Improve acute care for stroke victims by improving the chain as a whole

Stroke patients have a better chance of receiving thrombolysis in a region where medical care for this group has been centralized. The number of patients that can be treated with thrombolysis in time (i.e. within 4.5 hours of the onset of a stroke) increases from 14% to 22% when medical care is centralized. Improvements in the trajectory prior to arrival in hospital is one of the main factors. These are the conclusions of research conducted by Maarten Lahr of the UMCG. Lahr would like to see the entire chain of acute medical care for stroke patients (from the first symptoms and emergency telephone call, through to administering drugs) analysed and improved. He will be awarded a PhD by the University of Groningen on 18 November.

Lahr carried out his research in the North of the Netherlands, working closely with 14 hospitals, the ambulance services and emergency GP services who were willing to share their working practices. He compared a region where all patients went to a central hospital with a region where every patient went to his or her local hospital (decentralized model).

Variation

Every year, more than 30,000 people in the Netherlands suffer an ischemic stroke. Another 10,000 have a haemorrhagic stroke. Both types are known simply as strokes. Only patients who have suffered an ischemic stroke can be treated with thrombolysis. According to Lahr, the number of patients given thrombolysis in Dutch hospitals varies from 5% to 15%. The main reason for these low figures is that patients often arrive in hospital too late.

Chain

Lahr found differences between the two models for acute medical care for strokes. ‘Ambulances were used more often in the centralized model, and more patients were given high priority for ambulance transport’, explains Lahr. ‘Although the journey to hospital took longer in the centralized model, the treatment on arrival in the central, specialized hospital was much faster, making up for the longer journey time.’ Some Dutch hospitals have coordinated their acute care with partners in the chain very closely, and achieve good results by administering thrombolysis, but this is not the case everywhere in the Netherlands. Lahr thinks that it would certainly be worth investigating whether a centralized organization model in these areas would produce the same results as in the North of the Netherlands.

Diagnosis

Time is a decisive factor in the recovery of a patient having a stroke. ´Thrombolysis is highly effective because it dissolves the blood clot, but it must be administered within 4.5 hours of the first symptoms’, says Lahr. ‘A test to determine whether the stroke was caused by a blood clot or a cerebral bleed is the first step. Thrombolysis is only appropriate in the case of blood clot.’ To make the right diagnosis, a CT scan of the brain is carried out in hospital.

Social debate

Lahr’s research fits in well with current social debate on the specialization and concentration of hospital care. ‘Acute care for stroke patients is a relevant topic in discussions about the quality of hospital care. This research shows that we need to study the entire chain and relate this to the outcomes of patient care’, continues Lahr. ‘Figures from 2012 show that throughout the Netherlands, an average of 14% of stroke victims are given thrombolysis. Our research shows that we could increase the percentage of patients receiving this vital treatment if we were to improve the chain organization as a whole.’

Curriculum Vitae

Maarten Lahr (Groningen, 1981) studied Movement Sciences and Neurosciences at the University of Groningen. He conducted his research in the Neurology Department of the University Medical Center Groningen (UMCG) and the Business Administration Department of the University of Groningen, as part of the Graduate School of Medical Sciences. Lahr’s research was funded by the Netherlands Organisation for Health Research and Development (ZonMw) and supervised by Prof. E. Buskens, Dr G.J. Luijckx, Dr P.C.A.J. Vroomen and Dr D.J. van der Zee. His thesis is entitled ‘Organizational models for thrombolysis in acute ischemic stroke: a simulation exemplar.’ Since completing his PhD research, Lahr has worked as a member of the Healthy Ageing project team at the UMCG, more specifically on the E-Health theme.