Tolga D. Dittrich, MD
In acute stroke care, time is arguably the most critical outcome-determining factor. In addition to early recognition of stroke symptoms, prompt transport to a qualified hospital by emergency medical services (EMS) is essential to ensure optimal care. Cash and colleagues evaluated EMS time intervals for adults with suspected stroke in the United States between 2018 and 2019 and examined differences by geographic location.
Approximately 410,000 call-outs were considered, of which the vast majority of transports (98%) were ground-based. A comparison of ground-based and air-bound transports revealed that the time between dispatch and hospital arrival was considerably longer for air-bound transports (ground-based vs. air-bound (median, IQR): 35 min [27-45] vs. 56 min [43-70]), demonstrating disparity to the disadvantage of rural and border regions. In each transport group, 10% of the patients had pre-hospital times outside the target recommendations (≥58 minutes in the ground-based transport group, ≥86 minutes in the air-bound transport group).1
Stroke care stands and falls with the first steps in the treatment chain: recognizing stroke symptoms, alerting the EMS, and fast transport to an adequate hospital. There have been a series of measures to raise awareness of stroke symptoms in the public. However, this large-scale cross-sectional study shows impressively for the U.S. that there is still potential for optimization regarding hospital transport, especially in rural regions. Since the urban-rural divide is already well known, the AHA2 has issued specific recommendations for rural stroke transport. These include a maximum transport time of 60 minutes for cases with suspected large vessel occlusion for the triage decision for air transport.
In the absence of more specific reasons for the choice of transport mode in the present study, it can at least be said that air-bound transport is not, per se, associated with short time intervals. A possible starting point for improving transport times in the future could be expanding the availability of specialized stroke centers for primary care in border regions.
1. Jauch, E. C., Schwamm, L. H., Panagos, P. D., Barbazzeni, J., Dickson, R., Dunne, R., Foley, J., Fraser, J. F., Lassers, G., Martin-Gill, C., O’Brien, S., Pinchalk, M., Prabhakaran, S., Richards, C. T., Taillac, P., Tsai, A. W., Yallapragada, A., & Prehospital Stroke System of Care Consensus Conference (2021). Recommendations for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities From the Prehospital Stroke System of Care Consensus Conference: A Consensus Statement From the American Academy of Neurology, American Heart Association/American Stroke Association, American Society of Neuroradiology, National Association of EMS Physicians, National Association of State EMS Officials, Society of NeuroInterventional Surgery, and Society of Vascular and Interventional Neurology: Endorsed by the Neurocritical Care Society. Stroke, 52(5), e133–e152. https://doi.org/10.1161/STROKEAHA.120.033228
2. Stroke rural transport recommendations [Internet]. Prehospital/EMS Care. 2021 [cited 2022 Feb 2]; Available from: https://www.stroke.org/-/media/stroke-files/ems-resources/stroke-destination-change-032021/ds17297_asa-stroke-transport-graphics_rural-final.pdf?la=en