Use of a Smartphone Application to Speed Up Interhospital Transfer of Acute Ischemic Stroke Patients for Thrombectomy

Notice they tell us nothing about 100% recovery  or what door-to-needle time is required to get to 100% recovery.  With no set time goal to meet, you'll never get there.

Use of a Smartphone Application to Speed Up Interhospital Transfer of Acute Ischemic Stroke Patients for Thrombectomy

Sheng-Ta Tsai^1,2†, Wei-Chun Wang^1,2†, Yu-Ting Lin^3,4, Wei-Shih Huang^1,2, Hung-Yu Huang¹, Chun-Ju Wang¹, En-Zu Lin⁵, Wei-Ling Kung⁶, Yuh-Cherng Guo^1,2, Kang-Hsu Lin^1,2, Ming-Kuei Lu^1,2,7, Pao-Sheng Yen⁸, Wei-Laing Chen⁹, Ying-Lin Tseng⁹, Chin-Chi Kuo^2,3,10, Der-Yang Cho^5,11, Chun-Chung Chen^5,11 and Chon-Haw Tsai^1,2,7*

• ¹Department of Neurology, China Medical University Hospital, Taichung, Taiwan
• ²College of Medicine, China Medical University, Taichung, Taiwan
• ³Big Data Center, China Medical University Hospital, China Medical University, Taichung, Taiwan
• ⁴Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
• ⁵Stroke Center, China Medical University Hospital, Taichung, Taiwan
• ⁶Department of Neurology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
• ⁷Everflourish Neuroscience and Brain Disease Center, China Medical University Hospital, Taichung, Taiwan
• ⁸Department of Radiology, Kuang Tien General Hospital, Taichung, Taiwan
• ⁹Department of Radiology, China Medical University Hospital, Taichung, Taiwan
• ¹⁰Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
• ¹¹Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan

Background: In most countries, large cerebral artery occlusion is identified as the leading cause of disability. In 2015, five large-scale clinical trials confirmed the benefit of intra-arterial thrombectomy. However, thrombectomy is a highly technical and facility-dependent procedure. Primary stroke centers need to transfer patients to comprehensive stroke centers to perform thrombectomy. The time-lapse during interhospital transfer would decrease the chance of the patient's proper recovery. Communication barriers also contribute to this delay.

Aims: We used a smartphone application to overcome communication barriers between hospitals. We aimed to shorten the door-to-puncture time of interhospital transfer patients.

Methods: We began using a smartphone application, “LINE,” to facilitate interhospital communication on May 01, 2018. We carried out retrospective data analyses for all the transfer patients (n = 351), with the primary outcome being the door-to-puncture time in our comprehensive stroke center (China Medical University Hospital). We compared the three periods: May 01 to Dec 31, 2017 (before the use of the smartphone application); May 01 to Dec 31, 2018 (the 1st year of using the smartphone application); and May 01 to Dec 31, 2019 (the 2nd year of using the smartphone application). We also compared the transfer data with non-transfer thrombectomies in the same period.

Results: We compared 2017, 2018, and 2019 data. The total number of transfer patients increased over the years: 63, 113, 175, respectively. The mean door-to-puncture time decreased significantly, going from 109, through 102, to 92 min. Meanwhile, the mean door-to-puncture time in non-transfer patients were 140.3, 122.1, and 129.3 min. The main reason of time saving was the change of the way of communication, from point-to-point interhospital communication to hub-to-spoke interhospital communication.

Conclusions: We used this smartphone application to enhance interhospital communication, changed from the point-to-point to hub-to-spoke method. It made us overcome the communication barrier and build up interhospital connection, thus shortening the door-to-puncture time. Our experience demonstrated the importance of close communication and teamwork in hyperacute stroke care, especially in interhospital transfer for thrombectomy.

Introduction

Stroke has been identified as one of the leading causes of morbidity and mortality around the world (1). Large vessel occlusion (LVO) is the most devastating form of stroke (2, 3). About the definition of LVO, we used the broad definition that included internal carotid artery (ICA), the first segment of the middle cerebral artery (M1), the second segment of the middle cerebral artery (M2), the basilar artery (BA), anterior cerebral artery (ACA), posterior cerebral artery (PCA), and vertebral artery (VA) occlusions (4). Every 1-min delay of recanalization will lead to the death of 1.9 million neurons (5). Thus, it is crucial to save the brain immediately (6–8). The most modifiable factor in salvaging the brain is door-to-puncture (DTP) time (9).

In 2015, five large-scale clinical trials confirmed the benefits of intra-arterial thrombectomy (10–14). However, thrombectomy is deemed as a highly technical and facility-dependent procedure (15). Thrombectomy capabilities are not exclusive to comprehensive stroke centers. The time-lapse during interhospital transfer would then decrease the chance of adequate recovery of patients (16–18).

There are many factors affecting the timeliness of interhospital transfer of patients for thrombectomy (19). Previous research reported that interhospital communication barriers are a major cause of time delay (20). Several teams have developed smartphone applications in order to facilitate communication (20, 21).

In Taiwan, the most popular smartphone application for social communication is “LINE.” In 2019, “LINE” had over 21 million users in Taiwan (89% of the total population, 23.6 million) (22), with each user spending more than 1 h on it per day (23).

As a result, after several interhospital transfer meetings with primary stroke centers, we created an encrypted group in “LINE” in order to overcome communication barriers and speed up the workflow of thrombectomy.