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Seners P, Ter Schiphorst A, Wouters A, Yuen N, Mlynash M, Arquizan C, Heit JJ, Kemp S, Christensen S, Sablot D, Wacongne A, Lalu T, Costalat V, Albers GW, Lansberg MG. Clinical change during inter-hospital transfer for thrombectomy: Incidence, associated factors, and relationship with outcome. Int J Stroke 2024:17474930241246952. [PMID: 38576067 DOI: 10.1177/17474930241246952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
BACKGROUND Patients with acute ischemic stroke with a large vessel occlusion (LVO) admitted to non endovascular-capable centers often require inter-hospital transfer for thrombectomy. We aimed to describe the incidence of substantial clinical change during transfer, the factors associated with clinical change, and its relationship with 3-month outcome. METHODS We analyzed data from two cohorts of acute stroke patients transferred for thrombectomy to a comprehensive center (Stanford, USA, November 2019 to January 2023; Montpellier, France, January 2015 to January 2017), regardless of whether thrombectomy was eventually attempted. Patients were included if they had evidence of an LVO at the referring hospital and had a National Institute of Health Stroke Scale (NIHSS) score documented before and immediately after transfer. Inter-hospital clinical change was categorized as improvement (⩾4 points and ⩾25% decrease between the NIHSS score in the referring hospital and upon comprehensive center arrival), deterioration (⩾4 points and ⩾25% increase), or stability (neither improvement nor deterioration). The stable group was considered as the reference and was compared to the improvement or deterioration groups separately. RESULTS A total of 504 patients were included, of whom 22% experienced inter-hospital improvement, 14% deterioration, and 64% were stable. Pre-transfer variables independently associated with clinical improvement were intravenous thrombolysis use, more distal occlusions, and lower serum glucose; variables associated with deterioration included more proximal occlusions and higher serum glucose. On post-transfer imaging, clinical improvement was associated with arterial recanalization and smaller infarct growth and deterioration with larger infarct growth. As compared to stable patients, those with clinical improvement had better 3-month functional outcome (adjusted common odds ratio (cOR) = 2.43; 95% confidence interval (CI) = 1.59-3.71; p < 0.001), while those with deterioration had worse outcome (adjusted cOR = 0.60; 95% CI = 0.37-0.98; p = 0.044). CONCLUSION Substantial inter-hospital clinical changes are frequently observed in LVO-related ischemic strokes, with significant impact on functional outcome. There is a need to develop treatments that improves the clinical status during transfer. DATA ACCESS STATEMENT The data that support the findings of this study are available upon reasonable request.
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Affiliation(s)
- Pierre Seners
- Stanford Stroke Center, Palo Alto, CA, USA
- Department of Neurology, Rothschild Foundation Hospital, Paris, France
- INSERM U1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP), Paris, France
| | | | - Anke Wouters
- Stanford Stroke Center, Palo Alto, CA, USA
- Division of Experimental Neurology, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | | | | | | | - Jeremy J Heit
- Department of Radiology, Stanford University, Palo Alto, CA, USA
| | | | | | - Denis Sablot
- Neurology Department, CH Perpignan, Perpignan, France
| | | | | | - Vincent Costalat
- Department of Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
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Rede de atenção às urgências e emergências: atendimento ao acidente vascular cerebral. ACTA PAUL ENFERM 2023. [DOI: 10.37689/acta-ape/2023ao00061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Allen M, Pearn K, Ford GA, White P, Rudd AG, McMeekin P, Stein K, James M. National implementation of reperfusion for acute ischaemic stroke in England: How should services be configured? A modelling study. Eur Stroke J 2021; 7:28-40. [PMID: 35300255 PMCID: PMC8921787 DOI: 10.1177/23969873211063323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 10/25/2021] [Accepted: 10/29/2021] [Indexed: 11/21/2022] Open
Abstract
Objectives To guide policy when planning thrombolysis (IVT) and thrombectomy (MT) services for acute stroke in England, focussing on the choice between ‘mothership’ (direct conveyance to an MT centre) and ‘drip-and-ship’ (secondary transfer) provision and the impact of bypassing local acute stroke centres. Design Outcome-based modelling study. Setting 107 acute stroke centres in England, 24 of which provide IVT and MT (IVT/MT centres) and 83 provide only IVT (IVT-only units). Participants 242,874 emergency admissions with acute stroke over 3 years (2015–2017). Intervention Reperfusion delivered by drip-and-ship, mothership or ‘hybrid’ models; impact of additional travel time to directly access an IVT/MT centre by bypassing a more local IVT-only unit; effect of pre-hospital selection for large artery occlusion (LAO). Main outcome measures Population benefit from reperfusion, time to IVT and MT, admission numbers to IVT-only units and IVT/MT centres. Results Without pre-hospital selection for LAO, 94% of the population of England live in areas where the greatest clinical benefit, assuming unknown patient status, accrues from direct conveyance to an IVT/MT centre. However, this policy produces unsustainable admission numbers at these centres, with 78 out of 83 IVT-only units receiving fewer than 300 admissions per year (compared to 3 with drip-and-ship). Implementing a maximum permitted additional travel time to bypass an IVT-only unit, using a pre-hospital test for LAO, and selecting patients based on stroke onset time, all help to mitigate the destabilising effect but there is still some significant disruption to admission numbers, and improved selection of patients suitable for MT selectively reduces the number of patients who would receive IVT at IVT-only centres, challenging the sustainability of IVT expertise in IVT-only centres. Conclusions Implementation of reperfusion for acute stroke based solely on achieving the maximum population benefit potentially leads to destabilisation of the emergency stroke care system. Careful planning is required to create a sustainable system, and modelling may be used to help planners maximise benefit from reperfusion while creating a sustainable emergency stroke care system.
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Affiliation(s)
- Michael Allen
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Kerry Pearn
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Gary A Ford
- Radcliffe Department of Medicine, Oxford University and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Phil White
- Translational and Clinical Research Institute, Newcastle University and Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Anthony G Rudd
- Kings College London and Guy’s and St Thomas, NHS Foundation Trust, London, UK
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle Upon Tyne, UK
| | - Ken Stein
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Martin James
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
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Sablot D, Farouil G, Leibinger F, Van Damme L, Aptel S, Fadat B, Tardieu M, Dutray A, Gascou G, Olivier N, Seiller I, Nguyen Them L, Smadja P, Ibanez-Julia MJ, Arquizan C, Mas J, Jurici S, Dumitrana A, Ferraro A, Costalat V, Bonafe L. Endovascular treatment for acute ischemic stroke at a primary stroke center: First results of the Perpignan center. Rev Neurol (Paris) 2021; 178:377-384. [PMID: 34556344 DOI: 10.1016/j.neurol.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/05/2021] [Accepted: 05/17/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Converting a high-volume primary stroke center (PSC) into a stroke center that can perform emergency endovascular treatment (EVT) could reduce the time to thrombectomy. We report the first results of a newly established EVT facility at the Perpignan PSC and their comparison with the targets defined by the established guidelines. PATIENTS AND METHOD For this comprehensive observational study, data of patients with acute ischemic stroke (AIS) due to proximal large vessel occlusion (LVO) and treated by EVT at the Perpignan PSC from December 5, 2019 to September 15, 2020 were extracted from an ongoing prospective database. RESULTS During the study period, 37 patients underwent EVT at the Perpignan PSC. The median (range) symptom-onset to recanalization time was 262min (100-485min). The median (range) intra-hospital times were: 20min (2-58min) for door-to-imaging, 57min (30-155min) for imaging-to-puncture, 55min (15-180min) for puncture-to-recanalization, and 137min (59-319min) for door-to-recanalization. At 3 months post-AIS, the favorable outcome (modified Ranking Score: 0-2) rate was 50% and the mortality rate was 19.4%. These results are comparable to those of previous clinical trials, and meet the targets defined by the current consensus statements for EVT. DISCUSSION AND CONCLUSION Our results show the feasibility and safety of EVT in a PSC for patients with AIS due to LVO. The implementation of this strategy may be important for shortening the time to thrombectomy.
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Affiliation(s)
- D Sablot
- Neurology Department, Perpignan hospital, Perpignan, France; Regional health agency of Occitanie, Montpellier, France.
| | - G Farouil
- Radiology Department, Perpignan hospital, Perpignan, France
| | - F Leibinger
- Intensive care unit, Perpignan hospital, Perpignan, France
| | - L Van Damme
- Neurology Department, Perpignan hospital, Perpignan, France
| | - S Aptel
- Radiology Department, Perpignan hospital, Perpignan, France
| | - B Fadat
- Neurology Department, Perpignan hospital, Perpignan, France
| | - M Tardieu
- Radiology Department, Perpignan hospital, Perpignan, France
| | - A Dutray
- Neurology Department, Perpignan hospital, Perpignan, France
| | - G Gascou
- Neuroradiology Department, University hospital of Montpellier, Montpellier, France
| | - N Olivier
- Neurology Department, Perpignan hospital, Perpignan, France
| | - I Seiller
- Radiology Department, Perpignan hospital, Perpignan, France
| | - L Nguyen Them
- Neurology Department, Perpignan hospital, Perpignan, France
| | - P Smadja
- Radiology Department, Perpignan hospital, Perpignan, France
| | | | - C Arquizan
- Neurology Department, University hospital of Montpellier, Montpellier, France
| | - J Mas
- Neurology Department, Perpignan hospital, Perpignan, France
| | - S Jurici
- Neurology Department, Perpignan hospital, Perpignan, France
| | - A Dumitrana
- Neurology Department, Perpignan hospital, Perpignan, France
| | - A Ferraro
- Neurology Department, Perpignan hospital, Perpignan, France
| | - V Costalat
- Neuroradiology Department, University hospital of Montpellier, Montpellier, France
| | - L Bonafe
- Radiology Department, Perpignan hospital, Perpignan, France; Neuroradiology Department, University hospital of Montpellier, Montpellier, France
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To support safe provision of mechanical thrombectomy services for patients with acute ischaemic stroke: 2021 consensus guidance from BASP, BSNR, ICSWP, NACCS, and UKNG. Clin Radiol 2021; 76:862.e1-862.e17. [PMID: 34482987 DOI: 10.1016/j.crad.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/05/2021] [Indexed: 01/01/2023]
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Schröder H, Brockert AK, Beckers SK, Follmann A, Sommer A, Kork F, Rossaint R, Felzen M. [Appropriate allocation of resources for interhospital transfer in emergency medical service-is a physician in the dispatch center helpful?]. Anaesthesist 2020; 69:726-732. [PMID: 32671429 DOI: 10.1007/s00101-020-00817-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/05/2020] [Accepted: 06/20/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The number of interhospital transfers is constantly increasing because of specialization of medical facilities, capacity balancing between intensive care units as well as earlier rehabilitation procedures. This leads to an increase in requests for emergency physicians to accompany patient transfers. This study investigated whether clarification of interhospital transport by an emergency physician at the dispatch center can optimize the use of emergency services resources. METHOD All transport clarifications performed by a tele-emergency physician between 1 January 2018 and 31 December 2019 were retrospectively analyzed as well as the transport request forms. Furthermore, all data on the number and alarmed rescue resources for interhospital transfers in the city of Aachen from 2013 onwards were exported from the dispatch center databank and included in the evaluation. RESULTS In total 2333 requests for interhospital patient transfers from 2018 and 2019 were analyzed as well as 10,923 transports recorded from 2013 to 2019. The number of patient transfers accompanied by an emergency physician from 2013 to 2019 was significantly reduced from 786 (68.2%) to 495 (30.5%, p > 0.001). The correct resources of rescue vehicles and staff was requested in 1816 cases (77.8%). The urgency of emergency patient transfers was correctly evaluated in 567 (89.2%) cases. In total 526 assignments were carried out without an emergency physician and 315 of these patients were accompanied by a tele-emergency physician during transfer. CONCLUSION The immediate clarification of interhospital transport requests by an emergency physician at the dispatch center leads to a significant reduction in unnecessary medical accompaniment of patient transfers. The choice of an appropriate transfer vehicle and staff should not be left to the requesting hospital physician alone.
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Affiliation(s)
- H Schröder
- Klinik für Anästhesiologie, Medizinische Fakultät, Uniklinik RWTH Aachen, RWTH Aachen University, Aachen, Deutschland.,Aachener Institut für Rettungsmedizin & zivile Sicherheit, Berufsfeuerwehr Aachen, Uniklinik RWTH Aachen & Stadt Aachen, Aachen, Deutschland
| | - A-K Brockert
- Klinik für Anästhesiologie, Medizinische Fakultät, Uniklinik RWTH Aachen, RWTH Aachen University, Aachen, Deutschland.,Aachener Institut für Rettungsmedizin & zivile Sicherheit, Berufsfeuerwehr Aachen, Uniklinik RWTH Aachen & Stadt Aachen, Aachen, Deutschland
| | - S K Beckers
- Klinik für Anästhesiologie, Medizinische Fakultät, Uniklinik RWTH Aachen, RWTH Aachen University, Aachen, Deutschland.,Aachener Institut für Rettungsmedizin & zivile Sicherheit, Berufsfeuerwehr Aachen, Uniklinik RWTH Aachen & Stadt Aachen, Aachen, Deutschland.,Ärztliche Leitung Rettungsdienst, Berufsfeuerwehr Aachen, Stadt Aachen, Stolberger Str. 155, 52068, Aachen, Deutschland
| | - A Follmann
- Klinik für Anästhesiologie, Medizinische Fakultät, Uniklinik RWTH Aachen, RWTH Aachen University, Aachen, Deutschland
| | - A Sommer
- Aachener Institut für Rettungsmedizin & zivile Sicherheit, Berufsfeuerwehr Aachen, Uniklinik RWTH Aachen & Stadt Aachen, Aachen, Deutschland
| | - F Kork
- Klinik für Anästhesiologie, Medizinische Fakultät, Uniklinik RWTH Aachen, RWTH Aachen University, Aachen, Deutschland
| | - R Rossaint
- Klinik für Anästhesiologie, Medizinische Fakultät, Uniklinik RWTH Aachen, RWTH Aachen University, Aachen, Deutschland
| | - M Felzen
- Klinik für Anästhesiologie, Medizinische Fakultät, Uniklinik RWTH Aachen, RWTH Aachen University, Aachen, Deutschland. .,Aachener Institut für Rettungsmedizin & zivile Sicherheit, Berufsfeuerwehr Aachen, Uniklinik RWTH Aachen & Stadt Aachen, Aachen, Deutschland. .,Ärztliche Leitung Rettungsdienst, Berufsfeuerwehr Aachen, Stadt Aachen, Stolberger Str. 155, 52068, Aachen, Deutschland.
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Safety of inter-hospital transfer of patients with acute ischemic stroke for evaluation of endovascular thrombectomy. Sci Rep 2020; 10:5655. [PMID: 32221353 PMCID: PMC7101346 DOI: 10.1038/s41598-020-62528-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/15/2020] [Indexed: 11/09/2022] Open
Abstract
Stroke networks facilitate access to endovascular treatment (EVT) for patients with ischemic stroke due to large vessel occlusion. In this study we aimed to determine the safety of inter-hospital transfer and included all patients with acute ischemic stroke who were transferred within our stroke network for evaluation of EVT between 06/2016 and 12/2018. Data were derived from our prospective EVT database and transfer protocols. We analyzed major complications and medical interventions associated with inter-hospital transfer. Among 615 transferred patients, 377 patients (61.3%) were transferred within our telestroke network and had transfer protocols available (median age 76 years [interquartile range, IQR 17], 190 [50.4%] male, median baseline NIHSS score 17 [IQR 8], 246 [65.3%] drip-and-ship i.v.-thrombolysis). No patient suffered from cardio-respiratory failure or required emergency intubation or cardiopulmonary resuscitation during the transfer. Among 343 patients who were not intubated prior departure, 35 patients (10.2%) required medical interventions during the transfer. The performance of medical interventions was associated with a lower EVT rate and higher mortality at three months. In conclusion, the transfer of acute stroke patients for evaluation of EVT was not associated with major complications and transfer-related medical interventions were required in a minority of patients.
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