Long-term effect of field triage on times to endovascular treatment for emergent large vessel occlusion

Abstract

BackgroundDelays to endovascular therapy (EVT) for stroke may be mitigated with direct field triage to EVT centers. We sought to compare times to treatment over a 5.5 year span between two adjacent states, one with field triage and one without, served by a single comprehensive stroke center (CSC).MethodsDuring the study period, one of the two states implemented severity-based triage for suspected emergent large vessel occlusion, while in the other state, patients were transported to the closest hospital regardless of severity. We compared times to treatment and clinical outcomes between these two states. We also performed a matched pairs analysis, matching on date treated and distance from field to CSC.Results639 patients met the inclusion criteria, 407 in State 1 (with field triage) and 232 in State 2 (without field triage). In State 1, scene to EVT decreased 6% (or 8.13 min, p=0.0004) every year but no decrease was observed for State 2 (<1%, p=0.94). Cumulatively over 5.5 years, there was a reduction of 43 min in time to EVT in State 1, but no change in State 2. Lower rates of disability were seen in State 1, both for the entire cohort (all OR 1.22, 95% CI 1.07 to 1.40, p=0.0032) and for those independent at baseline (1.36, 95% CI 1.15 to 1.59, p=0.0003).ConclusionsComparing adjacent states over time, the implementation of severity-based field triage significantly reduced time to EVT.

Most Promising Approaches to Improve Stroke Outcomes: The Stroke Treatment Academic Industry Roundtable XII Workshop

“…In 1 study, the utilization of the Los Angeles Motor Scale to bring patients directly to the comprehensive stroke center was associated with timely endovascular reperfusion of those with large vessel occlusion (LVO) strokes. 12,13 Other instruments have shown comparable utility. 14,15 However, specificity and sensitivity of all prehospital scales remain suboptimal, leading some patients without LVO to bypass primary stroke centers potentially delaying IVT.…”

Triage of Emergent Large Vessel Occlusion (ELVO) patients directly to Comprehensive Stroke Centers (CSCs) is good practice and benefits patients in Urban and Suburban population Centers – New insights from the TRIAGE-STROKE and RACECAT studies

“…Where implemented, these direct to CSC/TCC triage programs have consistently led to marked reductions in times to intervention without sacrificing access to IV thrombolytic therapy. [12][13][14][15][16] Mohamad et al, reported improved outcomes, with higher rates of functional independence (62% vs 43%, odds ratio (OR) 3.08, confidence interval (CI) 1.08 to 8.78), for patients undergoing thrombectomy when they were transported directly to a CSC under a field triage system. 12 Jayaraman et al, demonstrated that stroke patients with a Los Angeles Motor Score (LAMS) of 4 or higher, achieved functional independence in 68% of cases if transported directly to a CSC vs only 42% if first taken to a PSC.…”

“…Importantly, there were also higher rates of IV lytic administration to patients triaged directly to CSCs (78%) vs PSCs (67%)confirming previous studies which have consistently demonstrated that the excess transportation time required to get to a CSC does not diminish access to lytic therapy. [12][13][14][15][16] Finally, there was absolutely no indication in the data that direct to CSC triage could be harmful for patients with suspected ELVO. On the contrary, the risk of dependence or death trended higher for patients triaged to a PSC for patients both with (1.72; 95% CI, 0.46 to 7.27) and without (3.85; 95% CI, 0.32 to 210) a demonstrated ELVO.…”