Drip and Ship versus Mothership: Transportation and Treatment Strategies for Acute Ischemic Stroke Patients
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2019-07-22
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Abstract
Ischemic stroke with large vessel occlusion can be treated with alteplase and/or endovascular therapy. While endovascular therapy has been proven more effective than alteplase the administration of both treatments is highly time sensitive. There are geographic disparities in access to endovascular therapy. For patients outside the immediate vicinity of a hospital equipped to perform endovascular therapy it is unknown whether transport directly to an endovascular center for alteplase and endovascular therapy (mothership) or transport to the closest centre for immediate alteplase treatment followed by transfer to the endovascular center (drip-and-ship) will result in best patient outcomes. In this thesis, this is explored using theoretical conditional probability. Models were generated using existing data from clinical trials of stroke treatment, the accuracy of prehospital large vessel occlusion screening tools, and time from onset to stroke treatment (a function of both geography and hospital efficiency). The models were used to determine which strategy predicts the greatest probability of excellent outcome for stroke patients in several different scenarios. The optimal transport strategy is influenced by three different factors, the impact of which is summarized as follows from the perspective of the drip and ship approach. First, the most probable diagnosis of the patient. As the positive predictive value of the large vessel occlusion screening tool decreases the importance of the drip and ship model is appreciated. Second, the speed of treatment at the receiving hospitals. Fast treatment at thrombolysis centres is key for the drip and ship model to remain viable. Finally, the patient’s travel time to and between the different hospitals. As the distance between the thrombolysis and endovascular centre increases again the importance of the drip and ship model is realized. This thesis presents a novel way of conceptualizing the pre-hospital transport of suspected stroke patients. Decision-making for pre-hospital transport can be modelled using existing clinical trial data; these models can be dynamically adapted to changing realities. As the radius of superiority of the different transport strategy is context specific regional customization transport protocols for stroke patients is essential.
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Holodinsky, J. K. (2019). Drip and Ship versus Mothership: Transportation and Treatment Strategies for Acute Ischemic Stroke Patients (Doctoral thesis, University of Calgary, Calgary, Canada). Retrieved from https://prism.ucalgary.ca.