Authors (including presenting author) :
Ma SH (1), Leung WH (1,2), Soo OY (1), Lai MH (3), Wong KT (3), Cheung KH (4), Cheng CH (4), Yeung HM (5), Li SH (6), Cheung CY (7), Wong KC (9,10)
Affiliation :
(1). Department of Medicine and Therapeutics, PWH. (2) Department of Medicine, the Chinese University of Hong Kong. (3). Department of Imaging and Interventional Radiology, PWH. (4) Department of Accident and Emergency, PWH. (5), Department of Medicine, AHNH. (6). Department of Medicine, NDH. (7) Department of Radiology, AHNH / NDH (8) Neurosurgery, Department of Surgery, PWH. (9) Neurosurgery, Department of Surgery, CUHK
Introduction :
Acute Ischemic Stroke due to Large Vessels Occlusion (LVO) is a severe condition with high mortality and morbidity. Timely recannalization by Endovascular Thrombectomy (EVT) can tremendously reduce infarct size and greatly improve functional recovery. However, EVT triage is complex and involve multi-disciplinary input, often resulting in delay in treatment delivery. Therefore it is vital to design a EVT triage workflow which allow rapid identification of candidate for EVT and treatment delivery.
Objectives :
To design and implement a new EVT triage workflow in order to shorten the Door-to-Treatment time ( from patient arrival to receive operation ) for Endovascular Thrombectomy (EVT) service in NTEC in order to improve the neurological outcome of acute stroke patient.
Methodology :
NTEC EVT team has implemented a new EVT triage workflow emphasising on parallel triage and early notification. Parallel triage allows simultaneous patient assessment from various parties, it helps to shorten the triage time and avoid duplicated process. We had taken several steps for this.
First, stroke team attend every suspected stroke patient immediately upon patient arrival, before AED team assessment and brain imaging. Then the patient would be assessed simultaneously by both AED team and stroke team. AED team stabilise the patient, assess vitals while stroke team focus on neurological assessment and the eligibility for revascularization therapy. It minimise duplicated assessment and reduce the triage time. In the original workflow, patient would first be assessed by AED team, confirming clinical suspicion of ischemic stroke and plain CT brain ruling out alternate diagnosis before contacting stroke team.
Second, we combined separate imaging studies into a single comprehensive cerebral assessment package. It includes brain matter scanning (plain CT), vascular imaging (CT angiogram) and viability study (CT perfusion). In order to achieve this, we prepare every suspected stroke patient as potential CTA/CTP candidate regardless of the clinical presentation. Neurologist decide whether CTA/CTP is necessary at the spot, before plain CT. And proceed to the plain CT / CTA and CTP at the same scanning session without additional patient transfer. On the order hand, radiology team had set up a fast track CTA/CTP arrangement pathway for stroke with designated neuro-radiologist in-charge of the arrangement and interpretation. In the original workflow, patient would first underwent plain CT brain and transfer back to AED before stroke team assessment. CTA/CTP would only be arranged if necssary as a separate scan afterwards causing unnecessary patient transfer and delay.
Third, early notification to the team. Whenever encountering potential EVT candidate, notification would be sent via operator to the DECT phone of the relevant parties. While clinical information would be disseminated via group chat function in HA chat. Patient progress would also be updated real-time. It allows preparing and vacating the facilities for the incoming patient early in the triage process. Especially for CT room and Operation Theatre which are usually packed with cases and need a considerable time for preparation before proceed. It also aid communication across different hospitals within NTEC
With the new triage workflow, the triage time could be greatly reduced and allow our patients to receive treatment as soon as possible.
Result & Outcome :
Since the implementation of the new NTEC EVT workflow in July 2020 till Oct 2021, NTEC EVT team has triaged 170 potential patient and performed EVT on 91 patients in total. The average Door-to-puncture time which is the time needed from patient arrival, to completion of the triage and begin the procedure, reduced by 42%, reduced from 93min before the change in workflow to 54min. Good functional outcome as defined by modified Rankin Scale less then 2 (patient can independently mobolize and take care of his/her own activities of daily living) also improved by 33%, from 0.42 to 0.56.
In conclusion, the new NTEC EVT triage workflow is feasible and successfully shorten the triage time and improve patient outcome
