Machine Learning–Enabled Automated Large Vessel Occlusion Detection Improves Transfer Times at Primary Stroke Centers

But still not fast enough to get to 100% recovery and you're not even measuring that!

Survivors want to know how many got to 100% recovery! If you're not measuring that you'll never get there, and just to make sure I'd have you all fired for incompetently not even understanding the only goal in stroke for survivors is 100% recovery!

“What's measured, improves.” So said management legend and author Peter F. Drucker 

Machine Learning–Enabled Automated Large Vessel Occlusion Detection Improves Transfer Times at Primary Stroke Centers

Ngoc Mai Le,

Ananya S. Iyyangar,

Youngran Kim,

Mohammad Rauf Chaudhry,

Sergio Salazar‐Marioni,

Rania Abdelkhaleq,

Arash Niktabe,

Anjan N. Ballekere,

Hussain Azeem,

Sandi Shaw,

… See all authors

Originally published29 Mar 2024https://doi.org/10.1161/SVIN.123.001119Stroke: Vascular and Interventional Neurology. 2024;0:e001119

Abstract

BACKGROUND

Accelerating door‐in‐door‐out (DIDO) times at primary stroke centers (PSCs) for patients with large vessel occlusion (LVO) acute ischemic stroke transferred for possible endovascular stroke therapy (EVT) is important to optimize outcomes. Here, we assess whether automated LVO detection coupled with secure communication at non‐EVT performing PSCs improves DIDO time and increases the proportion of patients receiving EVT after transfer.

METHODS

From our prospectively collected multicenter registry, we identified patients with LVO acute ischemic stroke that presented to one of 7 PSCs in the Greater Houston area from January 1, 2021, to February 27, 2022. Noncontrast computed tomography and computed tomographic angiography were performed in all patients at the time of presentation, per standard of care. A machine learning (artificial intelligence [AI]) algorithm trained to detect LVO (Viz.AI) from computed tomographic angiography was implemented at all 7 hospitals. The primary outcome of the study was DIDO at the PSCs and was determined using multivariable linear regression adjusted for sex and on/off hours. Secondary outcomes included likelihood of receiving EVT post‐transfer.

RESULTS

Among 115 patients who met inclusion criteria, 80 were evaluated pre‐AI and 35 post‐AI. The most common occlusion locations were middle cerebral artery (51.3%) and internal carotid artery (25.2%). There were no substantial differences in demographics or presentation characteristics between the 2 groups. Median time from onset to PSC arrival was 117 minutes (interquartile range, 54–521 minutes). In univariable analysis, patients evaluated at the PSCs after AI implementation had a shorter DIDO time (median difference, 77 minutes; P<0.001). In multivariable linear regression, patients evaluated with automated LVO detection AI software were associated with a 106‐minute (95% CI, −165 to −48 minutes) reduction in DIDO time but no difference in likelihood of EVT post‐transfer (odd ratio, 2.13 [95% CI, 0.88–5.13).

CONCLUSION

Implementation of a machine learning method for automated LVO detection coupled with secure communication resulted in a substantial decrease in DIDO time at non‐EVT performing PSCs.

Adapted from Biomedical Image Analysis (AI vs Traditional Techniques), by BioRender.com (2023). Retrieved from https://app.biorender.com/biorender‐templates .

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Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke

Survivors don't care about transfer time, they care about 100% recovery. Get the hell out of stroke if you don't understand what survivors want!

The latest useless shit here:

Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke

Brian Stamm, MD^1,2; Regina Royan, MD, MPH^3,4,5; Mihai Giurcanu, PhD⁶; et al Steven R. Messe, MD⁷; Edward C. Jauch, MD, MS⁸; Shyam Prabhakaran, MD, MS⁹

Author Affiliations

JAMA. 2023;330(7):636-649. doi:10.1001/jama.2023.12739

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Key Points

Question  What is the median door-in-door-out time for interhospital transfer of patients with stroke, and what patient and hospital-level factors are associated with door-in-door-out time?

Findings  In this retrospective US registry–based study that included 108 913 patients with acute stroke requiring interhospital transfer from 1925 hospitals, the median door-in-door-out time was 174 minutes. Age 80 years or older, female sex, Black race, and Hispanic ethnicity were significantly associated with longer door-in-door-out times, whereas emergency medical services prenotification, severe stroke, and ischemic stroke eligible for endovascular therapy were significantly associated with shorter times.

Meaning  This US registry–based study evaluated door-in-door-out times for patients with acute stroke requiring interhospital transfer and identified disparities and health system factors that could be possible targets for quality improvement initiatives.

Abstract

Importance  Treatments for time-sensitive acute stroke are not available at every hospital, often requiring interhospital transfer. Current guidelines recommend hospitals achieve a door-in-door-out time of no more than 120 minutes at the transferring emergency department (ED). (Regardless of transfer time, survivors still expect 100% recovery! GET THERE!)

Objective  To evaluate door-in-door-out times for acute stroke transfers in the American Heart Association Get With The Guidelines-Stroke registry and to identify patient and hospital factors associated with door-in-door-out times.

Design, Setting, and Participants  US registry–based, retrospective study of patients with ischemic or hemorrhagic stroke from January 2019 through December 2021 who were transferred from the ED at registry-affiliated hospitals to other acute care hospitals.

Exposure  Patient- and hospital-level characteristics.

Main Outcomes and Measures  The primary outcome was the door-in-door-out time (time of transfer out minus time of arrival to the transferring ED) as a continuous variable and a categorical variable (≤120 minutes, >120 minutes). Generalized estimating equation (GEE) regression models were used to identify patient and hospital-level characteristics associated with door-in-door-out time overall and in subgroups of patients with hemorrhagic stroke, acute ischemic stroke eligible for endovascular therapy, and acute ischemic stroke transferred for reasons other than endovascular therapy.

Results  Among 108 913 patients (mean [SD] age, 66.7 [15.2] years; 71.7% non-Hispanic White; 50.6% male) transferred from 1925 hospitals, 67 235 had acute ischemic stroke and 41 678 had hemorrhagic stroke. Overall, the median door-in-door-out time was 174 minutes (IQR, 116-276 minutes): 29 741 patients (27.3%) had a door-in-door-out time of 120 minutes or less. The factors significantly associated with longer median times were age 80 years or older (vs 18-59 years; 14.9 minutes, 95% CI, 12.3 to 17.5 minutes), female sex (5.2 minutes; 95% CI, 3.6 to 6.9 minutes), non-Hispanic Black vs non-Hispanic White (8.2 minutes, 95% CI, 5.7 to 10.8 minutes), and Hispanic ethnicity vs non-Hispanic White (5.4 minutes, 95% CI, 1.8 to 9.0 minutes). The following were significantly associated with shorter median door-in-door-out time: emergency medical services prenotification (−20.1 minutes; 95% CI, −22.1 to −18.1 minutes), National Institutes of Health Stroke Scale (NIHSS) score exceeding 12 vs a score of 0 to 1 (−66.7 minutes; 95% CI, −68.7 to −64.7 minutes), and patients with acute ischemic stroke eligible for endovascular therapy vs the hemorrhagic stroke subgroup (−16.8 minutes; 95% CI, −21.0 to −12.7 minutes). Among patients with acute ischemic stroke eligible for endovascular therapy, female sex, Black race, and Hispanic ethnicity were associated with a significantly higher door-in-door-out time, whereas emergency medical services prenotification, intravenous thrombolysis, and a higher NIHSS score were associated with significantly lower door-in-door-out times.

Conclusions and Relevance  In this US registry–based study of interhospital transfer for acute stroke, the median door-in-door-out time was 174 minutes, which is longer than current recommendations for acute stroke transfer. Disparities and modifiable health system factors associated with longer door-in-door-out times are suitable targets for quality improvement initiatives.

Full Text

Updated guidelines for safe transfer of patients with a brain injury

What the fuck lazy shitshow is this? GUIDELINES NOT PROTOCOLS! 

Protocols: With this starting point you do this, this, this exactly and recover.

Guidelines: With no defined starting point, we suggest you do this, this, this.

See the difference? Until the stroke world gets protocols stroke survivors are fucking screwed. We need to have a lot of people in stroke fired. 

Updated guidelines for safe transfer of patients with a brain injury

Guidelines published today (2 December 2019) in the journal Anaesthesia, produced by the Association of Anaesthetists and the Neuro Anaesthesia and Critical Care Society, provide practical guidance for ensuring the safe transfer between hospitals of patients with a brain injury. The transfer of patients is potentially hazardous if poorly executed and these updated guidelines are for those responsible for planning, managing and undertaking transfer of brain-injured patients. The aim is to ensure a safe transfer of patients and also to assist in local discussions when establishing new or improving existing transfer arrangements.
The location of care for many brain-injured patients has changed following the development of major trauma centres and advances in management of ischaemic stroke have led to the urgent transfer of many more patients. Patients with an isolated head injury, major trauma, and those who deteriorate while in hospital may require transfer between hospitals. In some regions, critical care networks and transfer groups have been established, but elsewhere patients with a brain injury will require staff within a local unit to arrange and undertake a transfer.

The guidelines provide 11 recommendations, covering key areas including:

Organisational aspects - The safe transfer of patients with brain injuries requires an effective partnership between the referring teams, the regional neurosciences or stroke unit, and the local ambulance service. Every hospital that receives patients with serious brain injuries should have facilities for resuscitation and diagnosis, including 24 h access to CT imaging. Appropriate staff and equipment should be available at all times to ensure a safe transfer to the neuroscience unit when necessary.
Preparation for transfer - The decision to transfer a patient with a brain injury should be made by senior medical staff at the referring hospital in consultation with senior staff at the neurosciences unit. Appropriate resuscitation and stabilisation of the patient before transfer is the key to avoiding complications during the journey. When a request is made for an ambulance to transfer the patient (including those with acute ischaemic stroke), the dispatcher should be told the patient has a life-threatening emergency. 
Care during the transfer - During transfer, patient management will be centred on maintaining oxygenation and adequate blood pressure, and minimising rises in ICP. As far as possible, a smooth journey (without marked acceleration and deceleration) will have less impact on a patient with an injured brain. A patient who is physiologically stable before departure is more likely to remain so for the duration of the transfer, although there is still the need for constant vigilance and prompt action to deal with complications.
Paediatric transfers – Paediatric transfers are high-risk and there should be a pre-determined pathway for referral and transfer of brain-injured children developed in agreement by the regional transport service, regional trauma network and the regional neuroscience network.
Dr Mike Nathanson, President-Elect of the Association of Anaesthetists and Chair of the guidelines working party, said: “We believe that high-quality transfer of patients with a brain injury is associated with a better outcome. These guidelines encourage departments to review their own practices and suggest training and organisational improvements to ensure safe transfer with the aim of avoiding harm to patients. Most principles of safe transfer are common to all seriously ill patients, but these guidelines highlight specific risks that apply to those with an acute brain injury.”
Roger Lightfoot, President of the Neuroanaesthesia and Critical Care Society, said: “The collaboration of the Neuroanaesthesia and Critical Care Society with the Association of Anaesthetists has allowed this version of the guidelines to be relevant and set the correct standards to ever developing area of patients with acute brain injury. The important inclusion of organisational aspects as well as clinical guidelines will allow local departments to undertake a comprehensive review of their own practice and therefore improve care. It has been an honour to work with the Association and going forwards we hope to build on this partnership.”
A webinar about these guidelines will take place on Monday 9 December 2019. Full details of the webinar can be found here. 

Read the guidelines in the journal Anaesthesia