Emergency Department Door-to-Puncture Time Since 2014

Abstract

Background and Purpose— The impact of a mobile stroke unit (MSU) on access to intraarterial thrombectomy (IAT) is a prespecified BEST-MSU substudy (Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit Compared to Standard Management by Emergency Medical Services). On the MSU, IAT decision-making steps, such as computed tomography, neurological exam, and tPA (tissue-type plasminogen activator) treatment are completed before emergency department arrival. We hypothesized that such pre-ED assessment of potential IAT patients on an MSU improves the time from ED arrival to skin puncture time (door-to-puncture-time, DTPT). Methods— BEST-MSU is a prospective comparative effectiveness study of MSU versus standard management by emergency medical services (EMS). We compared ED DTPT among the following groups of MSU and EMS patients: all IAT patients, IAT patients post-tPA, and IAT patients post-tPA meeting thrombolytic adjudication criteria over the first 4 years of the study. Results— From August 2014 to July 2018, a total of 161 patients underwent IAT. Ninety-four patients presented to the ED via the MSU and 67 by EMS. One hundred forty patients received tPA before IAT, 85 in the MSU arm, and 55 in the EMS arm. One hundred twenty-six patients received tPA within thrombolytic adjudication criteria: 76 MSU and 50 EMS. DTPT in minutes was shorter for MSU patients (all IAT MSU versus EMS 89 versus 99, P =0.01; IAT post-tPA MSU versus EMS 93 versus 100, P =0.03; and IAT post-tPA within adjudicated criteria MSU versus EMS 93 versus 99.5, P =0.03). From 2014 to 2018, DTPT decreased at a faster rate for EMS compared with MSU-managed patients, improving by about an hour. Conclusions— Pre-ED IAT evaluation on an MSU results in faster DTPT compared with arrival by EMS. Since 2014, dramatic improvement in ED IAT metrics has attenuated this difference. However, DTPT in all groups indicates substantial room for improvement.

Association of Medicare-Medicaid Dual Eligibility and Race and Ethnicity With Ischemic Stroke Severity

“… 40 Similarly, the use of mobile stroke units, even in smaller urban areas have shown to be effective in reducing door-to-needle time compared with traditional emergency transport. 41 , 42 High-risk patients, patients with DE, and minority patients should be intentionally targeted by such programs. Furthermore, living in neighborhoods with high SES compared with low SES has been associated with better poststroke function, biopsychosocial health, and fewer depressive symptoms in adults with moderate to severe strokes as well as better function in those with minor strokes.…”

Advances in pre-hospital care - operational experiences from the Melbourne mobile stroke unit

“…Therefore, the proportion of MSU EVT cases that need repeat imaging will likely decrease with ongoing operation. In comparison, the time savings for hospital arrival to EVT commencement for US-based MSUs were 10 min or less [20,21] .…”

“…Using a comparator of all direct and metropolitan secondary transfer patients to the largest EVT center in Victoria (Royal Melbourne Hospital), patients receiving facilitated thrombectomy via the Melbourne MSU did so a median of 51 min (95%CI: 30-72) faster. On further analysis, cases that bypassed of the local non-EVT hospital received the most time saving of 71 min (95%CI: 46-96), whereas the equivalent time saving if the patient was located closest to a comprehensive center was 6 min (95%CI: [19][20][21][22][23][24][25][26][27][28][29][30][31]. This suggests that a large proportion of the time savings are due to improved triage and avoidance of secondary transfers.…”

Mobile Stroke Units: Current and Future Impact on Stroke Care

“…This includes unnecessary delays in patient transfer from PSCs to MT-capable centers and earlier mobilization of inpatient stroke and MT teams resulting in faster door-to-groin puncture times for patients treated on the MSU. 56,57 The transfer of MT-eligible patients from the MSU directly to the angiography suite (thereby minimizing delays in the ER) could further reduce the time to reperfusion of ischemic penumbral tissue that might lead to improved clinical outcomes.…”