Review Of: Patel M, Rose K, O’Brien E, et al. Prehospital notification by emergency medical services reduces delays in stroke evaluation findings from the North Carolina stroke care collaborative. Stroke. 2011;42 [Epub ahead of print].
The Science: This study comes out of North Carolina’s Stroke Care Collaborative, which includes 52 hospitals throughout the state. These hospitals submit data to the collaborative—and that data was used for this study. The authors looked at the influence EMS (compared to private arrival) had on imaging and interpretation times: less than 25 minutes and less than 45 minutes, respectively. Of all eligible patients (13,894), 21% had their brains imaged in less than 25 minutes, and 23% had the images interpreted in less than 45 minutes. When patients were brought in by EMS (with and without pre-notification) they were 3 and 1.9 times more likely to have their brain imaged within the 25-minute window and 2.7 and 1.7 times more likely to have the images interpreted within the 45-minute window. The authors concluded that patients brought to hospitals by EMS were more likely to have imaging and interpretation of that imaging significantly faster compared to those brought in by private transport.
Doc Wesley: This is a fascinating report. Although it suffers from the common issues that occur with data mining from large databases, it does provide us with a thought-provoking glimpse of the quality of stroke care and how EMS affects it. We all know that the sooner a patient arrives to the hospital and has brain imaging, the sooner they may obtain lifesaving thrombolytic therapy. But there are many roadblocks to meeting the 3-hour window of eligibility.
First, patients must recognize their symptoms and call 9-1-1. This study supports this fact by showing that simply arriving by EMS increased the likelihood of receiving appropriate therapy. But more importantly, if EMS providers note the presence of stroke symptoms and provide pre-notification by radio or cell phone to the emergency department (ED), then the patient is significantly more likely to have their tests performed and interpreted within 45 minutes.
Secondly, hospitals must develop stroke code programs to react appropriately to EMS pre-notification. In this report, overall (including EMS and non-EMS patients) only 21% received imaging within 25 minutes of hospital arrival. The patients delivered with EMS pre-notification were three times more likely to meet the imaging and interpretation timelines, yet this still represents a sad minority of the eligible patients. This is due to hospital delays and the lack of understanding of the potential value of lytic therapy.
Patients whose symptom onsets were greater than 2 hours were significantly less likely to receive timely imaging and lytic therapy even with pre-notification. Recent studies have shown that patients who wake up with symptoms are quite often candidates for therapy, but they aren’t considered because physicians and EMS providers consider the time of symptom onset to be when they were last awake. Additional studies have shown that for large middle cerebral artery infarctions, the 3-hour window can be stretched to as long as 6 hours.
Hopefully, other states will conduct similar analysis of their stroke care. EMS can take the lead for improved care by working with community leaders and healthcare providers to promote citizen education. EMS medical directors can use this information to pressure receiving hospitals to improve their efficiency. Together, we can make a difference in this tragic condition.
Medic Marshall: I’m with the doc on this one. This is a great study, which highlights the positive effect EMS can have on the treatment of strokes. Furthermore, I think it also highlights an excellent opportunity for EMS–educating the public on recognizing the signs and symptoms of stroke and the importance of not only early recognition, but also the importance of acting and calling 9-1-1. Like the doc said, that 3-hour window is crucial, but in some cases it can be extended.
I’m fortunate enough to work in an area that has stroke code programs in place with several certified stroke centers. It really does make life easier on the streets, but it also makes me feel far more worthwhile and that I’m really a part of the spectrum of care. When I walk through the ED and straight into CT, I think to myself, “Wow”¦I’m really helping this person.” It’s a very uplifting and rewarding feeling, especially since it seems like we only make significant impacts on other patients less frequently.
In closing, I would congratulate these authors a on a job well done with this study. And I think it really helps to point out the benefits EMS providers can bring to the rapid care of strokes.
Prehospital Notification by Emergency Medical Services Reduces Delays in Stroke Evaluation Findings from the North Carolina Stroke Care Collaborative
Mehul D. Patel, MSPH; Kathryn M. Rose, PhD; Emily C. O’Brien, MSPH; Wayne D. Rosamond, PhD
Background and Purpose–Individuals with stroke-like symptoms are recommended to receive rapid diagnostic evaluation. Emergency medical services (EMS) transport, compared with private modes, and hospital notification before arrival may reduce delays in evaluation. This study estimated associations between hospital arrival modes (EMS or private and with or without EMS pre-notification) and times for completion and interpretation of initial brain imaging in patients with presumed stroke.
Methods–Among patients with suspected stroke identified and enrolled by the North Carolina Stroke Care Collaborative registry in 2008 to 2009, we analyzed data on arrival modes, meeting recommended targets for brain imaging completion and interpretation times (<25 minutes and <45 minutes since hospital arrival, respectively) and patient- and hospital-level characteristics. We used modified Poisson regression to estimate adjusted risk ratios and 95% CIs.
Results–Of 13,894 eligible patients, 21% had their brain imaging completed and 23% had their brain imaging interpreted by a physician within target times. Arrival by EMS (versus private transport) was associated with both brain imaging completed within 25 minutes of arrival (EMS with pre-notification: risk ratio, 3.0; 95% CI, 2.1 to 4.1; EMS without
pre-notification: risk ratio, 1.9; 95% CI, 1.6 to 2.3) and brain imaging interpreted within 45 minutes (EMS with pre-notification: risk ratio, 2.7; 95% CI, 2.3 to 3.3; EMS without pre-notification: risk ratio, 1.7; 95% CI, 1.4 to 2.1).
Conclusions–Patients with presumed stroke arriving to the hospital by EMS were more likely to receive brain imaging and have it interpreted by a physician in a timely manner than those arriving by private transport. Moreover, EMS arrivals with hospital pre-notification experienced the most rapid evaluation. (Stroke. 2011;42:00—00.)