New regional policy to guide EMS response could improve stroke care

Patients with suspected acute ischemic stroke who are taken by emergency medical services (EMS) directly to comprehensive stroke centers rather than the nearest stroke center are more likely to receive treatment endovascular, according to research conducted by researchers at the University of Chicago Medicine. , in collaboration with local health care and emergency response groups.

The study highlights the importance of a regional policy that has guided the SMU’s response in Chicago to a suspected stroke since 2018 -; which the researchers say will lead to better patient outcomes. The results were published on August 9 in JAMA Neurology.

Regional stroke care policies are still in their infancy compared to cardiac or trauma care, where there is more experience in directing people to the right hospital based on the level of care they are receiving. need. We are one of the first regions in the United States to implement this type of multilevel policy for stroke. “

Shyam Prabhakaran, MD, professor and chair of neurology at UChicago Medicine, and lead author of the study

Several years ago, the American Heart Association recommended that patients suspected by the EMS of having an occlusion of a large vessel be transported to the nearest comprehensive stroke center, provided they are found at a reasonable distance. Evidence has shown that comprehensive stroke centers provide essential treatments that improve outcomes for patients with large vessel occlusions or blocked arteries, which account for most disabling strokes.

Following this recommendation, Chicago City Hospitals and Emergency Departments worked together to develop a new regional policy to guide EMS response to suspected stroke.

The team of researchers led by UChicago Medicine decided to use the policy implementation in 2018 to better understand how the policy change affected stroke care. The team included various collaborators from the University of Chicago, Northwestern University, Chicago EMS, Advocate Illinois Masonic Medical Center, Cook County Department of Emergency Medicine, and the American Heart Association. .

“It’s really tragic when a patient with ischemic stroke receives delayed care. Time is the brain: the minutes and hours that are wasted when a patient has to be transferred from one hospital to another cannot be recovered, often leading to worse outcomes, “Prabhakaran says.” Health care systems like ours in Chicago have developed protocols to identify stroke patients based on stroke severity in the field and move them to the right hospital. Today we are one. the first to have implemented such a system and studied its effect. “

The policy provides a set of guidelines for EMS to quickly assess potential stroke patients and, depending on the outcome and location of the call, the intervention team may choose to transport the patient directly to a full stroke center, rather than a primary stroke center. . This is important because some treatments for acute ischemic strokes -; as endovascular therapy, an important treatment for occlusion of large vessels -; are only available at full stroke centers.

Endovascular therapy (VTE) involves threading tiny catheters through blood vessels in the groin or wrist to the location of the blood clot causing the large vessels to occlude. The blood clot can then be removed using devices such as stents or suction catheters, in a procedure known as thrombectomy, or dissolved using drugs in a process called thrombolysis.

In the study, the researchers found that when the EMS used a three-item stroke scale to quickly assess patients and direct those with suspected large vessel occlusion directly to full stroke centers. , there was a rapid increase in the number of patients who received EVT. Importantly, nearly three times as many patients received EVT after implementing the new protocol compared to before. While the study did not look directly at patient outcomes, the researchers say the results are promising.

“We know that the ischemic brain ages physiologically by several years with each hour that treatment is delayed and that providing EVT reduces disability and mortality in patients by almost 20%,” said the author. Principal Tareq Kass-Hout, MD, assistant professor and director of endovascular neurology at Chicago Medicine. “As this treatment improves outcomes, and as policy changes like ours increase the delivery of this powerful treatment, it is imperative that other regions also consider ways to implement referral policies to lead patients. stroke patients to the appropriate stroke center. In doing so, there will be a major impact on public health, because we know that the more EVT is used in a population, the more people are saved from disability and death. “

Prabhakaran hopes the study will inspire other regions to develop similar policies -; and helping Chicago patients understand that they can be confident in the EMS response and need to react quickly when they have a stroke.

“A lot of people don’t realize that a stroke is an emergency that needs to be taken care of right away,” Prabhakaran said. “The time lost in the first few hours can never come back. We need to teach our community that timely care is extremely important and that patients shouldn’t have to find the right places on their own. Calling 9-1-1 should be enough for patients to receive the level of care appropriate to their needs. We need to overcome the fears and doubts people may have when calling EMS and explain that we have policies in place that help people from all walks of life get emergency medical care. Based on these results, people should have a real belief that as a city we are able to provide the best possible quality of stroke care.

Source:

Journal reference:

Kass-Hout, T., et al. (2021) Effects of implementing a comprehensive prehospital triage policy for stroke centers on endovascular therapy in a large urban area. JAMA Neurology. doi.org/10.1001/jamaneurol.2021.2485.

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