Recommendations for the Establishment of Stroke Systems of Care

Essential Workflow and Performance Measures for Optimizing Acute Ischemic Stroke Treatment in India.

Advances in stroke care will have the greatest effect on stroke outcome if care is delivered within a regional stroke system designed to improve both efficiency and effectiveness. The ultimate goal of stroke care is to minimize ongoing injury, emergently recanalize acute vascular occlusions, and begin secondary measures to maximize functional recovery. These efforts will provide stroke patients with the greatest opportunity for a return to previous quality of life and decrease the overall societal burden of stroke.

Regionalization, systems of care design, and quality improvement (QI) registry participation all promote the widespread dissemination of guideline-based evidence into actual practice. As a result, policy statements from the American Heart Association/American Stroke Association (AHA/ASA) advocate for the creation of regional systems of care for various time-critical diagnoses, including ST-elevation myocardial infarction (STEMI), out-of-hospital cardiac arrest resuscitation, and acute stroke.1–3 Creation of these regional networks requires multidisciplinary collaboration to implement 5 mutually reinforcing core elements4 that build each system: (1) Designation of certain hospitals with special treatment capabilities as Receiving Centers for STEMI, resuscitation, or stroke; (2) emergency medical services (EMS) destination protocols that allow for direct transport of certain patients identified by explicit triage criteria to a designated Receiving Center, thus allowing for bypass of closer hospitals if they lack the needed specialty service; (3) organized interhospital transfer and transport protocols to a Receiving Center for appropriate patients who initially self-present or are mistriaged to a Referral Hospital; (4) communication or telemedicine options to provide real-time expert consultation as needed from a Receiving Center to its associated Referral Hospitals or EMS providers; and (5) participation in a regional and/or national QI registry to track relevant process-of-care metrics and meaningful risk-adjusted clinical outcomes. Within each of the 50 states, unique challenges exist for stakeholders attempting to implement the 5 aforementioned core elements of regional or statewide systems of care. In particular, substantial variation exists with regard to the starting point for these initiatives. For example, some states already have sufficient regulatory authority within their EMS agency or state department of health (DOH) to regionalize care of time-critical diagnoses, whereas other states require new legislation to create coordinated systems. In October 2011, the Advocacy Coordinating Committee of the AHA convened a multispecialty task force to assess the …

Leaving No Large Vessel Occlusion Stroke Behind: Reorganizing Stroke Systems of Care to Improve Timely Access to Endovascular Therapy.

According to The Journal of Emergency Medical Services (EMS) the goal of stroke care is to minimize brain injury and maximize recovery. The stroke chain of survival links actions taken by patients, family, EMS and healthcare providers. Recent innovations in stroke treatment require accurate identification and appropriate triage to the appropriate treatment facility. Evidence in the literature demonstrates variability with EMS correct identification of stroke patients between 30% and 80%. Our 164 bed primary stroke center in rural Pennsylvania has been active in providing stroke education on an annual basis to emergency medical services within a two county radius. As part of our ongoing process improvement we wanted to evaluate the emergency medical technicians and paramedics knowledge of stroke signs and symptoms, their understanding of the evaluation, treatment and triage of stroke patients. A standard questionnaire with 14 variables was developed using the American Heart and Stroke Association prehospital guidelines. The questionnaire included 16 stroke and non stroke symptoms, identifying transport to primary verses comprehensive stroke centers and initial evaluation. A sample population of 90 emergency medical service staff were asked to complete the questionnaire with 28 (31%) responses received. All participants indicated they were confident to recognize stroke signs and symptoms but 6 of the non stroke items were chosen as stroke symptoms. All participants indicated they were confident in the initial evaluation of a stroke patient but 14 (50%) appropriately identified airway, breathing, circulation as the first evaluation. Evaluating triage knowledge, 26 (93%) stated confidence in decision to transport to a primary stroke center and 22 (79%) to a comprehensive stroke center, however, appropriate decision to transport to a primary stroke center was identified correctly by 46% a comprehensive stroke center 66%. In conclusion, results from this study suggest that in this rural setting, barriers exist in prehospital recognition and evaluation of the stroke patient for which proper education may be remediable. Our goal is to use this information to revise our current EMS stroke education program and enhance prehospital assessment and triage.

Background: Emergency medical services (EMS) transportation of a potential stroke patient may provide a means of reducing evaluation and treatment times and improve fibrinolytic treatment rates; yet, state-level data have not been linked to diagnosis at discharge and clinical outcomes. Objectives: To link the South Carolina (SC) statewide EMS database with hospital discharge diagnosis and evaluate the impact of EMS transportation in improving identification and treatment of acute stroke. Methods: A retrospective analysis was conducted of the statewide EMS database linked with statewide hospital discharge records stored at SC Department of Health and Environmental Control, for the calendar year 2010. Patients with a discharge diagnosis of stroke were included in the analysis. Patients transported via EMS were compared with patients not transported by EMS. Variables considered included patient demographics, transportation time, location/ type of destination hospital and treatment with intravenous tissue plasminogen activator (tPA). Results: In the year 2010, 18,962 hospitalized patients in SC were assigned a primary discharge diagnosis of stroke. Of these, 36% (6,824) were transported via EMS. The average time from 911 call to hospital arrival was 44.6 minutes. Time from 911 calls to EMS on scene was on average of 1.2 minutes longer for patients residing in rural areas than those in urban areas. About 48% of all stroke cases were treated in primary stroke centers (PSCs) and 4.3% of all ischemic cases received thrombolytic therapy. EMS identification of stroke signs and symptoms was associated with shorter transfer times and a higher transfer rate to a PSC than cases whose symptoms were not identified as stroke by EMS (50% vs. 43% for all strokes, P<0.001; 50% vs. 41% for ischemic strokes, P<0.001). For patients with ischemic stroke, EMS identification of stroke resulted in a markedly higher tPA treatment rate (10.9%) than cases whose symptoms were not identified as stroke by EMS (3.6%) and cases arriving by private vehicles (3.5%, P<0.001). Conclusions: EMS identification of stroke signs and symptoms was associated with increased rate of transportation to PSCs and fibrinolytic treatment for ischemic stroke.

Background: Global Burden of Disease identified stroke as the second leading cause of death worldwide after ischemic heart disease. Many stroke risk factors are preventable with lifestyle changes. A better understanding of the relationship between demographics and knowledge of stroke risk factors and warning signs may help in identifying target populations for preventative stroke education. Purpose: This study aimed to explore 1)knowledge of stroke risk factors and warning signs among Minnesota adults, 2)association between knowledge of risk factors and presence of risk factors and 3)association between the knowledge of warning signs and family history of stroke. Methods: A cross-sectional survey of 207 consenting adults who completed open-ended questionnaires on identifying stroke risk factors and warning signs per American Stroke Association (ASA) was used. Self-reported demographics, medical/family history and lifestyle behaviors data were combined with measured height, weight and blood pressure to provide an individual stroke risk score per the ASA Stroke Risk Score. Results: Most participants(90.3%) correctly identified at least one stroke warning sign, but <1% identified all warning signs (FAST+Walking+Vision). 58.9% identified ≥3 stroke risk factors while only 2.4% identified 6 risk factors. Of the highest ranked stroke risk factors(hypertension, smoking, diabetes, diet, obesity, exercise, age, gender, atrial fibrillation), hypertension and obesity were the most named, correctly identified by 64.3% and 53.1% respectively. Females were slightly more knowledgeable of risk factors(63.9% females vs. 51.8% males) and warning signs(62.3% females vs. 58.8% males). No statistically significant associations were observed between knowledge of risk factors and presence of them, or between family history of stroke and knowledge of stroke warning signs. Conclusion: The findings of this study identified the need for public education of stroke risk factors and warning signs as a critical first step in behavior change. Gender differences in knowledge was slightly different. Other demographic differences was not identified due to study sample homogeneity. Additional efforts should be made to increase sample diversity in future studies.

IntroductionThe use of personal protective equipment (PPE) is a salient component of reducing occupational risk in many fields. Emergency medical services (EMS) personnel use PPE to reduce risk of exposure and defend against various pathogens they come in contact with while providing patient care. Currently, the understanding of factors that predict the use of PPE by an EMS responder during a pandemic is limited. In this study our objective was to identify factors that influenced PPE use by EMS responders during the coronavirus disease 2019 (COVID-19) pandemic, which may guide future planning for responders in similar austere or personal risk situations.MethodsWe conducted a retrospective chart review among all EMS encounters across an EMS agency affiliated with a large New York health system from March 16–June 30, 2020. All adult, emergency encounters with available prehospital record data were analyzed. We assessed patient- and EMS encounter-level data as possible factors that influence PPE utilization. The use of PPE was defined and guided by the literature as being either full or partial PPE, or “not documented.” We used multinomial logistic regression to identify factors that influence PPE use among EMS responders.ResultsWe identified 28,693 eligible EMS encounters during the study period; 54.2% of patients were male, the median patient age was 58 years, and 66.9% of patients had at least one chronic medical condition. The use of PPE was documented in 92.8% of encounters, with full PPE used in 17.8% of these encounters. Full PPE utilization, relative to partial, was most strongly influenced by dispatch codes indicative of “breathing problems” (odds ratio [OR] 4.89; 95% confidence interval [CI]: 4.40, 5.46) and “cardiac/respiratory arrest” (OR 3.82; 95% CI: 2.99, 4.88), in addition to a patient’s positive screening for COVID-19 on 9-1-1 dispatch (OR 3.97; 95% CI: 3.66, 4.32).ConclusionEmergency medical services responders more frequently used full PPE for calls with dispatch codes indicative of respiratory distress or cardiac arrest. Understanding factors that influence PPE use among EMS personnel, particularly during times of public health emergencies, is essential to mitigate exposure and ensure the safety of frontline responders.

Should Primary Stroke Centers Perform Advanced Imaging?

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.

Stroke is a potentially life-threatening, time-dependent event, and one of the leading causes of mortality and lasting morbidity in South Africa (SA). It is of vital importance that Emergency Medical Services (EMS) call-takers accurately recognise stroke symptoms and prioritise time as well as adequate care. EMS call-takers are the first link in stroke care and improving call-taker recognition of stroke signs and symptoms can drastically improve patient outcome. The Newcastle Face Arm Speech Time (FAST) test is a mnemonic aimed at improving diagnostic accuracy of stroke. To assess the use of the FAST test at a call-taker level to raise early suspicion of stroke and appropriately allocate resources to increase awareness of time and decrease delays on scene. A retrospective diagnostic study to determine the accuracy of the FAST mnemonic at identifying stroke when applied at EMS call-taker level. The outcome of the FAST assessment was compared with EMS stroke diagnosis for cases of a private SA EMS over a three-month period (N=146). Using FAST, call-takers were able to identify stroke with a sensitivity of 87.5% and a specificity of 17.4% (positive predictive value 34%, negative predictive value 74%). This yielded an overall accuracy of 40.41%. FAST is a useful screening tool for identifying stroke at call-taker level. FAST has acceptable sensitivity when used as a screening tool; however, specificity and diagnostic effectiveness are lacking. Further studies should be considered to determine call-taker as well as general public knowledge of stroke risk factors and presentation. Stroke is one of the leading causes of death and lasting morbidity in South Africa (SA) and is increasing in incidence. Early recognition of stroke at initial emergency call may expedite treatment, thus improving outcomes. This study demonstrates that the application of the FAST assessment at emergency contact centre level in SA, might be useful at identifying stroke early. Future research should investigate barriers to its use.

See related article, pages 2331–2335. Educating the public on the warning signs of stroke is considered a critical part of the chain of survival and of better stroke care.1 Repeated studies have demonstrated that high-risk groups, such as the elderly, minority groups, or those of low socioeconomic status, often have the poorest knowledge of stroke warning signs.2–4 Although mass media can be a powerful tool in stroke public education,5 it is not without its limitations. To be effective, mass media needs adequate reach and frequency to break through the advertising “clutter”—which requires significant and sustained funding. Moreover, the ability of mass media to target specific high-risk subgroups, whether ethnic, socioeconomic, or linguistic, is unclear. In this issue of Stroke , Kleindorfer et al6 describe a community-based project in which beauticians were used to deliver stroke education to black women, …

Until recently, the prehospital and ED management of nonhemorrhagic stroke was largely supportive care. Studies have now demonstrated the potential of certain therapeutic interventions to reverse the debilitating consequences of such strokes. The clinical benefit for such interventions and the risk of significant therapeutic complications are highly time-dependent. To optimize the chances of a better outcome for the patient with stroke, each community must establish and continue to refine a chain of recovery for stroke patients. The chain of recovery is a metaphor that describes a series of sequential actions that must take place in a timely fashion to optimize the chances of recovery from stroke. Each of these sequential actions forms an individual link in the chain, and each link must be intact. The links include: identification of the onset of stroke symptoms by the patient or bystanders; dispatch life support services, which preferably include enhanced 9-1-1 and medically supervised and trained dispatchers who can rapidly deploy the closest responders and transport units; emergency medical services (EMS) personnel who can rapidly assess and transport the stroke patient to the closest appropriate center capable of providing advanced stroke diagnostics and interventions; en route notification of the receiving facility so that appropriate personnel can be readied for rapid diagnosis and intervention; and receiving facilities capable of providing rapid diagnosis and advanced treatment of stroke, including the availability of specialists who can evaluate underlying etiologies as well as plan future therapies and rehabilitation. To ensure that the chain of recovery is in place, aggressive public education campaigns should be implemented to increase the probability that stroke symptoms and signs will be recognized as soon as possible by patients and bystanders. In addition, because most of the current training programs for EMS dispatchers and EMS personnel are lacking with regard to stroke, it is recommended that such personnel and their EMS system managers be updated on current management and treatment strategies for stroke.

Stroke continues to be a significant cause of morbidity and mortality in the United States. Approximately 700 000 Americans have a new or recurrent stroke each year, and stroke remains the third leading cause of death in the United States when considered independently from other cardiovascular diseases. Stroke also remains a leading cause of serious, long-term disability in the United States.1 Major advances have been made during the past several decades in stroke prevention, treatment, and rehabilitation. Despite successes in delivering effective new therapies, significant obstacles remain in ensuring that scientific advances are consistently translated into clinical practice. In many instances, these obstacles can be related to a fragmentation of stroke-related care caused by inadequate integration of the various facilities, agencies, and professionals that should closely collaborate in providing stroke care. There is increased emphasis on improving the components of stroke care, including recommendations from the Brain Attack Coalition for primary stroke centers and a formal process provided through the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for the certification of primary stroke centers.2–4 It is critically important to look carefully at how the distinct components can be better integrated into systems of stroke care. The American Stroke Association (ASA), a division of the American Heart Association (AHA), is dedicated to improving stroke prevention, treatment, and rehabilitation through research, education, advocacy, and the development and application of scientifically based standards and guidelines. The ASA convened a multidisciplinary group, the Task Force on the Development of Stroke Systems, to describe the current fragmentation of stroke care, to define the key components of a stroke system, and to recommend methods for encouraging the implementation of stroke systems. The term “stroke system” is used in this article to avoid the corporate and financial connotations associated with the words “network” and …

Background: An organized stroke system of care includes the development of Primary Stroke Centers (PSCs) and preferential emergency medical services (EMS) routing to deliver suspected stroke patients to designated PSCs. EMS routing of stroke patients is not nationally governed and in California, EMS routing is decided on the county level. EMS routing policies might provide a financial or competitive incentive for hospitals to invest in PSC accreditation. We sought to evaluate the relationship between the independent adoption of EMS stroke routing protocols and hospital acquisition of PSC designation in California. Methods: All dates of California PSC certification were obtained through The Joint Commissions website qualitycheck.org and follow-up call to the stroke coordinator. Starting dates of EMS stroke routing policies were obtained for each county with at least one PSC. We describe the number of hospitals achieving PSCs designation relative to implementation of EMS routing policies, and annual rates of conversion to PSC for each county. Results: As of June 2012 there are 127 PSCs in California in 27 counties; 22 of 58 counties have implemented EMS routing policies. The greatest number of PSCs were in Los Angeles County (29) followed by San Diego (11) and Santa Clara (9) counties. Achievement of PSC designation was more frequent in the periods immediately before and after a county’s adoption of EMS routing (48 PSCs,38% of total, designated within one year and 81,64%, within 2 years). In Los Angeles, there were 4 hospitals with PSC certification >1 year in advance of EMS routing, 11 within a year of EMS routing and 13 additional PSC’s >1 year after EMS routing policies. The rate of conversion to stroke center accelerated prior to EMS diversion policy adoption and decelerated in the years following. Conclusion: Implementation of EMS routing policies may be an important factor driving PSC certification. National adoption of EMS routing policies for stroke may lead to greater numbers of PSCs, which could positively impact patient care.