In 2017, professionals from the Germans Trias and Vall d'Hebron hospitals, and from the ICS Hospital Directorate, with the coordination of the Director Plan for Cerebral Vascular Disease of the Ministry of Health of the Government of Catalonia, and in collaboration with the Medical Emergency System (SEM) and the 28 reference hospitals for stroke in the public network of Catalonia began a study to determine where patients suffering from a severe stroke should be transferred and who are far from a high-tech hospital center where endovascular treatment can be done, which is necessary in 50% of the most serious strokes. Last Saturday, the results of the study, called RACECAT, were presented at the European Stroke Congress.
RACECAT study aims to determine which are the most effective transfer circuits for patients with severe stroke. These patients often require endovascular treatment to remove the thrombus, which is only available in some centers of the stroke care network, and which is often far from the place where the patient is. The results indicate that the chances of clinical recovery are just as good whether the transfer is made directly to one of the centers with the capacity for endovascular treatment or if a first care is made in one of the local centers and later a secondary transfer when be necessary.
The results of the study provide an answer to a scientific question of great interest for the organization of stroke care systems. The characteristics of the Catalan model have made it possible to carry out the study with 28 hospitals involved and coordinated with SEM, a highly cohesive stroke network, the involvement of more than 2,000 professionals, the use of a common stroke code registry and central coordination from the office of the Director Plan for Cerebral Vascular Disease. The study was carried out over a period of 3 years and a total of 1,400 patients were included.
“This study answers a key question in the management of stroke during the first minutes. The results indicate that, if the patient is transferred to a nearby center and this is well coordinated with a tertiary center, the treatment is just as effective”, explains Dr. Marc Ribó, neurologist at the Stroke Unit at Vall d’Hebron University Hospital. For her part, Natalia Pérez de la Ossa, neurologist at the Germans Trias Hospital and head of the Stroke Director Plan of Generalitat de Catalunya, highlights that “the study has served to highlight that the model of the Stroke care network in Catalonia is exemplary and highly effective” and adds: “With these results it is clear that we must demand that we continue to maintain this quality of care, a highly coordinated system that goes from the first care of the emergency services (SEM) to the hospital, and that it has proven to be very beneficial for our patients”.
The RACECAT study has been possible because in Catalonia there is a Stroke Code system with good coordination between prehospital and hospital care, and a highly consolidated registry of patients with the stroke code (CICAT registry), with high-quality data, centralized monitoring of the patients, and open publication of quality metrics. "Both the network care model and the registry, promoted by the Director Plan, have been key both for the execution of the study and for its results", comments Sonia Abilleira, former director of the Director Plan for Cerebral Vascular Disease, and current director care of ICS hospitals.
The RACECAT study shows the effectiveness of the stroke care circuits in our territory thanks to the high coordination between the EMS and the hospital centers. 45% of patients with severe ischemic stroke receive a thrombectomy, which is one of the highest rates in Europe, and treatment begins very quickly, with an average of 4 and a half hours from the onset of symptoms, even in patients who are far away and are initially cared for in a first local stroke center. The direct transfer to a center where the intervention can be done allows to accelerate the treatment in almost 1 hour. On the contrary, this circuit involves transferring to a hospital some patients in whom a sure diagnosis has not been made and who ultimately do not require advanced treatment to a remote hospital. The results indicate that both options are equally safe and the longer transfer does not carry an increased risk of complications during the transfer.
The results of the RACECAT study are of global interest as they help to plan the organization of referral and transfers of stroke patients. In other territories, making a first visit to a local hospital can lead to a significant delay in starting definitive treatment, and this can lead to fewer options for recovery. According to the results of the RACECAT study, in Catalonia patients receive care in the first hospital with 88 minutes on average, the first tests and the first care are performed in less than 40 minutes, and they arrive at the second hospital where thrombectomy can be performed with 180 minutes on average. These times are extremely fast compared to other territories, and show the effectiveness of the stroke care network in Catalonia, managed and monitored by the Director Plan for Cerebral Vascular Diseases.
Currently in Catalonia, endovascular treatment is available in 6 tertiary stroke centers on a continuous basis, and it is being extended part-time to another 4 hospitals in the territory to make it accessible earlier and not have to make such long transfers by ambulance.
The best circuit for the stroke code
Currently, when the SEM is notified of a person who has suffered a stroke, the ambulance transfers him to the proximity stroke center -up to 28 throughout the territory- in accordance with the instruction of the Stroke Code, which is an international reference. This Stroke Code system organizes care based on SEM and a network of 28 hospitals with the capacity to accurately and quickly diagnose patients with suspected stroke, and administer intravenous thrombolytic treatment, if necessary.
The implementation of the RACE scale (acronym for Rapid Arterial oClusion Evaluation), is a key element in the beginning of the stroke care chain, when medical emergencies provide patient care "in situ", in the place of the events. The incorporation of the RACE scale in the initial evaluation by the SEM allows adding information on the severity, of great value for the hospital that will receive the patient in the first instance because it allows an early approach to the treatment. RACE is a scale created by neurologists from the Germans Trias Hospital and developed by SEM professionals, which has become an international reference and allows easy evaluation in the same place of the events, and by SEM professionals (emergency medical technicians, TES), the severity of the stroke and determine if it is possible that the patient may have one of the main arteries of the brain obstructed.
When the patient is cared for in the hospital, they make an accurate diagnosis that determines whether the stroke was caused by a hemorrhage (hemorrhagic stroke) or by the obstruction of a blood vessel in the brain (ischemic stroke or cerebral infarction). This conditions the treatment that will be done later. The degree of brain involvement is also evaluated.
In the case of obstruction of one of the main blood vessels, the treatment that has been shown to be the most effective is the performance of a mechanical thrombectomy. If the hospital where the patient is treated cannot perform this intervention, the patient is administered a thrombolytic drug -when necessary, in coordination via telematics with a larger center- and, if this treatment does not work, they are transferred to a center that can perform a brain catheterization. The RACECAT study supports this circuit, which does not present worse records than doing the service directly at the most distant high-tech center.
Several studies have shown that patients from remote areas treated, at first, in a hospital who cannot perform thrombectomy and who must later be transferred to a tertiary center, may have fewer options to benefit from catheterization but, until now, no scientific evidence was available to support it. Precisely, the results obtained by RACECAT have ruled out this hypothesis, showing that the initial evaluation using the RACE scale already allows the hospital center to prepare to start treatment as quickly as possible.