The adage “time is brain” has guided stroke protocols for decades – even the acronym to recognize stroke symptoms, BE FAST, references the need for speed. Recently, we realized the importance of time constraints beyond initial stroke recognition and transport to the emergency department. Each minute in the care continuum must be strategically budgeted to provide patients with rapid access to the most appropriate therapy.
The best systems of care are patient-centered and driven by a collaborative medical community that is unified by the mission to triage patients to the appropriate level of care as quickly as possible. This system of care not only has to provide care for those in densely populated regions but also must facilitate rapid access for those in more rural areas where access to appropriate therapy is more challenging. It takes a village of well-educated families, emergency medical services (EMS) personnel, and doctors to mitigate the brain damage associated with stroke.
The North Central Texas Trauma Regional Advisory Council (NCTTRAC) Stroke Committee is working on outlining a regional stroke plan that will incorporate new guideline recommendations and facilitate rapid access to the most appropriate therapy. As Chair of the NCTTRAC Stroke Committee, I see three main areas where we need to focus attention:
- EMS prenotification to the receiving hospital that a patient with possible stroke is en route
- Early identification of a large vessel occlusion (LVO)
- Facilitate expedited interhospital transfers to higher-level care
1. EMS prenotification
There is a lot to learn from our colleagues in cardiology. Heart programs around North Texas have developed a strong system of “what to do” messaging for EMS teams when responders suspect a heart attack. Responders are trained to contact the emergency room and notify the staff that the patient is headed their way. The ER team prepares the necessary equipment and can immediately begin potentially lifesaving care as soon as the patient arrives.
In the absence of pain, stroke symptoms sometimes can be more difficult to recognize, even to trained medical professionals. Advance notice, even by just a few minutes, allows teams to be mobilized and ready to take action even before patient arrival. The American Stroke Association Guidelines indicate that prenotification increases the likelihood that eligible patients receive potentially lifesaving tissue plasminogen activator (tPA) within three hours and decreases the time to lifesaving treatment. Despite the advantages of prenotification, the Get With The Guidelines registry found that only 67 percent of hospitals receive prenotification from EMS teams about inbound stroke patients.
2. Early identification of LVO
Timely identification of the type of stroke and quick transfer to the most appropriate stroke center is vital. The best option for certain patients might be the closest emergency room; meanwhile, a slightly longer drive to a more capable hospital might make the difference between a good outcome and a bad outcome.
Patients whose strokes are caused by a large blood vessel being blocked have the worst outcomes. Unfortunately, these patients respond poorly to the medication tPA, which is used to dissolve the clot. Their greatest hope is to get to a hospital that offers a procedure to mechanically remove the clot. Utilizing a large vessel screening tool in the field while triaging the patient, EMS might be able to identify those patients with the most severe strokes who need to get to the centers capable of mechanically removing clots.
Hospitals and medical centers today are categorized into three designations that indicate to EMS responders and community members where a patient can receive specific types of stroke care. Each type of center plays a vital role:
- Acute stroke-ready hospitals: These hospitals provide basic stroke care, such as the gold-standard stroke treatment, tPA. The providers at these centers stabilize patients and initiate transfer to more intensive care environments as necessary.
- Primary stroke centers: These centers are the next level of care and can receive patients from acute stroke-ready hospitals. Primary stroke center physicians can provide in-hospital care and perform a range of standard stroke care procedures. Doctors at these centers also initiate transfer of patients with complex needs to the next level of care.
- Comprehensive stroke centers: These centers can provide advanced procedures such as mechanical thrombectomy, a clot-removal procedure that is now approved up to 24 hours from last known normal, as well as intensive postsurgical care. UT Southwestern Medical Center, for example, is a comprehensive stroke center.
So why not take all patients directly to comprehensive stroke centers? This is not advised for couple reasons:
- Comprehensive stroke centers are not close to all patients. If a patient is not suffering a large-vessel occlusion, proper care can be provided much quicker by transferring to the closest stroke capable hospital. Remember, time is brain.
- Influxes of patients to just a few centers can cause delayed care. In order to maintain a high functioning system of care, we need to recognize the valuable role each hospital designation plays. Only patients with a large vessel occlusion potentially benefit by adding a 15-minute delay to bypass a closer stroke hospital in order to reach a comprehensive stroke center where they can receive a clot-removal treatment. The majority of strokes are not caused from a large vessel occlusion, and adding additional delay to treatment could lead to worse outcomes for these patients.
Successful stroke care in our region is dependent upon timely transfers between these three types of stroke centers, which hinges on early identification of the most severe strokes – large vessel occlusions.
3. Interhospital transfers
Hospital and EMS systems must implement protocols and interhospital transfer agreements that facilitate quick door-in/door-out times with the goal to rapidly move patients along the system of care to the most appropriate level of care. It is said we lose 1.9 million neurons per minute that the blood vessel remains blocked in stroke. Thus, even small delays in appropriate care can lead to worse outcomes.
Every level of stroke center has an important role in regional stroke systems of care. By taking a unified, patient-centered approach to reduce the timeline, doctors and EMS personnel across North Texas can achieve an optimal algorithm to ensure patients are getting the highest-quality stroke care.