Interhospital Transfer of Stroke Patients for Endovascular Treatment
2019; Lippincott Williams & Wilkins; Volume: 139; Issue: 13 Linguagem: Inglês
10.1161/circulationaha.118.039425
ISSN1524-4539
Autores Tópico(s)Traumatic Brain Injury and Neurovascular Disturbances
ResumoHomeCirculationVol. 139, No. 13Interhospital Transfer of Stroke Patients for Endovascular Treatment Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBInterhospital Transfer of Stroke Patients for Endovascular TreatmentAn Increasing Trend but Maybe Not the Best Answer James C. Grotta, MD James C. GrottaJames C. Grotta James C. Grotta, MD, 6410 Fannin Street, Suite 1423, Houston, Texas 77030. Email E-mail Address: [email protected] Memorial Hermann Hospital-Texas Medical Center, Houston. Originally published25 Mar 2019https://doi.org/10.1161/CIRCULATIONAHA.118.039425Circulation. 2019;139:1578–1580This article is a commentary on the followingUse, Temporal Trends, and Outcomes of Endovascular Therapy After Interhospital Transfer in the United StatesArticles, see p 1568The universe of acute stroke management went through a major shift at the beginning of 2015 when five randomized trials virtually simultaneously reported similar results showing that endovascular thrombectomy (EVT) dramatically reduced disability after acute ischemic stroke caused by intracranial large vessel occlusion.1–5 These are the worst strokes that most often do not respond to systemic thrombolytics. The number needed to treat to result in one additional patient with no residual disability was only 4. Endovascular treatment was started within 6 hours of stroke symptom onset, but as with systemic thrombolysis and most reperfusion therapies, outcomes were better with faster achievement of successful reperfusion. Specialty societies and their guidelines almost immediately adopted EVT as standard of care.6 In 2018, additional studies showed that some patients with adequate collaterals as identified on tissue/perfusion computed tomography or magnetic resonance imaging can benefit from EVT up to 24 hours after stroke symptom onset.7,8The dual accomplishment of establishing a powerful new treatment and expanding the time window for its application to more patients has galvanized the stroke community. However, it has also created some problems, the main one being that the interventionalists and hospitals trained and equipped to identify good candidates and carry out EVT are largely limited to tertiary centers in urban areas. This is important, as for example, almost half of the US population does not live within a 60-minute drive of such a tertiary center9 and must be transferred from another center. This issue, ie, getting patients eligible for EVT to the right hospital, is the broad topic addressed by the important study by Shah et al10 published in this issue of Circulation.Using the Get With The Guidelines database, the authors found that since 2012, 43% of patients receiving EVT arrived by transfer from another hospital, with a sharp increase after 2015 when results from the 5 trials demonstrating EVT effectiveness were first presented and published. Furthermore, patients who were transferred-in took over an hour longer to get treated by EVT as calculated from the time the patient was last known normal to EVT initiation. Although transfer-in patients were moved from the emergency department door to EVT faster than those arriving directly, the door-to-EVT initiation times for the 2 groups still exceeded an hour (68 minutes for transfer versus 128 minutes for direct).These data graphically illustrate a major problem with current stroke systems of care. Roughly half of patients who need the most effective stroke treatment available have to be moved from one hospital to another to receive it, resulting in substantial delay, not to mention cost and inconvenience.These findings are consistent with current trends in stroke management. Transfers for "higher level of care" (not just for EVT) have increased dramatically over the past two decades since the development of comprehensive stroke centers and the increasing complexity of optimal management for patients with the most severe strokes. Transfer-in patients now represent the majority of inpatients in the stroke units and neurology intensive care units at most comprehensive stroke centers. Transferring patients from one hospital to another is not a simple or quick process. In other studies, interhospital transport delayed EVT by 95 to 109 minutes.11–14 Every 4-minute faster start of EVT is associated with a lower degree of 90-day disability for 1 of 100 treated patients. Mistriage is associated with an absolute 8% lower freedom from disability and an absolute 9% lower functional independence.Not surprisingly, Shah et al10 found that transfers were associated with worse outcome. This had also been found in other studies.11–14 What is unusual about the findings of Shah et al10 is that worse outcome was seen in transfer-in patients even after controlling for the delay in initiating EVT. The explanation for this finding is not clear. Transfer-in patients more often arrived during off hours compared with direct-admit patients that might have affected their management and outcomes. Although similar in most variables affecting outcome, the transfer-in and direct-admit patients in the Shah et al study10 were not prospectively identified and randomized and so might have differed in some unmeasured respects that could have affected outcome. It is also possible that the transfer process itself may be harmful. For instance, patients with large-vessel occlusion may deteriorate because of hemodynamic or respiratory complications during transfer. The take-home message of these findings is that the current process of relying on interhospital transfer for patients to receive EVT needs to be re-examined.The results of Shah et al10 highlight the following important issues that need to be addressed: (1) Door-to-EVT initiation times range from 1 to 2 hours, which is much slower than for ST-segment–elevation myocardial infarction, which is a comparable clinical emergency. There is much room for improvement in this metric. (2) Most patients still receive tPA (tissue-type plasminogen activator) before EVT. Developing prehospital triage algorithms that maximize identification of appropriate candidates for tPA and EVT and minimize delays to receiving both treatments represents another major focus of improving stroke systems of care. One solution, using mobile stroke units to treat patients with tPA in the field and identify EVT candidates and triage them to the nearest appropriate center, is one solution under evaluation.15 (3) Finally, we need to improve on the current system of transferring patients from one hospital to an EVT center as is the current process described by Shah et al10One solution is having patients with the most severe strokes bypass the closest hospital and non–EVT-capable primary stroke centers and be directly routed to an EVT-capable center. However, this is not the only solution and probably not the best one. In addition to the time delay, another reason is that current stroke scales and other nonimaging methods for detecting large-vessel occlusion patients in the prehospital space are inexact, so that any triage decisions made in the field by Emergency Medical Services or even by vascular neurology specialists are likely to exclude a portion of patients who might benefit from EVT. An alternative solution is to make more primary stroke centers EVT-capable by spreading the distribution of endovascular expertise. Acute stroke treatment is too time-sensitive for the current hierarchical stroke center system. That was the lesson learned from tPA—treatment rates and speed only improved when all stroke centers were required to give it and give it quickly. So instead of moving patients to the EVT center, perhaps we should move the EVT centers to the patient. This might mean having two tiers of EVT centers. Further research is needed to determine the minimum requirements, training, and procedures needed to achieve good EVT outcomes. Also, is it better to try to orchestrate systematic change of an innovation when it is going through rapid growth like EVT, or after its growth plateaus? Finally, will the optimal distribution of such centers be determined by a top-down or market-driven process? Here, the cardiology community has an opportunity to inform the stroke community by its experience disseminating percutaneous coronary intervention and other effective interventions.DisclosuresDr Grotta is a principal investigator for the BEST-MSU Study (Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit Compared to Standard Management), a comparative effectiveness study of prehospital care including tPA treatment using a mobile stroke unit versus standard management by Emergency Medical Services (PCORI R-1511-33024 Patient Centered Outcomes Research Institute). Dr Grotta is also a consultant for Frazer Ltd., which manufactures mobile stroke units.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.https://www.ahajournals.org/journal/circJames C. Grotta, MD, 6410 Fannin Street, Suite 1423, Houston, Texas 77030. Email james.c.[email protected]tmc.eduReferences1. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, van Walderveen MA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach HZ, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YB, van der Lugt A, van Oostenbrugge RJ, Majoie CB, Dippel DW; MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke.N Engl J Med. 2015; 372:11–20. doi: 10.1056/NEJMoa1411587CrossrefMedlineGoogle Scholar2. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, Yan B, Dowling RJ, Parsons MW, Oxley TJ, Wu TY, Brooks M, Simpson MA, Miteff F, Levi CR, Krause M, Harrington TJ, Faulder KC, Steinfort BS, Priglinger M, Ang T, Scroop R, Barber PA, McGuinness B, Wijeratne T, Phan TG, Chong W, Chandra RV, Bladin CF, Badve M, Rice H, de Villiers L, Ma H, Desmond PM, Donnan GA, Davis SM; EXTEND-IA Investigators. Endovascular therapy for ischemic stroke with perfusion-imaging selection.N Engl J Med. 2015; 372:1009–1018. doi: 10.1056/NEJMoa1414792CrossrefMedlineGoogle Scholar3. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn SI, Swartz RH, Barber PA, Coutts SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD; ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke.N Engl J Med. 2015; 372:1019–1030. doi: 10.1056/NEJMoa1414905CrossrefMedlineGoogle Scholar4. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, San Román L, Serena J, Abilleira S, Ribó M, Millán M, Urra X, Cardona P, López-Cancio E, Tomasello A, Castaño C, Blasco J, Aja L, Dorado L, Quesada H, Rubiera M, Hernandez-Pérez M, Goyal M, Demchuk AM, von Kummer R, Gallofré M, Dávalos A; REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke.N Engl J Med. 2015; 372:2296–2306. doi: 10.1056/NEJMoa1503780CrossrefMedlineGoogle Scholar5. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, Albers GW, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, Baxter BW, Devlin TG, Lopes DK, Reddy VK, du Mesnil de Rochemont R, Singer OC, Jahan R; SWIFT PRIME Investigators. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke.N Engl J Med. 2015; 372:2285–2295. doi: 10.1056/NEJMoa1415061CrossrefMedlineGoogle Scholar6. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL; American Heart Association Stroke Council. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke. 2018; 49:e46–e110. doi: 10.1161/STR.0000000000000158LinkGoogle Scholar7. Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, McTaggart RA, Torbey MT, Kim-Tenser M, Leslie-Mazwi T, Sarraj A, Kasner SE, Ansari SA, Yeatts SD, Hamilton S, Mlynash M, Heit JJ, Zaharchuk G, Kim S, Carrozzella J, Palesch YY, Demchuk AM, Bammer R, Lavori PW, Broderick JP, Lansberg MG; DEFUSE 3 Investigators. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging.N Engl J Med. 2018; 378:708–718. doi: 10.1056/NEJMoa1713973CrossrefMedlineGoogle Scholar8. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, Yavagal DR, Ribo M, Cognard C, Hanel RA, Sila CA, Hassan AE, Millan M, Levy EI, Mitchell P, Chen M, English JD, Shah QA, Silver FL, Pereira VM, Mehta BP, Baxter BW, Abraham MG, Cardona P, Veznedaroglu E, Hellinger FR, Feng L, Kirmani JF, Lopes DK, Jankowitz BT, Frankel MR, Costalat V, Vora NA, Yoo AJ, Malik AM, Furlan AJ, Rubiera M, Aghaebrahim A, Olivot JM, Tekle WG, Shields R, Graves T, Lewis RJ, Smith WS, Liebeskind DS, Saver JL, Jovin TG; DAWN Trial Investigators. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct.N Engl J Med. 2018; 378:11–21. doi: 10.1056/NEJMoa1706442CrossrefMedlineGoogle Scholar9. Adeoye O, Albright KC, Carr BG, Wolff C, Mullen MT, Abruzzo T, Ringer A, Khatri P, Branas C, Kleindorfer D. Geographic access to acute stroke care in the United States.Stroke. 2014; 45:3019–3024. doi: 10.1161/STROKEAHA.114.006293LinkGoogle Scholar10. Shah S, Xian Y, Sheng S, Zachrison KS, Saver JL, Sheth KN, Fonarow GC, Schwamm LH, Smith EE. Use, temporal trends, and outcomes of endovascular therapy after interhospital transfer in the United States.Circulation. 2019; 139:1568–1580. doi: CIRCULATIONAHA/2018/036509LinkGoogle Scholar11. Goyal M, Jadhav AP, Bonafe A, Diener H, Mendes Pereira V, Levy E, Baxter B, Jovin T, Jahan R, Menon BK, Saver JL; SWIFT PRIME investigators. Analysis of workflow and time to treatment and the effects on outcome in endovascular treatment of acute ischemic stroke: results from the SWIFT PRIME randomized controlled trial.Radiology. 2016; 279:888–897. doi: 10.1148/radiol.2016160204CrossrefMedlineGoogle Scholar12. Froehler MT, Saver JL, Zaidat OO, Jahan R, Aziz-Sultan MA, Klucznik RP, Haussen DC, Hellinger FR, Yavagal DR, Yao TL, Liebeskind DS, Jadhav AP, Gupta R, Hassan AE, Martin CO, Bozorgchami H, Kaushal R, Nogueira RG, Gandhi RH, Peterson EC, Dashti SR, Given CA, Mehta BP, Deshmukh V, Starkman S, Linfante I, McPherson SH, Kvamme P, Grobelny TJ, Hussain MS, Thacker I, Vora N, Chen PR, Monteith SJ, Ecker RD, Schirmer CM, Sauvageau E, Abou-Chebl A, Derdeyn CP, Maidan L, Badruddin A, Siddiqui AH, Dumont TM, Alhajeri A, Taqi MA, Asi K, Carpenter J, Boulos A, Jindal G, Puri AS, Chitale R, Deshaies EM, Robinson DH, Kallmes DF, Baxter BW, Jumaa MA, Sunenshine P, Majjhoo A, English JD, Suzuki S, Fessler RD, Delgado Almandoz JE, Martin JC, Mueller-Kronast NH; STRATIS Investigators. Interhospital transfer before thrombectomy is associated with delayed treatment and worse outcome in the STRATIS Registry (Systematic Evaluation of Patients Treated with Neurothrombectomy Devices for Acute Ischemic Stroke).Circulation. 2017; 136:2311–2321. doi: 10.1161/CIRCULATIONAHA.117.028920LinkGoogle Scholar13. Saver JL, Goyal M, van der Lugt A, Menon BK, Majoie CB, Dippel DW, Campbell BC, Nogueira RG, Demchuk AM, Tomasello A, Cardona P, Devlin TG, Frei DF, du Mesnil de Rochemont R, Berkhemer OA, Jovin TG, Siddiqui AH, van Zwam WH, Davis SM, Castaño C, Sapkota BL, Fransen PS, Molina C, van Oostenbrugge RJ, Chamorro Á, Lingsma H, Silver FL, Donnan GA, Shuaib A, Brown S, Stouch B, Mitchell PJ, Davalos A, Roos YB, Hill MD; HERMES Collaborators. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis.JAMA. 2016; 316:1279–1288. doi: 10.1001/jama.2016.13647CrossrefMedlineGoogle Scholar14. Rinaldo L, Brinjikji W, McCutcheon BA, Bydon M, Cloft H, Kallmes DF and Rabinstein AA. Hospital transfer associated with increased mortality after endovascular revascularization for acute ischemic stroke.J Neurointerv Surg. 2017; 9:1166–1172.CrossrefMedlineGoogle Scholar15. Yamal JM, Rajan SS, Parker SA, Jacob AP, Gonzalez MO, Gonzales NR, Bowry R, Barreto AD, Wu TC, Lairson DR, Persse D, Tilley BC, Chiu D, Suarez JI, Jones WJ, Alexandrov A, Grotta JC. Benefits of stroke treatment delivered using a mobile stroke unit trial.Int J Stroke. 2018; 13:321–327. doi: 10.1177/1747493017711950CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Raza S and Rangaraju S (2021) Prognostic Scores for Large Vessel Occlusion Strokes, Neurology, 10.1212/WNL.0000000000012797, 97:20 Supplement 2, (S79-S90), Online publication date: 16-Nov-2021. Panesar S, Volpi J, Lumsden A, Desai V, Kleiman N, Sample T, Elkins E and Britz G Telerobotic stroke intervention: a novel solution to the care dissemination dilemma, Journal of Neurosurgery, 10.3171/2019.8.JNS191739, 132:3, (971-978) Reddy S, Friedman E, Wu T, Arevalo O, Zhang J, Rahbar M, Ankrom C, Indupuru H and Savitz S (2020) Rapid Infarct Progression in Anterior Circulation Large Vessel Occlusion Ischemic Stroke Patients During Inter-Facility Transfer, Journal of Stroke and Cerebrovascular Diseases, 10.1016/j.jstrokecerebrovasdis.2020.105308, 29:12, (105308), Online publication date: 1-Dec-2020. Kapral M, Hall R, Gozdyra P, Yu A, Jin A, Martin C, Silver F, Swartz R, Manuel D, Fang J, Porter J, Koifman J and Austin P (2020) Geographic Access to Stroke Care Services in Rural Communities in Ontario, Canada, Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques, 10.1017/cjn.2020.9, 47:3, (301-308), Online publication date: 1-May-2020. Pallesen L, Winzer S, Barlinn K, Prakapenia A, Siepmann T, Gruener C, Gerber J, Haedrich K, Linn J, Barlinn J and Puetz V (2020) Safety of inter-hospital transfer of patients with acute ischemic stroke for evaluation of endovascular thrombectomy, Scientific Reports, 10.1038/s41598-020-62528-4, 10:1, Online publication date: 1-Dec-2020. Pallesen L, Winzer S, Hartmann C, Kuhn M, Gerber J, Theilen H, Hädrich K, Siepmann T, Barlinn K, Rahmig J, Linn J, Barlinn J and Puetz V (2022) Team Prenotification Reduces Procedure Times for Patients With Acute Ischemic Stroke Due to Large Vessel Occlusion Who Are Transferred for Endovascular Therapy, Frontiers in Neurology, 10.3389/fneur.2021.787161, 12 Reddy S, Savitz S, Friedman E, Arevalo O, Zhang J, Ankrom C, Trevino A and Wu T (2020) Patients transferred within a telestroke network for large-vessel occlusion, Journal of Telemedicine and Telecare, 10.1177/1357633X20957894, (1357633X2095789) Related articlesUse, Temporal Trends, and Outcomes of Endovascular Therapy After Interhospital Transfer in the United StatesShreyansh Shah, et al. Circulation. 2019;139:1568-1577 March 26, 2019Vol 139, Issue 13 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.118.039425PMID: 30908102 Originally publishedMarch 25, 2019 KeywordsstrokethrombectomytriageEditorialsemergency medical servicesinterfacility transferPDF download Advertisement SubjectsCerebrovascular Disease/StrokeHealth ServicesIschemic Stroke
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