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Abstract WP300: Optimal Prehospital Stroke Triage is Highly Dependent on Individual Hospital Reperfusion Times


 Background:
 Prehospital routing decisions for patients with suspected stroke depends on many factors. Past decision modeling analyses have incorporated patient and hospital characteristics such as age, stroke severity, and average door-to-reperfusion times. However, these models do not include actual hospital performance data. We sought to determine whether inclusion of actual hospital data for door-to-needle and door-to-puncture times for thrombolysis (tPA) and thrombectomy (EVT) affects optimal routing destinations.
 
 
 Methods:
 Our previously published simulation model incorporates geographic, patient, and hospital data to determine optimal transport destination, using a standard distribution of tPA and EVT times by hospital type (PSC vs CSC). We enhanced the model using actual hospital performance data on tPA and EVT treatment times from all Northeast Get with the Guidelines Stroke hospitals. We used 1000 patient locations based on census density with 10 levels of stroke severity at each location, running 2,000 simulations for each hypothetical scenario (20 million simulations per model version) to determine the optimal treatment destination. We compared model recommendations from the 2 versions to determine if the results changed with use of actual hospital data. Potential gains to patients were calculated using quality-adjusted life years.
 
 
 Results:
 Of the 10,000 simulated scenarios, 2170 scenarios (21.7%) had the same optimal destination in both model versions. Of the 7830 scenarios with changed recommendations, 542 (6.9%) scenarios had a change from PSC to CSC recommendation, 2927 (37.3%) from CSC to PSC, and 4361 (55.7%) changed within group from one PSC to another, or from one CSC to another. Likelihood and type of recommendation change did not vary significantly by stroke severity. Optimized hospital destination led to gains of up to 78 quality-adjusted days relative to the baseline model.
 
 
 Conclusion:
 Prehospital routing models for patients with suspected stroke may benefit from inclusion of actual hospital performance characteristics. In our model, this resulted in more than a third of patients switching from CSC to PSC and keeping initial care local. Further replication is needed to avoid patient harm and potential overtriage to CSC.
