Air vs. Road Decision for Endovascular Clot Retrieval in a Rural Telestroke Network

You wouldn't need to make decisions like this if you have protocols leading to 100% recovery for all survivors. This is thinking small and not the sign of true leadership. 

Air vs. Road Decision for Endovascular Clot Retrieval in a Rural Telestroke Network

Shyam Gangadharan^1*, Thomas Lillicrap², Ferdinand Miteff^1,2, Pablo Garcia-Bermejo¹, Thomas Wellings¹, Billy O'Brien³, James Evans³, Khaled Alanati¹, Christopher Levi^1,2, Mark W. Parsons^2,4, Andrew Bivard^2,4, Carlos Garcia-Esperon^1,2† and Neil J. Spratt^1,2† for the Northern NSW Telestroke Investigators

• ¹Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
• ²Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
• ³Department of Neurology, Gosford Hospital, Gosford, NSW, Australia
• ⁴Department of Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia

Background and Purpose: Telestroke aims to increase access to endovascular clot retrieval (ECR) for rural areas. There is limited information on transfer workflow for ECR in rural settings. We sought to describe the transfer metrics for ECR in a rural telestroke network with respect to decision making.

Methods: A retrospective cohort study was employed on consecutive patients transferred to the comprehensive stroke center (CSC) for ECR in a rural hub-and-spoke telestroke network between April 2013 and October 2019, by road or air. Key time-based metrics were analyzed.

Results: Sixty-two patients were included. Mean age was 66 years [standard deviation (SD), 14] and median National Institutes of Health Stroke Scale 13 [interquartile range (IQR), 8–18]. Median rural-hospital-door-to-CSC-door (D2D) was 308 min (IQR, 254–351), of which 68% was spent at rural hospitals [door-in-door-out (DIDO); 214 min; IQR, 171–247]. DIDO was longer for air transfers than road (P = 0.004), primarily because of a median 87 min greater decision-to-departure time (Decision-DO, P < 0.001). In multiple linear regression analysis, intubation but not thrombolysis was associated with significantly longer DIDO. The distance at which the extra speed of an aircraft made up for the delays involved in booking an aircraft was 299 km from the CSC.

Conclusions: DIDO is longer for air retrievals compared with road. Decision-DO represents the most important component of DIDO, being longer for air transfers. Systems for rapid transportation of rural ECR candidates need optimization for best patient outcomes, with decision support seen as a potential tool to achieve this.

Introduction

Endovascular clot retrieval (ECR) is the standard of care in the treatment of acute stroke patients with large vessel occlusion (LVO) (1). It has been shown to be major benefits in selected patients up to 24 h (2, 3), but earlier treatment leads to greater benefit (4–6). This presents logistical challenges in Australia, because patients from widely dispersed geographic regions are eligible for this treatment, but it is offered only in limited metropolitan centers (7, 8).

Telestroke is being increasingly used in Australia to help overcome geographical disparities in access to acute stroke care (9–11). Optimal implementation of ECR through telestroke requires efficient workflow from primary hospital to the comprehensive stroke center. Door-in-door-out (DIDO) time at the primary hospital has been thought to have the greatest impact on outcome for patients with LVO being transferred for ECR, among modifiable factors (12–14). A recent study in metropolitan Australia proposed that the target time for DIDO should be shortened to 45 min (15, 16).

Despite the fact that about 29% of Australia's population live in rural and remote areas, with people in very remote areas having a mortality rate almost 1.4 times as high as in major cities (17), there is a paucity of data on transfer workflow specific to rural Australia to guide further development of ECR in these areas. We aimed to describe the transfer metrics for ECR from rural hospitals to a regional comprehensive stroke center in a telestroke network in rural Australia, with respect to key points in clinical decision making.

Clinical decision making in stroke care is complex (18), with there being a correlation between decision delay in acute stroke and both pre-hospital and in-hospital delays (19–21). In addition to transfer workflow, we extended our study to look at the relationship between transfer metrics and clinical decision making so that the results might be more readily adapted to modify routine clinical practice and potentially identify areas for decision support. We sought to compare different transport modalities. Our main hypothesis was that DIDO for air transfers would be longer than for road transfers.