Comparison of Acute Ischemic Stroke Care and Outcomes Between Comprehensive Stroke Centers and Primary Stroke Centers in the United States

Man, Shumei; Zhao, Xin; Uchino, Ken; Hussain, Muhammad Shazam; Smith, Eric E.; Bhatt, Deepak L.; Xian, Ying; Schwamm, Lee H; Shah, Shreyansh; Khan, Yosef; Fonarow, Gregg C.

doi:10.1161/circoutcomes.117.004512

Cited by 69 publications

(74 citation statements)

References 22 publications

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“…16 In such decentralized healthcare system, it is very challenging for all of the 9 stroke receiving centers to implement comprehensive protocols to achieve the fastest DNT for IVT. [4][5][6][7][8][9][10][11]14 Our quality improvement initiative is easily-implementable, effective and safe. Uncontrolled hypertension is one of the most frequently reported factors causing delayed DNT.…”

Section: Discussionmentioning

confidence: 99%

“…13 In a recent study comparing stroke care and outcomes between CSCs and primary stroke centers (PSCs) in the U.S. from 2013 to 2015, the median DNT was 52 (IQR, 39-70) minutes at CSCs and 60 (IQR, 47-83) minutes at PSCs. 14 The IVT rates were only 14.3% and 10.3%, respectively. It appears that centralized hospital system in developed countries were able to implement quality improvement initiatives efficiently.…”

Section: A Study Of Ais Patients Registered In Get With the Guidelinementioning

confidence: 93%

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Three Easily-Implementable Changes Reduce Median Door-To-Needle Time for Intravenous Thrombolysis by 23 Minutes

Tran

Zhu

Shafie

et al. 2019

Preprint

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Background: The benefit of intravenous thrombolysis (IVT) for acute ischemic stroke is time dependent. Despite great effort, the median door-to-needle time (DNT) was 60 minutes at the United States stroke centers. We investigated the effect of a simple quality improvement initiative on DNT for IVT. Methods: This is a single-center study of patients treated with IVT between 2013 and 2017. A simple quality improvement initiative was implemented in January 2015 to allow the Stroke team to manage hypertension in the emergency room, to make decision for IVT before getting blood test results unless patients were taking oral anticoagulants, and to give IVT in the CT suite. Baseline characteristics, DNT and outcomes at hospital discharge were compared between pre- and post-intervention groups. Results: Ninety and 136 patients were treated with IVT in pre- and post-intervention groups, respectively. The rate of IVT was significantly higher in the post-intervention group (20% vs. 14.4%, p=0.007). The median DNT with interquartile range (IQR) was reduced significantly by 23 minutes (63[53-81] vs. 40[29-53], p<0.001) with more patients in the post-intervention group receiving IVT within 60 minutes (81.6% vs. 46.7%) and 45 minutes (64.0% vs.17.8%). There was no significant difference in symptomatic intracerebral hemorrhage rate (1.5% vs. 1.1%), modified Rankin Scale 0-1 (29.4% vs. 23.3%), and hospital mortality (7.4% vs. 6.7%) between the 2 groups. Conclusions: Three easily-implementable quality improvement initiative increases IVT rate and reduces DNT significantly without increasing the rate of IVT-related complications in our comprehensive stroke center.

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Section: Discussionmentioning

confidence: 99%

Section: A Study Of Ais Patients Registered In Get With the Guidelinementioning

confidence: 93%

Three Easily-Implementable Changes Reduce Median Door-To-Needle Time for Intravenous Thrombolysis by 23 Minutes

Tran

Zhu

Shafie

et al. 2019

Preprint

View full text Add to dashboard Cite

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“…In contrast, our CSC, the only academic medical center in Orange County, California, is one of the 9 stroke receiving centers serving a population of 3.19 million [16]. In such decentralized healthcare system, it is very challenging for all of the 9 stroke receiving centers to implement comprehensive protocols to achieve the fastest DNT for IVT [4][5][6][7][8][9][10][11]14].…”

Section: Discussionmentioning

confidence: 99%

“…It appears that centralized hospital system in developed countries were able to implement quality improvement initiatives efficiently [4][5][6][7][8][9]. The healthcare system in the U.S. is decentralized with higher average annual IVT volume in CSCs than in PSCs (40 vs. 22) [14]. Due to overall low annual volumes and labor-intensive code stroke protocols, the stroke centers in the U.S., including CSCs and PSCs, appear to have significant logistic restraints in implementing comprehensive quality improvement initiatives 24/7 [11][12][13].…”

Section: Introductionmentioning

confidence: 99%

Three Easily-Implementable Changes Reduce Median Door-To-Needle Time for Intravenous Thrombolysis by 23 Minutes

Tran

Zhu

Shafie

et al. 2019

Preprint

View full text Add to dashboard Cite

Background: The benefit of intravenous thrombolysis (IVT) for acute ischemic stroke is time dependent. Despite great effort, the median door-to-needle time (DNT) was 60 min at the United States stroke centers. We investigated the effect of a simple quality improvement initiative on DNT for IVT. Methods: This is a single-center study of patients treated with IVT between 2013 and 2017. A simple quality improvement initiative was implemented in January 2015 to allow the Stroke team to manage hypertension in the emergency room, to make decision for IVT before getting blood test results unless patients were taking oral anticoagulants, and to give IVT in the CT suite. Baseline characteristics, DNT and outcomes at hospital discharge were compared between pre-and post-intervention groups. Results: Ninety and 136 patients were treated with IVT in pre-and post-intervention groups, respectively. The rate of IVT was significantly higher in the post-intervention group (20% vs. 14.4%, p = 0.007). The median DNT with interquartile range (IQR) was reduced significantly by 23 min (63[53-81] vs. 40[29-53], p < 0.001) with more patients in the post-intervention group receiving IVT within 60 min (81.6% vs. 46.7%) and 45 min (64.0% vs.17.8%). There was no significant difference in symptomatic intracerebral hemorrhage rate (1.5% vs. 1.1%), modified Rankin Scale 0-1 (29.4% vs. 23.3%), and hospital mortality (7.4% vs. 6.7%) between the 2 groups. Conclusions: Three easily-implementable quality improvement initiative increases IVT rate and reduces DNT significantly without increasing the rate of IVT-related complications in our comprehensive stroke center.

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“…The door-to-needle time was estimated to be 60 minutes in all primary stroke centers and 50 minutes in all intervention centers. 26 Door-in-door-out time in the primary stroke centers was considered to be 100 minutes; door-to-groin time in the intervention centers 85 minutes for directly admitted patients and 55 minutes for transferred patients. 7 Stroke scale characteristics, LVO prevalence, and workflow times were varied in the sensitivity analyses to assess their effect on the preferred strategy.…”

Section: Methodsmentioning

confidence: 99%

Prehospital Triage Strategies for the Transportation of Suspected Stroke Patients in the United States

Venema

Burke

Roozenbeek

et al. 2020

Stroke

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Background and Purpose: Ischemic stroke patients with large vessel occlusion (LVO) could benefit from direct transportation to an intervention center for endovascular treatment, but non-LVO patients need rapid IV thrombolysis in the nearest center. Our aim was to evaluate prehospital triage strategies for suspected stroke patients in the United States. Methods: We used a decision tree model and geographic information system to estimate outcome of suspected stroke patients transported by ambulance within 4.5 hours after symptom onset. We compared the following strategies: (1) Always to nearest center, (2) American Heart Association algorithm (ie, directly to intervention center if a prehospital stroke scale suggests LVO and total driving time from scene to intervention center is <30 minutes, provided that the delay would not exclude from thrombolysis), (3) modified algorithms with a maximum additional driving time to the intervention center of <30 minutes, <60 minutes, or without time limit, and (4) always to intervention center. Primary outcome was the annual number of good outcomes, defined as modified Rankin Scale score of 0–2. The preferred strategy was the one that resulted in the best outcomes with an incremental number needed to transport to intervention center (NNTI) <100 to prevent one death or severe disability (modified Ranking Scale score of >2). Results: Nationwide implementation of the American Heart Association algorithm increased the number of good outcomes by 594 (+1.0%) compared with transportation to the nearest center. The associated number of non-LVO patients transported to the intervention center was 16 714 (NNTI 28). The modified algorithms yielded an increase of 1013 (+1.8%) to 1369 (+2.4%) good outcomes, with a NNTI varying between 28 and 32. The algorithm without time limit was preferred in the majority of states (n=32 [65%]), followed by the algorithm with <60 minutes delay (n=10 [20%]). Tailoring policies at county-level slightly reduced the total number of transportations to the intervention center (NNTI 31). Conclusions: Prehospital triage strategies can greatly improve outcomes of the ischemic stroke population in the United States, but increase the number of non-LVO stroke patients transported to an intervention center. The current American Heart Association algorithm is suboptimal as a nationwide policy and should be modified to allow more delay when directly transporting LVO-suspected patients to an intervention center.

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Comparison of Acute Ischemic Stroke Care and Outcomes Between Comprehensive Stroke Centers and Primary Stroke Centers in the United States

Cited by 69 publications

References 22 publications

Three Easily-Implementable Changes Reduce Median Door-To-Needle Time for Intravenous Thrombolysis by 23 Minutes

Three Easily-Implementable Changes Reduce Median Door-To-Needle Time for Intravenous Thrombolysis by 23 Minutes

Three Easily-Implementable Changes Reduce Median Door-To-Needle Time for Intravenous Thrombolysis by 23 Minutes

Prehospital Triage Strategies for the Transportation of Suspected Stroke Patients in the United States

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