A team at Mount Sinai Hospital in New York, USA, has shown that their trip-and-treat model is associated with shorter treatment times for endovascular therapy for stroke patients than the more widely-used drip-and-ship model.
As efforts are being made the refine the stroke workflow so that eligible patients are treated quickly, stroke teams are assessing the various options for getting the patient to an endovascular capable centre. The idea of the drip-and-ship model is to admit the patient first to the closest stroke centre, start them on IV t-PA and then transfer (or “ship”) them to an endovascular capable centre for treatment. Another concept is to “bypass” the primary stroke centre (IV t-PA only capable centre) and transfer the patient directly to the comprehensive stroke centre for immediate endovascular therapy.
What the team at Mount Sinai is doing with the trip-and-treat model is having a physician capable of performing endovascular procedures travel (or “trip”) to the patient at the admitting hospital rather than transferring the patient themselves to Mount Sinai for treatment.
“Trip-and-treat is an inter-hospital service delivery model that has not previously been evaluated in the literature and consists of a shared mobile interventional stroke team that travels to primary stroke centres to provide on-site interventional capability,” the investigators write in Stroke. To evaluate the feasibility of their model, the Mount Sinai team compared treatment times between the trip-and-treat model and the traditional drip-and-ship model.
Daniel Wei (Icahn School of Medicine at Mount Sinai, New York, USA) and colleagues performed a retrospective analysis on 86 consecutive eligible patients with acute ischaemic stroke secondary to large vessel occlusion who received endovascular treatment at four hospitals in Manhattan. Patients were divided into two cohorts: trip-and-treat (n=39) and drip-and-ship (n=47). The primary outcome was initial door-to-puncture time, defined as the time between arrival at any hospital and arterial puncture. Investigators also recorded and analysed the times of last known well, IV t-PA (intravenous tissue-type plasminogen activator) administration, transfer, and reperfusion.
“Mean initial door-to-puncture time was 143 minutes for trip-and-treat and 222 minutes for drip-and-ship (p<0.0001). Although there was a trend in longer puncture-to-recanalisation times for trip-and-treat (p=0.0887), initial door-to-recanalisation was nonetheless 79 minutes faster for trip-and-treat (p<0.0001). There was a trend in improved admission-to-discharge change in National Institutes of Health Stroke Scale (NIHSS) for trip-and-treat compared with drip-and-ship (p=0.0704),” the investigators report.
Wei et al conclude that compared with drip-and-ship, the trip-and-treat model demonstrated shorter treatment times for endovascular therapy in their experience. This research indicated that the trip-and-treat model offers a valid alternative to current inter-hospital stroke transfers in urban environments.