RESUMEN
Background: Time to reperfusion is an important predictor of outcome in ischaemic stroke from large vessel occlusion (LVO). For patients requiring endovascular thrombectomy (EVT), the transfer times from peripheral hospitals in metropolitan and regional Victoria, Australia to comprehensive stroke centres (CSCs) have not been studied. Aims: To determine transfer and journey times for patients with LVO stroke being transferred for consideration of EVT. Methods: All patients transferred for consideration of EVT to three Victorian CSCs from January 2017 to December 2018 were included. Travel times were obtained from records matched to Ambulance Victoria and the referring centre via Victorian Stroke Telemedicine or hospital medical records. Metrics of interest included door-in-door-out time (DIDO), inbound journey time and outbound journey time. Results: Data for 455 transferred patients were obtained, of which 395 (86.8%) underwent EVT. The median DIDO was 107 min (IQR 84-145) for metropolitan sites and 132 min (IQR 108-167) for regional sites. At metropolitan referring hospitals, faster DIDO was associated with use of the same ambulance crew to transport between hospitals (75 (63-90) vs 124 (99-156) min, p<0.001) and the administration of thrombolysis prior to transfer (101 (79-133) vs 115 (91-155) min, p<0.001). At regional centres, DIDO was consistently longer when patients were transported by air (160 (127-195) vs 116 (100-144) min, p<0.001). The overall door-to-door time by air was shorter than by road for sites located more than 250 km away from the CSC. Conclusion: Transfer times differ significantly for regional and metropolitan patients. A state-wide database to prospectively collect data on all interhospital transfers for EVT would be helpful for future study of optimal transport mode at regional sites and benchmarking of DIDO across the state.
RESUMEN
OBJECTIVE: 'Code Stroke' (Code) is used in health services to streamline hyperacute assessment and treatment delivery for patients with ischaemic stroke. However, there are few studies that detail the time spent on individual components performed during a Code. We sought to quantify the time taken for each process during a Code and investigate associations with modifiable and non-modifiable factors. DESIGN: Continuous observation workflow time study. SETTING AND PARTICIPANTS: Recordings of 100 Codes were performed at a high-volume primary stroke centre in Melbourne, Australia, between January and June 2020 using a body camera worn by a member of the stroke team. MAIN OUTCOME MEASURES: The main measures included the overall duration of Codes and the individual processes within the Code workflow. Associations between variables of interest and process times were explored using linear regression models. RESULTS: 100 Codes were captured, representing 19.2% of all Codes over the 6 months. The median duration of a complete Code was 54.2 min (IQR 39.1-74.7). Administrative work performed after treatment is completed (median 21.0 min (IQR 9.8-31.4)); multimodal CT imaging (median 13.0 min (IQR 11.5-15.7)), and time between decision and thrombolysis administration (median 8.1 min (IQR 6.1-10.8)) were the longest components of a Code. Tenecteplase was able to be prepared faster than alteplase (median 1.8 vs 4.9 min, p=0.02). The presence of a second junior doctor was associated with shorter administrative work time (median 10.3 vs 25.1 min, p<0.01). No specific modifiable factors were found to be associated with shorter overall Code duration. CONCLUSIONS: Codes are time intensive. Time spent on decision-making was a relatively small component of the overall Code duration. Data from body cameras can provide granular data on all aspects of Code workflow to inform potential areas for improvement at individual centres.