Abstract
BackgroundOptimizing access to recanalization therapies in acute ischemic stroke patients is crucial. Our aim was to measure the short and long term effectiveness, at the acute phase and 1 year after stroke, of four sets of actions implemented in the Rhône County.MethodsThe four multilevel actions were 1) increase in stroke units bed capacity and development of endovascular therapy; 2) improvement in knowledge and skills of healthcare providers involved in acute stroke management using a bottom-up approach; 3) development and implementation of new organizations (transportation routes, pre-notification, coordination by the emergency call center physician dispatcher); and 4) launch of regional public awareness campaigns in addition to national campaigns. A before-and-after study was conducted with two identical population-based cohort studies in 2006–7 and 2015–16 in all adult ischemic stroke patients admitted to any emergency department or stroke unit of the Rhône County. The primary outcome criterion was in-hospital management times, and the main secondary outcome criteria were access to reperfusion therapy (either intravenous thrombolysis or endovascular treatment) and pre-hospital management times in the short term, and 12-month prognosis measured by the modified Rankin Scale (mRS) in the long term.ResultsBetween 2015–16 and 2006–7 periods ischemic stroke patients increased from 696 to 717, access to reperfusion therapy increased from 9 to 23% (p < 0.0001), calls to emergency call-center from 40 to 68% (p < 0.0001), first admission in stroke unit from 8 to 30% (p < 0.0001), and MRI within 24 h from 18 to 42% (p < 0.0001). Onset-to-reperfusion time significantly decreased from 3h16mn [2 h54-4 h05] to 2h35mn [2 h05-3 h19] (p < 0.0001), mainly related to a decrease in delay from admission to imaging. A significant decrease of disability was observed, as patients with mild disability (mRS [0–2]) at 12 months increased from 48 to 61% (p < 0.0001). Pre-hospital times, however, did not change significantly.ConclusionsWe observed significant improvement in access to reperfusion therapy, mainly through a strong decrease of in-hospital management times, and in 12-month disability after the implementation of four sets of actions between 2006 and 2016 in the Rhône County. Reducing pre-hospital times remains a challenge.
Highlights
Optimizing access to recanalization therapies in acute ischemic stroke patients is crucial
The primary outcome criterion was admission-to-imaging time, and the main secondary outcome criteria was access to reperfusion therapy, either intravenous thrombolysis (IVT) or endovascular treatment (EVT) in the short term and 12-month prognosis measured by the modified Rankin Scale in the long term
The National Institute of Health Stroke Scale (NIHSS) score was too rarely performed by the emergency department physicians in the AVC69 cohort 2006–7 to be accurately analyzed and we present only the NIHSS observed in STROKE69 cohort
Summary
Optimizing access to recanalization therapies in acute ischemic stroke patients is crucial. Several actions were defined by the European Academy of Neurology and European Stroke Organization to improve effectiveness of acute stroke care organization throughout the overall process of pre-hospital care [4] Those actions target each step of the patient’s journey and include: public awareness programs to increase the number of patients calling the centralized emergency call center (ECC) in a timely manner, using a unique telephone number (#15 in France or #112 in Europe); training of emergency staff to accurately identify acute stroke patients using validated tools; establishment of clear transportation routes to the nearest suitable hospital; organizational procedures such as pre-notification or direct arrival in the radiology department; and implementation of registries to monitor key performance indicators. The primary outcome criterion was admission-to-imaging time, and the main secondary outcome criteria was access to reperfusion therapy, either IVT or EVT in the short term and 12-month prognosis measured by the modified Rankin Scale (mRS) in the long term
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