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A System-Based Intervention to Improve Access to Hyperacute Stroke Care

  • Richard H. Swartz (a1) (a2), Elizabeth Linkewich (a1), Shelley Sharp (a3), Jacqueline Willems (a4), Chris Olynyk (a5), Nicola Tahair (a3), Megan L. Cayley (a2) and Mark T. Bayley (a6)...

Abstract

Background: Hyperacute stroke is a time-sensitive emergency for which outcomes improve with faster treatment. When stroke systems are accessed via emergency medical services (EMS), patients are routed to hyperacute stroke centres and are treated faster. But over a third of patients with strokes do not come to the hospital by EMS, and may inadvertently arrive at centres that do not provide acute stroke services. We developed and studied the impact of protocols to quickly identify and move “walk-in” patients from non-hyperacute hospitals to regional stroke centres (RSCs). Methods and Results: Protocols were developed by a multi-disciplinary and multi-institutional working group and implemented across 14 acute hospital sites within the Greater Toronto Area in December of 2012. Key metrics were recorded 18 months pre- and post-implementation. The teams regularly reviewed incident reports of protocol non-adherence and patient flow data. Transports increased by 80% from 103 to 185. The number of patients receiving tissue plasminogen activator (tPA) increased by 68% from 34 to 57. Total EMS transport time decreased 17 minutes (mean time of 54.46 to 37.86 minutes, p<0.0001). Calls responded to within 9 minutes increased from 34 to 59%. Conclusions: A systems-based approach that included a multi-organizational collaboration and consensus-based protocols to move patients from non-hyperacute hospitals to RSCs resulted in more patients receiving hyperacute stroke interventions and improvements in EMS response and transport times. As hyperacute stroke care becomes more centralized and endovascular therapy becomes more broadly implemented, the protocols developed here can be employed by other regions organizing patient flow across systems of stroke care.

Une intervention systémique pour améliorer l’accès aux soins pour les patients atteints d’un accident vasculaire cérébral suraigu. Contexte : L’accident vasculaire cérébral (AVC) suraigu nécessite un traitement d’urgence dont les résultats sont d’autant meilleurs que le traitement est administré plus rapidement. Le facteur temps est donc critique. Quand l’accès aux systèmes de prévention de l’AVC se fait par les services médicaux d’urgence (SMU), les patients sont dirigés vers des centres de traitement de l’AVC suraigu et sont traités plus rapidement. Cependant, plus du tiers des patients atteints d’un AVC ne sont pas conduits à l’hôpital par les SMU et peuvent être dirigés par inadvertance vers des centres qui ne fournissent pas de tels soins. Nous avons élaboré et étudié l’impact de protocoles pour identifier et transporter rapidement les patients qui se présentent à un centre où des soins suraigus ne sont pas offerts vers un centre régional de traitement de l’AVC. Méthodologie et résultats : Un groupe de travail multidisciplinaire et multi-institutionnel a élaboré des protocoles qui ont été déployés dans 14 hôpitaux de soins aigus dans la grande région de Toronto en décembre 2012. Les indicateurs clés ont été comptabilisés 18 mois avant et 18 mois après leur mise en œuvre. Les équipes ont revu régulièrement les rapports d’incidents de non-observance du protocole et les données de cheminement des patients. Les transports ont augmenté de 80%, soit de 103 à 185. Le nombre de patients qui ont reçu de l’activateur du plasminogène tissulaire (APt) a augmenté de 68%, soit de 34 à 57 patients. Le temps de transport par SMU a diminué de 17 minutes (le temps moyen de 54,46 est passé à 37,86 minutes, p < 0,0001). Les réponses en dedans de 9 minutes ou moins ont augmenté de 34 à 59%. Conclusions : Une approche systémique, qui incluait une collaboration multi-organisationnelle et des protocoles fondés sur un consensus de transport des patients d’un hôpital où les soins de l’AVC suraigu ne sont pas disponibles vers un centre régional de traitement de l’AVC, s’est traduite par une augmentation du nombre des patients qui reçoivent des interventions pour un AVC suraigu et par des améliorations de la réponse des SMU et des temps de transport. Comme les soins de l’AVC suraigu deviennent plus centralisés et le traitement endovasculaire est plus largement utilisé, les protocoles élaborés ici peuvent être appliqués dans d’autres régions pour organiser le transport des patients vers les centres de soins de l’AVC.

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Copyright

Corresponding author

Correspondence to: Richard H. Swartz, Department of Medicine (Neurology), Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Suite A442, Toronto, Ontario M4N 3M5, Canada. Email: rick.swartz@sunnybrook.ca.

References

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A System-Based Intervention to Improve Access to Hyperacute Stroke Care

  • Richard H. Swartz (a1) (a2), Elizabeth Linkewich (a1), Shelley Sharp (a3), Jacqueline Willems (a4), Chris Olynyk (a5), Nicola Tahair (a3), Megan L. Cayley (a2) and Mark T. Bayley (a6)...

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