Countywide acute stroke system delivers ‘substantial’ thrombolysis rate
MedWire News: Implementation of a spoke-and-hub system for treating patients with acute stroke in Orange County, California, has been successful, delivering "substantial" rates of acute reperfusion therapy, say researchers.
Around one in five patients who proved to have ischemic stroke underwent intravenous thrombolysis, report Steven Cramer (University of California Irvine Medical Center, USA) and colleagues in Stroke.
Fourteen community hospitals formed the spokes of the system and nine specialized stroke neurology receiving centers (SNRCs) formed the hubs. The SNRCs adopted as many of the Brain Attack Coalition's comprehensive stroke center features as was feasible.
Between April 2009 and 2010, the emergency medical services delivered 1360 patients with suspected stroke to the hub centers. Of these, 40.7% were diagnosed with ischemic stroke, 15.4% with hemorrhagic stroke, 10.4% with transient ischemic attack, and 32.6% with other conditions.
The emergency medical services bypassed spoke hospitals to take 18.1% of patients directly to a SNRC hub. Just 2.1% of patients went first to a spoke hospital before being routed to a SNRC hub.
The average door-to-needle time for thrombolysis at the SNRCs was 86.4 min, with 25% of patients exceeding the recommended time of less than 60.0 min.
The researchers say that discussions with SNRC staff revealed three factors that contributed to treatment delays: lack of knowledge about the treatment target; delays in obtaining laboratory test results; and the timing of additional imaging, when needed.
The average door-to-needle time was significantly longer in the six SNRCs that were equipped to provide neurointerventional therapies, at 100 min compared with 73 min in the other three SNRCs.
"This might reflect a preference for a more detailed diagnostic evaluation before therapeutic evaluation in such a setting, a possibility that requires further study," suggest Cramer et al.
The neurointervention-ready SNRCs provided acute reperfusion therapies for 25.1% of their patients, with 14.4% receiving intravenous therapy alone, 8.1% receiving intra-arterial therapy only, and 2.5% undergoing both treatments.
The distribution of stroke arrivals at all SNRCs varied across the day, the researchers report. They say that although there was a clear dip in the number of arrivals overnight, 13% of patients arrived between the hours of 22:00 and 06:00 "emphasizing the importance of around-the-clock coverage."
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By Eleanor McDermid