Abstract
BackgroundVarious studies demonstrate better patient outcome and higher thrombolysis rates achieved by centralized stroke care compared to decentralized care, i.e. community hospitals. It remains largely unclear how to improve thrombolysis rate in decentralized care. The aim of this simulation study was to assess the impact of previously identified success factors in a central model on thrombolysis rates and patient outcome when implemented for a decentral model.MethodsBased on a prospectively collected dataset of 1084 ischemic stroke patients, simulation was used to replicate current practice and estimate the effect of re-organizing decentralized stroke care to resemble a centralized model. Factors simulated included symptom onset call to help, emergency medical services transportation, and in-hospital diagnostic workup delays. Primary outcome was proportion of patients treated with thrombolysis; secondary endpoints were good functional outcome at 90 days, Onset-Treatment-Time (OTT), and OTT intervals, respectively.ResultsCombining all factors might increase thrombolysis rate by 7.9%, of which 6.6% ascribed to pre-hospital and 1.3% to in-hospital factors. Good functional outcome increased by 11.4%, 8.7% ascribed to pre-hospital and 2.7% to in-hospital factors. The OTT decreased 17 minutes, 7 minutes ascribed to pre-hospital and 10 minutes to in-hospital factors. An increase was observed in the proportion thrombolyzed within 1.5 hours; increasing by 14.1%, of which 5.6% ascribed to pre-hospital and 8.5% to in-hospital factors.ConclusionsSimulation technique may target opportunities for improving thrombolysis rates in acute stroke. Pre-hospital factors proved to be the most promising for improving thrombolysis rates in an implementation study.
Highlights
Treatment with tissue plasminogen activator or thrombolysis is the most effective therapy for acute ischemic stroke patients within the first 4.5 hours following the onset of stroke symptoms [1,2]
We demonstrated a 50% greater likelihood and up to 22% overall rate of treatment with thrombolysis achieved by a stroke center in a centralized organizational model versus nine community hospitals united in a decentralized organizational system of acute stroke care [11]
Factors in which the central model performed significantly better than the decentral model were incorporated in the simulation model: lapse between symptom onset to call for help, first responder; i.e. 911 or General Practitioner (GP), Emergency Medical Services (EMS) transport, high priority transport by EMS, and the time from hospital arrival to neurological- and neuroimaging (Computed Tomography, CT) examination
Summary
Treatment with tissue plasminogen activator (tPA) or thrombolysis is the most effective therapy for acute ischemic stroke patients within the first 4.5 hours following the onset of stroke symptoms [1,2]. Currently between 1–8% [3,4,5] are treated with tPA worldwide and around 11% (ranging from 4–26%) within the Netherlands [6], while 24–31% may be achieved in optimized settings [7,8]. Various studies demonstrate better patient outcome and higher thrombolysis rates achieved by centralized stroke care compared to decentralized care, i.e. community hospitals. The aim of this simulation study was to assess the impact of previously identified success factors in a central model on thrombolysis rates and patient outcome when implemented for a decentral model
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