Abstract
Introduction: With recent trials demonstrating benefit to thrombectomy up to 16 or 24 hours (h) from last known well time (LKWT), EMS systems must consider stroke center routing for patients with LKWT ≤24h. Increased transport times can strain resources and may be unnecessary if few patients receive the intended therapy. We sought to determine the frequency of thrombectomy by prehospital-determined LKWT (p-LKWT) in a large regional acute stroke care system. Methods: In January 2018 Los Angeles (LA) County EMS initiated two-tiered routing within its regional system of 50 approved stroke center (ASC) serving 10 million persons. Patients with suspected stroke with p-LKWT ≤24h are routed to ASCs. Patients with potential LVOs (LA Motor Scale (LAMS) of 4 or 5) are routed directly to a designated thrombectomy-capable center (TSC or comprehensive stroke center (CSC)) if within 30 minutes; others are routed to the closest ASC. We abstracted adult EMS transports to a TSC or CSC from January 2018 to March 2019 with final diagnosis of AIS. We excluded transfers and patients without documented LKWT. We determined the frequency of thrombectomy by time intervals from p-LKWT to first medical contact (FMC). Results: During the study period, 1317 AIS patients with p-LKWT ≤24h were transported to a TSC or CSC; 360 (27.1%) received endovascular thrombectomy. Patients were 47% male, median age 77 years (IQR 66-86), median NIHSS 11 (IQR 4-19), and median p-LKWT-to-FMC time interval 69 minutes (IQR 22-360). The table shows the frequency of thrombectomy by p-LKWT-FMC time intervals. Respectively, the ≤6h, >6 to ≤16h, and >16 to ≤24h windows accounted for 76.8%, 18.3%, and 4.9% of transports to thrombectomy-capable centers. Conclusion: With two-tier routing in this regional stroke system, patients in the >6h post-onset window accounted for nearly one quarter of transports to TSCs and CSCs and 22% received thrombectomy. These findings support EMS stroke routing policies up to 24h post-onset.
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