Proposed Topic (Most preferred): :
Clinical Safety and Quality Service I (Projects aiming to improve efficiency and effectiveness of care delivery to meet international standards)
Authors (including presenting author) :
CHEUNG CCC(1), KWONG CLJ(2), LUI CKV(2), MAN WY(3), CHAN WK(4)
Affiliation :
(1)Integrated Neurosurgery and Neurology Ward, Department of Neurosurgery, Princess Margaret Hospital, Kowloon West Cluster (2)Acute Stroke Unit, Department of Medicine & Geriatrics, Caritas Medical Centre, Kowloon West Cluster (3)Acute Stroke Unit, Department of Medicine, Yan Chai Hospital, Kowloon West Cluster (4)Accident and Emergency Department, North Lantau Hospital, Kowloon West Cluster
Introduction :
KWC has been providing cluster-based 24-hour intravenous thrombolysis (IVT) service and 8am-8pm intra-arterial mechanical thrombectomy (IAMT) for acute ischemic stroke patients since 2019 and 2021 respectively. KWC stroke nurses have received more than 950 hyperacute stroke initiation (TPA triggers) per year in 2022 and 2023, 200 more triggers comparatively to those in 2019-2021. Around one-third of the TPA triggers resulted in IVT and/or IAMT. To further expand the IAMT service to cover 24 hours by 3Q2023, updated protocol, unified workflow and re-defining roles and responsibilities of different stakeholders across all involved parties were established to facilitate collaboration and coordination. With that the KWC has launched 24-hour cluster-wide reperfusion therapy since 31 Jul 2023.
Objectives :
• To revise the protocol to triage acute stroke patients for eligibility of mode of reperfusion therapy, i.e. IVT and/or IAMT, and selection of imaging modality by stroke nurse assessment. • To unify workflow, roles and responsibilities of different stakeholders across all KWC hospitals to ensure efficient and safe delivery of reperfusion therapy.
Methodology :
• Pilot on new workflow with CT-CTA coupling was done since Dec 2022 in PMH/NLTH and since Mar2023 in CMC/YCH. The selection of imaging modality relies on stroke nurse assessment on patient’s NIHSS and premorbid status by modified Rankin Scale (mRS). Plain CT brain and contrast CT angiogram (CTA) and CT perfusion for acute ischemic stroke patients with good functional premorbid status and suspected large vessel occlusion (LVO) are performed in A&E Department (AED). Patients who are eligible for IAMT are given IVT bridging directly at AED if indicated and then transferred out to PMH for IAMT. It aims to minimize door-to-CTA time and to enhance door-to-groin time for eligible IAMT cases. • Unified assessment forms are used among all KWC hospitals. Such standardization can facilitate collaboration and communication amongst staff in different hospitals and departments. Sister hospitals prepare IAMT cases according to same checklist before transferring to PMH. • The SMART communication tool, a system of submission of a hyperacute stroke referral via HA Chat, is a handy platform for communication between on-site stroke nurse and off-site neurologist. A standardized report, automatically sent via email, serves as a formal documentation on treatment recommendation by neurologist.
Result & Outcome :
• KWC has catered 78 IAMT cases in 2023, 48 of which were performed after 24-hour IAMT service was commenced on 31 Jul 2023. Compared to 28 IAMT cases in 2022, it shows a significant increase in the number of IAMT. • Mean door-to-CTA time was reduced to 43 minutes from > 60 minutes after workflow on CT-CTA coupling was commenced. The time-lag between CT brain and CTA was reduced to 0-10minutes. • The mean door-to-groin (DTG) time during office hours in PMH in 2023 is 98 min while it was 142 min in 2022. Mean DTG time during non-office hours in 2023 after 24-hour IAMT service was commenced was 154 min. • Compared to DTG of transfer-in cases from sister hospitals during office hours, mean DTG time in 2023 was 150 min while in 2022 it was 201min. Mean DTG time of transfer-in cases during non-office hours in 2023 after 24-hour IAMT service was commenced was 194 min
