EMS and Acute Stroke Care: Evidence for Policies to Reduce Delays to Definitive Treatments

Abstract

Tremendous advances have altered the management of stroke over the past two decades. In a landmark paper in 1995, intravenous tissue plasminogen activator (TPA) was shown to improve outcomes in stroke patients when compared with the standard treatment at the time. Municipalities around the country created destination plans for their EMS systems to direct stroke patients to an appropriate stroke center and therefore prevent the costly time delays associated with interfacility transports. When properly identified as a stroke by EMS, studies show that EMS prenotification to the hospital leads to faster in-hospital times and in some cases faster treatment times. With such an important role of EMS in stroke care, the importance of proper recognition by EMS became paramount. Stroke identification tools were developed to aid in stroke recognition with varying results. Some systems developed mobile stroke units to bring the emergency department to the patient to expedite TPA administration. Recently, five studies published in 2015 demonstrated the benefit of intraarterial thrombolysis (IAT) for patients with large-vessel occlusions (LVO). While primary stroke centers are able to provide TPA management, comprehensive stroke centers are the only centers capable of providing intra-arterial interventions. Should IAT become the standard of care, EMS will have a responsibility to adjust its stroke recognition systems to differentiate patients with LVOs who might benefit from intervention at a comprehensive stroke center (CSC) and appropriately bypass a primary stroke center (PSC) for a CSC to provide them the best opportunity to receive this time-sensitive therapy and prevent the significant interfacility transport delays.

Quantifying the Impact of Acute Stroke System of Care Transfer Protocols on Patient Outcomes

“…33 Although stroke recognition by EMS providers in the field is a critical step in stroke care, accurate stroke identification is challenging because of the low sensitivity and specificity of prehospital stroke assessment tools. 37,38 Hospitals may have limited resources for stroke care, namely, the availability of stroke centers and stroke teams, as well as sufficient capacity for stroke patients. 36,39 Telemedicine has been proposed as an effective method to increase access to stroke expertise, but challenges lie in developing telecommunication connectivity and implementing an effective reimbursement policy.…”

“…Several municipalities and states have begun to develop protocols based on these guidelines. [13][14][15] For example, several states have passed legislation that requires emergency medical service (EMS) providers to bypass BSCs for patients with acute stroke symptoms and transport them to certified stroke centers. 15 Challenges have been identified, however, in providing access to certified stroke centers for stroke patients in rural areas.…”

Availability of Hospital Resources and Specialty Services for Stroke Care in North Carolina

“…[17][18][19] Furthermore, ongoing research is investigating the benefit of direct transport of acute stroke patients to an endovascular-capable hospital based on symptom onset and severity. [20][21][22][23] Many stroke centers use a network of hospitals for providing telemedicine and facilitating interfacility transfers with community hospitals. 24 Effective regionalization of stroke care requires further assessment and coordination of limited, geographically concentrated resources.…”