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Optimising acute stroke care organisation: a simulation study to assess the potential to increase intravenous thrombolysis rates and patient gains.

ABSTRACT: OBJECTIVES:To assess potential increases in intravenous thrombolysis (IVT) rates given particular interventions in the stroke care pathway. DESIGN:Simulation modelling was used to compare the performance of the current pathway, best practices based on literature review and an optimised model. SETTING:Four hospitals located in the North of the Netherlands, as part of a centralised organisational model. PARTICIPANTS:Ischaemic stroke patients prospectively ascertained from February to August 2010. INTERVENTION:The interventions investigated included efforts aimed at patient response and mode of referral, prehospital triage and intrahospital delays. PRIMARY AND SECONDARY OUTCOME MEASURES:The primary outcome measure was thrombolysis utilisation. Secondary measures were onset-treatment time (OTT) and the proportion of patients with excellent functional outcome (modified Rankin scale (mRS) 0-1) at 90 days. RESULTS:Of 280 patients with ischaemic stroke, 125 (44.6%) arrived at the hospital within 4.5?hours, and 61 (21.8%) received IVT. The largest improvements in IVT treatment rates, OTT and the proportion of patients with mRS scores of 0-1 can be expected when patient response is limited to 15?min (IVT rate +5.8%; OTT -6?min; excellent mRS scores +0.2%), door-to-needle time to 20?min (IVT rate +4.8%; OTT -28?min; excellent mRS scores+3.2%) and 911 calls are increased to 60% (IVT rate +2.9%; OTT -2?min; excellent mRS scores+0.2%). The combined implementation of all potential best practices could increase IVT rates by 19.7% and reduce OTT by 56?min. CONCLUSIONS:Improving IVT rates to well above 30% appears possible if all known best practices are implemented.

SUBMITTER: Lahr MMH

PROVIDER: S-EPMC7045180 | biostudies-literature | 2020 Jan

REPOSITORIES: biostudies-literature

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Optimising acute stroke care organisation: a simulation study to assess the potential to increase intravenous thrombolysis rates and patient gains.

Lahr Maarten M H MMH van der Zee Durk-Jouke DJ Luijckx Gert-Jan GJ Buskens Erik E

BMJ open 20200120 1

<h4>Objectives</h4>To assess potential increases in intravenous thrombolysis (IVT) rates given particular interventions in the stroke care pathway.<h4>Design</h4>Simulation modelling was used to compare the performance of the current pathway, best practices based on literature review and an optimised model.<h4>Setting</h4>Four hospitals located in the North of the Netherlands, as part of a centralised organisational model.<h4>Participants</h4>Ischaemic stroke patients prospectively ascertained f ...[more]

PMID: 31964668

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Project description:PurposeBeyond intravenous thrombolysis, evidence is lacking on acute treatment of minor stroke caused by large artery occlusion. To identify candidates for additional endovascular therapy, we aimed to determine the frequency of non-haemorrhagic early neurological deterioration in patients with intravenous thrombolysis-treated minor stroke caused by occlusion of large proximal and distal cerebral arteries. Secondary aims were to establish risk factors for non-haemorrhagic early neurological deterioration and report three-month outcomes in patients with and without non-haemorrhagic early neurological deterioration.MethodWe analysed data from the SITS International Stroke Thrombolysis Register on 2553 patients with intravenous thrombolysis-treated minor stroke (NIH Stroke Scale scores 0-5) and available arterial occlusion data. Non-haemorrhagic early neurological deterioration was defined as an increase in NIH Stroke Scale score ≥4 at 24 h, without parenchymal hematoma on follow-up imaging within 22-36 h.FindingsThe highest frequency of non-haemorrhagic early neurological deterioration was seen in 30% of patients with terminal internal carotid artery or tandem occlusions (internal carotid artery + middle cerebral artery) (adjusted odds ratio: 10.3 (95% CI 4.3-24.9), p < 0.001) and 17% in extracranial carotid occlusions (adjusted odds ratio 4.3 (2.5-7.7), p < 0.001) versus 3.1% in those with no occlusion. Proximal middle cerebral artery-M1 occlusions had non-haemorrhagic early neurological deterioration in 9% (adjusted odds ratio 2.1 (0.97-4.4), p = 0.06). Among patients with any occlusion and non-haemorrhagic early neurological deterioration, 77% were dead or dependent at three months.ConclusionsPatients with minor stroke caused by internal carotid artery occlusion, with or without tandem middle cerebral artery involvement, are at high risk of disabling deterioration, despite intravenous thrombolysis treatment. Acute vessel imaging contributes usefully even in minor stroke to identify and consider endovascular treatment, or intensive monitoring at a comprehensive stroke centre, for patients at high risk of neurological deterioration.

Dataset Information

Optimising acute stroke care organisation: a simulation study to assess the potential to increase intravenous thrombolysis rates and patient gains.

Publications

Optimising acute stroke care organisation: a simulation study to assess the potential to increase intravenous thrombolysis rates and patient gains.

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