Rohan Arora, MD
Despite the progress in stroke treatment protocols in the United States, the rate of tPA use remains low due to the inability of ischemic stroke patients to reach the hospital within the narrow therapeutic window. EMS plays a very crucial role in acute stroke care by decreasing prehospital delay and by providing prenotification for the stroke team activation, which leads to decrease in door-to-needle time.
Gu et al. analyzed data from the Chinese Stroke Centre Alliance for patients with ischemic stroke from 2015 to 2018 to study the pattern of EMS use, factors associated and its impact on prehospital delay and the treatment. Absolute standardized difference and multivariate logistic models were used. Of 560447 patients with ischemic stroke, only 12.5% used EMS for transportation to the hospital. EMS use was significantly less in the younger population, low income group, milder stroke symptoms, HTN, DM and PVD, while its use was significantly more in patients with history of CVD. Perhaps EMS education regarding stroke in the young might still be something to continually work on. EMS transport was significantly associated with less prehospital delay, shorter onset-to-door time, shorter door-to-needle time (if prenotification is sent) and more rapid treatment. The authors concluded that a low proportion of AIS patients using EMS could be due to lack of accessibility to EMS or lack of awareness for urgent stroke treatment.
We at Northwell Health conducted a similar multi-hospital study on Emergency Medical Providers’ knowledge, practices, and barriers to stroke management.(1) Our trained college student summer volunteers administered a voluntary survey to EMS providers with questions about the methods they use to identify stroke, time window for tPA administration, information they provide for prenotification of an incoming suspected stroke patient, barriers to providing prenotification, whether and how they would like to receive a feedback. 96.0% of EMS providers used the Cincinnati Prehospital Stroke Scale to identify stroke; only 28.9% and 11% of EMS providers correctly reported the time window for IV TPA administration as within 3 hrs and 4.5 hrs of last know well time, respectively. Information being lost in dispatch (40.5%), inability to directly communicate with the ED staff (30.2%) and short transportation time (40.5%) were listed as the common barrier to prenotification.
This highlights the importance of educating the EMS by including them in the stroke care. There were deficits in stroke care knowledge among EMS providers besides the presence of barriers to providing prenotification; it is possible that this had a role to play in the study by Gu et al. Awareness and education programs structured and customized to the hospital and community will go a long way in increasing prehospital notification and, hence, early stroke treatment.
Acknowledgement: I would like to thank our research scholar, Sneh Preet Munder, for help with conducting our study and helping me with this blog post.
References:
- Li T, Munder SP, Chaudhry, Madan R, Gribko M, Arora R. Emergency Medical Services Providers’ Knowledge, Practices, And Barriers To Stroke Management. Open Access Emerg Med. 2019:11;297-303.
