A novel emergency medical services protocol to improve treatment time for large vessel occlusion strokes

Abstract

In many systems, patients with large vessel occlusion (LVO) strokes experience delays in transport to thrombectomy-capable centers. This pilot study examined use of a novel emergency medical services (EMS) protocol to expedite transfer of patients with LVOs to a comprehensive stroke center (CSC). From October 1, 2020 to February 22, 2021, Indianapolis EMS piloted a protocol, in which paramedics, after transporting a patient with a possible stroke remained at the patient’s bedside until released by the emergency department or neurology physician. In patients with possible LVO, EMS providers remained at the bedside until the clinical assessment and CT angiography (CTA) were complete. If indicated, the paramedics at bedside transferred the patient, via the same ambulance, to a nearby thrombectomy-capable CSC with which an automatic transfer agreement had been arranged. This five-month mixed methods study included case-control assessment of use of the protocol, number of transfers, safety during transport, and time saved in transfer compared to emergent transfers via conventional interfacility transfer agencies. In qualitative analysis EMS providers, and ED physicians and neurologists at both sending and receiving institutions, completed e-mail surveys on the process, and offered suggestions for process improvement. Responses were coded with an inductive content analysis approach. The protocol was used 42 times during the study period; four patients were found to have LVOs and were transferred to the CSC. There were no adverse events. Median time from decision-to-transfer to arrival at the CSC was 27.5 minutes (IQR 24.5–29.0), compared to 314.5 minutes (IQR 204.0–459.3) for acute non-stroke transfers during the same period. Major themes of provider impressions included: incomplete awareness of the protocol, smooth process, challenges when a stroke alert was activated after EMS left the hospital, greater involvement of EMS in patient care, and comments on communication and efficiency. This pilot study demonstrated the feasibility, safety, and efficiency of a novel approach to expedite endovascular therapy for patients with LVOs.

Emergency medical service utilization and timely treatment among acute ischemic stroke patients in Beijing from 2018 to 2021

“…According to the results, though EMS utilization was not associated with the proportion of patients receiving endovascular therapy within 90 min, the adjusted time for imaging-to-puncture and door-to-puncture was significantly shorter in the EMS group. Recent research has developed and validated various tools to identify large vessel occlusion strokes in the prehospital setting enabling rapid triage and timely treatment of patients [27][28][29][30][31][32]. Efforts for prehospital risk identification for eligible endovascular patients in the EMS system may further optimize endovascular therapy and improves outcomes [33][34][35][36][37][38].…”

On the Use of Simulation and Optimization for the Analysis and Planning of Prehospital Stroke Care

“…It should be further emphasized that when an EV delivers a stroke patient to the acute hospital, the ambulance paramedics typically do not remain at the patient's bedside, and the EV leaves the hospital. Glober et al [12] contribute a clinical-based study to examine the use of a new EMS policy, asserting that after delivering a patient with a suspected stroke to an acute hospital, the paramedics should remain at the patient's bedside until clinical assessment and diagnosis are completed, and they get the permission to leave the hospital. In case the patient is in need of special treatment, the ambulance paramedics at the bedside transfer the patient using the same ambulance to the closest special clinic.…”