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Ischemic stroke
Original research
Evaluation of direct-to-angiography suite (DTAS) and conventional clinical pathways in stroke care: a simulation study
  1. Mehrad Bastani1,
  2. Timothy G White2,
  3. Gabriela Martinez3,
  4. Joseph Ohara4,
  5. Kinpritma Sangha5,
  6. Michele Gribko6,
  7. Jeffrey M Katz7,
  8. Henry H Woo8,
  9. Artem T Boltyenkov9,
  10. Jason Wang10,
  11. Elizabeth Rula11,
  12. Jason J Naidich12,
  13. Pina C Sanelli13
  1. 1 Radiology, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
  2. 2 Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
  3. 3 Siemens Healthcare USA, Manhasset, New York, USA
  4. 4 Northwell Health, New Hyde Park, New York, USA
  5. 5 Siemens Healthineers AG, Malvern, Pennsylvania, USA
  6. 6 North Shore University Hospital, Manhasset, New York, USA
  7. 7 Neurology, North Shore University Hospital at Manhasset, Manhasset, New York, USA
  8. 8 Neurosurgery, Northwell Health, Manhasset, New York, USA
  9. 9 Siemens Healthineers USA, Malvern, Pennsylvania, USA
  10. 10 Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
  11. 11 Harvey L Neiman Health Policy Institute, Reston, Virginia, USA
  12. 12 Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
  13. 13 Hofstra Northwell School of Medicine at Hofstra University, Hempstead, New York, USA
  1. Correspondence to Dr Mehrad Bastani, Radiology, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA; mbastani{at}northwell.edu

Abstract

Background Rapid time to reperfusion is essential to minimize morbidity and mortality in acute ischemic stroke due to large vessel occlusion (LVO). We aimed to evaluate the workflow times when utilizing a direct-to-angiography suite (DTAS) pathway for patients with suspected stroke presenting at a comprehensive stroke center compared with a conventional CT pathway.

Methods We developed a discrete-event simulation (DES) model to evaluate DTAS workflow timelines compared with a conventional CT pathway, varying the admission NIHSS score treatment eligibility criteria. Model parameters were estimated based on 2 year observational data from our institution. Sensitivity analyses of simulation parameters were performed to assess the impact of patient volume and baseline utilization of angiography suites on workflow times utilizing DTAS.

Results Simulation modeling of stroke patients (SimStroke) demonstrated door-to-reperfusion time savings of 0.2–3.5 min (p=0.05) for a range of DTAS eligibility criteria (ie, last known well to arrival <6 hours and National Institutes of Health Stroke Scale ≥6–11), when compared with the conventional stroke care pathway. Sensitivity analyses revealed that DTAS time savings is highly dependent on baseline utilization of angiography suites.

Conclusions The results of the SimStroke model showed comparable time intervals for door-to-reperfusion for DTAS compared with a conventional stroke care pathway. However, the DTAS pathway was very sensitive to baseline angiography suite utilization, with even a 10% increase eliminating the advantages of DTAS compared with the conventional pathway. Given the minimal time savings modeled here, further investigation of implementing the DTAS pathway in clinical care is warranted.

  • stroke
  • statistics
  • CT angiography
  • thrombectomy

Data availability statement

Data are available upon reasonable request. The data that support the findings of this study are available from the corresponding author upon reasonable request.

https://doi.org/10.1136/neurintsurg-2021-018253

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    Data availability statement

    Data are available upon reasonable request. The data that support the findings of this study are available from the corresponding author upon reasonable request.

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    Footnotes

    • Twitter @timothywhiteMD, @henrywoomd

    • Contributors MB: Substantially contributed to the conception and design of the study. Substantially contributed to the data curation and organization. Substantially contributed to the model conception, construction, curation, and verification. Substantially contributed to the study analyses. Substantially contributed to the writing and revision of the manuscript. Approved the final version of the manuscript. Accountable for the manuscript’s contents. Rest of the co-authors: Substantially contributed to the conception and design of the study. Substantially contributed to the data curation and organization. Substantially contributed to the writing and revision of the manuscript. Approved the final version of the manuscript. Accountable for the manuscript’s contents

    • Funding Research reported in this publication was supported by The Feinstein Institutes for Medical Research, Northwell Health, National Institute of Neurological Disorders and Stroke of the National Institutes of Health under award number R56NS114275, Siemens Healthineers, and the Harvey L. Neiman Health Policy Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

    • Competing interests Gabriela Martinez and Kinpritma Sangha are Siemens Healthineers employees and stockholders. Artem Boltyenkov reports research funding support from the National Institute of Neurological Disorders and Stroke of the National Institutes of Health under award number R56NS114275 and Siemens Healthineers. Jeffrey Katz reports research funding support from the National Institute of Neurological Disorders and Stroke of the National Institutes of Health under award number R56NS114275, and Siemens Healthineers. Elizabeth Rula reports research funding support from the National Institute of Neurological Disorders and Stroke of the National Institutes of Health under award number R56NS114275. Pina C Sanelli reports research funding support from the National Institute of Neurological Disorders and Stroke of the National Institutes of Health under award number R56NS114275, Siemens Healthineers, and the Harvey L. Neiman Health Policy Institute. Henry Woo receives research funds from Siemens and Balt.

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

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.