Components and Trends in Door to Treatment Times for Endovascular Therapy in Get With The Guidelines-Stroke Hospitals

Abstract

Background: Endovascular therapy (EVT) is standard of care in patients with acute disabling ischemic stroke attributable to large-vessel occlusion and is more effective when delivered quickly. It is currently unclear whether time targets achieved in clinical trials can be achieved in clinical practice. We describe interval times from patient arrival in the emergency department (door) to first pass (treatment initiation) in patients receiving EVT within Get With The Guidelines-Stroke hospitals and analyze patient- and hospital-level variables associated with these times. Methods: Data are from sites participating fully as Comprehensive Stroke Centers within Get With The Guidelines-Stroke hospitals from October 2014 to September 2016. Workflow times analyzed include door to imaging, imaging to arterial access, arterial access to first pass, and the composite door to first pass time. Data are described overall and by calendar-year quarters. Multivariable modeling was used to identify patient- and hospital-level variables associated with workflow times. Results: Among 2929 patients with EVT from 195 hospitals (median age, 71 years [interquartile range {IQR}, 60–81]; 50.7% female; median baseline National Institute of Health Stroke Score, 17 [IQR, 12–22]; median annual EVT administration number, 16 [IQR, 10–27]), median door to first pass time was 130 minutes (IQR, 101–170 minutes), door to imaging time was 12 minutes (IQR, 7–20 minutes), imaging to arterial puncture time was 93 minutes (IQR, 68–126 minutes), and arterial puncture to first pass time was 18 minutes (IQR, 4–31 minutes). Overall, 3% patients achieved a door to first pass time ≤60 minutes. A statistically significant linear time trend was noted for door to first pass time (quarter 4 year 2014 median time, 134.5 minutes to quarter 3 year 2016 median time, 128 minutes, P =0.002). In multivariable analysis, older age, arrival during nonregular hours, and history of diabetes mellitus were associated with longer door to first pass time. Hospitals achieving shorter door to intravenous alteplase administration (door to needle) times were more likely to achieve faster door to first pass time ( P <0.001). Each 5 cases/y increase in EVT case volume was associated with a 3% shorter door to first pass time, up to a case volume of 40 per year ( P <0.001). Conclusions: Although EVT treatment times are modestly improving, additional efforts are needed to streamline workflow so that the true potential of this treatment is realized. These data may inform benchmark goals for EVT workflow times.

How do treatment times impact on functional outcome in stroke patients undergoing thrombectomy in Germany? Results from the German Stroke Registry

“…17 Three American Registry Studies (2014–2016) reported a DTGT of 80–123 min. 14,18,19 In a registry study, recruiting patients in southern Germany, DTGT was 90 min in CSC patients and 64 min in PSC patients. 20 However, although comprehensive stroke centers in the GSR–ET achieve adequate treatment times by national and international comparison, most contributing centers are high-volume centers, and for these, a current international consensus statement suggests a DTGT within 62 min.…”

Sensitivity of prehospital stroke scales for different intracranial large vessel occlusion locations

“…Because the effect of endovascular treatment (EVT) for ischaemic stroke is strongly time-dependent, it is important to optimise prehospital and in-hospital workflows to reduce unnecessary treatment delays. 1 – 3 Interhospital transfers are an important cause of treatment delay and are associated with worse functional outcome. 4 , 5 Prehospital stroke scales may be helpful for the selection of patients with a high likelihood of a large vessel occlusion (LVO), to bypass the primary stroke centre for direct transport to an intervention centre capable of EVT and thereby avoiding time-consuming interhospital transfers.…”

“… Imaging assessment committee: Charles BLM Majoie3(chair); Wim H van Zwam6; Aad van der Lugt2; Geert J Lycklama à Nijeholt13; Marianne AA van Walderveen10; Marieke ES Sprengers3; Sjoerd FM Jenniskens27; René van den Berg3; Albert J Yoo 38 ; Ludo FM Beenen3; Alida A Postma6; Stefan D Roosendaal3; Bas FW van der Kallen13; Ido R van den Wijngaard13; Adriaan CGM van Es2; Bart J Emmer , 3; Jasper M Martens12; Lonneke SF Yo33; Jan Albert Vos8; Joost Bot 36 ; Pieter-Jan van Doormaal2; Anton Meijer27; Elyas Ghariq13; Reinoud PH Bokkers29; Marc P van Proosdij 37 ; G Menno Krietemeijer33; Jo P Peluso26; Hieronymus D Boogaarts20; Rob Lo18; Dick Gerrits 35 ; Wouter Dinkelaar 2 Auke PA Appelman29; Bas Hammer16; Sjoert Pegge27; Anouk van der Hoorn29; Saman Vinke20. …”

Therapie des akuten ischämischen Schlaganfalls

“…Anpassung der lokalen Schlaganfallversorgungskonzepte [96]. In einer Metaanalyse konnte gezeigt werden, dass schnelle Prozesszeiten für die Thrombolyse einhergehen mit ebenfalls schnellen Zeiten für die endovaskuläre Therapie [97]. Die Pilotstudie zum "One-Stop-Management" (wenn NIHSS > 9 Punkte: Rettungsdienst-Übergabe des Patienten direkt im Angiografieraum und Flachdetektor-Computertomografie) konnte eine signifikante Reduktion der Zeit von Eintreffen des Patienten bis zur Leistenpunktion belegen (54,5 min versus 20,5 min, p 0,001) [98].…”