Bijoy K Menon1, Haolin Xu2, Margueritte Cox2, Jeffrey L Saver3, Mayank Goyal1, Eric Peterson2, Ying Xian2, Roland Matsuoka4, Reza Jehan5, Dileep Yavagal6, Rishi Gupta7, Brijesh Mehta8, Deepak L Bhatt9, Gregg C Fonarow10, Lee H Schwamm11, Eric E Smith1. 1. Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Canada (B.K.M., M.G., E.E.S.). 2. Duke Clinical Research Institute (H.X., M.C., E.P., Y.X.), Duke University, Durham, NC. 3. Department of Neurology (J.L.S.), University of California, Los Angeles. 4. Departments of Biostatistics and Bioinformatics (R.M.), Duke University, Durham, NC. 5. Departments of Neurosurgery and Radiology (R.J.), University of California, Los Angeles. 6. Departments of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.Y.). 7. Wellstar Neuroscience Institute, Georgia Institute of Technology, Marietta (R.G.). 8. Memorial Regional Hospital, Hollywood, FL (B.M.). 9. Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.). 10. Ahmanson-University of California, Los Angeles, Cardiomyopathy Center, Ronald Reagan-University of California, Los Angeles, Medical Center (G.C.F.), University of California, Los Angeles. 11. Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.).
Abstract
BACKGROUND: Endovascular therapy (EVT) is standard of care in patients with acute disabling ischemic stroke attributable to large-vessel occlusion and is more effective when delivered quickly. It is currently unclear whether time targets achieved in clinical trials can be achieved in clinical practice. We describe interval times from patient arrival in the emergency department (door) to first pass (treatment initiation) in patients receiving EVT within Get With The Guidelines-Stroke hospitals and analyze patient- and hospital-level variables associated with these times. METHODS: Data are from sites participating fully as Comprehensive Stroke Centers within Get With The Guidelines-Stroke hospitals from October 2014 to September 2016. Workflow times analyzed include door to imaging, imaging to arterial access, arterial access to first pass, and the composite door to first pass time. Data are described overall and by calendar-year quarters. Multivariable modeling was used to identify patient- and hospital-level variables associated with workflow times. RESULTS: Among 2929 patients with EVT from 195 hospitals (median age, 71 years [interquartile range {IQR}, 60-81]; 50.7% female; median baseline National Institute of Health Stroke Score, 17 [IQR, 12-22]; median annual EVT administration number, 16 [IQR, 10-27]), median door to first pass time was 130 minutes (IQR, 101-170 minutes), door to imaging time was 12 minutes (IQR, 7-20 minutes), imaging to arterial puncture time was 93 minutes (IQR, 68-126 minutes), and arterial puncture to first pass time was 18 minutes (IQR, 4-31 minutes). Overall, 3% patients achieved a door to first pass time ≤60 minutes. A statistically significant linear time trend was noted for door to first pass time (quarter 4 year 2014 median time, 134.5 minutes to quarter 3 year 2016 median time, 128 minutes, P=0.002). In multivariable analysis, older age, arrival during nonregular hours, and history of diabetes mellitus were associated with longer door to first pass time. Hospitals achieving shorter door to intravenous alteplase administration (door to needle) times were more likely to achieve faster door to first pass time ( P<0.001). Each 5 cases/y increase in EVT case volume was associated with a 3% shorter door to first pass time, up to a case volume of 40 per year ( P<0.001). CONCLUSIONS: Although EVT treatment times are modestly improving, additional efforts are needed to streamline workflow so that the true potential of this treatment is realized. These data may inform benchmark goals for EVT workflow times.
BACKGROUND: Endovascular therapy (EVT) is standard of care in patients with acute disabling ischemic stroke attributable to large-vessel occlusion and is more effective when delivered quickly. It is currently unclear whether time targets achieved in clinical trials can be achieved in clinical practice. We describe interval times from patient arrival in the emergency department (door) to first pass (treatment initiation) in patients receiving EVT within Get With The Guidelines-Stroke hospitals and analyze patient- and hospital-level variables associated with these times. METHODS: Data are from sites participating fully as Comprehensive Stroke Centers within Get With The Guidelines-Stroke hospitals from October 2014 to September 2016. Workflow times analyzed include door to imaging, imaging to arterial access, arterial access to first pass, and the composite door to first pass time. Data are described overall and by calendar-year quarters. Multivariable modeling was used to identify patient- and hospital-level variables associated with workflow times. RESULTS: Among 2929 patients with EVT from 195 hospitals (median age, 71 years [interquartile range {IQR}, 60-81]; 50.7% female; median baseline National Institute of Health Stroke Score, 17 [IQR, 12-22]; median annual EVT administration number, 16 [IQR, 10-27]), median door to first pass time was 130 minutes (IQR, 101-170 minutes), door to imaging time was 12 minutes (IQR, 7-20 minutes), imaging to arterial puncture time was 93 minutes (IQR, 68-126 minutes), and arterial puncture to first pass time was 18 minutes (IQR, 4-31 minutes). Overall, 3% patients achieved a door to first pass time ≤60 minutes. A statistically significant linear time trend was noted for door to first pass time (quarter 4 year 2014 median time, 134.5 minutes to quarter 3 year 2016 median time, 128 minutes, P=0.002). In multivariable analysis, older age, arrival during nonregular hours, and history of diabetes mellitus were associated with longer door to first pass time. Hospitals achieving shorter door to intravenous alteplase administration (door to needle) times were more likely to achieve faster door to first pass time ( P<0.001). Each 5 cases/y increase in EVT case volume was associated with a 3% shorter door to first pass time, up to a case volume of 40 per year ( P<0.001). CONCLUSIONS: Although EVT treatment times are modestly improving, additional efforts are needed to streamline workflow so that the true potential of this treatment is realized. These data may inform benchmark goals for EVT workflow times.
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