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Review
. 2024 Oct;24(10):495-505.
doi: 10.1007/s11910-024-01367-6. Epub 2024 Aug 16.

Hyper-Acute Stroke Systems of Care and Workflow

Timothy J Kleinig  1 , Patrick McMullan  2 , Geoffrey C Cloud  3   4 , Prof Christopher Bladin  5 , Anna Ranta  6   7
Affiliations
Review

Hyper-Acute Stroke Systems of Care and Workflow

Timothy J Kleinig et al. Curr Neurol Neurosci Rep. 2024 Oct.

Abstract

Purpose of review: Recent stroke treatment advances have necessitated agile, broad-scale healthcare system redesign, to achieve optimal patient outcomes and access equity. Optimised hyperacute stroke care requires integrated pre-hospital, emergency department, stroke specialist, radiology, neurosurgical and endovascular neurointervention services, guided by a population-wide needs analysis. In this review, we survey system integration efforts, providing case studies, and identify common elements of successful initiatives.

Recent findings: Different regions and nations have evolved varied acute stroke systems depending on geography, population density and workforce. However, common facilitators to these solutions have included stroke unit care as a foundation, government-clinician synergy, pre-hospital pathway coordination, service centralisation, and stroke data guiding system improvement. Further technological advantages will minimize the geographical distance disadvantages and facilitate virtual expertise redistribution to remote areas. Continued treatment advances necessitate an integrated, adaptable, population-wide trans-disciplinary approach. A well-designed clinician-led and government-supported system can facilitate hyperacute care and scaffold future system enhancements.

Keywords: Geographical disparity; Learning health care system; Stroke; Systems of care; Telemedicine.

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Conflict of interest statement

TK was head of the RAH during and following system reorganisation, is the current chair of the SA State Stroke Community of Practice and was the Clinical Lead establishing the SA/NT Telestroke service. GC was a member of the Healthcare for London Cardiovascular Board which oversaw the London change and was also Clinical Lead for Southwest London Stroke Clinical Network, responsible for implementation. CB was the inaugural Chair of the Victorian Stroke Clinical Network in the Victorian Department of Health (2007) which led to the establishment of the Victorian Stroke Telemedicine (VST) service with Federal funding support in 2013. He is currently the Director of VST in Ambulance Victoria and has an active leadership role in the Australian Stroke Alliance. AR reports personal fees from Dr Ranta reports personal fees from New Zealand Ministry of Health in her role as the National Clinical Leader for Stroke, Chairing the National Stroke Network, and subsequently Co-Chairing the National Hyperacute Stroke Program during periods of implementation discussed in this article. PM has no competing interests.

Figures

Fig. 1
Fig. 1
Idealised LVO Stroke pathway for Comprehensive and Primary Stroke Centre. Common idealised elements regardless of patient initial hospital presentation include an immediate call to emergencies services by an educated ‘F.A.S.T.’ (Face, Arm, Speech, Time)-aware bystander, followed by rapid ambulance despatch facilitated by the call-taker. Ambulance services extract the patient quickly, and (if CT-enabled) can perform on-site neuroimaging, distinguish ischaemic stroke from ICH, identify large vessel occlusion, and administer thrombolytic and/or other acute stroke treatments as indicated, assisted potentially by telemedicine. If taken to the CSC, either through proximity or due to suspected or proven LVO, then the patient should be taken straight to the CT on the ambulance stretcher, with thrombolytic administered within 30 min of arrival. The EVT team should be notified immediately once LVO is demonstrated (or highly suspected) and mobilise rapidly to perform thrombectomy within an hour of arrival. If taken to the PSC, thrombolytic should again be administered within 30 min of arrival, with CSC contacted promptly if LVO is detected. As the ambulance crew has taken the patient directly to the CT scanner, the same ambulance bed and crew (if transporting via road) should then promptly take the patient to the CSC, departing within 60 min of arrival, and transporting the patient directly to the EVT suite, where EVT can be performed immediately, as the interventionalist has been mobilised while the patient is en route. All patients should then receive certified stroke unit care. CT = Computed Tomography, tPA = tissue Plasminogen Activator. CSC = Comprehensive Stroke Centre, PSC= Primary Stroke Centre, DIDO = Door-In-Door-Out.
See this image and copyright information in PMC

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