Abstract
Introduction: Patients with emergent large vessel occlusions (ELVO) are often brought to the closest hospital, possibly given intravenous tPA, and transferred to a hospital capable of performing endovascular intervention. This results in significant delays to thrombectomy and worse patient outcomes when compared with patients brought directly to endovascular centers. In New York City, the pre-hospital system has created a protocol for EMS to use a clinical screening tool to triage stroke patients, and bring those with suspected ELVO directly to comprehensive (CSC) or thrombectomy-capable stroke centers (TSC). Objective: To model the impact of EMS triage protocols on administration of tPA, initiation of endovascular therapy, and recanalization of large vessel occlusions using a real life cohort of thrombectomy patients. Methods: Using our system wide prospectively collected stroke database, we selected a consecutive cohort of 80 thrombectomy patients who were brought by EMS to a primary stroke center then transferred to a TSC or CSC for endovascular intervention. The patient’s initial EMS pickup address was used to calculate the closest TSC or CSC using Google Maps API. Driving time was calculated based on traffic patterns at the time of pickup. Using data from a cohort of 69 consecutive patients that were brought directly to a TSC or CSC by EMS and underwent endovascular intervention, we derived median door to needle and door to groin puncture times. These times, combined with calculated driving distance, were used to model the timing of treatment in the triage model. Timings in the actual cohort versus the model were compared. Results: In the “actual” drip and ship cohort versus our model, first medical contact (FMC) to endovascular center door was 211 versus 32 minutes (p<0.01), first medical contact (FMC) to tPA was 91 versus 81 minutes (p=0.07), FMC to groin puncture was 265 versus 154 minutes (p<0.01), and FMC to TICI2B+ recanalization was 313 versus 205 minutes (p<0.01). Conclusions: Modeled EMS pre-hospital triage of ELVO patients results in a significant decrease in endovascular treatment times without change in tPA times. As triage tools increase in sensitivity and specificity, EMS triage protocols stand to improve patient outcomes.
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