A Real-World Perspective on Interfacility Transfers of Acute Ischemic Stroke from a Semi-Rural Center

Lluís Llauger,Francisco Sanchez-Mendez,Ester Puyuelo

doi:10.4236/ojem.2020.81001

Abstract

Introduction: Interfacility transfers (IFT) of acute ischemic stroke (AIS) may not always lead to a better prognosis. Methods: Retrospective cohort study included AIS patients at an emergency department (ED) with telestroke. Multiple linear regression for departure time from ED (DT), quantile regression for length of in-hospital stay (LOS), and Kaplan-Meier estimator with Cox proportional hazards model for one-year survival (SV) were performed. Results: 192 patients included were categorised according to IFT. Mechanical thrombectomy was performed in 50% who had been transferred. Differences were found in DT, discharge disposition and LOS. An inverse relationship existed between DT and NIHSS. The strongest predictor of LOS was TACS (β = 3.14 [0.03 - 8.49]; p = 0.005). SV was related to IFT (HR 4.68 [1.37 - 16.07]; p = 0.014), age (HR 1.1 [1.04 - 1.17]), BI < 60 (HR 2.7 [1.02 - 7.1]), TACS (HR 9.82 [1.08 - 88.95]) and NIHSS ≥ 6 (HR 2.85 [1.05 - 7.74]). Conclusions: Shared decision-making with a stroke unit through telemedicine enabled a standardised clinical management in a non-metropolitan setting. Several improvement opportunities were identified: multimodal computed tomography availability before transfer, as well as optimization of response time and training in neurosonology of emergency physicians.

Highlights

Interfacility transfers (IFT) of acute ischemic stroke (AIS) may not always lead to a better prognosis
The increase in costs and variability between centres has generated the need to establish efficiency criteria. With this objective, the implementation of telematic tools for specialised consultation [6] aims to increase diagnostic accuracy [7] and avoid transfers considered futile because so many times they do not involve the application of additional techniques by the neurologist
The cohort was categorised (Figure 1, Table 1) into TRANSFER (n = 38; 57.8% men) and NON-TRANSFER (n = 154; 51.9% women), who differed in age (67 vs. 81; p < 0.001), BI < 60 (2.6% vs. 18%; p = 0.0268), mRankin ≤ 1 (84% vs. 67%; p = 0.0465), Oxfordshire/Bamford LACS/PACS/POCS/TACS topographic diagnosis ratio (13/45/18/24 vs. 38/41/7/14; p = 0.004), AF + INR < 2 (21% vs. 13.6%; p < 0.001), NIHSS (6 vs. 2; p = 0.0396), NIHSS ≥ 6 + mRankin ≤ 1 (42% vs. 5.8%; p = 0.0102), alteplase thrombolysis (9 vs. 7; p = 0.0008), echocardiography (26% vs. 3.9%; p = 0.0118)

Summary

Introduction

Interfacility transfers (IFT) of acute ischemic stroke (AIS) may not always lead to a better prognosis. In the Autonomous Community of Catalonia, reperfusion strategy for acute ischemic stroke (AIS) was indicated in total for 3752 patients, exclusively in accordance with a standardised protocol by the health care administration [3]. The increase in costs and variability between centres has generated the need to establish efficiency criteria With this objective, the implementation of telematic tools for specialised consultation [6] aims to increase diagnostic accuracy [7] and avoid transfers considered futile because so many times they do not involve the application of additional techniques by the neurologist

Objectives

Methods

Results

Discussion

Conclusion