Adherence to Guidelines by Emergency Medical Services During Transport of Stroke Patients Receiving Intravenous Thrombolytic Infusion

Abstract Background Out-of-hours (OOH) healthcare services in Western countries are often differentiated into out-of-hours primary healthcare services (OOH-PC) and emergency medical services (EMS). Call waiting time, triage model and intended aims differ between these services. Consequently, the care pathway and outcome could vary based on the choice of entrance to the healthcare system. We aimed to investigate patient pathways and 1- and 1–30-day mortality, intensive care unit (ICU) stay and length of hospital stay for patients with acute myocardial infarction (AMI), stroke and sepsis in relation to the OOH service that was contacted prior to the hospital contact. Methods Population-based observational cohort study during 2016 including adult patients from two Danish regions with an OOH service contact on the date of hospital contact. Patients <18 years were excluded. Data was retrieved from OOH service databases and national registries, linked by a unique personal identification number. Crude and adjusted logistic regression analyses were performed to assess mortality in relation to contacted OOH service with OOH-PC as the reference and cox regression analysis to assess risk of ICU stay. Results We included 6826 patients. AMI and stroke patients more often contacted EMS (52.1 and 54.1%), whereas sepsis patients predominately called OOH-PC (66.9%). Less than 10% (all diagnoses) of patients contacted both OOH-PC & EMS. Stroke patients with EMS or OOH-PC & EMS contacts had higher likelihood of 1- and 1–30-day mortality, in particular 1-day (EMS: OR = 5.33, 95% CI: 2.82–10.08; OOH-PC & EMS: OR = 3.09, 95% CI: 1.06–9.01). Sepsis patients with EMS or OOH-PC & EMS contacts also had higher likelihood of 1-day mortality (EMS: OR = 2.22, 95% CI: 1.40–3.51; OOH-PC & EMS: OR = 2.86, 95% CI: 1.56–5.23) and 1–30-day mortality. Risk of ICU stay was only significantly higher for stroke patients contacting EMS (EMS: HR = 2.38, 95% CI: 1.51–3.75). Stroke and sepsis patients with EMS contact had longer hospital stays. Conclusions More patients contacted OOH-PC than EMS. Sepsis and stroke patients contacting EMS solely or OOH-PC & EMS had higher likelihood of 1- and 1–30-day mortality during the subsequent hospital contact. Our results suggest that patients contacting EMS are more severely ill, however OOH-PC is still often used for time-critical conditions.

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Variability in Criteria for Emergency Medical Services Routing of Acute Stroke Patients to Designated Stroke Center Hospitals

Western Journal of Emergency Medicine ◽

10.5811/westjem.2015.7.26179 ◽

2015 ◽

Vol 16 (5) ◽

pp. 743-746 ◽

Cited By ~ 1

Author(s):

Nikolay Dimitrov ◽

William Koenig ◽

Nichole Bosson ◽

Sarah Song ◽

Jeffrey Saver ◽

...

Keyword(s):

Acute Stroke ◽

Emergency Medical Services ◽

Medical Services ◽

Stroke Patients ◽

Emergency Medical ◽

Stroke Center

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Hospital Prenotification of Stroke Patients by Emergency Medical Services Improves Stroke Time Targets

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2011.06.018 ◽

2013 ◽

Vol 22 (2) ◽

pp. 113-118 ◽

Cited By ~ 71

Author(s):

James S. McKinney ◽

Krishna Mylavarapu ◽

Judith Lane ◽

Virginia Roberts ◽

Pamela Ohman-Strickland ◽

...

Keyword(s):

Emergency Medical Services ◽

Medical Services ◽

Stroke Patients ◽

Emergency Medical

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Abstract W P187: Utilization of Emergency Medical Services to Transfer Acute Stroke Patients Directly to Scanning Reduces the Length of Time to Scan Result

Stroke ◽

10.1161/str.45.suppl_1.wp187 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Scott Dunbar ◽

Theresa Hoffecker ◽

Avery Schwenk

Keyword(s):

Acute Stroke ◽

Ct Scan ◽

Emergency Medical Services ◽

Ct Scanning ◽

Medical Services ◽

Time Of Arrival ◽

Stroke Patients ◽

Emergency Medical ◽

Number Of Patients ◽

The Mean

Background: Rapid assessment and treatment of acute stroke patients including computerized tomography (CT) scanning to determine the need for tissue plasminogen activator (tPA) has been shown to be vital to positive patient outcomes. As part of an ongoing effort to reduce door-to-needle time for such patients, the door-to-CT result time was identified as an area that could be reduced by collaborative effort between Emergency Medical Services (EMS) and Emergency Department (ED) staff. We hypothesized that implementing an EMS protocol for direct-to-CT scanning as part of a collaborative stroke alert protocol would reduce overall door-to-CT result time. Methods: Local EMS and ED implemented criteria to alert the ED of acute stroke patients being transported to their facility. This alert included an estimated time of arrival and was sent to radiology, neurology, registration and pharmacy. Upon arrival, the patient was met by ED personnel while still on the EMS gurney. If the ED physician concurred with the field impression of acute stroke, the patient was taken directly to CT scanning by EMS. Data on time of door-to-CT result were collected from 7/9/12 to 7/8/13 and divided into those patients who received a stroke alert from EMS (n=41), and those who did not (n=81). All data are expressed as mean ± standard error. Results: The time for door-to-CT result was reduced (p<0.0001) for patients who received a stroke alert from EMS [16.5 ± 1.2 vs 31.6 ± 1.5 minutes, alert vs no alert, respectively]. Similarly, in the subset of patients who received tPA after the CT scan, the mean time door-to-CT scan results was reduced (p<0.005) in those patients who received a stroke alert from EMS (14.3 ± 1.1 vs 36.4 ± 7.3 minutes, alert vs no alert, respectively). Conclusions: Implementation of a stroke alert including a direct-to-CT protocol by EMS significantly reduced the mean door-to-CT result time in acute stroke patients. Expanding this protocol to include other area EMS services and hospitals could potentially result in a greater number of patients benefiting from these reduced times.

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Abstract 206: Pre-notification by Emergency Medical Services is Associated with More Timely Evaluation and Treatment of Acute Ischemic Stroke

Stroke ◽

10.1161/str.43.suppl_1.a206 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Cheryl Lin ◽

Eric D Peterson ◽

Eric E Smith ◽

Jeffrey L Saver ◽

Li Liang ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Emergency Medical Services ◽

Medical Services ◽

Stroke Patients ◽

Emergency Medical ◽

Intravenous Tissue Plasminogen Activator ◽

Tissue Plasminogen ◽

Get With The Guidelines

Background: The benefits of intravenous tissue-plasminogen activator (tPA) in acute ischemic stroke are time-dependent. Emergency medical services (EMS) pre-notification of stroke arrivals may provide a means of reducing evaluation and treatment times. In this study we used data from the nationwide Get With The Guidelines Stroke (GWTG-Stroke) program to determine the effect of EMS pre-notification on acute ischemic stroke processes of care. Methods: Acute ischemic stroke patients transported by EMS to 1585 GWTG-Stroke hospitals from April 2003 to March 2011 were studied. The association between EMS pre-notification and door-to-imaging (DTI) times, door-to-needle (DTN) times, onset-to-needle times (OTN), and tPA treatment rates were analyzed using multivariable GEE regression analyses. Results: Of 371,988 EMS transported acute ischemic stroke patients, EMS pre-notification occurred in 249,197 (67.0%). Patients with pre-notification had shorter door-to-imaging times, shorter onset-to-needle times, and were more likely to be treated with tPA when eligible ( Table ). EMS pre-notification was independently associated with increased odds of DTI ≤25 minutes (adjusted OR 1.53, 95% CI 1.44–1.63, p<0.0001), DTN times ≤60 minutes (aOR 1.20, 95% CI 1.10–1.31, p<0.0001), OTN times (aOR 1.17, 95% CI 1.09–1.25, p<0.0001), and tPA use within 3 hours among eligible patients arriving by 2 hours (aOR 1.64, 95% CI 1.50–1.79, p<0.0001), without significant increases in complications of thrombolytic therapy. Conclusion: EMS pre-notification is independently associated with more rapid patient imaging and increased timeliness in IV tPA administration. These results support the need for initiatives targeted at increasing EMS pre-notification rates as a mechanism from improving quality of care and outcomes in acute ischemic stroke.

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Is Door-to-Needle Time Reduced for Emergency Medical Services Transported Stroke Patients Routed Directly to the Computed Tomography Scanner on Emergency Department Arrival?

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2019.104477 ◽

2020 ◽

Vol 29 (1) ◽

pp. 104477 ◽

Cited By ~ 1

Author(s):

Bryan Sloane ◽

Nichole Bosson ◽

Nerses Sanossian ◽

Jeffrey L. Saver ◽

Lorrie Perez ◽

...

Keyword(s):

Computed Tomography ◽

Emergency Department ◽

Emergency Medical Services ◽

Medical Services ◽

Stroke Patients ◽

Emergency Department Arrival ◽

Emergency Medical ◽

Computed Tomography Scanner

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Clinical Characteristics of Elderly Acute Ischemic Stroke Patients Calling Emergency Medical Services

Annals of Geriatric Medicine and Research ◽

10.4235/agmr.2017.21.4.164 ◽

2017 ◽

Vol 21 (4) ◽

pp. 164-167

Author(s):

In Hwan Lim ◽

Hyung Jong Park ◽

Hyun Young Park ◽

Kyeong Ho Yun ◽

Dae-Han Wi ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Emergency Medical Services ◽

Clinical Characteristics ◽

Medical Services ◽

Stroke Patients ◽

Emergency Medical

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Abstract 102: Use of Emergency Medical Services by Stroke Patients

Stroke ◽

10.1161/str.45.suppl_1.102 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Aaron M Anderson ◽

Heidi Sucharew ◽

Kathleen Alwell ◽

Charles J Moomaw ◽

Opeolu Adeoye ◽

...

Keyword(s):

Emergency Medical Services ◽

Time Window ◽

Action Plan ◽

Medical Services ◽

Stroke Severity ◽

Stroke Patients ◽

Awareness Campaigns ◽

Emergency Medical ◽

Stroke Awareness ◽

Prior Stroke

Introduction: Rapid evaluation and treatment with rt-PA is the hallmark of acute stroke care, yet only a fraction of ischemic stroke patients arrive within the time window for treatment. National stroke awareness campaigns have attempted to increase community awareness of stroke with action plans to call 911. We sought to compare the use of emergency medical services (EMS) by stroke patients between 2005 and 2010. Methods: Stroke and TIA patients were identified in a population of 1.3 million in the Greater Cincinnati area in 2005 and 2010. Patient charts were abstracted by research nurses and reviewed by study physicians. For this analysis, patients must have resided at home and presented to a local ED. Proportion of EMS users was computed. Logistic regression was used to test for associations of EMS use with age, race, sex, prior stroke, stroke type and severity, and setting (home, work, other) where stroke occurred. Results: There were 2546 stroke cases identified in 2005 and 2704 in 2010 which met criteria for analysis. The mean age was 68 years (SD 15), 54% female, and 20% black in both study periods. EMS use did not change between study periods, 52.7% in 2005 and 52.0% in 2010 (p=.64). In both study years, increasing age, increasing stroke severity, and hemorrhagic stroke were associated with EMS use. History of prior stroke was associated with increased EMS use in 2005, but this association was not seen in 2010. Sex, race, and the setting where stroke occurred were not associated with EMS use. Discussion: Rates of EMS use in our population-based study are still only about 52% and did not increase between 2005 and 2010. Community stroke awareness campaigns should include an action plan containing the urgency of calling 911 as soon as any stroke symptoms occur.

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Community Intent to Activate Emergency Medical Services May Be Associated with Regional tPA Treatment

Cerebrovascular Diseases ◽

10.1159/000518729 ◽

2021 ◽

pp. 1-7

Author(s):

Mellanie V. Springer ◽

Ran Bi ◽

Lesli E. Skolarus ◽

Chun Chieh Lin ◽

James F. Burke

Keyword(s):

Emergency Medical Services ◽

Regional Variation ◽

Medical Services ◽

Behavioral Risk ◽

Treatment Rate ◽

Stroke Patients ◽

Symptom Recognition ◽

Stroke Symptom ◽

Emergency Medical ◽

Lower Accuracy

Introduction: Acute stroke treatments are underutilized in the USA. Enhancing stroke preparedness, the recognition of stroke symptoms, and intent to call emergency medical services (EMS) could reduce delay in hospital arrival thereby increasing eligibility for time-sensitive stroke treatments. Whether higher stroke preparedness is associated with higher tissue plasminogen activator (tPA) treatment rates is however uncertain. We therefore set out to determine the contribution of stroke preparedness to regional variation in tPA treatment. Methods: The region was defined by hospital service area (HSA). Stroke preparedness was determined by using Behavioral Risk Factor Surveillance System survey questions assessing stroke symptom recognition and intent to call 911 in response to a stroke. We used Medicare data to determine the percentage of tPA-treated hospitalized stroke patients in 2007, 2009, and 2011, adjusting for number of stroke hospitalizations in each HSA (primary outcome). We performed multivariate linear regression to estimate the association of regional stroke preparedness on log-transformed tPA treatment rates controlling for demographic, EMS, and hospital characteristics. Results: The adjusted percentage of stroke patients receiving tPA ranged from 1.4% (MIN) to 11.3% (MAX) of stroke/TIA hospitalizations. Across HSAs, a median (IQR) of 86% (81–90%) of responses to a witnessed stroke indicated intent to call 911, and a median (IQR) of 4.4 (4.2–4.6) out of 6 stroke symptoms was recognized. Every 1% increase in an HSA’s intent to call 911 was associated with a 0.44% increase in adjusted tPA treatment rate (p = 0.05). Lower accuracy of recognition of stroke symptoms was associated with higher adjusted tPA treatment rates (p = 0.05). Conclusions: There was little regional variation in intent to call EMS and stroke symptom recognition. Intent to call EMS and stroke symptom recognition are modest contributors to regional variation in tPA treatment.

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Abstract 3633: A National Assessment of Factors Influencing Emergency Medical Services Times Among Acute Stroke patients.

Stroke ◽

10.1161/str.43.suppl_1.a3633 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Vikram Jadhav ◽

Saqib A Chaudhry ◽

Gustavo J Rodriguez ◽

M. Fareed K Suri ◽

Adnan I Qureshi

Keyword(s):

Acute Stroke ◽

Emergency Medical Services ◽

Symptom Onset ◽

Emergency Services ◽

Medical Services ◽

Time Interval ◽

Stroke Patients ◽

Accurate Identification ◽

Critical Determinant ◽

Emergency Medical

Background: The time spent in Emergency Medical Services [EMS] assessment and transport is a critical determinant of time interval between symptom onset and treatment for acute stroke. Objective: To study the determinants that influence EMS times which is a composite of response, assessment, and transport times for acute stroke patients. Methods: The 2009 national Emergency Services Information System [NEMSIS] Research dataset representing 26 states in US was accessed to identify the patients diagnosed by EMS personnel to be having stroke / cerebrovascular accident [CVA] on arrival at the scene of incident. Total EMS times defined as time interval between dispatch call and completion of transport to emergency department [reported in mins (confidence intervals)] were calculated and compared in various patient strata defined by factors such as dispatch center identification of stroke / CVA, barriers (language and physical) at the scene, location and demographical factors. Results: A total of 52282 patients were identified to have stroke / CVA by EMS personnel on arrival at scene. Significant differences were seen in EMS times with accurate identification compared to non-identification of stroke / CVA by dispatch center [41.8 (41.5-42.2) vs 49.8 (49.3-50.2), P <0.001]. Language and physical barriers at scene were associated with EMS time delays [48.4 (47.3-49.6) vs 45.2 (44.8-45.6), P <0.001]. EMS times increased from urban to suburban, rural, and wilderness settings [42.6 (42.3-42.9) vs 48.6 (47.6-49.5) vs 50.5 (49.6-51.4) vs 62.4 (59.8-64.9), P <0.001]. Similarly, Pacific and Mid-Atlantic regions had faster EMS times compared to Mountain regions [35.2 (34.6-35.8) vs 36.5 (35.6-37.4) vs 46.6 (45.4-47.8), P <0.001]. Patients ≥65 years had less EMS times compared to those aged <65 years [44.9 (44.5-45.2) vs 46.9 (46.4-47.4), P <0.001]. Conclusion: EMS times in patients with acute stroke are influenced by multiple factors. A better understanding of modifiable and region specific factors can expedite time interval between symptom onset and treatment for acute stroke patients.

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