Richard Jackson, MD
Robert Harrington, MD, wrote a commentary in the July issue of Stroke on the Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update: A Policy Statement From the American Stroke Association, which is pertinent to many issues being experienced by many of us involved in the direction and coordination of stroke systems of care. He focuses his commentary mainly surrounding the triage for treatment of large vessel occlusions with thrombectomy and states that it is thought that the suburban/urban boundary setting is the area which will be most difficult to create EMS triage protocols and that thrombectomy-ready centers might be a solution for the rural setting despite the controversy in its role.
Particularly pertinent to my hospital system and its primary stroke center is our travel distance to the local comprehensive stroke center (CSC), which is over 1 hour away by ambulance or helicopter, not including door in/door out and time to groin puncture times. We are considered a rural setting with another non-stroke center designated hospital between our stroke center and the local CSC with a cardiology PCI program designated as a critical access program indicating the difficulty in timely transfer of these patients. In the stroke treatment paradigms, this creates problems with EMS protocols bringing patients further away from the CSC to our center despite the shorter transfer times and potential for delay in IV-tPA. The potential for treatment with thrombectomy could effectively solve this problem similar to the PCI critical access designation for treatment of MI.
At the 2016 National Society of Vascular and Interventional Neurology, there was a panel to debate whether a possible solution to the lack of resources to perform thrombectomy could be to expand the procedure into other specialties such as cardiology and vascular surgery or increase the education of Vascular Neurologists to include thrombectomy in order to increase patient access. To my knowledge, this problem has not been addressed to date. Currently, we work closely with the local CSC for transfer of appropriate patients, but ASPECT Failure and transfer times remain high. To further complicate the situation in rural settings, many of the EMS squads are volunteer and not medical professionals, which makes EMS triage algorithms and screening more difficult. At least for hospitals with similar situations to my own with critical access type designations, it seems that thrombectomy ready status could be a viable solution; however, lack of physicians to perform these procedures, insufficient numbers for call and coverage, and neurosurgical evaluation continue to be the limiting steps.