Department of Neurology (V.L.-R., S.S.-M., R.A., S.I.S., A.L.C., Y.J.A., G.S., T.-C.W., L.D.M., S.A.S.), UTHealth McGovern Medical School, Houston, TX.
Institute for Stroke and Cerebrovascular Disease (S.I.S., P.R.C., S.A.S.), UTHealth McGovern Medical School, Houston, TX.
Stroke. 2021 Mar;52(3):1022-1029. doi: 10.1161/STROKEAHA.120.032710. Epub 2021 Feb 4.
The optimal endovascular stroke therapy (EVT) care delivery structure is unknown. Here, we present our experience in creating an integrated stroke system (ISS) to expand EVT availability throughout our region while maintaining hospital and physician quality standards.
We identified all consecutive patients with large vessel occlusion acute ischemic stroke treated with EVT from January 2014 to February 2019 in our health care system. In October 2017, we implemented the ISS, in which 3 additional hospitals (4 total) became EVT-performing hospitals (EPHs) and physicians were rotated between all centers. The cohort was divided by time into pre-ISS and post-ISS, and the primary outcome was time from stroke onset to EPH arrival. Secondary outcomes included hospital and procedural quality metrics. We performed an external validation using data from the Southeast Texas Regional Advisory Council.
Among 513 patients with large vessel occlusion acute ischemic stroke treated with EVT, 58% were treated pre-ISS and 43% post-ISS. Over the study period, EVT procedural volume increased overall but remained relatively low at the 3 new EPHs (<70 EVT/y). After ISS, the proportion of patients who underwent interhospital transfer decreased (46% versus 37%; <0.05). In adjusted quantile regression, ISS implementation resulted in a reduction of time from stroke onset to EPH arrival by 40 minutes (<0.01) and onset to groin puncture by 29 minutes (<0.05). Rates of postprocedural hemorrhage, modified Thrombolysis in Cerebral Infarction (TICI) 2b/3, and 90-day modified Rankin Scale were comparable at the higher and lower volume EPHs. The improvement in onset-to-arrival time was not reflective of overall improvement in secular trends in regional prehospital care.
In our system, increasing EVT availability decreased time from stroke onset to EPH arrival. The ISS provides a framework to maintain quality in lower volume hospitals.
目前尚不清楚最佳的血管内卒中治疗（EVT）护理提供结构。在此，我们介绍了创建综合卒中系统（ISS）的经验，该系统旨在扩大我们区域内 EVT 的可及性，同时保持医院和医生的质量标准。
我们确定了我们的医疗保健系统中所有在 2014 年 1 月至 2019 年 2 月期间接受 EVT 治疗的大血管闭塞性急性缺血性卒中患者。2017 年 10 月，我们实施了 ISS，其中 3 家额外的医院（共 4 家）成为 EVT 执行医院（EPH），医生在所有中心之间轮转。该队列根据时间分为 ISS 前和 ISS 后，主要结局是卒中发病至 EPH 到达的时间。次要结局包括医院和程序质量指标。我们使用来自东南德克萨斯地区咨询委员会的数据进行了外部验证。
在 513 例接受 EVT 治疗的大血管闭塞性急性缺血性卒中患者中，58%的患者在 ISS 前接受治疗，43%的患者在 ISS 后接受治疗。在研究期间，EVT 手术量总体上有所增加，但在 3 家新的 EPH 中相对较低（<70 例/年）。ISS 实施后，进行医院间转移的患者比例下降（46%对 37%；<0.05）。在调整后的分位数回归中，ISS 实施使卒中发病至 EPH 到达的时间减少了 40 分钟（<0.01），发病至腹股沟穿刺的时间减少了 29 分钟（<0.05）。在较高和较低手术量的 EPH 中，术后出血、改良脑梗死溶栓（TICI）2b/3 和 90 天改良 Rankin 量表的发生率相当。发病至到达时间的改善并不能反映区域院前护理的整体改善。
在我们的系统中，增加 EVT 的可及性降低了卒中发病至 EPH 到达的时间。ISS 为维持低容量医院的质量提供了一个框架。
