Thrombolysis can be carried out at most hospitals (spoke) with an Emergency Department but thrombectomy can only be carried out at a specialist hospital (hub).
The paramedics will, except under very special circumstances, take the patient to the nearest hospital to receive early thrombolysis, but where a so call “by pass protocol” has been agreed they could decide to travel further to a thrombectomy hub. This will delay thrombolysis but potentially allow thrombectomy to be done earlier. The paramedics will, perhaps with advice from a stroke specialist, make a decision and pre-alert the receiving hospital.
The paramedics could:
Take the patient to the nearest hospital which can carry out an emergency CT scan, and provide thrombolysis if appropriate. That hospital will decide, based on a more detailed scan of the brain arteries (CT angiography or CTA), whether to refer to a Thrombectomy hub. This pathway is sometimes known as Drip (i.e. thrombolyse) and Ship (transfer to thrombectomy centre).
OR
By-pass the spoke and take the patient directly, but further to the thrombectomy hub. This will potentially delay thrombolysis (making it less effective because time is brain), but reduce the delay to a potential thrombectomy making that more effective. This pathway is sometimes referred to as “Mothership”.
Select the crosses below to see the advantages and disadvantages of the ‘Drip and Ship” and “Mothership” pathways.
In Jimmy’s case
The paramedics decided, after discussion with a stroke consultant on a “prof to prof” call (in line with the agreed by-pass protocol) that since the patient seemed to have a definite stroke with quite severe symptoms that the patient might be suitable for thrombectomy, and that they would by-pass the local spoke, and drive an additional 30 minutes to the thrombectomy hub. See Additional Information for more details.
Advantages of “Drip and Ship”
- Reduce delay to thrombolysis and increases its effectiveness
- Ensures local treatment if thrombectomy not indicated
- Reduced ambulance journey time for majority
Disadvantages of “Drip and ship”
- Delays thrombectomy and reduces its effectiveness
- Involves an extra ambulance journey
Advantages of “Mothership” pathway
- Reduced delay to thrombectomy and increases its effectiveness
- Reduces number of ambulance journeys for those suitable for thrombectomy
Disadvantages of “Mothership” pathway
- Delayed thrombolysis which reduces its effectiveness
- Patient admitted to distant hospital – difficult for visiting
- Most patients taken to thrombectomy centre will not be suitable for thrombectomy
- Likely to have to be transferred back to local hospital
- Increased pressure in the Emergency Dept of thrombectomy centre
- Increased pressure on beds in thrombectomy centre
- Increased work for ambulance service which might affect response time for other emergencies
