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Original Investigation
August 9, 2021

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

Author Affiliations
  • 1Department of Neurology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
  • 2Department of Preventive Medicine (Biostatistics), Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 3Section of Emergency Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois
  • 4Chicago EMS System, Chicago, Illinois
  • 5Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
  • 6Department of Emergency Medicine, University of lllinois College of Medicine, Advocate Illinois Masonic Hospital, Chicago, Illinois
  • 7Department of Emergency Medicine, Cook County Health, Chicago, Illinois
  • 8American Heart Association, Midwest Region, Chicago, Illinois
JAMA Neurol. 2021;78(10):1220-1227. doi:10.1001/jamaneurol.2021.2485
Key Points

Question  Is the implementation of a regional prehospital transport policy for comprehensive stroke center triage associated with increased rates of endovascular therapy (EVT)?

Findings  This preimplementation-postimplementation study of 663 patients who arrived at the hospital within 6 hours of onset of acute ischemic stroke found an association of increased EVT rates from the preimplementation period (4.8% [95% CI, 3.0%-7.8%]) to 13.6% [95% CI, 10.4%-17.6%) in the postimplementation period. No change in time to thrombolysis or rate of thrombolysis was observed.

Meaning  These findings suggest that implementation of a regional prehospital transport policy for comprehensive stroke center triage may result in a significant increase in EVT rates in patients with acute ischemic stroke and large vessel occlusion.

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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    1 Comment for this article
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    Recommendations on evaluating prehospital triage policies in suspected stroke
    Martijne Duvekot, MD | Department of Neurology, Albert Schweitzer hospital, Dordrecht, the Netherlands
    We appreciate the work of Kass-Hout and colleagues in evaluating a regional EMS-transport policy for suspected stroke patients.1 We agree with the authors that prehospital triage may have a positive effect on outcomes of patients with ischemic stroke, when implemented under the right circumstances.2 However, we have some doubts about the interpretation of the results of their study.
    The main objective of prehospital triage in patients with suspected stroke is to avoid interhospital transfers and thereby expedite endovascular thrombectomy (EVT) in large vessel occlusion (LVO) stroke to improve functional outcomes. The benefit of expedited EVT should outweigh the harm caused
    by delaying thrombolysis in (non-)LVO stroke patients. Unfortunately, the outcome measure chosen by the authors (i.e., EVT-rate) does not cover these aspects.
    The evaluated emergency medical services (EMS)-transport policy included the 3-item stroke scale (3I-SS) assessment. In case of a positive screening and additional driving time to the comprehensive stroke center (CSC) <15 minutes, patients were transported to a CSC. However, almost simultaneously to this implementation several other interventions were implemented. Most importantly, CSCs received education on emergency department protocols regarding vessel imaging and LVO definition. Regardless of the 3I-SS score, EMS-personnel got the possibility to consult with online medical control if stroke suspicion was high. It seems reasonable that the increased EVT-rate is in part caused by increased knowledge of acute stroke imaging and treatment willingness due to the intensive education in CSCs and the opportunity of online consultancy, rather than the EMS-transport policy.
    The authors demonstrated an increased EVT-rate due to several regional interventions. However, this study does not provide enough insight to state the effect of the EMS-transport policy itself. To directly evaluate the effect of an EMS-transport policy, prehospital triage data should be linked to hospital data to demonstrate how many patients were triaged and if triage recommendations were adhered. This will also provide insight into another important aspect of prehospital triage: the change in patients flows, which can be covered in the rates of overtriage and undertriage. For example, a high rate of over triage could cause crowding at emergency departments and might have a negative effect on acute care, which might not be limited to stroke patients.
    For future studies on the effect of prehospital triage, we recommend a prehospital, prospective design with a focus on the trade-off between expedited EVT and delayed thrombolysis, and rates of overtriage and undertriage.

    Co-authors:
    Martijne H.C. Duvekot (1,2) (MD), Ruben M. van de Wijdeven (2) (MD), Bob Roozenbeek (2) (MD, PhD), Henk Kerkhoff (1) (MD, PhD)
    1 Department of Neurology, Albert Schweitzer hospital, Dordrecht, the Netherlands
    2 Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands

    Conflicts of interest:
    The authors do not report any conflict of interest.

    References
    1. Kass-Hout T, Lee J, Tataris K, et al. Prehospital Comprehensive Stroke Center vs Primary Stroke Center Triage in Patients With Suspected Large Vessel Occlusion Stroke. JAMA Neurol. 2021.
    2. Venema E, Lingsma HF, Chalos V, et al. Personalized Prehospital Triage in Acute Ischemic Stroke. Stroke. 2019;50(2):313-320.
    CONFLICT OF INTEREST: None Reported
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