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ESOC 2022 | Improving time to thrombectomy with the flying intervention team model

Endovascular thrombectomy is the gold standard treatment approach for appropriately selected patients with acute ischemic stroke, up to 24 hours from symptom onset. The evidence is clear that timing is crucial and for the many patients living in rural areas, rapid access to thrombectomy is unavailable. Gordian J. Hubert, MD, Academic Teaching Hospital of the Ludwig-Maximilians-University of Munich, Munich, Germany, discusses an alternative approach to the conventional drip-and-ship model: the flying intervention team. In this model, an intervention team are flown to the local stroke center to perform thrombectomy on site, rather than patients travelling to comprehensive stroke centers. A newly published study, comparing deployment of a flying intervention team versus standard patient interhospital transfer, aimed to see if this model is associated with a shorter time to thrombectomy. Data from 157 patients shows an improvement in median time to thrombectomy of 90 minutes in the flying team, compared to the transfer team. Questions remain regarding the applicability to other geographic setting and healthcare systems, and further research is underway to understand the long-term clinical outcomes of this model. This interview took place at European Stroke Organisation Conference 2022 in Lyon, France.

Transcript (edited for clarity)

Yes, this is the approach of the flying intervention team, as we called it. I work with a largely rural population. We work together with many rural hospitals that do not have access to thrombectomy and especially do not have fast access to thrombectomy. When we learned that thrombectomy is efficient and is time dependent, we really had to rethink our whole system. Can we really decentralize stroke care as we’ve done it so far? There are two conventional ways of how to treat these patients...

Yes, this is the approach of the flying intervention team, as we called it. I work with a largely rural population. We work together with many rural hospitals that do not have access to thrombectomy and especially do not have fast access to thrombectomy. When we learned that thrombectomy is efficient and is time dependent, we really had to rethink our whole system. Can we really decentralize stroke care as we’ve done it so far? There are two conventional ways of how to treat these patients. The first is the drip-and-ship model, where you bring the patient to this closest stroke unit in the area and then once you identify that he’s somebody who needs thrombectomy, you transfer him to a big center, comprehensive stroke center, or the mothership approach where you triage in the field. On scene, you triage him and if he’s likely to have a large vessel occlusion, you send him to the comprehensive stock center. These two models both have disadvantages. We sat together and developed a new system of care for these patients and that is what we call the flying intervention team.

We set a set up intervention team of neurointerventionists and their angiography assistants in our center in Munich. And we got funding for a helicopter and a pilot crew. Once we identify via telemedicine that there is a patient in need of thrombectomy, we would alert the intervention team and they would jump into the helicopter, fly out to that rural hospital and perform thrombectomy on site. Then they would return and the patient stays in that local hospital for further care. So we reverse the system. We don’t transfer the patient, we transfer the team.

We have done a study of the first 19 months of this project. And it’s been published in JAMA today where we compared the flying intervention team deployment versus the conventional drip-and-ship model, the interhospital transfer. One week we had the service on and the next week we had just the transfer system available for the patients. And so we had a control group. We compared these two groups and what we wanted to find out is whether there’s a time difference, whether we are able to treat patients faster with this new model of care.

And we found out that we are faster by 90 minutes when we fly out, instead of transferring. The transfer process always takes a long time because patients have to be prepared for the transfer. The transportation vehicle has to come, they have to be transferred. Then they have to be, I want to say, unwrapped in the next center and re-evaluated, and then they go to the angio. And so this takes a long time. When we fly there, we can do these processes in parallel. While the intervention team is flying there, the hospital can already prepare the patient in the angio. Everything can be done at the same time and then sort of once the intervention team comes, they can straight away start with the procedure. So parallelization of the process is really the key to why this is so much faster.

As far as I know, we’re the only project so far who’ve set up this kind of system of care. And we cannot say much about generalizability of this study. This has been studied only in Germany, within our telestroke network. We have very specific approach to these networks. We do a lot of quality management. We do this video conferencing for them. They have a very special quality of care for the stroke patients. We do not know whether we can transfer this to other hospitals or other areas in the world. We’ll need to find out really, and we need to have other people setting this up, to know more about it. And also what level of care do these primary stroke centers need to have to really perform thrombectomy and to be on the safe side there. Now in our study, we had a low complication rate during the procedure, but also afterwards during the in-hospital stay. That was very equal to our comprehensive stroke centers. We are quite comfortable in treating these patients out there.

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