Abstract 5: Analysis of Workflow Aad Determinants of Delays in the Escape Randomized Controlled Trial
Introduction: The ESCAPE trial used innovative imaging and aggressive target time metrics to demonstrate the benefit of additional endovascular treatment over standard care in patients with disabling acute ischemic stroke. We performed a detailed analysis of workflow and determine modifiable factors resulting in delays.
Methods: The trial enrolled 316 patients fulfilling eligibility criteria and presenting within 12 hours of stroke symptom onset from 22 sites across 3 continents between February 2013 and October 2014. We considered four specific interval times: onset-to-ED arrival, ED-arrival-to-qualifying CT scan, qualifying CT scan-to-groin puncture, groin puncture-to-reperfusion. Missing times were not imputed. When reperfusion was not achieved, the reperfusion time was considered missing and was not imputed. Interval times from stroke symptom onset to first reperfusion are reported using medians and inter-quartile range. To assess the relationship between patient, hospital and health system characteristics as predictors of longer interval times, a negative binomial regression provided the best fit to the data.
Results: Stroke symptom onset to arrival in emergency room of endovascular capable hospital time was 42% (34 mins) longer among patients who received intravenous alteplase at the referring hospital (drip and ship) vs. patients directly transferred to the endovascular capable hospital (direct to mother ship) (Figure). Qualifying CT to groin puncture time was 15% (8 mins) shorter among patients presenting during work hours vs. off hours. Time from qualifying CT to groin puncture was 41% (24 min) shorter in drip and ship patients than vs. when intravenous alteplase was administered after qualifying CT (mothership). General anesthesia prolonged this time by 43% (22 min). Balloon guide catheter during endovascular procedure shortened time from groin puncture to reperfusion by 21% (8 mins).
Conclusions: Inefficiencies in triaging systems, presentation during off hours, intravenous alteplase administration, GA utilization and endovascular techniques offer major opportunities for improvement.
Author Disclosures: B.K. Menon: Research Grant; Significant; The ESCAPE trial was supported partially by a grant to the University of Calgary from Covidien AG.. T.T. Sajobi: None. Y. Zhang: None. J.L. Rempel: None. A. Shuaib: None. J. Thornton: None. D. Williams: None. D. Roy: None. A.Y. Poppe: None. T.G. Jovin: None. B. Sapkota: None. B. Baxter: None. T. Krings: None. F.L. Silver: None. D.F. Frei: None. C. Fanale: None. D.I. Tampieri: None. J. Teitelbaum: None. C. Lum: None. D.D. Dowlatshahi: None. M. Eesa: None. M.W. Lowerison: None. N. Kamal: None. A.M. Demchuk: None. M.D. Hill: Consultant/Advisory Board; Modest; Adjudication panel for Merck for a clinical trials outcomes panel.. Research Grant; Significant; Research grant to the University of Calgary from Covidien AG for the ESCAPE trial. Other Research Support; Significant; Drug in kind support for the TEMPO-1 trial from Hoffmann-La Roche Canada Ltd. Ownership Interest; Significant; Calgary Scientific Inc. M. Goyal: Research Grant; Significant; Funding from Covidien for design and conduct of SWIFT PRIME trial. Part funding of ESCAPE trial from Covidien provided to Univ of Calgary. Speakers' Bureau; Significant; For teaching engagements from Covidien and Stryker.
- © 2016 by American Heart Association, Inc.