Stroke Cart Improves Efficiency in Acute Ischemic Stroke Intervention

Transcription

1 Stroke Cart Improves Efficiency in Acute Ischemic Stroke Intervention MR Amans, F Settecase, R Darflinger, M Alexander, A Nicholson, DL Cooke, SW Hetts, CF Dowd, RT Higashida, VV Halbach Interventional Neuroradiology Division Department of Radiology and Biomedical Imaging University of California San Francisco No relevant financial disclosures

2 Time is Brain 1 In a typical stroke, 1.9 million neurons are lost each minute 1 Delays in treatment are associated with worse patient outcomes in patients receiving IV tpa and intra-arterial thrombectomy (IAT) 2, 3 Good outcomes are dependent on achieving near complete recanalization (TICI 2b or 3) 4 Comparing the recent 5 IAT trials 4 : IAT consistently increased the proportion of patients able to live independently (mrs 0-2) compared to controls (CTL) receiving standard medical therapy Improvement in mrs 0-2 with IAT diminishes with increased time from last seen normal (LSN) to groin puncture (GP) Shorter LSN to GP is associated with better outcomes (i.e. faster time to groin puncture = higher proportion with good outcome) Grotta J and Hacke W. Stroke Neurologists Perspective on the New Endovascular Trials. Stroke June Saver JL. Time is brain--quantified. Stroke; a journal of cerebral circulation. Jan 2006;37(1): Emberson J, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet. Nov 2014;384(9958): Fransen P. Time to reperfusion and effect of intra-arterial treatment in the MR CLEAN trial. Presented at: International Stroke Conference; February 12, 2015; Nashville, TN Grotta JC, Hacke W. Stroke Neurologist's Perspective on the New Endovascular Trials. Stroke; a journal of cerebral circulation. Jun 2015;46(6):

3 UCSF Stroke Cart Modeled after ACLS Code Cart Mobile unit containing all devices required to perform IAT Also contains RN Stroke Cheat Sheets attached to side of the cart that include typical doses of medications used and instructions for reconstitution

4 Hypothesis UCSF Stroke Cart improves efficiency in IAT

5 Methods 25 consecutive patients referred to NIR, 9 prior to and 16 after UCSF Stroke Cart introduction in April of 25 were excluded (1 prior and 3 after stroke cart): Loss of airway protection requiring conversion from monitored anesthesia care (MAC) to GA (1) Spontaneous recanalization after IV tpa (2) Cervical ICA occlusion requiring PTA/stenting (1)

6 Outcome Measures In Room time to time of Groin Puncture (IR to GP) In Room time to time of microcatheter beyond the CloT (IR to CT) In Room time to Recanalization Time (IR to RT) Groin Puncture time to time of microcatheter beyond the CloT (GP to CT) Groin Puncture to Recanalization Time (GP to RT) Student s t-test, single tailed, to compare the mean times before and after UCSF Stroke Cart implementation

7 Results Table 1: Patient characteristics prior to implementation of the UCSF Stroke Cart in violet and after in blue. Age Gender LVO location Device used (number of passes with device) #of passes Final mtici score Anesth 66 F R M1 Trevo 2 1 MAC 70 M L M1 Trevo 2 2b Gen 74 M R M1 Trevo 3 2b Gen 76 F L M2 Microcatheter 1 2b Gen 62 M L M1 Solitaire (2)/Trevo (2) 4 2b Gen 65 F L ICA Solitaire 1 3 Gen 80 M BTA Trevo x 3, Solitaire x1 4 0 Gen 56 M R M1 Solitaire + IA tpa 2 3 Gen 85 M R M1 Solitaire 3 2b MAC 73 M L M2 Trevo 1 3 Gen 68 M R ICA T Solitaire (2), Penumbra (3) 5 2b MAC 88 F L M1 Trevo x 3, Penumbra (2) 4 2a Gen 43 M L M1 Trevo 1 3 Gen 82 F BA Trevo 1 2b Gen 87 F R M1 Trevo + IA tpa 3 2a Gen 38 F R ICA T Solumbra 2 3 MAC 71 F L M1 Solumbra 1 3 MAC 81 F L M1 Trevo 1 2b Gen 78 F R ICA T Trevo 1 2b Gen 84 M L tandem Solitaire 1 2b Gen 68 M BA Solumbra 1 2b Gen Pre-Cart Post-Cart

8 Table 2: Average time in minutes Results Metric Pre Post p 140" IR to GP " 100" IR to CT IR to RT GP to CT Minutes( 80" 60" 40" 20" GP to RT " IR"to"GPT" IR"to"CT" IR"to"RT" GP"to"CT" GP"to"RT" Pre2Stroke"Cart" Post2Stroke"Cart"

9 Discussion UCSF Stroke Cart is a mobile unit containing all of the tools required for stroke intervention, from groin puncture to clot retrieval Implementing the UCSF Stroke Cart resulted in significantly faster time to intervention Groin puncture to recanalization is highly variable among stroke patients based on the pathophysiology and patient anatomy; however, this metric was also trending towards significance

10 Discussion Mobile unit placed near the patient minimizes time to obtain tools for the procedure Promotes efficiency by facilitating parallel workflows of technologists, nurses, and physicians Facilitates all team members to assist in all aspects of setup and obtaining tools Implementation of the Stroke Cart at multiple sites increases team familiarity

11 Discussion Confounding factors As time progresses, we expect team members to improve. Some increased efficiency may be secondary to increased ED, Neurology, Anesthesia and other Radiology systems of care improvements. All cases are different and some require several devices or attempts for treatment to be effective.

12 Conclusion The UCSF Stroke Cart, a mobile unit containing all of the tools required to perform revascularization procedures to treat large vessel occlusion acute ischemic stroke, improves efficiency in stroke treatment Improved efficiency is expected to improve patient outcomes