Neal S. Parikh, MD 

Katz BS, Adeoye O, Sucharew H, Broderick JP, McMullan J, Khatri P, et al. Estimated Impact of Emergency Medical Service Triage of Stroke Patients on Comprehensive Stroke Centers. An Urban Population-Based Study. Stroke. 2017

Whether all acute stroke patients should be taken to a comprehensive stroke center (CSC) remains unclear. However, there is mounting computer modeling and clinical data that support transporting acute stroke patients directly to CSCs, especially when the additional travel time is not excessive. The American Heart Association recommends transporting patients directly to CSCs if additional travel time does not exceed 15–20 minutes.

Brian Katz and colleagues performed an analysis to examine real-world EMS transport practices in the Greater Cincinnati/Northern Kentucky (GCNK) region. They performed computer modeling to evaluate the implications of adhering more closely to AHA recommendations. The authors identified patients with acute stroke from the GCNK Study who were transported by EMS in 2010. The GCNK region has 1 CSC and a total of 14 primary stroke centers (PSC) and acute stroke ready hospitals (ASRH). Patients’ addresses were geocoded, and software was used to estimate travel distances to each patient’s initial presenting hospital and also to the CSC.

Of the 2,720 patients in the GCNK study, 1,102 were transported by EMS. Of the 929 patients with available data, 806 patients were taken to a PSC/ASRH, and 123 were transported to the CSC. Based on software estimates, the mean EMS travel time was 11.5 minutes for patients who were transported to PSCs/ASRHs. Had these patients been taken to a CSC, the estimated EMS travel time would have been 19.4 minutes, with few patients increasing their travel time by more than 30 minutes.

On a systems level, transporting all patients to the CSC would have increased its CSC volume by 14 patients per week. However, selecting only patients with NIHSS >9 and symptom onset within 6 hours for triage to the CSC increased the CSC’s volumes by only 2–3 patients per week. The annual loss of volume per PSC/ASRH was negligible in this scenario (8–12 cases per year).

This study has significant limitations. Primarily, the GCNK region has only one CSC, and the data in this study are from 2010, 5 years before MR CLEAN was published. Therefore, the results of this study do not reflect a failure to appropriately triage patients with suspected large vessel occlusion strokes.

Rather, the important conclusion is that even in the GCNK region, where there is only one CSC and a considerable degree of suburban sprawl, transporting patients to the CSC does not egregiously increase EMS transport times beyond the limits of AHA recommendations. Additionally, if time-based and stroke severity screening tools are implemented, the overall impact on stroke systems of care is manageable.