read all possibly relevant full text articles and rated the methodological quality where relevant. The literature search identified 11011 unique references. A total of 120 publications were read in full text. None of the identified articles fulfilled our inclusion criteria, thus our question on the effects of pre-hospital triage systems, if one system is better than other systems, and the question on effects of using the same triage system in two or more settings of the EMS, remain unanswered. We conclude that there is an evidence gap regarding the effects of pre-hospital triage systems and the effects of using the same triage system in two or more settings of the EMS. The finding does not mean that pre-hospital triage systems are ineffective, but that we lack knowledge about potential effects. When introducing a new assessment tool in the EMS, it is timely to conduct well-planned studies aimed to assess the effect.

Project description:BackgroundPre-hospital identification of major trauma in elderly patients is key for delivery of optimal care, however triage of this group is challenging. Elderly-specific triage criteria may be valuable. This systematic review aimed to summarise the published pre-hospital elderly-specific trauma triage tools and evaluate their sensitivity and specificity and associated clinical outcomes.MethodsMEDLINE and EMBASE databases were searched using predetermined criteria (PROSPERO: CRD42019140879). Two authors independently assessed search results, performed data extraction, risk of bias and quality assessments following the Grading of Recommendations, Assessment, Development and Evaluation system.Results801 articles were screened and 11 studies met eligibility criteria, including 1,332,300 patients from exclusively USA populations. There were eight unique elderly-specific triage criteria reported. Most studies retrospectively applied criteria to trauma databases, with few reporting real-world application. The Ohio Geriatric Triage Criteria was reported in three studies. Age cut-off ranged from 55 to 70 years with ≥ 65 most frequently reported. All reported existing adult criteria with modified physiological parameters using higher thresholds for systolic blood pressure and Glasgow coma scale, although the values used varied. Three criteria added co-morbidity or anti-coagulant/anti-platelet use considerations. Modifications to anatomical or mechanism of injury factors were used by only one triage criteria. Criteria sensitivity ranged from 44 to 93%, with a median of 86.3%, whilst specificity was generally poor (median 54%). Scant real-world data showed an increase in patients meeting triage criteria, but minimal changes to patient transport destination and mortality. All studies were at risk of bias and assessed of "very low" or "low" quality.ConclusionsThere are several published elderly-specific pre-hospital trauma triage tools in clinical practice, all developed and employed in the USA. Consensus exists for higher thresholds for physiological parameters, however there was variability in age-cut offs, triage criteria content, and tool sensitivity and specificity. Although sensitivity was improved over corresponding 'adult' criteria, specificity remained poor. There is a paucity of published real-world data examining the effect on patient care and clinical outcomes of elderly-specific triage criteria. There is uncertainty over the optimal elderly triage tool and further study is required to better inform practice and improve patient outcomes.

Dataset Information

Pre-hospital Triage of Acute Ischemic Stroke Patients-Importance of Considering More Than Two Transport Options.

Publications

Pre-hospital Triage of Acute Ischemic Stroke Patients-Importance of Considering More Than Two Transport Options.

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