Modeling the Impact of Prehospital Triage on a True-Life Drip and Ship Mechanical Thrombectomy Urban Patient Cohort

<b><i>Objective:</i></b> The aim of the study was to model the effect of prehospital triage of emergent large vessel occlusion (ELVO) to endovascular capable center (ECC) on the timing of thrombectomy and intravenous (IV) thrombolysis using real-world data from a multihospital system. <b><i>Methods:</i></b> We selected a cohort of 77 consecutive stroke patients who were brought by emergency medical services (EMS) to a nonendovascular capable center and then transferred to an ECC for mechanical thrombectomy (MT) (“actual” drip and ship [DS] cohort). We created a hypothetical scenario (bypass model [BM]), modeling transfer of the patients directly to an ECC, based on patients’ initial EMS pickup address and closest ECC. Using another cohort of 73 consecutive patients, who were brought directly to an ECC by EMS and underwent endovascular intervention, we calculated mean door-to-needle and door-to-arterial puncture (AP) times (“actual” mothership [MS] cohort). Timings in the actual MS cohort and the actual DS cohort were compared to timings from the BM cohort. <b><i>Results:</i></b> Median first medical contact (FMC) to IV thrombolysis time was 87.5 min (interquartile range [IQR] = 38) for the DS versus 78.5 min (IQR = 8.96) for the BM cohort, with <i>p</i> = 0.1672. Median FMC to AP was 244 min (IQR = 97) versus 147 min (IQR = 8.96) (<i>p</i> &#x3c; 0.001), and median FMC to TICI 2B+ time was 299 min (IQR = 108.5) versus 197 min (IQR = 8.96) (<i>p</i> &#x3c; 0.001) for the DS versus BM cohort, respectively. <b><i>Conclusions:</i></b> Modeled EMS prehospital triage of ELVO patients’ results in shorter MT times without a change in thrombolysis times. As triage tools increase in sensitivity and specificity, EMS triage protocols stand to improve patient outcomes.

Performance of the RACE Prehospital Triage Score During Working and Nonworking Hours

BACKGROUND Prehospital triage scores aim to identify large vessel occlusions (LVOs) in the field; however, their real‐world performance and accuracy across a 24‐hour period remains unknown. In this study, we compare the positive predictive value of the prehospital Rapid Arterial occlusion Evaluation (RACE) score for the detection of LVO during working hours and nonworking hours. METHODS We performed a retrospective review of all patients presenting with a RACE score of ≥5 at one comprehensive and one thrombectomy‐capable hospital between July 2015 and December 2019. Patients were dichotomized to those presenting during “working hours” (7:00 am to 6:00 pm on weekdays) or “nonworking hours” (6:01 pm to 6:59 am on weekdays or anytime during weekends). The primary outcome was diagnosis of LVO. Secondary outcomes included diagnosis of acute neurovascular syndromes, door‐to‐treatment time metrics, and a modified Rankin Scale of ≤2 in those undergoing mechanical thrombectomy. RESULTS Of the 701 patients with RACE score ≥5, 687 patients were included (355 nonworking hours and 332 working‐hours cohorts). Mean age was 71 and 72 years in the nonworking hours and working hours groups, respectively ( P =0.13). Median National Institutes of Health Stroke Scale and baseline demographics were comparable between the 2 groups. There was no significant difference in the diagnosis of LVO (36.3% versus 34.6%; P =0.69) or final discharge diagnosis. The positive predictive value of the RACE score for the detection of an acute neurovascular syndrome (transient ischemic attack and stroke) was improved during nonworking hours (76.3% versus 67.8%; P =0.01). In patients undergoing mechanical thrombectomy, rates of good clinical outcome were similar (44.7% versus 48%; P =0.76), despite the shorter door‐to‐groin‐puncture and revascularization times during working hours. CONCLUSIONS The RACE score shows a consistent positive predictive value in determining LVO during working and nonworking hours. However, it is more accurate in determining acute neurovascular syndromes during nonworking hours, which is driven by a decrease in stroke mimics during this time.

Prehospital Stroke Triage

Purpose of the ReviewThis article reviews prehospital organization in the treatment of acute stroke. Rapid access to an endovascular therapy (EVT) capable center and prehospital assessment of large vessel occlusion (LVO) are 2 important challenges in acute stroke therapy. This article emphasizes the use of transfer protocols to assure the prompt access of patients with an LVO to a comprehensive stroke center where EVT can be offered. Available prehospital clinical tools and novel technologies to identify LVO are also discussed. Moreover, different routing paradigms like first attention at a local stroke center (“drip and ship”), direct transfer of the patient to an endovascular center (“mothership”), transfer of the neurointerventional team to a local primary center (“drip and drive”), mobile stroke units, and prehospital management communication tools all aimed to improve connection and coordination between care levels are reviewed.Recent FindingsLocal observational data and mathematical models suggest that implementing triage tools and bypass protocols may be an efficient solution. Ongoing randomized clinical trials comparing drip and ship vs mothership will elucidate which is the more effective routing protocol.SummaryPrehospital organization is critical in realizing maximum benefit from available therapies in acute stroke. The optimal transfer protocols directed to accelerate EVT are under study, and more accurate prehospital triage tools are needed. To improve care in the prehospital setting, efficient tools based on patient factors, local geography, and hospital capability are needed. These tools would optimally lead to individualized real-time decision-making.

Using the South African Triage Scale for prehospital triage: a qualitative study

Background Triage is a critical component of prehospital emergency care. Effective triage of patients allows them to receive appropriate care and to judiciously use personnel and hospital resources. In many low-resource settings prehospital triage serves an additional role of determining the level of destination facility. In South Africa, the Western Cape Government innovatively implemented the South African Triage Scale (SATS) in the public Emergency Medical Services (EMS) service in 2012. The prehospital provider perspectives and experiences of using SATS in the field have not been previously studied. Methods In this qualitative study, focus group discussions with cohorts of basic, intermediate and advanced life support prehospital providers were conducted and transcribed. A content analysis using an inductive approach was used to code transcripts and identify themes. Results 15 EMS providers participated in three focus group discussions. Data saturation was reached and four major themes emerged from the qualitative analysis: Implementation and use of SATS; Effectiveness of SATS; Limitations of the discriminator; and Special EMS considerations. Participants overall felt that SATS was easy to use and allowed improved communication with hospital providers during patient handover. Participants, however, described many clinical cases when their clinical gestalt triaged the patient to a different clinical acuity than generated by SATS. Additionally, they stated many clinical discriminators were too subjective to effectively apply or covered too broad a range of clinical severity (e.g., ingestions). Participants provided examples of how the prehospital environment presents additional challenges to using SATS such as changing patient clinical conditions, transport times and social needs of patients. Conclusions Overall, participants felt that SATS was an effective tool in prehospital emergency care. However, they described many clinical scenarios where SATS was in conflict with their own assessment, the clinical care needs of the patient or the available prehospital and hospital resources. Many of the identified challenges to using SATS in the prehospital environment could be improved with small changes to SATS and provider re-training.

Implementation and Findings On A One-Minute Sit-Stand Test for Prehospital Triage in Patients With Suspected COVID-19 - A Pilot Project

Introduction: During the initial Coronavirus Disease 2019 (COVID-19) pandemic wave, sparse personal protection equipment made telephone triage of suscpeted COVID-19 patients for ambulance transport necessary. To spare resources, stable patients were often treated and released on-scene, but reports from Italy suggested that some later detoriated. We implemented a prehospital sit-stand test to identify patients in risk for detoriation. Methods The test was implemented as part of a new guideline in stable suspected COVID-19 patients younger than 70 years with no risk factors for serious disease triaged by general practitioners to ambulance response in the Central Denmark Region. Data were collected from April 6th to July 6th 2020. This was a two-part study evaluating guideline adherence and results of the sit-stand test. The primary outcome of each separate part was 1) the proportion of patients sit-stand tested before treat-and-released and 2) the proportion of patients treated with oxygen within 7 days among patients decompensating and not decompensation during the test. Results Data on 156 patients triaged to ambulance response by general practioners were analysed. In total 86/156 (55%) were tested with the sit-stand test, among these 30/86 (47%) were either older than 70 or had risk factors for serious disease. Of those treated and released, 50/52 (96%) were tested. In total, 17/86 (20%) decompensated during the test and of these, 9/17 (53%) were treated with oxygen compared to 2/69 (3%) in patients who did not decompensate (p < 0.001). This difference was only significant in the elderly group of patients with risk factors for serious disease. 10/156 (6%) of patients had a positive COVID-19-test. Conclusion The sit-stand test was implemented in 96% of patients treated and released on-scene, but was also used in elderly patients with risk factors for serious disease. Decompensation was observed in 20% of patients and was associated with oxygen treatment within 7 days – but only in the elderly group of patients with risk factors for serious disease. These findings are hypotheses-generating and suggest that physical exercise testing may be usefull for decision making in emergency settings.

Results from HART-c: innovations in prehospital triage for acute cardiac symptoms, a multicentre prospective study

Introduction Cardiac symptoms are one of the most prevalent reasons for emergency department (ED) visits [1], however most of these patients do not have acute cardiovascular disease. This leads to ED overcrowding which subsequently leads to worse patient outcomes and increased costs [2,3]. Attempts to reduce overcrowding have focused mostly on in-hospital triage. The Hollands-midden Acute Regional Triage – cardiology (HART-c) study uses a newly developed triage platform which includes live monitoring, real-time admission capacity, in-hospital data and cardiologist consultation for improved prehospital triage. Purpose The HART-c study aims to safely increase the percentage of patients with cardiac symptoms not referred to the hospital after emergency medical service (EMS) consultation. Methods Patients aged 18 years or older visited by the EMS for cardiac symptoms were included in the region Hollands-Midden from September 2019 till March 2020 (non-COVID period) and compared with the year earlier. Patients were excluded when primary PCI was indicated. EMS consultation consisted of medical history, physical examination, vital parameters and ECG. All data were transferred to a newly developed platform combining pre-hospital data, shown in real-time, and hospital data, such as medical records and admission capacity. The paramedic contacted an on-call triage cardiologist and decided whether admission was necessary and, if so, which regional hospital was most appropriate (figure 1). The study objective was defined as the percentage of patients not referred to the hospital after EMS consultation. Safety of the triage method was defined in the non-referred patients in the intervention as the percentage of MACE (death and acute coronary syndrome) 30 days after non-referral. Results In the intervention group 1755 patients (age 69±15 years, 53% men), and in the control group 1629 patients (age 68±15 years, 53% men) were consulted by the EMS during the HART-c study. In the intervention group 11.4% of patients consulted to the EMS were left at home, compared to 5.5% in the control group (figure 2). Logistic regression was performed to evaluate the effect of the triage intervention. The model was corrected for gender, age and seasonal changes. The chance of being left at home after EMS consultation was 2.29 (95% CI 1.73–3.02, p&lt;0.001) times higher in the intervention group compared to the control. All patients left at home in the intervention group and their GP's were contacted for adverse events, after case-by-case review the MACE rate was &lt;1%. Furthermore a decrease in interhospital transfers was seen, from 206 in the intervention to 173 in the control. Conclusion Implementation of an innovative triage method successfully increased the percentage of patients with cardiac symptoms safely left at home. FUNDunding Acknowledgement Type of funding sources: None. Triage without (A) and with (B) platform Non-referral in intervention and control

A translational triage research development tool: standardizing prehospital triage decision-making systems in mass casualty incidents

Background There is no global consensus on the use of prehospital triage system in mass casualty incidents. The purpose of this study was to evaluate the most commonly used pre-existing prehospital triage systems for the possibility of creating one universal translational triage tool. Methods The Rapid Evidence Review consisted of (1) a systematic literature review (2) merging and content analysis of the studies focusing on similarities and differences between systems and (3) development of a universal system. Results There were 17 triage systems described in 31 eligible articles out of 797 identified initially. Seven of the systems met the predesignated criteria and were selected for further analysis. The criteria from the final seven systems were compiled, translated and counted for in means of 1/7’s. As a product, a universal system was created of the majority criteria. Conclusions This study does not create a new triage system itself but rather identifies the possibility to convert various prehospital triage systems into one by using a triage translational tool. Future research should examine the tool and its different decision-making steps either by using simulations or by experts’ evaluation to ensure its feasibility in terms of speed, continuity, simplicity, sensitivity and specificity, before final evaluation at prehospital level.

Identifying trauma patients with benefit from direct transportation to Level-1 trauma centers

Background Prehospital triage protocols typically try to select patients with Injury Severity Score (ISS) above 15 for direct transportation to a Level-1 trauma center. However, ISS does not necessarily discriminate between patients who benefit from immediate care at Level-1 trauma centers. The aim of this study was to assess which patients benefit from direct transportation to Level-1 trauma centers. Methods We used the American National Trauma Data Bank (NTDB), a retrospective observational cohort. All adult patients (ISS > 3) between 2015 and 2016 were included. Patients who were self-presenting or had isolated limb injury were excluded. We used logistic regression to assess the association of direct transportation to Level-1 trauma centers with in-hospital mortality adjusted for clinically relevant confounders. We used this model to define benefit as predicted probability of mortality associated with transportation to a non-Level-1 trauma center minus predicted probability associated with transportation to a Level-1 trauma center. We used a threshold of 1% as absolute benefit. Potential interaction terms with transportation to Level-1 trauma centers were included in a penalized logistic regression model to study which patients benefit. Results We included 388,845 trauma patients from 232 Level-1 centers and 429 Level-2/3 centers. A small beneficial effect was found for direct transportation to Level-1 trauma centers (adjusted Odds Ratio: 0.96, 95% Confidence Interval: 0.92–0.99) which disappeared when comparing Level-1 and 2 versus Level-3 trauma centers. In the risk approach, predicted benefit ranged between 0 and 1%. When allowing for interactions, 7% of the patients (n = 27,753) had more than 1% absolute benefit from direct transportation to Level-1 trauma centers. These patients had higher AIS Head and Thorax scores, lower GCS and lower SBP. A quarter of the patients with ISS > 15 were predicted to benefit from transportation to Level-1 centers (n = 26,522, 22%). Conclusions Benefit of transportation to a Level-1 trauma centers is quite heterogeneous across patients and the difference between Level-1 and Level-2 trauma centers is small. In particular, patients with head injury and signs of shock may benefit from care in a Level-1 trauma center. Future prehospital triage models should incorporate more complete risk profiles.