The chain of care enabling tPA treatment in acute ischemic stroke: a comprehensive review of organisational models.
Protracted and partial implementation of treatment with intravenous tissue plasminogen activator (tPA) within 4.5 h after acute stroke onset results in potentially eligible patients not receiving optimal treatment. The goal of this study was to review the performance of various organisational models of acute stroke care delivery, and subsequent attempts to improve implementation of tPA treatment. Publications comprehensively reporting on organisational models to improve implementation of i.v. tPA treatment of acute ischemic stroke patients were selected. The efficacy of organisational models was assessed using process outcome measures: thrombolysis rates, time-dependent operational endpoints (time delays), functional outcomes: safety (rate of symptomatic intracranial hemorrhage, mortality rates) and clinical outcome at 90 days (modified Rankin Scale). Fifty-eight published studies assessing organisational models were identified. Four dominant models of acute stroke care delivery were discerned, i.e., primary and comprehensive stroke centres, telemedicine, and the mobile stroke unit. Performance reported for these models suggest a large variation in administration of thrombolytic therapy (0.7-30 %). Time delays and functional outcomes found varied considerably, just like safety and mortality (0.0-11.5 %, and 3.4-31.9 %, respectively). These findings suggest that improving organisational models for tPA treatment may improve acute stroke care. However, implementation may be hampered by regional variation in acute stroke care capacity, expertise, and a fragmented approach towards organising stroke care.
Department of Neurology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, P.O. Box 30001, 9700 RB, Groningen, The Netherlands. m.m.h.lahr@umcg.nl
Maarten M H
MM
Lahr
Gert-Jan
GJ
Luijckx
Patrick C A J
PC
Vroomen
Durk-Jouke
DJ
van der Zee
Erik
E
Buskens
D002545:Brain Ischemia / Q000150:complications; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D017146:Models, Organizational; D020521:Stroke / Q000188:drug therapy* / Q000209:etiology; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D016896:Treatment Outcome
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator