Fast-Track Systems Improve Timely Carotid Endarterectomy in Stroke Prevention Outpatients.
BACKGROUND
For optimal stroke prevention, best practices guidelines recommend carotid endarterectomy (CEA) for symptomatic patients within two weeks; however, 2013 Ontario data indicated that only 9% of eligible patients from outpatient Stroke Prevention Clinics (SPCs) achieved this target. The goal of our study was to identify modifiable system factors that could enhance the quality and timeliness of care among patients needing urgent CEA.


METHODS
We conducted a retrospective chart review of transient ischemic attack/stroke patients assessed in Champlain Local Health Integrated Network SPCs between 2011 and 2014 who subsequently underwent CEA. Descriptive statistics were used to define patient characteristics, timelines from symptom onset to CEA, and system factors that contributed to delays or improvements in care. Multivariate analysis was used to determine statistically significant variations between groups.


RESULTS
Seventy-five records were eligible for study inclusion. Median time from initial symptoms to CEA was 31 days, with 21.3% of patients undergoing surgery within 2 weeks. Significant delays were common in patient presentation and assessment following symptom onset, wait times for vascular imaging and neurological assessment, and time from surgical assessment to CEA completion. Rapid testing and triage, coupled with collaborative initiatives among SPC, surgical, and radiology teams were associated with significantly improved timelines.


CONCLUSIONS
Success factors for rapid CEA are multifaceted, including system changes that address public awareness of stroke and 911 response, improvements in vascular imaging access, and redesign of clinical services to promote collaboration and fast-tracking of care. Implementation of performance measures to monitor and guide clinical innovations is recommended.
1The Ottawa Hospital, Champlain Regional Stroke Network,Ottawa Hospital Research Institute,Ottawa,Ontario,Canada.
Sophia
S
Gocan
1The Ottawa Hospital, Champlain Regional Stroke Network,Ottawa Hospital Research Institute,Ottawa,Ontario,Canada.
Aline
A
Bourgoin
2Saint John Regional Hospital,Horizon Health Network,Division of Neurology,Saint John,New Brunswick,Canada.
Dylan
D
Blacquiere
3Ottawa Stroke Research Group, Ottawa Hospital Research Institute,Ottawa,Ontario,Canada.
Rany
R
Shamloul
4The Ottawa Hospital,Division of Neurology,Ottawa Hospital Research Institute,Ottawa,Ontario,Canada.
Dar
D
Dowlatshahi
4The Ottawa Hospital,Division of Neurology,Ottawa Hospital Research Institute,Ottawa,Ontario,Canada.
Grant
G
Stotts
D000368:Aged; D000369:Aged, 80 and over; D016208:Databases, Factual / Q000706:statistics & numerical data; D016894:Endarterectomy, Carotid / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D002546:Ischemic Attack, Transient / Q000150:complications / Q000601:surgery*; D008297:Male; D017063:Outcome Assessment, Health Care; D010045:Outpatients; D012189:Retrospective Studies; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*; D013997:Time Factors
Carotid endarterectomy; Cerebrovascular disease; Stroke prevention
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