Background and purpose Intra-arterial therapy (IAT) is most effective when performed rapidly after ischemic stroke onset. However, there are limited performance benchmarks in IAT and there is a scarcity of information on how to structure an effective IAT protocol and its impact on time to treatment. The objective of our study was to detail a standardized IAT protocol, and to assess its influence on time to treatment in ischemic stroke.
Methods This was a retrospective observational study over 4 years at a comprehensive stroke center. A standardized IAT protocol was implemented in June 2013 that included pre-notifying the stroke team before hospital arrival, defining clinician roles, processing tasks in parallel, and standardizing IAT procedures. Three time metrics were examined and reported as median (IQR) minutes: arrival to CT imaging, CT to groin puncture, and puncture to recanalization. We compared these metrics in patients admitted before implementation (January 2012–May 2013) to patients admitted after (June 2013–December 2015) using Wilcoxon Mann–Whitney tests.
Results 380 patients were included. After the protocol was implemented, there were significant reductions in time from arrival to CT (17 (14–21) vs 13 (11–19) min, p<0.001), CT to puncture (46 (30–82) vs 31 (23–54) min, p<0.001), and puncture to recanalization (65 (33–90) vs 37 (22–65) min, p<0.001). 60% of time was saved during puncture to recanalization. Significant reductions in time were observed during both normal working hours and off-hours.
Conclusions Implementation of a standardized protocol resulted in a significant reduction in time to recanalization for patients with an ischemic stroke. A standardized IAT protocol decreases time to recanalization when team roles are clearly defined, tasks are processed in parallel, and procedures are standardized.
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Contributors All authors gave final approval of the published version and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Specifically, DF contributed to conception and acquisition of the data and critical revision. CM contributed to data acquisition, conception, and design, analysis and interpretation of the data, and drafting the manuscript. KM contributed to acquisition of the data and critical revision. MW contributed to acquisition of the data and critical revision. RJB contributed to critical revision. DL contributed to critical revision. JW contributed to critical revision. AO contributed to acquisition and interpretation of the data, drafting the manuscript, and critical revision. DB-O contributed to interpretation of the data and critical revision.
Competing interests DF is a consultant for Penumbra, Covidien, Microvention, Siemens, and Stryker. JW is a speaker for Genentech. MW was on the Activase Speakers Bureau in 2015; was a consultant for Clinical Data Management in 2015; and was a consultant for Lombardi Hill 2015-current. RJB was a speaker for Penumbra.
Ethics approval The study was approved by the local institutional review board.
Provenance and peer review Not commissioned; internally peer reviewed.
Data sharing statement Anonymized data and statistical code are available from the corresponding author.
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