Good outcomes doubled with primary stroke centre protocol, study shows

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A study published online by JAMA Neurology has found that when a specific primary stroke centre protocol was fully executed in the treatment of patients suspected of having an emergent large vessel occlusion (ELVO) presenting at a primary stroke centre, the rate of good outcomes was doubled and the time from arrival at the primary stroke centre to reperfusion at the comprehensive stroke centre was almost one hour less than that with only a partial execution of the protocol.

Study authors Ryan A McTaggart (Warren Alpert School of Medicine, Brown University, Providence, USA) and colleagues investigated whether a standardised protocol that is based on (1) early notification to the closest comprehensive stroke centre, (2) computed tomographic angiography concurrently with noncontract computed tomography of the brain and within 30 minutes of arrival at the primary stroke centre, and (3) electronic image sharing prior to transfer to the comprehensive stroke centre could improve efficiency and outcomes.

In this retrospective cohort study, 14 regional primary stroke centres unfamiliar with the management of patients with ELVO were instructed on the use of the standardised protocol for patients presenting with a Los Angeles Motor Scale score 4 or higher. A total of 101 patients were transferred from regional primary stroke centres to the comprehensive stroke centre between 1 July, 2015, and 31 May, 2016, and received mechanical thrombectomy for acute ischaemic stroke.

According to the authors, the comprehensive stroke centre serves approximately 1.7 million people and partners with 14 primary stroke centres located between 6.4 and 73.6km away. All consecutive patients with internal carotid artery or middle cerebral artery occlusions transferred over an 11-month period were reviewed, and they were divided into two groups based on whether the primary stroke centre protocol was partially or fully executed.

The primary outcomes were efficiency measures including time from primary stroke centre door-in to primary stroke centre door-out, time from primary stroke centre door to comprehensive stroke centre groin puncture, and 90-day modified Rankin Scale score (range, 0–6; with scores of 0–2 indicating a good outcome).

Ryan A McTaggart

McTaggart et al state that although 101 patients were transferred, only 70 patients met the inclusion criteria during the study period. The standardised protocol was partially executed for 48 patients (68.6%) (mean age 77 years [interquartile range, 65–84 years]; 22 of the 48 patients [45.0%] were women) and fully executed for 22 patients (31.4%) (mean age 76 years [interquartile range, 59–86 years]; 13 of the 22 patients [59.1%] were women).

“When fully executed, the protocol was associated with a reduction in the median time for primary stroke centre arrival to comprehensive stroke centre groin puncture (from 151 minutes [95% CI, 141–166 minutes] to 111 minutes [95% CI, 88–130 minutes]; p<0.001). This was primarily related to an improvement in the time from primary stroke centre door-in to door-out that reduced from a median time of 104 minutes (95% CI, 82–112 minutes) to a median time of 64 minutes (95% CI, 51–71 minutes) (p<0.001). When the protocol was fully executed, patients were twice as likely to have a favourable outcome (50% vs. 25%, p<0.04),” they report.

The study showed that when fully implemented, a standardised protocol at primary stroke centres is associated with a reduction in time to groin puncture and improved outcomes. The authors further noted that the protocol used in this study can be easily replicated between primary stroke centre and comprehensive stroke centre partners and may improve stroke care delivery for patients with ELVO presenting to centres without endovascular capability.

Highlighting the importance of these findings, McTaggart et al write: “while prehospital triage to the closest comprehensive stroke centre may improve the delivery of care for patients with suspected emergent large vessel occlusion, efficient systems of care must also exist for patients with ELVO who first present to a primary stroke centre”.

McTaggart (who can be found tweeting @mobilestroke4U) told NeuroNews that he believes ELVO is “probably the most time-dependent diagnosis in medicine right now.” He added “we must immediately change our system to match this disease using mobile stroke unit technology, changing point-of-entry protocols for stroke to match those of Level I trauma, and the primary stroke centre ELVO protocol described above to be sure that we leave no ELVO behind and that all ELVO patients have timely access to mechanical thrombectomy and the best chance for a favourable outcome.”

In an accompanying editorial also published online by JAMA Neurology, Kori Sauser Zachrison and Lee H Schwamm (Massachusetts General Hospital and Harvard Medical School, Boston, USA) add that “while this study cannot definitively establish whether protocol compliance in and of itself led to improved patient care and outcomes, it does reinforce the importance of ensuring that effective protocols are in place for patients with potential ELVO. Potential confounders such as emergency department crowding and variation in emergency department experience are largely beyond our control. Yet, with the implementation of a protocol that educates the emergency department team, systematises the care process and facilitates rapid patient transfer, benefits accrue.”