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Workflow and Time to Treat Thrombectomy in ESCAPE Trial
Study Questions:
What is the impact of time on clinical outcomes and the effect of patient, hospital, and health system characteristics on workflow within the ESCAPE trial of endovascular treatment in patients with acute ischemic stroke?
Methods:
The ESCAPE trial was a multicenter randomized controlled trial assessing the additional benefit of modern endovascular treatment as compared to guideline-based standard of care for patients with acute ischemic stroke in 316 patients across 22 sites. The relationship between the modified Rankin Scale (mRS) and interval times (stroke onset to hospital arrival, to qualifying computed tomography [CT], to groin puncture, and to reperfusion) were modeled using logistic regression. A functionally independent outcome was defined as a 90-day mRS of 0-2.
Results:
For each 30-minute increase in CT-to-reperfusion time, the probability of achieving a functionally independent outcome was reduced by 8.3% (p = 0.006). Symptom onset-to-imaging time was not associated with a functionally independent outcome. Symptom onset-to-endovascular-capable hospital arrival time was 42% longer (34 minutes) in patients who received intravenous alteplase at a referring hospital before transfer to an endovascular-capable hospital as compared to arrival directly at an endovascular-capable hospital. CT-to-groin puncture time was 15% shorter (8 minutes) when patients presented during work hours as compared to nonwork hours. Balloon-guided catheter use shortened the puncture-to-reperfusion time by 21% (8 minutes).
Conclusions:
The authors concluded that the imaging-to-reperfusion time interval was a significant predictor of a functionally independent outcome in the care of patients with acute ischemic stroke who were treated with endovascular techniques. The authors also concluded that inefficiencies in triage, off-hours presentation, use of intravenous alteplase, and various endovascular techniques offer opportunities for time-interval improvement.
Perspective:
This study brings lessons learned from the use of primary percutaneous coronary intervention to the treatment of acute ischemic stroke patients with endovascular techniques. By observing the time intervals between each critical care step for patients undergoing emergent endovascular treatment of an acute ischemic stroke, the authors have highlighted areas for potential workflow improvement that may impact clinically important outcomes. As has been done with ST-elevation myocardial infarction care, coordinated care of acute ischemic stroke must be continually improved both within a single health care system and throughout larger regions that rely on transferring patients to endovascular-capable hospitals for advanced stroke care.
Keywords: Critical Care, Endovascular Procedures, Percutaneous Coronary Intervention, Secondary Prevention, Standard of Care, Stroke, Thrombectomy, Time-to-Treatment, Tissue Plasminogen Activator, Tomography, Tomography, X-Ray Computed, Triage, Workflow
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