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. 2021 Oct 1;78(10):1220-1227.
doi: 10.1001/jamaneurol.2021.2485.

Prehospital Comprehensive Stroke Center vs Primary Stroke Center Triage in Patients With Suspected Large Vessel Occlusion Stroke

Tareq Kass-Hout  1 , Jungwha Lee  2 , Katie Tataris  3   4 , Christopher T Richards  5 , Eddie Markul  4   6 , Joseph Weber  4   7 , Scott Mendelson  1 , Kathleen O'Neill  8 , Renee M Sednew  8 , Shyam Prabhakaran  1
Affiliations

Prehospital Comprehensive Stroke Center vs Primary Stroke Center Triage in Patients With Suspected Large Vessel Occlusion Stroke

Tareq Kass-Hout et al. JAMA Neurol. .

Abstract

Importance: Endovascular therapy (EVT) improves functional outcomes in acute ischemic stroke (AIS) with large vessel occlusion (LVO). Whether implementation of a regional prehospital transport policy for comprehensive stroke center triage increases use of EVT is uncertain.

Objective: To evaluate the association of a regional prehospital transport policy that directly triages patients with suspected LVO stroke to the nearest comprehensive stroke center with rates of EVT.

Design, setting, and participants: This retrospective, multicenter preimplementation-postimplementation study used an interrupted time series analysis to compare treatment rates before and after implementation in patients with AIS arriving at 15 primary stroke centers and 8 comprehensive stroke centers in Chicago, Illinois, via emergency medical services (EMS) transport from December 1, 2017, to May 31, 2019 (9 months before and after implementation in September 2018). Data were analyzed from December 1, 2017, to May 31, 2019.

Interventions: Prehospital EMS transport policy to triage patients with suspected LVO stroke, using a 3-item stroke scale, to comprehensive stroke centers.

Main outcomes and measures: Rates of EVT before and after implementation among EMS-transported patients within 6 hours of AIS onset.

Results: Among 7709 patients with stroke, 663 (mean [SD] age, 68.5 [14.9] years; 342 women [51.6%] and 321 men [48.4%]; and 348 Black individuals [52.5%]) with AIS arrived within 6 hours of stroke onset by EMS transport: 310 of 2603 (11.9%) in the preimplementation period and 353 of 2637 (13.4%) in the postimplementation period. The EVT rate increased overall among all patients with AIS (preimplementation, 4.9% [95% CI, 4.1%-5.8%]; postimplementation, 7.4% [95% CI, 7.5%-8.5%]; P < .001) and among EMS-transported patients with AIS within 6 hours of onset (preimplementation, 4.8% [95% CI, 3.0%-7.8%]; postimplementation, 13.6% [95% CI, 10.4%-17.6%]; P < .001). On interrupted time series analysis among EMS-transported patients, the level change within 1 month of implementation was 7.15% (P = .04) with no slope change before (0.16%; P = .71) or after (0.08%; P = .89), which indicates a step rather than gradual change. No change in time to thrombolysis or rate of thrombolysis was observed (step change, 1.42%; P = .82). There were no differences in EVT rates in patients not arriving by EMS in the 6- to 24-hour window or by interhospital transfer or walk-in, irrespective of time window.

Conclusions and relevance: Implementation of a prehospital transport policy for comprehensive stroke center triage in Chicago was associated with a significant, rapid, and sustained increase in EVT rate for patients with AIS without deleterious associations with thrombolysis rates or times.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Richards reported receiving conference speaker travel reimbursement from the American Heart Association, the American College of Emergency Medicine, and the Illinois EMT (Emergency Medical Technicians) Association; receiving grants from the Agency for Healthcare Research and Quality (AHRQ); and participating on the American Stroke Association Advisory Board (noncompensated) and National Registry of EMTs National Clinical Content Task Force (noncompensated). Dr Prabhakaran reported receiving grants from the AHRQ and the National Institute of Neurological Disorders and Stroke; contributing to UpToDate; and consulting for AbbVie. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Study Cohort Assembly Flowchart
EMS indicates emergency medical services; GWTG-Stroke, Get With The Guidelines–Stroke.
Figure 2.
Figure 2.. Monthly Rates of Intravenous Tissue Plasminogen Activator (tPA) Therapy and Endovascular Therapy (EVT) Before and After Implementation in Chicago
Participants include patients with acute ischemic stroke arriving by emergency medical services transport within 6 hours of the last time the patient was confirmed to be symptom free.
See this image and copyright information in PMC

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