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EXPEDITING WORKFLOW IN THE ACUTE STROKE PATHWAY FOR ENDOVASCULAR THROMBECTOMY; A SIMULATION MODELLING APPROACH.
Abstract
Background and Aims
Ischemic stroke with large vessel occlusion can be treated with intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT). The efficacy of both treatments is highly time dependent. The aim of this study is to identify barriers for timely EVT delivery and to study the effects of hypothetical workflow improvements in the acute stroke pathway.
Methods
Data from 248 patients in the MR CLEAN registry, treated with EVT in the north of the Netherlands between July 2014 and November 2017. Eighty-three patients arrived directly at the comprehensive stroke centre (CSC), and 165 patients were transferred from primary stroke centres (PSCs) to the CSC. Two simulation models for a ‘mothership’- and a ‘drip-and-ship’ set-up were developed and diagnostic steps and time delays were collected for each patient. The main outcome measures were total delay from stroke onset until the start of EVT and functional independence at 90 days (modified Rankin Scale 0-2).
Results
Barriers identified included fast-track emergency department routing, pre-alert for transfer to the CSC, reduced handover time between PSC and ambulance, direct transfer from CSC arrival to angiography suite entry and reducing time to groin puncture. Taken together the hypothetical workflow improvements could reduce onset to groin time by approximately 1 hour. An additional 7.2% (‘drip-and-ship’) and 8.6% (‘mothership’) of patients might regain functional independence after 90 days.
Conclusions
Simulation modelling is a useful tool to assess the potential effects of interventions reducing the onset to EVT time.