Not good enough, this is just a protocol for transport. WHERE THE HELL ARE THE PROTOCOLS FOR 100% RECOVERY?
EMS Stroke Protocols Questioned
More rules are necessary to ensure patients get to Level 1 stroke centers, government panel told
"We have to change the protocol," said Frei, a neurointerventional surgeon in Denver, at a meeting of the National EMS Advisory Council (NEMSAC), a quasi-governmental organization that advises the federal government on issues related to emergency medical services (EMS).
Stroke Severity Scales Matter
Stroke costs the country $34 billion each year, noted Frei, who is past president of the Society for Neurointerventional Surgery (SNIS). Most strokes (87%) are ischemic strokes; of those, the most dangerous are severe ischemic strokes with emergent large vessel occlusion (ELVO), with 150,000 to 200,000 such strokes occurring each year, he said.
At the EMS level, EMTs often use the Cincinnati Prehospital Stroke Scale to determine whether the patient is likely having a stroke. "The problem is, it doesn't differentiate a minor stroke from a severe stroke," Frei said. "We need to have a better assessment."
"One thing where we could enlist your help at the national level: let's pick one," he told the council members. "People are like, 'Well, I have to learn a stroke severity scale, there are like a dozen of these. Which one do we use?' If we could get some guidance from the national level ... Maybe we just give them one [to use]. It doesn't matter which one."
For patients with an ELVO, the most effective treatment is a thrombectomy, which is done mostly at Level 1 stroke centers. These are so designated by the SNIS if they offer a full spectrum of neuroendovascular therapies, have a dedicated stroke unit, and meet other criteria. An alternative tier system has been proposed by the American Heart Association/American Stroke Association (AHA/ASA).
"If time is brain and you're losing 2 million neurons per minute, you want to do them quickly," said Frei. "The average procedure time for us is 15 minutes, and we have performed it in less than 5 minutes on many patients. Clinical trials have proven beyond any doubt that this is [very effective] for severe strokes," and yet only about 15% of ELVO patients are receiving this treatment, he said.
Level 1 Trauma a Good Model
"Most states do not have a protocol in place for EMS to transport ELVO patients to a center that can perform a thrombectomy -- a Level 1 stroke center," said Frei, adding that this issue is very analogous to trauma patient care. In trauma care, "policies and regulations are really a state-by-state issue, and they vary widely. The majority of [EMTs] that I talk to, their protocol is 'Hey, I pick up a patient, and I bring them to the nearest hospital. That's what I'm instructed to do.'"
However, "there are some exceptions," Frei said. "High-level trauma -- if you think it's a Level 1 trauma patient, what do you do? You bring them to a Level 1 trauma center. If you think the patient is having a STEMI [ST-elevation myocardial infarction], you don't bring them to a hospital that can't perform coronary stenting or PCI [percutaneous coronary intervention]; you bring them to a hospital that can do PCI. We need the same type of protocol in place for large-vessel occlusion stroke, and that is not being done in the majority of the United States. That's a problem."
The solution, according to Frei, is "we need to update EMS protocols to make sure these patients go directly to a Level 1 stroke center, which has facilities that can perform thrombectomy 24/7/365," even if it's not the closest facility. "We're waiting for these patients, we're ready for these patients, but if they don't get to us in time, we can't help them." The SNIS is encouraging this protocol adoption through its "Get Ahead of Stroke" campaign, he said.
That's a bit different from the AHA/ASA's policy recommendation, which states that "[w]hen there are several intravenous alteplase-capable hospitals in a well-defined geographic region, extra transportation times to reach a facility capable of endovascular thrombectomy should be limited to no more than 15 minutes in patients with a prehospital stroke severity scale score suggestive of LVO. When several hospital options exist within similar travel times, EMS should seek care at the facility capable of offering the highest level of stroke care."
Council member Chuck O'Neal, deputy executive director for the Kentucky Board of Emergency Medical Services, noted that in his state, rural EMS providers may be looking at very long drives -- as much as 4.5 hours -- to get to a Level 1 stroke center, and they may be hesitant to do it. "I think it's an education thing, and a public relations outreach thing," he said.
Frei agreed there are "different solutions in rural areas -- Colorado is mostly rural, half the counties are frontier counties. We use a lot of helicopter transport. If you have a severe stroke patient and it takes [4.5] hours to get them there, try to figure out a way to get them there faster, but if you don't get them to a Level 1 or comprehensive stroke center, they're not going to get better."
Many Factors Intervene
Council member Shawn Baird, co-owner of Woodburn Ambulance Service in Portland, Oregon, applauded Frei's efforts. He pointed out that "the biggest barrier to transporting patients directly to any stroke center is it's not just a matter of implementing a protocol -- a medical director can't necessarily with a sweeping hand, even at the state level, decide that that's what's going to happen. EMS transport sits in the center of half a dozen competing interests about where patients are transported to."
One issue is "the expedience of the local EMS system in not wanting to exhaust resources, so they go to the closest hospital by default," said Baird. "This is typical in particularly rural areas where you may only have one ambulance and if they leave the area there's no ambulance for the next person who calls 911."
"Secondly [is] our health systems who are the payers for our patients; they have a lot to say about where our patients are taken," he continued. "If you're a patient of health system X, they want you to go to a hospital that's affiliated with that payer group, especially in a managed care environment. Thirdly [is] who the patient's local primary care physician is, and more so for folks with chronic medical conditions or the elderly. They may be experiencing symptoms of stroke this time, but they want to go to the hospital where they've been routinely seen for their congestive heart failure because that's their center of care."
"Then you have family members who have an interest in being able to easily access the patient when they get transported, and you have time/distance factors," Baird concluded. The reason that some states are able to easily get severely injured patients to Level 1 trauma centers "is because the state where that works passed statewide enabling legislation that says, 'You'll do it, that payer group will pay for it if you do it, [and] you don't have to go to the closest hospital and you're off the hook if there's an adverse event because you're a few minutes longer in the vehicle' ... All of those outside-the-fishbowl factors get accounted for when a state passes enabling legislation."
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