Effect of Pre-Hospital Workflow Optimization on Treatment Delays and Clinical Outcomes in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.

Background The prehospital phase is critical in ensuring that stroke treatment is delivered quickly and is a major source of time delay. This study sought to identify and examine Pre-Hospital Stroke Workflow Optimizations (PSWO) and their impact on improving health systems, reperfusion rates, treatment delays, and clinical outcomes. Methods The authors conducted a systematic literature review and meta-analysis by extracting data from several research databases (PubMed, Cochrane, Medline, and Embase) published since 2005. We used appropriate key search terms to identify clinical studies concerning prehospital workflow optimization, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results The Authors identified 27 articles that looked at the impact of pre-hospital workflow optimizations on time and treatment parameters, 26 were included in the meta-analysis. The PSWO were sub-grouped into 3 categories: Improved Intravenous Thrombolysis (IVT) Triage, Large Vessel Occlusion (LVO) bypass, and Mobile Stroke Unit (MSU). The salient findings are: Improved IVT Triage led to significantly improved rates of IVT (RR=1.80; 95% CI, 1.18-2.75); however, MSU did not (RR=1.22; 95% CI, 0.98-1.52). Improved IVT Triage (SMD=-0.82; 95% CI, -1.32 - -0.32), LVO bypass (SMD=-0.80; 95% CI, -1.13- -0.47) and MSU (SMD=-0.87; 95% CI, -1.57 - -0.17) were found to significantly reduce door to needle time for IVT. MSU was found to significantly reduce call to needle (SMD=-1.41; 95% CI, -1.94 - -0.88) and onset to needle (SMD= -1.15; 95% CI, -1.74- -0.56) times for IVT. MSU additionally demonstrated significant reduction in door to perfusion (SMD= -0.72; 95% CI, -1.32 - -0.12) as well as call to perfusion (SMD= -0.73; 95% CI, -1.08- -0.38) times for EVT. Finally, PSWO did not demonstrate significant improvements in rates of good functional outcome (RR=1.04; 95% CI, 0.97-1.12) or mortality at 90 days (RR=1.00; 95% CI, 0.76-1.31). Conclusions This systematic review and meta-analysis found that PSWO significantly improves several time metrics related to stroke treatment leading to improvement in IVT reperfusion rates. Thus, the implementation of these measures in stroke networks is a promising avenue to improve an often-neglected aspect of the stroke response. However, the limited available data suggest functional outcomes and mortality are not significantly improved by PSWO, hence further studies and improvement strategies vis a vis PSWOs are warranted.