Analysis of Workflow and Time to Treatment on Thrombectomy Outcome in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) Randomized, Controlled Trial
Analysis of Workflow and Time to Treatment on Thrombectomy Outcome in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) Randomized, Controlled Trial
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DOI：
10.1161/circulationaha.115.019983
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发表时间：
2016-06-07
期刊：
影响因子：
37.8
通讯作者：
Goyal, Mayank
中科院分区：
文献类型：
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作者：
Menon, Bijoy K.;Sajobi, Tolulope T.;Goyal, Mayank
背景-小核心和近端闭塞性缺血性中风的血管内治疗 (ESCAPE) 试验使用创新的成像和积极的目标时间指标来证明血管内治疗对急性缺血性中风患者的益处。我们分析了时间对临床结果的影响以及患者、医院和卫生系统特征对试验中工作流程的影响。方法和结果-结果（改良Rankin量表）和间隔时间之间的关系通过逻辑回归建模。使用负二项式回归对时间间隔（卒中发作到到达有血管内治疗的医院、到合格的计算机断层扫描、到腹股沟穿刺和再灌注）与患者、医院和卫生系统特征之间的关联进行建模。计算机断层扫描到再灌注时间每增加 30 分钟，实现功能独立结果（90 天改良 Rankin 量表 0-2）的可能性就会降低 8.3%（P=0.006）。症状出现至影像学时间与结果无关（P>0.05）。与直接转移（母船）相比，在转诊医院接受静脉阿替普酶（点滴和运送）的患者从发病到血管内到达医院的时间长 42%（34 分钟）。工作时间就诊的患者与非工作时间就诊的患者相比，计算机断层扫描到腹股沟的穿刺时间缩短了 15%（8 分钟），与母亲相比，点滴患者的计算机断层扫描至腹股沟穿刺时间缩短了 41%（24 分钟），全身麻醉时则延长了 43%（22 分钟）。在血管内手术过程中使用球囊引导导管将穿刺到再灌注时间缩短了 21%（8 分钟）。 结论：成像到再灌注时间是 ESCAPE 试验中结果的重要预测因素。分诊、非工作时间就诊、静脉阿替普酶给药、全身麻醉和血管内技术的使用效率低下，为改进工作流程提供了重要机会。
Background-The Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) trial used innovative imaging and aggressive target time metrics to demonstrate the benefit of endovascular treatment in patients with acute ischemic stroke. We analyze the impact of time on clinical outcome and the effect of patient, hospital, and health system characteristics on workflow within the trial.Methods and Results-Relationship between outcome (modified Rankin Scale) and interval times was modeled by using logistic regression. Association between time intervals (stroke onset to arrival in endovascular-capable hospital, to qualifying computed tomography, to groin puncture, and to reperfusion) and patient, hospital, and health system characteristics were modeled by using negative binomial regression. Every 30-minute increase in computed tomography-to-reperfusion time reduced the probability of achieving a functionally independent outcome (90-day modified Rankin Scale 0-2) by 8.3% (P= 0.006). Symptom onset-to-imaging time was not associated with outcome (P> 0.05). Onset-to-endovascular hospital arrival time was 42% (34 minutes) longer among patients receiving intravenous alteplase at the referring hospital (drip and ship) versus direct transfer (mothership). Computed tomography-to-groin puncture time was 15% (8 minutes) shorter among patients presenting during work hours versus off hours, 41% (24 minutes) shorter in drip-ship patients versus mothership, and 43% (22 minutes) longer when general anesthesia was administered. The use of a balloon guide catheter during endovascular procedures shortened puncture-to-reperfusion time by 21% (8 minutes).Conclusions-Imaging-to-reperfusion time is a significant predictor of outcome in the ESCAPE trial. Inefficiencies in triaging, off-hour presentation, intravenous alteplase administration, use of general anesthesia, and endovascular techniques offer major opportunities for improvement in workflow.