Stroke systems of care and care pathways have evolved and improved dramatically in the past decade with new innovations including mobile stroke units, improvements in neurocritical care, stroke center certifications, and endovascular therapy, according to the American Stroke Association’s Policy Statement, Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update.1 But there are still many opportunities for hospitals to streamline and improve their stroke care pathways for more rapid assessment and treatment of patients, which has been shown to improve outcomes.
Audit of Stroke Care Pathway Presented at SLICE
Dr. Benjamin Gory, MD, PhD, a neuroradiologist at the University Hospital of Nancy in Nancy, France, presented a symposium at the 2019 Stroke Live Course SLICE multidisciplinary stroke team meeting held at Palais De La Méditerranée in Nice, France.2 Dr. Gory shared the work his team at Nancy Hospital did to reduce time delays along their stroke care pathway to improve the time from admission to reperfusion in stroke patients.
European guidelines recommend a median time from admission at the hospital to reperfusion following thrombectomy of 90 minutes. At the start of Gory’s assessment, Nancy’s median time from admission to reperfusion was 2.5 to 3 hours. “This is not good compared to the guidelines, so we wanted to improve the time,” said Gory.
Developing and Implementing an Action Plan for Improvement
Their first step was to evaluate what was causing the delay in treatment time. “If you don’t evaluate, you don’t know what to do,” said Gory. “Once we know what is causing the delay, we can work to improve it.” To accomplish this, they conducted a two-month audit of the stroke care pathway as it was configured at the time—a “before” snapshot. The team broke the care pathway down into its component steps, measuring each with timestamps at beginning and end: admission, imaging (usually MRI at their hospital), thrombolysis, and thrombectomy. Three working groups met repeatedly to discuss how best to standardize the procedures and what might be done to improve the delay in each step.
For example, Dr. Gory recommended that thrombolysis should be performed in the stroke unit, but most of the time, the stroke unit is located far from the MRI room. Transporting the patient means lost time, and the recommendation that thrombolysis be performed within an hour after admission is very difficult to achieve. “If we admit directly to the imaging department, it’s not necessary to move the patient, and you win some time,” said Gory.
The teams found that delays occurred throughout all the steps of the process due to the time it took to transfer the patients. So improving the efficiency of patient transfer was a focus. “There were a lot of small things—a small thing and an additional small thing add up to a lot of time,” said Gory. They found other challenges as well, such as during odd hours, late at night or other times when there were a smaller number of staff available. Fewer staff at the hospital led to longer treatment delays.
After the team implemented the action plan of solutions they developed, they re-evaluated the time delays in individual steps along the way twice, at three-month intervals, and achieved significant reductions—decreasing the median time to reperfusion by 30 percent overall. Still, they were unable to fully meet the recommendations even with these significant improvements.
Testing a New Approach: DIRECT-TO-ANGIO
Following this stroke care pathway improvement process, Gory realized that there is still a need to further reduce time to treatment, particularly for patients with large vessel occlusion who will need thrombectomy. Why not, he wondered, admit them straight to the angio room for thrombectomy and not waste time in the stroke unit?
Thus was born the DIRECT-TO-ANGIO Approach, in which the patient is admitted directly to the angio suite for thrombectomy. Gory is involved in a multicenter trial that is being launched to see what kinds of improvements can be realized in time to thrombectomy with this approach. “The rationale of this trial is to improve the clinical outcome of the patients. We can skip diagnostic imaging and avoid two transfers, and we can win 30 to 60 minutes,” said Gory.
With the new flat planel CT imaging present in the angio suite, physicians can use both non-constrast 3D and 3D IV protocols imaging to visualize the vessels and parenchyma within the angio suite itself, ruling out intracranial hemorrhage and identifying large vessel occlusions. This allows them to evaluate the patient and perform thrombectomy within one hour and without any transfers.
While this new approach is appealing, it is not without difficulty in implementation. “The challenge of the DIRECT-TO-ANGIO approach is the hospital triage,” said Gory. “It’s not possible to know for certain which patients present with large vessel occlusion. We can propose, but it’s not present in all cases….Most of the difficulty is to put the good patient in the right place.”
To determine which patients are likely to have large vessel occlusion, the physician in the SAMU (Urgent Medical Aid Service) liases with the fire crew who transported the patient and they make the assessment together. The hospital also uses certain criteria to determine who is likely to have large vessel occlusion (LVO)—those under age 60 without hypertension. If LVO is confirmed by imaging, thrombectomy is performed immediately without thrombolysis, but if no LVO is detected, the patient goes back to the normal management pathway with MRI.
DIRECT-TO-ANGIO Clinical Trial Underway Soon
The DIRECT-TO-ANGIO study is enrolling very soon and includes ten centers in France.3 It will compare two strategies for patients less than 60 years of age with suspected LVO—the usual approach with admission to the diagnostic imaging department first and transport to thrombectomy, compared with direct admission to the angio suite. The primary endpoint will be evaluated at 90 days. Dr. Gory is hopeful that they will see a significant improvement showing the superiority of the DIRECT-TO-ANGIO approach.
1. Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update. American Stroke Association. https://www.ahajournals.org/doi/10.1161/STR.0000000000000173 Last Accessed October 30, 2019.
2. Stroke Live Course SLICE: The Multidisciplinary Stroke Team Meeting. https://www.slice-online.com Last Accessed October 30, 2019.
3. Effect of DIRECT Transfer to ANGIOsuite on Functional Outcome in Severe Acute Stroke (DIRECTANGIO). U.S. National Library of Medicine. https://clinicaltrials.gov/ct2/show/NCT03969511 Last Accessed October 30, 2019.