Analysis of Workflow and Time to Treatment on Thrombectomy Outcome in the ESCAPE Randomized Controlled Trial
Background—The ESCAPE trial used innovative imaging and aggressive target time metrics to demonstrate benefit of endovascular treatment in patients with acute ischemic stroke. We analyze the impact of time on clinical outcome and the effect of patient, hospital and health system characteristics on workflow within the trial.
Methods and Results—Relationship between outcome [modified Rankin Scale (mRS)] and interval times was modeled using logistic regression. Association between time intervals (stroke onset to arrival in endovascular capable hospital, to qualifying CT, to groin puncture and to reperfusion) and patient, hospital and health system characteristics were modeled using negative binomial regression. Every 30-minute increase in CT-to-reperfusion time reduced the probability of achieving a functionally independent outcome (90 day mRS 0-2) by 8.3%. (p=0.006). Symptom-onset-to-imaging time was not associated with outcome (p>0.05). Onset to endovascular hospital arrival time was 42% (34 mins) longer among patients receiving intravenous alteplase at the referring hospital (drip and ship) vs. direct transfer (mothership). CT-to-groin-puncture time was 15% (8 mins) shorter among patients presenting during work hours vs. off hours, 41% (24 min) shorter in drip-ship patients vs. mothership and 43% (22 min) longer when general anesthesia was administered. Balloon-guide-catheter use during endovascular procedure shortened puncture-to-reperfusion time by 21% (8 mins).
Conclusions—Imaging-to-reperfusion time is a significant predictor of outcome in the ESCAPE trial. Inefficiencies in triaging, off-hour presentation, intravenous alteplase administration, GA utilization and endovascular techniques offer major opportunities for improvement in workflow.
Clinical Trial Registration Information—clinicaltrials.gov. Identifier: NCT01778335.
- Received October 18, 2015.
- Revision received April 5, 2016.
- Accepted April 8, 2016.