Abstract P266: Bypass of Local Acute Care Facilities for Primary Stroke Centers in North Carolina

Abstract

In some regions of the US, emergency medical services (EMS) policies recommend transporting acute stroke patients directly to specialized stroke centers, bypassing local facilities unable to provide appropriate care. However, this prehospital care practice has not been thoroughly studied. We describe the pattern of bypass in a random sample of 301 suspected stroke patients transported by EMS from 53 of 100 North Carolina (NC) counties in 2010. We geocoded scene and destination addresses and calculated driving distances using GIS network analysis (ArcGIS 9.2, ESRI). EMS bypass was defined as the transport of a patient to a hospital other than the closest in driving distance. We characterized each destination as either a Joint Commission certified Primary Stroke Center (PSC) or not (non-PSC). The 301 stroke incidents were transported by EMS to 59 hospitals, including 16 designated as PSCs. EMS bypassed the closest facility for 91 patients (30%). On average, bypass resulted in an additional 10.0 miles of travel [median 4.7 miles (IQR 1.7, 10.6)]. Bypass did not vary widely by patient age, sex, or race. Bypass was more likely to occur in urban counties compared to rural counties (34% vs. 26%), with the mean additional travel distance shorter in urban counties (5.0 miles vs. 16.1 miles). Overall, 151 (of 301) patients were transported to a PSC while only 125 patients would have gone to a PSC if all had been transported to the closest hospital. Therefore, we found EMS bypass resulted in an additional 26 patients transported to a PSC. Further, EMS bypassed a closer non-PSC for a PSC in 36 cases while 10 patients were taken to a non-PSC instead of a closer PSC. Of these 10, the majority, 8, were transported based on patient or family choice. Our data suggest EMS bypass practices can increase access to specialized stroke care centers. Bypassing local hospitals appears to occur more frequently in urban areas where PSCs are more prevalent and in closer proximity. Yet, EMS bypass is not uncommon in rural areas of NC. EMS care, geographic location, and patient choice are all influential in determining a stroke patient's destination. Future studies should incorporate travel times in addressing access to timely stroke care.