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Emergency transport of stroke suspects in a rural state: opportunities for improvement.

ABSTRACT: Time delay is the key obstacle for receiving successful stroke treatment. Alteplase therapy must start within 4.5 hours from stroke occurrence. Rapid transport to a primary stroke center (PSC) or acute stroke-ready hospital (ASRH) by the emergency medical system (EMS) paramedics is vital. We determined transport time and destination data for EMS-identified and -delivered stroke suspects in Arkansas during 2013. Our objective was to analyze transport time and the hospital qualification for stroke care across the state.The state's 75 counties were placed into 8 geographical regions (R1-R8). Transport time and hospital qualification were determined for all EMS-identified strokes. Each hospital's stroke care status was categorized as PSC, ASRH, a nonspecialty or unknown care facility (NSCF), out-of-state, or nonapplicable designation facilities.There were 9588 EMS stroke ground transports with median within-region transport times of 29-40 minutes. Statewide, only 65% of EMS-transported stroke patients were transported to either PSC (12%) or ASRH (53%) facilities. One-third of the patients (30.6%) were delivered to NSCFs, where acute stroke therapy may rarely be performed. Regions with the highest suspected-stroke cases per capita also had the highest percentage of transports to NSCFs.With only a few PSCs in Arkansas, EMS agencies should prioritize transporting stroke patients to ASRHs when PSCs are not regionally located.

SUBMITTER: Brown AT

PROVIDER: S-EPMC4998736 | biostudies-literature | 2016 Aug

REPOSITORIES: biostudies-literature

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Emergency transport of stroke suspects in a rural state: opportunities for improvement.

Brown Aliza T AT Wei Feifei F Culp William C WC Brown Greg G Tyler Ryan R Balamurugan Appathurai A Bianchi Nicolas N

The American journal of emergency medicine 20160614 8

<h4>Introduction</h4>Time delay is the key obstacle for receiving successful stroke treatment. Alteplase therapy must start within 4.5 hours from stroke occurrence. Rapid transport to a primary stroke center (PSC) or acute stroke-ready hospital (ASRH) by the emergency medical system (EMS) paramedics is vital. We determined transport time and destination data for EMS-identified and -delivered stroke suspects in Arkansas during 2013. Our objective was to analyze transport time and the hospital qua ...[more]

PMID: 27344100

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Project description:In the United States (US), the lifetime incidence of incarceration is 6.6%, exceeding that of any other nation. Compared to the general US population, incarcerated individuals are disproportionally affected by chronic health conditions, mental illness, and substance use disorders. Barriers to accessing medical care are common in correctional facilities. We sought to characterize the local incarcerated patient population and explore barriers to medical care in these patients. We conducted a retrospective, observational cohort study by reviewing the medical records of incarcerated patients presenting to the adult emergency department (ED) of a single academic, tertiary care facility with medical or psychiatric (med/psych) and trauma-related emergencies between January 2012 and December 2014. Data on demographics, medical complexity, trauma intentionality, and barriers to medical care were analyzed using descriptive statistics, unpaired student's t-test or one-way analysis of variance for continuous variables, and chi-square analysis or Fisher's exact test as appropriate. Trauma patients were younger with fewer medical comorbidities and were less likely to be admitted to the hospital than med/psych patients. 47.8% of injuries resulted from violence or were self-inflicted. Most trauma-related complaints were managed by the emergency medicine physician in the ED. While barriers to medical care were not correlated with hospital admission, 5.4% of med/psych and 2.9% of trauma patients reported barriers as a contributing factor to the ED encounter. Med/psych patients commonly reported a lack of access to medications, while trauma patients reported a delay in medical care. Trauma-related presentations were less medically complex than med/psych-related complaints. Medical management of most injuries required no hospital resources outside of the ED, indicating a potential role for outpatient management of trauma-related complaints. Additional opportunities for health care improvement and cost savings include the implementation of programs that target violence, prevent injuries, and promote the continuity of medical care while incarcerated.

Project description:Background and purposeThe criteria for choosing between drip and ship and mothership transport strategies in emergency stroke care is widely debated. Although existing data-driven probability models can inform transport decision-making at an epidemiological level, we propose a novel mathematical, physiologically derived framework that provides insight into how patient characteristics underlying infarct core growth influence these decisions.MethodsWe represent the physiology of time-dependent infarct core growth within an ischemic penumbra as an exponential function with consideration to rate-determining collateral blood flow. Monte Carlo methods generate distributions of infarct core volumes, which are translated to distributions of 90-day modified Rankin Scale scores. We apply the model to a stroke network that serves rural Bastrop County and urban Travis County by simulating transport strategies from thousands of potential patient pickup locations. In every pickup location, the simulation yields a distribution of outcomes corresponding to each transport strategy. A 2-sample Kolmogorov-Smirnov test and Student t test determine which transport strategy provides a significantly better probability of a good outcome for a given pickup location in each respective county (P<0.01).ResultsIn Travis County, drip and ship provides significantly better probabilities of a good outcome in 24.0% of the pickup locations, while 59.8% favor mothership. In Bastrop County, 11.3% of the pickup locations favor drip and ship, while only 7.1% favor mothership. The remaining pickup locations in each county are not statistically significant in either direction. We also reveal how differing rates of infarct core growth, the application of bypass policies, and the use of large vessel occlusion field tests impact these results.ConclusionsModeling stroke physiology enables the use of clinically relevant metrics for determining comparative significance between drip and ship and mothership in a given geography. This formalism can help understand and inform emergency medical service transport decision-making, as well as regional bypass policies.

Dataset Information

Emergency transport of stroke suspects in a rural state: opportunities for improvement.

Publications

Emergency transport of stroke suspects in a rural state: opportunities for improvement.

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