Geographic modeling of best transport options for treatment of acute ischemic stroke patients applied to policy decision making in the USA and Northern Ireland

Background Emergency Medical Services (EMS) is a vital link in the overall chain of stroke survival. A Primary Stroke Center (PSC) relies heavily on the 9-1-1 response system along with the ability of EMS personnel to accurately diagnose acute stroke. Other critical elements include identifying time of symptom onset, providing pre-hospital care, selecting a destination PSC, and communicating estimated time of arrival (ETA). Purpose Our purpose was to evaluate the EMS component of thrombolysed acute ischemic stroke patient care at our PSC. Methods In a retrospective manner we retrieved electronic copies of the EMS incident reports for every thrombolysed ischemic stroke patient treated at our PSC from September 2001 to August 2005. The following data elements were extracted: location of victim, EMS agency, times of dispatch, scene, departure, emergency department (ED) arrival, recordings of time of stroke onset, blood pressure (BP), heart rate (HR), cardiac rhythm, blood glucose (BG), Glasgow Coma Scale (GCS), Cincinnati Stroke Scale (CSS) elements, emergency medical personnel field assessment, and transport decision making. Results Eighty acute ischemic stroke patients received thrombolysis during the study interval. Eighty-one percent arrived by EMS. Two EMS agencies transported to our PSC. Mean dispatch-to-scene time was 6 min, on-scene time was 16 min, transport time was 10 min. Stroke onset time was recorded in 68%, BP, HR, and cardiac rhythm each in 100%, BG in 81%, GCS in 100%, CSS in 100%, and acute stroke diagnosis was made in 88%. Various diagnostic terms were employed: cerebrovascular accident in 40%, unilateral weakness or numbness in 20%, loss of consciousness in 16%, stroke in 8%, other stroke terms in 4%. In 87% of incident reports there was documentation of decision-making to transport to the nearest PSC in conjunction with pre-notification. Conclusion The EMS component of thrombolysed acute ischemic stroke patients care at our PSC appeared to be very good overall. Diagnostic accuracy was excellent, field assessment, decision-making, and transport times were very good. There was still room for improvement in documentation of stroke onset and in employment of a common term for acute stroke.

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Abstract TP56: Endovascular Treatment Decisions in Acute Ischemic Stroke Patients With Low Baseline Aspects: Insights From an International Multidisciplinary Survey

Stroke ◽

10.1161/str.51.suppl_1.tp56 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Johanna M Ospel ◽

Nima Kashani ◽

Bijoy Menon ◽

Mohammed Almekhlafi ◽

Ravinder Singh ◽

...

Keyword(s):

Decision Making ◽

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Symptom Onset ◽

Multivariable Logistic Regression Analysis ◽

Stroke Patients ◽

Acute Stroke Care ◽

Early Management ◽

Local Resources

Background and Purpose: Current AHA/ASA guidelines for the early management of patients with acute ischemic stroke restrict level 1A recommendations for endovascular therapy (EVT) to patients with baseline ASPECTS score >5. However, a recent meta-analysis from the HERMES group showed a treatment benefit in patients with ASPECTS ≤5. We aimed to explore how physicians across different specialties and countries approach endovascular treatment decision-making in acute ischemic stroke patients with low baseline ASPECTS. Methods: In an international multidisciplinary survey, 607 physicians involved in acute stroke care were randomly assigned 10 out of a pool of 22 case-scenarios, 3 of which involved patients with baseline ASPECTS < 6 (A: 40-year old with ASPECTS 4, B: 33-year old with ASPECTS 2 C: 72-year old with ASPECTS 3), otherwise fulfilling all EVT-eligibility criteria. Participants were asked how they would treat the patient in the given scenario A) under their current local resources and B) under assumed ideal conditions, i.e. without any external (monetary, policy-related or infrastructural) restraints. Overall and scenario-specific decision rates were calculated. Clustered multivariable logistic regression analysis was used to determine variables associated with EVT decision in patients with low baseline ASPECTS. Results: 827/6070 responses were available for the low ASPECTS scenarios. Current and ideal treatment EVT decision rates were 57.1% and 57.6% respectively. Current and ideal decision rates were 69.9% and 60.4% for scenario A, 60.0% and 61.5% for scenario B, 41.3% and 40.2% for scenario C respectively. Annual center EVT volume (OR 1.004,p=.004), annual operator EVT volume (OR 1.009, p=.018) and time since symptom onset (OR 4.543,p<.001) were significantly associated with EVT decision-making under current local resources, while annual operator EVT volume (OR 1.007,p<.029) and time since symptom onset (OR 5.687,p<.001) were associated with decision-making under assumed ideal conditions. Conclusion: A majority of physicians decided to proceed with EVT despite low baseline ASPECTS. Operators and centers doing more EVT per year were more likely to offer EVT to patients with low ASPECTS.

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