Workflow Intervals of Endovascular Acute Stroke Therapy During On- Versus Off-Hours
Authors: Hinsenveld Wouter H. , de Ridder Inger R. , van Oostenbrugge Robert J. , Vos Jan A. , Groot Adrien E. , Coutinho Jonathan M. , Lycklama à Nijeholt Geert J. , Boiten Jelis , Schonewille Wouter J. ,   on behalf of the MR CLEAN Registry Investigators, Dippel Diederik W.J. , van der Lugt Aad , Majoie Charles B.L.M. , Roos Yvo B.W.E.M. , van Zwam Wim H. , Jansen Ivo G.H. , Mulder Maxim J.H.L. , Goldhoorn Robert-Jan B. , Compagne Kars C.J. , Kappelhof Manon , Majoie Charles B.L.M. , Wermer Marieke J.H. , van Walderveen Marianne A.A. , Staals Julie , van Zwam Wim H. , Hofmeijer Jeannette , Martens Jasper M. , Roozenbeek Bob , Emmer Bart J. , de Bruijn Sebastiaan F. , van Dijk Lukas C. , van der Worp H. Bart , Lo Rob H. , van Dijk Ewoud J. , Boogaarts Hieronymus D. , de Kort Paul L.M. , Peluso Jo J.P. , van den Berg Jan S.P. , van Hasselt Boudewijn A.A.M. , Aerden Leo A.M. , Dallinga René J. , Uyttenboogaart Maarten , Eshghi Omid , Schreuder Tobien H.C.M.L. , Heijboer Roel J.J. , Keizer Koos , Yo Lonneke S.F. , den Hertog Heleen M. , Sturm Emiel J.C. , Majoie Charles B.L.M. , van Zwam Wim H. , van der Lugt Aad , van Walderveen Marianne A.A. , Sprengers Marieke E.S. , Jenniskens Sjoerd F.M. , van den Berg René , Yoo Albert J. , Beenen Ludo F.M. , Postma Alida A. , Roosendaal Stefan D. , van der Kallen Bas F.W. , van den Wijngaard Ido R. , van Es Adriaan C.G.M. , Emmer Bart J. , Martens Jasper M. , Yo Lonneke S.F. , Bot Joost , van Doormaal Pieter-Jan , Dippel Diederik W.J. , van der Lugt Aad , Majoie Charles B.L.M. , Roos Yvo B.W.E.M. , van Zwam Wim H. , Hofmeijer Jeannette , Martens Jasper M. , van der Worp H. Bart , Lo Rob H. , Hofmeijer Jeannette , Flach H. Zwenneke , Lingsma Hester F. , el Ghannouti Naziha , Sterrenberg Martin , Puppels Corina , Pellikaan Wilma , Sprengers Rita , Elfrink Marjan , de Meris Joke , Vermeulen Tamara , Geerlings Annet , van Vemde Gina , Simons Tiny , van Rijswijk Cathelijn , Messchendorp Gert , Bongenaar Hester , Bodde Karin , Kleijn Sandra , Lodico Jasmijn , Droste Hanneke , Wollaert M. , Jeurrissen D. , Bos Ernas , Drabbe Yvonne , Aaldering Nicoline , Zweedijk Berber , Khalilzada Mostafa , Venema Esmee , Chalos Vicky , Geuskens Ralph R. , van Straaten Tim , Ergezen Saliha , Harmsma Roger R.M. , Muijres Daan , de Jong Anouk , Berkhemer Olvert A. , Boersc Anna M.M. , Huguet J. , Groot P.F.C. , Mens Marieke A. , van Kranendonk Katinka R. , Treurniet Kilian M. , Tolhuijsen Manon L. , Alves Heitor 
Published: August 2019

Background and Purpose—
Endovascular treatment (EVT) of patients with acute ischemic stroke because of large vessel occlusion involves complicated logistics, which may cause a delay in treatment initiation during off-hours. This might lead to a worse functional outcome. We compared workflow intervals between endovascular treatment–treated patients presenting during off- and on-hours.

Methods—
We retrospectively analyzed data from the MR CLEAN Registry, a prospective, multicenter, observational study in the Netherlands and included patients with an anterior circulation large vessel occlusion who presented between March 2014 and June 2016. Off-hours were defined as presentation on Monday to Friday between 17:00 and 08:00 hours, weekends (Friday 17:00 to Monday 8:00) and national holidays. Primary end point was first door to groin time. Secondary end points were functional outcome at 90 days (modified Rankin Scale) and workflow time intervals. We stratified for transfer status, adjusted for prognostic factors, and used linear and ordinal regression models.

Results—
We included 1488 patients of which 936 (62.9%) presented during off-hours. Median first door to groin time was 140 minutes (95% CI, 110–182) during off-hours and 121 minutes (95% CI, 85–157) during on-hours. Adjusted first door to groin time was 14.6 minutes (95% CI, 9.3–20.0) longer during off-hours. Door to needle times for intravenous therapy were slightly longer (3.5 minutes, 95% CI, 0.7–6.3) during off-hours. Groin puncture to reperfusion times did not differ between groups. For transferred patients, the delay within the intervention center was 5.0 minutes (95% CI, 0.5–9.6) longer. There was no significant difference in functional outcome between patients presenting during off- and on-hours (adjusted odds ratio, 0.92; 95% CI, 0.74–1.14). Reperfusion rates and complication rates were similar.

Conclusions—
Presentation during off-hours is associated with a slight delay in start of endovascular treatment in patients with acute ischemic stroke. This treatment delay did not translate into worse functional outcome or increased complication rates.