Stroke Pathway impact on healthcare processes and outcomes: a retrospective observational study

BACKGROUND AND AIM: The Stroke Pathway performance assessment is a key quality improvement element in healthcare. The aim of this study was to carry out a retrospective assessment of the Stroke Pathway in a first level Stroke Unit in Northern Italy and the possible impact of the COVID-19 pandemic. METHODS: A retrospective observational study was carried out analysing data from 1/01/2010 to 31/12/2020. Data considered were: case volume and characteristics of patients undergoing intravenous thrombolysis, baseline modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS) scores, Onset-to-Door (OTD), Door-To-Imaging (DTI) and Door-To-Needle (DTN) Times, mRS score 3 months after the ischemic event onset (3m-mRS) and NIHSS score 24 hours after the ischemic event onset (24h-NIHSS). The study also compared the pre-COVID-19 pandemic period (March-December 2019) with the one following it (March-December 2020). RESULTS: During the considered 10 years range, 418 patients underwent pharmacological thrombolysis. Treatment was extended to older patients (mean age from 66.3 to 75.51 years; p = 0.006) and with a higher baseline disability level (from 0.22 to 1.22; p = 0.000). A statistically significant reduction was found for DTN (from 90 to 61 minutes average value; p = 0.000), so that in 2019 more than 50% and in 2020 more than 60% of patients were treated within 60 minutes (golden hour). Comparing pre- and COVID-19 pandemic periods, the number of patients remained almost unchanged, but with a significantly higher baseline disability (mRS=1.18 vs 0.72, p = 0.048). The OTD increased from 88.13 to 118.48 minutes, although without a statistically significant difference (p = 0.197). CONCLUSIONS: The study highlighted the Stroke Pathway positive impact, even during the COVID-19 pandemic, both on healthcare processes and patients’ outcomes. Nevertheless, both of them could be further improved through specific changes of the Pathway hospital phase and health communication actions. KEY MESSAGES: • Stroke Pathway hospital phase (DTN score) could be improved by starting thrombolysis in the diagnostic imaging department to further align with the international guidelines standards. • Communication actions should be promoted to improve the Stroke Pathway pre-hospital phase (OTD score) providing the public with essential information to timely recognize stroke signs and symptoms.