Background
Methods
Procedure for Delphi exercise
Below we present a description of 12 potential options for delivering thrombectomy with an explanatory footnotes (where required). Please score each of the 12 options using a 7-point Likert scale: |
1. Any local provider “ad hoc”a |
2. Any local provider delivers IAT on a formal rotab |
3. Transfer to nearest primary coronary percutaneous intervention unit and cardiology managec |
4. Transfer to nearest primary coronary percutaneous intervention unit and shared care with stroke physiciansd |
5. Ambulance bypass for all acute stroke patients of known time onset to comprehensive stroke unit where advanced imaging and “expert intra-arterial thrombectomy [IAT]” are available 24/7e |
6. Local CT and transfer all patients with NIHSS ≥10 to the nearest neuroscience centre for interventional neuroradiologist delivered “expert thrombectomy”f |
7. Local CT/CTA then transfer all large artery occlusive stroke patients to nearest neuroscience centre for interventional neuroradiologist delivered “expert thrombectomy”g |
8. Local advanced imaging then selective transfer to nearest neuroscience centre for “expert thrombectomy”h |
9. Local CT/CTA then transfer large artery occlusive stroke patients to nearest neuroscience centre for advanced imaging and “expert thrombectomy” |
10. Advanced imaging performed locally but interpreted centrally by Neuroradiology then selective transfer to nearest neuroscience centre for “expert thrombectomy” |
11. Selective transfer to nearest on call neuroscience centre for “expert thrombectomy”i |
12. Interventional neuroradiologist and necessary support team on standby in Neuroscience centre – they transfer to patient’s hospital to deliver expert intra-arterial thrombectomy when large arterial occlusion stroke is confirmedj |
Procedure for ranking exercise
Percentage Responses | |||||||
---|---|---|---|---|---|---|---|
Proposition Number (from original list in Table 1) | 1 very strongly disapprove | 2 quite strongly disapprove | 3 disapprove | 4 neutral | 5 Approve | 6 quite strongly approve | 7 very strongly approve |
2. Any local provider delivers IAT on a formal rota |
55
|
18
|
27
| ||||
4. Transfer to nearest primary coronary percutaneous intervention unit and shared care with stroke physicians |
18
|
18
|
37
|
18
|
9
| ||
5. Ambulance bypass for all acute stroke patients of known time onset to comprehensive stroke unit where advanced imaging and “expert intra-arterial thrombectomy [IAT]” are available 24/7 |
9
|
55
|
18
|
18
| |||
6. Local CT and transfer all patients with NIHSS ≥10 to the nearest neuroscience centre for interventional neuroradiologist delivered “expert thrombectomy” ** |
9
|
27
|
27
|
27
| |||
7. Local CT/CTA then transfer all large artery occlusive stroke patients to nearest neuroscience centre for interventional neuroradiologist delivered “expert thrombectomy” ** |
27
|
37
|
27
| ||||
8. Local advanced imaging then selective transfer to nearest neuroscience centre for “expert thrombectomy” |
18
|
18
|
18
|
37
|
9
| ||
9. Local CT/CTA then transfer large artery occlusive stroke patients to nearest neuroscience centre for advanced imaging and “expert thrombectomy” |
18
|
18
|
46
|
18
| |||
10. Advanced imaging performed locally but interpreted centrally by Neuroradiology then selective transfer to nearest neuroscience centre for “expert thrombectomy” |
9
|
27
|
9
|
46
|
9
| ||
11. Selective transfer to nearest on call neuroscience centre for “expert thrombectomy” |
36
|
46
|
18
|
Wider BASP members (N = 43) Percentage Responses | |||||||
Using your experience and judgement, please take the following elements into consideration when assigning scores to the options: availability; practicality/deliverability; and cost (including of any additional software or hardware likely to be required in your region) | 1 very strongly disapprove | 2 quite strongly disapprove | 3 disapprove | 4 neutral | 5 approve | 6 quite strongly approve | 7 very strongly approve |
1. Patients with large artery occlusive stroke are transferred to nearest [neuroscience] centre for thrombectomy based on local CT/CTA alonea |
2
|
21
|
53
|
23
| |||
2. Patients are transferred to nearest [neuroscience] centre for thrombectomy based on advanced imaging obtained at referring hospitalb |
12
|
5
|
16
|
23
|
21
|
16
|
7
|
3. Selective transfer to nearest on call [neuroscience] thrombectomy centre for expert thrombectomyc |
16
|
19
|
12
|
19
|
14
|
12
|
9
|
Using your experience and judgement, please take the following elements into consideration when assigning scores to the options: availability; practicality/deliverability; and cost (including of any additional software or hardware likely to be required in your region) Whilst options 2 & 3 are both “Advanced Imaging Triage” they may differ in deliverability, cost & practicality so they have been separated out for this exercise. There is of course uncertainty over the strength of evidence supporting either option | Full members of the BSNR (N = 21) Percentage Responses | ||||||
1. Patients are transferred for thrombectomy based on local CT/CTA aloned |
5
|
5
|
5
|
19
|
29
|
38
| |
2. Patients are transferred for thrombectomy based on formal ASPECTS & Collateral Scoring in addition to confirming large artery occlusion present - “Advanced Imaging Triage ACS”e** |
24
|
29
|
14
|
14
|
14
| ||
3. Patients are transferred for thrombectomy based on CT Perfusion parameters in addition to confirming large artery occlusion present - “Advanced Imaging Triage PERFUSION”f** |
14
|
19
|
38
|
14
|
10
| ||
4. Selective transfer to nearest on call neuroscience centre for “expert thrombectomy”g |
5
|
29
|
5
|
29
|
5
|
29
|