Systematic review of stroke thrombolysis service configuration

Abstract

Intravenous recombinant tissue plasminogen activator is a highly effective treatment for acute ischemic stroke, but routine provision is challenging. We compared the activity, safety and response times of five service configurations: local services, redirection of selected or all suspected stroke patients by emergency medical services (EMS) to stroke centers and the use of telemedicine with and without secondary transfer to a stroke center. In total, 59 relevant service descriptions were identified. Pooled treatment rates (mean ± standard deviation [SD]) per 100 confirmed stroke patients were: local service design, 2.5 ± 2.5 (n = 21417); EMS redirection of only patients potentially eligible for thrombolysis, 3.9 ± 1.2 (n = 1872); EMS redirection of all suspected stroke patients, 3.8 ± 1.1 (n = 5427); telemedicine with secondary transfer, 6.9 (no pooled SD; n = 749); and telemedicine without secondary transfer, 3.4 (no pooled SD; n = 6610). A comprehensive stroke patient register was completed for only five regional collaborations, resulting in pooled ischemic stroke treatment rates of 5.7 (95% confidence interval: 4.6–6.9; n = 7815) compared with 3.1 (95% confidence interval: 2.1–4.1; n = 31411) for local services. Pooled symptomatic hemorrhage rates were similar for all service designs (range: 3.9–5.1%). Average door–needle times exceeded 60 min in most studies. We conclude that regional collaborations achieve higher rates of thrombolysis than local services working in isolation. Stroke services should continue to publish thrombolysis activity and safety data in a recommended format in order to determine the most suitable configuration for different settings.

Keywords::

• emergency medical service
• health service
• stroke
• stroke center
• thrombolytic therapy
• tissue plasminogen activator

Financial & competing interests disclosure

This review was funded by an NIHR Programme Grant for Applied Research (RP-PG-0606-1241). The views and opinions expressed here are those of the authors and do no necessarily reflect those of the Department of Health. G Ford and his employing institution have received research grants, honoraria for clinical trial, consultancy and educational activities from Boehringer Ingelheim, the manufacturer of alteplase. F Clement is supported by a postdoctoral fellowship from the Canadian Health Services Research Foundation and the Alberta Heritage Foundation for Medical Research. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of the manuscript.