Protocol approaches negate the "weekend effect" for endovascular stroke treatment.

Abstract

Background: Endovascular management of stroke from acute large vessel occlusion (LVO) requires complex, emergent diagnostic and therapeutic procedures. The "weekend effect" (worsened outcomes from stroke presenting on weekends or evenings) is a recognized phenomenon, attributed to nonuniform availability of services throughout the week. We assessed the impact of institutional protocols for stroke patients undergoing endovascular therapy during off hours. Method(s): We analyzed a prospective observational stroke database for consecutive patients with anterior circulation stroke undergoing endovascular therapy between 6/2012 and 10/2015. Patients were grouped and analyzed based on day of the week and time of presentation to the emergency department. Off-hours were considered between 1900hrs and 0700hrs on weekdays and 1900hrs on Friday to 0700hrs on Mondays for weekends. Functional outcome was assessed prospectively by 3 month modified Rankin scale (mRS), dichotomized into good (mRS 0-2) versus poor (mRS 3-6). Result(s): In a cohort of 129 patients, 75 (58%) patients were treated off-hours. Patients treated offhours demonstrated equivalent imaging to groin puncture times (78 vs 72 min, p = 0.4) and procedure durations (75 vs 68 min, p = 0.3). Reperfusion rates (TICI 2b or 3) were 68% off hours and 76% during working hours (p = 0.4). Complication rates were similar between the two groups. Outcome at 90 days was no different in the patients treated off hours, with 35 of 75 treated off-hours achieving a good outcome (mRS 0-2) compared to 22 of 54 treated during working hours (p = 0.6). With protocol adherence, temporal improvement was noted in imaging to groin times. Discussion/Conclusions: Following recent evidence of benefit from endovascular therapy for LVOs there is increased attention to care delivery. Our findings demonstrate that under the guidance of protocols, the "weekend effect" was negated. Evaluation and treatment times, and 90 day outcomes were equivalent in patients treated off- vs business hours, with improving treatment times as familiarity with protocols increased. Our findings highlight the importance of establishing institutional and regional protocols in the optimized management of these patients.