Integrated Stroke System Model Expands Availability of Endovascular Therapy While Maintaining Quality Outcomes

Abstract

Background and Purpose: The optimal endovascular stroke therapy (EVT) care delivery structure is unknown. Here, we present our experience in creating an integrated stroke system (ISS) to expand EVT availability throughout our region while maintaining hospital and physician quality standards. Methods: We identified all consecutive patients with large vessel occlusion acute ischemic stroke treated with EVT from January 2014 to February 2019 in our health care system. In October 2017, we implemented the ISS, in which 3 additional hospitals (4 total) became EVT-performing hospitals (EPHs) and physicians were rotated between all centers. The cohort was divided by time into pre-ISS and post-ISS, and the primary outcome was time from stroke onset to EPH arrival. Secondary outcomes included hospital and procedural quality metrics. We performed an external validation using data from the Southeast Texas Regional Advisory Council. Results: Among 513 patients with large vessel occlusion acute ischemic stroke treated with EVT, 58% were treated pre-ISS and 43% post-ISS. Over the study period, EVT procedural volume increased overall but remained relatively low at the 3 new EPHs (<70 EVT/y). After ISS, the proportion of patients who underwent interhospital transfer decreased (46% versus 37%; P <0.05). In adjusted quantile regression, ISS implementation resulted in a reduction of time from stroke onset to EPH arrival by 40 minutes ( P <0.01) and onset to groin puncture by 29 minutes ( P <0.05). Rates of postprocedural hemorrhage, modified Thrombolysis in Cerebral Infarction (TICI) 2b/3, and 90-day modified Rankin Scale were comparable at the higher and lower volume EPHs. The improvement in onset-to-arrival time was not reflective of overall improvement in secular trends in regional prehospital care. Conclusions: In our system, increasing EVT availability decreased time from stroke onset to EPH arrival. The ISS provides a framework to maintain quality in lower volume hospitals.

Advances in Stroke: Quality Improvement

“…A study from 4 hospitals in Houston, TX, examined an integrated stroke system of care model. 8 This included physician coverage shared across hospitals, nursing protocols, order sets, and centralized QI data collection. The objective of the program was to improve endovascular therapy for patients with large vessel occlusion acute ischemic stroke at low-volume hospitals.…”

Prehospital scales in acute ischaemic stroke management

“…Further prospective studies must be encouraged, but alternative solutions to the current challenges in the organisation of acute stroke care should be pursued. Among them, increasing the availability of endovascular therapy, 3 improving the efficiency of primary stroke centres, 4 implementing mobile interventional stroke teams that can do endovascular thrombectomy at the hospital where the patient is primarily transported, 5 and applying portable devices (ie, transcranial Doppler) that can identify large-vessel occlusion in a prehospital setting. 6 Furthermore, the transport models (mothership vs drip-and-ship) are context specific and need to take into account regional population distribution and density.…”

“…We fully agree with these concerns and reiterate that the tradeoff between potential harm and benefit should be made at the patient level, as shown previously in our personalised decision model. 3 This model estimates the probability of a good outcome for the drip-and-ship versus mothership…”

Annual Endovascular Thrombectomy Case Volume and Thrombectomy-capable Hospitals of Korea in Acute Stroke Care

“…According to a systematic review of studies to date, EVT candidates might benefit from the MS model as compared to the DS model [ 18 ]. In addition, the MS model may allow an efficient organization of on-call staff, intramural patient flow, stroke unit, institutional protocol, and quality improvement activities in each region [ 18 , 19 ].…”