Review of: Abdullah AR, Smith EE, Biddinger PD, et al: "Advance hospital notification by EMS in acute stroke is associated with shorter door-to-computed tomography time and increased likelihood of administration of tissue-plasminogen activator." Prehospital Emergency Care. 12(4):426-31, 2008.
In Massachusetts EMTs are required to provide call-in information on the patients they're transporting to the emergency department (ED). The researchers of this study hypothesized that early notification of the EDs that the patient had signs and symptoms consistent with an acute stroke would result in shorter door-to-CT times as well as higher use of thromboylitcs if the patient was a candidate. The national goal for door-to-CT is 25 minutes.
From March 2004 to June 2005 EMS transported 188 patients who would've met criteria for thrombolytics. Of the patients, 44 were delivered to the EDs with prior notification of "possible or probable stroke" and 74 were not. The door-to-CT times for those with notification was 17% shorter (40 vs. 47 minutes, p = 0.01). Also, thrombolysis occurred twice as often (41% vs. 21%, p = 0.04) in those with notification compared to those without.
The authors noticed a trend for those patients with notification to have more profound stroke symptoms. They also noted the patients who didn't receive thrombolysis yet who were candidates had a higher incidence of diabetes but did not have significantly elevated or low blood-glucose levels.
The authors concluded,"Advance notification of patient arrival by EMS shortened time to CT and was associated with a modest increase in the use of thrombolysis at our hospital."
This is just one of many studies to confirm that early notification of EDs of the impending arrival of the very ill or injured improves the care of those patients. This is true whether the patient suffers a STEMI, multiple trauma or, in this case, stroke.
There are several system issues to be addressed for hospitals to respond to a "Stroke Code." However, they're far less daunting than that for STEMI or trauma. They require that the CT be ready to rapidly receive the patient. They also require that the ED physician be prepared to rapidly evaluate the patient to determine the severity of the deficit and alert the neurologist and radiologist of the patient's arrival. Once the CT is completed, it must be interpreted quickly and the decision made to either administer IV or intra-arterial lytics in the interventional radiology suite.
Meeting the goal of 25 minutes to the CT scan is doable but only with prior notification. This study raises two very important questions. First, why did more than half the patient not receive prior notification? Were their symptoms too vague? Have we not educated EMS providers sufficiently to the signs and symptoms of stroke? Is the prevalence of diabetes in the stroke population leading us to assume that the symptoms are secondary to this rather than to stroke? Is the fear of being wrong causing us to hesitate from calling a "Stroke Code"? I understand how that may be the case with STEMI, because you're calling in a specialized team. But if your system includes primary stroke centers, then they must have 24/7 availability of CT scanners. If so, you're not wasting anyone's time.
The mere fact that you witness signs and symptoms in the field consistent with stroke should be enough for you to consider the diagnosis. Don't assume it may be a TIA and that the symptoms will get better. Assume they will get worse or stay the same. There is nothing wrong in being wrong. If you're wrong, the patient gets better. If you're right, the patient goes directly to the CT scan and gets lytics and gets better. Win-Win.
Finally, although the authors state that the increase in lytic use was only moderate in their hospital, the actual data showed that the prior notification group was twice as likely to get lytics statewide. In the smaller hospitals, you may have a larger influence than you know by raising the level of suspicion of the possibility of stroke with ED physicians.