Workflow and Short-Term Functional Outcomes in Simultaneous Acute Code Stroke Activation and Stroke Reperfusion Therapy
, Amanda Wagner 1, Asif Sheriff 2, Colleen Taralson 3, Nadine Moniz 3, Jason Opsahl 3, Thomas Jeerakathil 1, Brian Buck 1, William Sevcik 4, Ashfaq Shuaib 1 and Mahesh Kate 1,*Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThis retrospective study evaluates the impact of simultaneous acute code stroke activation on stroke patients' outcomes. In the study, 545 patients received intravenous thrombolysis or endovascular thrombectomy. Three or more stroke patients presenting simultaneously to the emergency department may complicate the doll-to-CT and door-to-groin puncture times.
Methods
1. A hospital's human resources and equipment play a significant role in managing stroke patients. It is important to report the center's human resource and equipment, such as the CT scanner, the EVT suit, and the EVT nurse.
2. Whether stroke patients and patients with other diseases are managed simultaneously by the emergency department physician and nurse.
Discussion:
3. Between lines 235 and 237. This statement is not appropriate. It only includes the mortality rate of your hospital, not the mortality rate of a low volume center.
Author Response
This retrospective study evaluates the impact of simultaneous acute code stroke activation on stroke patients' outcomes. In the study, 545 patients received intravenous thrombolysis or endovascular thrombectomy. Three or more stroke patients presenting simultaneously to the emergency department may complicate the doll-to-CT and door-to-groin puncture times.
Methods
- A hospital's human resources and equipment play a significant role in managing stroke patients. It is important to report the center's human resource and equipment, such as the CT scanner, the EVT suit, and the EVT nurse.
Response: We thank you for the comment, we have added the following line on page 2 line 78,"The study site has three computed tomography (CT) scanners (one scanner in the ED and two elsewhere in the hospital), two EVT suites and 1 EVT nurse."
- Whether stroke patients and patients with other diseases are managed simultaneously by the emergency department physician and nurse.
Response: Yes, both stroke and non-stroke patients are managed in the ED. We have added the following line on page 2 line 80, "Both stroke and non-stroke patients receive treatment in the study site ED."
Discussion:
- Between lines 235 and 237. This statement is not appropriate. It only includes the mortality rate of your hospital, not the mortality rate of a low volume center.
Response: Thanks for pointing that out. We have modified the sentence to include the mortality rates at both low volume and high-volume sites.
Reviewer 2 Report
Comments and Suggestions for AuthorsThank you for the opportunity to review your manuscript. Overall, it is a very interesting piece of work, that could be repeated across different centres. The abstract is generally well written although im not sure if "home time" is considered a short term functional outcome. Maybe the title could be reworded. To clarify, is Home time the same as patient discharge from hospital? This was a little confusing although I am not familiar with the terminology used in Canada.
The introduction would benefit from further justification - why is it important that there is no delay to imaging, decision making, medical errors, DTP time. Why do you need to look at workflow metrics? How does this effect patients, families, costs etc... Why is it so important to undertake this study?
Line 71 and Line 201: bracket(s) missing
The methods are fairly well described although some of this section could be in the introduction. The analyses are appropriate for this study.
The results are clearly presented, some spacing issues but otherwise good.
Table 3 belongs in the results (not the discussion)
The first paragraph of the discussion (Lines 235-248) needs to link back to the current study better. What do high and low volume centres have to do with your study? Is it about resourcing? Do they have more stroke teams that can deal with simultaneous ACSA?
You have defined the limitations well. The conclusion sums up your findings nicely.
Comments on the Quality of English Language
The English language is generally fine. Some very minor edits required.
Author Response
Thank you for the opportunity to review your manuscript. Overall, it is a very interesting piece of work, that could be repeated across different centres. The abstract is generally well written although im not sure if "home time" is considered a short term functional outcome. Maybe the title could be reworded. To clarify, is Home time the same as patient discharge from hospital? This was a little confusing although I am not familiar with the terminology used in Canada.
Response: Many thanks for your comment. Home time at 90 days is a validated short-term functional outcomes measure (McDermid I, Barber M, Dennis M, Langhorne P, Macleod MJ, McAlpine CH, Quinn TJ. Home-Time Is a Feasible and Valid Stroke Outcome Measure in National Datasets. Stroke. 2019 May;50(5):1282-1285. doi: 10.1161/STROKEAHA.118.023916. PMID: 30896358.). It can be used as a surrogate measure of functional outcomes in patients with stroke.
The introduction would benefit from further justification - why is it important that there is no delay to imaging, decision making, medical errors, DTP time. Why do you need to look at workflow metrics? How does this effect patients, families, costs etc... Why is it so important to undertake this study?
Response: We agree with your comments. We have revised the introduction and added the following lines: Line 45: Delays in IVT or EVT are associated with reduced benefits of reperfusion treatment, worse functional outcomes and longer hospital stays. Line 63: To understand the effect of simultaneity on the hospital system assessing workflow metrics will be helpful like DTP.
Line 71 and Line 201: bracket(s) missing
Response: Edited.
The methods are fairly well described although some of this section could be in the introduction. The analyses are appropriate for this study.
Response: Thank you.
The results are clearly presented, some spacing issues but otherwise good.
Response: We will allow the editing team to guide us regarding spacing issues.
Table 3 belongs in the results (not the discussion)
Response: We did not get the space on that page to add the table. We ended up dded in the first instance where possible.
The first paragraph of the discussion (Lines 235-248) needs to link back to the current study better. What do high and low-volume centres have to do with your study? Is it about resourcing? Do they have more stroke teams that can deal with simultaneous ACSA?
Response: Thank you for your comments. We have modified the first paragraph as follows,
Data on simultaneous ACSA is not available. However, we can hypothesize that higher admission volume centers may have increased simultaneity and be subjected to similar workflow metrics effects.
You have defined the limitations well. The conclusion sums up your findings nicely.
Response: Thank you for your comments and time. They have been helpful.
Round 2
Reviewer 2 Report
Comments and Suggestions for AuthorsThank you for addressing the previous feedback. The manuscript is much improved and flows nicely. A valuable piece of work. Well done.
