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Original research
Workflow and factors associated with delay in the delivery of intra-arterial treatment for acute ischemic stroke in the MR CLEAN trial
  1. Esmee Venema1,2,
  2. Nikki Boodt2,
  3. Olvert A Berkhemer3,4,5,
  4. Pleunie P M Rood6,
  5. Wim H van Zwam4,
  6. Robert J van Oostenbrugge7,
  7. Aad van der Lugt3,
  8. Yvo B W E M Roos8,
  9. Charles B L M Majoie5,
  10. Hester F Lingsma1,
  11. Diederik W J Dippel2
  12. on behalf of the MR CLEAN investigators
  1. 1Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
  2. 2Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
  3. 3Department of Radiology, Erasmus University Medical Center, Rotterdam, The Netherlands
  4. 4Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
  5. 5Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
  6. 6Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
  7. 7Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
  8. 8Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
  1. Correspondence to Esmee Venema, Department of Public Health and Department of Neurology, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands; e.venema{at}erasmusmc.nl

Abstract

Objective The effect of intra-arterial treatment (IAT) for acute ischemic stroke is highly time-dependent. We investigated the delay of IAT and factors associated with such delay.

Methods MR CLEAN was a randomized trial of IAT plus usual care versus usual care alone (n=500). With multivariable linear regression, we analyzed the effect of intravenous treatment, general anesthesia, off-hours and inter-hospital transfer on time to admission to the emergency department (ED) of the intervention center and time to treatment. Furthermore, we assessed compliance with a target of 75 min for time from ED to treatment, and calculated the potential absolute increase in the number of patients with a good outcome (modified Rankin Scale score ≤2) if this target had been achieved in all treated patients.

Results Inter-hospital transfer prolonged time to ED by 140 min (95% CI 129 to 150) but reduced time from ED to treatment by 77 min (95% CI 64 to 91). Time from ED to treatment was increased by 19 min by general anesthesia (95% CI 5 to 33) and total time was increased by 23 min during off-hours (95% CI 6 to 40). The in-hospital target was achieved in 11.5% (22/192) of patients. Full compliance with the target time of 75 min from ED to treatment would have increased the proportion of patients with a good outcome by 7.6% (95% CI 6.7% to 8.5%).

Conclusion Inter-hospital transfer is an important cause of delay in the delivery of IAT and every effort should be made to avoid transfers and reduce transfer-related delay. Furthermore, in-hospital workflow should be optimized to improve functional outcome after IAT.

  • stroke
  • thrombectomy

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Footnotes

  • Contributors WHZ, RJvO, AvdL, YBWEMR, CBLMM and DWJD conceived the study, designed the trial, and obtained research funding. OAB supervised the conduct of the trial and data collection. EV and NB analyzed the data and drafted the manuscript (authors contributed equally). HFL provided statistical advice. All authors contributed substantially to its revision. DWJD takes responsibility for the paper as a whole.

  • Funding The Multicenter Randomized Clinical Trial of Endovascular Therapy for Acute Ischemic Stroke in the Netherlands (MR CLEAN) was partly funded by the Dutch Heart Foundation and by unrestricted grants from AngioCare BV, Medtronic/Covidien/EV3, MEDAC Gmbh/LAMEPRO, Penumbra, Stryker, and Top Medical/Concentric.

  • Competing interests Academic Medical Center received funds from Stryker for consultations by YBWEMR and CBLMM. Erasmus University Medical Center received funds from Stryker for consultations by DWJD and AvdL, and from Bracco Imaging for consultations by DWJD. Maastricht University Medical Center received funds from Codman and Stryker for consultations by WHZ. The other authors report no conflicts.

  • Ethics approval The trial protocol was approved by all ethical boards of the participating centers, and all participants (or their legal representatives) provided written informed consent.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data available.

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