Inclusion of Hospital Performance in Prehospital Stroke Routing: A Simulation Study

OBJECTIVES: Prehospital routing decisions for patients with suspected stroke are complex, and consideration of actual hospital performance data for door-to-needle and door-to-puncture times for thrombolysis and endovascular thrombectomy (EVT) may impact on-scene decision making. We sought to determine whether optimal routing destinations for patients with suspected stroke in the prehospital setting differ between three strategies: 1) American Heart Association (AHA) consensus recommendations, 2) personalized decision modeling without hospital-specific performance data (base model) and 3) with inclusion of actual hospital data for door-to-needle and door-to-puncture times for thrombolysis and EVT (enhanced model). METHODS: Our previously published decision-analytic model (base model) incorporates geographic, patient, and hospital data to determine optimal transport destination, using a standard distribution of thrombolysis and EVT times by hospital type (primary vs comprehensive stroke center). We enhanced the model by incorporating real hospital performance data on thrombolysis and EVT treatment times from all Northeast United States Get with the Guidelines-Stroke hospitals (enhanced model). We generated 500 probable pick-up locations with 800 patient profiles of varying age, stroke severity, and last known well time, giving 400,000 patient-location scenarios. For each scenario we determined the optimal destination based on AHA consensus recommendations and from 1000 simulations each using base and enhanced models to determine the optimal destination for each strategy. We compared destination recommendations and examined conditions under which results changed. RESULTS: Of the 400,000 patient-location scenarios, 56.1% and 63.1% of routing destinations were different from the consensus recommendations in the base and enhanced models, respectively, as patients were more often directed to hospitals with faster times to reperfusion. Higher stroke severity and greater odds of large vessel occlusion were associated with concordance of recommendations. CONCLUSIONS: Prehospital routing models for patients with suspected stroke may benefit from inclusion of actual hospital performance characteristics.