Why acute ischemic stroke patients in the United States use or do not use emergency medical services transport? Findings of an inpatient survey

Abstract Background Patients with acute ischemic stroke (AIS) who use emergency medical services (EMS) receive quicker reperfusion treatment which, in turn, mitigates post-stroke disability. However, nationally only 59% use EMS. We examined why AIS patients use or do not use EMS. Methods During 2016–2018, a convenience sample of AIS patients admitted to a primary stroke center in South Carolina were surveyed during hospitalization if they were medically fit, available for survey when contacted, and consented to participate. The survey was programed into EpiInfo with skip patterns to minimize survey burden and self-administered on a touchscreen computer. Survey questions covered symptom characteristics, knowledge of stroke and EMS importance, subjective reactions, role of bystanders and financial factors. Descriptive and multiple regression analyses were performed. Results Of 108 inpatients surveyed (out of 1179 AIS admissions), 49% were male, 44% African American, mean age 63.5 years, 59% mild strokes, 75 (69%) arrived by EMS, 33% were unaware of any stroke symptom prior to stroke, and 75% were unaware of the importance of EMS use for good outcome. Significant factors that influenced EMS use decisions (identified by regression analysis adjusting for stroke severity) were: prior familiarity with stroke (self or family/friend with stroke) adjusted odds ratio, 5.0 (95% confidence interval, 1.6, 15.1), perceiving symptoms as relevant for self and indicating possible stroke, 26.3 (7.6, 91.1), and bystander discouragement to call 911, 0.1 (0.01,0.7). Further, all 27 patients who knew the importance of EMS had used EMS. All patients whose physician office advised actions other than calling EMS at symptom onset, did not use EMS. Conclusion Systematic stroke education of patients with stroke-relevant comorbidities and life-style risk factors, and public health educational programs may increase EMS use and mitigate post-stroke disability.

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Determinants of Emergency Medical Services Use in a Brazilian Population with Acute Ischemic Stroke

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2011.08.007 ◽

2013 ◽

Vol 22 (3) ◽

pp. 244-249 ◽

Cited By ~ 10

Author(s):

Gustavo W. Kuster ◽

Monique Bueno Alves ◽

Miguel Cendoroglo Neto ◽

Gisele Sampaio Silva

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Emergency Medical Services ◽

Brazilian Population ◽

Medical Services ◽

Emergency Medical ◽

Services Use

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Value Utilization of Emergency Medical Services Air Transport in Acute Ischemic Stroke

Journal of Emergency Medicine ◽

10.1016/j.jemermed.2020.08.005 ◽

2020 ◽

Vol 59 (5) ◽

pp. 687-692

Author(s):

Amelia K. Adcock ◽

Joseph Minardi ◽

Scott Findley ◽

Deb Daniels ◽

Michelle Large ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Emergency Medical Services ◽

Air Transport ◽

Medical Services ◽

Emergency Medical

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Use of Emergency Medical Services and Timely Treatment Among Ischemic Stroke

Stroke ◽

10.1161/strokeaha.118.024232 ◽

2019 ◽

Vol 50 (4) ◽

pp. 1013-1016 ◽

Cited By ~ 8

Author(s):

Hong-Qiu Gu ◽

Zhen-Zhen Rao ◽

Xin Yang ◽

Chun-Juan Wang ◽

Xing-Quan Zhao ◽

...

Keyword(s):

Ischemic Stroke ◽

Emergency Medical Services ◽

Chinese Patients ◽

Tissue Type ◽

Medical Services ◽

Stroke Severity ◽

Emergency Medical ◽

Early Arrival ◽

Timely Treatment ◽

Iv Tpa

Background and Purpose— Emergency medical services (EMSs) are critical for early treatment of patients with ischemic stroke, yet data on EMS utilization and its association with timely treatment in China are still limited. Methods— We examined data from the Chinese Stroke Center Alliance for patients with ischemic stroke from June 2015 to June 2018. Absolute standardized difference was used for covariates’ balance assessments. We used multivariable logistic models with the generalized estimating equations to account for intrahospital clustering in identifying demographic and clinical factors associated with EMS use as well as in evaluating the association of EMS use with timely treatment. Results— Of the 560 447 patients with ischemic stroke analyzed, only 69 841 (12.5%) were transported by EMS. Multivariable-adjusted results indicated that those with younger age, lower levels of education, less insurance coverage, lower income, lower stroke severity, hypertension, diabetes mellitus, and peripheral vascular disease were less likely to use EMS. However, a history of cardiovascular diseases was associated with increased EMS usage. Compared with self-transport, EMS transport was associated with significantly shorter onset-to-door time, door-to-needle time (if prenotification was sent), earlier arrival (adjusted odds ratio [95% CIs] were 2.07 [1.95–2.20] for onset-to-door time ≤2 hours, 2.32 [2.18–2.47] for onset-to-door time ≤3.5 hours), and more rapid treatment (2.96 [2.88–3.05] for IV-tPA [intravenous recombinant tissue-type plasminogen activator] in eligible patients, 1.70 [1.62–1.77] for treatment with IV-tPA by 3 hours if onset-to-door time ≤2 hours, and 1.76 [1.70–1.83] for treatment with IV-tPA by 4.5 hours if onset-to-door time ≤3.5 hours). Conclusions— Although EMS transportation is associated with substantial reductions in prehospital delay and improved likelihood of early arrival and timely treatment, rate of utilization is currently low among Chinese patients with ischemic stroke. Developing an efficient EMS system and promoting culture-adapted education efforts are necessary for improving EMS activation.

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Intravenous thrombolytic therapy for acute ischemic stroke in Hubei, China: a survey of thrombolysis rate and barriers

10.21203/rs.2.231/v1 ◽

2019 ◽

Author(s):

Yanfeng Zhou ◽

Shijiao Yan ◽

Xingyue Song ◽

Yanhong Gong ◽

Wenzhen Li ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Emergency Medical Services ◽

Best Practice ◽

Hubei Province ◽

Medical Services ◽

Multivariable Logistic Regression Model ◽

Stroke Treatment ◽

Early Admission ◽

Emergency Medical

Abstract Background: Rates of thrombolysis in most countries are well below best practice benchmarks. We aimed to investigate thrombolysis utilization and its associated factors in acute ischemic stroke (AIS) patients in Hubei province, China, to assess neurologists’ experiences of the treatment, and to identify barriers against the treatment from perspective of AIS patients and neurologists. Methods: Survey of 2096 AIS patients and 709 neurologists from 66 hospitals was conducted in Hubei province between 2014 and 2015. A multivariable logistic regression model was utilized to identify the factors associated with thrombolysis utilization and neurologists’ experiences with thrombolysis. Results: Of the 2096 AIS patients, only 3.8% received thrombolysis. Of the 709 neurologists, 66.0% reported using thrombolysis for AIS patients. The main reasons for not using thrombolysis were late arrival of patients, fear of the risk of complications of thrombolysis, and light or quickly recovered stroke symptoms. The behavior and clinical characteristics of patients, including early admission to hospital (odds ratio [OR]=5.81, 95% confidence intervals [CI] 3.31-10.20), using emergency medical services to be hospitalized (OR=3.36, 95% CI 2.00-5.62), stroke history (OR=0.53, 95% CI 0.28-0.99), and National Institute of Health Stroke Scale score < 4 (OR=0.46, 95% CI 0.27-0.77) were shown to significantly affect the thrombolysis utilization in the multivariate model. In addition, hospital grade (OR=2.84, 95% CI 1.84-4.37), education level (OR=2.49, 95% CI 1.09-5.73), and working years (OR=1.88, 95% CI 1.18-3.00) were strongly associated with neurologists’ experiences of thrombolysis. Conclusions: A very low proportion of AIS patients received thrombolysis in Hubei province, China. Considerable education programs and interventions were required regarding knowledge of stroke treatment for clinicians and proper behavior after stroke for AIS patients and their families. Keywords: Thrombolysis; stroke; neurologists; emergency medical services; China; Risk factor.

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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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