A conversation with Dr. Ethan Brandler, MD, MPH, FACEP, assistant professor of clinical emergency medicine at the State University of New York at Stony Brook, during the International Stroke Conference 2018 poster session.
Interviewed by Dr. Rohan Arora, MD, director of stroke fellowship at Hofstra Northwell School of Medicine.
How often does EMS call you before bringing a stroke patient to your center? How do you use that information to expedite stroke treatment? Wondering how EMS pre-notification can make a difference in your center’s outcomes?
Read this author interview for an update on how EMS triage can tremendously benefit patients with LVO (large vessel occlusions).
Dr. Arora: What were some of the most interesting sessions on EMS prehospital notification for stroke that you attended during ISC 2018? Please tell us which ones of those interested you, and why?
Dr. Brandler: From an emergency medical services perspective, the most exciting presentations at ISC were the presentations about the Rhode Island system by McTaggart, where we really learned that many patients do better when they are transported primarily to a comprehensive center. Most impressive was the fact that EMS can weed out the sickest patients, those with large vessel occlusions, and bring them past the primary stroke center to a comprehensive center. It was also striking how the metrics around last known well to needle time also improved. This has potential benefit even for those patients who do not have a lesion amenable to mechanical thrombectomy. Mortality was markedly decreased. It’s a big win. (1)
I also was intrigued by use of the RACE score by EMS to create a leveled stroke code in the receiving hospital. (2)
Dr. Arora: Nationwide, there is no consensus on best practices of EMS feedback and EMS prehospital notification for stroke because of regional differences across the U.S. In an ideal world, where do you see this going?
Dr. Brandler: Where I think EMS will be now trying to hit a moving target, that is, to use real-time quality assurance data on door to needle and door to groin times combined with predicted travel time and patient severity in order to have a computer algorithm determine which hospital destination is most likely to benefit a particular patient at a particular place and time. It’s a very exciting time in EMS trying to match these successes to practical concerns in local and regional EMS systems. (3)
Dr. Arora: Congratulations on your poster on utility of LA motor scale for LVO at ISC 2018. Can you tell us briefly why you think this scale is better than others, and what is the supporting evidence?
Dr. Brandler: For starters, my study, “Utility of the Los Angeles Motor Score in Predicting Large Vessel Occlusions,” was performed studying paramedic exams. We looked at how well the paramedic assessment, including all the elements of RACE and LAMS, and other predictor variables, such as medical history, perform. We reported, for the purpose of this abstract, only the utility of the LAMS score with the addition of the speech element from the Cincinnati Prehospital stroke scale. We chose this because we had seen from earlier peeks at our data that it was the elements of LAMS that were best predictive of stroke, but that speech improved the sensitivity slightly without adding any noise to the system. We also chose to look at these elements because these scales (Cincinnati and LAMS) are already in use in many areas, and our medics were familiar with them.
Most EMTs only see a few strokes in their careers because they work in low-volume settings or because they work as part of large teams only performing a bit of the process on any one patient. So, while the other scales may be better when you are looking at retrospective reviews of stroke codes with exams performed by neurologists, simpler may actually be more effective in the long run. A prehospital scale has to be useable by EMTs or even lesser trained folks who may have less than 150 hours of training on all diseases and their prehospital management and obviously far fewer hours on stroke.
Additionally, a scale has to be good at picking out these cases that will get an endovascular intervention. The new guidelines make thrombectomy a Level 1 recommendation only for MCA and carotid disease, problems that LAMS identifies targets and grades specifically. (4)
Dr. Arora: Based on the work you have done on EMS prenotification and stroke systems of care, what is your advice to primary stroke centers that are looking to develop a robust partnership between EMS, ED and Stroke Neurology?
Dr. Brandler: Primary stroke centers have to behave as if they care about their patients and seek to get them the most effective and timely care in whatever system they operate in. When EMS provides a strong stroke notification, the wheels of the stroke code process should be turning before that patient arrives at the hospital. Regardless of the eligibility for tPA, the process should move swiftly and in response to the EMS assessment. If the patient seems like a potential candidate for endovascular thrombectomy, transfer arrangements to the comprehensive center should start to be made. Once initial imaging and tPA have been administered, transfers of LVO patients should occur expeditiously.
This smooth operation will only happen if everyone sits down and lays out what their expectations are for the others at the table. The communication has to be a two-way street. EMS providers need to know that their actions and communications are engendering a change on the hospital side, that is, the EMS pre-notification is met with an appropriate ramp-up of readiness in the receiving hospital and that EMS gets the opportunity to make a solid presentation to the receiving physicians.
Those same EMS providers should be provided with feedback on what they did well and what they missed. Usually, this should occur through some sort of feedback letter to their agency QA officer. Receiving institutions and their staffs should also get feedback from EMS on how the hospital is receiving their patients and information. Basically, there needs to be a group understanding of what everyone’s role in the system is and how well they are doing it. These meetings need to be iterative and not single encounters.
- INTERNATIONAL STROKE CONFERENCE 2018 ORAL ABSTRACTS SESSION; TITLE: EMERGENCY CARE/SYSTEMS ORAL ABSTRACTS II Abstract 95: EMS Triage to CSC Reduces Time to Treatment and Improves Outcomes in Patients With Large Vessel Occlusion. Mahesh V Jayaraman, Morgan Hemendinger, Grayson Baird, Shadi Yaghi, Shawna Cutting, Ali Saad, Matthew Siket, Tracy E Madsen, Kenneth Williams, Karen L Furie, Ryan A McTaggart. Stroke. 2018;49:A95.
- Abstract 96: Assessment of the Rapid Arterial Occlusion Evaluation (RACE) Scale in Real-World Practice for Prediction of Large Vessel Occlusion and Reducing Time to Thrombectomy. Brijesh P Mehta, Ashutosh Jadhav, Joy Sessa, Randy Katz, Hoang Duong, Andrey Lima, Gina DiMartini, Lakota Woodall, Peter Antevy, Ryan McTaggart, Ronil V Chandra, Thabele M Leslie-Mazwi, Joshua A Hirsch, Albert J Yoo, Tudor Jovin, Raul G Nogueira. Stroke. 2018;49:A96.
- Regional Evaluation of the Severity-Based Stroke Triage Algorithm for Emergency Medical Services Using Discrete Event Simulation. Brittany M. Bogle, Andrew W. Asimos and Wayne D. Rosamond; Stroke. 2017; 48:2827-2835, originally published September 15, 2017.
- Utility of the Los Angeles Motor Score in Predicting Large Vessel Occlusions. Ethan S Brandler, Karol Perez, Raja Boddepalli, Henry C Thode Jr, SUNY Stony Brook, Stony Brook, NY, ISC 2018 Poster Presentation.